Clinical social work: Integrating a critical anti-oppressive lens
Critical clinical social work: A narrative review
Eliza Zanuso
School of Health, University of New England, Armidale, Australia.
Abstract
Background: There is an assumption that it is impossible for clinical social work to integrate critical perspectives in practice. While the biomedical approach is considered neutral and objective, it can be argued that it is influenced by euro-centric neoliberal thinking which leads to decontextualising and pathologising mental distress.
Aim: This review aims to explore specific models, skills and practices to operationalise critical social work theory in clinical practice.
Methods: A narrative review was selected to provide an overview of the findings and draw out themes. The searches took place in late August 2022 of Psychinfo, ProQuest Social Services, PsycArticles, InfoRMIT, CINAHL, Google Scholar and hand searching.
Results: Fourteen articles were assessed against the inclusion and exclusion criteria and included in this review.
Discussion: Three key themes emerged including; the importance of building meaningful relationships, critical examination and repurposing of power and the use of critical reflective practice.
Conclusion: A range of multi-dimensional practice frameworks highlights a nuanced series of models, skills, and practices that expand the notion of ‘person in environment’ and create more possibilities for critically informed clinical social work.
Keywords
critical clinical social work, critical social work, clinical practice, anti-oppressive practice,
Implications statement
· This review highlights the potential for greater expansion of critical analysis in the practice of clinical social work.
· The results suggest that meaningfully integrating critical clinical social work practice potentially involves changes in direct practice, social work education, and supervision.
· This research challenges the current status quo of neoliberally dominated clinical practice through offering practice responses that actively engage a critical perspective.
Social work is embedded in many clinical spaces, often underpinned by neo-liberal, bio-medical discourses that medicalise and pathologise distress (Larson, 2008). While there has always been a clear pathway in the practical application of critical social work theory in academic, policy and community development fields of practice, these perspectives appear to be less readily applied in social work in clinical settings underpinned by neo liberal and bio medical discourses (Brown, 2020). There is an assumption that critical practices are not synonymous with clinical practice. Furthermore Brown (2021) argues that social work clinical service delivery in the current neoliberal climate is based on principles of managerialism which values cost-effectiveness over quality of care. This can result in the social and ecological determinants of health, which are a key concern of social workers and are often caused by systemic and structural injustice, to become secondary (Brown, 2021; Larson, 2008).
There are many reasons for social workers to consider social justice and equity in terms of clinical practice (Brown, 2021). In the Australian context, people diagnosed with a mental illness are more likely to have experienced lower socioeconomic status, be women and First Nations Peoples (Corscadden et al., 2019). While Australia has universal healthcare (Medicare), many medical services, including mental health clinicians, charge out-of-pocket costs that are comparatively high in relation to government rebates (Callander, 2017: Farag et al., 2013). In a study by Callander et al. (2017), over 40% of respondents who suffered from mental health conditions cited that due to costs being prohibitively high, they were forced to skip mental health care altogether (Callander et al., 2017).
The biomedical model as a dominant authority
It is important to contextualise this topic within the landscape of present-day clinical settings, which continue to be dominated by managerialist, neoliberal, and biomedical culture (Weinberg, 2020). The basic assumption of biomedical theory that dominates clinical practice settings today is based on an ideology of universal and unbiased neutrality (Gordon, 1988).
As early as the late seventies, Engel (1977) argued that the dominance of the biomedical model is ensured in large part by political, social, and economic interests, and leaves no space for alternate understandings of distress. These factors are important in terms of the ways they could create barriers for social workers seeking to practice critically in clinical settings (Brown, 2021; Larson, 2008).
Despite decades of criticism, the DSM itself remains legitimised and bolstered by corporate neo-liberal interests (Lafrance & McKenzie-Mohr, 2013). In a study by Cosgrove et al. (2014) research highlights that even increased transparency and mandatory disclosure policies would not be enough to prevent bias in the revision process and clinical decision-making in terms of which interventions for mental disorders appear in the DSM. The data highlights financial linkages between DSM review panel members and the pharmaceutical companies who have a vested interest in their products finding new clinical indications (Cosgrove et al., 2014).
In addition, the neoliberal economic project widely influences service provision in Australia and globally, emphasising the “biomedicalisation, pathologisation, individualisation, responsibilisation, and privatisation of services” (Brown, 2021, p. 647; Weinberg, 2020). It can be argued that in clinical settings, the biomedical model is the dominant ideological force (Brown, 2021). In addition, social workers concerned with social justice are pressured to adopt standardised practices, knowledge and principles of medicine, psychiatry and psychology (Brown, 2021).
Biomedicine of mental distress; failure and fallacy
The authority held by psychiatry and psychology in clinical settings has insulated these professions from more holistic views and excluded the voice of other fields of knowledge such as social work (Brown, 2021; Engel, 1977; Webber, 2013). According to the biomedical model, mental distress can be scientifically understood and identified objectively in terms of biological imbalances and deficiencies or excesses caused by diseases of the brain (Thachuk, 2011). However, due to the inconsistent, amorphous nature of the concept of mental disorder, definitions remain elusive (Frances & Widiger, 2012). The system of diagnostic classification is the result of accident and necessity as opposed to the result of scientific rigour or rationalised criteria (Frances & Widiger, 2012). While it can be argued that biomedical constructions of mental health may offer some level of medical legitimacy, people who suffer from mental illness still experience profound marginalisation and stigmatisation both within and outside the medical system (Lafrance & McKenzie-Mohr, 2013). In addition, Frances and Widigier (2012) argue that the DSM is simply a guide, which fails to meet its own standards as an evidence-based, objective scientific authority.
Furthermore, Morrow and Malcoe (2017) highlight widespread discrepancies in treatment efficacy of psychiatric medication. In a recently published comprehensive ‘umbrella’ systematic review, Moncrieff et al. (2022) identified that the majority of research did not identify conclusive evidence that lower serotonin is associated with depression. Although this study did not specifically review the efficacy of antidepressants, two senior authors of this study highlight that there is still a pervasive narrative propagated by psychiatrists and doctors that chemical imbalances are the cause of depression, which is not supported by scientific evidence (Love, 2022; Moncrieff et al., 2022).
In addition, the review brings into perspective questions that prescribing doctors cannot be certain of the long-term impact of antidepressants on the brain, and perhaps should be more considered in prescribing. While there are other hypotheses for why antidepressants may work for some, not others, this recent study highlights the lack of scientific rigour and professional consensus of treatment protocols for mental illness. Brown (2020) argues that the pervasive dominance of the biomedical approach and DSM delegitimise alternative forms of knowledge that may be of importance to supporting people who experience mental illness. Finally, whilst robust research supports the therapeutic relationship as key to creating positive outcomes, the structural landscape of clinical service provision actively reduces the time clinicians have for quality relationship building, with increased paperwork, and time-limited evidence-based interventions (Brown, 2020; Weinberg, 2020).
The impact of the biomedical model on social work
In terms of the Australian context, a self-completed survey conducted in mid-1997 of Victorian supervisors and social workers in mental health settings highlights the length of time that there has been a depreciation in the specific skills and perspectives of social work (Ziguras et al., 2008). As well as a shift towards the “mainstreaming of mental health services” (Ziguras et al., 2008, p. 59). The study included a response rate of around 46% from social workers, with 34% members of AMHSW, close in numbers to the population rate for AMHSW at the time (Ziguras et al., 2008, p. 54). This study indicates a sample size reasonably represented by the number of social workers employed in Victorian mental health settings at the time.
The age of the Victorian study highlights a potentially lengthy diminishment of the differentiation of the role and holistic perspective of social work, due to “the dominance of the biomedical model”, which focuses overly on prescribing medication and assessment of a person's mental state (Ziguras et al., 2008, pp. 57-58). A more recent study in Victoria, which conducted qualitative face-to-face interviews with MA Social Work students doing their placements in mental health settings, highlighted ambiguity and confusion about their identity as social workers (Smith et al., 2022). Perhaps the professionalisation of social work has led to uncertainty around the critical aspects of the profession and adherence to the biomedical model (Finn, 2016).
In a recent Canadian study by Brown et al. (2022), 71% of surveyed social workers who work in mental health services indicated they were unable to practice in ways that centre justice, critical or anti-oppressive perspectives. The study in Nova Scotia, Canada used multiple methods to produce data saturation and ensure consistency of the study (Brown et al., 2022). Data was collected from clinicians, clients and supervisors through an online socio-demographic questionnaire, and followed up with semi-structured narrative interviews and three focus groups (Brown et al., 2022). The thematic analysis by Brown et al. (2022) indicates that a top-down, neoliberal biomedical system created less self-determination and autonomy for social workers. In terms of the scope of practice and policy, an increased focus on assessment and paperwork, preference to standardised evidence-based models over more holistic approaches that address social inequity, and aid in reducing systematic barriers to support (Brown et al., 2022).
Furthermore, from a critical perspective, it can be argued that the dominance of biomedical evidence in clinical practice and policy space occurs to the exclusion of other disciplines (Morrow & Malcoe, 2017). In addition, other forms of knowing to generate robust and important knowledge relating to mental distress, such as Indigenous knowledge systems, sociology, and anthropology (Morrow & Malcoe, 2017).
Critical social work theory
The Australian practice standards for Social Workers and Mental Health Social Workers highlight a commitment to acting on issues of justice, the need for knowledge of the person in society, recognition of rights and a critically reflective approach (AASW, 2014; 2020). Critical social theory has deep roots in postmodernism, and the two share common concerns, such as an analysis of both the emancipatory and oppressive uses of power, the importance of dominant discourse, and an emphasis on difference and cultural relativity (Briskman et al., 2009; Leonard 1997; Mendes, 2009). Instead of than seeking universal definitions, this review is informed by a dynamic lens of critical theory which provides a broad theoretical framework that encompasses a number of ideas such as anti-oppressive theory (Brown, 2020; Leonard, 1997; Payne, 2014, Weinberg, 2020). This definition is deliberate in terms of acknowledgement of critical social work theory and practice as varied. These perspectives have emerged where it can be argued that the person in the environment framework may not adequately address power differentials (Finn & Jacobson, 2003). In this way, this work is grounded in a perspective that emphasises critical analysis of underlying power differentials, and a commitment to the creation of a more equitable and just society (Weinberg, 2020).
While the biomedical model claims scientific objectivity and neutrality, this review uses a critical lens that considers the complexity of environmental and biological factors contributing to mental distress and acknowledges that social work practice can neither be objective nor neutral (Morrow & Malcoe, 2017; Weinberg, 2020). As Fook (2002) writes, a common theme of critical theory is the recognition that knowledge itself is both empirical and constructed. The knowledge and capacity to practice is not only reflectively, but reflexively centred at the core of best practice for critical clinical social work (Fook, 2002). This refers to the capacity to analyse the dissemblance between professional, cultural, societal and personal values (Weinberg, 2020).
In addition, Weinberg (2020) argues that to be critically informed, practitioners must ask themselves not only “what should I do”, but also “how should we live”, to examine the use of power, and broader structural inequities (pp. 136). Similarly, Brown (2020) argues that social work holds a defined value position, and those engaged in clinical settings must be willing to critique the dominant systems and discourses that emphasise an approach that excludes how structural and systemic oppression contribute to mental distress. This project takes on this perspective, that unlike other professionals in clinical settings who claim neutrality, social work is a value-laden profession that boldly takes on the plight of the marginalised and oppressed (Brown, 2020).
Aim
This narrative review aims to identify and appraise literature relating to specific models, skills and tools that can be used to operationalise critical social work theory in clinical practice settings. Narrative reviews are useful in providing a current synthesis of published literature and can support the development of practice guidelines.
Methods
This review includes published, peer-reviewed primary research, practice papers, case studies and articles that examine the practices and perspectives required to operationalise critical social work theory in clinical practice. Numerous searches were performed in late August 2022 of four databases, including PSYCHINFO, CINAHL, ProQuest social services, PsychArticles, InfoRMIT, as well as Google Scholar and hand searching. There was difficulty in constructing search strings, and this aspect of the review required some creativity. After a number of tests, it was clearly impractical to focus on particular theories connected to critical theory such as ‘clinical feminist theory’ as the searches yielded more results than were feasible for the scope of this review. The final search strings included ‘critical social work practice’ AND ‘clinical settings’ as well as ‘clinical social work’ AND ‘anti-oppressive practice’.
Table 1:
Inclusion and exclusion criteria.
Figure 1:
Selection process of articles.
Results
Articles identified through searches were selected through initial screening by title and then reviewed for inclusion and exclusion by abstract. This process is summarised in Figure 1: Selection process of articles. Articles were considered at each stage of the selection process and screened by the author against the inclusion and exclusion criteria. The first series of tests brought in upwards of 20,000 articles which were outside of the scope of this review. It was important to narrow down the search strings to target critical theory as it relates to social work in clinical practice. The search in total returned 395 articles, of which 355 were screened by title and excluded mostly for content redundancy, or were more than ten years old. Of the forty articles which were screened by abstract fourteen were selected by the author for inclusion as well as an additional seven retrieved through hand searching and reference lists.
The review included studies and papers from the UK – 1, the United States – 8, Australia – 2, and Canada – 3. A total of fourteen articles met the inclusion criteria which included one case study, one paper using inductive qualitative design, one paper discussing a case composite, one concurrent mixed methods study, one article presenting the HEART framework (Healing Ethnoc-Racial Trauma) and one article using a multi-case example. Furthermore, one paper presents evidence from ‘in the field’ experience, one qualitative study draws on phenomenological analysis of consumer voices, one review of existing study findings and one paper utilised critical reflection as methodology. Finally, one article that presents a vignette of client treatment, one qualititative narrative inquiry, one qualitative study that examines clinical social work faculty responses to case vignettes and one qualitative study of regional youth mental health. As part of the review each paper was read and systematically analysed, and three key themes began to emerge, these include; interventions grounded in the importance of building meaningful relationships, critical examination and repurposing of power and the use of critical reflective practice.
Interventions grounded in the importance of building meaningful relationships
Through the incorporation of Critical Race Theory, Liberation Psychology, the Critical Conversations framework and Integrative Sociopolitical and Psychological Analysis (ISPA), the Structural Clinical Model (SC Model) creates a practical tool for clinicians to examine and initiate a dialogue within therapeutic relationship about the relational aspects of the therapeutic process such as transference and countertransference, as historically, culturally and socially located in larger societal group dynamics (del Mar Farina & O’Neill, 2022). The highly relational nature of this model provides rich ground for navigating the complex power dynamics in both supervisory and therapeutic interpersonal relationships. The SC Model encourages the clinician to openly acknowledge that structural traumas can be triggered or enacted as schemas between client and clinician that mimic the broader sociopolitical histories and potentially its harms (del Mar Farina & O’Neill, 2022). In this way, the model suggests that a clinician take an active role in incorporating a critical perspective as it relates to relational dynamics as part of their therapeutic interventions.
Similarly, research by Wright and Ord (2015) highlights the importance of targeted relational approaches for addressing mental health concerns in young people. This includes clinicians initiating community-based group work, which involves building social connections, experiential learning, and creating a safe space, rather than directive clinical treatment focused on correcting presenting symptoms (Wright & Ord, 2015). These groups create linkages that build mutual support, as well as safe spaces to unpack social stigmas, political discourse, and participate in collective empowerment (Wright & Ord, 2015). Furthermore, Australian research by Hyde et al. (2015) similarly highlights the relational importance of mutual support groups and listening spaces as a central tool for social connection, healing and recovery for clients in inpatient settings. In addition, these create safe space for people to express their pain, reflect and make meaning of their experiences with peers that can relate to their experiences (Hyde et al., 2015).
The qualitative research conducted by Hyde et al. (2015) was conducted as a series of semi-structured interviews in an inpatient mental health facility in regional Australia, which utilised a hermetic methodology that emphasised centring and platforming the subjective experience of consumers. To acknowledge the lack of clinical outcomes on community-based clinical interventions, a series of four case studies by Ferguson et al. (2018) explore macro therapeutic interventions that include participatory community-oriented interventions that focus on collective empowerment. Within this small study, the four case studies suggest that clients experienced positive outcomes in terms of increased self-efficacy through participation in community-based participatory partnerships, organising and research where they had decision-making power (Ferguson et al., 2018). Ferguson (2018) argues that both structural and clinical interventions better enable clinical practice to customise interventions to meet individual needs.
Critical examination and repurposing of power
In terms of broadening the perspective of clinical work, this can also be seen at first as an inner process of evolution and conscientization (Jemal, 2022). The evolution of this shift starts with acknowledging that clinical assessment and intervention has too often individualised and dehumanised distress, by asking “what’s wrong with you? (Jemal, 2022, p. 8). However more recently, clinical work has evolved to incorporate a trauma-informed approach that considers a person’s experiences as contributing to mental distress, reflected in the question “what happened to you? (Jemal, 2022, p. 8). Finally, Jemal (2022) argues a truly critical clinical approach would include a more expansive perspective that asks “what do you need to support your humanity at this moment? (p. 8).
In its multi-modal approach, the Critical Transformative Potential Development (CTPD) framework embodies all three themes highlighted in this review and posits the clinician as not just an ‘expert’ objective professional, but rather positions them as an active relational agent in the process of helping individuals build awareness, conscientisation and accountability (Jemal, 2022). The CTPD framework does this by challenging the clinician to consider their own power and social positionality and how they might contribute to, or benefit from systems that perpetuate harm (Jemal, 2022).
In addition, research in rural southwest England highlights how clinicians can also re-purpose their power to reframe clinical practice. This research conducted within a Child and Adolescent Mental Health Service uncovered the desire of youth to see significant changes in the delivery of mental health services (Wright & Ord, 2015). The research shows a need to transform clinical mental health services into more participatory, community-based, flexible, non-stigmatising practice, that includes youth-led community groups (Wright & Ord, 2015). In addition, this research suggests that, for youth mental health interventions to be effective, clinical practice clinicians must be willing to challenge the dominant discourses around deviance, non-conformity, and be significantly less risk-averse (Wright & Ord, 2015).
In terms of individual clinical practice this research further highlights the importance of clinicians explicitly reflecting on power differentials in clinical work, but also conceiving of power as shared and fluid (Wright & Ord, 2015). Power can be repurposed, such as bridging dialogues that reframe and re-contextualise adolescent ‘difficult’ behaviours as adaptive and resilient, as well as empowering clients to engage in constructing counter-narratives (Wright & Ord, 2015). This can be emphasised in practice by supporting youth in “channelling rather than challenging feelings of anger”, acknowledging them as sources of internal personal power, creativity and protest (Wright & Ord, 2015, p. 72).
The use of critical reflective practice.
Many previous models and frameworks discussed contain an embedded skill of reflective and reflexive practice, in terms of reflecting on relationships between client and clinician, as well as power within relationships. Pender Green and Blitz (2012) argue that taking time for trust-building is crucial to critically reflect on differences between themselves and their clients. Cultural responsiveness is not just an intellectual endeavour but requires a kind of intimate and experiential “immersion in the experience of racism”, which includes both the emotional and intellectual parts of the clinician (Pender Green & Blitz, 2012, p. 206). Clinicians must be self-aware of any assumptions, biases or beliefs both internally as well as aware of dominant public and political discourse arising in their communities (Pender Green & Blitz, 2012).
In Australian research, Morley and Stenhouse (2021) use critical reflection as a research methodology and unpack dominant discourse to create possibilities for critical practice within a clinical social work placement. This research highlights the importance of the educator as a facilitator of the critical method of analysis, which enabled the student to move beyond binary understandings of their role as a “powerless student” who is silenced within a dominant medical system (Morley & Stenhouse, 2020, p. 88). This process was emancipatory in that it uncovered the subjective fluid nature of identity with power (Morley & Stenhouse, 2021).
Furthermore, the student was able to reconstruct their sense of power by initiating discussions with a psychiatrist, such as naive questions as a strategy to challenge the dominant hegemonic discourses (Morley & Stenhouse, 2021). The skill of exploring the assumptions and biases held within agency cultures is crucial to reflective practice. Similarly, the SC Model includes an assessment tool that critically examines the relational structural factors in agencies (del Mar Farina & O’Neill, 2022). This process enables workers and clients to engage in critical reflective and nuanced assessment of the factors that might impact clinical service and quality of care (del Mar Farina & O’Neill, 2022). These examples highlight how the themes of relational work, the importance of power, and critical reflection are interdependent.
Discussion
A core challenge evidenced throughout this review has been both real and perceived barriers to integrating critically oriented theory into real world clinical social work (Howard, 2018; Morley & Stenhouse, 2021). A core behaviour of critical clinical social work practice is developing critical thinking skills to examine and articulate complex linkages between biopsychosocial aspects of mental health and the social, cultural and political context of people’s lives. For example, the neurobiological outcomes of a lifetime of racism and discrimination, such as neighbourhood segregation, poor access to healthcare or safe drinking water, could produce an epigenetic difference, brain changes, trauma, chronic stress, dissociation, alongside the social impacts on opportunities, housing, and employment (Jemal, 2022). In this way, to appropriately validate clients’ experiences, clinicians need to develop skills to critically analyse and articulate their understanding of the structural causes of distress.
It is important to acknowledge the significant contribution of knowledge and research from Black, Indigenous, and People of Colour (BIPOC) academics, clinicians and researchers. In some cases, models and tools were robust enough to be located across multiple domains of practice. For example, the SC Model was developed to counteract and challenge the misuse of power, such as over pathologisation of clients' mental distress and address social injustice and inequity in organisations, processes, and relationships (del mar Farina & O’Neill, 2022). In addition, this model is also deeply relationally focused, and critically examines the impact on relationships, in terms of negative social identity formation, internalisations and othering both for the client, supervisor and clinician. Similarly, the CTPD framework integrates relational interventions, and reflective practices, and engages new skills and narratives through the arts (Jemal, 2022). Furthermore, it radically re-envisions clinical practice by positing the skills involved in coordinating community and cultural grassroots organising as a clinical intervention.
In the Canadian context, a qualitative research study between 2010 and 2016 with six undocumented Gender-fluid Indigenous Latinx youth was interviewed using a methodology grounded in narrative inquiry (Tenebaum & Singer, 2018). These findings highlight the significant barriers facing youth in accessing mental health care from a position of respecting and deeply comprehending their social, cultural and political location (Tenebaum & Singer, 2018). In addition, similar to research discussed earlier on youth mental health services in the UK, this study highlights the need for a significant structural paradigm shift in how mental health services are delivered (Tenebaum & Singer, 2018). For example, services need long-term committed funding towards grass-roots initiatives, such as social groups that centre client autonomy and actively create the conditions to foster social connection (Tenebaum & Singer, 2018). A “critical or decolonised” approach underpinned this study to psychology rather than social work, and was included to highlight the importance of not keeping knowledge around critical approaches to practice siloed in single disciplines, but working in ways that are interdisciplinary (Tenebaum & Singer, 2018 p. 1).
Integrating a critical lens in traditional mental health approaches
Rather than replacing existing psychological interventions, integrating a critical clinical lens in the existing tools can enhance efficacy (Howard, 2018). Asakura et al. (2020) address the power differential in undertaking clinical assessment and challenge clinicians to move beyond standardised assessment and consider experiences of injustice and oppression. In addition, this process should include rigorous reflection and consideration of historical and present-day oppressions in the process of clinical assessment, treatment, planning and intervention (Jemal, 2022). These types of questions are often not asked as part of clinical assessment, let alone given time for reflection and discussion. Through an examination of de-identified case studies, Howard (2018) highlights ways to integrate psychological strategies within an anti-oppressive framework. For example, cognitive behavioural approaches can help normalise the connection between discrimination and clinically significant psychological distress (Howard, 2018). Similarly, Chaves-Duenas et al. (2019) propose that Trauma-Focused Cognitive Behavioural Therapy (TF-CBT) can be easily adapted to integrate the process of ‘conscientization’, which supports clients to locate and acknowledge their own social, political and cultural contexts.
In addition, Langerian mindfulness techniques can support multiple perspectives when a client with privilege might experience distress relating to their own uninvestigated social bias (Langer, 1989, as cited in Howard, 2018). This tool asks clinicians to directly address stereotypes and pain generated through dominant discourse and uses psycho-educative tools to support clients to understand the affective consequences of ongoing oppression (Howard, 2018). In a practice paper vignette, Pender Green and Blitz (2012) highlight how commonly adopted models, such as strengths-based practice, can be adapted to incorporate critical cultural lens. For example, acknowledging race, culture, and spirituality as important aspects that support and shape individuals and can be a crucial source of strength and resourcing (Pender Green & Blitz, 2012).
Similarly, in a framework proposed by Chavez-Duenas e al. (2019) “Seven Latinx Psychological Strengths” are emphasised, which can support the development of strength-based practice in treatment, and enhance and strengthen cultural pride and connection (p. 57). This framework argues that clinicians must develop specific knowledge of their clients “phenomenological experience” and comprehend how and why culture can be a source of strength (Chavez-Duenas et al., 2019, p. 56). In addition, white anglo clinicians must be brave and skillful enough to initiate robust empathetic and non-judgemental conversations about social identity and oppression, while also centring choice and agency with the client (Pender Green & Blitz, 2012).
In terms of bridging the cultural divide, clinicians can build trust through considered self-disclosure of their own personal struggles with oppression, privilege or complicity (Pender Green & Blitz, 2012). This can be done playfully using humour to help support social engagement between clinician and client (Pender Green & Blitz, 2012). In practice, clinicians need to understand that following the client's lead or adhering to manualised protocols is unlikely to initiate critical conversations, as marginalised people have complex and valid reasons not to bring up the oppression they experience (Pender Green & Blitz, 2012). From a trauma-informed perspective, accumulated microaggressions can lead to traumatic injury, which perpetuates a subtle “social segregation” and hinders opportunities for meaningful multicultural relationships (Pender Green & Blitz, 2012, p. 204). This highlights the need for a considered approach to creating safe spaces to discuss difficult issues, which leads to more effective treatment outcomes, and increased self-esteem and self-efficacy (Pender Green & Blitz, 2012). Finally, empowering people to view themselves and their relationships within a structural context enables them to see more dimensions of their identities, which reduces shame and creates compassion (del mar Farina, & O’Neill, 2022).
While the focus of this review is critical social work perspectives, there is no doubt that lessons can be shared between other disciplines. The framework proposed by Chaves-Duenas et al. (2019) highlights contributions from other disciplines to integrate critical theories in clinical practice. Chaves-Duenas et al. (2019) propose the Heart Framework (Healing Ethno Racial Trauma grounded in Intersectional Theory and Liberation Psychology, which is a trauma-informed approach to healing ethno-racial trauma. Similarily to the SD Model and CPTD Framework, this involves conceptualising clinical practice within a broader multimodal scope, centering the promotion of self-determination, resistance and hope (Chavez-Duenas et al., 2019). Trauma treatment usually necessitates developing physical and emotional safety and stabilisation for the client. Where that is not possible, clinicians partnering with the community to develop physically located “sanctuaries”, or safe spaces is a creative and adaptive response that can allow experiences of solidarity, healing through cultural traditions, social connection, and liberation (Chavez-Duenas el., 2019, p. 56).
Social work education and supervision
The incorporation of critically informed frameworks for supervision is essential in supporting and bolstering the capacity of social workers to implement critical interventions, particularly in clinical settings, which are often ideologically at odds with agencies and funding bodies (Asakura & Maura, 2018; Jemal, 2022). Furthermore, del Mar Farina and O’Neill (2018) argue that clinical supervision is often fraught with oppressive social and political pressures within agencies, as well as the reverberations of structural power dynamics, superiority and unexamined stereotypes, which can all be internalised and reenacted relationally without critically informed supervision. Many of the models analysed in this review, including the SP Model and CTPD Framework, offer robust roadmaps to allow supervisors and clinicians to create a transformative collaborative space to critically reflect on their own and others’ intersecting identities, professional, personal and collectively held values, as well as the structural power differentials that inhabit and inhibit professional practice (Asakura & Maura, 2018; Jemal, 2022; O’Neill & del Mar Farina, 2018). Critical clinical social work greatly advances the person in the environment stance of social work to create more pathways toward justice and collective structural healing.
Recommendations for further research
Higher learning institutions both in Australia and overseas are key in ensuring that social work students can operationalise the key mandate of social justice within clinical social work practice (Varghese, 2016). While the work by Asakura et al. (2020) and Varghese (2016) identify key ways educators might help students use critical theory in clinical practice. It may be important to target specific research and training on preparing critically oriented clinicians for the real-world ethical challenges they might encounter in biomedical and neo-liberal workplaces. For example, detailed information on the political and cultural context of agencies might help students navigate these challenges while maintaining their ethical commitments (Asakura, 2020). Furthermore, there were stark gaps in the research papers identified in the original search, such as gaps in research and practice around the Australian context and First Nation Peoples.
In addition, Varghese’s (2016) study highlights the need for research to bring critical theories such as intersectional analysis, critical race theory and social justice frameworks into education. Research by Varghese (2016) suggests teaching staff lack critical knowledge about race, racism, and linkages to structural oppression and relevance in clinical work by university professors teaching clinical social work. For example, their responses to a supplied case study overemphasise diagnosis even when the client's definition of depressive symptoms is not congruent with clinical definitions (Varghese, 2016). This study highlights the need for services and institutions to commit to a core ethic of social work (social justice), the acquisition of learning and development for teaching staff, and the centring of marginalised voices in training (Brinkman & Donohue, 2020). In addition, future research could also include interdisciplinary work to study the impact of structural and multi-level oppression on the brain long term and identify what interventions might mitigate these harms (Jemal, 2022). Finally, Ferguson et al. (2018) suggest that clinicians and researchers need to collaborate, and that future research needs to standardise measures to longitudinally track clinical outcomes that emerge from macro community-oriented interventions.
Conclusion
It is important to clearly articulate that the ongoing transgenerational impacts of colonisation, discrimination, marginalisation, and oppression are profoundly clinically important to people's mental health in all places where community building and mental health interventions occur (Brown, 2021; Howard, 2018; Pender Green & Blitz, 2011). Furthermore, the knowledge and insight required for critical clinical practice for social workers are crucial if clinicians are to more deeply and holistically understand the complex intersections of social identity, privilege and harm experienced by their clients (Pender Green & Blitz, 2011). The multimodal frameworks represent robust holistic individual and collective practice responses, far extending the social work scope of person in environment. Finally, it is critically important to de-pathologise people’s experiences of systemic and structural oppression and counter the normalisation of the biomedical paradigm to create a broader understanding of mental distress that is interactional, relational, and dialectical (del Mar Farina & O’Neill, 2022).
Disclosure Statement
The author reports that there are no competing interests to declare.
Funding Details
This work took place as part of a Capstone unit within MSW placement at University of New England.
References
Asakura, K., & Maurer, K. (2018). Attending to Social Justice in Clinical Social Work: Supervision as a Pedagogical Space. Clinical Social Work Journal, 46(4), 289–297. https://doi.org/10.1007/s10615-018-0667-4
Asakura, K., Strumm, B., Todd, S., & Varghese, R. (2020). What does social justice look like when sitting with clients? A qualitative study of teaching clinical social work from a social justice perspective. Journal of Social Work Education, 56(3), 442-455. https://doi.org/10.1080/10437797.2019.1656588
Australian Association of Social Workers (2014). Practice Standards for Mental Health Social Workers. https://www.aasw.asn.au/document/item/6739
Australian Association of Social Workers (2020). Code of Ethics. https://www.aasw.asn.au/practitioner-resources/code-of-ethics’
Brinkman, B. G., & Donohue, P. (2020). Doing intersectionality in social justice oriented clinical training.Training and Education in Professional Psychology, 14(2), 109-115. https://doi.org/10.1037/tep0000274
Briskman, L., Pease, B., Allan, J. (2009). Introducing critical theories for social work in a neo-liberal context. In J. Allan, L. Briskman, & B. Pease (Eds.), Critical Social Work: theories and practices for a socially just world. (pp. 1-14). Allen and Unwin.
Brown, C. (2020). Critical Clinical Social Work: Theoretical and Practical Considerations. In C. Brown & J. E. Macdonald (Eds.), Critical Clinical Social Work: Counterstorying for Social Justice. (pp. 121-140). CSP Books Inc.
Brown, C. (2021). Critical Clinical Social Work and the Neoliberal Constraints on Social Justice in Mental Health. Research on Social Work Practice, 31(6), 644–652. https://doi.org/10.1177/1049731520984531
Brown, C., Johnstone, M., Ross, N., & Doll, K. (2022). Challenging the Constraints of Neoliberalism and Biomedicalism: Repositioning Social Work in Mental Health. Qualitative Health Research, 32(5), 771–787. https://doi.org/10.1177/10497323211069681
Callander, E. J., Corscadden, L., & Levesque, J. F. (2017). Out-of-pocket healthcare expenditure and chronic disease - do Australians forgo care because of the cost? Australian Journal of Primary Health, 23(1), 15–22. https://doi.org/10.1071/PY16005
Chavez-Dueñas, N. Y., Adames, H. Y., Perez-Chavez, J. G., & Salas, S. P. (2019). Healing Ethno-Racial Trauma in Latinx Immigrant Communities: Cultivating Hope, Resistance, and Action. The American Psychologist, 74(1), 49–62. https://doi.org/10.1037/amp0000289
Corscadden, L., Callander, E. J., & Topp, S. M. (2019). Disparities in access to health care in Australia for people with mental health conditions. Australian Health Review, 43(6), 619–627. https://doi.org/10.1071/AH17259
Cosgrove, L., Krimsky, S., Vijayaraghavan, M., & Schneider, L. (2006). Financial Ties between DSM-IV Panel Members and the Pharmaceutical Industry. Psychotherapy and Psychosomatics, 75(3), 154–160. https://doi.org/10.1159/000091772
Cosgrove, L., Krimsky, S., Wheeler, E. E., Kaitz, J., Greenspan, S. B., & DiPentima, N. L. (2014). Tripartite Conflicts of Interest and High Stakes Patent Extensions in the DSM-5. Psychotherapy and Psychosomatics, 83(2), 106–113. https://doi.org/10.1159/000357499
del Mar Fariña, M., & O'Neill, P. (2022). The structural clinical model: Disrupting oppression in clinical social work through an integrative practice approach.Clinical Social Work Journal, https://doi.org/10.1007/s10615-022-00841-3
Duffy, F. (2017). A Social Work Perspective on How Ageist Language, Discourses and Understandings Negatively Frame Older People and Why Taking a Critical Social Work Stance Is Essential. British Journal of Social Work, 47(7), 2068–2085. https://doi-org.ezproxy.une.edu.au/10.1093/bjsw/bcw163
Engel, L. G. (1977). The Need for a New Medical Model: A Challenge for Biomedicine. Science (American Association for the Advancement of Science), 196(4286), 129–136. https://doi.org/10.1126/science.847460
Farag, I., Sherrington, C., Ferreira, M., & Howard, K. (2013). A systematic review of the unit costs of allied health and community services used by older people in Australia. BMC Health Services Research, 13(1), 69–69. https://doi.org/10.1186/1472-6963-13-69
Ferguson, K. M., Teixeira, S., Wernick, L. J., & Burghardt, S. (2018). Macro interventions and their influence on individual and community well-being.Journal of Social Work, 18(6), 679-702. https://doi.org/10.1177/1468017318757160
Finn, J. L. (2016). Just practice: A social justice approach to social work (3rd ed.). New York, NY: Oxford University Press.
Finn, L., & Jacobson, J. (2003). Just practice: Steps toward a new social work paradigm. Journal of Social Work Education, (39)57–78. doi:10.1080/10437797.2003.10779119
Frances, A. J., & Widiger, T. (2012). Psychiatric Diagnosis: Lessons from the DSM-IV Past and Cautions for the DSM-5 Future. Annual Review of Clinical Psychology, 8(1), 109–130. https://doi.org/10.1146/annurev-clinpsy-032511-143102
Fook, J. (2002). Social Work Critical Theory and Practice. London. Sage Publications.
Gordon, D. R. (1988). Tenacious assumptions in Western medicine. In M. Lock & D.R. Gordon (Eds.), Biomedicine examined (pp. 19–56). Dordrecht, Netherlands: Kluwer Publishers. http://dx.doi.org/10.1007/978-94-009-2725-4_3
Howard, S. (2018). The black perspective in clinical social work. Clinical Social Work Journal, 48(4), 335-342. https://doi.org/10.1007/s10615-018-0663-8
Hyde, B., Bowles, W., & Pawar, M. (2015). ’We’re Still in There’--Consumer Voices on Mental Health Inpatient Care: Social Work Research Highlighting Lessons for Recovery Practice. British Journal of Social Work, i62–i78. https://doi-org.ezproxy.une.edu.au/10.1093/bjsw/bcv093
Jemal, A. (2022). Critical clinical social work practice: Pathways to healing from the molecular to the macro.Clinical Social Work Journal, https://doi.org/10.1007/s10615-022-00843-1
Larson, G. (2008). Anti-oppressive Practice in Mental Health. Journal of Progressive Human Services, 19(1), 39–54. https://doi.org/10.1080/10428230802070223
Lafrance, M. N., & McKenzie-Mohr, S. (2013). The DSM and its lure of legitimacy. Feminism & Psychology, 23(1), 119–140. https://doi.org/10.1177/0959353512467974
Leonard, P. (1997). Postmodern welfare : reconstructing an emancipatory project. SAGE Publications.
Love, S. (2022, July 25). The New study on Serotonin and Depression isn’t about Antidepressants. Vice. https://www.vice.com/en/article/88qge4/the-new-study-on-serotonin-and-depression-isnt-about-antidepressants-chemical-imbalance
Mendes, P. (2009) Tracing the origins of critical social work practice. In J. Allan, L. Briskman, & B. Pease (Eds.), Critical Social Work: theories and practices for a socially just world. (pp. 17-29). Allen and Unwin.
Moncrieff, J., Cooper, E. R., Stockman, T., Amendola, S., Hentgartner, M. P., & Horowitz, A. M. (2022). The Serontonin Theory of Depression: a systematic umbrella review of the evidence. Molecular Psychiatry. https://doi.org/10.1038/s41380-022-01661-0
Morley, C., & Stenhouse, K. (2021). Educating for critical social work practice in mental health. Social Work Education, 40(1), 80–94. https://doi.org/10.1080/02615479.2020.1774535
Morrow, M., & Malcoe, L. H. (Eds.). (2017). Critical Inquiries for Social Justice in Mental Health. University of Toronto Press. http://www.jstor.org/stable/10.3138/j.ctv2fjwzfc
Payne, M. (2014). Modern Social Work Theory. Palgrave Macmmillan.
Pender Greene, M., & Blitz, L. V. (2011). The elephant is not pink: Talking about white, black, and brown to achieve excellence in clinical practice. Clinical Social Work Journal, 40(2), 203-212. doi:https://doi.org/10.1007/s10615-011-0357-y
Smith, F. L., Harms, L., & Brophy, L. (2022). Factors Influencing Social Work Identity in Mental Health Placements. The British Journal of Social Work, 52(4), 2198–2216. https://doi.org/10.1093/bjsw/bcab181.https://www.aihw.gov.au/reports/indigenous-australians/rheumatic-heart-disease-in-australia-2016-2020/summary
Tenenbaum, S., & Singer, K. (2018). Borders of belonging: Challenges in access to anti-oppressive mental health care for indigenous Latinx gender-fluid border-youth. AlterNative, 14(3), 245–250. https://search-informit-org.ezproxy.une.edu.au/doi/10.3316/informit.298785398941823
Thachuk, A. K. (2011). Stigma and the Politics of Biomedical Models of Mental Illness. International Journal of Feminist Approaches to Bioethics, 4(1), 140–163. https://doi.org/10.3138/ijfab.4.1.140
Varghese, R. (2016). Teaching to transform? Addressing race and racism in the teaching of clinical social work practice. Journal of Social Work Education, 52(1),134–147. doi:10.1080/10437797.2016.1174646
Webber, M. (2013). Developing advanced practitioners in mental health social work: Pedagogical considerations. Social Work Education, 32(7), 944–955. https://doi.org/10.1080/02615479.2012. 723684
Weinberg, M. (2020). Critical Clinical Ethics. In C. Brown & J. E. Macdonald (Eds.), Critical Clinical Social Work: Counterstorying for Social Justice. (pp. 121-140). CSP Books Inc.
Wright, E., & Ord, J. (2015). Youth Work and the Power of 'Giving Voice': a reframing of mental health services for young people. Youth and Policy, (115), 63. http://search.proquest.com.ezproxy.une.edu.au/scholarly-journals/youth-work-power-giving-voice-reframing-mental/docview/1862049943/se-2
Ziguras, S., Henley, K., Conron, W., & Catford, N. (2008). Social work in mental health services: A survey of the field. Australian Social Work, 52(2), 53–59. https://doi.org/10.1080/03124079908414125