Abstract
For a full century, social workers have grappled with defining social work practice. Today, efforts to define clinical social work continue to be challenging as there are varied occupational tasks within practice often applying theories from other disciplines (e.g., psychology or sociology; Noble & Henrickson, 2014). Social work's foundations in the early 1900s grounded practice in the case work model which assessed how the individual's environment was a source of or relief from stress (2015). Through the 1970s, social work continued to place emphasis on the social component of the work, looking to person-in-environment as components of change (Cooper-Bolinskey, 2019; 2015). From the 1940s to 1970s, social work focused on the process of licensure and regulation with the goal of protecting practitioners and consumers (Johnson, 1970); this appears to coincide with a shift in clinical practice from person-in-environment to intrapsychic processes (Thyer, 2017). While the delineation and definition of clinical social work in licensing emerged from efforts to professionalize practice and protect clients, it has caused a rift in the discipline's identity (Cooper-Bolinskey, 2019; Plitt Donaldson et al., 2014; Weiss-Gal & Welbourne, 2008). Within direct practice work there now appears to be a designation between clinical and nonclinical work (Cooper-Bolinskey, 2019; Groshong, 2009). Research on social work's definitions of clinical practice in licensure and the potential impact of these regulations on the profession is emergent (Cooper-Bolinskey, 2019, 2016; Groshong, 2009) yet has considerable implications for those in the field.
The notion of clinical social work practice is sometimes associated with private practice, which is typically viewed as more mentally sustainable and financially lucrative (Slater, 2020). The establishment of private practices in the 1970s coincided with the proliferation of associated clinical licensure, allowing social workers to set their own rates for psychotherapy services and bill insurance companies (Gibelman & Schervish, 1996). This process may have also tied the notion of clinical licensure solely to billing for psychotherapy, thus limiting the goal of professionalizing or standardizing services to best serve clients. It may also link the idea of individual psychotherapy, and perhaps implicitly the tasks of the private practitioner, as the truest or only form of clinical practice. Case management, for example, was explicitly excluded from discussions of clinical practice in the 1970s. In 1976, the Joint Commission on Accreditation of Hospitals issued a report designating case management as an environmental intervention that was inherently different from other therapeutic interventions. The Joint Commission limited the definition of case management to assessment, planning, linking, monitoring, and advocacy, explicitly removing the therapeutic components of the practice (Kanter, 1989). This report emerged from efforts to comply with a key element of a National Institute of Mental Health model rather than through a comprehensive evaluation of case management and its theoretical base (Kanter, 2020). Perhaps due to this lack of clear definition in the literature and in policy, it appears each state delineates clinical social work practice in a different way.
There is limited discussion of the clinical license and its processes in the research literature. The authority to regulate and license social work practice is delegated to the states. Jurisdictions adopt their own standards and requirements in statutes and regulations. States nearly uniformly require social workers to obtain clinical licensure through education from a Council on Social Work Education (CSWE) accredited program, examination, and documentation of experience (i.e., field practicum and work experience). Although there are exceptions for states that offer alternate paths or different sets of education and experience requirements for the same bachelor's or master's license, requirements to obtain a clinical license is somewhat uniform across states including practice activities possibly designated as a Licensed Clinical Social Worker (LCSW) or Licensed Independent Clinical Social Worker (LICSW). There are generally two steps post-master's required prior to clinical licensing: passing the clinical licensing exam and completing a minimum of practice hours under the supervision of a licensed professional.
There is limited research however on why practitioners choose each category of licensure including whether it is required by their employer. Some states require a generalist or master's category of license (e.g., Licensed Master Social Worker (LMSW), Certified Social Worker (CSW), or Licensed Graduate Social Worker (LGSW)) which the practitioner must hold while working to obtain their independent clinical license (Arndt et al., 2021). Obtaining master's level license may require passing the master's examination; 28 of the 49 states with a clinical and master's license require licensees to first pass the master's exam and obtain the master's license before they can work to obtain supervised practice experience for the clinical license (Association of Social Work Boards [ASWB], 2022; Supplement 1). An analysis of the path to licensure in Hawai’i found that most social work graduates do not pursue licensure and that the state-level policies impacted this decision. Hawai’i's model has three categories of licensure (i.e., Licensed Bachelor Social Worker, the Licensed Social Worker (LSW) and LCSW). The state does not require that a practitioner obtain an LSW prior to an LCSW. Researchers found that 60% of a licensed Master of Social Work (MSW) graduation cohort in Hawai’i maintained an LSW alone while the remaining 40% pursued an LCSW (Arndt et al., 2021).
While there is little to no formal research on why practitioners choose to pursue the clinical category of licensure; what is clear is the need for licensing to offer protections to practitioners and clients. The process allows practitioners to appeal to a higher body (i.e., their licensing board) when asked to do something unethical in the workplace and offers some collective standards for pay and benefits. Perhaps as evidence of the importance of practitioner-level protections, research suggests employers attempt to subvert licensure. In Texas, for example, agencies assign jobs with different job titles (e.g., case manager) with the same duties as LSWs to avoid hiring and paying licensed providers (Bowblis & Smith, 2021; Cavazos, 2001). The effects of not hiring LSWs are seen in nursing homes, where federal regulations require a social services staff person only for facilities with more than 120 beds and do not require that person have a social work degree. The lack of licensed social service professionals has had an adverse impact on the quality-of-care provided to nursing home residents (Bern-Klug et al., 2018; Bern-Klug et al., 2021). Discharge planning has suffered from a lack of attention to psychosocial factors (Bern-Klug et al., 2018; Bern-Klug et al., 2021) and adverse behavioral health outcomes have been associated with lack of more highly qualified workers, including licensed professionals (Roberts et al., 2020).
Social work regulated scope of practice activities appears to vary by the state more than other health professions (e.g., nursing; Cooper-Bolinskey, 2019; Groshong, 2009). In a 2017 qualitative study of social workers, participants cited inconsistency in social workers’ ability to diagnose mental health disorders or provide psychotherapy and perceptions from the public that social workers did not provide psychotherapy and were often seen solely as child welfare workers (Cooper-Bolinskey, 2019). Also noteworthy, are a variety of exemptions across states that allow individuals to practice social work without a license. For example, social workers employed by designated state agencies are exempt from licensure in 22 states. Social work trainees under supervision and individuals responding to an emergency need not be licensed in several states. Other states are more specific and do not require any category of licensure for those conducting hypnosis (California), employees of community mental health clinics (Colorado), directors of social service agencies (West Virginia), and foster care workers (Vermont; Sanner, 2020). The impact of these exemptions on clients and practitioners has not been explored in the literature.
Regulation protects clients or social work consumers by offering recourse if they are treated unethically by licensed providers including a states’ ability to prevent the proliferation of harm through the use of unethical treatments for clients (Jenkins & Johnston, 2004) and unethical interpersonal behavior (Boland-Prom, 2009; Magiste, 2020). Nationally, the most frequent ethical violation appears to involve boundary violations in the form of dual relationships; 22% of sanctions placed on licensees were due to boundary violations half of which are described as sexual and romantic relationships with clients. The next highest categories are licensure-related including continuing education noncompliance (10.5%), working without a license (4.5%), and misrepresentation of information or training (3%); followed by crimes (e.g., thefts in billing; 6% and driving under the influence 3%); and then meeting basic practice requirements (e.g., not maintaining records 6% and violation of confidentiality 2%; Boland-Prom, 2009). In one state, 38% of ethical violations involved licensure itself (e.g., failure to meet continuing education requirements) while 26% represented boundary violations (e.g., sexual relationships with clients; Magiste, 2020).
In the 1970s, voices in the field criticized the licensure process as a “status accruing device” (Hardcastle, 1977, p. 20). The primary role of the licensing process is to protect practitioners and, perhaps most importantly, clients. The field should also pay attention to any unintended consequences of licensing regulations and practices. One such unintended consequence is the appearance of a separation of clinical and nonclinical direct practice social work. To support workers in the field and inform future policy, research, and discussion on how states define clinical practice is warranted.
Methods
The authors were interested in how licensing boards define post-master's degree social work experience required under the direction of a supervisor to apply for a clinical license. Each state's (including the District of Columbia, Guam, Northern Mariana Islands, and US Virgin Islands) statutes regulating social work were searched individually for both definitions of clinical social work practice and the type of clinical social work practice experience required under supervision to achieve the highest level of clinical licensure. Note, Puerto Rico does not require post-master's experience for licensure (Law of Puerto Rico 20 § 844, 2012). Some states defined clinical social work practice that qualifies for supervised practice to meet clinical licensure requirements separately from their statutory definition of clinical social work practice. In these cases, the definition provided in the statutes describing required work experience was used. Definitions were identified by first (a) navigating to the state regulating body (e.g., Board of Social Work) website; (b) following links or searching for referenced state statutes and regulations outlining definitions, policies, and procedures; and (c) recording these definitions and their sources (Supplement 2). All definitions were cross-referenced with documentation from and consultation with the ASWB.
Results
States require between 2,000 and 4,000 hours of supervised practice post-master's degree to apply for clinical licensure (Table 1). Fourteen states, and Guam, require that a portion or all post-master's degree supervised practice hours consist of psychotherapy only. Alaska, for example, defines “clinical social work” as “the diagnosis of psychiatric disorders and the use of techniques of applied psychotherapy” (State of Alaska, May, 2021). Some states, like New Jersey, allow a certain proportion of hours to include activities outside psychotherapy. Psychotherapeutic counseling, is however, still a required form of supervised practice to meet independent licensure standards (New Jersey Administrative Code Title 13, 2020). A total of 31 states, plus the US Virgin Islands and Northern Mariana Islands, include treatment modalities outside of psychotherapy in their definition of clinical social work practice that qualify for clinical licensure. Some states are specific about including psychotherapy but not limiting other forms of practice. Connecticut provides an example, “clinical social work includes, but is not limited to, counseling, psychotherapy, behavior modification and mental health consultation” (Connecticut General Statutes § 383b-20–195m, 1995).
Jurisdiction, level of licensure, summary definition and requirements of supervised practice toward clinical licensure.
There are six states (Table 2) that have more specific or different language related to the regulation of clinical practice. Washington, DC and North Carolina allow for the inclusion of clinical case management in their qualifying hours of supervision. Washington, DC states, “most ‘case management’ will not count toward [the licensed independent clinical social worker (LICSW)] licensure, clinical case management may be considered by the Board if the application can demonstrate how [the applicant's] 3,000 hours of clinical practice experience included and focused on diagnostic assessment, biopsychosocial assessment, goal-oriented psychotherapeutic treatment, and receipt of theory-based clinical supervision” (District of Columbia Board of Social Work, 2014). In North Carolina, clinical case management is defined as “… planning, implementation, and management of care for clients with one or more of the following: mental, emotional, addictive, behavioral, or developmental disorders and conditions … grounded in clinical social work theory …” (North Carolina Administrative Code § 21–63-.0102, 2017). Indiana, Kentucky, Mississippi, and Utah use different terminology including “counseling” (State of Indiana, 2012), “treatment of an emotional disorder or mental illness as related to the total health of the individual” (Kentucky Revised Statutes § 23:070 (2021)), “a holistic approach to psychotherapy and the client's relationship with [their] environment” (Mississippi Code § 30–1902–1.1 (2011)), and “mental health therapy” in Utah (Social Work Licensing Act Rule, 2015).
Jurisdictions with more specific definitions of clinical practice.
Discussion
Based on analysis of licensing boards, it appears there are two definitions of clinical social work practice. Fifteen jurisdictions have chosen a restrictive definition that excludes practice outside of psychotherapy. A second cohort uses a more inclusive definition of clinical work. One example of this expanded definition of clinical social work practice can be found in the case management literature. A working definition of social work case management is the process of engagement, education, networking, advocating, and brokering linkages to resources for an individual (Vourlekis & Greene, 2017). The notion of clinical case management takes this definition a step further, noting the leveraging of community resources but also an ongoing therapeutic relationship and therapeutic processes inherent to the practice (Kanter, 1989; 2020). While often associated with clients living with severe and persistent mental illness, the practice of clinical case management and other advanced case management models have been used with clients with chronic illness and in geriatric care settings (Kuo et al., 2018; Iliffe et al., 2019). The key component shifting this work to clinical social work is investigation into and engagement in dialog surrounding the emotional or psychological needs of the client (Kanter, 2020). Arguably, brief interventions that do not develop a therapeutic relationship (e.g., hospital discharge planning) would not meet this definition of social work case management. Additionally, the Centers for Medicaid and Medicare (CMS) allow for billing for case management from the perspective of the client population rather than the therapeutic processes involved. Here, CMS defines targeted case management as helping special groups of enrollees such as those with developmental disabilities or chronic mental illness to gain access to needed services (e.g., medical, or mental health; CMS, 2007). Of note, the ASWB (2020) created a model law for state social work boards and legislatures that includes psychotherapy but does not explicitly exclude other forms of clinical practice.
Unintended Consequences
The current study's findings are different from Cooper-Bolinskey (2019) where clinical social workers felt limited in their ability to provide psychotherapy to clients; some jurisdictions restrict the definition of clinical social work to psychotherapy. Boards of Social Work that limit clinical social work to psychotherapy may create challenging situations for practitioners seeking clinical licensure. Evidence-based psychotherapies have started to integrate systems-level interventions, including case management, into their models of practice. The most prominent example of this is dialectical behavioral therapy (DBT; Linehan et al., 2015). The psychotherapeutic processes of DBT target impulsive behaviors including suicide and other forms of self-harm using mindfulness, cognitive behavioral, and case management interventions. The goal of case management in DBT is to facilitate an environment for healing through the engagement of support systems including family members or community resources and is essential to DBT's efficacy (Linehan et al., 2015; 2006). Here, DBT provides an interesting example. In some jurisdictions, social workers working towards clinical licensure may have to stop the clock when providing these concrete services, as they would not count towards requirements. Social workers could then resume counting their experience when providing one-on-one psychotherapy per the DBT protocol.
The exclusion of forms of clinical practice outside of psychotherapy may also restrict access to clinical licensure, potentially perpetuating wealth, White, and male privilege in the social work profession (Bhuyan et al., 2017). One might infer that limiting these paths to obtain clinical licensure for new social workers protects private practitioners from competition. Securing a job that solely provides individual psychotherapy may also not be possible in the reality of contemporary social work practice or these jobs may be highly competitive. First, positions providing services like case management are readily available. A 2017 report from CSWE, National Association of Social Workers (NASW), and George Washington University (Salsberg et al., 2017) found that almost 90% of new social workers perceive case management jobs as the most available in the field. Second, income disparity may influence who does or does not become licensed as a clinical social worker. Hospital-based social work, for example, would likely not qualify as a psychotherapeutic work experience yet generally pays better than agency-based psychotherapy practice (NASW, 2010). Thus, those needing positions making living wages may take hospital positions at the risk of not achieving clinical licensure. In terms of race and gender, a report from the CSWE found that 5% of White MSWs work in private practice settings as opposed to 2.9% of African American MSWs and 0% of Asian or Pacific Islander MSWs. Male social workers are more likely than female social workers to work with people with mental health concerns (37% vs. 26%; of note the CSWE did not ask about nonbinary gender identity in their survey; Salsberg et al., 2018).
Applications of Clinical Skills
Counting only psychotherapy as clinical practice may also exclude other forms of practice that require advanced clinical skills. In medical social work, practitioners engage systems-level thinking and ethical standards of social justice. Medical social workers within primary care or inpatient settings mitigate fragmentation of medical care (Kuo et al., 2018; Iliffe et al., 2019) and improve continuity of care (Haggerty et al., 2003). These activities require an understanding of complex practice theories and skills. Effective engagement and assessment are dependent upon the establishment of a therapeutic relationship quite rapidly. This process of rapport building requires an understanding of psychodynamic principles including defense mechanisms, transference, and countertransference (Vourlekis & Greene, 2017). The social worker conducts an assessment (Wade & Halligan, 2017), identifying goals, assets, and barriers to achieving those goals, as well as needed resources. This process calls upon the social worker's knowledge of eco-systems theory (Turner, 2017). To successfully link clients with community resources, the social worker uses psychotherapeutic techniques such as problem solving (Alexopoulos et al., 2016) or cognitive behavioral therapy (2010).
Protecting Consumers
The goal of regulation and licensure is to protect consumers; it is possible that clinical practice as defined in regulation is more closely aligned with direct practice in psychotherapy because psychotherapy is perceived as having the greatest risk of harm to the client. The research evidence on ethical violations does not bear this out. Outside of violations to licensure itself, the most frequent violations involve boundaries including sexual relationships with clients, criminal activity outside of the practice environment, and basic practice standards (e.g., abandoning clients or violations of confidentiality; Boland-Prom, 2009; Magiste, 2020). These violations could occur while engaging in a variety of practice modalities including psychotherapy or case management, and in practice settings like hospitals or nursing homes.
Limitations
In the spirit of street-level bureaucracy (Lipsky, 2010), it is not known how policies defining qualifications for post-master's experience that qualify for licensure are put into practice. For example, these 15 jurisdictions may allow other types of practitioners (e.g., hospital social workers) to demonstrate how their work would meet the definition of psychotherapy and thus allow them to use those hours towards independent licensure. As such, Boards or administrators may make decisions to interpret statutes as written.
Recommendations for the Profession
Public health, medicine, nursing, psychology, and other professions have become leaders in health care's attempts to address poverty, racism, sexism, and other social determinants of health. Medical care accounts for only 10%–20% of contributors to modifiable health outcomes (e.g., prescription medication for hypertension)—the remaining 80%–90% are attributable to social needs (e.g., access to healthy foods, the stress of poverty; Hood et al., 2016). This statistic, which has been used to introduce conversations about social determinants of health, is not surprising to social workers yet interventions aimed at impacting social needs do not fit many definitions of clinical practice. Additionally, systems including hospitals (Reeves, 2015), nursing homes (Bern-Klug et al., 2018), and outpatient medicine (2018) are adopting a trauma-informed care lens for their work. Trauma-informed care requires screening for past traumatic events, improving patient-provider relationships, collaborative and well-coordinated care, and a dedication to self-determination (Reeves, 2015). Social work practice outside of traditional mental health practice settings using the trauma-informed lens, requires the extensive clinical training, supervision, and continuing education social workers receive with a clinical license (Levenson, 2017).
Licensing boards might consider a more inclusive definition of clinical practice. Social work outside of traditional psychotherapy can include an ongoing therapeutic relationship, use of therapeutic processes (Kanter, 1989; 2020), and the processes of engagement, education, networking, advocating, and brokering linkages to resources that are inherent to working with social determinants of health and trauma-formed care (Levenson, 2017). Excluded from this definition, are brief interventions that do not use a therapeutic relationship to explore psychotherapeutic processes or barriers to goal attainment. This definition allows for key practices in the field of social work occurring in hospitals and community-based agencies to meet the definition of clinical social work. An alternative to defining clinical social work more broadly may be to place decisions about the clinical nature of the work in the hands of supervisors, who already attest to the number and nature of practice hours for applicants and are generally already licensed in that state.
Conclusions
This discussion calls to mind the notion of privileging in all its definitions and applications. While licensing and regulation protects consumers, it can also serve as a gatekeeper—privileging some forms of practice over others. The evidence suggests that social work outside of psychotherapy, when clearly defined, provides clinical services to the most vulnerable clients. Social workers perform a variety of tasks in myriad settings (e.g., with clients living with serious mental illness or chronic illness). Evidence suggests these services are effective and psychotherapeutic techniques and skills are essential for their implementation. It appears that in some instances social work licensing authorities have erroneously assumed that social workers not performing psychotherapy are providing brief, purely administrative interventions and not engaging in clinical work. Social work researchers and policymakers may consider efforts to standardize and refine the definitions of clinical social work. Social workers connect clients to needed concrete resources and do so with aplomb. Neglecting training and education for the more clinical or therapeutic aspects of the work further perpetuates the myth that people with severe and persistent mental illness or living in poverty do not have psychotherapeutic needs (Santiago et al., 2013). This carving of the definition of social work arguably places attention to the social context lower in the hierarchy than a focus on psychotherapeutic processes.
Supplemental Material
sj-pdf-1-rsw-10.1177_10497315221118361 - Supplemental material for Defining Clinical Social Work and its Implications for Practice
Supplemental material, sj-pdf-1-rsw-10.1177_10497315221118361 for Defining Clinical Social Work and its Implications for Practice by Katharine Bloeser, Cara Sanner and Jennifer Henkel in Research on Social Work Practice
Supplemental Material
sj-docx-2-rsw-10.1177_10497315221118361 - Supplemental material for Defining Clinical Social Work and its Implications for Practice
Supplemental material, sj-docx-2-rsw-10.1177_10497315221118361 for Defining Clinical Social Work and its Implications for Practice by Katharine Bloeser, Cara Sanner and Jennifer Henkel in Research on Social Work Practice
Footnotes
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. The opinions expressed in this article are those of the authors and do not represent the opinions of the Association of Social Work Boards (ASWB).
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
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References
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