On Building a Social Work Consciousness

My perspective on social work has been shaped by my work roles, the agencies where I have worked and primarily, the clients I have served.

My first real job after my Bachelor’s degree was a Head Start teacher. I learned from 3 and 4 year olds that I could not teach if I couldn’t connect with and engage each child in my class. I learned to create an environment of collaboration so my classroom was supportive and fun. The Head Start model also includes the concept of “shared governance.” I learned from the parents–housekeepers, migrant farmworkers, people living in deep poverty–how to organize, lead and create a sense of community.

I went back to school to study social work because as a teacher, I was living in poverty and barely making a living. We had an MSW on staff, Gracie, and she made more money than the teachers. She was also more independent, going out on home visits and meeting with families. At the time, her job was something to strive for. She was the first social worker I ever knew. Once I began my MSW courses, I found in social work a calling beyond mere employment. Social work was versatile and based on values of equality and social justice. I learned I could do research, and intervene on multiple levels to make society better. I was then and continue to be an idealist. I was also able to apply the foundation of empowerment and community that I learned from my Head Start kids and their families.

As a clinical social worker, it is still the clients that continue to shape my practice, my worldview and what I find valuable to pass on to the next generation of workers.  I learned about power dynamics from my work as a disability benefits coordinator at a major insurance company.  It took me a few months to understand my role as part of an oppressive system while working on an inpatient child and adolescent unit.  I thought I was helping when I worked diligently to place kids in residential settings.  I realized much later that I was part of the problem.  I should have been working to address the abusive home environments they had to endure.  Instead I was jumping neatly through each hoop to have them placed in psychiatric inpatient settings away from home.  Those lives weigh on me the most.  I believed to be helping when instead I was an agent of coercion.  I take those lessons with me now when I talk to students about critical consciousness raising in social work practice.

Often I can only embody critical consciousness through words scribbled on a process recording: “What do you think the client might have said if you had let them speak rather than pushing your own agenda?”  “Speak to the unstated emotion, not to the words they are saying.”  “Your client offers you tiny gifts throughout the session, be on the lookout for them, because they appear tentatively and if ignored, may not reappear again.”  I wonder if my students understand the role of dialogue in clinical practice?  I wonder if they see their clients as objects?  How often do I practice the “I and Thou” relationship I aspire to teach?

These questions plague my work today still…as much as they did when I was fresh out of my MSW program.  Possibly more now that I now better.  The paraphrased words of William Schwartz haunt me–it’s not group work in social work practice unless I’m mobilizing my clients toward the social change that will improve their condition.  I am haunted but unresolved.  I know not yet how to change a society that substitutes materialism for social connection, patriarchy for social justice.  I feel like some days the best I can do is only “see and hear” the person before me.  How often do we acknowledge another’s humanity?  Is the 45 minute session in my office when I focus on the person sitting in the chair in front of me with all my heart and soul enough?  Is it enough to be working to empower and activate humanity one person, one group at a time enough?  I do not know.  All I know is to keep going.

And now, as a PhD student, I have been shaped to seek knowledge from thinkers in my field and in other fields–psychology, economics, sociology, education. Through the doctoral study process, have been liberated from my own mind. For a long time, I did not question my own ideas. If I “knew it,” it must be right. In the past 2 years, I’ve had to stop myself and challenge my own thought process repeatedly. I know now that there are multiple ways to know an issue. And only a mind that seeks to know with open curiosity will begin to approach the truth.
Critical Consciousness: A long story, longer…

I have been working on a project at work. We provide substance abuse treatment but we are having a difficult time reaching people who are using intravenous opioids. There is a small population of patients that get severe infections because of shooting up. They end up going into the hospital for long stays during which they are given pain medication while inpatient and upon discharge–dilaudid, morphine, oxycodone. These patients may want to enter treatment but they have little incentive to do so. I’ve been part of a workgroup trying to address this problem. Step one: stop prescribing narcotics to addicts. Step two: get the addicts in treatment. We are still on step one (we need to get the doctors on board with the idea, this is proving to be difficult).

That was two weeks ago.

Last week a man walked into my agency asking for help detoxing from dilaudid. He was just in the hospital for 7 weeks being treated for endocarditis. When he was discharged he was given a filled prescription with 2 weeks worth of dilaudid. Five days after discharge the dilaudid was gone and he was back to buying off the street, trading favors for a high. He was homeless and staying at a temporary bed in the local homeless shelter. He had track marks up and down his arms. He said he’d been trying to get help but “I keep finding closed doors.”

I wanted to help him, but I had to tell him to come back in 3 days. That was the first intake appointment I could get. He came back (most people don’t). As a social worker, I could focus on his individual problem (he’s an IV drug user seeking help to quit) but what about the systemic problem that was keeping him sick? What about the doctor who gave him drugs while he was in the hospital? What about the society that encourages isolation and consumerism over education and connection?

My questions imply a the need for analysis of the problem beyond the individual. A web of social, psychological, behavioral and biological factors create disparities in health & behavioral health.

The man came back, three days later as scheduled. I saw him in the lobby. He was distressed. The doctor had seen him but said he wasn’t meeting criteria for withdrawal. His urine toxicology screen had also come back negative for opioids. “How can that be? I took my last shot last night?? I’m going to leave and get my fix off the street.” I stepped in as social worker and administrator. I knew our doctor had a history of not liking to work with addicts. I found out the facts. She had asked him to wait till 1pm to reassess after another urinalysis. It was 12:30PM. After advocating for him with the doctor and the nurse, I went outside again to talk to the man. I asked him to wait 30 minutes. I told him what the doctor was looking for–signs and symptoms of distress. It was obvious to me he was in withdrawal. He said to me, “When I get to a place and I know I’m safe and I’m going to get help, I relax.” I had to tell him to appear as distressed as possible. The doctor needed to see signs and symptoms of withdrawal in order to medicate him.

The man “passed the test.” He got the medication he needed and he got into treatment. He is committed. He takes notes in group. He has goals and ambitions (“to be a better father to my kids”) that he didn’t have when he was using. I saw him Friday and I thought to myself–there has to be a better way to help people heal from substance use disorders. It should not be this hard to get help. I haven’t figured the answers yet, but thanks to this man’s experience I can begin to ask better questions to help me transform the system.


2 thoughts on “On Building a Social Work Consciousness

  1. This article is really inspiring to me after a difficult day at work. After a few months of stepping into the unfamiliar healthcare world and beginning a brand new social work career, I am finally getting a feel of what my role is as a hospital discharge planner in conjunction with my social work background. But coming to the realization of what exactly my role is has been a little disheartening; my social work heart wants to work much more thoroughly with the patients and their families, take a broader look at the health care system and what it’s oppressors are (specifically in my community/region), and work toward solutions to those oppressors! BUT, I am quickly realizing that the nature of the inpatient hospital world is fast paced, and that there is hardly any time to get the necessary job done effectively (i.e. discharge patients appropriately), let alone work toward those other “social work” goals. How did you transition from just getting to the surface/accomplishing the necessary–to going above and beyond for your patients and clients and figuring out how to identify specific problem areas to focus on?

    Liked by 1 person

    1. Amazing question that hits to the heart of what I was trying to communicate. As a social worker in the field, it took me a long time before I was able to question my role and how I am often the oppressive arm bearing down on the client, in service of the system.
      The job I had in the insurance company? It took such an emotional toll that I took the first chance I got to leave. Why? Because it went completely against my social work values and the system was too ingrained and powerful for me to be able to change it. I would have had to become a lobbyist for healthcare reform. Or a researcher on how healthcare companies’ decisions impact people’s lives. I was speaking to someone I worked with at the time and she said that job gave her bad karma. We never felt we were working in the service of anyone but the insurance company. It was dehumanizing for all and ultimately we couldn’t take it anymore.

      Hospital discharge planning is tough work in a similar sense. You’re there to work for the system and the system is often inhuman. And yet we are trained to see the human, connect and help on a human level. I hear you because I’ve been there– job is also extremely fast paced so you are often moving too fast to be able to pay attention to the detail that’s needed. Often it’s only been in retrospect that I can see how far I drifted from my fundamental social work values.

      My advice to you is to learn the ins and outs of the job. Critically analyze your system…are your personal & professional goals aligned with the values & mission of the healthcare system you work for? If not, find another place to work (easier said than done, I know). Get licensed if you aren’t already. That brings power. We can’t make big systematic changes without power, respect and buy-in. But you have to earn that through time, expertise and social connection within the system.

      I learned to go beyond myself by challenging myself and looking for the places I was wrong. That has always been an ongoing process. I’m still wrong. Still make mistakes. I haven’t stopped fighting though. But I have been able to get to a place in the system where I work where I can make those systemic changes. Usually just one program or one small procedural change at a time. But those add up. And I find that if I’m clear with my values, it’s easier to figure out if I’m on the surface working the system or going deep (usually one interaction at a time). My values are human connection, easing the suffering of others, doing high quality work and clinical innovation.

      I don’t get the every time, but I know if I’m clear of my aim, I’ll get there more often than not.

      In your day to day? Connect with the people you can. Treat them as human beings and be aware of the power differential you carry with you when you walk into a room. See the gaps in the system (both in the hospital and in the community) as social problems to be solved…and network, build human connections everywhere you go through your role as a social worker. Those build over time and people remember you care. That is the true power of social work and how we can eventually make a difference in the lives of our clients.

      Liked by 1 person

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