Advanced Clinical Social Work Practice

Relational Principles and Techniques

Eda Goldstein, Dennis Miehls, Shoshana Ringel

• Editorial: Columbia University Press
• Año: 2009
• ISBN:
  9780231520447
• Categoría: Scienze sociali
• Categoría: Lavoro in ambito sociale

Advanced Clinical Social Work Practice traces the development of relational ideas from their origin in object relations and self psychology to their evolution in current relational, intersubjectivity, and attachment theory. Relational treatment emphasizes openness and collaboration between client and therapist, mutual impact, the client's subjectivity, and the therapist's empathy, genuineness, and use of the self in therapeutic interaction. The approach treats the relationship and dialogue between client and therapist as crucial to the change process and shows how the therapeutic relationship can be used to help clients and therapists bridge differences, examine similarities, overcome impasses, and manage enactments.

The relational emphasis on the subjective experience of both client and therapist is beautifully illustrated throughout this book as the authors draw from their clinical work with clients from diverse backgrounds, including gay and lesbian clients, immigrants, and clients of color. They demonstrate how relational principles and techniques can be applied to multiple problems in social work practice—for example, life crises and transitions, physical and sexual abuse, mental disorders, drug addiction, and the loss of a loved one. The authors also discuss the integration of relational constructs in short-term treatment and with families and groups.

This volume opens with a historical perspective on the role of relational thinking in social work and the evolution of relational theory. It presents an overview of the key concepts in relational theory and its application throughout the treatment process with diverse clients and in different practice modalities. The book concludes with a discussion of the challenges in learning and teaching new theoretical and practice paradigms, particularly in creating a more mutual exchange in the classroom and during supervision.

1. THE RELATIONAL CORE OF SOCIAL WORK PRACTICE

Social work practice has reflected relational thinking throughout the profession's history and, despite variations in emphasis, has been organized around two main principles. First, social work practice has been grounded on the belief that human behavior develops and can only be understood in the context of interpersonal relationships and social and cultural conditions. Thus, a key feature of social work assessment is its person-in-situation perspective. Second, almost all social work practice models, with the exception of the cognitive-behavioral approach, place importance on the client–worker relationship in the therapeutic process (Turner 1996).

As the social work professional evolved, the originators of different practice models drew on their experience and wisdom and on emerging psycho-dynamic and social science theory in shaping their approaches. Social work authors incorporated many concepts from the burgeoning body of relational thought into their writings. Today, relational theories provide clinical social workers with a theoretical rationale for many familiar practices but also enrich clinical social work practice with a broad range of clients, including those from diverse cultural backgrounds and those who have been the victims of oppression.

This chapter describes how major social work practice models have reflected relational thinking during the profession's history. This review is selective and does not include family, group, and crisis and other short-term approaches, which later chapters discuss. The chapter also comments on some current issues and controversies surrounding the use of relational approaches in social work practice.

THE EARLY PROFESSIONAL RELATIONSHIP

The friendly visitors and settlement workers of the late nineteenth century before social work became a profession recognized the impact of interpersonal relationships and social conditions on behavior. In the preprofessional period, usually affluent women volunteered to help economically impoverished individuals and families, many of whom had recently immigrated to the United States. During this period, there was little theory on which to draw in order to understand human behavior or to guide the helping process. In reflecting on this period, Gordon Hamilton (1958:13) wrote, “The truth was simply that the causes of behavior were little understood. The culture imposed its morals and values on social work, as well as on all of the humanistic professions.” The early social work pioneers drew on their practice experience and wisdom and emerging theoretical frameworks in psychology and sociology to shape the emerging practice methodology (Goldstein 1995:30–31).

Mary Richmond (1917, 1922), who is credited with transforming charity work into a more scientific and professional activity (Germain 1970), focused on helping individuals but showed an understanding of the social determinants of behavior. “At any given time a man's mental make-up is the sum of his natural endowment and his social experiences and contacts up to that time” (Richmond 1922:131). She appreciated the impact of the clients’ cultural background on their view of the world and their expectations and behavior in treatment. Likewise, other prominent social workers such as Ida Cannon, Jane Addams, and Bertha Reynolds drew attention to the negative impact of socioeconomic and political conditions on mental and physical diseases, family life, and daily life (Sheppard 2001).

As charity became more scientific and the social work profession emerged, Richmond recognized the significance of the client-worker relationship and viewed it as a lynchpin of the helping process. “The idea that the relationship of worker and client is important in helping people to help themselves—‘not alms but a friend’—is one of the oldest in casework” (Hamilton 1940:28). Richmond made repeated references to the teaching functions of the relationship, which she thought should embody such qualities as simple friendliness, tact, goodwill, deep respect, a loving attitude, and mutuality. Unfortunately, during the period in which Richmond wrote, it was not unusual for volunteers to display patronizing, moralistic, and puritanical attitudes and religious values in their work (Horowitz 1998; Sheppard 2001). Moreover, in adopting a medical model in her view of poverty or pauperism as a disease, Richmond likened the friendly visitor to a social physician or general practitioner of charity who is called upon to heal complex conditions (Germain 1970:13). Her emphasis on the development of a method of systematic fact-gathering (study) that would lead to a diagnosis of the problem and a treatment plan took precedence over a focus on relational processes in treatment. Her study-diagnosis-treatment framework became a core feature of the diagnostic model or school of social work, which was developed further by faculty members of the New York (later Columbia University) and Smith Schools of Social Work.

THE NEUTRAL/ANONYMOUS AND TRANSFERENCE RELATIONSHIP

Beginning in the 1920s, classical Freudian psychoanalytic theory and treatment had a dramatic and long-lasting impact on social work practice. Most writers have not considered Freud's views to be relational because he viewed the role of the drives and past early childhood conflict as central and minimized the interpersonal and social determinants of behavior. Likewise, he emphasized the irrational or transference rather than real aspects of the therapeutic relationship. He assumed that the psychoanalyst, like a scientist in a laboratory, could study the client objectively without having an impact on the client. He likened analysts’ insight-oriented techniques to surgeons’ scalpels and viewed these tools rather than the therapeutic relationship as crucial to successful treatment.

Psychoanalytic treatment aimed at making unconscious conflicts conscious, modifying pathological defenses and character traits, and analyzing clients’ irrational attitudes. Analysts were advised against being real and instead were instructed to be neutral in their comments, to refrain from gratifying or supporting the client, and to remain anonymous in order to maximize the irrational or transference aspects of the client-worker relationship. They were taught to minimize, analyze, or eliminate their own feelings and attitudes toward clients or countertransference because these were thought to be potential obstructions to the work caused by analysts’ own unresolved problems. They were advised not to divulge personal information that would contaminate their clients’ transference or undermine their authority with the client. Freud wrote that “the physician should be impenetrable to the client, and, like a mirror, reflect nothing but what is shown to him” (1912:18). It is somewhat ironic to note that clients, by virtue of coming for help, were supposed to reveal their most personal secrets.

Many social workers became intrigued by Freudian psychoanalytic theory and its focus on the unconscious, and it became the major theoretical underpinning to social work practice for several decades. It appeared to offer an explanation for why many clients had difficulty making meaningful changes in their lives and for their refusal of help altogether. It also offered a new method for helping clients to overcome their problems (Hollis 1963).

The application of Freudian theory treatment principles focused on the inner person rather than the individual in relation to others and to the environment, emphasized the client's psychopathology, and stressed the impact of past rather than current experiences. Moreover, it failed to recognize the importance of the therapeutic power of the client-worker relationship in engaging the client, instilling hope, helping clients feel less alone, providing fuel for the change process, and creating reparative experiences.

The attempt to carry psychoanalytic principles and techniques into social work practice led to what some have described as excesses and wrong turns in the profession (Meyer 1970). Social work practice became “so preoccupied with the inner life as almost to lose touch with outer reality and the social factors with which social workers were most familiar” (Hamilton 1958:23). One critic wrote, “This emphasis on the past and on the efficacy of probing the unconscious mind… casts both therapist (social worker) and patient (client) into particular roles. The client is assumed to be psychologically ill, in need of treatment in preparation for which he will be diagnosed and tentatively categorized, and of which he will be the passive recipient. The immediate presenting problem is regarded as merely a symptom of a deeper, all-pervading psychological condition, the proper domain of the caseworker-therapist, who assesses and treats over an indefinite stretch of time, assuming sole responsibility for the goal and direction of treatment… but always as a neutral, basically uninvolved figure” (Yelaja 1986:48).

EXERCISING CHOICE AND GROWING THROUGH RELATIONSHIP

Although Freudian theory was a dominant force in shaping social work practice in the 1920s and 1930s, some prominent social workers embraced other theoretical frameworks that had different implications for social work practice generally and for the client-worker relationship specifically. For example, Jessie Taft (1933) and Virginia Robinson (1930), both faculty members of the Pennsylvania School of Social Work, reacted negatively to and actively opposed the diagnostic model and its reliance on Freud's views of personality development and his treatment principles and techniques (Dunlap 1996; Yelaja 1986). The growing revolution against traditional science's static and deterministic view of the physical world and its linear view of causation also influenced them. Moreover, they were students of the philosophy and teaching of Herbert Mead and John Dewey.

Taft and Richmond put forth a new social work practice model, the functional approach, drawing heavily on the writings and teachings of Otto Rank (1924, 1928, 1936, 1941), an early follower of Freud who broke away from him and developed his own theory. Rank served on the faculty of the Pennsylvania School of Social Work and was a strong influence in the social work community there, although he did not personally contribute to the development of the functional model. In Rank's view, “The Ego needs the Thou in order to become the Self” (1941:290). He viewed the birth trauma as the prototype for all later separation experiences and the separation process as instrumental in normal growth and in treatment. He saw “each therapeutic hour as a microcosm of life, a time with its own beginning and end… and emphasized the present, rather than the past or future. He encouraged patients to ‘experience’ rather than to analyze the thoughts, feelings, and behaviors arising from the therapeutic process…. Rank is perhaps most famous for setting time limits” (Dunlap 1996:322).

In generating their new practice model, Taft and Robinson incorporated Rank's positive view of the growth process, emphasis on will, self-determination, and relationships, and focus on the use of time as a motivating force in treatment. In contrasting it to the diagnostic approach, Yelaja wrote, “The view of the individual as the hapless product of interacting external and internal forces had given way to a positive, hopeful view: people fashioning their own fate, capable of creatively using inner and outer experiences to shape their own lives. A psychology of illness was rejected and in its place a psychology of positive human potential and capacity for change gave impulse and direction to a new method in social work. Turning its back decisively on the diagnostic preoccupation with the past, functionalism placed new and creative emphasis on the present experience and its power to release growth potential” (1986:51).

The functional school rejected the diagnostic school's emphasis on extensive fact-gathering and diagnosis as a separate phase in the treatment process. Instead they saw it as woven throughout treatment with the client's active participation. More important, the functionalists believed that it was through a relationship process that clients could exercise choice and grow despite past negative growth experiences. “The casework relationship, premised on an implicit trust in the growth potential, provides a unique opportunity for the release of that potential. It provides this opportunity through consistent attitude of respect for and faith in the worth and strength of clients and a consequent creation of an atmosphere in which clients can feel safe and free to be truly themselves” (56).

In contrast to the Freudian-dominated diagnostic model, the functional approach regarded clients’ resistance as inevitable and necessary for growth and change. “Resistance, an unavoidable phenomenon in the beginning casework relationship, is not only a natural and essential attempt on the part of the individual to maintain his personality, but is a sign of the strength of the will indispensable to new growth” (57).

It is important to note that the characteristic of the functional model that gave it its name had nothing to do with Rankian theory. Concerned about what they felt was the diagnostic model's focus on the inner person and seeming divorce from reality and the social environment during the period of the Great Depression, when so many individuals and families were suffering economically and social workers were overwhelmed by clients’ requests for help, Taft and Robinson viewed the social agency as the link between the therapeutic relationship and growth process and the services that clients sought from social agencies. In this way, the social agency became the bridge between the individual and the interests of society. The functional model was based on the view that the structure and function of the agency defined the focus, direction, content, and duration of service. “Through the therapeutic relationship, the client and the clinician work together to discover what can be done with the help that is offered” (Dunlap 1996:319). The worker represents what the agency can offer, and the client is free to accept or reject the agency's service as a result of the relationship process.

The emergence of the functional model led to heated debate and a deep schism between the diagnostic and functional social workers that pervaded the field for some time. In addition to the controversy over the two models’ key features and underlying theories, each approach had its own excesses to which followers of the alternative model could point. Some criticized the diagnostic model for its reliance on a medical and disease model in viewing human behavior, categorization of behavior, pessimism about human nature, robbing individuals of responsibility for moving their lives forward, creating undue dependency, removing itself from the reality of people's lives, and never-ending process of exploration. Alternatively, the functional model was attacked for overstressing client self-determination, individual responsibility, and agency function to the point of depriving individuals of needed services, for engaging in a relationship process as an end itself, and for utilizing withholding and punishing techniques in order to provoke what was thought to be a necessary will struggle in the treatment (Goldstein 1995:33).

THE SUPPORTIVE AND CORRECTIVE POTENTIAL OF THE CLIENT–WORKER RELATIONSHIP

At the end of the 1930s and throughout the post–World War II period, ego psychology gained recognition in the United States and had an important impact on social work practice. Although it had its roots in Freudian theory, ego psychology was more positive and humanistic in its view of human life and potential, growth oriented, and concerned with the impact of the social environment. Numerous social workers drew on ego psychology to correct for some of the excesses of the earlier era.

Gordon Hamilton, a prominent contributor to the diagnostic school, was a major force in transforming social work practice. Writing of the climate at this time, she wrote, “When ego psychology began to permeate psychoanalytic theory caseworkers would no doubt have grasped its importance even if they had not been harrowed in a literal sense by reality stresses of the depression years. The experience of this period helped them to rediscover those inner resources of character to which casework itself had always been attuned. It is part of man's heritage that under the greatest pressure he seems to attain his greatest stature. Perhaps the renewed emphasis on ego strength was a desperate last stand in a world what was crumbling to pieces; perhaps it was part of the vision of man's strength and sturdiness under adversity” (1958:22).

Although Hamilton's writings date back to the 1920s, Theory and Practice of Social Casework, a major text that put forth the principles of the evolving diagnostic approach, appeared in 1940. Influenced by the Gestalt emphasis in psychology, Hamilton drew attention to the interaction of phenomena as part of a larger whole or field, to a consideration of multiple causality in human events, and to an emphasis on growth, development, and change. She began to use the term “psychosocial” to describe the model although the term was initiated much earlier. She stressed the person-in-situation configuration. Hamilton taught that, in addition to understanding the client's feelings, the worker must engage him or her as an active participant in change (Germain 1970:19).

Among the most significant changes in the casework process to which applications of ego psychology contributed were those that involved the client–worker relationship. “Ego psychological concepts recognized the reality of the client–worker relationship in contrast to an exclusive focus on its transference or distorted aspects… they underscored the importance of engaging the client in a helping relationship in which he or she could exercise innate ego capacities and take more responsibility for directing his or her own treatment and life” (Goldstein 1995:36). Hamilton viewed “a special kind of love,” called “acceptance,” as a central dynamic in the helping process and “a part of any real healing.” She wrote that the relationship “consists of warmth, concern, therapeutic understanding, and an interest in helping the person to get well,” that is, to regain control of his or her own life and conduct. Although the worker was to show a “disciplined concern,” not “indulgence for oneself,” Hamilton recognized that there may be some degree of reciprocity since the worker “may benefit indirectly or incidentally” from the relationship (McCormick 1962:21). She also appreciated the fact that the worker's own personality and values had an impact on clients. Thus, she advised practitioners to cultivate their self-knowledge and to overcome their prejudices. “In any of the professions aiming to help people knowledge of the self is essential for the conscious use of relationship. If one is to use the self, then one must be aware of how the self operates. Not only should the caseworker know something of his motivation for choosing this profession, but he must also surmount another hurdle by recognizing his own subjectivity, prejudices and biases” (1940:41).

The focus on ego strength led to a greater focus on the role of the casework relationship in providing ego support to clients, and the concept of ego-oriented intervention became an important feature of casework practice. In contrast to earlier views that stressed the importance of worker neutrality and objectivity, there was greater emphasis on the worker's ability to show empathy for clients, to engage in controlled involvement, and to convey genuineness. Sometimes fueled by the client's perception of the worker as a benign parental figure (positive transference), the worker provided support by fostering the client's phase-appropriate needs, ego functions, and adaptation. Sometimes the worker functioned as a role model or teacher. Other diagnostic social workers, such as Lucille Austin (1948), Louise Bandler (1963), Grete Bibring (1950), Eleanor Cockerill and colleagues (1953), Annette Garrett (1958), Florence Hollis (1949), Isabel Stamm (1959), and Charlotte Towle (1948), contributed to the refinement of the diagnostic or psychosocial model during the 1940s and 1950s.

Some of these social workers also drew on the work of two revisionist psychoanalysts, Franz Alexander and Thomas M. French (1946, 1963), to expand the use of the casework relationship to include the provision of emotionally corrective experiences, that is, experiences in which the worker functioned in a more benign fashion than did the client's original parents. For example, Austin (1948) wrote of the importance of the worker's attempts at fostering experiences in the client's life situation or in treatment that promoted growth and completion of the maturation process.

PROMOTING ENGAGEMENT AND PROBLEM SOLVING

Helen Harris Perlman's problem-solving model of social work practice (1957) reflected a somewhat different view of the client–worker relationship. She drew on the work of those ego psychologists who emphasized the concepts of ego mastery and growth motivation, and she incorporated some aspects of John Dewey's and Jean Piaget's ideas into her approach. Influenced also by her mentor and friend, Charlotte Towle (1936, 1940), who wrote extensively about the characteristics of the helping relationship, Perlman attempted to correct for what she felt were some of the dysfunct...