Clinical Social Work

In order for clinicians to practice successfully in rural communities, it is important for them to be trained in working with a variety of people, including those that may be stigmatized by seeking therapy. Children and substance abusers in rural areas may already be ostracized by the general population. Additionally, poverty is an abiding characteristic in rural communities. There are problems with Gestalt Therapy, in particular, its tendency to focus on the clinician. Narrative Therapy is not an effective choice either. Rural children often come from single-parent homes there is a lack of focus on the patient's family in Narrative Therapy. Of the Cognitive Behavior Therapy approach, Rational Emotive Behavior Therapy is one in which the clinician is an active supporter of the patient. This is a good approach to use in rural areas where it is particularly important to explain the initial, maintenance, and termination phases of clinical social work to the patient.

Fritz Perls developed Gestalt Therapy as a reaction against the Freudian theory. Gestalt became popular during the 1960s when clinicians were searching for new methods of treatment and theory. Some of the main difficulties with Gestalt derived from Perl's personality. Martin Shepard asserts that too many Perls was an "undisciplined, cantankerous, and lecherous old man” (1975). Arthur Janov claims Perls strutted about “leading weird encounter groups and advocating complete sexual freedom” (2005). Criticisms of Perl's match criticisms of Gestalt Therapy. Its approach is very aggressive. Gestalt clinicians challenge and provoke their patients. Scorn is a characteristic that Gestalt clinicians inherited from Perls (Shepard, 1975). Not only was Perl's theory taught to new clinicians but also Perl's “irascible, scornful style” (Janov, 2005).

Part of traditional Gestalt Therapy is the hot-seat. By putting the patient on display and haranguing them with challenges and questions the clinician provokes responses that make the patient look foolish. The hot-seat idea was based on another therapeutic technique known as psychodrama in which patients would role-play. By assuming someone else’s role patients were supposed to get a feel for what it would be like if they behaved like someone else (Janov, 2005). The Gestalt clinician would use this technique as a means of making someone change his or her undesirable behaviors. Jaonov discusses the failure of these techniques and adds that actors who play roles and do not fundamentally change their personality or behavior. Role-playing is not therapeutically helpful. These and other Gestalt techniques are basically a performance with the clinician as the star (2005). The concentration is on the clinician not the patient in Gestalt. The patient’s feelings, neuroses, depression, or other issues that brought them into therapy are not addressed. Gestalt is not a thoughtful scientific therapy.

Narrative therapy developed as an alternative to medical and psychoanalytical therapy paradigms. It is from the family therapy and group therapy setting tradition. Narrative Therapy was criticized vehemently when it tried to take on cases of schizophrenia (Clough, 2011). Narrative Therapy has been rift with conflicts over philosophy and applications. Some criticize Narrative Therapy because narrative clinicians work with patients who have family problems without including the family in the sessions (Minuchin, 1998).

Other legitimate criticisms of Narrative Therapy address its lack of clinical data when trying to treat patients with serious mental illnesses. Because narrative therapy discusses its results in terms of qualitative results there is no way to evaluate its value empirically. Respected studies use large samples and provide in-depth quantitative analysis. The outcomes are circulated via scientific journals and other scholarly publications (Etchison & Kleist, 2000).

Albert Ellis developed the basics of Rational Emotive Behavior Therapy (REBT) in the 1950s after completing his Ph.D. in New York. Ellis was a devoted scholar of ancient western philosophy. REBT represents his training in psychotherapy and his studies in philosophy. Ellis worked from a hypothesis that when people are agitated it is a result of their reaction to the things taking place in their lives. Depression, for example, is a response to the view one takes toward an event. One of Ellis’ favorite quotes was coined by Epictetus, a servant turned philosopher in ancient Greece. That quote, “men are disturbed not by events, but by the views which they take of them" reflects Ellis’s recurrent theme of viewpoint, (Seddon, 2001).

The REBT therapeutic approach is one of the therapies that are a part of the Cognitive Behavior Therapy (CBT) tradition. REBT is the primogenital therapy of all the CBT approaches in use today (Dryden & Neenan, 2003). In REBT the clinician assumes the role of the helper (Blanchette, n.d.). Unlike other therapeutic approaches, the clinician is neither a nurturer nor a scolder. The job of the clinician is to help the patient recognize the irrational beliefs that are causing the patient's mental disturbances (Dryden & David, 2008).

In REBT the clinician begins by having the patient identify their problem or problems (Garske & Bishop, 2004). The clinician then identifies which of these problems are caused by irrational beliefs. The clinician explains the nature of these irrational beliefs to the patient and also explains why the beliefs are irrational. Then through a series of exercises in session and as homework the clinician helps the patient dispute the irrational beliefs (Garske & Bishop, 2004). The clinician and patient explore alternative beliefs and work to substitute them for irrational beliefs. In this way, the clinician’s participation is important because the clinician encourages the patient to challenge the irrational beliefs that are causing the patient problems (Garske & Bishop, 2004).

As stated by Dryden and David (2008) the clinician, whom they refer to as the helper, uses techniques such as visual imagery to help patients recall times when their irrational beliefs caused them problems. By going back to those times the patient can dispute the irrational belief and consider the episode in light of a new belief. Visual imagery is reinforced and the patient is advised to use it as a tool to confront future incidents (Dryden & David, 2008). Helping patients rethink their irrational beliefs into rational beliefs is only one of the challenges faced by the clinician. Working to help the patient change is another job of the clinician (Garske & Bishop, 2004). Clinicians work to keep the patient in the present and actively working on the goals of the therapy in and out of session.

REBT is attractive to people who seek to solve their problems without medication (Dryden & David, 2008). By recognizing, assessing, and challenging irrational beliefs the patient not only feels better but also gets better over time. The clinician assists the patient in getting better by working actively with the patient in session and by assigning the patient homework-type tasks as well. In simplistic terms, the clinician is helping the patient change negative thinking patterns (Dryden & David, 2008).

The clinician and patient relationship in REBT is a good and positive one. It is unlike Gestalt Therapy techniques in which the clinician challenges and even humiliates patients in order to prompt change. The REBT clinician is considerate of the patient’s feelings and helps the patient confront his or her own beliefs in order to prompt change. Besides visual imagery, the clinician may use a wide variety of techniques to assist help their patients (Dryden & David, 2008). The clinician needs to actively participate and evaluate the patient in order to determine which techniques will work best in a given situation.

Community-based clinical social work, like all social work, has as its goal the improvement and care of the psychosocial functioning in patients. Clinical social work is the scientific application of social work theory used to prevent psychosocial dysfunction. It utilizes one or more theories of human development. The viewpoint of person-in-situation is part of the clinical social work viewpoint. Sometimes clinical social work requires intervention, especially involving substance abuse and children. Clinicians working in clinical settings assess, diagnosis, and counsel patients (Austin, Coombs, & Barr, 2005).

Ginsberg’s text, Social Work in Rural Communities, explains how most government and social service models are based on the needs of urban populations therefore the clinician must seek adaption suited to the rural population. Rural-based clinical social work involves treating a patient population that has very high rates of unemployment. Rural settings may mean that the clinic is trying to serve a geographically distant group of patients who do not have access to public transportation. Recruitment and retention are more difficult in rural areas because the notion that therapy is frivolous or irrelevant often dominates rural thinking. People who live in rural areas have a lower socio-economic level than people do in urban areas (Ginsberg, 2005). Therefore the rural population may not have access to funding for therapy.

Children in rural areas are often raised in the female head of household situations that statistically are more likely to function in uninterrupted, persistent poverty (Ginsberg, 2005). In these communities, there is difficulty maintaining confidentially and single mothers may resist the implications that could arise from seeking therapy for their child. Additionally, children may not be brought to therapy because of the judgmental nature of small communities.

In rural areas, a CBT style treatment like REBT is especially effective when used in treating children and substance abusers. These vulnerable patients have many problems different problems Substance abusers may have served jail or prison time; they often come from traumatic family situations. REBT works best when behavior modification therapy begins as early as possible. Therefore rural children who may have had their education truncated and/or suffer from health problems benefit from the early use of REBT.

The phases of the clinical relationship in rural-based clinical social work are like other types of social work in other locations. There is a beginning, middle, and end to the clinical relationship. It is especially important to explain to patients in rural settings the phases of therapy because they may have little or no knowledge about how it works. The clinician must explain the inevitable end to the relationship, but not too early in the process. The initial phase of therapy involves addressing the patient’s immediate needs (Ginsberg, 2005).

One of the first issues to address is whether the patient is qualified to enter the clinical program and whether the program is appropriate to the patient. Rural-based clinical social work needs to have conditions for the services and conditions for when services cannot be offered. The clinician must be careful when explaining conditions of services to rural patients. There will be more flexibility expected in rural situations by the population because they have little experience with clinical forms of therapy or with professional therapy at all.

After the period of stabilization clinicians and their patients enter into a maintenance phase. The clinician should review a patient's case every one to three months. There are several objectives of the review. It is important to evaluate the treatment strategy and converse about the progress made toward the therapy goals. In addition, this is a good time to devise a treatment strategy to cover the next one to three months.

Substance abusers may require adjustments to the usual length of maintenance and stabilization periods. Clinicians need to make a complete evaluation of the patient's status in order to assess the addiction. Clinicians need to use caution during stabilization and maintenance of substance abusers especially of those patients are involved family or others who are substance abusers as well.

The end of the therapeutic relationship runs on a continuum from feelings of success to sadness at the pending loss of association. That is why it is important for the clinicians to have worked correctly with the patient during the beginning and maintenance phases of treatment. If the correct discussions have taken place then the transition to therapy termination will be expected. A patient will have had time to express any fear of abandonment issues with the clinician. The clinician will have been encouraging the patient’s autonomy.

One concrete thing the clinician should do is arrange a final date on which the therapy will end and make that date a face-to-face session. Because the clinician and patient agree on the date and time both can prepare for this very important meeting. Additionally, by setting a specific date, the patient may realize they have issues that they have not resolved in the therapy and this situation can be discussed.

All the feelings that go along with ending any relationship (denial, anger, anxiety, and resolution) are a part of ending the therapeutic relationship. Encourage the patient to ask questions and express their feelings about the termination. This allows the clinician to determine if the patient id, in fact, ready to terminate therapy. Patients may confuse the feelings they have about termination with not being ready to terminate. The clinician can help them resolve these issues in the session. Ideally, the patient will see termination as a new phase of their lives.

In rural areas, the awareness of time is different than it is in urban areas (Ginsberg, 2005). That is why it is so important for clinicians working in peripheral communities to discuss termination issues with their patients. The termination phase is one in which patients often regress or relapse. Substance abusers and children, in particular, will have trouble visualizing beyond the immediate. The clinician’s goal is to assure an easy transition into termination so that the patients do not feel abandoned.

In past decades clinicians were not trained in the treatment of rural social problems. This created obstacles to the effectiveness of providing social work to communities that were under-serviced, to begin with. Additionally, clinicians who did go to treat rural people had not been trained in understanding the specific problems that arise in peripheral communities. Clinicians work in a professional capacity with their patients every day and having a correct perspective on the population from which patients originate is crucial. With child patients in rural communities developing, dependence can ultimately be destructive to the patient’s well-being. It can also be hard to resist. Peripheral populations need to cope with the support offered by clinicians without duplicating damaging relationships from their past.

References

Austin, M., Coombs, M., & Barr, B. (2005). Community-centered clinical practice is the integration of micro and macro social work practice possible. Journal of Community Practice, 13, 4, 9-30.

Blanchette, Kelsey. (n.d.) Myself as a helper: Rational-emotive behavior therapy, University of Maine at Farmington. Retrieved from students.umf.maine.edu/kelsey.blanchette

Chan, F., Berven, N. L., & Thomas, K. R. (2004). Counseling theories and techniques for rehabilitation health professionals. New York: Springer.

Clough, J. (2011). The relationship between narrative therapy and family therapy: A review and consideration of recent literature. Cumbria Partnership Journal of Research Practice and Learning, 1(2), 2-5.

Dryden, W., & David, D. (January 01, 2008). Rational emotive behavior therapy: Current Status. Journal of Cognitive Psychotherapy, 22, 3, 195-209.

Dryden W., & Neenan M. (2003). Essential rational emotive behaviour therapy. Wiley. Internet Resource.

Etchison, M., & Kleist, D. M. (January 01, 2000). Review of narrative therapy: Research and Utility. Family Journal: Counseling and Therapy for Couples and Families, 8, 1, 61-66.

Garske, G. & Bishop, M. (2004). Rational-emotive behavior therapy. In F. Chan, N. Berven, & K. Thomas, (Eds.), Counseling theories and techniques for rehabilitation health professionals (pp. 177-193). New York: Springer.

Ginsberg, L. H. (2005). Social work in rural communities. Alexandria, VA: Council on Social Work Education.

Janov, Arthur. (2005). Grand Delusions: Psychotherapies without feeling. Chapter 12: Gestalt Therapy: Being Here Now, Keeping Unfinished Business Unfinished. Retrieved from primaltherapy.com

Minuchin, S. (1998). Where is the family in narrative family therapy?. Journal of Marital and Family Therapy, 24, 4, 397-403.

Seddon, K. (2001). Epictetus. Internet Encyclopedia of Philosophy. Retrieved from www.iep.utm.edu/epictetu

Shepard, M. (1975). Fritz. New York: Saturday Review Press.