Understanding How Social Workers Balance Strengths and Disorders in Clinical Practice

Background and Purpose: The place of the DSM (Diagnostic and Statistical Manual of Mental Disorders) in social work practice continues to be a topic of intense debate, yet there has been little research about social workers' experience balancing the contradictory demands of legitimizing a client's need for service (via diagnosis) while maintaining strength-based values. A diagnostic label is the entrée to service and financial support, yet emphasis on problems and pathology runs counter to social work's core belief in client strengths (Blundo, 2001; Sands, 2001) and endorsement of the diagnostic system may be seen as betrayal of the very ethic that sets social workers apart from other mental health professionals (Ishibashi, 2005). Given that social workers provide more therapeutic services than any other group of professionals (Kirk, 2005), it is important to explore their experience addressing this issue. An exploratory study was thus conducted to examine in what ways and to what extent clinical social workers incorporate concepts from the strengths perspective into assessment and treatment.

Method: A purposive sample of clinical social workers was recruited to take part in individual, semi-structured interviews. In-depth interviews were conducted with 12 social workers (7 female, 5 male) to elicit rich idiographic information about their experience balancing these two perspectives. Interview transcriptions were analyzed via open (in vivo) and axial coding (Charmaz, 1995, 2006), using the constant comparison method of grounded theory (Corbin & Strauss, 1990) to identify core categories and relationships among categories. Thematic clusters were identified across interviews (Miles & Huberman, 1994) until saturation was achieved.

Results: Findings revealed four major themes: (1) when and how “thinking diagnostically” is useful, in contrast to “labeling;” (2) waiting for strengths to emerge, rather than clinician-directed efforts to seek or point them out; (3) pitfalls of timing, readiness, and counter-transference; and (4) the need for sensitivity in balancing validation of the problem with transformation of the problem. The theme of balance emerged as the central phenomenon: participants felt able to make use of the diagnostic system when and how it seemed helpful, without feeling that doing so compromised their fundamental identity as social workers. Rather than experiencing this dual perspective as a source of stress, they valued the ability to tap into both realms and considered it an enrichment of their clinical palette.

Conclusions and Implications: Besides providing new insights, this study offers direction for further research as well as implications for social work practice and policy. Clearly, one of the determinants of mental health policy is the system for determining who gains access to treatment and what kind of treatment. At present, the gatekeeper for services remains a DSM diagnosis; a client's strengths may, in fact, be minimized, lest they limit the duration or intensity of services. Given social workers' expanding role in providing mental health treatment, it is vital to understand how they address this issue – what works and what are the pitfalls – in order to develop effective practices and policies that best benefit clients.