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Journal of Social Work Practice, 2013

Vol. 27, No. 3, 249257, http://dx.doi.org/10.1080/02650533.2013.818941

Carol Tosone

ON BEING A RELATIONAL PRACTITIONER


IN AN EVIDENCE-BASED WORLD

Contemporary clinical practice requires social workers to keep abreast of and apply
evidence-based practice approaches. This may be a more difficult challenge for
psychodynamically oriented social workers who focus on the therapeutic relationship as the
principal mechanism of change. Research supporting the efficacy of the therapeutic
relationship is presented, as is a case vignette that illustrates the core principles of relational
social work, a postmodern contextual approach that focuses on the mutuality inherent in the
therapeutic endeavor. Emphasis is placed on examining the client and clinician-in-
situation and the interactional nature of the intrapsychic, interpersonal and macro social
systems in which the client and clinician operate.

Keywords relational; relational social work; evidence-based practice; EBP;


relational psychoanalysis

Introduction

In the USA, social workers reside in a fast-paced, clinical world dominated by managed
care, HIPAA regulations and a plethora of acronyms that they are expected to learn,
converse in and, in select instances, employ in their daily work. Among the better-known
acronyms CBT, DBT, DSM, EST, EBP, EBT, EVT, ICD, IPT, LTPP, RCT, RST, SR
and TF-CBT there is one that generally evokes strong reactions among
psychodynamically oriented clinicians. Evidence-based practice (EBP), has been described
as a process having multiple meanings and steps aimed at enhancing treatment outcomes
(Drisko, 2011). From a contemporary psychodynamic or relational clinicians perspective,
EBP often represents a rigid, manualized approach to client care, one that minimizes the
curative aspects of the therapeutic relationship and defines success solely by circumscribed
symptom reduction.
This paper discusses the evolution of the EBP movement in social work, its
definitive impact on the nature of clinical practice and the general response from the
clinical social work community. As a key component of the relational approach, and in
reaction to criticism of psychodynamic practice by proponents of EBP interventions,
the clinical social work community underscores the centrality of the therapeutic
relationship. The core aspects of the relational approach as practiced in an EBP-
managed care environment are discussed and illustrated through a case vignette.

q 2013 GAPS
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EBP in clinical social work


The roots of EBP can be traced back to the inception of evidence-based medicine which
emphasized that, in order to maximize treatment outcomes, clinical decisions need to
stem from the best quantitative research evidence (Sackett et al., 1997). Evidence is
derived from databases dedicated to the promotion and application of quality outcome
research in practice and policy; the best-known and most used research collaborative
databases are the Cochrane Collaboration and the Campbell Collaboration. As Berger
notes (2010), what constitutes evidence is restricted to randomized controlled trials
(RCTs) for specific diagnostic problems. Not only do theoretical and qualitative studies
fall short in the criteria for inclusion, but also the complex nature of diverse, multi-
problem and co-morbid social work client populations often excludes them from
participation in RCT studies.
Despite these practical obstacles, the professional social work literature is replete
with discussions about the merits of the EBP process with at-risk populations. EBP
involves five steps as proposed by Sackett et al. (1997) and later articulated by others in
the social work research community (Thyer, 2004; Thyer & Pignotti, 2012): (1)
formulating an answerable question to a specific practice need; (2) identifying the best
evidence to answer the question; (3) critiquing the evidence based on its validity and
impact, as well as practice applicability; (4) determining the intervention based on the
integration of the critical appraisal with ones clinical expertise and the clients
characteristics and values and (5) evaluating effectiveness and ways of enhancing future
practice decisions.
Not only has the term EBP been prevalent in the social work literature, but also
Thyer and Pignotti (2012) reported that their PsychINFO search for the period 2006
2011 using social work and EBP yielded twice as many references as did social
work and psychotherapy. Their results are congruent with a growing trend toward
familiarity, acceptance and usage of EBP among mental health disciplines. When
comparing social work to psychologists and licensed marriage and family counselors,
Parrish and Rubin (2012) found that more recent MSW graduates had more favorable
views of EBP than did social workers educated in the pre-EBP era. Citing related
research (Aarons, 2004), Parrish and Rubin note that practitioners with less experience
are more versed in and receptive to using EBP interventions.
It is not surprising that proponents of EBP may take a strident tone when discussing
experienced clinicians lack of interest in applying empirical results to their practices.
Gambrill (2010), a particularly vocal critic of non-EBP clinicians, asserts that
interventions not vetted through the rigorous EBP methodology are propagandistic
(p. 312). Epstein (2011) suggests that EBP rhetoric reinforces a disempowering
dichotomy between those who produce knowledge and those who are supposed to
apply it. In this hierarchy, practitioners are truly second-class citizens in the
knowledge production project of social work (p. 287). From the EBP perspective,
practice wisdom is considered weak and lacking in critical thinking, a position that is
consistent with the National Association of Social Workers (NASW). Specifically, the
NASW Code of Ethics (2008) Competency section includes a statement that social
workers practice needs to be based on empirical knowledge.
ON BEING A RELATIONAL PRACTITIONER 251

The response of the clinical social work community


Despite disparaging rhetoric and mandates from professional organizations, the clinical
social work community has generally maintained the position that the therapeutic
relationship is the major curative factor (Woods & Hollis, 1990; Goldstein, 2007;
Simpson et al., 2007). This position is supported by years of research indicating that
various aspects of the therapeutic relationship are instrumental in treatment outcome,
especially the working alliance and real relationship (Duncan et al., 2010; Gelso,
2010).
Gelso (2010), for example, views the therapeutic relationship as a tripartite
structure, composed of the transference countertransference matrix, working alliance
and the real relationship. He emphasizes the importance of the real relationship in the
development of the working alliance, and notes its therapeutic value in psychodynamic
as well as EBP models. The real relationship involves the clinicians authenticity,
empathy and personality in interaction with similar elements in the client; there is
ongoing mutual influence and intertwining of perceptions in the therapeutic dyad.
Similarly, Duncan et al. (2010) report extensive empirical validation to support the
efficacy of the therapeutic relationship in different forms of treatment, including
psychodynamic and EBP. They emphasize key aspects of the therapists role, including
the following: (1) instilling hope and expectation of change in the client, (2) targeting
core client difficulties, (3) monitoring client progress and (4) enhancing the therapeutic
relationship in an ongoing manner. Duncan and colleagues provide a contemporary,
empirically based perspective on Rosenzweigs (1936) assertion decades earlier: the
nature and quality of the therapeutic relationship are a key curative element in diverse
psychotherapy approaches.
Rosenzweig coined the term the Dodo Bird Verdict, referring to the fact that all
therapies, regardless of their distinct aspects, produce equivalent outcomes due to
common factors, including the quality of the therapists involvement. The Dodo Bird
Verdict gained further credibility with Luborskys research (Luborsky et al., 1975, 2002)
that focused on comparative treatment approaches; findings included that there were few
differences in regard to outcome, attributable in large part to therapist characteristics.
These findings were analogous to those later found by Duncan et al. in terms of the nature
of the therapeutic relationship. Although Luborskys research spawned ongoing debate
about the validity of the Dodo Bird Verdict, there has been substantial research
supporting the positive effects of the therapists genuine investment in the patient and
belief in the efficacy of his or her approach (Wampold, 2007).

The centrality of the therapeutic relationship in relational


social work

The therapeutic relationship provides the vehicle through which the clinician delivers
the essential elements of his or her approach. Thomas (2007) describes the therapeutic
relationship as the invisible component of what is in broad terms called EBP (p. 56).
While the therapeutic relationship factors have been considered difficult to develop
into specific measurable constructs, Thomas posits that 50 years of meta-analytic
252 JOURNAL OF SOCIAL WORK PRACTICE

studies of outcome research conclude that relational factors account for as much as
75% of success in treatment while models and techniques account for only 25% of
success.
As to what constitutes relational factors, it is important to keep in mind that each
client and clinician are unique individuals and, as a pair, form a distinct therapeutic
dyad that differs from other dyads in terms of dynamics, focus and rapport. Commonly
accepted relational elements include the therapists warmth, empathy, non-judgmental
stance, patience, perseverance, flexibility and professional use of self (Woods & Hollis,
1990). Although the major mental health professions endorse these elements, clinical
social work and relational psychoanalysis underscore their importance in practice
delivery. Relational social work, a variant of clinical social work practice, is particularly
aligned with relational psychoanalysis in the use of the treatment relationship as the
catalyst for client change.
The relational social work approach as articulated by Borden (2000), Tosone
(2004, 2005, 2006), Ornstein and Ganzer (2005), and Ganzer (2007) was inspired by
relational psychoanalysis (Mitchell, 1988). The basic tenets of relational psycho-
analysis, according to Mitchell, grew out of the British object relations and American
interpersonal traditions, both of which emphasized the intersubjective nature of
practice and the therapeutic relationship as the primary medium of therapeutic action.
Relational psychoanalysis has continued to evolve and is steeped in additional
theoretical vantage points, including intersubjectivity and feminist theories, as well as
postmodern influences of philosophical epistemology and the narrative construction of
subjective truth.
As noted by Tosone (2004) and Ornstein and Ganzer (2005), relational
psychoanalysis and relational social work share several key features:
. Two-person psychology The therapist is an active participant in the treatment
process and there is a co-construction of the clients narrative; the focus is less on
the one-person model of insight and interpretation of the clients psychopathology
and more on the mutative potential for client and clinician as a result of their
therapeutic interaction.
. Mutuality Embedded in the two-person perspective, the personal attributes of
the clinician enter into the treatment relationship, both shaping and refining the
process, and being influenced as a result of the interaction. There is ongoing
mutuality in that both the client and clinician shape each others affect, thoughts
and actions based on the interaction of their unique configurations of their
subjectivities and interpersonal experiences.
. Subjective nature of truth Truth is subjective in nature and contextualized by the
historic, ethnic, gender, religious, socio-political and other matrices that shape
ones intrapsychic make-up, belief system and interactions with others, including
the therapist. Objective or historical truth is a modern, abstract construct not
possible because the perceiver of the truth has a unique perspective on the subject,
one that is not duplicated by others. From a relational postmodern perspective,
truth is subjective and decentralized, and the clients truth is perceived and filtered
by the clinician through his or her own subjective perspective.
. Enactment Although committed to providing a corrective emotional experience
through the therapeutic relationship, the clinician and client invariably find
ON BEING A RELATIONAL PRACTITIONER 253

themselves engaged in an enactment of their old ways of being. Through the


transference, the client may perceive the clinician to be like a person from his or
her past and elicits a similar reaction from the clinician. The clinician, in turn,
responds through his or her own subjective lens and past experiences. The
enactment itself provides therapeutic value; the discussion and working through
the experience potentially lead to mutual growth and reparation.
. Countertransference as a therapeutic tool The enactment described above may lead to
therapist self-disclosure of countertransference reactions. From a relational
perspective, countertransference is a core therapeutic tool in the clinicians
armamentarium to better understand the client, not a hindrance to be overcome.
Countertransference, like transference, is inevitable and reflects both the
clinicians subjective experience of the client based on his or her past experience
and an externally based response to the clients actions and provocations.
Selective disclosure of countertransference reactions may be used to facilitate the
treatment.

Although the above approaches share much in common, the term relational in a
social work context is broadened to include not only internal and actualized object
relations but also the individuals internalization of and interface with the macro
systems of the larger society. As I have written previously (Tosone, 2004), these
macro systems are dynamic in nature, and laden with conscious and unconscious
meanings for both client and clinician. Consider the frequency with which social
workers refer clients for agency services only to learn that the clients did not
avail themselves of the needed help. The relational social workers interventions
take into account the meaning of seeking and receiving services in the context of
(1) the clients specific culture and subculture, (2) nature of ones membership
in community organizations and peer groups, (3) family dynamics and (4) intrapsychic
functioning. While the point of intervention is with the individual and not the
larger systems, the emphasis is on the meanings the client assigns to these
interactions.
In essence, the relational social work clinician is a systems expert; that is, an expert
in understanding the interactional nature of the intrapsychic, interpersonal and macro
systems of the community and larger society. They practice with an appreciation for
the extent to which their own and their clients respective intrapsychic functioning is
impacted and shaped by their interpersonal functioning in families and other groups
that, in turn, is impacted and shaped by social programs and policies. As individuals and
as a dyadic unit, the client and clinician both impact and are impacted by these complex
internal and external factors.
The unit of attention is not the person-in-situation (Hamilton, 1940) but rather
the client and clinician-in-situation (Tosone, 2004). The nature of the practice is context-
bound, and varies depending on the nature of the setting. Working with an adolescent
in private practice, for instance, is qualitatively different than working with him or her
in a residential facility, inpatient psychiatric unit, juvenile detention center, child
protection services or foster care agency. The focus of attention and involvement of
outside third parties vary from setting to setting.
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Case illustration and discussion


The following private practice case vignette illustrates the core principles of relational
practice as taking place in the larger context of the EBP world, and one clinicians
efforts to not abandon these principles.
Anna is a single 30-year-old Latina and accomplished advertising executive, soft-
spoken and diminutive in stature, who sought treatment for depression. Like her
mother and maternal grandmother, Anna has been battling depression since her late
teens. Although Anna was under the care of a psychopharmacologist, a close friend
suggested the names of several therapists for her to interview for individual
psychotherapy. Ivy educated and approaching the consultation as an employer would a
potential job candidate, Anna wanted to know about my fees and available hours, as
well as my training, professional background and treatment approach. Did I practice
cognitive therapy for depression, she inquired? Her psychopharmaclogist suggested
that the approach had a good evidentiary base and that it would be essential to see a
therapist well versed in the technique.
Unlike the other clinicians she interviewed, I did not assure her that I would use
cognitive techniques; I did acknowledge my familiarity with the approach and
suggested that together we would come to understand her needs and how I could be
helpful. If it was useful at a particular point, cognitive therapy could be incorporated
into our work but it would be a joint decision, not one I unilaterally imposed on her. I
could not predict at the outset, the course that our work would take. Instead, I
attended to her deeper anxiety: could she be helped?
Having seen several therapists and taking numerous medications, with only modest
improvement, Anna was terrified that she could not be helped. I silently questioned if I
could be useful to her; surely she could find other clinicians who embraced the
potential efficacy of cognitive therapy with more confidence and gusto. I voiced her
concern, and assured her that if she chose to work with me, our task would be to work
hard to help alleviate her suffering. I also told her that I could not predict the course
our work would take; it was a collaborative process that would unfold with time.
While we were both anxious about the task at hand, Anna chose to work with me.
As we began to explore her feelings surrounding her depression, it became clear that
she feared failure and feared disappointing me as her therapist. If she did not get better,
she believed it meant she was not working hard enough and that she was a bad patient.
As a child, she consistently got good grades through hard work, and as a result,
received accolades from her parents and teachers. Anna was the first generation
Dominican born in the USA and the first in her family to graduate from college. While
she succeeded at school, she felt herself struggling at work. She feared that the benefits
she received as a result of affirmative action policies would eventually reveal her
limited abilities in the work setting. Despite positive evaluations, Anna was convinced
that she would be fired for poor performance.
The natural course of our work was to examine and challenge her fixed, erroneous
beliefs about work, an approach consistent with cognitive therapy but one that also
took into account the interpersonal aspects of her depression. As with school, her work
success was largely in service of others, and Anna believed that she sacrificed for others
at her own expense. She was acutely aware that she lacked a partner and close friends.
ON BEING A RELATIONAL PRACTITIONER 255

Feeling better, she came to realize, should be for her, and not to make others happy or
proud of their participation in her growth.
Despite these important insights, implications for the transferencecounter-
transference matrix, and the fact that we had only been working for a short period of
time, Annas psychopharmacologist grew impatient with our work and voiced his
concerns to Anna and to me. Parenthetically, I had periodic phone contact with him to
discuss her case. While Anna had imbued me with the power to help her, I felt helpless
and pressured to perform according to the expectations of others, notably the
psychopharmacologist. Anna and I discussed the impact of these outside expectations
on our work. She acknowledged feeling pressure to get better from everyone,
including me. I acknowledged the corresponding pressure, and that it would be
important for our work to be in service of her best interests as defined by her. What
I did not voice was the kindred pressure I felt to be successful as the first college
graduate from my working class Italian family, nor my self-imposed pressure to
demonstrate the viability of the relational approach.
An honest, open discussion of these concerns was liberating in our work, and
ultimately led Anna to early memories of her mothers depression. Anna could now
access the deep, ongoing despair she felt in trying to connect with her mother. Anna came
to realize that her own depression served as a way to connect to her mothers emotional
state, to know her in an intuitive and intimate way. Correspondingly, her mother
intuitively knew how devastating and challenging depression could be for Anna. Anna also
came to realize that her depression insured care and concern from others, and gave her a
legitimate reason to take a break from the expectations of others.
The work with Anna continues in earnest, and while we share the mutual goal of
alleviation of her suffering, the treatment course is a co-creation in progress, one
requiring patience and dedication on both our parts. As a distinct therapeutic dyad, we
each bring our anxieties, hopes, needs and desires to the process. Subjectivities in
interaction with one another, we are shaped by our individual experiences with and
perceptions of our families and other interpersonal systems with which we interact.
We are also shaped by the larger societal systems and the representatives of those
macro systems; those representatives may have perceived and interacted differently
with Anna than with myself due to our unique characteristics and the representatives
experiences with similar individuals.
As women from modest, ethnic roots our shared need was to be successful for our
respective families, and this mutuality contributed to an enactment. Specifically, as
individuals and as a dyad, we felt the enormity of the pressure to succeed at work and
home and to receive the approval of authority figures and loved ones, all while feeling a
deep-seated insecurity about our abilities. As a relational social work practitioner, I felt
additional pressure to represent the approach well to the psychopharmacologist, a
member of the mental health hegemony. Acknowledging and successfully working
through such enactments can lead to new, more constructive internalized and actual
experiences of self and other.
Most important to note in the case example is that relational social work does not
preclude the use of cognitive therapy and other EBP approaches. Rather, these and
other therapeutic techniques are applied in the context of a relationally based
treatment. The principal change agent is the therapeutic relationship itself, and
interpretation is a relational process.
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Conclusion
Relational social work is the practice of using the therapeutic relationship as the
principal vehicle to affect change in the clients systemic functioning, referring to the
inherent interconnection of the intrapsychic, interpersonal and larger community
systems. Inherent in this definition is the conviction that the individuals internalized
and actualized object relations mutually influence one another, and also act on and are
impacted by macro environmental structures. Core aspects of relational practice
include mutuality, the inevitability of enactments, a postmodern approach to the
individual and practice contexts and an appreciation for the co-constructed narrative.
Relational social work is respectful of the clients contribution to the therapeutic
process and in line with Drisko and Gradys (2012) approach to EBP. They eloquently
observe, Informed, shared decision making by the client is a co-equal component in
EBP. The clients role is just as important as research knowledge or clinical
expertise . . . EBP is not a top-down authoritative enterprise, but a shared, cooperative
one (p. 23). I echo their sentiment, a position that respects both the science and art of
the therapeutic process.

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Carol Tosone is an Associate Professor of New York University Silver School of Social
Work. Address: New York University Silver School of Social Work, New York, NY 10003,
USA. [E-mail: ct2@nyu.edu]
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