Social Work A Lifetime Of Practice - Do you enjoy it?

 Summary

This is a blog post by David G. Markham, a Licensed Clinical Social Worker, reflecting on his 44-year career. He discusses the challenges and rewards of his profession, particularly the evolving role of technology in communication with clients. Markham highlights the importance of maintaining client confidentiality and navigating the complexities of private practice. He emphasizes the dual nature of his work, combining therapy with business management, and concludes by sharing his continued enjoyment of his career. The post also announces future articles focusing on his lifetime of experience in social work.

To read the article click here.

Psycho-technological proficiency

Many of us did not become therapists expecting to be required to develop technological abilities, however, we believe that psycho-technological proficiency is now a basic required skill. Just as we attempt to stay updated with the latest reading on the modalities we work with, we now need to accept that staying up to date with psycho-technological development is also necessary. We have passed the point where being a “technophobe” is an acceptable reason for not developing these crucial skills.

Weinberg, Haim; Rolnick, Arnon; Leighton, Adam. Advances in Online Therapy: Emergence of a New Paradigm (p. 54). Taylor and Francis. Kindle Edition. 

One of the things that irritates me beyond the significance of the event is to go to a workshop and have the presenter fool around with equipment, not being able to make it work properly while the audience sits there fiddling awaiting the opening remarks.

I am thinking to myself, “Really?!” You didn’t run an equipment check and sound check before you took the stage?”

The same situation occurs when a therapist is conducting an online session and doesn’t know how to operate the equipment being used for the transmission.

“It’s outside my job description” doesn’t cut it in this day and age of telehealth when the provider is responsible for providing a safe, secure, reliable means for communication in virtual reality.

Being an old guy I know many physicians who decided to retire rather than learn and adapt to electronic health records and other forms of digital communication. Some agencies provided them with “scribes” and technical assistants to operate the digital equipment while they provided the clinical services.

To operate a clinical psychotherapy practice one must be relatively proficient in using the various digital management tools both hardware and software. I have tried to teach myself about the technology and have taken other workshops and classes, but I still find the use of the technology a challenge. It seems like just when I learn how to accomplish a task using the software, an update comes out and there are aspects of operating the software I have to relearn. As choices in software multiply to address the same activities and tasks it becomes even more confusing how to set up these administrative processes and what tools to use.

How psycho-technologically competent would you rate yourself: low, medium, high or use a ten point scale with 0 dumb as a rock and 10 a rocket scientist. I would give myself about a 5. I spent two hours yesterday trying to figure out how to attach a google doc file to an email. I learned today that it can’t be done. The google doc has to be converted to some other format first.(This still doesn’t seem right to me. Does anyone know better?)

Flexibility in rules about format with online therapy.

However, we also noticed that some of the writers emphasized, directly or indirectly, another factor: the question of flexibility, which is probably one of the main factors that impacts the outcome of online therapy. Once we stop being obsessed with the question how similar online therapy is to in-person therapy (still a common error which we warned against in our previous book) and acknowledge that it is NOT the same as in-person therapy, that the setting is not controlled and structured by the therapist, that failures of communication are inevitable, that it's difficult to establish conditions of safety and a holding environment – we have to flex the usual rigid boundaries and rules of conservative psychotherapy. Perhaps this is the main threat for more traditional therapists, since immediately the question that might pop up is: “how flexible should we become?”

Weinberg, Haim; Rolnick, Arnon; Leighton, Adam. Advances in Online Therapy: Emergence of a New Paradigm (p. 39). Taylor and Francis. Kindle Edition. 

Online therapy is not the same as face to face therapy. The questions of how it is the same and how it is different become relevant. The editors of Advances In Online Therapy note in their introduction that practitioners of online therapy have to be flexible. The old ideas about “holding environments” and “boundaries” no longer seem transferable to this new format entirely. So what rules should therapists of online therapy follow and what can be flexed or disregarded?

What rules can be flexed in implementing online therapy as compared to face to face therapy?

I was wrong about video therapy and telehealth.

During the pandemic there was a mass transition of therapists to online therapy, according to one survey an estimate of 98% of therapists used online therapy during the pandemic (Sampaio et al., 2021). This vast amount of health care professionals working online have created a huge body of experience, knowledge, research, and academic articles. The number of research studies about online therapy jumped exponentially in the past two years. This book attempts to share a carefully chosen part of this accumulated knowledge.

Weinberg, Haim; Rolnick, Arnon; Leighton, Adam. Advances in Online Therapy: Emergence of a New Paradigm (pp. 35-36). Taylor and Francis. Kindle Edition. 

I have argued in my posts that online therapy is not the same as face to face implying that it is not as effective. Turns out that I have been wrong. Online line therapy is different in some ways from face to face therapy but it is becoming apparent that in many cases is as effective and in some cases more effective. The devil is in the details.

Many thanks to Martha Gilmore for mentioning in one of her posts that her husband, Haim Weinberg and two of his colleagues have edited a book entitled, “Advances In Online Therapy: Emergence Of A New Paradigm.” I have bought the book both in print and kindle editions and am learning a lot. Old dogs can learn new tricks. At least this old dog can and it keeps me young.

I wondered about the finding in one survey that at least 98% of therapists used online therapy during the pandemic. The reference cited does not appear in the footnotes so I couldn’t find the source.

During the pandemic I kept my office open for face to face as well as offering video therapy and teletherapy. My experience was that 90% of my clients wanted face to face while about 4% wanted video therapy and 6% wanted teletherapy.

The sense I have gotten from posts on this list is that many therapists closed their physical offices and have moved their practices to videotherapy. Does anyone have any idea what percentage of psychotherapists have closed their physical offices and moved exclusively to video therapy and telehealth?

Perhaps 98% of psychotherapists have used some form of videotherapy and/or teletherapy, but what  kind of use is this: partial, exclusive, hybrid?

Necessity is the mother of invention and having had to close my physical office because of orthopedic problems with my legs making it difficult to stand and walk, I am now planning on opening a video therapy practice. I am learning that I was wrong about thinking that videotherapy is not as effective as face to face.

I am interested in any comments people have who have transitioned their practices from face to face to video and telehealth about the benefits and the deficits of these practice formats?

Health care and human services are NOT profit making enterprises.

I don't operate my practice for profit, and as a Social Worker I see people in need of service regardless of their ability to pay. It's an ethical commitment when I joined the profession and is required in our code of ethics.

I realized when I chose the profession I would never get rich and could make a lot more money in many other professions. I chose Social Work though because of my values which have served me well for 54 years even though I often worked 2 and 3 jobs to derive enough income to support my family of nine children.

How mental health professionals ever chose to sell their souls to the insurance companies still mystifies me. I realize it is a slippery slope and people get sucked in slowly below their conscious awareness. Nonetheless when it becomes increasingly clear that the devil is in charge of the system, what makes people cooperate?

Framing - It's importance in psychotherapy and life.

Taken from Richard Nisbett’s book, Mindware, highlighting the importance of framing:

Consider the Trappist monks in two (apocryphal) stories. 

Monk 1 asked his abbot whether it would be all right to smoke while he prayed. Scandalized, the abbot said, “Of course not; that borders on sacrilege.”

Monk 2 asked his abbot whether it would be all right to pray while he smoked. “Of course,” said the abbot, “God wants to hear from us at any time.

Editor's note:

I learned about framing from Dr. Susan McDaniel back in the 1980s when she was training a group of us at Park Ridge Mental Health Center in Brockport, NY in strategic family therapy. The frame can make all the difference in achieving positive outcomes in psychotherapy.

Most of us are familiar with the idea of framing even though we might not call it that. Most of us are familiar with the question "is the glass half full or half empty?"

Framing also is called "point of view", "thought system," "perspective," "bias," "lens," "filter," and a number of other things. Framing is what contributes to our interpretation of the facts not the fact itself. Most of cognitive processing consists of interpretation which is the creation of our own reality and therefore an illusion. One of the fundamental ideas about Cognitive Behavioral Therapy, CBT, is to help the person change their frame so they can interpret their experiences in most positive and less depressing ways.

The basic existential questions.

The existential psychotherapy approach posits that the inner conflict bedeviling us issues not only from our struggle with suppressed instinctual strivings or internalized significant adults or shards of forgotten traumatic memories, but also from our confrontation with the “givens” of existence.

Yalom, Irvin. The Gift of Therapy: An Open Letter to a New Generation of Therapists and Their Patients . HarperCollins. Kindle Edition. 

Dr. Paul Pearsall wrote that the three big existential questions which most human beings consider are: why was I born, what is the purpose of my life, and what happens when I die? These questions rarely come up explicitly in psychotherapy but they are the background story lying in the unconscious whatever the client’s complaint. Sometimes they do come up in the course of therapy and the competent therapist must be able to manage them in a non anxious manner. Knowing the answers to these questions is the basis for understanding what makes a person tick. In order for the therapist to manage these concerns in a non anxious way, the therapist must have some understanding of his/her own answers. As the Temple of Apollo at Delphi famously had engraved over the entrance, “Know thyself.”