"Sense" and Sensitivity: The Development of Clinical Expertise in a Residential Treatment Center for Children
Contemporary scholars of social work practice have debated the relative value of various domains of knowledge, at times acknowledging the importance of so-called “practice wisdom” (Gilgun, 2005; Klein & Bloom, 1995) or “clinical expertise” (Fook, Ryan, & Hawkins, 1997; Haynes, Devereaux, & Guyatt, 2002) in effective and ethical social work practice. However, empirical studies of how these constructs are understood and enacted in contexts of actual social work practice are few. This ethnographic study of mental health workers in a residential treatment center for emotionally disturbed children asks: 1) What are mental health workers’ understandings of what constitutes clinical expertise in direct practice with their clients? And, 2) What are the processes through which clinical expertise is learned and enacted in this context?
Methods
This paper is part of a larger ethnographic study conducted by the author, which is based on 13-months of participant observation and interviews in a residential treatment center for children in the Midwestern U.S. 1500 hours of participant observation of 78 consenting mental health workers—including MSW and BSW level dormitory counselors, LCSW and PhD level psychotherapists, program managers, and executive staff—were conducted during work shifts, which included interactions with clients in the residential milieu, group psychotherapy, staff meetings, and trainings. Tentative theories in regard to these research questions were developed through participant observation, and checked and refined through 35 semi-structured interviews with key informants. In the iterative process of theory building characteristic of ethnography, these theories were refined again through additional conversations with key informants.
Results
Mental health workers often adamantly described “common sense” as a natural, un-learnable attribute of effective mental health workers and as central to their conceptions of clinical expertise. However, participant observation of direct practice and informants’ accounts of failures of common sense reveal that what workers term common sense is in fact complex and highly context-specific—if often tacit—knowledge about clients, the organization, clinical theory, and research. As such, the locally valued attribute of clinical “sense” is not naturally occurring, but acquired by novice workers through processes of legitimate peripheral participation (Lave & Wenger, 1991) in the therapeutic milieu. It is argued that the attribute of sensitivity (a vigilant, searching, carefully attuned orientation to physical and social surroundings) allows certain novice workers to capitalize on their ability observe expert workers in action and quickly develop what is locally recognized as “common sense,” but may be better termed clinical expertise.
Implications
This study suggests that mental health workers often identify innate “common sense” as a key component of clinical expertise in the context of residential treatment. However, data support the conclusion that novice workers are indeed able to acquire and enact clinical expertise through informal apprenticeship among expert workers, supporting the idea that “transparent” work environments, such as the therapeutic milieu, make situated learning possible (Lave & Wenger, 1991). This study represents an early step in building an empirically-grounded theory of the composition and development of clinical expertise in social work practice.