Clinical Practice with Individuals

Professional social work seeks to enhance adaptations among clients and the systems within which they are embedded (Meyer, 1993). Many practice models exist to accomplish this. Behavioral and cognitive­behavioral approaches, the effectiveness of which is supported by extensive data, are among these practice models, and many excellent books, chapters, and articles presenting them have been written (Gambrill, in press; Granvold, 1994; Schwartz, 1983; Schwartz & Goldiamond, 1975; Thyer, Himle, & Santa, 1986).

So why is this book needed?

• There exists a lack of information that applies current state-of-the-art behavioral theory and findings from basic research (some of which have never, to my knowledge, been extended to applied work) to social work practice, even though we have learned a great deal in recent years. For example, cognitive approaches demonstrated their usefulness in the 1970s. Only recently, however, has it become clear that cognition can most usefully be viewed as a subset of behavior, which leads to a new understanding of why cognitive techniques work and how to apply them in practice in an organic way (Hayes, 1992; Kohlenberg & Tsai, 1991, 1994). Both behavioral and cognitive-behavioral strategies are outlined in this book but within an integrated conceptual framework.
• Much of what is available in the literature is not grounded firmly in the professional practice of social work. Many techniques are borrowed from other disciplines, and the principles of the science of behavior do not change depending on who is using them. Social workers, however, do something other than what psychologists or certified addictions counselors do. Social work practice is not a collection of unrelated techniques for changing the behavior of individuals but rather an integrated approach for enhancing the fit between client and environment. Ecobehavioral social work practice is not the same as what other professions do, but this fact has often not been emphasized, and perhaps sometimes not recognized, in the behavioral social work literature.
• Because many of the most recent behavioral findings have so far been presented only at a highly technical level, the learning curve can be steep. Although an understanding of concepts such as differential reinforcement and equivalence relations is important to effective practice, most social workers do not yet speak that language. My goal in this book is to present practical guidelines for practice that are firmly rooted in contemporary state-of-the-art knowledge in accessible ways that are immediately applicable to practice. This book is about clinical practice with individuals. In no way does this suggest that working with clients one-on-one is the best modality. Individual, family, group, organizational, and community practice are all modalities central to the profession, and adequate practice requires recognition of the need for each (Mattaini, 1995). In day-to-day practice, however, many clients are seen individually, sometimes by design and sometimes because of situational realities.

Why do individual work? Is it not more important to work on community and policy levels, especially at moments in history in which the most vulnerable populations (social work's historic constituency) are facing increasing exploitation and oppression? This is a difficult issue, and some social work scholars have argued that community-level work is the only responsible choice and that the best way to help people is to build healthy communities (Specht, 1990; Specht & Courtney, 1994). Bertha Capon Reynolds (1934/1982) struggled with this question more than 60 years ago during the height of the Great Depression. Her resolution—and mine—was that the need for social action and advocacy is acute; at the same time, we cannot leave individuals to suffer unaided, and building healthier people also contributes to a healthier community. This is not an either/or choice.

AN ECOBEHAVIORAL APPROACH

Multiple practice "models" or approaches are available for social work practice. This book outlines one model, an ecobehavioral (see Lutzker, Frame, & Rice, 1982, for the origins of the term) approach. This model is highly collaborative and empowering and avoids pathologizing normal reactions to unfortunate circumstances and learning histories. Social workers can practice from this approach and call what they are doing "casework," "therapy," "treatment," "counseling," or "personal consultation." I personally prefer the last term because I believe it emphasizes the collaborative nature of the process and suggests similarities with other professional relationships (for example, in law, management, or finance) in which the professional outlines options, assists the client to understand the factors that are relevant, and guides and encourages the client to make effective decisions. I believe this model is closer to what social workers do, or should do, than is a medical model in which the worker "fixes" what is wrong with the client.

Because the approach presented here is firmly rooted in empirical data, practice based on this approach has a high likelihood of being effective. I include references to important examples and reviews of such work in the reference lists at the end of each chapter. Basing practice on demonstrably effective strategies is, of course, essential; each case, however, is in some ways unique, and many are unique. Practitioners often cannot simply select the "right" interventive protocol from a menu, as a physician might select a drug. Therefore, social workers also require a comprehensive and coherent conceptual framework to guide them in identifying the key factors operating in a particular case and in inventing new interventions when necessary. The present model is both based on empirical data and firmly grounded in comprehensive theory.

The ecobehavioral approach can often be effectively applied on a short-term basis. Contemporary practice, as in managed care, may place time limits on service. Behavioral approaches generally work relatively quickly, and time limits can be beneficial under certain circumstances. Professional practice encourages contracting with the client for brief blocks of sessions (sometimes several times) but requires that the extent of intervention ultimately be guided by the data—to work as quickly as possible, but no faster (see Gambrill, 1994, for a discussion of arbitrary time limits). Strictly arbitrary time limits may pose serious ethical problems.

I have been asked why I use the term ecobehavioral. Why not just behavioral (or the traditional social work term, sociobehavioral)? Although some practitioners from the behavioral social work community strongly disagree, I believe the ecosystems perspective (Meyer, 1995) and ecological models of practice (for example, Germain & Gitterman, 1996) have something important to teach us—that social workers may need to attend to not only the behavior of the individual but also the behavior of the multiple members of the multiple cultures (including family, organizational, neighborhood, ethnic, or even national cultures) within which the client is embedded. Using the term culture in this broad sense, it is often essential to work with the client to design family, organizational, peer, and other cultures that will support achieving the client's goals and maintenance of changes the client makes. Ultimately, social workers are not interested in simply changing behavior but in changing behavior­environment relations or more precisely in changing patterns of events embedded indivisibly in person and world (Lee, 1994). This model often involves linking the client to new cultures and modifying those that exist, for example, in the family or the peer group, to support positive change, and doing so requires a deeply contextualized perspective.

ORGANIZATION OF THIS BOOK

This book is organized as follows: Chapter 1 presents basic terms, principles, and theory that will be used throughout the book. Included is material that may be new even to readers with some familiarity with common behavioral principles; this material has emerged over the past decade or so and allows the approach to be applied in more complex areas of human and social functioning than in earlier treatments.

Chapter 2 covers engagement and assessment. Building an adequate relationship with the client is often essential both for gathering the data needed to complete an assessment and for motivating change. Effective practice also clearly requires adequate assessment. The area of assessment is one in which an ecobehavioral approach to clinical practice may provide particular advantages.

Chapters 3 through 5 outline general behavioral interventive strategies and techniques that are applicable across a broad range of clinical issues, including cognitive techniques. Chapter 6 is a brief, critical chapter outlining what is known about maintaining change once it has been achieved. Maintaining positive change has proved difficult for all practice approaches that have examined it. For example, in substance abuse treatment, the risk of relapse is high regardless of basic treatment approach, and similar issues often arise with regard to emotional, relationship, and many other human problems. Because of their propensity to actually collect data on client functioning, behaviorists were among the first to identify the problem clearly and have therefore focused significant energy on developing effective responses.

Chapters 7 through 10 focus on several common issues that social workers deal with in daily practice. The problems covered are depression and demoralization, relationship issues (particularly in the family), substance abuse, and severe mental and behavioral disorders (including what are commonly and, I argue, inaccurately labeled "personality disorders"). This selection of issues is not meant to suggest that these are the only problems clinical social workers see or that they are the most important; many forms of human pain can be equally devastating. I have chosen these particular issues because they are common among social work clients (including members of particularly vulnerable populations such as homeless and poor people and insular single-parent families), because they cover a broad range of concerns and therefore demonstrate the breadth of the approach, and because they are problems with which I have substantial clinical and programmatic experience.

INADEQUATE RESOURCES

Many social work clients experience severe problems with resource limitations, including extreme poverty, lack of adequate (or any) housing options, and lack of access to services (often associated with racism, sexism, homophobia, and other forms of oppression). Assisting clients to address these areas is an integral and organic part of clinical social work and one that may often be far more important than any "psychological" intervention. Assistance with these problems is often categorized separately as providing "concrete services" or working with "environmental problems." I do not make this artificial separation in this book.

These reality factors are often among the most critical variables involved in behavioral contingencies (behavior­environment relationships) in clinical situations and should therefore not be seen as a separate, and especially not as a separate and unequal, aspect of practice. In the chapters that follow, problems with inadequate tangible and social resources will therefore be integrated into the discussion. For example, poverty is often associated with depression and demoralization (as well as with each of the other clinical issues highlighted). The particular contribution of an ecobehavioral approach is surely not to notice poverty but rather to assist in understanding how poverty may contribute to demoralization and what potential options may therefore exist for ameliorating the effects.

CONCLUSION

In this brief introduction, I have sketched the reasons why I believe an ecobehavioral approach has much to offer contemporary social workers and their clients. There may be other approaches that are capable of doing an even better job (certainly improvements will come with time), but it is the responsibility of those who espouse these approaches to demonstrate their usefulness. In the meantime, I believe social workers have an ethical responsibility to familiarize themselves with an approach that substantial data suggest can make a profound difference in the lives of clients. A brief guide such as this one can only sketch the broadest outlines of the model, but perhaps this outline will provide motivation to look more closely at the details.

REFERENCES

Gambrill, E. (1994). What's in a name? Task-centered, empirical and behavioral practice. Social Service Review, 68, 578­599.

Gambrill, E. (in press). Helping clients: A critical thinker's guide. White Plains, NY: Longman.

Germain, C. B., & Gitterman, A. (1996). The life model of social work practice (2nd ed.). New York: Columbia University Press.

Granvold, D. K. (Ed.). (1994). Cognitive and behavioral treatments: Methods and applications. Pacific Grove, CA: Brooks/Cole.

Hayes, S. C. (1992). Verbal relations, time and suicide. In S. C. Hayes & L. J. Hayes (Eds.), Understanding verbal relations (pp. 109­118). Reno, NV: Context Press.

Kohlenberg, R. J., & Tsai, M. (1991). Functional analytic psychotherapy: Creating intense and curative therapeutic relationships. New York: Plenum Press.

Kohlenberg, R. J., & Tsai, M. (1994). Improving cognitive therapy for depression with functional analytic psychotherapy: Theory and case study. Behavior Analyst, 17, 305­319.

Lee, V. L. (1994). Organisms, things done, and the fragmentation of psychology. Behavior and Philosophy, 22, 7­48.

Lutzker, J. R., Frame, R. E., & Rice, J. M. (1982). Project 12-Ways: An ecobehavioral approach to the treatment and prevention of child abuse and neglect. Education and Treatment of Children, 5, 141­155.

Mattaini, M. A. (1995). Generalist practice: People and programs. In C. H. Meyer & M. A. Mattaini (Eds.), The foundations of social work practice: A graduate text (pp. 225­245). Washington, DC: NASW Press.

Meyer, C. H. (1993). Assessment in social work practice. New York: Columbia University Press.

Meyer, C. H. (1995). The ecosystems perspective: Implications for practice. In C. H. Meyer & M. A. Mattaini (Eds.), The foundations of social work practice: A graduate text (pp. 16­27). Washington, DC: NASW Press.

Reynolds, B. C. (1982). Between client and community: A study in responsibility in social case work. Washington, DC: National Association of Social Workers. (Original work published 1934)

Schwartz, A. (1983). Behavioral principles and approaches. In A. Rosenblatt & D. Waldfogel (Eds.), Handbook of clinical social work (pp. 202­228). San Francisco: Jossey-Bass.

Schwartz, A., & Goldiamond, I. (1975). Social casework: A behavioral approach. New York: Columbia University Press.

Specht, H. (1990). Social work and the popular psychotherapies. Social Service Review, 64, 345-357.

Specht, H., & Courtney, M. (1994). Unfaithful angels: How social work has abandoned its mission. New York: Free Press.

Thyer, B. A., Himle, J., & Santa, C. (1986). Applied behavior analysis in social and community action: A bibliography. Behavior Analysis and Social Action, 5, 14­16.