Adelphi-university-doctoral-program-in-clinical-social-work-1980

James Donnelly, CSW

This essay will attempt to formulate from the experience of a beginning supervisor in social work on the Medical-Surgical service of a general hospital, some concepts and theoretical constructs that may be useful for a more general practice theory of social work supervision. The method will be to first describe in narrative form the tasks faced in this position, the actions taken in response to the tasks and the thinking that informed both the assessment of the tasks and the actions taken to accomplish them. From this, an attempt will be made to draw out more generalized concepts with a particular focus on the experience of tension in the supervisory process.

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Prior to being appointed to supervisor, I had worked on assignment to the Psychiatry Clinic of the hospital – involving direct psychotherapeutic work with clients. For two years before this transfer, I had also been a Field Instructor in the Clinic for second year master’s students from the Columbia University Graduate School of Social Work. This had been the extent of any ‘supervisory’ experience on my part. Transition to the position of supervisor in the department involved not only a role change within the department, but also service in a quite different area of social work practice – a service that was much more involved and integrated into the general hospital system and the overall health care delivery system in New York City.

Initially, two Master’s level social workers were assigned; an assignment that was gradually increased to my present responsibility for the supervision of six full time M.S.W workers. Three of these workers are new to the department and two are recent graduates.

According to Kadushin (1976), there are three major aspects of the supervisory process: administrative, educative and supportive. Naturally, I was most comfortable with the educative and supportive aspects of the role – because of a strong clinical frame of reference and the need to adjust to new a role relationship with former peers and supervisors. The administrative aspects of the responsibility were the newest and least comfortable. Much of the following narrative can be seen, in fact, as an attempt, both in action and theory, to integrate this aspect of supervisory clinical practice – the other two aspects, education and support, being more familiar and comfortable lines of responsibility.

I began by structuring weekly individual conferences, which is the general supervisory practice in the department. These conferences have and continue to focus on discussion of case material – identifying each worker’s style, strengths and areas of learning, as well as the discussions around case assessments and clinical tactics. Along with this, of course, are the various system difficulties that prop up, i.e. departmental procedures, coordinating activities with medical and service staff, etc.

In these conferences, two general themes have been emerging with all the workers: the importance – in this interdisciplinary setting – of each worker’s understanding of his or her role, and a continued process of clarification about one’s professional identity in an hospital setting. The reciprocity between dealing with the task of providing service to the client in this setting and the development of a strong professional identity and clear role definition is most evident. The supervisory process appears to be an important instrument serving the clarity of professional purpose as well as the integration of the needs of the service and worker development.

Within this context came the onus of the administrative tasks. The supervisors are mandated by the director to continually review the workers’ chart notes.  My task, then, was to review the documentation and set up an instrument of accountability. My accommodation to this task was done by assimilating it to the workers’ educational and supportive needs. This was the first occasion of tension that I sought to use productively to serve the needs of the client, worker, service and hospital.

Taking a guide for chart documentation that had been recently developed by a staff committee, I created a form. Each worker was asked to submit several names of client to be reviewed each week.  In the review, comments were made addressing both the form and frequency of the documentation. This was supplemented by comments to the dynamics of the case and various assessment and/or tactical alternatives. The task was used to extend supervision along educative and supportive lines while integrating the tension of accountability into the ongoing supervisory process.

Once this process was under way, certain aspects of the nature of the service and the workers’ dilemma within it became quite evident:

1. The Medical-Surgical service is the one that has the least status both within the department and with many medical personnel. It is at the same time the most politically sensitive in terms of the department’s position within the hospital system.
2. This service is probably the most frequent entry point for new graduates and inexperienced workers into the department. The turnover rate is higher than on the other services. It usually has the highest proportion of inexperienced workers.
3. The documentation of the workers on this service is reviewed and exposed to potential criticism form many sources outside the department: medical staff, utilization review nurses, hospital administrators and third party reviewers. Deficits in documentation have a direct financial implication for the hospital.
4. The workload is continuous and often difficult to structure. There is additional pressure because of the mandates from the State through the P.S.R.O. and utilization review committee for discharge planning to maximize the efficient use of hospital beds and to minimize hospital stays beyond the acute phase of illness. Most discharge planning difficulties arise on the Medical-Surgical service.
5. There are a great variety of illnesses and consequent psychosocial trauma to which the workers are continuously exposed.  The emotional distance between the worker and client on a medical service is much less structured than in a mental health setting.  The need to mobilize community resources and provide concrete service is very high and is seen, initially, as most important to clients, medical personnel and hospital administrators. The value of good casework interventions to address these issues is apparent to few outside the department.

Consequently, it is not difficult to understand that the morale among these workers is traditionally much lower than those in the specialty areas. This is also true of the general level of professional self-esteem. The potential for burn out is much higher on this service (Pines, A. and Maslach, C. 1978).

As I became familiar with the service it became evident that in order to extract a consistent level of gratification, as well as to perform effectively with some clinical depth, a high level of assessment and intervention skills, a strong sense of initiative and comfort with working autonomously, a strong sense of personal and professional self-esteem and a clear and articulate understanding of professional identity and purpose are required: these are the qualities of a competent, experienced social worker.

It was also evident that the support system for this group of workers had been individualized, largely informal and unfocused. My supervisory task, then, was to set in motion a focused, effective support system – geared both to the realities of the service and the professional developmental needs of each worker.

As it turned out, the development of such a system was accomplished around incorporating those very administrative and reality needs of the service rather than finding relief from them.

It appeared to me that the very tensions generated out of the demands of the service could be used, and were even necessary, to the professional developmental needs of the workers and the mission of the profession. A way had to be sought to focus, manage and use this tension to the advantage of the clients, workers, department and hospital.

As soon as there were a sufficient number of workers assigned to me, I initiated group meetings on a weekly basis – in addition to the individual conferences. My expressed purpose was educative and supportive. I intended to use the group to foster a sense of group identity and support. The medium for this was case discussion with an emphasis on common clinical, procedural and tactical concerns. There were certain themes evolving in the individual conferences, i.e. understanding and articulating of role and professional identity. These were focused on in the group as well. This group process lent itself to the generation of the feeling that there was an immediate commonality in struggling with these issues as well as the specifics of their tasks with clients and service staff.  The reciprocal relationship between these themes and their tasks were continually pointed out.

It soon became evident, however, that the administrative matters of assignment of cases, productivity and workloads needed to be in the group discussions – since these were a major source of stress for the workers.

Initially, it seemed to me that the administrative and educational issues were separate and support meant a little of this and a little of that: helping workers to ventilate, for feeding with good case discussion. The tension of administrative tasks was in the group, but not clearly related to the clinical discussions and we bounced back and forth between the two foci.

Because of short staffing, the floor assignment of cases for each worker at the time of my assignment was not sufficient for coverage. The assistant director of the department had taken on the assignment of cases to the Medical-Surgical workers. She acted as screener of admissions and attempted to monitor an equitable caseload distribution for these workers. Around this system, some informal norms were established: e.g., if two cases were assigned and, were opened, only one case would be assigned the next day. In actual practice, it was not really possible to keep to that norm consistently. This generated a good deal of tension between the assistant director, the workers and myself. I felt that much of the feelings of stress generated by their work were over-focused on this assignment system.  Initially, the assistant director had the onus of this system and kept it to buffer me until I became adjusted to my new role.  After a while, I began to feel a non-productive splitting going on with the workers around this assignment system and felt I was losing something valuable (though uncomfortable) in my supervision because of this.

I requested and was given the task of case assignment for my workers.

To incorporate this tension into the supervision, I again resorted to a group process. The workers agreed to meet with me briefly each morning to distribute the assignments.  It was felt that this would be a more efficient and fair way to distribute the stress and load. Two things emerged from this:

First, the workers were less buffered from the actual demands of the quantity of referrals to the department; but, at the same time, were supported by the group in facing it.

Secondly, the group had to take responsibility for screening decisions.

The workers were now in a position to be more responsible to both the demands of the work and to each other trying to cope with those demands.

As this process continued, individual differences in style and caseload management became evident. Another tension began to enter the group: if I am willing to take three cases today because you can’t take one – and this happens consistently – do I have entrée to ask you about your practice? Discussion of this issue led directly to a contract for peer supervision and gave us an instrument to pull together for the workers and myself both clinical and administrative issues in an integrating way.

After a brief time, we were restored to full staffing and the assignment system returned to floor assignments. This allowed for no buffer for the workers from the referral demands. To deal with this, the workers elected to meet each morning to ‘touch base’ and take cases for each other when possible.

Let me now share plans to use the group again in another administrative manner.

By the end of November, the supervisors were asked by the director to arrive at a productivity figure for their services. This is a quality vs. quantity dilemma that the director and workers feel intensely. The plan is this:

Suggest to the workers that this task be a group project. The following method was suggested. In the clinical meetings, we pick out areas of casework process in this setting to examine. For example, assessment and plan formulation: each will present case situations in turn, and as a group we will look at what is needed by the worker to do an adequate and effective assessment … and how much time that takes. That will vary from case to case and from worker to worker. One worker may need a supervisory session (formal or informal) before formulating a sound plan. Another may need to develop system skills to involve the medical staff more effectively.

By looking at an administrative task in this manner, the group process supports each worker’s responsibility to improve his or her skills in the face of a real task. Hopefully, the by-product of this process will be a documented and realistic productivity estimate that preserves the concern for casework quality.

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We turn now to the task of drawing out from this narrative some general concepts regarding the supervisory process.

The narrative indicates a progressive understanding of the usefulness and even necessity of tensions generated by the demands of the department’s, my own as a new supervisor and the workers’ tasks for both the supportive and educative aspects of the supervisory process – as well as the administrative. In fact, the use of tension in this manner almost blurs the distinctions between these three aspects – or perhaps, integrates them in a more centralized, unifying process. It appears on the experiential level that the use and management of tensions has an essential significance in an understanding of supervision – and, perhaps of the profession itself.

Tension implies a kind of holding or tautness – a balance of sorts between polarities of some kind.  At first glance, it appears almost obvious what the polarities in the narrative are:  task or client demands vs. worker need for development; supervisor needs vs. worker needs; worker needs vs. agency, or department needs; worker needs vs. peer supervision needs.  This would lead to an interactional or interpersonal emphasis in the understanding of tension which would be much in line with a great deal of social work conceptualization. The concept of psychosocial, for example, is one which holds the integrity or balance of tension between the person and environment.

It occurs to me, however, that the use if tension in this essay implies a somewhat different formulation.

To examine this further, two phenomena in relation to tension are quite striking.

First, is the reciprocal relationship between tension and the formulation of structures in response to it. Tension, in a sense, evokes structures; which, in turn, manage, direct and use it. Without structure, tension breaks balance and becomes diffuse stress or chaos. Tension and the capacity for structure are mutually causal and reciprocal in their relation. Implicit in the notion of tension is that of form or pattern.

Second, tension held in this way has a transformative effect or the effect of altering and re creating forms to hold and use it.

The original structure of supervision is modified to incorporate tension or to create tension out of a drift towards diffuse stress. This, in turn, has a transformative impact upon the supervisory process, the workers’ and supervisor’s development as well as the manner of addressing and managing administrative tasks. This, in turn, leads to different tensions and different reformulations; for example, peer supervision. In other words, the conditions for this transformation process to continue lie in the creation of a structure to incorporate, manage and utilize tension. It is hard to describe this process in a linear manner since it appears to work in all directions at the same time. All elements in the structure to hold, manage and direct tension are transformed simultaneously. Although this presentation has many similarities in thinking to C. Germain’s Ecological Perspective, I feel there are some underlying philosophical differences (Germain, C. 1973; Germain, C and Gitterman, A. 1980).

It appears to me that the essential meaning of the phenomenon of tension must be distinguished from its occasions.

Interactions, for example, between person and environment may occasion tension but do not reveal its meaning and dynamism. That lies in describing the basic polarity as one between structure and process. This makes more intelligible the process structuralization and reformulation revealed in the transformative process. Aspects of phenomena that appear related but discrete in an interactional framework appear as integrated aspects of a unified process – if the basic polarity is conceptualized as between structure and process.

Within the framework of such a conceptualization, one continually operates to incorporate tension rather that seek relief from it.

The essence of supervision, then, is operationalized as the thought and activity that constructs and maintains the structures for a transformative process to occur and continue by incorporating and responding to tensions occasioned by the professional mission, tasks and needs of the worker as well as the needs of the service and the department-agency in a specific context. The approach presented here is at variance with the suggestion that administrative and educative supervision be split (Foekler, M. and Deutschberger, P. 1970; Miller, I. in Enclycopedia of Social Work, Vol.2. 1977).

There are many implications to be drawn for this conceptualization of social work supervision that space will not allow. Let me touch upon two.

First, the primary commitment of the supervisor as well as the social worker is primarily to a process and not to any specific structure, person or group of persons, i.e. the profession, the agency, the worker, the client. As the servant of a process present in all these areas, this formulation helps one to see tasks in a more holistic manner, and reduces the tendency generated in a more interactional, interpersonal formulation to see problems simply in conflictual terms. One acts to have a transformative effect in all these areas together by developing one’s capacity to develop structures that incorporate and hold increasing and more complex tensions.  This addresses itself to an understanding of the value commitment of the profession of social work and needs much more elaboration.

Secondly, there appears to be a spontaneous and, perhaps, essential relationship between this formulation and the use of the group process. The use and operation of the group as described in the narrative has elements in common with all three a approaches to social group work as described in the Encyclopedia  of  Social Work by Tropp, Schwartz, Glasser and Carvin (Encyclopedia of Social Work, Vol.2. 1977) . It is developmental and existential, interactional in some sense, with a work and task emphasis; it is organizational and related to the accomplishment of social goals.

There is, however, a basically different underlying set of assumptions between the formulation set forth here and these models of social group work practice (Apaka, T, Hirsch, S. and Kleidman, S. 1967). In this formulation, the group is basically and instrument to hold, manage and direct tension; it is not there for itself or its members but for the process. Although, indeed, the members benefit, as does the agency and the client, the group is there to serve a process that transcends all structures of which it is a part. It assumes a somewhat different understanding of  human relationships than what informs the three models mentioned.

I would like to make a few remarks in comparing the understanding and approach to supervision set forth here with those of Alfred Kadushin and Bertha Reynolds.

Kadushin (1976) presents us with a very comprehensive look at supervision in all its aspects. It is more a description and explanation of supervision than a theory. His treatment of the role and process within an organizational framework is both realistic and helpful. He ties the development of supervision to the historical development of social work within the agency structure. The agency is the meeting place of both the social structure of society and the profession. The necessity and uniqueness of the development of supervision in the profession reflects in some way the boundary aspect of the profession itself. In terms of the society at large, there is an essential meditational quality to the profession and consequently a dual accountability. The supervisor is in some way the instrument that guarantees good service both to the client and society.

In the context of his discussion of the educational aspects of supervision, Kadushin talks about tension.  The supervisor is responsible to maintain a balance between a degree of tension that motivates and challenges – and a degree of tension that can immobilize. In his discussion the supportive aspects, he mentions the disequilibrium involved in practice learning as a source of tension. For Kadushin, tension is an aspect of supervision, but not a central theme. His emphasis is more organizational and sociological.

Bertha Reynolds (1965), is less comprehensive and organizationally focused in her treatment of supervision than Kadushin. Her theoretical orientation is more related to supervision as an instrument and process of development of the professional self in the worker. Yet her outline of the stages involved in the development of the professional self has an inherent process and transformation emphasis. Reynolds sees the supervisor as the one who sets the condition for this process to occur. It is essentially a growth process and under the right conditions in the supervisor-worker relation, occurs spontaneously.  Her model of the good supervisor is that of the good teacher in the midwife tradition.  Unlike Kadushin, Reynolds does not emphasize the organizational aspects nor integrate them into the development of the professional self. I don’t recall her using the word tension, yet in her emphasis on the growth process, her model of supervision has more sympathy with the one presented in this paper than Kadushin’s. Her approach, though organic, lacks a clear sense of the dynamic tension in the relationship between structure and process. Her focus is less sociological than Kadushin’s or this present paper.

In conclusion, concepts of supervision were presented here which have arisen out of beginning practice of supervision in a hospital setting on a Medical-Surgical service. They present the supervisory process as centered on the holding, management and use of tension occasioned by the tasks of the profession, department and worker in this medical setting. The process itself was seen as transformative and the activity of the supervisor as one of attending to the establishment and maintenance of the conditions that support a continuous transformative process within the service, the department, the supervisor and the worker.

REFERENCES

Apaka, T., Hirsch, S., and Kleidman, S. Establishing group supervision in a hospital social work department. Social Work, October. 1967.

Foekler, M. and Deutschgerger, P.  Growth oriented supervision. Public Welfare, July. 1970.

Germain, C.  An ecological perspective in casework practice. Social Work, June. 1973.

__________, and Gitterman, A.  The life model of social work practice.  New York: Columbia University Press. 1980.

Glasser, P. and Garvin, C.  Social groupwork: the organizational and environmental approach. In Encyclopedia of Social Work, Vol. 2. Washington: NASW. 1977.

Kaduchin, A. Supervision in social work. New York: Columbia University Press. 1980.

Maslach, C. and Kahan, R. Job burnout. Public Welfare. Spring, 1978.

_________ and Pines, A. Characteristics of staff burnout in mental health settings. Hospital and Community Psychiatry, Vol. 29, No 4. 1978.

Miller, I.  Supervision in social work. In Encyclopedia of Social Work, Vol. 2. Washington: NASW. 1977.

Reynolds, B. Learning and teaching in the practice of social work. New York: Russel and Russel. 1965.

Schwartz, W. Social groupwork: the interactional approach. In Encyclopedia of Social Work, Vol. 2. Washington: NASW. 1977.

Tropp, E. Social groupwork: the developmental approach. In Encyclopedia of Social Work, Vol. 2. Washington: NASW. 1977.

© 2014 James Donnelly, DSW.LCSW

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South Garden Press, New York

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