The Healing Power of Clinical Social Work

People come to therapy for three reasons: to heal, to problem solve, and to grow.  Psychological wounds heal only through the soothing, transformative, and liberating power of successful attachments to other human beings.  Our psychological selves come into being through attachment and we grow and develop as psychological beings through successful attachment and attachment supported differentiation.  Without bonding to another human figure, newborn  babies will not thrive and may die.  Much of mental illness is a result, in part, from failed, punitive, insecure or deficient human attachments.  In general, the earlier in life the attachment failures or deprivations, the more severe the psychological consequences.  Conversely, successful early attachments make for a more resilient person who is able to cope with a wide variety of human and other problems later in life.

Psychological growth involves a never ending series of attachments and attachment supported differentiations.  These connections spiral upward in their complexity while maintaining the same basic physical and emotional bonding behaviors that were established in earliest life.  Each attachment success or failure is internalized and becomes part of a person’s adaptive mechanisms.  These internalizations are physical and emotional and may or may not involve conscious memory.  The opportunities for human healing and growth through attachment continues throughout the entire life span.

The central role of attachment and differentiation in human development, functioning, and life experience has been known to social workers from the beginning.  While early knowledge of the central role of attachment in human life was based on clinical experience and grounded theory, now we find that more rigorously obtained empirical findings support these earlier assumptions and observations.  Put differently, some of the central assumptions upon which traditional clinical social work was founded are being confirmed by contemporary empirical research.

The name of our profession, social work, connotes that our work focuses on the relationships between people.  Our understandings of the primacy of attachment in human happiness and well being stands at the center of all theories and approaches along the practice continuum from micro to macro.  As the world becomes more technologically and socially complex and as the pace of social change accelerates, it is easy to lose sight of the fundamentals of human existence which are that people develop and find meaning in intimate attachments to other people.  William Gordon felt that social work operated at the interface between person and environment.  A long standing postulate is that social work only knows a person in context.  For the most part, but not exclusively, the environment or context is a human or social environment.

The antithesis to attachment centered theories of clinical practice is that of behaviorism.   An early reaction against reductionism, attachment deprivation, and the mechanistic nature of behaviorism was the work of presidential candidate, peace activist, and pediatrician, Dr. Benjamin Spock.  He reports that he wrote his first book on nurturing and care for babies in reaction to behavioral theories which made mothers afraid to hug, cuddle, and soothe their infants.  Spock did us all a service by demonstrating that scientism, regardless of rigor, cannot be valid if it contradicts valid human experience.  It is not a matter of science contradicting and correcting errors in human observation, a proper role of science.  It was merely a matter of a pseudo-science which came into being by ignoring the very nature of its subject matter.  Thus, the observational and inductive methods used in studying primates and infants have been proven more valid than experimental laboratory science.  The lesson from this history is that we cannot discard knowledge from observation and induction, grounded theory, because it is not as aesthetically designed and statistically correct as experimental research.

 Because of our expertise regarding attachments, clinical social workers have the base knowledge that must inform social policy, social program, and social administration if these social work specializations are to effectively meet the human service goals of the profession.  Put differently, social work objectives, regardless of practice specialization, are always directed toward enhancing the possibilities for people to develop and sustain nurturing and satisfying human relationships.  This common perspective, the attachment or relationship perspective, gets lost when members of the profession engage in the unproductive and divisive rhetoric of cause-function, institutional-residual, and direct-indirect practice catfights.  In each of these historical, polarizing, arguments, clinical practice which seeks to heal, problem solve, or nurture the relationship repair of individuals, families, and small groups, is characterized, implicitly or explicitly, as blaming victims, promoting conformity to an unfair status quo, or acting as a sedative or palliative in order to get victims to passively accept their fate.  The distortion whereby clinical practice is characterized as a form of norm enforcement, social control, and victim opiate has not been effectively or vigorously opposed by clinicians.  Since most social workers are direct practitioners, it is small wonder that clinical social workers have a morale problem given that from graduate school on, their work as been characterized in this fashion.

Attachment problems and the pain and distortions they incur know no boundaries.  These are issues for all people in all times across cultures, races, ethnicities, sexes and social classes.  Attachment issues are as significant and painful in the English Royal family and in the White House as they are among public assistance clients.  We are all the same in our needs to be wanted, loved, understood, validated, recognized, witnessed, and valued by significant others in our lives.  What begins with the mother-child bond continues through attachments that confirm or disconfirm our inner psychological selves.  Such confirmation is the fuel of self-esteem and psychological growth.  While attachment relationships become more complex over the life cycle, our need for them and their power to promote growth or decay does not change.  What does change is the social context and the institutional environment in which attachment behavior, strivings, and drama unfold.

 For the clinical social worker, the social history is analogous to a series of x-rays in that the process of history taking reveals the internal twists and bruises that bind or trouble a particular client.  It reveals the areas of injury whose sensitivity is too great for rapid exploration.  The skilled clinician listens with the third ear ever mindful of what is omitted, what brings tears or anger or sadness or defense, and what reveals shame, doubt, and despair.  Because these inner bruises have been acquired through attachments, clinicians know that clients approach the clinical relationship with great hope for repair, great fear of acquiring additional wounds, and even greater fear that the pain and/or shame exposed in therapy will be more than can be endured.  Further, the clinician perceives that many wounds cannot be discussed explicitly but are revealed, addressed, and explored through metaphor, analogy, and allegory.  Thus, clinicians attempt to reconstruct a client story or narrative from these various clues about the client’s inner life.

Along with this and of equal or more importance, clinicians track affect as though it were a movie soundtrack.  Affect leads the clinician to the wounds, especially when affect is exaggerated, inappropriately absent, or fails to match the client’s narrative. In this way, clinicians wed their knowledge of attachment behavior with an understanding of how script and narrative and affective soundtrack represent a client’s form of presenting and ultimately understanding and healing their attachment wounds.  All of this takes place in the context of a healing dialogue and attachment with the clinician.  This complex process using the skill of an artful clinical social worker cannot fairly be seen as a form of social control or social repression.  Such characterizations of clinical social work stem from misunderstandings of the clinician’s skill and mission.

The healing process reaches beyond the client and it is a rare client whose therapeutic healing does not extend to other attachments ranging from family of origin to family’s of procreation and other relationships.  This may occur through conjoint sessions, family therapy, and many times, it is a natural consequence of the client’s healing in individual therapy.  It is a rare client whose own healing is not accompanied by attempts to repair relationships with family and friends.  Thus, the best form of marketing is quality service.

The centrality of attachment can be seen in the usual types of situations which confront clinical social workers in daily practice.  Working with adults, the symptoms and relationship conflicts my clients bring to therapy are for the most part reenactments of earlier attachment conflicts with primary relationships, mostly parents, siblings, and extended family members.  A client gave me a picture of Wile E. Coyote which hangs on the wall in my office to symbolize the repetition compulsion, which was Freud’s term for conflict reenactment.  While Freud felt that as with Wile E. Coyote, people keep doing the same thing over and over in an attempt to get it right.  Some current therapists believe that such reenactments serve the purpose of promoting recurring guilt and shame in an attempt to punish the self and relieve the parents of responsibility for attachment failures.

In my experience, I believe that either or both can be true.  I meet clients who seem to be chronically self-defeating.  At the same time, I see clients whose repetitive behavior has compensated for attachment failures to such an extent that the overcoming has created its own level of problems.  This is common among businessmen who believe that they can only be loved if they make a lot of money.  This belief becomes bizarrely distorted when such men come to believe that the more money, the more love. Great anger ensues when these men feel that the love and appreciation they receive are not commensurate with the amount of money they have made or are willing to spend.  In either case, reenactments, whether of self-flagellation or overcompensation, fail to heal earlier attachment wounds.

The paradox of attachment healing is that differentiation, psychological separation, and psychological growth can only occur when early attachment wounds are healed and this healing can only occur in the context of a strong and loving relationship.  Modern research supports the idea that attachment wounds are physical as well as psychological and that healing involves creating new, or unblocking old, linkages in the brain.  While it seems straightforward to clinicians that a happy and fulfilling life ensues from healing the wounds of early attachments and bringing the fruits of this healing into current relationships, this vision is not always shared by clients.  Many children of abusive parents seal off the attachment wounds by creating fantasies of loving relationships with their parents.  These fantasy bonds, so important to childhood security, are not easily surrendered in adult life and can tend to block exploration and healing on the part of adult clients.  The exploration of feelings about primary relationships can result in overwhelming feelings of guilt and betrayal.  For most clients, the loss of childhood developed fantasies about love bonds can result in grief and sometimes depression.  What Freud would have called resistance, we now know as family loyalty.  Furthermore, family of origin members may react defensively when clients begin to explore their history and development.

From the above it is easy to see that the task of the clinician is complex and requires great knowledge, sensitivity, and artfulness.  Adding to the clinician’s difficulties is the fact that client situations stimulate feelings and memories and reactions regarding attachment failures and conflicts in the memory bank and psychological structure of the clinician.  For most clinicians, years of therapy, supervision, and experience are necessary in order for clinicians to function optimally as therapists for clients whose circumstances, affect, and expectations tend to be provocative, wearing, and challenging for the clinician.

Those who suggest that clinical social workers provide services for the walking or worried well trivialize a sacred and vital calling.  Others whose rhetoric suggests that clinical social work lacks a knowledge base do so by using a distorted concept of knowledge.  Finally, from the above, the complexities of the task, the years of training and experience and the challenges to the self demonstrate that those who achieve optimal levels of expertise as clinicians are a very special type of people.  Not everyone who enters our profession has the aptitude, character, and motivation to master the craft necessary to be a clinical social worker.  While the critics of clinical social work have had the upper hand in terms of rhetoric, clinicians have continued to practice and where permitted teach others to do so.  It is somewhat remarkable that the craft continues with so little support and so much outright ridicule and opposition from social work educators.  This tenacity speaks to the vitality and sacred mission of the clinical social work profession.

Harry Butler, Ph.D.

Professor Emeritus of Social Work (1975-2000)

San Diego State University