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Clinical Social Work Journal
Vol. 24, No. 1, Spring 19

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CSWJFORUM

WHAT IS CLINICAL SOCIAL WORK?
LOOKING BACK TO MOVE AHEAD

Eda G. Goldstein, DSW

ABSTRACT: This paper traces the evolution of the concept of clinical social
work and looks at where we are and where we are headed as clinical social work-
ers. It reaffirms the view that clinical social workers intervene with clients pre-
senting the full range of problems in a variety of facilities and in private practice
and must draw on a broad knowledge base within a person-situation perspective
and .address the special needs of culturally diverse and oppressed populations. The
paper also considers the move toward legal regulation, the role of private practice,
the need for clinical doctoral education, the importance of new models for clinical
research, and the significance of advocacy for a broad range of services to clients.

KEY WORDS: clinical social work; direct practice.

While the term “clinical social work” entered our professional lan-
guage in the late 1960s and early 1970s, its definition still eludes con-
sensus. Conceived in controversy and dedicated to the “people-helping”
rather than “society-changing” pole of social work’s dual mission (Gold-
stein, 1980), it connotes different things to different people and con-
tinues to arouse often passionate debate, if not outright antagonism
(Specht & Courtney, 1994; Walz & Groze, 1991). Much time has passed
since clinical social work’s infancy and our society and profession have
witnessed staggering changes. As we approach the 21st century, it
seems timely to review where we have been, who and where we are, and
where we are headed as clinical social workers.

THE BEGINNINGS OF CLINICAL SOCIAL WORK

During the Kennedy-Johnson presidencies society turned its atten-
tion to eradicating social problems through the mounting of large-scale

89 ICl 1996 Human Sciences Press, Inc.

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federal programs. Prior to this period, casework, which relied heavily on
Freudian theory and ego psychology for its knowledge base, dominated
the social work arena although family and group modalities also were
utilized extensively. During the 1960s, however, the social work profes-
sion itself turned its attention away from individual, family, and group
treatment to community organization, social program and policy design,
and social action. This change had many ramifications: service delivery
changed dramatically; caseworkers and others in direct practice lost sta-
tus; many schools of social work reduced the amount of curriculum
space allocated to personality theory and “microsystems” intervention in
favor of social science, organizational, and social change theories and
“macrosystems” intervention; crisis and short-term intervention took
hold; social work undergraduate programs proliferated resulting in
large numbers of B.S.W. trained individuals entering the field; and so-
cial work doctoral programs increasingly emphasized administration,
social policy and planning, and research rather than direct practice
(Goldstein, 1995; Strean, 1993).

The Civil Rights movement, feminism, and somewhat later, the gay
liberation movement contributed to an anti-labeling and anti-treatment
atmosphere. There was widespread criticism of the medical model. Sup-
porters of individual treatment were accused of being agents of social
control and were attacked for ”blaming the victim” rather than the ef-
fects of oppression, poverty, and trauma and for “pathologizing” the be-
havior of women, gays and lesbians, and other culturally diverse per-
sons rather than respecting their unique characteristics and strengths.

Discouraging research findings on casework’s effectiveness also di-
minished the dominance of direct practice (Mullen, Dumpson, & Associ-
ates, 1972; Fischer, 1976). Many called for more systematic outcome
studies and different ways of addressing the integration of research and
practice. Some researchers even advocated disregarding theory as a
guide to practice altogether in favor of interventions derived from empir-
ical studies (Bloom, 1983; Blythe & Briar, 1985; Fischer & Hudson,
1983; Levy, 1983; Mullen, 1983; Reid, 1983).

Not all of these developments were greeted enthusiastically. Large
numbers of social work practitioners felt that clients’ problems were be-
ing viewed simplistically as a function of social and environmental fac-
tors solely and that they were being deprived of needed individualized
services; that the poor were being viewed as if they lacked personal psy-
chodynamics and variable coping mechanisms; that social work students
were not being equipped with the full knowledge base and skills neces-
sary to help their clients, particularly those showing more severe coping
difficulties; that practice standards were eroding; that social work was
becoming deprofessionalized; and that treatment models and interven-
tions that were the easiest to operationalize and measure but not neces-

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EDA G. GOLDSTEIN

sarily the best were being promulgated. Many felt abandoned by NASW,
ignored by professional journals, and alienated from the profession gen-
erally (Frank, 1980, p. 16).

In the late 1960s, social workers began to organize to reverse the
tide. Dismayed about their place within the profession, many were also
concerned about their acceptance by the larger comm.unity as qualified
clinicians, along with psychologists and psychiatrists. They became ac-
tive in efforts to promote direct practice, to establish higher standards
and professional credentials, and to achieve legal regulation for private
practice. An early formal use of the term clinical can be found in a 1968
California licensing statute (Waldfogel & Rosenblatt, 1983, p. x:xv).

In 1971, groups of practitioners in various geographic areas, partic-
ularly New York and California initially; were instrumental in the for-
mation of a new professional organization, the Federation of Societies
for Clinical Social Work, that had different aims from the broader-based
National Association of Social Workers. The Clinical Social Work Jour-
nal was initiated one year later in 1972. A vocal number of the Federa-
tion’s leadership saw themselves as psychotherapists and psychoana-
lysts, some having undertaken advanced training in psychoanalytic
institutes, and were interested in the advancement and protection of
private practice (personal communication with Helen Krackow, Presi-
dent the New York State Chapter of the Society for Clinical Social Work-
ers, New York, New York, April 19, 1995). The stated aim of the Federa-
tion, however, was to establish standards for direct-service practitioners,
to meet the needs of practitioners and consumers of direct practice, and
thereby to correct for the perceived lack of attention to direct practice on
the part of the larger profession (Strean, 1993, p. 15).

WHAT’S IN A NAME?

As numerous authors have pointed out, the word “clinical” itself
was heavily laden with meanings that aroused mixed, if not negative
sentiments. Its original meaning connoted the treatment of disease or
“medical treatment at sickbed” (Waldfogel & Rosenblatt, 1983, p. xxvi).
Many social workers both inside and outside of the Federation equated
clinical social work with psychodynamically-oriented casework and psy-
chotherapy aimed at promoting a person’s internal resources, an effort
to promote private practice, and an attempt on the part of a segment of
the profession to achieve greater status by setting themselves apart
from the rest as they viewed “psychiatric” social workers as doing previ-
ously (Frank, 1980, pp. 14-15). Consequently, broader-based social work
practitioners and academics raised questions about the appropriateness
of both the term and the concept, viewing it as too connected to the

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medical model, narrow in scope, elitist, and ill-suited to a profession
whose mission it was to address the concerns of poor and oppressed pop-
ulations.

In other helping professions, however, the term “clinical” referred to
“hands-on” care and aptly captured the spirit of direct practice defined
more broadly. Moreover, it portrayed social work practitioners as shar-
ing certain similarities with other mental health clinicians, an advan-
tage with respect to social workers’ quest for acceptance of their compe-
tence to provide therapeutic services. Moreover, it lent itself to a more
contemporary conception of direct practice that was not wedded to indi-
vidual treatment but instead embraced a range of treatment modalities.
Some saw the need for the term, however problematic, as brought about
by the emergence of new knowledge bases, the expansion of the unit of
attention to encompass individuals, families, and groups, renewed inter-
est in work with the social environment, and the need to establish an
empirical base for practice (Waldfogel & Rosenblatt, 1983, p. xxvii).

Thus, to many in the profession, clinical social work transcended a
narrow definition as a psychotherapeutic specialization and became
more of an umbrella term-another name for social work treatment,
direct practice, or “microsystems” intervention that draws on an expand-
ing and diverse knowledge base, encompasses a broad range of tradi-
tional and emerging practice models and roles, and spans both agency
and private practice.

Despite what appeared to many practitioners as its lack of attention
to the needs of clinical social workers, NASW surprisingly and some-
what controversially moved to recognize and establish standards for
clinical social work by issuing a Registry of Clinical Social Work in 1976.
Embodying a broad conception of clinical social work, it defined clinical
social workers as those who ”by education and experience … were qual-
ified at the autonomous practice level to provide direct, diagnostic, pre-
ventive, and treatment services to individuals, families, and groups
where functioning is threatened or affected by social and psychological
stress or impairment (Registry of Clinical Social Workers, 1976, p. xi).
Clinical social work services could be provided in private practice or in
public, voluntary, or proprietary settings. Those MSW social workers
who had completed two years of supervised experience or its equivalent
in providing clinical social work services could apply for listing in the
Register.

In 1978, NASW formed a Task Force on Clinical Social Work, as a
response to the pressing needs of practitioners, many of whom were un-
comfortable about the “split” in the professional organizations. Its report
along with numerous papers that were presented at the National Invita-
tional Forum on Clinical Social Work in June, 1979 (Ewalt, 1980) de-
fined clinical social work broadly. Attempting to convey that clinical so-

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EDA G. GOLDSTEIN

cial work had a central core that was consistent with the values and
goals of the social work profession, it reaffirmed its person-situation per-
spective, its concern with the social as well as personal context, its bio-
psychosocial assessment lens, its inclusion of a range of approaches
encompassing work with individuals and environments, its broad knowl-
edge base, its use in both private practice and a host of agency settings,
its acknowledgement of psychotherapy as a part but not the whole of the
intervention process, and its reliance on interventions with people di-
rectly or the social situation (Cohen, 1980, pp. 23-32). The Handbook of
Clinical Social Work (Waldfogel & Rosenblatt, 1983) also embodied this
inclusive definition and its principles have been maintained in later
more specific definitions.

If the equation of clinical social work with psychodynamically ori-
ented psychotherapy and private practice was viewed as too narrow and
elitist by many members of the profession, the broader use of the term
was criticized for being too all-inclusive. It raised questions about
whether there are any boundaries to clinical social work and whether it
reflects a unique core of values, knowledge, and skill.

EFFORTS AT A UNIFYING CONCEPTION OF
SOCIAL WORK PRACTICE

Unhappy with the traditional polarization in the profession between
direct practice and social change and attempting to put forth a distinc-
tive and unifying conception of social work practice, a number of authors
proposed that general systems theory become an overarching framework
(Bartlett, 1970; Gordon, 1969, pp. 5-11). Germain (1979) and later Ger-
main & Gitterman (1980) developed the ecological perspective or life
model that is a broad, systemic conceptualization of practice. The propo-
nents of this approach attempted to correct for what they perceived as
clinical social work’s continuing reliance on psychodynamic theory and
psychotherapy and lip-service attention to a person-situation perspec-
tive. It emphasizes person-environmental transactions and working at
the interface between people and environments. The life model empha-
sizes a strengths rather than pathology orientation, focuses on helping
clients with problems in living rather than their disorders or illness, and
is more transactional and environmentally oriented than therapeuti-
cally oriented in its choice of interventions, including an emphasis on
organizational and social change. Thus, it encompasses both micro- and
macrosystems foci. While, in principle, ecosystems theory can include
both in-depth and in-breadth knowledge of and interventions with peo-
ple and environments, its followers have tended to minimize the impor-
tance of more dynamically oriented individual, family, and group theo-

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ries and therapeutically oriented treatment. Thus, a variation or
continuation of the longstanding controversy about whether the social
work profession should emphasize “people-helping” or “society-chang-
ing” reasserted itself. This division can be described as clinical vs. eco-
systems or clinical vs. traditional or “real” social work.

While initially it was more of a perspective than an intervention
model and many of its principles were difficult to operationalize, the
ecological perspective has developed extensively in its application and
has achieved considerable popularity among broad-based practitioners
and academics. A well-known social work theoretician proclaimed that
the “ecological systems perspective has evolved into a basic conceptual
framework for our practice theories as well as for our behavior theories
. . . and we now have a viable, highly useful, and basic paradigm for
social work, as well as for clinical practice (Siporin, 1985, pp. 200-01).
Despite this positive appraisal, the ecological framework still lacks ap-
peal to certain segments of the direct practice community who argue
that it negates the importance of personality theory and more severe
psychopathology and has contributed to the dilution of this content in
social work educational programs, that it does not equip workers with
an in-depth knowledge base of what occurs within rather than across a
variety of systems, and that its focus on working at the interface be-
tween people and environments does not encompass certain types of
necessary intervention skills.

THE RESURGENCE OF DIRECT PRACTICE

Direct practice reasserted its importance during the 1970s and
1980s for numerous reasons. General disillusionment in government
was prevalent as a consequence of political assassinations, the struggle
over and failure of the Vietnam War, and disappointment in the results
of the Great Society programs aimed at wiping out poverty. The prevail-
ing political philosophy became increasingly more conservative as the
government did not believe its role was to bear responsibility to help
those who were economically disadvantaged. Social work professionals
were among those who felt powerless about creating and maintaining
responsive social programs and policies as services to the poor were cut
back (Goldstein, 1995, p. 43).

Concurrently, the awareness of the pressing needs of clients for in-
dividualized services led to renewed attention to microsystems interven-
tion and generated creative approaches in work with special popula-
tions. More traditional theories were refined and extended and new
frameworks and intervention models emerged. For example, many psy-
chodynamically oriented clinicians moved away from an exclusive re-

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liance on classical psychoanalytic psychology and embraced the newer
developments in ego psychology, object relations theory, and self psy-
chology which are more interpersonal and transactional in nature; cou-
ple and family theories exploded; the cognitive/ behavioral approach
gathered more adherents; crisis intervention, task-centered, and other
short-term models became prevalent; more affirmative and empowering
models for work with women, people of color, and gays and lesbians were
put forth; empirically based practice models were advocated; practi-
tioners began to experiment with hypnosis, biofeedback, gestalt tech-
niques, and other newer forms of intervention. A popular social work
text cites over twenty different frameworks for practice and does not
include some of those which have developed since (Turner, 1986). For
example, some clinical social workers have integrated more spiritually
oriented approaches into their work and newer models such as the nar-
rative and social constructionist approaches have emerged, both of
which take a radically different stance than do traditional psycho-
dynamic frameworks.

During the height of this experimentation, one author noted that to
some it seemed as if clinical social work theory was in disarray and that
the climate represented “an effort to accumulate new techniques, piling
the new upon the old, in a wild kind of eccleticism that gives the appear-
ance of thoughtless ignorance and inconsistent, illogical self-contradic-
tions” (Siporin, 1979, p. 76). He goes on to say, however, that this be-
havior reflected a positive and constructive attempt at acquiring new
knowledge, techniques, and self-development as helping persons (p. 76)
and in a later paper, proclaimed the health of clinical social work theory
and practice, in all its diversity, as good and of proven effectiveness and
saw a rapprochement growing between practice and research (Siporin,
1985, pp. 198-99).

CLINICAL SOCIAL WORK TODAY

Clinical social workers comprise the largest proportion of social
workers in the country. Among NASW members, 70 percent of master’s-
level and 40 percent of doctoral-level workers describe direct services as
their primary function. The proportion of students who indicate direct
practice or clinical practice as their primary field of interest has in-
creased. There are approximately 10,000 members of the National Fed-
eration of Societies of Clinical Work and about 20,000 clinical social
workers hold Diplomates either through NASW or the American Board
of Examiners (Swenson, 1995: 504). For the first time, clinical social
work had its own entry in the 19th Edition of the Encyclopedia of Social
Work (1995, pp. 502-12).

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Clinical social workers intervene with clients presenting the full
range of problems in a variety of facilities and in private practice, for
example, Vietnam veterans, persons with AIDS and their families, sur-
vivors of physical and sexual abuse and other types of trauma, those
with mental illness and less severe forms of emotional disorder, sub-
stance abusers, victims and perpetrators of domestic violence, rape and
other violent crimes, those with physical illness and disability, family
problems, or normative life cycle and situational crises. Likewise, clini-
cal social workers integrated, albeit slowly, theory and practices that
address the special needs of culturally diverse and oppressed popula-
tions. Based on their work with these populations, clinical social work-
ers grasped the importance of utilizing individual, family, and group
modalities and a full range of direct practice interventions and roles
including case management, educational and support groups, linkage to
environmental resources, client-centered advocacy, and other types of
environmental interventions.

The broadened theoretical thrust of clinical social workers was evi-
dent in a national study of experienced clinicians drawn from a 1982
Register of Clinical Social Workers. While the majority of respondents
still identified ego psychology as guiding their approach, socio-cultural,
cognitive/behavioral, and family systems theories had important second-
ary influence. Further, “these clinical social workers did not adopt a uni-
dimensionsal stance in choosing theories of human behavior upon which
to ground their understanding of clients … the average number of theo-
ries identified as having a significant role in one’s theoretical perspec-
tive was greater than two” (Mackey, Burek, and Charkoudian, 1987, p.
372). A more recent study of private practitioners drawn from the 1991
NASW Register of Clinical Social Workers found that respondents said
they utilized 4.2 theoretical bases in their work. “Psychodynamic or psy-
choanalytic theory was reported used by 83 percent of the respondents,
systemic by 53 percent, and cognitive/behavioral by 62 percent” (Strom,
1994, p. 80-81). The results also indicated that task-centered and cogni-
tive/behavioral approaches were gaining ground.

The American Board of Examiners in Clinical Social Work, which
issues the Board Certified Diplomate, recognized clinical social work’s
enlarged focus, defining it “as a form of social work grounded in the
overall mission, values, ethics, and principles of the social work profes-
sion” and consisting of “direct client intervention, client-centered clinical
supervision, and client-centered consultation,” where direct client inter-
ventions “include but are not limited to, differential diagnosis, crisis in-
tervention, brief and extended psychotherapy, case management, and
client-centered advocacy.” It also views clinical social work as encom-
passing “a wide range of client diversity associated with race, culture,
socioeconomic status, gender, sexual orientation, age, and physical chal-
lenges (American Board of Examiners, 1995, pp. iv-v).

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EDA G. GOLDSTEIN

THE GROWTH OF PRIVATE PRACTICE

If clinical social work encompasses a broad range of intervention
models and roles, a diverse knowledge base, and both facility-based and
private practice, why is there a lingering perception of clinical social
workers as narrow, elitist, and sometimes misguided practitioners who
have flocked to private practice, abandoned their commitment to the
values of the profession, and disidentified with the social work profes-
sion altogether? No doubt this perception is promulgated and fueled, in
part, by a combination of legitimate philosophical differences about the
social work profession’s mission, deep-seated beliefs about the legitimate
goals and locus of intervention, and sometimes outright distortions re-
garding the motivations of clinical social workers, the objectives and
scope of their practice, and the nature of the clientele that they serve
(Specht & Courtney, 1993). Nevertheless, clinical social workers them-
selves have contributed to this extreme view in various ways.

Concurrent with the resurgence of direct practice in the 1970s and
1980s and clinical social work’s extension and application to a range of
special problems and special populations, increasing numbers of social
workers entered private practice. This resulted from a variety of factors:
1) a general climate which stressed the unbridled pursuit of financial
gain; 2) the attack on people who were poor and on public services; 3)
the increasing business ethos in agency settings, budgetary and service
constraints, and regulatory and other paperwork demands that created
administrative burdens on workers, lessened their autonomy, dimin-
ished the time available to spend with clients, and lessened the quality
and availability of services; 4) the absence of career ladders and finan-
cial rewards for direct practice social workers in agencies; 5) the move
toward privatization of services in which agencies and independent pro-
viders competed for contracts to deliver services; 6) the demand for and
ability to pay for services on the part of the middle class; and 7) a de-
crease in the numbers of applicants to social work programs who were
interested in working with the poor and who wanted to become thera-
pists.

By the early 1990s, 63 percent of NASW members reported that
they were in private practice although more than 30 percent indicated
that they saw clients 10 or fewer hours a week (Swenson, 1995, p. 507).
Some studies show that those in private practice generally are serving
clients who come from the middle class (Brown, 1990; Strom, 1994). Fur-
ther, private practitioners do seem to differ substantially from non-pri-
vate practice practitioners in their value systems, main activities, and
identifications with the social work profession (Brown, 1990; Perlman,
1994; Seiz & Schwab, 1992; Strom, 1994). Regrettably there are those
who do seem to disassociate themselves from and abandon their identi-
fication with the profession (Perlman, 1994).

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Despite the increase in the percentage of social work practitioners
in private practice, however, most who are so engaged do so on a part-
time rather than full-time basis and continue to be identified with social
work as a profession. According to one study, social workers entered
private practice an average of 10 years after receiving their MSW’s and
the majority were employed in another social work position concurrently
(Brown, 1990). Further, those in private practice are not uniform. There
are those individuals who engage in advocacy and other forms of social
and political action. One study clearly indicated that “combination work-
ers” -those who work in both agency and private practice-occupy a
middle position with respect to their values. “Combination practitioners
value job security, having peer support, helping the poor and promoting
social justice through social change significantly more than do private
practitioners only. This may explain in part why they remain employed
in an agency where these values can be met” (Seiz & Schwab, 1992, p.
332).

Thus, the vast majority of clinical social workers are employed in
social agencies where clinical knowledge and skills, broadly defined, as
well as advocacy and linkage to necessary resources are necessary to
help clients. Further, even working in private practice with middle class
clients exclusively does not, in itself, determine the focus of interven-
tion. Middle class clients are not immune from physical and mental ill-
ness and disability, unemployment, substance abuse, having to place
parents in nursing homes, and other problems that necessitate involve-
ments with organizational structures and environmental resources.

While some have suggested that the values and interests of social
work students are inconsistent with traditionally defined concepts of so-
cial work identify (Bogo, Raphael, & Roberts, 1993), a national study of
graduate social work students shows that the beliefs about “students
flight from traditional social work values into entrepreneurial, private
practice orientations have been overestimated.” It presents evidence
that “students, now as in the past, are predominantly entering social
work to advance their professional skills and potential and are highly
committed to the concept of involvement with the disadvantaged” (Abell
& McDonnell, 1990, pp. 63-64).

LEGAL REGULATION

While the profession established practice standards and a variety of
credentials, the Federal government, private insurance companies, and
the managed care industry have looked to legal regulation increasingly
as the standard by which providers are recognized as competent and
eligible for financial reimbursement. Certification offers title protection;

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EDA G. GOLDSTEIN

licensing establishes who can do what; and vendorship allows one to
qualify for third party payment. The Federation of Societies for Clinical
Social Work, often in collaboration with NASW and other groups led the
fight for licensing and vendorship. While the forms of legal regulation,
titles, and scopes of practice differ from state to state, all states and the
District of Columbia had some form of licensing by 1993 (Biggerstaff,
1995, p. 1518).

Unfortunately, not all of the licensing statutes are equally protec-
tive and practitioners in some states are not able to compete effectively
in the managed care arena. A majority of the states have multi-level
licensing with licensed clinical social work being the most advanced
level with special requirements for supervised experience and other
qualifying criteria. Some have criticized this move as creating a clinical
social work specialization that is elitist and divides the profession while
others argue that the educational and experience standards for autono-
mous and clinical social work practice should be even stronger. A fact
that often is overlooked is that legal regulation not only has enabled
social work private practitioners to achieve more recognition and parity
with other mental health professionals, it also has benefitted consumers
and social work practitioners in agencies across the board by establish-
ing standards and clearly defined titles and scopes of practice.

INCREASING SPECIALIZATION AND THE CLINICAL SOCIAL
WORK IDENTITY

From the 1970s to the present, questions about the scope and
boundaries of clinical social work have continued. The abundance of in-
tervention models and varied interests has led to an exciting array of
treatment models and techniques but also to increasing specialization
and professional fragmentation. There is considerable controversy about
whether certain approaches are consistent with social work practice and
about the knowledge and skills that constitute its core. For example, if
the person-situation perspective is essential to guiding clinical social
work assessment and intervention, are psychoanalysis, hypnosis, bio-
feedback, cognitive/behavior therapies, and certain schools of couple,
family, and group therapy, a legitimate part of clinical social work, par-
ticularly when they are utilized by practitioners who identify more with
members of their particular specialty, regardless of their professional
discipline, than with social workers generally?

The nature of the range of complex problems that clients present
requires no less than that we draw upon diverse conceptual frameworks
and treatment strategies in the process of our work whether we practice
in private or facility-based settings. No theory or intervention model has

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proven itself to be useful in all or most circumstances. We cannot return
to a reliance on those psychodynamic or other theories that conceptually
isolate people from their interpersonal relationships or environment or
psychotherapeutic models exclusively but we also cannot disregard cli-
ents’ difficulties in coping that stem from impairments or deficits in
their inner capacities and their need for more supportive and intensive
individual, family, and group treatment. A person-situation perspective
remains central to a clinical social worker’s assessment lens. While
some of the treatment models that are being used may focus more on the
person than on the environment or the linkage between them, it is natu-
ral that different clients will require different approaches. Nevertheless,
the choice of intervention should be based on our assessment of what
the client needs rather than our favorite treatment model. The view that
psychotherapy is aimed self-understanding or self-actualization rather
than or in addition to helping clients cope more effectively represents a
gross misunderstanding of the treatment process (Specht & Courtney,
1984). In the wake of managed care and the current widespread govern-
mental attack on mental health, health, and other social services, it
seems less important to argue about the boundaries and scope of clinical
social work and more important to protect and foster clients’ rights to a
range of services based on their need and the role of clinical social work-
ers in providing such services in both private and facility-based practice.

While essential to addressing the complex problems that clients pre-
sent, diversity and specialization do create a diffusion and confusion in
our core identification as social workers and in how we portray our pro-
fessional activities. There is not a simple solution to this. The impor-
tance of maintaining a strong and vital profession requires that what-
ever our individual pursuits, we remain identified as clinical social
workers, as part of a profession in which we take pride, and that we stay
connected to its organizations. Clinical social workers must take the
lead in applying our vast knowledge base to addressing the problems of
diverse, oppressed, and economically disadvantaged populations. De-
spite their direct practice focus, clinical social workers must strive to
remain committed to the historical mission and values of the profession
and to fight with others for responsive social policies and service deliv-
ery to all groups in society but particularly those who are disem-
powered. The “age of narcissism” must be replaced by an era of responsi-
ble autonomy. The very legitimacy that clinical social work has had over
the past several decades demands no less, particularly as we face the
constraints on practice that stem from shrinking budgets, the widening
gap between clients’ needs and available resources, the increasing em-
phasis on very brief treatment, the mechanical and indiscriminate appli-
cation of managed care, and efforts to dismantle social welfare programs
and the service delivery structure as we have known it for over fifty
years.

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EDUCATION AND ADVANCED TRAINING FOR CLINICAL
SOCIAL WORK

A continuing problem for clinical social work is the inadequate edu-
cational preparation that practitioners receive in our schools of social
work. A result of guidelines established by the Council on Social Work
Education, social work curricula at the MSW level have tended to em-
body a generalist or multi-method model of practice that addresses work
with individuals, families, groups, organizations, and social change.
While each program is able to select its own Advanced Concentration,
the curriculum guidelines for MSW programs tend to be skewed in the
direction of macrosystems content at the expense of personality theory,
family systems theories, and groups theories and models. Likewise, un-
til more recently, there was a dearth of doctoral programs that offered
specializations in direct practice or clinical social work and there has
been a negative sentiment expressed against the idea of developing clin-
ical social work doctorates both within university based schools of social
work and free-standing, non-university based programs on the part of
certain individuals (Shore, 1991). It is of interest that a 1991 study com-
paring university based traditional and clinical or direct practice doc-
toral programs, which numbered 10 out of 48 such programs, found no
differences in their structure, requirements, or standards (Walsh, 1993).

Several problems have resulted from this state of affairs. First,
MSW graduates lack the clinical knowledge and skill necessary for di-
rect practice whatever the setting, and both the availability and quality
of agency social work supervision appears to have declined substantially.
Further, unless state licensing laws establish clear guidelines for auton-
omous practice, MSW social workers can enter private practice upon
graduation and do not have to undertake supervision or any additional
education and training. Second, post-MSW social workers who want to
enhance their knowledge and skills in clinical social work through a
formal course of study must attend programs outside of schools of social
work for the most part. This prompts them to enter training institutes
in various therapeutic modalities in which they often are not taught or
supervised by social workers nor imbued with social work’s mission and
values. Third, the faculty in schools of social work commonly lack expe-
rienced practitioners. Professors who have attained doctorates in admin-
istration, social policy, or research oriented programs do not necessarily
have the educational background or clinical experience, broadly defined,
to be able to serve as experts in the classroom while other professors
who were once grounded in practice may not have seen a client in years.

There is an urgent need for social work educational programs to
address the needs of practitioners by allocating more curriculum space
to clinical content, to creating substantive specializations at the MSW,
DSW, and PHD levels for those who wish to be clinical social workers, to

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recruiting and supporting experienced practitioners for faculty positions
and helping them to achieve tenure, and by involving qualified and re-
spected practitioners in the curriculum building and teaching process.

THE ROLE OF CLINICAL RESEARCH

Since the discouraging studies on casework’s effectiveness men-
tioned earlier, findings on the outcomes of intervention have yielded
more positive results (Rubin, 1985: 469-76; Thomlison, 1984: 51-56). Yet
the problem of operationally defining psychosocial variables and inter-
vention processes remains. There have been more studies of behavioral,
cognitive, and task-centered therapies, whose techniques and outcomes
are more easily specified and measured, than of more dynamically-ori-
ented or transactional intervention models.

Outcome evaluation is not the only type of research methodology
that can be used to study practice. While studies of the effectiveness of
intervention with specific target problems and populations are needed,
qualitative and other diverse research strategies that move beyond the
current preoccupation with large experimental or single case designs are
equally necessary. Practice principles ought to guide the choice of re-
search strategy rather than research methodology drive clinical work
(Simon, 1994; Thyer, 1994). This issue is likely to become increasingly
important as managed care demands the use of reductionist measure-
ment tools to evaluate patient outcomes and to authorize treatment.
While those involved in practice must help to formulate, design, and
implement clinical research either by acquiring practice research exper-
tise themselves or through collaboration with researchers interested in
clinical studies, it is essential that researchers become more practice
friendly. “From this critical perspective, the real crisis in social work
research is the alienation of countless students from experiencing re-
search as useful or relevant and the failure to articulate an approach to
inquiry that is rooted in the mission and values of the profession and
the realities of practice” (Witkin, 1995, p. 426).

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Eda G. Goldstein, DSW
New York University
Shirley M. Ehrenkrantz School of Social Work
1 Washington Square North
New York, New York 10003-6654

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