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Even if m y rationale for the relatedness of research to clinical training is incorrect, do clinical workers really wish to leave the scientific assessment of their own work to others? Many believe that such assessment must not only continue but increase. It seems likely that clinical social workers would, as they have in the past, loudly protest assessment by others who they felt did not understand the goals of the process they were assessing. I urge reconsideration of the very tentative position taken on research in the clinical social work curriculum. This seems desirable if only out of self-interest. Hopefully it would have a more constructive rationale, the assumption of a share in responsibility for increasing the knowledge base of the profession. Overall, I applaud the effort to define a social work specialization. I hope clinical social work is just that, a specialization within social work. If social work may be considered the profession which uniquely focusses on the interactions of individuals with their environment, some may prefer to deal primarily with the large systems environment; others, with transactions between systems and individuals, primarily focussed on the systems; and still others, such as clinical social workers, primarily with individuals as they interact with systems. In m y view this is a continuum with work needing to be done at every point in the range.

University of Kansas School of Social Welfare Lawrence, Kansas 66045

Clinical Social Work Journal Vol. 5, No. 4, 1977

DISCUSSION BY ESTELLE G A B R I E L

Estelle Gabriel, M.A., is in private practice in Chicago, Ill. The position paper presented by Pinkus and co-authors raises many issues which are pertinent to the survival of clinical social work, both as a profession and as a method of service delivery. There is the familiar ring, in the paper, of long-held values to which many clinical social workers still adhere in spite of the inroads made in our thinking b y existential philosophy and other systems of thought. On the other hand, there has been so much popularization of basic psychological knowledge, so much "psychologizing" b y untrained and partially trained persons, and "psychological treatment services" offered b y individuals outside of the mental health team professions of psychiatry, clinical

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social work, psychology, and psychiatric nursing, that at times it seems we have our very own Theater o f the Absurd with all of us as players. The Borderline Syndrome, noted for a confusing combination of symptoms, of psychosis, neurosis, character disturbances, and many healthy elements, seems to have invaded the field of mental health professionals, including social workers. I'm dismayed, b u t n o t surprised. Cultural changes since World War II have affected the forms of mental illness, leading me to believe that this particular form of mental illness, the Borderline Syndrome, is only an exaggeration of many psychosocial elements in our environment. These elements have been for some time most observable in our art forms; in ballet in the emphasis on form and changing form, b u t no theme development; in the greater dissonance in music and the pulsating electrification of sound which captures and momentarily has a contagious pull, but shrills on into noise; in m o d e m dance wherein each responds individually to expressing impulses which are felt from the insistent beat, b u t little coherent form; and in the Theater of the Absurd with the depiction of the dilemmas of the human condition and no character development. There are no real persons, just objects, voids, and absences. Verbalization o f thought as communication is absent. Is it our responsiveness to new cultural forces which has temporarily or permanently affected our capacity for rational thought? A basic theme in the profession of social work historically has rested on the emphasis on the individual. Social policies and social thought have been predicated on maintaining respect for individual freedom to choose a lifestyle geared to differences. There is indication that some of our national policies have created a trend to computer c o n f o r m i t y and that people have become more stratified--resulting in an increasing gap between the haves and the have-nots, the fortunate and the unfortunate, the productive and the loafers, the smarts and the jerks. With the larger group being in the latter categories, impersonality is an element in our culture which has negatively affected all members. However one "makes it" is acceptable, regardless of means. The frustration and anger in being ordered by the c o m p u t e r , with no redress, is c o m m o n to all. Even the training we receive, though fragmented, is to conform, rather than to object, and to think for ourselves and learn. Knowledge is expected to be instantaneously acquired. It is not only the c o m p u t e r that teaches this lesson, it is also the mugger on the street. We think it is truly wiser to c o m p l y to his demands than to resist. Our thinking and behavior have been modified but the loss in free expression m a y be a costly one. The link b e t w e e n this social dilemma and the educational criteria for clinical social w o r k lies in the absence o f indications of self identity, and the resulting depressive loneliness of clinical social workers. A

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reaffirmation of the values of the concept of human growth and change, of the presence of the past, hope in the future, and the relationship of each to the present gives character to human life and reduces the sense of alienation--today's plague. Educational content, so essential for clinical social work, is fragmented among graduate schools of social work. The necessary, arduous, and rigorous integration of knowledge of human behavior and growth, and the pathological deviations from healthy growth, is a b o d y of knowledge well delineated in the position paper. This knowledge resists instant feeding formulas. Continuous incorporation and the time to digest and integrate theory precludes a speed-up of the present trend to shorten the time to produce a clinical social worker. Of equal value is the integration of fieldwork practice with academic theory. In this area particularly, there appears to be a slow disintegration of communication between academic instructor and field instructor. Students as well as schools seek field placements which can ensure practice learning in which experience can solidify theory. That search seems to be dwindling in the clinical area. Does this reflect a change in agency policy? Management b y objectives and zero-based budgeting and adherence to program limitations have validity in administrative planning. But when these are geared to the policy of the organization b u t irrelevant to the client's needs, it is as absurd as a family agency which cannot offer services to an emancipated individual or a lonely individual because they do not belong to a family. "We" expect " t h e m " to conform to our criteria--not always, b u t too much so. Communication lines between the schools and the field agencies exist, b u t often mutual support and guidance have low priority. Translation of theory into practice with skilled clinical supervision cannot be too much to require from a graduate educational experience. Fragmentation in learning b y the student is t o o costly to be tolerated. The conclusion arrived at b y Pinkus and co-authors that dynamic casework should be a basic underpinning for all social work is n o t a practical reality. This is regrettable, b u t probably true. All students do not choose to engage in direct interventive work with people. It is to be hoped that graduate training includes enough integration of these values to affect the training of students in planning, administration, and policy curricula. There remain a majority of students who do choose direct practice. It is this segment of our educational programs which needs strengthening. The dilution of content in clinical knowledge and the lack of agreement on the nature of the required knowledge base for producing clinical social workers can only appear to ourselves, and others, as professional suicide. It occurs at a time when we seek recognition as third-party vendors

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in the health care field. Again, it seems as if we are coming directly from the Theater of the Absurd. Clinical social work has been a prime contributor to the treatment of individuals afflicted by mental illness and emotional distress. We have been willingly used, and used ourselves in such work. Recognition, stature, and recompense have n o t followed automatically. The struggle to achieve a modicum of return for productive efforts is becoming increasingly strong. Efforts to gain recognition as third-party vendors by insurance companies for psychotherapeutic work points to the ultimate goal of inclusion in national health insurance. In this struggle, outside accusations have been addressed to an alleged lack of training in social workers to treat mental illness. In answers to such questioners, the facts are presented that graduate training and content are specifically geared to knowledge of psychopathology and treatment. Fortunately, the efforts of interested members have resulted in the creation of registries of clinical social workers. Standards have been delineated which outline educational and practice requirements. The core curriculum in education, a standard which is unique to the Registry of Health Care Providers in Social Work, is a vital element in responding to criticism from legislators that social w o r k expertise rests only in c o m m u n i t y work. H o w long can such a core curriculum remain a valid and practical requirement if the present shortening of graduate programs continues? Graduate schools have struggled for decades to include essential course content and not provide too much for student consumption. The absurdity of the present conflict professionally is that we are going in opposite directions simultaneously and calling it progress. Efforts to obtain reimbursement for psychotherapeutic treatment of clients in agencies, in mental health clinics, and in private practice are, n o t seem to be, a professional must. Already the lack of recognition b y insurance companies for reimbursement for social workers is resulting in the preferred hiring of psychologists in family agencies and mental health centers. Executives of organizations are caught in a bind o f budgetary demands and professional preference. The advertising of jobs reflects these trends. The opposing trend, as reflected in the job market, is the listing of MSW o r BSW for job openings. Often the lower salaries, more acceptable to the nongraduate-school applicant, lead to hiring practices which result in a reduction in the job market for MSWs. J o b definitions and manpower guides are of little consequence to administrators w h o must meet budgetary pressures. Social work department administrators in hospitals have d o c u m e n t e d the struggle to raise requirements for e m p l o y m e n t of social workers for many years. Their individual efforts are applauded b u t most hospitals lack such trained personnel and relegate the "social w o r k e r " to contacting the welfare system and

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arranging release provisions for patients. Social workers must be allowed the opportunity to practice dynamic casework if they are to prove their competency. The notion of the "fifth profession" stems from the reality of the last few decades, in which mental health clinics have been staffed by psychiatrists, clinical social workers, psychologists, and psychiatric nurses. All have interchangeably provided psychotherapy to patients with a wide range of psychological problems. There is a recognized overlapping of professional competence in the treatment of vast numbers of out-patients who have no organic illness producing the mental disturbance. It would seem that the portion of training in all four professions which leads to successful treatment of such emotional states could b e c o m e a "specialty" b o d y of knowledge and skill, making for a separate and specific profession in itself. The choice of such specialized knowledge and training b y clinical social workers would reduce much of the b o d y of knowledge which has given them a broader and more comprehensive view of treatment than that geared solely to a patient and his internal problems. It has been the inclusion of the family, the community, and the culture in our assessment of individual strengths and weaknesses which has emphasized the strength of our profession. When these external pressures are combined with historical trauma, additional clues are provided to causes and cures in the individual illness. The same combination of historical and present reality elements affects family and c o m m u n i t y health. The knowledge of social welfare policy issues, b o t h historically and today, combined with heavy emphasis on legal issues and human rights, provides clinical social work with a larger public health perspective than otherwise possible. The use of the microscope and the telescope (gaining b o t h a particular and a broad view of human life) is unique to social work and increases our understanding of the external as well as the internal forces in the individual. The method of helping individuals, families, and groups through learned basic skills in communication is another area of knowledge and competence in social work with a valuable history. Charlotte Towle's work provides many examples of such skill in understanding communication. All this is t o o rich a professional heritage for clinical social workers to consider relinquishing it for a " f i f t h " profession. Therefore, if it is considered essential to have a two-year graduate curriculum for the making of clinical social workers, it must contain: (1) knowledge of developmental human growth and behavior, and of pathology resulting from interferences in this normal growth; (2) methods in basic skills of communication; (3) social welfare policy issues; (4) supervised clinical field work continuously linked with theory building; and (5) research, a final ingredient in most graduate programs giving

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professional substance to training. It does not seem possible to compress it further. Students in clinical social work cannot be trained to become researchers, or policy planners, or educators, or administrators. These are specialties as is clinical social work. An understanding of the purposes and use of such specialties is necessary for direct service and the understanding and use of clinical social work is necessary in areas of different expertise. General survey courses cannot produce a specialist. In
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Are we truly worth the trust of the client and the m o n e y from the system? 55 E. Washington St., Room 1817 Chicago, Ill. 60602

Clinical Social Work Journal Vol. 5, No. 4, 1977

DISCUSSION BY CAROL H. MEYER

Carol H. Meyer, DSW, is Professor, Columbia University School o f Social Work, N e w York City.

It is interesting to be a guest in the house of the clinical social workers. This is m y first venture across the ideological abyss t h a t separates us. I assume that it was not accidental that I was asked to c o m m e n t upon this position paper. It is certainly clear from a glance at my vita that I belong to the social work side of the controversy being addressed here. Thus, it is a fine gesture that the hosts in this house have been so gracious as to invite me in. The Education Committee has made a distinct contribution in providing a definition of the clinical social worker, for the term is used loosely in the field. Analysis of the knowledge, skills, and processes in clinical social work often seem hard, in some areas, to differentiate from direct practice in social work. But now we have a real distinguishing feature when the clinical social worker is defined as a health care provider. This i s a timely definition, for it looks ahead to the era of health insurance and third-party payments. With this definition in mind, it is possible to understand the thrust and purposes of the position paper. Without this definition, the antecedent arguments are unsubstantiated, unclear, and unconvincing. One cannot in this limited allotted space comment upon the lack of accountability, the lack of sophistication of systemic relationships among phenomena, the lack of awareness of history, the naivet~ about fiscal constraints, and the tunnel vision approach to professional concerns that are revealed in the position paper. Unfortunately, space restrictions also make it impossible to address fully the curriculum design that is based upon the presumption of social work practiced in a policy vacuum. Nor is it possible to c o m m e n t fully upon the misunderstanding of environmental impact upon the individual, despite the times the word environment is used in the position paper. It is only possible to try to get at the heart of the matter. The heart of the matter is political and economic, as are most