Jonathan Singer
April 1, 1996
MSSW Colloquium
Dr. Cynthia Franklin

Constructing A Model for Personal Practice

The other day, I overheard myself talking to my-self. My-self was talking about the kinds of values and personal characteristics my-self noticed in myself. "How lucky," I thought. In the final paper for my Masters in Social Work I was to discuss how my values and personal characteristics related to my theoretical orientation. Not wanting to miss this opportunity of capturing internal dialogue, I turned on a tape recorder and captured some very revealing self-talk. If you are interested, please, read on.

"...he really values the feeling of connection that he gets with some people. It's a level of communication that transcends the talk where both people are understanding each other without words, although words are sometimes a nice embellishment."

"How can you say that? He hates it when people act like they know what is going on with him. He is really hard to get to know at a deep level, I think because he resents it when people try and come down here."

"I think what you are getting at is that he values feeling in control of the situation. Sometimes people try and impose their ideas on him and he gets very defensive. He really believes he knows what is best for himself."

"So what is it about those people he likes to connect with?"

"He trusts them. He can be challenged by those people without getting defensive."

"Yeah, I guess they can debate with him. Besides, its not like he does not like to talk. He loves to talk and throw around ideas. Talking clarifies things for him, and he really values that."

"He also values following ideas through. For example, when he came into the School of Social Work after a year of community organizing for the environment, he saw there was no recycling program so he started one. He really believes in advocacy; his world is what he makes it..."

(I told you it was good. Let's look at some of those personal characteristics)

"He also prides himself on being very trustworthy. People can always count on him to support them if they need supporting. He always shows up to meetings, late sometimes, but he is always there."

"He is really supportive, isn't he. He is able to mediate really well; he can listen without taking sides, or if he does it doesn't show."

"Well, that's not always true. Sometimes when he hears somebody talking about something that really goes against his values, he will speak up. He is very confident."

"Ok, so he speaks up. I guess I was referring to the fact that most of the time he is aware of when he is responding to the situation at hand or using that situation to work out some unresolved issues from another situation."

"Oh, counter-transference."

"Yeah, but that is such a psychoanalytic term. He doesn't believe in the unconscious. He is too behaviorally oriented."

"But he's also very analytical. He loves to figure out the situation. For example, at the Insoo Kim Berg workshop(3/28/96)some members of the audience were debating with Insoo Kim Berg the role of the therapist. As the debate continued, the tension in the workshop rose. Jonathan found it more interesting to figure out the dynamics of tension than to listen to the content of the the debate. When he figured out what was going on, he felt very satisfied."

"Great! I don't want to hear how satisfied he was at that moment. Sometimes he gets too into figuring a situation out. He is so analytical about things. He wants to synthesize everything, so he jumps from idea to idea looking for connections..."

"Hey! You are making him out to sound like he is some academic type."

"Well, he is."

"Ok, point taken. But he is also very sensitive to certain issues. He works hard to be culturally aware and non-sexist. His pro-feminist stance encourages him to not silence anybody, and he is very careful about what he says and does."

"Oh, my hero!"

"Why are you so sarcastic?"

"Because he is."

"Can't you think of anything more original to say than that? At least he is somewhat creative..."

Werner (1986) identifies 12 main assumptions of change and human behavior in cognitive theory. I, however, disagree with most of them. I have compiled 6 assumptions, combining Werner's with others from the literauture, which reflect my own assumptions. In doing so I have constructed my own version of the reality of cognitive assumptions. I believe this is in keeping with the tenets of cognitive constructivism, and therefore an appropriate introduction to this section.

Assumptions

1. There is no unconscious in the traditional Freudian sense. According to Rychlak (1981), "Freud considered the unconscious to be an actual region of mind, one that was much larger than consciousness and that lived a mental life of its own" (p. 45). Cognitive theory assumes that people do not act out of unconscious forces, although they "can be unaware of the origins of current attitudes, of the impression they making, or of the effect of their behavior on others" (Werner, 1986, p. 92). Consequently, cognitive treatment looks at thoughts, emotions, expressed motives and behaviors, not on unconscious content.
2. People are goal oriented. Alfred Adler believed we organize our lifestyles and make choices in order to reach certain goals (Rychlak, 1981).
3. People construct their versions of reality through interactions with others in their environment (Neimeyer and Neimeyer, 1995).
4. It is important to focus on the strengths and competencies of the client. People inherently strive for competence and a sense of completion, referred to by Maslow (1968) as growing toward self-actualization.
5. Insight and awareness are not needed in order to produce change, although the client needs to take responsibility for her/his behavior (Franklin, 1995; Werner, 1986).
6. Cognition, behavior, and emotions are all influenced by each other. Nurius and Berlin (1995) note that this interrelationship is a point of debate within the cognitive community, with more traditional cognitivists (such as Werner) arguing that thinking determines emotions and behaviors. This issue will be discussed in more detail later on in the paper.

According to Hepworth and Larsen (1993), there are five cardinal values of social work. First, people should have "access to the resources, services, and opportunities which they require" (Code of Ethics VI, P.2 cited in Hepworth and Larsen, 1993, p. 54). Cognitive theory addresses the development and utilization of resources by looking at both the personal cognition and the environmental situation. Nurius and Berlin (1995) note that people experience problems when they view themselves, others and the world in inflexible, restrictive and outdated ways. As a result, they are unable to recognize and use resources to develop solutions to difficult situations. De Shazer's solution-focused approach is useful in helping the client to identify resources they might not have recognized, because they were exceptions rather than the rule (Becvar and Becvar, 1994). At times, "environmental deficits such as deprivation, danger, and abandonment or personal inadequacies beyond the individual's control" become the therapeutic focus (Nurius and Berlin, 1995, p. 520). Drawing from Maslow's hierarchy of needs, the cognitive perspective would recognize the client has basic needs, such as food, shelter, and safety, without which other levels of functioning are not possible. Cognitive theory does not advocate for external change specifically, but would work with the client to identify areas of influence wherein the client could make some differences.

The second social work value states that practitioners should "affirm the dignity and self-worth of those whom they serve" (Hepworth and Larsen, 1993, p. 55). Cognitive-constructivist theory expresses this value through the non-expert stance taken by the therapist. Insoo Kim Berg suggests that this value can be upheld by encouraging the client to be the expert on their own lives. She does this by "staying one step behind the client" (Seminar, 3/28/96). This value is important in building a trusting, therapeutic alliance.

The third social work value is "affirming uniqueness and individuality." Constructivist theory holds that as a basic value. Because everyone creates their own version of reality, every one has a unique perspective on life. It is impossible not to hold that value and at the same time discover what the client's constructed reality is. In this sense, constructivist theory is more in line with this value than psychodynamic or strict behavioral theories, which reduce human personality to either a few basic drives or products of conditioning.

The fourth social work value states that social workers should help the client in their problem-solving capacities and "affirm their right and capacity to exercise free choice (self-determination) responsibly" (Hepworth and Larsen, 1993, p. 71). While much of cognitive theory works well to uphold the value problem-solving, some of the new constructivist theories disbelieve the value of identifying problems in the first place (Becvar and Becvar, 1993). Solution-oriented therapies believe that identifying problems reinforces a deficit model. In most situations clients have already found solutions. It is just a matter of identifying them and supporting the client to repeat them. So, while problem-solving is not ignored, it is eschewed in favor of alternative models.

The fifth social work value is self-determination (Hepworth and Larsen, 1993, p. 71). Cognitive therapists support the value of self-determination through exploration of negative thought patterns that might keep the client (or the therapist for that matter) from acting responsibly. Dolgoff and Skolnik (1992) criticize self-determination as valuing the individual over the group. In the case of groups, self-determination can sometimes become confusing because "the self-determination of one or more group members might run counter to self-determined decisions of the groups or other members" (Dolgoff and Skolnik, 1992, p. 103). Using a cognitive approach I might use the dilemma as an opportunity for the group to determine whether its goals have changed. Or, I could work with an individual in the group and let the group work as a support team.

The final value is confidentiality. It appears that this value has less to do with the specific theory than the practitioner. Like self-determination, Dolgoff and Skolnik (1992) criticize the value of confidentiality as biased towards individual vs. group application. The extent to which confidentiality can be ensured is reduced the more people are involved in the confidential situation. The rules for confidentiality need to be modified to fit the group (Dolgoff and Skolnik, 1992). Cognitive therapists often run psycho educational groups, as well as therapeutic groups. From a cognitive perspective, I might explain confidentiality in terms of how the way we think about confidentiality will influence how we act and feel about it. If group members have an easy time maintaining confidentiality, then it would follow that their thoughts about confidentiality would positively correlate to their personal (and possibly group) goals.

Ethical Dilemma

Early in my first-year internship (Sept. 13, 1994) I was confronted with a very powerful ethnical situation. In a drug education group with Mexican-American youth from the SIHRY project, Spanish and English were spoken interchangeably. As the group slipped in an out of the two languages, I realized that some of the youth were more comfortable communicating personal information in Spanish. As it were, both myself and my co-leader spoke both Spanish and English. I was struck by how limiting it would have been had we been able to speak only English. Had I not been working with Spanish speaking youth I might not have realized the importance of communicating with a client in their primary language. This realization was powerful not because we were acting unethically, but because of how common and accepted it is to discriminate based on language. To deny the youth either language would have been to deny them the right to communicate. Surely this issue must be covered in the Social Work code of ethics, I thought to myself. At the present, discrimination based on language is not mentioned in the code of ethics, but it might apply under the auspice of "race". Under the code VI. P. 1. "The social worker should act to prevent and eliminate discrimination..." This omission suggests that the code of ethics does not value linguistic diversity. It will be interesting to see if the code changes as the linguistic demographics of social workers changes.

Many cases of denying opportunity can be traced back to denying language. I worked as a community organizer on such a case up in San Francisco in the summer of 1994. The San Francisco Bay was found to have excess levels of some toxins in its waters. In response, the city council posted warnings in English all over the bay describing the toxins and which fish were deemed un-safe to catch and eat. The problem was that the majority of the fishers were non-English reading, if not non-English speaking. Though well intentioned, the city council was promoting a form of discrimination that could prove deadly for the fishers and their families. The community organizing of the fishers was successful in putting pressure on the city council to stop this form of linguistic discrimination. Eventually, warnings were placed in 6 languages: English, Spanish, Chinese, Japanese, Vietnamese, and Laotian. The fishers had a new understanding that their language (and therefore their reality) was important to society at large. It would be unethical to deny anyone, from the fishermen, to the SIHRY youth, the opportunity to express themselves.

Strengths and Weaknesses of the Model

One of the strengths of constructivism that I most appreciate is the emphasis on starting where the client is. Since the client is the expert on their reality, it makes a great deal of sense to start with their understanding of reality. The therapist is an expert on the therapeutic relationship, not the expert on that client's life. Supporting the client to take responsibility for her/his life promotes client self-determination and self-worth.

Another strength of cognitive therapy is the emphasis on measurable goals. When goals are operationalized, it is easier for the client to see that their goals are being met. The therapist can identify areas where the therapy worked, and areas where it did not. The insurance companies can be assured that they are justified for paying for therapy because they have charts and graphs that testify to its effectiveness.

Cognitive therapies eschew causal thinking in favor of more systemic explanations for clients' situations. Causal thinking encourages the deficit model because it posits situations in cause and effect relationships (Granvold, 1995). Systemic approaches look at all the systems involved to identify the role each plays in any given situation. For example, a family comes in to therapy because their 13 year old ADHD son is making life unbearable for the family. Causal thinking is represented in the belief that the son is causing the family to be unhappy, as well as the belief that their son is ADHD, as opposed to diagnosed with ADHD. The technique of circular questioning can illicit the role that other systems play in the situation; which parts are played by each individual in the family and how the family dynamics allow this situation to occur. As I ask the family about these dynamics in a systemic way, I am providing them with an opportunity to see their situation in a new way. I do not suggest a new perspective on their reality, but instead I co-construct a perspective that is close enough to their own that it will seem familiar and non- threatening, but different nonetheless.

My Personal Attraction to the Model

Cognitive therapies have benefited from extensive research (Bergin and Garfield, 1994). Many of the techniques have been tested for validity and reliability with specific populations. I would feel more secure using some of those techniques because of their purported effectiveness. I would also be more inclined to use research design to test whether or not I was getting the same results as found in the literature; there is also the incentive of contributing to a growing body of literature.

According to Granvold (1995), there is an "active approach" and an "educational model" that is common feature in treatment across many cognitive approaches. The active approach is based on the notion of homework. I am personally attracted to this because I have done a lot of homework in my life, and have learned a great deal from it, especially when I was motivated to do it. The educational model employs "bibliotherapy, written assignments, the use of audiotapes and videotapes, and attendance at lectures and seminars" (Granvold, 1995, p. 526). Again, I already do all of those things, so it would be easy for me to use them purposefully as interventions with my clients.

The practical nature of the techniques makes them easily generalizable outside of the therapist's office; treatment can be coordinated with other systems working with the client, such as case manager, school personnel, guardians, etc. This type of coordination would not be possible with a psychodynamically oriented treatment that focused on in-depth exploration over a long period of time. I am a strong proponent of working with as many systems as possible to reinforce the treatments, especially in the case of adolescents.

Plans for Continuing Education with the Model

As I mentioned earlier, it is very important to be flexible. This applies to my knowledge of different theories as well. The psychosocial model provides a nice complement with the constructivist perspective. According to Turner (1986), the psychosocial model stresses healthy development (not just cognitive), and takes an optimistic view of the human condition. The "psychosocial" is a standard assessment tool in social work, and can provide important information for determining a global understanding of the client.

The ecological-systems model provides a good framework within which both cognitive and psychosocial theory can work. In addition, The Life Model has been developed as a practical application of the ecological perspective (Germain and Gitterman, 1986). I really appreciate the emphasis that is placed on the person:environment interdependence in this model. Another model that has arisen from this model is mutual-aid, which has been very useful in my work with groups. Like the life model, mutual-aid emphasizes the social benefits of a group where people can validate each others experience and "share data" that only someone "in the same boat" would have (Gitterman and Shulman, 1994). This complements the cognitive theories because it maintains that people in similar situations (women with breast cancer, teenage alcoholics etc) share similar (though not exact) views of reality and can therefore support each other.

Finally, I would look to feminist and Marxist theories for guidance in encouraging my clients to change the system. I have heard it said that therapists are the keepers of the status quo. Since there are a lot of things about society that I work to change, I will support my clients who wish to become agents of change to do so. For example, I would support my clients to get involved in community groups that are actively working to improve their environment. Since we cannot change anyone but ourselves, this would provide the client with an opportunity to improve their extra-psyche lives.

Personal Philosophy

A competent practitioner is able to work with a client in either a directive or non-directive way, and knows when to use the different styles to get the information that is necessary to move forward with the work. I believe that I am becoming more competent at doing the assessments required by Austin Child Guidance Center, although I am still focusing on the product more than I would like. I sometimes realize that the client has already told me something I need to know for my paper work, but did not pick up on it until later on in the conversation. The literature emphasizes that the therapeutic conversation is very purposeful and intentional. The competent practitioner will know how to keep a conversation from becoming trite and non-therapeutic. The competent practitioner will support their clients as well as challenge them in order to move beyond the ordinary into the therapeutic relationship.

The literature emphasizes that the most important component in successful therapy, across all theoretical perspectives, is the ability to develop a trusting, therapeutic relationship with the client (Greene, Jensen, and Jones, 1996). "This is not to say that techniques are irrelevant but that their power for change is limited when compared with personal influence" (Lambert and Bergin, 1994, p. 181). Thus the competent practitioner is able to join with the client in such a way that the client is motivated to work on the issues. A less competent practitioner will rely on technique to foster change, without recognizing the importance of the therapeutic relationship. The Insoo Kim Berg seminar (3/28/96) helped me recognize that even though she is very directive and uses many techniques (the miracle question, positive reframes, "wow!", etc.) she is successful because of her strong empathic relationship with her clients. From my own conversation with her, I felt like she was truly interested in what I had to say, not for any specific reason, but just because I was expressing myself. It was easier to be honest with her than to be dishonest. The competent practitioner knows she/he is effective when the client wants to be honest and do challenging work.

The less competent practitioner will "hit or miss" with their clients; they will not know what it is they are doing that is effecting change. The competent practitioner will know why she is effective (or not). I have great respect for therapists who can use clinical research as an integral part of their therapy to improve the quality of their performance with clients.

A competent practitioner has strong reflective listening skills. They can hear not only the words, but also the emotions, tone, context, etc. and be able to reflect the meaning behind the client's statements. The less competent practitioner confuses the art of reflection with interpretation, and will throw out interpretations based more on their own understanding of the client's situation than reflections based on the clients reality.

The competent practitioner is flexible and confident. She/he is culturally competent and is able to address issues of oppression when brought up by the client. The less competent practitioner is not interested in his work as a helper of people, but rather as an expert of people. He lets his ego get in the way of working effectively for clients. He does not keep up with the literature. He does not have strong boundaries and cannot recognize when he is bringing his own issues into the therapeutic relationship.

The competent practitioner is purposeful in what they do. I spend many hours every week reflecting on my clients' situations. I read the literature and consult with my supervisor and peers about different issues that have arisen. I am taking advantage of this opportunity, the luxury of time, to discover which avenues are available to increase my competence so that when I am a busy professional I can spend my time tapping the resources I have worked to find.

Cultural Competency in Practice

When I started my first-year internship in East Austin with Mexican-Americans, I was a less obvious foreigner, but a foreigner nonetheless. The fact that I spoke Spanish gave me a tool, not a passport, to learn about the Mexican-Americans with whom I worked. Over the year I learned that, as indicated in much of the literature, my beliefs in religion and family were different from the beliefs of many of my clients. I learned that I shared with my clients the ability to speak both Spanish and English, belief in the importance of education and hard work, and love of food. As with my experiences living abroad, I found that what I learned most about working in the Mexican-American community was myself. I was reminded that I have become competent at bridging the gap between my own culture the cultures with which I have been involved. My cultural competency was further increased when I took "Mexican-American Family Systems." I learned about specifics of personalismo, curanderos, and linguistic differences between Mexican Spanish and Tex-Mex Spanish (e.g. In Mexico eggs are called huevos, in Texas they are called blanquillos). Specifically for clinical work, we learned how to include cultural factors in assessment (using a culturagram,) and how to do a self-assessment to determine cultural compatibility with our clients (Remarries, 1991).

The cognitive constructivist perspective has application to clinical work with ethnically diverse clients (Greens, Jensen, and Jones, 1996). As discussed earlier, the constructivist perspective holds that people construct their own version of an objective reality through interactions with others. Ethnicity plays a major part in determining what that version of reality looks like. In the United States, there has been a long history of ethnic discrimination on both a micro and macro scale; from an individual using an ethnic slur, to federal policies that discriminate on the basis of ethnicity (e.g. Native Americans). "Consequently, a person from an ethnic group in the minority may construct a sense of self that is influenced by this devaluation, lack of power and discrimination in the societal context" (Greens, Jensen, and Jones, p. 173). Furthermore, the very same mechanisms involved in an ethnic minority constructing a devalued sense of self can be used by someone who does not share the devalued qualities of that ethnicity to construct a sense of self that is affirmed by society for not having those same qualities. For example, traditional Mexican-Americans believe it is disrespectful to look an authority figure in the eye. Since eye-contact is considered a sign of confidence and respect by the hegemony, traditional Mexican-Americans receive negative feedback from society for their lack of eye-contact. At the same time, as a middle-class white male, I have always been rewarded for my ability to look at someone in the eye. Thus the mechanism of reinforcing the importance of eye-contact can be used to construct two different senses of self.

Cognitive constructivism enables the therapist to co-construct reality with the client. As noted by Greens, et. al (1995), hierarchy and control is de-emphasized, and the client is perceived as the expert on her/his own situation (p. 173-4). Insoo Kim Berg commented that she tries to be "one step behind my clients" (Advanced Workshop, 3/28/96). Both of these perspectives enables the therapeutic relationship to be used as a vehicle for reconstructing the clients life in a more empowering way. Reframing the clients' ethnic identity is crucial to this process.

Critical Incidents

This experience reinforced my bias towards a cognitive perspective. Looking at my thought process revealed some beliefs I held about myself that impact every part of my life. I recognized that I had constructed a version of reality that was keeping me from moving on in my life. I doubted how much I could work through the resentment, and yet when I was supported to do the work I recognized strength and resources in myself that I had not known about. This impressed upon me the importance of building a strong therapeutic alliance. My Life Training experience convinced me that long lasting change could result from short and intensive work that incorporates cognitions, affect and behaviors.

Running the summer camp helped me recognize my strengths as an administrator. I received positive feedback from my supervisors on keeping up with the paper work, working with in the budget, and coordinating the curriculum I had worked out. I was also able to use my mediation skills to work through staff conflicts, which turned out to be more challenging than the youth. I also learned about the differences between the case management approach to working with people and the therapist approach. Case managers were more product oriented and the therapist was more process oriented, IE. the activity didn't matter as much as what was learned from the act of doing it.. For example, if a conflict occurred during an activity we would stop and process as a group what was going on. After a certain point, the case managers would start throwing out solutions to the situation, or take control and start imposing more structure on the situation. The therapist, on the other hand would sometimes encourage the processing beyond the point where the youth were gaining from it. I learned that it is important to know when to process and when to act. With adolescents it is often necessary to impose structure before the processing can take place.

I also learned that it is impossible to achieving conflicting goals. As a result of the processing, we rarely completed an activity. In the final report I explained that the positive outcomes were more apparent in the youths' increased ability to work through situations than in completing arts and crafts assignments, or learning vocabulary words. Without process studies, though, I can understand how it is difficult to keep funding for therapeutic camps.

One example of using video-tape feedback is in my final internship at the Austin Child Guidance Center. I am currently doing family therapy with a co-therapist. We noticed that although we agreed on goals for the session before we started, we found ourselves going in different directions in the session. Our supervisor gave us feedback that, while this was not uncommon, it would be a good idea to work on it. We video-taped our next session. From the video-tape we noticed that we were changing our goals to meet the family's goals. At first it looked like we were simply starting where the client was, an honorable social work value. Upon closer inspection, we realized that each parent had a different goal for the family. I was picking up more on what the mother felt should be the goal of the session, and my co-therapist was picking up on what the father's goals for the session were. Through video-tape analysis we identified how the family was bringing us in to their own conflict, and so we worked on ways that we could work through it ourselves. We modeled this to the parents as an intervention. Proponents of the solution-focused model would not be surprised to learn that it was in the details that we recognized patterns that were taken for granted which turned out to be the key to our success.

Summary

I believe I am prepared for supervised clinical practice. My skills as a practitioner are adequate to help people within a certain context; I have experience working in a state hospital with persons with schizophrenia, case management with high-risk families, and been successful doing clinical work with families and children. At a certain point I still am in need of direction and supervision. Eg, I have very little experience with counseling drug and alcohol addictions. I have worked with families that have the issues, but I have had no formal training, and I have not done any serious reading on the subject, although I feel comfortable reading the social work literature. The main area of improvement I see is in my role as a practitioner-researcher. It is my hope that I will feel more confident upon completing the Single-Subject Design. Ultimately, I feel it is important to know about theory, have an idea of my own biases, but to never let a certain perspective or technology limit what I can do for a client.