Gaps In Service

My previous posts seem a little more on the "academic" side of things, so I wanted to write something that is more of an opinion piece. After reading, please share your thoughts and perspectives on the issue as well. I am not married to the opinion...yet, so feel free to try and change my mind on the issue.

Today, as the title states, I wanted to discuss gaps in service. Not a specific gap in service other than an example to illustrate my point, but rather the overall concept. I often hear the term gap in service thrown around when social workers do not find a particular resource for a client; whether the would-be resource is sustainable or not.

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Example

Every now and then I am asked about detox services for youth in my county. There aren't any. One time in 2019 someone called me at working asking about this service. I explained that it was not available in county and provide some resources throughout the state and that insurance should be contacted. The caller stated that this was a gap in service and my employer needed to do something about it. I work for the county's behavioral health authority. I explained that in the time I worked there, this was one of two calls I had gotten about the service and that if she had data to back up the need I would love to talk more about it. She explained that people asked her all the time about detox for youth so I encouraged her to keep track so we could have some data. She hasn't called me back.

Recently there was a Facebook post asking about detox services for youth. There were several replies all saying basically the same thing; there aren't any. The original poster replied, "it seems this is a huge lack of resource in the community". Again with the gap in service.
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When a resource isn't available does it automatically become a gap? From a micro perspective I get it; a social worker has a client who needs a service that simply isn't available. From a macro perspective I struggle with this. How is a gap in service determined when no data on actual need is available? How do public and private agencies fund a service when known needs go unmet due to lack of funds? How is a service sustainable when only a relatively small number of people need it?

Data is really paramount in determining need. That "one client" isn't enough to change or develop a new system. We need more than anecdotal accounts. Data helps identify and substantive the need along with helping to determine how to plan to meet the need. The NASW Code of Ethics talks about the need for social workers to engage in social and political action to ensure that people have equal access to resources, employment, services, and opportunities that help them meet their basic needs. We live in a data driven world and to be able to effectively advocate for change we have to have the data that speaks to that need.

Just calling something a gap in service is not doing anything to fill that gap or increase opportunities for people in need in the future. As social workers we need to recognize the gap, collect data on the need, and then advocate for change. 

Evidence-Based Practice

I recently read an article entitled Where Is the Evidence for "Evidence-Based" Therapy by Jonathan Shedler (2018). As the title implies, the article focused on therapy. The term evidence-based has become almost synonymous with manualized therapy which most often more scripted forms of cognitive behavioral therapy. Shedler points out that while it is accepted that evidence-based therapy is better than other forms of psychotherapy, this is not always the case and empirical research shows weak results for evidence-based forms of therapy. It is an interesting article and I am not here to offer a critique, but it did make me this about the state of evidence-based practice and what it all actually means.

I recall being in my BSW and MSW programs and there being a focus on "evidence-based" treatments and we understand the evidence for these comes from scientific, peer-reviewed journals. It my experience, which I am sure will resonate with others, if there is literature that shows the effectiveness of an intervention then that intervention is evidence-based. The more literature available the better evidence for that practice. Now this is a good starting point, but evidence doesn't end there.

This is an important venn diagram to better conceptualize evidence-based practice. You'll see in the middle of the diagram is EBM (evidence-based medicine) another term for evidenced based practice. EBM started in the medical literature and was later adopted to other areas such as therapy. In looking at this diagram, you'll see there are three areas that contribute to what evidence-based practice really is. You may remember seeing this in school, but I believe it is a good reminder that it is not just the scientific evidence/peer-reviewed literature; it also includes clinical judgement and consideration for a patient's/client's values and preferences.

What does this mean for social workers? According to the NASW Code of Ethics (2017) " Social workers should critically examine and keep current with emerging knowledge relevant to social work and fully use evaluation and research evidence in their professional practice". It is our responsibility to evaluate evidence that is presented in the literature, but also to temper this with one's own clinical judgement and the client's values and preferences. Clinical judgement is developed through practice is experience. Reading literature and attending training is important, however it does not take the place of actual practice experience. Furthermore, we social workers also need to be culturally competent. I don't want to get into the topic of cultural competence, because that is reserved for an entire discussion itself. The Code of Ethics states that, "Social workers should understand culture and its function in human behavior and society, recognizing the strengths that exist in all cultures" (NASW, 2017). Understanding culture is one aspect to understanding a client's values and preferences, it is also important to build rapport to understand the idiosyncratic values and preferences of each client. 

Employing evidence-based practice is good social work practice, but relying solely on literature to implement evidence-based practice is not the best practice. One's own clinical judgement and the client's values and preferences need to be consider in addition to the literature, but a social worker should be competent (NASW, 2017) in the services they provide and they should monitor and evaluation the interventions they use (NASW, 2017). What is not included in this discuss and may be assumed by some, is that whatever the intervention, one should monitor and evaluate it's effectiveness. Social workers need to set-up measures that look at effectiveness during the course of the intervention.

Good, ethical social work practice involves competence, critically examining literature, experience to develop one's clinical judgement, understanding of culture and the client's values/preferences and then monitoring and evaluating chosen interventions for effectiveness.

Training Supervision

According to Ohio Administrative Code 4757-23-01, Training supervision refers to "supervision for the purpose of obtaining license and/or development of new areas of proficiency while providing services to clients. The training supervisor is responsible for providing direction to the supervisee, who applies social work theory, standardized knowledge, skills, competency, and applicable ethical content in the practice setting. The supervisor and the supervisee both share responsibility for carrying out their role in this collaborative processes of professional growth and development". 

Clinical supervision is about the act of supervising those who have a dependent license in a clinical setting. Clinical supervision can be provide by licensed independent social workers and other professionals with an independent practice to license such as a psychologist, licensed professional clinical counselor, or licensed independent marriage and family therapist. Training supervision can only be done for social workers by a independently licensed social worker with supervisor designation (LISW-S). 

Obtaining training supervision is one requirement for social workers seeking independent licensure. There are minimal training standards for the LISW-S, however, they are ethically responsible for providing training supervision within their own proficiency and competencies. The NASW Code of Ethics states that "Social workers who provide supervision or consultation (whether in-person or remotely) should have the necessary knowledge and skill to supervise or consult appropriately and should do so only within their ares of knowledge and competency" (Standard 3.01). An individual I supervised asked wanted to develop competency in marriage therapy. I do not have knowledge or competency in that so I suggested some training resources and we discussed the role of communication in relationships, however we did not discuss the actual practice of marriage therapy. I could have speculated on the subject and may drew from other experiences, however it would have been inappropriate me to address this directly with the supervisee because it is not an area I am proficient in. 

Knowledge and competency come from both education and experience; there is no substitute for professional experience. As a generalist social worker and graduating from an advanced generalist program, I have various experiences at the micro, mezzo, and macro levels and in addition to some specific interventions and therapies. I wouldn't consider myself an expert in a certain type of therapy or intervention because of my generalist practice. I however have developed a framework for supervision that I share with those I supervise. The framework addresses the theories and frameworks on draw on and those interventions we may discuss in supervision. 

Another role of training supervision which is not explicitly addressed in the Ohio Administrative Code, is the preparation for independent license and advanced practice. Training supervision's role is not intended to be remedial training on social work theories, values, ethics, or interventions; it is to help supervisee's move towards advanced practice. One resource I wanted to draw your attention to was CSWE's Advanced Social Work Practice in Clinical Social Work (PDF). This is a resource that takes the educational competencies and distinguishes what a social work should be able to do and an advanced practitioner should be able to do. I provide this resource to everyone I supervisee so they can understand what advanced practice looks like and it provides some guidance on how their logs can reflect advanced competency. CSWE provides other documents similar to this which are good resources as well. The Association for Community Organization and Social Action (ACOSA) has developed a document on Advanced Practice in Macro Social Work (PDF). Whatever level of practice a social worker focuses on, developing some skill in macro practice is important for all social workers. 

Introduction

About Me

I am a licensed independent social worker with supervisory endorsement and licensed independent chemical dependency counselor in Ohio. I have been practicing as a licensed social worker for nearly a decade and have come to fully appreciate the advanced generalist framework/perspective. I completed my MSW at the University of Toledo where I am pursing a PhD as well as a DSW from Walden University. For more about my professional experiences check out my LinkedIn and let's connect. 

Purpose

I want to want to be a blogger, but I'm not very creative in my writing nor do I have the constant inspiration to come out with content. Really, the purpose of this blog, website, or whatever you want to call it is to capture some of my thoughts and ideas and provide a place to capture resources that I find helpful.