As a social worker who works full time as a psychotherapist in New York City, I had a thought about something that could really use some clarification in the world of mental health care.
“Social worker” can mean a person with a bachelor’s degree in social work (BSW), a master’s degree (MSW), or a doctorate (DSW or PhD). Each of these degree levels qualifies you for a different kind of work:
— A BSW can practice as a “generalist”, such as doing crisis intervention, or interviewing, or case work (like your guest, Ray). A BSW cannot, in any state, practice psychotherapy.
— With an MSW, you can choose to specialise in clinical practice — like a psychologist specializing in clinical psychology — which entails additional supervised training in diagnosis and treatment of mental disorders. Social workers must be at this level of education and training to become licensed therapists.
— A doctoral degree (sometimes called DSW, sometimes called PhD in Social Work) does not give you more clinical authority, but does give you additional qualifications for research and teaching in the field of social work.
This is from the web site of the National Association of Social Workers:
“Did you know that social workers provide most of the country’s mental health services? According to government sources, 60% of mental health professionals are clinically trained social workers, compared to 10% of psychiatrists, 23% of psychologists and 5% of psychiatric nurses.”
There’s lots of confusion in the public, including people seeking mental health care and even among those of us in the field, about names and functions of the various professions involved in providing psychotherapy and medication to treat mental illness. (This is totally understandable to me, as I had no idea what the differences were before becoming a social worker myself. It’s confusing!)
The basic issue: people often use the words “psychologist” and “psychotherapist” or “therapist” interchangeably, even though each means something different. So you’ll often hear someone say they went to a “psychologist” when they mean they went for therapy — and it’s quite possible they were actually treated by a licensed clinical social worker. In every state in the US, clinical social workers, like clinical psychologists, are authorized to diagnose and treat mental disorders by providing psychotherapy and other services reimbursable by health insurance. In New York State, psychotherapy can also be provided by licensed practitioners of marriage and family therapy; creative arts therapy; mental health counselling; or psychoanalysis. The only practitioners who can also prescribe medication are physicians (usually psychiatrists or GPs) and nurse practitioners, which I think is also true in other states.
There’s a huge upside, of course, to having so many professions involved in mental health care. As a clinician I’ve benefited greatly from the opportunity to work with terrific psychologists, art therapists, counselors and psychiatrists. I’ve learned so much from them precisely because each discipline brings its own focus and its own toolbox to the field. Talking to a talented colleague who is trained to look at things from a totally different (but complementary) perspective can really open your eyes.
The problem for social workers, though, is that despite our prevalence and the scope of our practice, most people have absolutely no idea that we constitute the majority of US therapists, working in every kind of venue in mental health care — from private practice to clinics and hospitals to federal agencies and the military.
I think some of this has to do with our name. “Social worker” is often used interchangeably, and incorrectly, with “case worker.” (To understand the differences in education and training between social workers and case workers, think of the difference between lawyers and paralegals or law clerks.) Because of this, and because of the stigma around caseworkers in many communities (e.g. “they’re the ones who take your kids away”), many clinical social workers downplay the title and simply call themselves “therapists” instead.
Another factor in our popular invisibility, it seems to me, is that we definitely lack the professional swagger and collective ambition of our clinical psychologist colleagues. Although I know many social workers who have PhDs, run agencies or departments, or have successful private practices, they are generally the kind of people who introduce themselves with their first names. For whatever reason, it’s easier for us to see that making everyone call you “DOCTOR So-and-So” will never win you the magical status or obscene salaries accorded to physicians in our culture, no matter how many times you say it. Unlike at colleges and other settings, in the health care world everyone knows that the real “doctors” are the ones who write the scrips, call the shots, and make the bucks. Social workers know that for better or worse, we’re never getting an invite to join that club, any more than psychologists are. The difference is that we know it – and that many of us, including me, don’t want to be “doctors,” however much we’re subject to the same kinds of envy and resentment as anyone else.
I have realized that for me, however, when it comes to the titles we use, there’s something much more important at stake than disciplinary rivalries and vanities. When I ask patients to call me Matthew, I am trying to implicitly convey to them a core value of social work: though our roles here are different, we are equals. I’m saying, in a way, “Here’s the bad news and the good news all in one: getting better isn’t about you believing in me — it’s about us believing in you.” That’s why, no matter how many degrees we might end up with, if we became “doctors” we would no longer be social workers.
In terms of our particular skill set, what makes social workers different — and too often we don’t do a good job speaking up proudly about this — is that we are uniquely trained and equipped to treat mental illness as a biological, developmental, psychological, spiritual, sexual, economic, cultural, relational and communal phenomenon, in which none of these factors can be separated from the rest. Though we work with people from all backgrounds, our discipline was born, and is sustained, at the grassroots, and particularly among the poor and marginalized. This means we cannot conceptualize ‘mental health’ without taking into account the crucial psychosocial factors (like poverty, racism, sexism, homophobia, colonialism, exclusion, etc.) that create and perpetuate so much human suffering. When we are true to our mission, we are committed to equality and social justice, both for their own sake, and because as mental health care practitioners we know that human wellness is incompatible with leaving injustice, inequality and violence unchallenged.
When it comes to the clients we serve, our motto is “meet ’em where they are”, not “let ’em come to me.” We don’t toot our own horns very much, we’re often overlooked and most of us are seriously underpaid (no coincidence, of course, that 80% of social workers are women!). But make no mistake — when it comes to client/patient outcomes in recovery from mental illness, the results we get are second to none.
Anyway, Paul, that’s my spiel as one social worker doing my best here in the therapy trenches of Gotham. With apologies for the long email, hoping you can do your part to get the word out about who we are and what we do– and, as always, with much love and gratitude for who you are and what you do,