Social work approaches that support change
Social Work Approaches
The social work profession promotes, encourages and elicits social change in those they work with and society. This essay will examine two approaches used to support change in social work today, Task-Centred Practice and Cognitive-Behavioural Therapy, and compare and contrast these two. The essay will achieve this by applying these two interventions to Case Study Two, analysing the advantages and limitations of each method. Finally the essay will discuss any in the application of the discussed social work approaches.
Cognitive-Behavioural Therapy (hereon CBT) is a psychological approach based on a combination of theories of learning: social learning, operant and classical conditioning (Teater, 2010 p.141). The approach is a composite of behavioural and cognitive therapies, involving assessing and changing behaviours, thoughts and feelings together. CBT suggests that service user problems or difficulties are a result of thoughts, feeling and behaviours being unescapably linked, therefore how a service user views themselves or situations affects their behaviour and emotions (Vonk and Early, 2009). However, CBT only focuses on presenting problems and their current causes. The goal of CBT is to change service users existing faulty or negative thoughts feelings or behaviours and replace them with more socially acceptable and positive thoughts, feelings and behaviours that decrease the problem. The use of CBT derives from criticisms of Psychodynamic theory for not being evidence-based and not being effective in creating change (Howe, 2009). However CBT is not the only evidence-based approach.
Similar to CBT, Task-Centred Practice (hereon TCP) is based on strong research evidence; studies by Reid and Shyne, Reid and Epstein and Reid demonstrated planned short-term treatment using task-centred model was effective (Payne, 2005 p.99). In contrast to all other approaches TCP was developed within social work for social work practice, and is commonly used in social work today. TCP is focused on problem-solving; a versatile approach, TCP is used in a wide range of problems (Stepney and Ford 2012 p.102) including interpersonal conflict, dissatisfaction with social relations, problems in social transition, financial problems and behavioural difficulties (Ford, 1978 as cited in Stepney and Ford 2012 p.103). Doel (1991 as cited in Teater, 2010) states that TCP uses key values related to social work, for example partnership and empowerment: clients are seen as the experts in their problems; the approach builds on service users strengths rather than weaknesses; and finally that the Social Worker is providing help rather than treatment. TCPs assumption of client as expert is another point of contrast to CBT. However CBT has its own assumptions.
CBT holds three basic assumptions: firstly, an individuals cognitions mediate emotions and behaviours (Trowel et al, 1988; Vonk and Early, 2009 as cited in Teater, 2010 p.146); secondly, faulty or distorted cognitions lead to psychological distress and dysfunction (trowel et al, 1988 as cited in Teater); finally, diminishing or alleviating psychological distress and dysfunction requires modification and change to the faulty or distorted cognitions and behaviours (Trowel et al, 1988; Vonk and Early, 2009 as cited in Teater, 2010 p.146). CBT takes these assumptions and creates a structured approach to working with service users. Coulshed and Orme (2006 p.181-182) describe the CBT approach in eight clear stages; engagement, problem focus, problem assessment, teaching cognitive principles, dispute and challenge assumptions, encourage the clients self-disputing, set behavioural homework and finally, ending. This extremely structured approach is another point of comparison with TCP.
TCP, similar to CBT, is built around a clear model, and progresses through set stages. Firstly, identifying the problem; TCP is a collaborative approach which works to tackle problems the service users acknowledge and understand (Doel, 1991 as cited in Teater, 2010 p.178). In addition the service user must express a wish to work on the problem alone or with the help of worker (Reid and Epstein as cited in Teater, 2010 p.179) Next, exploring the problem in detail, selecting the problem that is causing the client most distress. From the problem define a goal which diminishes or removes the problem, establish tasks for the worker and service user towards reaching the goal, and finally evaluate if the goal has been met and if the problem is removed (Reid and Epstein, 1972 as cited in Teater, 2010). The essay will now examine how these approaches could be applied to Case Study Two.
Case Study Two presents many key issues. The service user, Neil, is facing many difficulties at one time, which include problems with family, aggressive behaviour which has resulted in his homelessness, and lack of money, food, bedding, and household items. In addition he is also worried about moving GP. Many of Neils problems could be tackled using either CBT or TCP; selective eclecticism allows social workers to choose which approach would best suit each problem. The problems of homelessness, money and the want of a job are better suited to TCP; they are problems of living that may also include some social factors which CBT would not account for. The problem of behaviour where Neil is swearing in the family and the anxiety toward the change of GP would be best suited for CBT intervention, as this is proven to help with problems of behaviour and anxiety (Sheldon, 2011).
In Neils case, the first stages of TCP, identifying problems, exploring problem and setting goals, would need to be applied in the early meetings between Neil and the social worker. The collaborative period needs careful discussions and mutual agreement on problems and goals. A possible outcome may be tackling the problems such as homelessness, lack of money, food and unemployment in order; however, other factors may make this unrealistic. The SMART method for goal setting is commonly applied, stating goals must be: specific, measurable, achievable, realistic and timely (Marsh and Doel, 2005 p.36). The assessment phase of CBT mirrors this early approach of TCP. During CBTs assessment phase the service user and worker examine the links in thoughts, feelings and behaviours using the A-B-C model, as well as measuring intensity, duration and frequency of the problem (Teater, 2010 p.145). After assessment both approaches then move to intervention phases.
TCP uses tasks as an intervention. The task should be planned carefully, asking: what is the task, the reason for the task, and what the person needs to be able to achieve the task. These stages can be simplified to what, why and how (Marsh and Doel, 2005 p.55). The tasks are performed by either the service user, the social worker or by both parties in session. In contrast, a CBT intervention is classified into distinct categories of intervention including cognitive restructuring, relaxation techniques, social skill training, assertion training, problem-solving skills, aversion therapy, systematic desensitisation, reinforcement and modelling (Teater, 2010 p.149-150). The actual intervention that is selected is dependent on the problem faced. In the case of Neil, cognitive restructuring may be suitable to approach the anxiety and his false belief that his doctor is the only one who can understand him. This is done by challenging the assumption, reinforcing self-challenging and homework. Next both approaches move on to the ending phase.
The ending or evaluation phase is critically important in both CBT and TCP. Both approaches use close evaluation of the goals and progress made in the intervention; this evidence-based practice is seen as a great benefit of both these approaches. CBT uses data collected in the assessment phase as a tool for evaluating the outcome of the intervention. This is done by comparing intensity, duration and frequency of thoughts or behaviours before the intervention and after, giving a measure of success or failure in the intervention (Sheldon, 2011). TCP uses a similar process of evaluation: firstly regular assessment of the outcome of the tasks set measures change in capability; secondly, TCP monitors whether the service users goals have been met or the problem solved. This measurability of evidence-based approaches finds them favoured by funders and managers in social work (Payne, 2005 p.101). These are not the only benefits of these approaches.
TCP has many other qualities that result in it being commonly used: it is generic, can be used in many settings and with many different clients groups (Teater, 2010 p.189). TCP can be used easily in combination with many other approaches, such as motivational interviewing to help someone who may be unsure about change (Teater, 2010 p.189). Both CBT and TCP are highly structured and easy to use (Payne, 2005). Furthermore both interventions are brief and time-limited while remaining effective (Stepney and Ford, 2012). However these approaches have some limitations.
TCP requires that service users can make connections between problems, tasks and goals; this is not possible with all service users, as some may be unwilling or experience difficulty in making connections (Marsh and Doel, 2005). CBT also faces similar difficulty with service user commitment the approach relies on equal involvement from the social worker and the service user in changing faulty learning process or behaviours (Teater, 2010 p.155). In addition, Payne (2005) suggests another weakness in TCP is its failure to tackle the long-term individual or social problems. This is especially pertinent in Neils case, in which he and his family have had previous social service interventions. Another criticism of CBT is that it only focuses on the individual: oppression, discrimination, racism and poverty are not addressed in the approach (Teater, 2010 p.155). Furthermore, by not accounting for oppression and discrimination, TCP and CBT may inadvertently exacerbate both.
Thompson (2012) as an approach to social work practice which seeks to eliminate discrimination and oppression, and argues it is fundamental to social work. However, a social work intervention often places power and influence in the hands of social work, and there is scope for discrimination and oppression in social work practice, whether intended or unintended. CBT focuses on changing behaviour from inappropriate to appropriate. What is appropriate behaviour is culturally relative and a misinformed social worker may attempt to change acceptable behaviour thus creating oppression. However, cultural sensitivity must be balanced with ability to challenge behaviour that causes discrimination in itself (., 2005 as cited in Teater, 2010 p.156). Marsh and Doel (2005 as cited in Teater, 2010 p.191) suggests that TCP is allied with empowerment-based approaches and anti-oppressive practice as TCP takes account of power and oppression in a wider social context. The approach emphasises partnership and transparency, highlighting any power imbalance should be made explicit from the beginning of the intervention (Teater, 2010 p.191). Doel and March (2005) further argue that the client should be informed and as involved as possible. However, TCP relies on the service user accepting that there is a problem; this point may become a point of oppression whereby the social worker may force their perspective of the problem upon the service user, particularly in mandated work (Doel, 2002 as cited in Teater, 2010). However, good practice in TCP sees the service user as the expert in their problem and the social worker as helper, rather than prescriber of a course of action (Teater, 2010 p.191).
In conclusion, supporting and eliciting change is a difficult job for social work. Numerous factors play a part in a service user problem or want. No one approach will consider all the factors all the time, therefore being eclectic in choosing an intervention is a key social work skill. As shown, both TCP and CBT are very practical approaches: each has a clear structure, a strong evidence-base and uses evaluation to show the efficacy of an intervention. However each approach has weaknesses: TCP fails to and asks service user to have good insight into their problems. CBT does not account for oppression, discrimination, racism and poverty, instead focusing on the individual. Like all interventions in service users lives, both CBT and TCP can be oppressive and discriminatory used casually or incorrectly. However, handled with care, collaboration and transparency, both TCP and CBT can be used to support service users to empower themselves into making the changes they want to make.