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SW: Final Project

Please see attachment

This assignment is due February 5. I attached two Required Readings that’ll assist you. Trauma informed social work practice page 25-37 and Interventions with adults page 147-176. Any population you choose is fine by me. Submit an 8- to 10-page scholarly paper supported with a minimum of six peer-reviewed articles as references.
For this Assignment, use will practice steps in Evidence-Based Practice.
1) You will think of a practice problem. 2) You then conduct a literature review on available research. 3) You will evaluate the evidence to determine which intervention to use. 4) You will consider client values and your clinical expertise. 5) You will think about what you hope the client gains from this intervention (i.e., decreased depression, increased quality of life, decreased PTSD symptoms) and consider how you might measure this change.

To prepare:

Choose a population of interest to you.
Children
Adolescents
Adults
Elderly/Aging
Choose a presenting problem (depression, family conflict, homelessness, etc.) related to the population of interest.
Conduct a literature review focused on the presenting problem within the population of interest.

By Day 7

Submit an 8- to 10-page scholarly paper supported with a minimum of six peer-reviewed articles as references. In the paper, you should:

1. Briefly describe the population and presenting problem you are focusing on for this assignment.
2. Provide a review of the articles you reviewed from this project and explain what you learned from conducting this research.
3. Briefly describe at least 2 evidence-based interventions currently used for your chosen population when addressing this particular problem. Provide supporting references when explaining the evidence behind the interventions.
4.Explain which of these interventions you might choose to use and why.
Consider client values and your clinical expertise and how those might affect your decision of which intervention to use.
5. Describe how you might apply the specific skills and techniques of the chosen intervention.
6. Briefly explain how you could measure the outcomes of this intervention.
7. Explain any cultural considerations that you need to take into account when working with this population or the particular presenting problem.
8. Discuss how the Code of Ethics applies when working with this particular presenting problem and population.
9. Explain how you would apply a trauma-informed lens when working with this population.

Support your Final Project with specific references to the resources. Be sure to provide full APA citations for your references

Chapter 6
Intervention With Adults

Bruce A

Thyer

Purpose: This chapter describes various resources social workers can access
to locate credible information regarding the effectiveness of psychosocial inter-
ventions for use with adults.
Rationale: Social workers have many sources of information to help guide
their practice. Many of them are outdated, incorrect, and potentially harmful.
It is important to be able to locate sources of information that are current and
accurate and reflect interventions that have credible evidence to support their
application with adults.
How evidence-informed practice is presented: The websites of the Cochrane
and Campbell Collaborations contain many systematic reviews that provide
credible appraisals of the state of the science pertaining to selected psychosocial
interventions.
Overarching question: Which resources can social workers consult to obtain
relevant information regarding the effectiveness of various interventions that
can be helpful for practice with adult clients?

This chapter reviews contemporary developments and advances regarding
the effectiveness of various psychosocial interventions and assessment
methods used by social workers who serve adult clients. Clinical social
workers comprise the largest professional group providing psychotherapy
services to adults in the United States, outnumbering psychologists and
psychiatrists combined by a considerable margin. By virtue of our mere
numbers, if not our sense of professionalism, it is crucial that members of
our discipline keep abreast of the latest information on psychosocial work
interventions’ effectiveness. The term psychosocial treatment or therapy
will be used throughout this chapter, because it is more inclusive than
psychotherapy, behavior analysis, case management, and other terms for
interpersonal helping. Barker (2003) provides the following definition of
psychosocial therapy:

A relationship that occurs between a professional and an individual, family,
group, or community for the purpose of helping the client overcome specific
emotional or social problems and achieve specified goals for well-being.

—(p. 349)

It is used here in a much broader sense than that employed by
Hollis (1964) in describing a particular theoretically based approach to

147

Holosko, M. J., Dulmus, C. N., Sowers, K. M., & Sowers, K. M. (2013). Social work practice with individuals and families : Evidence-informed assessments and
interventions. ProQuest Ebook Central http://ebookcentral.proquest.com
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148 Social Work Practice With Individuals and Families

social casework. It is juxtaposed to other major methods of intervention,
such as medications, surgery, hospitalization, or changes in laws or social
policy. It involves both intrapersonal and interpersonal processes as well
as changes in a person’s physical environment. Although much of this
chapter’s focus is on psychotherapies, the principles discussed apply to all
forms of psychosocial intervention. Occasional reference is made to these
other modes of helping—for example, case management, advocacy, behav-
ior analysis, mediation, and so on. In this chapter, persons chronologically
older than the teenage years are referred to as adults. The purpose of this
chapter is to provide the reader with information on how to locate major
resources pertaining to the selection of interventions most likely to be of
benefit to his or her clients.

Historical Background

In the past two decades, there have been a number of substantive ini-
tiatives to identify the evidentiary foundations of various psychosocial
interventions. These initiatives are largely independent efforts and have
continued on to the present. They are discussed sequentially, but this does
not imply any sense of priority or authoritativeness.

Task Force on Promotion and Dissemination
of Psychological Interventions

The first one to be addressed was developed at the initiative of Martin Selig-
man, then president of Division 12, the Division of Clinical Psychology,
one of more than 50 divisions within the American Psychological Associ-
ation. Seligman established a Task Force on Promotion and Dissemination
of Psychological Interventions, primarily composed of major players who
supported the scientist-practitioner model of psychological training. This
group was charged with three distinct tasks. The first was to identify some
set of evidentiary standards that could be used to assess the effectiveness
of different psychological treatments when applied to help clients with
discrete and specific so-called mental disorders. The second assignment
was, once these evidentiary guidelines were established, to actually apply
them in evaluating the evidence related to the effectiveness of these various
interventions and to prepare and publish lists of such well-supported treat-
ments. The third assignment was to prepare a list of treatment manuals for
these presumptively well-supported interventions, including information
about how these manuals could be obtained and where clinicians could
gain supervised experience in learning to use them. A treatment manual
was defined as a written document that provided sufficient detail so as
to permit a competent clinician to replicate the treatment. As you might
imagine, none of these tasks was undertaken without considerable discus-
sion, and, indeed, controversy (see Chambless & Ollendick, 2001), but the
original task force continued its work through several successive presidents
of Division 12 and was largely successful in completing its assignments.

Intervention With Adults 149

The first task was perhaps the most contentious, and in the interests
of space and time, I will simply refer to the final set of criteria described
in Chapter 5 of this volume. On the face of it, these criteria seem rel-
atively modest, but they certainly engendered a storm of controversy,
mostly stemming from two overlapping camps. The psychodynamically,
phenomenologically, and humanistically inclined psychotherapists were
anxious that their preferred treatments may not meet these seemingly (to
them) stringent standards and that this could negatively affect the cred-
ibility of their services. The second group of opponents were those who
advocated postmodernist perspectives and repudiated the idea that certain
forms of evidence (e.g., randomized controlled trials) should be given
greater credibility than other ways of knowing (e.g., case studies or other
forms of qualitative inquiry). The behavior analysts, who rarely employed
randomized controlled trials in their evaluations of therapy, successfully
insisted that a series of well-controlled single-case studies could also
provide convincing evidence related to the effectiveness of psychological
treatments.

Acceptance of the evidentiary criteria was helped through a recog-
nition that the task force was clearly committed to identifying genuinely
effective psychotherapies, irrespective of theoretical orientations, and also
that these standards were modeled after those used by the U.S. Food and
Drug Administration in the process to approve the safety, efficacy, and
use of new medications. These suggested standards appeared in various
publications (Chambless et al., 1998; Task Force, 1995), and the language
softened from referring to ‘‘empirically validated’’ to ‘‘empirically sup-
ported’’ treatments in order to provide some distance from any implication
that research on a given psychotherapy was concluded.

Once the bar had been set, members of the task force began assem-
bling reports on what psychological treatments met these standards and
developed lists of them. One such list is partially depicted in Table 6.1.
The original list is longer, listing about 25 therapies, and also includes
citations to the intervention research justifying the treatment’s inclusion.
Updates to this list appeared in later publications that collected a list of
the treatment manuals describing the well-established interventions and
provided information about where they were published or could otherwise
be acquired (Chambless et al., 1998; Woody, Weisz, & McLean, 2005).
Further publications appeared (Sanderson & Woody, 1995; Van Hasselt
& Hersen, 1996; Woody & Sanderson, 1998). Some members of the task
force went on to produce books describing these empirically supported
treatments, which have proven to greatly enrich the treatment literature
(e.g., Nathan & Gorman, 1998, 2007; Weisz, 2004).

A later initiative (Woody et al., 2005) was to conduct a survey
of APA-accredited doctoral and internship training programs in clinical
psychology in the United States and Canada, assessing the extent to
which these programs were providing training in task-force identified,
empirically supported treatments and to compare changes in such training
opportunities over the past decade (1993–2003). The picture was mixed.

150 Social Work Practice With Individuals and Families

Table 6.1 Examples of Supposedly Empirically Validated Treatments
Well-Established Treatments

Beck’s Cognitive Therapy for Depression
Behavioral Marital Therapy
Cognitive Behavior Therapy (CBT) for Panic Disorder With and Without

Agoraphobia
CBT for Generalized Anxiety Disorder
Exposure Therapy for Phobias
Exposure Therapy and Response Prevention for Obsessive-Compulsive

Disorder
Group CBT for Social Phobia
Interpersonal Psychotherapy for Bulimia
Token Economy Programs for the Chronically Mentally Ill
Probably Efficacious Treatments
Brief Psychodynamic Therapies
Dialectical Behavior Therapy for Borderline Personality Disorder
Lewinsohn’s Psychoeducational Treatment for Depression

Adapted from ‘‘Training in and Dissemination of Empirically-Validated Psychological
Treatments,’’ by the Task Force on Promotion and Dissemination of Psychological
Procedures, 1995, Clinical Psychologist, 48(1), pp. 3–23.

In 2003, the modal number of empirically supported treatments that
students were trained in during graduate school was 0(!), and the mode
for providing supervised training during the internship was also 0(!). The
mean numbers of empirically supported treatments (ESTs) taught dropped
from 11.5 (1993) to 9.5 (2003), but the responding programs differed
from the two surveys, so this is not a reliable index. Only four ESTs
were taught by more than 50% of the internship programs. ‘‘Most of
the treatments that have robust empirical support are not taught (in a
supervised way) by the majority of training programs’’ (Woody et al.,
2005, p. 9), a rather embarrassing finding considering the conspicuous
manner in which psychology says it is distinguished from other mental-
health fields by its rigorous adherence to a scientist-practitioner model
of training.

A subsequent national survey of psychotherapy training in psy-
chiatry, psychology, and social work was undertaken by social worker
Myrna Weissman et al. (2006). A cross-sectional survey of a probability
sample of all accredited training programs in psychiatry (n = 73), psy-
chology (n = 84), and social work (n = 64) responded. The survey asked
about required and elective didactic (lectures and reading) classes and
supervised clinical practica offering training in one or more empirically
supported interventions. Sixty-two percent of the social work programs
offered no didactic classes combined with clinical supervision in an empir-
ically supported intervention, and only about 10% of the MSW programs
offered both classes and supervised practice in this area. Overall, the MSW
programs fared more poorly in this arena than did those in psychiatry and

Intervention With Adults 151

clinical psychology. It should be noted that the accreditation standards for
both psychiatry and clinical psychology require education and training in
one or more empirically based treatments, something that current MSW
accreditation standards do not require.

The original task force has since been renamed the Committee
on Science and Practice, within Division 12 of the APA, and continues
its work, although in less striking ways (see http://www.psychology
.sunysb.edu/eklonsky-/division12/index.html).

The standards of evidence found in Chapter 5 remain in play, but the
list of ESTs is periodically (and appropriately) amended to reflect advances
in clinical research (Nathan & Gorman, 1998, 2007). This latter volume is
immodestly titled A Guide to Treatments That Work, but it really does live
up to its name. It was claimed, ‘‘This volume emanates from a task force of
the board of directors of Division 12 (Clinical Psychology) of the American
Psychological Association (APA) established in 1993 during my Presidency
of that division’’ (Seligman, 1998, p. v). Seligman wanted this book to be an
interdisciplinary, state-of-the-science summary of what is known to work
in terms of psychological (what we social workers would call psychosocial)
and pharmacological treatments, disorder by disorder by disorder: ‘‘The
work was to be a disinterested review of outcome studies, not a lobbying
effort: These volumes are intended to be scientific documents of a high
order. It is essential that their integrity be unimpeachable’’ (Seligman, 1998,
p. vi). There could be no involvement of researchers who received funding
from pharmaceutical companies or who had other financial conflicts of
interest, and there was to be no editorial control from either Division 12 or
the APA at large. The mandate to the clinician-scholars invited to author
various chapters was clear and compelling:

The purpose of these chapters is to present the most rigorous, scientifically
based evidence for the efficacy of treatments that is available. At the same time,
it is clear that for some disorders there are treatments widely recognized by
experienced clinicians to be useful that may not have been subjected to rigorous
investigation for a variety of reasons. Our aim is to be clear with readers what
treatments have been scientifically validated, what treatments are felt by a large
number of experts to be valuable but have never been properly scientifically
examined, and what treatments are known to be of little value.

—(Nathan & Gorman, 1998, p. x)

This project was carried out as proposed, with the first edition appearing
in 1998 and undated editions in 2002 and 2007. It is an invaluable resource
for social workers seeking guidance about effective interventions relevant
to adult clients who meet the formal diagnostic criteria for a mental
disorder. A related book, composed with the same intent, is titled A Guide
to Assessments That Work (Hunsley & Mash, 2008) and serves as the
assessment counterpart to the treatment guides. Chapters are structured
around DSM-defined clinical conditions and some other issues that are not
themselves formal mental illnesses (e.g., couple distress, pain). Each such

http://www.psychology

http://www.psychology.sunysb.edu/eklonsky-/division12/index.html

152 Social Work Practice With Individuals and Families

chapter contains a summary of the best (e.g., most scientifically legitimate)
assessment methods pertaining to that particular chapter’s focal problem.

Keep in mind that Division 12 is but one of more than 50 divisions
within the APA, and the APA as the host organization has taken great pains
not to officially endorse this initiative of Division 12, due to the sensitivities
of the larger community of psychologists, many of whom are decidedly
not enamored with efforts such as these. Indeed, the first edition contains
a legal disclaimer that lawyers within the APA insisted on including in A
Guide to Treatments That Work, stating that:

This book does not represent an official statement by APA, or any of its divi-
sions, but rather the personal views of the authors based upon their review of the
scientific literature relative to therapeutic techniques and drugs for various psy-
chological disorders. The book recites the literature and describes the controlled
outcome studies relative to therapies but it is not intended to recommend ‘‘treat-
ments of choice,’’ establish standards or guidelines for ‘‘care’’ or provide advice
on the efficacy of the therapies listed. . . . [H]ealth care providers and members of
the public are advised that this book should not be definitively relied upon in
making choices for appropriate care and treatment.

—(Seligman, 1998, p. vii)

So much for Seligman’s hope that there would be no outside editorial
control! Recently, the APA has begun using the language of evidence-based
practice (Kazdin, 2008; Norcross, Beutler, & Levant, 2006), reflecting the
more profound influence of this initiative, originating outside psychology
and described next, but unfortunately in doing so, the organization has
blurred the distinction between the concept of empirically supported
treatments (e.g., identifying interventions supported by a certain level of
evidence) and the process of evidence-based practice. Nevertheless, these
lists of ESTs can be a useful source of information for clinicians seeking
credible information regarding psychosocial treatments that have achieved
at least some minimal standard of research support.

Evidence-Based Practice
The term evidence-based medicine first appeared in print in a 1992 article
by Gordon Guyatt, a physician concerned with promoting the greater use
of scientifically reliable research findings in the practice of health care.
Guyatt, allied with a number of medical doctors with similar views, began
publishing a series of papers in the Journal of the American Medical Associ-
ation (JAMA), the British Medical Journal (BMJ), and other leading medical
journals, describing the basic tenets of what came to be called evidence-
based practice, a more broadly based term reflective of the application
of these principles to all health-care disciplines, not just medicine. The
best-selling textbook Evidence-Based Medicine: How to Practice and Teach
EBM has gone into its fourth edition (Strauss, Glasziou, Richardson &
Haynes, 2011), from which much of the content in this section of this
chapter is drawn.

Intervention With Adults 153

The definition of evidence-based medicine is deceptively simple:

Evidence-based medicine (EBM) requires the integration of the best research
evidence with our clinical expertise and our patient’s unique values and circum-
stances.

—(Strauss et al., 2011, p. 1)

This three-component sentence often has casual readers overlooking the
second and third elements in favor of an almost exclusive emphasis on
the first element, research evidence. In other words, many misconstrue
EBP to simply mean locating research evidence (e.g., best-supported inter-
ventions) and then applying them to practice. This is clearly a false
representation of EBP, because the definition involves three equally impor-
tant elements: research evidence, clinical expertise, and client’s values and
circumstances. Anyone who equates EBP solely with applying empirically
supported techniques has a gross and fundamental misunderstanding of
this process of learning, teaching, and practicing.

EBP arose due to some realizations among its originators:

• Clinicians have a great need for valid information about a client’s
problem, prognosis, effective ways to assess and diagnosis, how to
treat clients, and how to prevent problems.

• The traditional ways of communicating such information are inad-
equate. Books and journals are frequently out of date, wrong,
ineffective, or overwhelming, or they simply convey bogus infor-
mation.

• There are often growing disparities between our clinical skills, empir-
ically based knowledge, and practice effectiveness.

• There are serious limitations about how much time clinicians can
spend in tracking down clinically relevant and valid information.

However, there are some technological developments that make it
possible to overcome some of these factors inhibiting genuinely effective
practice:

• New ways to track down information efficiently.

• The creation and availability of systematic reviews (of which more
will be said later) of the effects of health-care and psychosocial
interventions.

• The development of evidence-based journals that reprint summaries
of genuinely useful information from recently published journals
(e.g., Evidence-Based Mental Health; see http://ebmh.bmj.com).

• The development of improved ways to learn about research evidence,
clinical skills, and assessment methods.

Evidence-based practice is best viewed as a process of learning or
of locating information and acting upon it rather than locating empirically

http://ebmh.bmj.com

154 Social Work Practice With Individuals and Families

supported treatments and applying them. Evidence-based practice is seen
as having five steps:

1. Converting the need for information (about prevention, diagnosis,
prognosis, therapy, causation, etc.) into an answerable question.

2. Tracking down the best evidence with which to answer that question.

3. Critically appraising that evidence for its validity (closeness to the
truth), impact (size of the effect), and applicability (usefulness in our
clinical practice).

4. Integrating the critical appraisal with our clinical expertise and our
patients’ unique biology, values, and circumstances.

5. Evaluating our effectiveness and efficiency in executing Steps 1 to 4
and seeking ways to improve them for next time. (Strauss et al.,
2011, pp. 2–3)

Strauss et al. (2011) and related primary resources spend a good deal
of space on each of these five steps, and the reader interested in learning
more about EBP within social work is strongly urged to begin with Strauss
et al. and other small books central to the EBP movement (e.g., Guyatt &
Rennie, 2002; Moore & McQuay, 2006) before delving into the related
literatures on EBP to be found in social work (e.g., J. Corcoran, 2000;
Cournoyer, 2004; Gibbs, 2003; Gray, Plath, & Webb, 2009; O’Hare, 2005;
Roberts & Yeager, 2006; Thyer & Kazi, 2004; Thyer & Wodarski, 2007).

Concurrent with the establishment of the EBP movement within
medicine, an international group of health-care professionals established an
organization called the Cochrane Collaboration (CC; www.cochrane.org).
I strongly urge you to sign on to the Cochrane website and take some
time perusing what it has to offer and to become familiar with this highly
influential organization. The CC is named after a distinguished British
epidemiologist, Archie Cochrane. The CC is both international and not for
profit and is

dedicated to making up-to-date, accurate information about the effects of health
care readily available worldwide. It produces and disseminates systematic reviews
of health care interventions and promotes the search for evidence in the form
of clinical trials and other studies of interventions. . . . The major product of the
Collaboration is the Cochrane Database of Systematic Reviews which is published
quarterly . . . .Those who prepare the reviews are mostly health professionals who
volunteer to work on one of the many Cochrane Review Groups, with editorial
teams overseeing the preparation and maintenance of the reviews, as well as
application of the rigorous quality standards for which Cochrane Reviews have
become known.

—(Cochrane website, downloaded March 16, 2007)

A description of how systematic reviews are defined by the Cochrane
Collaboration is presented in Table 6.2.

http://www.cochrane.org

Intervention With Adults 155

Table 6.2 What Is a Systematic Review?
A systematic review uses transparent procedures to identify, assess, and synthesize results of research on

a particular topic. These procedures are explicit, so that others can replicate the review, and are defined
in advance of the review:

Clear inclusion/exclusion criteria specify the study designs, populations, interventions, and outcomes that
will be covered in the review.

An explicit search strategy is developed and implemented to identify all published and unpublished studies
that meet the inclusion criteria. The search strategy specifies keyword strings and sources (i.e.,
electronic databases, websites, experts, and journals) that will be included in the search.

Systematic coding and analysis are provided for included studies’ methods, intervention and comparison
conditions, sample characteristics, outcome measures, and results.

Meta-analysis (when possible) estimates pooled effect sizes (ES) and moderators of ES.

How Are C2 Systematic Reviews Different From Other Systematic Reviews?
C2 reviews must include a systematic search for unpublished reports (to avoid publication bias).
C2 reviews are usually international in scope.
A protocol (proposal) for the review is developed in advance and undergoes careful peer review by

international experts in the substantive area, experts in systematic review methods, and a trial search
coordinator.

Study inclusion decisions and coding decisions are accomplished by at least two reviewers who work
independently and compare results.

C2 reviews undergo peer review and editorial review.
Completed C2 reviews are published in C2-RIPE and may be published elsewhere.

From ‘‘What Is a Systematic Review?’’ by Social Welfare Group, Campbell Collaboration. Retrieved March 16, 2007,
from www.campbellcollaboration.org/SWCG/reviews.asp

Health-care professionals from a variety of disciplines (including
social work) located around the world volunteer to serve on Cochrane
Review Groups (CRGs), of which there are dozens, such as the Childhood
Cancer Group; Depression, Anxiety, and Neurosis Group; Drug and Alcohol
Group; HIV/AIDS Group; Pain, Palliative, and Supportive Care Group;
Pregnancy and Childbirth Group; and the Schizophrenia Group, to list a
few of particular relevance to social work. There are also various methods
groups and many brick-and-mortar Cochrane Centers located around the
world. The CC hosts an annual international conference and many regional
or national meetings.

On its website, you can also locate the Cochrane Manual, a detailed
guide to designing and evaluating systematic reviews (SRs) of high-quality
research on health-care interventions and methods of assessment, roughly
categorized by the subject matter of the various review groups (see
Table 16.2). There are free summaries of these SRs available on the web-
site, and your local university library most likely subscribes to the CC
library, allowing you free access to these invaluable resources. In terms of
timely, comprehensive, and minimally biased appraisals of the effects of
various treatments, the CC reviews represent the state of the art. The CC
does admittedly focus on physical-health conditions, which includes mental
illnesses; the majority of the reviews deal with medical interventions, not

http://www.campbellcollaboration.org/SWCG/reviews.asp

156 Social Work Practice With Individuals and Families

psychosocial ones, but categorizing issues as either medical and psychoso-
cial problems or as medical treatments versus psychosocial treatments is
not always easy. An example is a report appearing in the British Medical
Journal describing a randomized controlled trial of the effects of providing
insulation in homes on the health and well-being of residents (Howden-
Chapman et al., 2007). The 4,407 low-income participants lived in 1,350
households, half of which were randomly selected to receive upgraded
insulation (to keep the homes warmer). The provision of more insulation
produced improved health, fewer days absent from work or school, and
fewer visits to the doctor. Is this a medical intervention? Regardless, the
implications for social work clinical and community practice seem clear,
and studies such as this, which will eventually be incorporated in CC
reviews, make it worthwhile for social workers to become familiar with
this database of information and reports on treatments for disorders that
afflict adult social work clients.

The Campbell Collaboration (C2; see www.campbellcollaboration
.org), named after psychologist Donald Campbell, is closely modeled
after the work, operation, and products of the Cochrane Collaboration.
Unlike CC, the C2, founded in 1999, focuses on preparing SRs in the
fields of education, criminal justice, and social welfare. It, too, hosts an
annual conference, supports a variety of centers around the world, devises
methodological standards, and encourages international social work schol-
ars to propose topics for SRs, develop research protocols related to those
titles, and then actually carry out these protocols and publish the SRs. At
present, there are more proposed titles and protocols (representing SRs in
development) than there are completed SRs (about 70 are available), but
the list of published SRs will expand greatly over the next few years. The
approach taken by the C2 with respect to systematic reviews is outlined
in Table 6.1. Strenuous efforts are made to control for or minimize bias
when completing these reviews, and they can be said to represent the most
methodologically rigorous and comprehensive evaluations of the literature
dealing with EBP-style answerable questions that are available to contem-
porary social workers. Both the Cochrane and Campbell Collaborations are
inclusive organizations, and they are always looking for competent social
workers to volunteer to serve on their various review groups or even to
undertake SRs in various areas of social welfare. Do not be bashful about
contacting them to see if you can help.

The two initiatives covered in this section—EST and EBP—seem to
have much in common, although EBP is a more sophisticated and fully
developed model. Within psychology, the language of EST and EBP is
slowly moving in the direction of the latter, to the detriment of EBP. The
reason is that lists of treatments perhaps inevitably take on an aspect of
imperativeness—that is, the sense that one must use one of these approved
therapies and to not do so is somehow ethically and professionally suspect.
This is a problem with lists of ESTs. Now, EBP on the other hand, does
not endorse particular interventions and clearly leaves open the option to
make conscientious decisions to not make use of the most scientifically

http://www.campbellcollaboration

http://www.campbellcollaboration.org

Intervention With Adults 157

supported treatments. This is because the EBP model uses additional
criteria to help make decisions, with clients, about what course of action to
follow. These other factors include client preferences and values, unique
features of the client (e.g., those with intellectual disabilities may not be
able to benefit from cognitive or insight-oriented treatments), available
resources, costs, one’s clinical expertise, professional ethics, and so on. All
these factors go into making treatment plans in the EBP model, whereas
they are virtually ignored in ESTs. Another problem is that clinicians often
object to being told what to do, and, if agency administrators dictate
that particular treatments be used for clients with particular diagnoses,
this is seen as undermining social worker autonomy and professionalism.
Some agency administrators and even governmental agencies do exactly
that: They select particular treatments and tell providers that this is what
they must offer, and this model is erroneously labeled as EBP (when it is
really more akin to EST). Thus EBP got tarred with the opprobrium that
rightly should be directed to EST and managerialism (see Thyer & Myers,
2011; Thyer & Pignotti, 2011, for more on the distinctions being made
here). There are ESTs (if you use the APA Division 12 standards for what
constitutes enough evidence). There are no EBPs, because EBP is a model
for arriving at scientifically informed decisions, which is also guided by
other important considerations. When people talk about EBPs, they almost
always have this term confused with ESTs.

Practice Guidelines
You may have heard of the intriguing term practice guidelines, and it may
be useful to review what is meant by this phrase:

[D]efined as ‘‘systematically developed statements to assist practitioner and
patient decisions about appropriate care for specific clinical circumstances’’
(Institute of Medicine, 1990, p. 27), practice guidelines are recommendations for
clinical care based on research findings and the consensus of experienced clin-
icians with expertise in a given practice area. Practice protocols, standards,
algorithms, options, parameters, pathways, and preferred practice patterns
are nuanced terms broadly synonymous with the concept clinical practice
guidelines.

—(Howard & Jenson, 1999b, p. 285)

There has been little discussion of the relevance of practice guidelines
within the social work literature. Howard and Jensen (1999b) guest-edited
a special issue of the distinguished journal Research on Social Work
Practice devoted to the topic of practice guidelines and clinical social work,
and Rosen and Proctor (2003) edited a book titled Developing Practice
Guidelines for Social Work Interventions: Issues, Methods, and Research
Agenda, based on a conference sponsored by the George Warren Brown
School of Social Work at Washington University. To date, I am unaware
of any practice guidelines developed by social workers within and for
the profession of clinical social work, and our discipline’s contributions

158 Social Work Practice With Individuals and Families

to practice guidelines appear to be meager. The National Association of
Social Workers (NASW) is a conspicuously absent player on the scene of
practice guidelines and is lacking major organizational initiatives; it seems
that relatively little will be forthcoming.

There is a very large interdisciplinary and disciplinary literature of
practice guidelines, however, for many hundreds of mental illnesses and
other psychosocial problems, some of which are obviously potentially
applicable to social work intervention with adults. However, these almost
always share a glaring problem that you may have overlooked in the
definition quoted earlier—namely, that practice guidelines are usually
based on an amalgamation of scientific research findings and the consensus
of experts. It is this latter feature that contaminates, in the view of many,
the credibility of practice guidelines. Those guidelines hammered out
behind closed doors, crafted in smoke-filled rooms by the Machiavellian
mavens of mental illness, lack the virtues of transparency associated with
the APA’s Division 12 EST task force or the SR protocols of the CC or
C2. You can assign weights to different levels of evidence when crafting
an SR, as in so much weight for a randomized controlled trial, so much
less weight for a quasi-experimental study, and so on. Also, you can use
independent raters to assure the reliability of such judgments. However,
you cannot do that when the pristine purity of transparently conducted
published research findings are contaminated with the dross of expert
consensus. It is like adding a drop of ink to a glass of clear water. The
weighty and distinguished voice of senior authority figures, wedded to a
given model of practice to which they have devoted their life’s work, may
overwhelm the timid research-based (but valid) appraisals of the more
junior clinical researcher.

Be that as it may, practice guidelines are available for many adult
disorders, and those of the American Psychiatric Association have some
of the widest currency. The American Psychiatric Association began pub-
lishing practice guidelines in 1991. These were initially published in issues
of the American Journal of Psychiatry, the flagship journal of the Ameri-
can Psychiatric Association, and were later made available for purchase at
the website (www.psych.org/psych_pract/treatg/pg/prac_guide.cfm). The
guidelines have a notation about when they were initially published, and
if your local university subscribes to the American Journal of Psychiatry,
you will very likely be able to download it directly from the journal at no
cost. Also available on this website is the American Psychiatric Associa-
tion’s Guideline Development Process, which describes how its practice
guidelines are crafted. In it is noted that

[t]he evidence base for practice guidelines is derived from two sources: research
studies and clinical consensus. Where gaps exist in the research data, evidence
is derived from clinical consensus, obtained through board review of multiple
drafts of each guideline. . . . Both research data and clinical consensus vary in
their validity and reliability for different clinical situations; guidelines state
explicitly the nature of the supporting evidence for specific recommendations,

http://www.psych.org/psych_pract/treatg/pg/prac_guide.cfm

Intervention With Adults 159

so that readers can make their own judgments regarding the utility of the
recommendations.

—(Steering Committee on Practice Guidelines, 2006, p. 4)

This approach differs significantly from that used by the APA task force and
the CC and C2, each of which largely exclude any role of so-called expert
consensus in the crafting of the evaluative reviews. Although the American
Psychiatric Association will indeed describe the available research evidence
in its practice guidelines, the reader is still left unclear about the extent
to which expert opinion was blended with a dispassionate appraisal of
empirical research. This renders the American Psychiatric Association’s
practice guidelines less credible in the view of those who subscribe to more
of a science orientation as opposed to an artistic perspective on practice.

One problem that psychologists in particular have noted with respect
to the American Psychiatric Association’s practice guidelines is that they
seemingly overemphasize the use of psychotropic medications at the
expense of possibly more efficacious psychosocial treatments (see Per-
sons, Thase, & Crits-Christoph, 1996). This is perhaps understandable,
because the psychiatrist’s unique contribution to the care of the mentally
ill largely resides in his or her ability to provide biological assessments
and treatments, whereas the practice of psychotherapy is provided by all
the other legally regulated mental-health professions. Does the field of
psychiatry’s considerable investment (sometimes literal) in psychophar-
macological treatments affect the therapy recommendations found in its
practice guidelines? Does the field of clinical psychology’s investment in
psychological treatments bias its appraisals of the research literature so that
it favors nonpharmacological interventions? Like Casablanca’s Inspector
Reynaud finding out that gambling is taking place in Rick’s Café Ameri-
cain, you, too, might be shocked to discover that pecuniary considerations
could influence the crafting of scientific documents—but not so naive as to
dismiss the possibility.

Clinical-treatment guidelines are now in the process of being devel-
oped by the American Psychological Association (see http://www.apa.org/
about/offices/directorates/guidelines/clinical-treatment.aspx), with one of
the first being oriented around the problem of obesity. Various writers have
suggested that clinical social work should undertake the development of
practice guidelines crafted by social workers for use in social work treat-
ment. This strikes me as absurd, and I have said so previously, in more
modest language (Thyer, 2003). We have psychiatrists creating practice
guidelines for helping people with schizophrenia, psychologists are doing
the same thing, as are the nurses, and so on. What seems more legitimate
and useful is for social work professional organizations to proactively
advocate for having clinical social workers well represented on expert
panels that craft interdisciplinary practice guidelines, not disciplinary ones.
No single field, and certainly not social work, can provide genuinely com-
prehensive care for adults with mental disorders. Psychiatry, psychology,
nursing, and clinical social work all have useful and sometimes admittedly

http://www.apa.org

http://www.apa.org/about/offices/directorates/guidelines/clinical-treatment.aspx

160 Social Work Practice With Individuals and Families

overlapping roles to play. Creating interdisciplinary practice guidelines for
use by all the major players and professions, ones that take into proper and
judicious account the biological and the psychosocial research literature,
would seem far more useful for adults with mental illnesses than having
distinct disciplinary practice guidelines for each of the major fields.

Howard and Jensen (1999b) list a wide array of resources that social
workers can consult in tracking down clinical practice guidelines, but,
to reiterate, the methodological quality of practice guidelines is uneven.
Some are based solely on expert consensus and are not the usual resource
one would seek out for state-of-the-art-and-science information on helping
adults.

Institute of Medicine

The Institute of Medicine (IOM) is a branch of the National Academies,
private but federally recognized entities charged with providing the
government and public with science-based, independent, and authoritative
advice on matters related to biomedical science, medicine, and health
(see www.iom.edu). Very few social workers belong to the IOM,
including Paula Allen-Meares, former dean of the University of Michigan
School of Social Work. The IOM periodically issues reports on various
topics, some of which pertain to social work practice with adults, and
although these reports lack the transparency and comprehensiveness
of SRs, they nevertheless can be a useful source of information
that contributes to social care for adults with various problems. A
recent one (dated 2012), for example, is titled Child Maltreatment
Research, Policy, and Practice for the Next Decade and is available for
free at http://www.iom.edu/Reports/2012/Child–Maltreatment–Research–
Policy–and–Practice–for–the–Next–Decade.aspx. Another report (dated
2011) is titled Preventing Violence Against Women, found on the same
site. Their relevance to social work practice is obvious.

National Registry of Evidence-Based Programs and Practices

The U.S. Substance Abuse and Mental Health Services Administration
(SAMHSA) has created a National Registry of Evidence-based Programs
and Practices (NREPP) for a wide array of mental disorders and substance
problems. This resource is described as follows:

The National Registry of Evidence-based Programs and Practices (NREPP) is a
searchable online registry of mental health and substance abuse interventions
that have been reviewed and rated by independent reviewers. The purpose of
this registry is to assist the public in identifying scientifically based approaches
to preventing and treating mental and/or substance use disorders that can be
readily disseminated to the field. NREPP is one way that SAMHSA is working to
improve access to information on tested interventions and thereby reduce the lag
time between the creation of scientific knowledge and its practical application in
the field.

—(downloaded from http://www.nrepp.samhsa.gov/AboutNREPP.aspx
on March 30, 2012)

http://www.iom.edu

http://www.iom.edu/Reports/2012/Child%E2%80%93Maltreatment%E2%80%93Research%E2%80%93

http://www.nrepp.samhsa.gov/AboutNREPP.aspx

http://www.iom.edu/Reports/2012/Child%E2%80%93Maltreatment%E2%80%93Research%E2%80%93Policy%E2%80%93and%E2%80%93Practice%E2%80%93for%E2%80%93the%E2%80%93Next%E2%80%93Decade.aspx

Intervention With Adults 161

Although laudable in intent, the evidentiary standards used to qualify
an intervention for listing on the NREPP are lamentably low, with more
than 20 interventions being supported solely by simple pretest-posttest
outcome studies with no control or comparison groups. It does the public
little good to lump such minimally supported treatments in among those
enjoying considerably higher levels of evidence. Social workers consulting
the NREPP need to carefully evaluate the research support behind each
listed program, because the overall qualification standards are poor, and
simply being listed on this national registry does not automatically imply
that the intervention is well supported.

Summary of Useful Resources

The available resources are impressively large relative to what was avail-
able only a couple of decades ago, but perhaps discouragingly meager
considering the seriousness, complexity, and vastness of needs.

The periodical publications that emerged from the Division 12
Task Force on the Promotion and Dissemination of Psychological
Interventions—for example, Chambless et al. (1996, 1998), Sanderson and
Woody (1995), Task Force (1995), Woody and Sanderson (1998), and
Woody et al. (2005)—are all available for free on the Division 12 web-
site (http://www.psychology.sunysb.edu/eklonsky–/division12/). Fran-
kly, however, a much better resource is Nathan and Gorman’s (2007)
A Guide to Treatments That Work. Each chapter is a comprehensive
research synthesis about what is known regarding the psychosocial or
pharmacological treatment for clients with a discrete diagnosable mental
illness. There is also a summary table at the beginning of the book (some
excerpts from this table are reproduced in Table 6.3). In the left column
is a specific syndrome, next is a list of empirically supported treatments,
the standards of proof used to make this determination, and, last, on
the right, some references to research supporting the inclusion of this
particular treatment. There are 29 diagnosable mental illnesses for which
the authors have provided comprehensive appraisals. The social worker
seeking information on effective treatments will find this resource of
great value.

Nathan and Gorman’s (2007) book is a summary of research and
can point social workers in the direction of effective treatments, but Van
Hasselt and Hersen (1996) provide actual treatment manuals for 17 adult
psychosocial and medical problems. These are listed in Table 6.4. These
treatment manuals describe interventions in sufficient detail to enable a
skilled clinician (social worker, psychologist, psychiatrist, etc.) to deliver
these services to clients. The interventions are all well supported, as defined
by the Division 12 task-force criteria, and consulting these manuals would
be a great first step for a social worker to begin acquiring clinical skills
in delivering these empirically supported psychosocial interventions. The
articles by Sanderson and Woody (1995) and Woody and Sanderson (1998)

http://www.psychology.sunysb.edu/eklonsky%E2%80%93/division12%00%00%00

162 Social Work Practice With Individuals and Families

Table 6.3 Summary of Treatments That Work

Syndromes Treatments Standards of Proof
Chapters in

Nathan & Gorman

Bulimia
Nervosa
(BN)

Several different classes of antidepressant
drugs produce significant, short-term
reductions in binge eating and purging.

A large number of Type 1
and Type 2
randomized clinical
trials (RCTs), utilizing
placebo as comparison.

Wilson and
Fairburn,
Chapter 22,
pp. 559–592

Manual-based cognitive-behavioral therapy
(CBT) is currently the treatment of
choice. Roughly half the patients
receiving CBT cease binge eating and
purging. Long-term maintenance of
improvement appears to be reasonably
good.

A very substantial
number of Type 1 and
Type 2 RCTs.

Schizophrenia Behavior therapy and
social-learning-token-economy programs
help structure, support, and reinforce
prosocial behaviors in persons with
schizophrenia.

Many Type 1 and Type 2
RCTs and a very large
number of Type 3
studies of behavior
therapy and
social-learning-token-
economy programs.

Kopelowicz,
Liberman, and
Zarate,
Chapter 8,
pp. 201–228

Structured, educational, family
interventions help patients with
schizophrenia maintain gains achieved
with medication and customary case
management.

More than 20 Type 1 and
Type 2 RCTs of
educational family
interventions.

Social-skills training has enabled persons
with schizophrenia to acquire
instrumental and affiliative skills to
improve functioning in their
communities.

More than 40 Type 1 and
Type 2 RCTs of
social-skills training.

Pharmacological treatment has had a
profoundly positive impact on the
course of schizophrenia. The
recent introduction of atypical
antipsychotics has been promising
because of their reduced side effects
and enhanced efficacy in some
refractory patients.

A very large number of
RCTs over 40 years.

Bradford, Stroup,
and Lieberman,
Chapter 7,
pp. 169–199

Specific
phobias

Exposure-based procedures, especially
in-vivo exposure, reduce or eliminate
most or all components of specific
phobic disorders.

A very large number of
Type 1 RCTs.

Barlow, Raffa,
and Cohen,
Chapter 13,
pp. 301–335

No pharmacological intervention has been
shown to be effective for specific
phobias.

Roy-Byrne and
Cowley,
Chapter 14,
pp. 337–365

Intervention With Adults 163

Table 6.4 Treatment Manuals for Adult Disorders Available in Van
Hasselt and Hersen (1996)

Panic Disorder and Agoraphobia
Obsessive-Compulsive Disorder
Cognitive-Behavioral Treatment of Social Phobia
Social-Skills Training for Depression
Cognitive-Behavior Therapy for Treatment of Depressed Inpatients
Biobehavioral Treatment and Rehabilitation for Persons With Schizophrenia*
Community Reinforcement Training With Concerned Others
Cognitive-Behavioral Treatment of Sex Offenders
Treatment of Sexual Dysfunctions
A Comprehensive Treatment Manual for the Management of Obesity
Lifestyle Change: A Program for Long-Term Weight Management
Managing Marital Therapy: Helping Partners Change
Insomnia
Cognitive-Behavioral Treatment of Body-Image Disturbances
Cognitive-Behavioral Treatment of Postconcussion Syndrome
Trichotillomania Treatment Manual
Anger Management Training With Essential Hypertensive Patients

*This manual was co-authored by a social worker, Stephen E. Wong, PhD.
Source: Sourcebook of Psychological Treatment Manuals for Adult Disorders, by V. B.
Van Hasselt and M. Hersen (Eds.), 1996, New York, NY: Plenum Press.

provide another listing of treatment manuals and how to obtain them, but
not copies of the actual manuals themselves.

The Campbell and Cochrane Collaborations are another exceedingly
useful resource for learning about the evidentiary status of various inter-
ventions potentially useful to social workers serving adult clients. If you
visit the websites of these two organizations, you will find a long list
of proposed topics (to be the subject of future SRs), a shorter list of
protocols proposed by various research teams that have been approved
by the respective collaborations, and an even shorter list of actual SRs.
However, although limited in number, these SRs probably represent the
most scientifically credible and up-to-date summaries of the research lit-
erature regarding the usefulness of various interventions and assessment
methods. Table 6.5 lists a selection of completed SRs that you can locate
on these collaborations’ websites. The last one listed, Work Programs
for Welfare Recipients, was completed in August 2006 and is an analy-
sis of randomized controlled studies, quasi-experimental outcome studies,
and cluster-randomized controlled trials of welfare-to-work programs for
persons receiving public assistance, such as Temporary Assistance for
Needy Families (TANF). The analysis of the research literature involved 46
programs encompassing more than 412,000 participants, with outcomes
reported for up to 6 years. The free document is 122 pages long. You
can see how an SR of this nature is potentially far more informative than
reading a single study appearing in a journal; and if you are a social worker

164 Social Work Practice With Individuals and Families

Table 6.5 Examples of Completed Systematic Reviews Addressing Psychosocial Interventions
for Adults

From the Cochrane Collaboration (www.cochrane.org)

• Screening and Case Finding Instruments for Depression
• Marital Therapy for Depression
• Short-Term Psychodynamic Psychotherapies for Common Mental Disorders
• Interventions for Helping People Recognize Early Signs of the Recurrence of Bipolar Disorder
• Psychological Debriefing for Prevention of Posttraumatic Stress Disorder (PTSD)
• Psychological Treatment of Posttraumatic Stress Disorder (PTSD)
• Individual Psychotherapy in the Outpatient Treatment of Adults With Anorexia Nervosa
• Interventions for Vaginismus

• Alcoholics Anonymous and Other 12-Step Programs for Alcohol Dependence
• Psychotherapeutic Interventions for Cannabis Abuse and/or Dependence in Outpatient Settings
• Family Intervention for Schizophrenia
• Token Economy for Schizophrenia
• Cognitive-Behavior Therapy for Schizophrenia
• Hypnosis for Schizophrenia
• Life-Skills Programmes for Chronic Mental Illnesses
• Art Therapy for Schizophrenia or Schizophrenia-Like Illnesses
• Supportive Therapy for Schizophrenia
• Individual Behavioural Counseling for Smoking Cessation
• Group-Behaviour-Therapy Programmes for Smoking Cessation
• Strategies for Increasing the Participation of Women in Community Breast-Cancer Screenings
• Reminiscence Therapy for Dementia
• Psychological Treatments for Epilepsy

From the Campbell Collaboration (www.campbellcollaboration.org)

• Cognitive Behavioral Programs for Juvenile and Adult Offenders: A Meta-Analysis of Controlled
Intervention Studies

• The Effectiveness of Incarceration-Based Drug Treatment on Criminal Behavior
• Interventions for Learning Disabled Sex Offenders
• Work Programmes for Welfare Recipients
• Advocacy Interventions to Reduce or Eliminate Violence and Promote the Physical and Psychosocial

Well-Being of Women Who Experience Intimate Partner Abuse
• Cognitive Behavioural Therapy for Men Who Physically Abuse Their Female Partners
• Court-Mandated Interventions for Individuals Convicted of Domestic Violence
• Cross-Border Trafficking in Human Beings: Prevention and Intervention Strategies for Reducing Sexual

Exploitation

• Effects of Drug-Substitution Programs on Offending Among Drug Addicts
• Effects of Second-Responder Programs on Repeat Incidents of Family Abuse
• Mindfulness-Based Stress Reduction (MBSR) for Improving Health, Quality of Life, and Social

Functioning in Adults
• Motivational Interviewing for Substance Abuse
• Personal Assistance for Adults (19–64) With Physical Impairments

http://www.cochrane.org

http://www.campbellcollaboration.org

Intervention With Adults 165

involved in serving TANF clients, a review of this comprehensive nature
could prove enormously useful for you in learning about what aspects of
welfare-to-work programs are genuinely helpful versus those that are less
beneficial.

Think of the implications of having information of such high quality
available, both for social work practice as well as for education. No
longer does an individual social worker have to search aimlessly through
journals, vainly hoping to locate some potentially useful studies. Other
very well-qualified scholars have already culled the literature, separated
the credible research from the less useful, and summarized the results for
your independent review and analysis of its applicability to your practice
situations and clients. Think of the absurdity of teaching social work
practice courses using one or more theories as the guiding framework
to structure the class when you and students have access to actual
outcomes research about various psychosocial treatments readily used by
social workers active in various areas of practice, such as schizophrenia,
depression, anxiety disorders, and so on. If we are in the business of
educating students to practice in these various areas, these systematic
reviews published by the Campbell and Cochrane Collaborations could
(should?) be a very important component of such instruction. Yet, sadly,
many social work students and practitioners have yet to come into contact
with these incredibly useful resources.

The IOM is another resource, arguably less comprehensive than the
work of the Campbell and Cochrane Collaborations but still potentially
valuable in learning about interventions for use with adult clients. A few
of its reports with applicability to our field include the following titles, all
available at www.iom.edu:

• Improving the Social Security Disability Decision Process

• Posttraumatic Stress Disorder: Diagnosis and Assessment

• Improving the Quality of Health Care for Mental and Substance-Use
Conditions

• WIC Food Packages: Time for a Change

• Improving Palliative Care: We Can Take Better Care of People With
Cancer

• Taking Action to Reduce Tobacco Use

The American Psychiatric Association has produced a series of
practice guidelines for selected mental illnesses, and these are avail-
able for purchase as PDF documents at its website (www.psych.org/
psych_pract/treatg/pg/prac_guide.cfm) for the following disorders:

• Acute stress disorder and PTSD.

• Alzheimer’s disease and other dementias of late life.

• Bipolar disorder.

http://www.iom.edu:

http://www.psych.org/psych_pract/treatg/pg/prac_guide.cfm

166 Social Work Practice With Individuals and Families

• Borderline personality disorder.

• Delirium.

• Eating disorders.

• HIV/AIDS.

• Major depressive disorder.

• Obsessive-compulsive disorder.

• Panic disorder.

• Psychiatric evaluation of adults.

• Substance-use disorders.

• Suicidal behaviors.

You may also be able to print them out for free from the applicable
issues of the American Journal of Psychiatry via your local university
library. Keep in mind that these practice guidelines typically overempha-
size pharmacological treatments at the expense of psychotherapeutic or
psychosocial services, and they involve elements of the consensus clinical
opinions of presumptive experts, but even with these caveats, they are still
informative.

Limitations of the Evidence

You can view the glass as half full or half empty. Do we know much
more now in terms of genuinely effective psychosocial interventions for
use with the adult clients of social workers than we did, say, 2 or 3 decades
ago? Absolutely! But it is undeniable that large gaps exist, and for many
important areas of social work practice, the interventive map remains
labeled terra incognita. For several dozen of the major mental illnesses,
significant strides have been made, and new advances appear in the clinical
research literature on a weekly if not daily basis. Keep in mind that the
process of evidence-based practice, or the lists of empirically supported
treatments, do not exclusively insist on a reliance on an accumulation
of pristine RCTs before social work practitioners can decide what to
do. We need to decide what to do every day and cannot defer making
important decisions about the nature of the services we offer our clients.
Evidence-based practice does point out that certain forms of evidence,
such as RCTs, meta-analyses, and SRs, can provide us with more credible
information about the effectiveness of services, but if that level of evidence
is unavailable, then you should act by taking into account the highest
quality evidence that is available. This may include quasi-experiments not
involving the random assignment of clients to various treatment conditions;
time-series studies, case-control investigations, economic analyses, single-
subject experiments; or even qualitative research, such as narrative case
studies. The point is to make a conscientious effort to seek out the highest-
quality-available information and integrate this with your own clinical

Intervention With Adults 167

skills and the clients’ values and circumstances in making decisions about
potential services to offer. It may be that the highest-quality evidence
suggests one course of action (e.g., cognitive therapy for depression),
but your own background provides you with insufficient training in this
method to be able to offer it. You can opt to provide something else (e.g.,
nonspecific supportive counseling), but at least you are doing so with the
conscious recognition that this is likely to be a less-than-optimal service for
your client. Or you may be prompted on the basis of your analysis of the
evidence to seek out additional training and supervision of an evidence-
based intervention that your client may need or to refer your client to a
service provider who can better meet the client’s needs.

It is widely recognized that many of the psychosocial interventions
that are empirically supported are based on studies in which people of
color and other historically oppressed groups are underrepresented. This
presents us with the problem of generalizing findings obtained from largely
Caucasian client samples to these other groups. There is no need to assume
that the treatments will be ineffective with other groups, but it is a far better
strategy for findings demonstrated to be valid with one group (Caucasians)
to have been successfully replicated in other groups (African Americans,
Hispanics, etc.). This is slowly being accomplished.

It is also well known that treatments demonstrated to be useful
in tightly controlled studies involving clients who meet the diagnostic
criteria for only one disorder, with services provided by atypically well-
trained and supervised therapists, may not yield similarly positive benefits
when implemented in other practice settings. In the real world, services
are likely to involve clients who meet the diagnostic criteria for mul-
tiple disorders, who experience impoverished environments, who have
additional stressors impacting them, who attend appointments less regu-
larly, and who get services from less-than-stellar clinicians. This problem,
too, is being vigorously addressed through translational research stud-
ies examining the transportability of empirically supported services into
routine care.

There are also significant gaps in the literature related to the disci-
plinary contributions specific to social work. In the field of psychotherapy,
clinical social workers comprise the largest professional group providing
such services in the United States, with far more practitioners than clinical
psychology or psychiatry; yet social workers are sadly underrepresented
in terms of designing, conducting, and publishing high-quality outcome
studies. There are many reasons for this. Clinical psychology emerged from
an academic discipline that had many decades of an experimentalist tradi-
tion in its history, whereas social work came from the Settlement House,
the church, and the community organization society, not the laboratory.
To be recognized as a psychologist, you must complete a doctorate—in
most cases, a research-based doctorate—whereas in social work we made
the disciplinary decision to lower the bar, so to speak, back in the mid-
1970s by admitting BSWs into our professional ranks (prior to that time,
a master’s degree was required). We continue to wrestle with defining

168 Social Work Practice With Individuals and Families

what the profession of social work actually is and who a social worker
is, and these issues make it difficult to carve out our discipline’s unique
niche in the human-services and health-care fields (Thyer, 2002). State
departments of children and family services rarely have a career ladder
specific to BSWs and MSWs and usually open up their child-welfare and
other human-services jobs to persons who have completed a wide array
of undergraduate or graduate majors. There is actually very little sound
evidence, for example, that BSWs make better child-protective-service
workers than non-BSWs (Perry, 2006a) or that social workers are better
supervisors in the human services than persons without the social work
degree (Perry, 2006b). We see life coaches, care coordinators, discharge
planners, nurses, philosophical counselors, clinical sociologists, and so on,
all undertaking tasks formerly largely conducted by members of our profes-
sion. All these issues make it difficult to convincingly assert a unique and
specific role for social work and social workers. Those who argue that we
somehow possess a value base and ethical system that sets us apart from
other fields usually make this argument in ignorance of the considerable
attention being given to issues of social justice, the alleviation of poverty,
and the provision of services to historically oppressed groups by psychol-
ogists, nurses, and psychiatrists. One has only to compare the massive
outreach and service efforts of the American Psychological Association to
the people of New Orleans following Hurricane Katrina, compared to the
minimal responses of the much larger NASW, to see that psychologists
were walking the walk, not merely talking the talk.

This is not to conclude that the profession of social work is not
incredibly valuable. It is. Indeed there are many aspects of our field that
are noble and inspiring. However, the services we provide and the theories
we learn about are primarily shared with, if indeed not derived from,
other disciplines. If we are to become more than the utility players of the
human services, we must take a much more active role as creators and
disseminators of the evidence-based knowledge that is increasingly being
seen as an important aspect of social care. This leads to the next section.

Implications for Social Work at the Micro-, Mezzo-,
and Macrolevels

What should we do with the information presented thus far? Here are a
few suggestions.

Micro- and Mezzolevel Practice

The focus of most of the preceding content has been on micro- and
mezzolevel social work practice, interventions with individuals, families,
small groups, and agencies (Barker, 2003, p. 272), and the implications
of this information should be pretty clear. Individual social work students
should regularly seek out the evidentiary foundations of what they are

Intervention With Adults 169

being taught. Politely ask, with a bright smile, the instructors of your direct-
practice classes if they can point you to any SRs or randomized controlled
studies demonstrating that the interventions you are being taught are really
capable of helping clients. Honest instructors should be able to do this
right away or do so in a few days, or else they should forthrightly tell you
that there is no such evidence. The intellectually corrupt ones will tell you
that randomized controlled studies are incapable of measuring the subtle
but nonetheless powerful effects of these interventions and that scientific
analyses have little place in the evaluation of social work interventions.
The morally corrupt ones will angrily inform you that you have no right
to ask such questions and that you should accept what they teach without
question on the basis of their clinical experience and theoretical knowledge.
Reinforce with smiles, attention, and words of encouragement instructor
efforts, minimal though they may initially be, to teach about empirically
supported treatments and the process of EBP. Use your course evaluations
to provide corresponding feedback, organizing your classmates to do
the same.

Established practitioners can investigate the intellectual resources
described in this chapter to learn more about empirically supported treat-
ments related to the fields of practice you are engaged in. Obtain empirically
supported practice guidelines and treatment manuals and attempt to
acquire skills in these interventions. Locate sources of qualified super-
vision in these methods and consider getting formal advanced training via
workshops and continuing-education programs. Contact your local NASW
chapter and ask it to sponsor Continuing Education Unit (CEU) programs
related to EBP and empirically supported treatments. Social work faculty
who teach direct-practice classes should begin integrating the principles
and resources described in this chapter into their classroom instruction
and clinical supervision. Purge your syllabi of outmoded or superceded
theory and replace it with readings and texts related to EBP and empirically
supported treatments.

Macrolevel Practice

At the macrolevel, meaning political action, community organizing, public
education, and the administration of agencies (Barker, 2003, p. 257), there
are a number of possible implications for social work practice. Within
our major professional organizations, the NASW could amend its code of
ethics to include something along the following lines:

Clients should be offered as a first choice treatment, interventions with some
significant degree of empirical support, where such knowledge exists, and only
provided other treatments after such first choice treatments have been given a
legitimate trial and shown not to be efficacious.

and
Clinicians should routinely gather empirical data on clients’ relevant behavior,
affect, and reports of thoughts, using reliable and valid measures, where such
measures have been developed. These measures should be repeated throughout

170 Social Work Practice With Individuals and Families

the course of treatment, and used in clinical decision making to supplement
professional judgments pertaining to the alteration or termination of treatment.

—(Thyer, 1995, p. 95)

The NASW could also greatly expand on the laudable standard it estab-
lished as far back as 1992, in its statement on reparative therapies:

Proponents of reparative therapies claim—without documentation, many suc-
cesses. They assert that their processes are supported by conclusive scientific data
which are in fact little more than anecdotal. NCOLGI protests these efforts to
‘‘convert’’ people through irresponsible therapies. . . . [E]mpirical research does
not demonstrate that . . . sexual orientation (heterosexual or homosexual) can be
changed through these so-called reparative therapies.

—(National Committee on Lesbian and Gay Issues, 1992, p. 1)

Similar standards were issued in an updated NASW position paper in
2000 (http://www.socialworkers.org/diversity/lgb/reparative.asp). If one
particular therapy is deemed by the NASW as unethical at least in part
because it lacks a sufficient empirical foundation, this has the appear-
ance of a precedent-setting standard that could be extended to other,
similarly nonempirically supported treatments. It is unclear why gay and
lesbian clients should be afforded protection against ineffective and harmful
treatments but not other social work clientele.

This series of recommendations would involve a two-pronged
approach: promoting the use of the empirically supported treatment and
discouraging the use of what has been shown not to be useful. This should
be done cautiously. Absence of evidence is not evidence of absence. Many
interventions have not yet been adequately tested and may ultimately
prove helpful. So an initial focus on treatments that are pretty clearly
harmful (e.g., rebirthing therapy, boot camps, primal-scream therapy) or
useless (thought-field therapy, neurolinguistic programming, therapeutic
touch, hypnosis for chronic mental illness, etc.) would be a good way to
shape the field.

Another leverage point the NASW could apply, as could the various
state licensure boards, would be to require the providers of continuing
education (CE) for social workers to list the evidentiary foundations
supporting the assessment and treatment methods they are disseminating.
There is much that is useless and bogus being purveyed by the providers
of CE, and by declining to endorse these programs in favor of those with
a focus on empirically supported treatments, the entire field would be
enhanced.

Apart from the NASW, other social work interest groups could
provide education to third-party payers, such as insurance companies
and managed-care firms, so that they would no longer reimburse social
workers who provided interventions known to be bogus or ineffective.
Turning off the funding stream that fertilizes the weeds found in private
or agency-based practice would be another useful way to improve the
discipline.

http://www.socialworkers.org/diversity/lgb/reparative.asp

Intervention With Adults 171

The CSWE could revise its accreditation standards mandating, as
do psychiatry and clinical psychology, that BSW and MSW students be
provided training in empirically supported treatments, and it could lessen
its emphasis on teaching theoretical content of dubious validity (Thyer,
1994, 2001). Instead, favor more of a problem-focused approach, wherein
students take courses in given areas of practice (e.g., child abuse and
neglect, domestic violence, chronic mental illness) and are taught about
assessment methods and psychosocial interventions that are empirically
supported, irrespective of the theoretical orientation they are derived from.
If they are helpful to clients, students should be taught about them.
Textbooks should be similarly structured around helpful interventions for
specific problems (e.g., O’Hare, 2005; Thyer & Wodarski, 2007), not by an
overarching theory or collection of theories.

In general, greater attention needs to be given to training in specific
methods of clinical intervention (see Thyer, 2007) as opposed to a gen-
eralized model of supportive engagement with clients, focusing solely on
such skills as empathy, warmth, genuineness, and unconditional positive
regard. This traditional model, based on the naive premise that somehow,
with the cheerleading of a supportive social worker, clients will be able
to dig deep within themselves to solve their own problems, has been
incredibly destructive to the effectiveness and credibility of professional
social work. These clinical skills are indeed important and need to be
taught and mastered by our students, but they are insufficient preparation
by themselves for one to be an effective clinician, absent competence
in providing one or more empirically supported treatments effective for
clients with specific problems.

Another source of change could involve some benevolent patron’s
underwriting the legal expenses of one or more clients who were seen
by licensed social workers and who were provided with a nonempirically
supported therapy for the treatment of a condition for which one or more
empirically supported treatments have been clearly established. These
clients would sue their social worker, alleging malpractice in that the
social worker failed to provide them (or at least offer) these empirically
supported treatments. The patron would provide sufficient funding to
ensure that these cases went to court, where they might be settled in
favor of the plaintiff, thus establishing the legal precedent that social work
clients should have the right to effective treatment where it is known to
exist (see Myers & Thyer, 1997). Oddly, and embarrassingly, this standard
does not appear to be established at present (see K. Corcoran, 1998).

Conclusion

There is much to be positive and optimistic about. Our profession has
access to powerful tools for effective social work practice with adults.
The evidentiary foundations undergirding major areas of practice are
rapidly expanding, and the values of transparency and scientific rigor

172 Social Work Practice With Individuals and Families

are assuming an ever-greater importance. These developments are most
evident in the fields of mental health and to a lesser extent the general
domain of clinical social work. Many long-cherished interventions used
within our field are being subjected to rigorous testing. Some are being
supported; others are being shown to be of little value; many remain
under-researched. These rapidly expanding developments require intel-
lectually nimble social workers committed to a lifetime of professional
learning and of keeping abreast with the newest developments. Advances
in information technology, such as the computerized searching of journal
databases and access via the Internet to international consortia, such as
the Campbell and Cochrane Collaborations, make it possible for virtu-
ally every social worker to remain current and continually refresh his or
her repertoire of effective clinical skills. This is not only a good practice
for the individual social worker but essential for the long-term survival
of a profession that is being increasingly challenged to demonstrate its
capability to prevent and remedy significant interpersonal and societal
problems.

At present, faculty in MSW programs reportedly strongly endorse
providing students with training in evidence-based practice and in empir-
ically supported treatments (Rubin & Parrish, 2007). Yet, curiously, our
MSW programs only rarely provide graduate students with training and
clinical supervision in the provision of empirically supported treatments
(Bledsoe et al., 2007; Weissman et al., 2006). Training programs in clinical
psychology and psychiatry are doing better in this regard. We can and
must improve the empirical foundations of what we teach and practice.

Key Terms

Empirical; empirically
supported
treatments (ESTs)

Evidence-based
practice
(EBP)

Practice
guidelines

Systematic review

Review Questions for Critical Thinking

1. Describe the purposes and conduct of the EST movement.

2. Describe the purposes and conduct of the EBP movement.

3. Describe the basic differences between the EST and EBP movements,
and how EBP is a more sophisticated approach to making practice
decisions.

4. Discuss how practice guidelines and lists of ESTs can assist the process
of EBP and how they can be misused.

5. Describe how students can help promote the adoption of EBP within
social work education and practice.

Intervention With Adults 173

Online Resources

http://www.cochrane.org/ The website of the Cochrane Collaboration
(CC). Founded in 1993, the Cochrane Collaboration is an international
network of more than 28,000 dedicated people from more than 100 coun-
tries. We work together to help health-care providers, policy makers,
patients, their advocates, and caretakers make well-informed decisions
about health care, based on the best available research evidence, by
preparing, updating, and promoting systematic reviews in the area of
health care.

http://campbellcollaboration.org/ The Campbell Collaboration (C2) helps
people make well-informed decisions by preparing, maintaining, and
disseminating systematic reviews in education, crime and justice, and
social welfare.

http://www.psychology.sunysb.edu/eklonsky-/division12/ The website
supported by Division 12, Section III of the American Psychological
Association is devoted to providing information on psychosocial
treatments that meet certain minimal standards of research support.

http://www.nrepp.samhsa.gov/ The National Registry of Evidence-Based
Practices and Policies is supported by the federal Substance Abuse and
Mental Health Services Administration.

http://www.psych.org/psych_pract/treatg/pg/prac_guide.cfm The web-
site is maintained by the American Psychiatric Association, which
provides access to the practice guidelines developed by this professional
organization. Most guidelines are centered around the assessment and
treatment of mental illnesses.

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O R I G I N A L P A P E R

Trauma-Informed Social Work Practice:

Practice Considerations

and Challenges

Carolyn Knight

Published online: 19 February 2014

� Springer Science+Business Media New York 2014

Abstract Adult survivors of childhood trauma are an

especially challenging group of clients, given the long-term

effects of the victimization and the present day difficulties

these individuals face. In this article, trauma-informed

practice is explained, incorporating the most recent theo-

retical and empirical literature. The purpose is to educate

and provide support to clinicians who encounter survivors

of childhood trauma in a range of settings that are partic-

ularly likely to serve this population like addictions, mental

health, forensics/corrections, and child welfare. The social

worker neither ignores nor dwells exclusively on the past

trauma. Rather, trauma-informed practitioners are sensitive

to the ways in which the client’s current difficulties can be

understood in the context of the past trauma. Further, they

validate and normalize the client’s experiences. Trauma-

informed practice requires the practitioner to understand

how the working alliance, itself, can be used to address the

long-term effects of the trauma. Emphasis is placed on

helping survivors understand how their past influences the

present and on empowering them to manage their present

lives more effectively, using core skills of social work

practice.

Keywords Childhood trauma � Sexual abuse � Clinical
intervention � Indirect trauma � Child maltreatment � Adult
survivors

Introduction

Adult survivors of childhood trauma account for a majority

of individuals seeking or required to seek clinical services

(Bride 2004; Harper et al. 2008; Probst et al. 2011). Much

has been written about working with this population, but

most of this literature assumes that the past trauma will be

the primary focus of the professional intervention. How-

ever, many practitioners encounter trauma survivors in

settings like addictions, mental health, child welfare, and

corrections/forensics, where these individuals are particu-

larly likely to require or seek out services (Macy 2007;

Pence 2011). The focus in these practice contexts typically

is on the present-day difficulties with which the survivor is

struggling, rather than the underlying past

trauma.

Clinicians in these settings often feel ill-equipped to be

helpful to survivors, mistakenly assuming they lack the

required knowledge and expertise (Binder and McNeil

2007; Fusco and Platania 2011). Survivors’ sense of

urgency regarding their current problems-in-living, cou-

pled with the limited role that many practitioners play in

meeting their clients’ needs, often results in the history of

past trauma being overlooked, along with the impact that

this may have on current functioning (Chemtob et al. 2011;

Pence 2011; McGowan 2013). This is frustrating to clini-

cians and survivors alike. In fact, practitioners who do not

attend to survivors’ past, and the relationship it plays in the

present, undermine their ability to deal with the underlying

trauma and the present-day challenges that brought them

into treatment in the first place (Harper et al. 2008; Twaite

and Rodriguez-Srednicki 2004).

This article addresses a gap in the trauma literature by

focusing on the many instances in which a survivor of

trauma seeks out or is required to seek out treatment, not

for the past trauma, but for current problems in living. It

C. Knight (&)
School of Social Work, University of Maryland Baltimore

County, 1000 Hilltop Circle, Baltimore, MD 21250, USA

e-mail: knight@umbc.edu

123

Clin Soc Work J (2015) 43:25–37

DOI 10.1007/s10615-014-0481-6

begins with an overview of current theory and research

regarding the nature and long-term consequences of

childhood trauma. This is followed by an examination and

discussion of what is referred to as trauma-informed

practice (Brown et al. 2012; Layne et al. 2011), incorpo-

rating the most recent theoretical and empirical literature.

Case examples illustrate core concepts. The case material

reflects composites of actual client situations; all identify-

ing information has been changed to protect clients and

practitioners.

Nature of Childhood Trauma

The earliest definitions of childhood trauma emphasized the

event, itself and the traumatizing effects it had on its victims.

More recent conceptualizations recognize that the same

event will be experienced differently, based upon a range of

variables including cultural context and social and psycho-

logical factors unique to the individual (Elliott and Urquiza

2006). Williams and Sommer (2002) argue that, ‘‘Trauma is

in the eyes of the beholder…’’ (p. xix). More recent con-
ceptualizations of trauma also have moved away from a sole

focus on pathology and dysfunction. Researchers point to the

existence of ‘‘adversarial’’ or ‘‘posttraumatic growth’’

(Bonnanno 2004; Linley and Joseph 2004); survivors’ sense

of self-efficacy, their ability to cope with challenging events

in the future, and their spirituality can be enhanced as a result

of exposure to trauma.

Childhood trauma, particularly in the form of interper-

sonal victimization like sexual and physical abuse, has

been found to be associated with a host of difficulties

ranging from emotional and psychological reactions such

as depression, low self-esteem, and suicidal ideation;

physical problems like chronic pain; psychiatric problems

such as anxiety/panic, borderline, post-traumatic stress, and

dissociative identity disorders; and behavioral problems

including substance abuse, eating disorders, domestic vio-

lence, and self-injury (Farrugia et al. 2011; Kuo et al. 2011;

Shafer and Fisher 2011; Spitzer et al. 2006).

Childhood trauma also distorts survivors’ thinking about

their social world and leads to social isolation and prob-

lems with attachment (Waldinger et al. 2006). Survivors

are likely to develop core beliefs about self and others that

are characterized by low self-esteem and feelings of

worthlessness, powerlessness, and vulnerability, as well as

mistrust of others (McCann and Pearlman 1990). Child-

hood trauma robs its victims of a stable sense of self. This

results in a lack of the ‘‘self-capacities’’ (McCann and

Pearlman 1990), that allow individuals to ‘‘maintain a

consistent sense of identity and positive self-esteem’’ (p.

21). These self-capacities reflect basic coping mechanisms

like the ability to: soothe and comfort oneself when

distressed; be alone and comfortable with oneself; experi-

ence a full range of affective reactions without being

overwhelmed by or denying them; regulate emotions; and

accept criticism and negative feedback.

There also is increasing evidence to suggest that expo-

sure to trauma in childhood leads to neurobiological

changes in the developing brain. These changes appear to

be more or less permanent and reinforce the previously

identified social, emotional, and behavioral consequences

of the abuse (Coates 2010; Delima and Vimpani 2011;

Rothschild 2003; Teicher et al. 2003).

Trauma-Informed Practice: Definition

When clinicians work in settings that are likely to serve

adults with histories of childhood trauma, it is important

that they entertain the possibility that the client could have

such a history, regardless of whether or not the client

presents her or himself as a survivor. Trauma informed

practice doesn’t mean that the practitioner assumes the

client is a survivor. It also doesn’t mean that the focus of

the intervention will be on the past trauma.

Rather, the practitioner is sensitive to this possibility and to

the ways in which the client’s current problems can be

understood in the context of past victimization. The worker

also recognizes the potential implications that being a survivor

have for the client’s willingness and ability to enter into a

working alliance; evidence suggests this may be especially

challenging for survivors, given core beliefs characterized by

hostility towards others, and their difficulties forming positive

attachments (Monahan and Forgash 2000; Stovall-McClough

and Cloitre 2006). ‘‘The development of the therapeutic alli-

ance…is often a daunting challenge with an interpersonally
victimized [client]. The [worker] may be perceived as a stand-

in for other untrustworthy and abusive authority figures to be

feared, challenged, tested, distanced from, raged against,

sexualized, etc.’’ (Courtois 2001, p. 481).

Unlike trauma-centered intervention, where the under-

lying trauma is the primary focus of the intervention,

trauma informed practice helps survivors ‘‘develop their

capacities for managing distress and for engaging in more

effective daily functioning’’ (Gold 2001, p. 60). The effects

of the past childhood trauma aren’t ignored, but ‘‘extensive

and detailed immersion in [traumatic] material itself is not

encouraged, because…this tactic is…destabilizing and
counter-productive’’ (Gold 2001, p. 60).

Importance of the Professional Relationship

Trauma-informed practice recognizes that the working

alliance can provide a corrective emotional experience for

26 Clin Soc Work J (2015) 43:25–37

123

survivors (Banks 2006). The relationship can challenge

distortions in thinking about self and others, and it can be a

means through which self-capacities can be developed

(McCann and Pearlman 1990). For example, when practi-

tioners understand and anticipate ‘‘traumatic transference’’

(Spiegel 1986), whereby they represent those who have

exploited the survivor, they can assist the client in con-

fronting directly fear and mistrust of others (Dalenberg

2004; Horvath 2000). Further, the worker’s affective

reactions to the survivor and her or his story affirm and

give voice to the client’s own reactions (Courtois 2001).

The therapeutic potential of the relationship depends

upon workers being knowledgeable about childhood

trauma and its relationship to the client’s current difficul-

ties. The worker acknowledges the trauma directly and

responds empathically, but does so in a way that is con-

sistent with her or his professional role (Glover et al. 2010;

Karatzias et al. 2012). The results of several studies reveal

that survivors of trauma are likely to have been in treat-

ment multiple times and to report having experiences with

professionals that were not helpful and often counterpro-

ductive (Beutler and Hill 1992; Palmer et al. 2001;

Schachter et al. 2003). Specifically, survivors reported as

unhelpful clinicians who: avoided addressing the trauma at

all, asked for too much detail and encouraged expression of

feelings when it wasn’t appropriate, and minimized the

significance of the trauma in the client’s current life.

The therapeutic potential of the working alliance also

depends upon the worker adhering to professional bound-

aries to enhance survivors’ self-capacities. Survivors’ sense

of urgency can lead the worker to engage in practice

activities that are inconsistent with her or his role in

agency-based or private practice. It also can lead the

worker to extend her or himself in ways that move the

relationship away from a professional one into a realm that

is more personal in nature. The following case example

reveals how easily boundaries can be violated.

Margaret was a twenty year old college student in her

sophomore year. She was sexually and physically

abused over a ten year period by her stepfather. She

began to have problems managing the stress associ-

ated with her school work. She also began to have

flashbacks and nightmares. One of her instructors

referred her to the school’s counseling center, where

she began to see a professional

clinician.

The center has a twelve session limit, and once

Margaret and her counselor reached the limit, Mar-

garet pleaded with the counselor to continue to see

her, since she believed the counselor was the ‘‘only

one’’ who could help her. The counselor agreed to see

Margaret ‘‘on the side’’, for free, in her home. Mar-

garet began to have thoughts of suicide and the

counselor invited her to spend the night with her each

time these thoughts surfaced.

This practitioner’s desire to help Margaret was under-

standable but misguided and ultimately undermined the

client’s self-capacities. The professional’s sense of urgency

could have been constructively channeled into advocating

for a more trauma-informed approach to treatment in her

agency, such as a change in policy regarding session limits

for clients like Margaret. Survivors already struggle with

entering into a therapeutic alliance; therefore, they benefit

greatly from an ongoing, stable relationship with the

clinician.

Instead, the clinician disregarded agency policy, which

ultimately undermined Margaret’s growth. What this

practitioner failed to appreciate was that terminating with

Margaret and referring her to another agency, though

painful, would have provided Margaret with an opportunity

to further develop self-capacities associated with beginning

and ending relationships and managing the difficult feel-

ings associated with these transitions. Unfortunately, the

clinician was significantly impacted by Margaret’s pain

and abandonment issues, suggesting an enactment of

countertransference, discussed later. Inviting Margaret to

stay with her further compromised Margaret’s ability to

manage her feelings on her own. The clinician also left

herself vulnerable to liability issues, because she no longer

was operating under the auspices of her employing orga-

nization. This situation did not end well. The practitioner

was forced to have Margaret hospitalized. Her involvement

with Margaret became known to the school, and she was

fired from her position.

Boundaries between workers and any client population

should remain fluid and open to adjustment, in response to

changing circumstances and contexts (Gabbard 1996;

Lazarus 1994; Reamer 2003). With survivors, the worker

may need to loosen boundaries to be more available in

times of crisis without losing sight of professional role and

responsibilities (Harper 2006). In the previous case, had the

clinician not had to terminate with Margaret, she might

have needed to be more available to the client to deal with

the suicidal thoughts. This doesn’t mean taking Margaret

home. However, it could mean establishing a safety con-

tract that required more frequent meetings with Margaret

and/or keeping in daily contact via phone or email.

In contrast to the last example, this next case illustration

demonstrates how the worker can empathize with a survi-

vor but still set limits and maintain boundaries that promote

empowerment.
1

The worker was a foster care worker and

was providing ongoing case management to Ms. Davies,

who lost custody of her young children after leaving them

1
Adapted from Knight (2009).

Clin Soc Work J (2015) 43:25–37 27

123

unsupervised for long periods of time. The worker, Anna,

visited Ms. Davies monthly to assess her progress on her

contract with the agency, the goal of which was re-unifi-

cation with the children. The following exchange took

place as their meeting was ending.

Anna: Well, I guess that’s it for today, Ms. Davies.

You’re doing very well, making a lot of progress. If

things continue on like this, I think you’ll be able to

have [her children] for an overnight visit very soon. Is

there anything else for today?

Ms. Davies: There’s just this one thing. Maybe I

actually already told you this. Did I ever tell you that

when I was a kid, my father pimped me out? He was

a drug addict, like me. He didn’t have no job or

nothing, so he used me to buy his drugs. He’d sell me

to his friends. Let them do what they want to me, and

then take money. Can you believe that? He sold his

own daughter, just to support his drug habit. That

son-of-a-bitch.

Anna: Oh, my, what a terrible story! I had no idea. It

took a lot of courage for you to tell me this. You must

have so many feelings about what your dad did to

you: anger, sadness, confusion. I guess maybe some

of the reason why you were using drugs yourself was

so you didn’t have to feel all this stuff?

Ms. Davies: Yeah, it hurts real bad. It got so, though,

that even when I was using, I would still be thinking

about what he done to me. It’s like I just keep seeing

what happened in my head over and over again.

Anna: I’m sure that this must be so difficult. [Pats

client on the shoulder.] What happened when you

were so little, and then not being able to stop thinking

about it now. You know that my job is to help you do

what it takes for you to get your kids back, right? I

am so glad that you have told me what you did,

because now I can be even more helpful to you. I’m

thinking that the fact that you have shared this with

me means that maybe you are ready to talk about it

with someone. What I’d like to do is refer you to

someone who can help you to do that.

This exchange exemplifies trauma-informed practice in

several ways. Most important, the worker responded

directly to the client’s disclosures of childhood trauma,

conveying her appreciation of the importance of what had

been shared. Anna empathized with Ms. Davies, which in

turn normalized and validated the client’s feelings. Yet,

Anna didn’t lose sight of her role. Anna didn’t offer ser-

vices she couldn’t provide, nor did she delve deeply into

Ms. Davies’s past. Asking Ms. Davies for more informa-

tion about her abuse could have been re-traumatizing and

undermined her self-capacities; it also was inconsistent

with Anna’s role as a foster care worker.

In yet another implication of boundaries, there may be

times when the worker wishes to use physical contact- in

Anna’s case a pat on the shoulder- to provide reassurance

and convey empathy to an adult survivor. Conceivably,

survivors can learn that touch can be soothing and com-

forting, not just harmful and exploitive. Yet, survivors of

childhood trauma need to be empowered to control who

touches them and how, as well as regulate the physical

distance between the clinician and them. Ms. Davies and

Anna had a longstanding relationship, and the client held a

great deal of trust in Anna. In many instances these char-

acteristics will not exist. Thus, the worker typically should

take a conservative approach and avoid using touch as a

therapeutic tool; in those rare instances when it is used, the

worker must adhere to three fundamental principles: The

client must be asked in advance if the worker can touch her

or him, be reassured that she or he can say no, and be

informed what the nature of that touch will be (O’Donohue

and Bowers 2006).

Boundaries should ensure that survivors remain in

control of their bodies. This is especially critical given the

findings of several studies which indicate that survivors of

sexual abuse are at greater risk of being sexually victimized

by therapists than other clients (Nachmani and Somer

2007). Practitioners also must be sensitive to the ways in

which survivors of sexual abuse are prone to sexualize the

relationship they have with the therapist, owing to their

history of having been exploited in intimate relationships

(Nachmani and Somer 2007; Somer and Nachmani 2005).

Practice Considerations

The four-fold principles of trauma-informed practice are:

normalizing and validating clients’ feelings and experi-

ences; assisting them in understanding the past and its

emotional impact; empowering survivors to better manage

their current lives; and helping them understand current

challenges in light of the past victimization (Courtois 2001;

Martsolf and Draucker 2005; Wright et al. 2003).

Practitioners working in settings that address clients’

present-day challenges often feel thwarted in their efforts

to be helpful to survivors because they ‘‘only’’ are able to

assist these individuals with their presenting problems.

However, directly addressing the trauma before the survi-

vor is psychologically and emotionally ready to do so may

serve only to re-traumatize the individual and affirm core

feelings of powerlessness (Classsen et al. 2011; Connor

and Higgins 2008; Harper et al. 2008; Martsolf and

Draucker 2005; Regehr and Alaggia 2006). In contrast,

assisting a survivor in, for example, staying clean, finding

employment, or remaining emotionally stable by taking

necessary medications, is an essential step in addressing

28 Clin Soc Work J (2015) 43:25–37

123

the long-term effects of the trauma. When the survivor is

better able to manage present-day challenges, her or his

self-capacities are enhanced, and this addresses the past

trauma in a powerful and important way (Glover et al.

2010).

Clinicians working in settings most likely to encounter

survivors of childhood trauma also often assume they lack

the skills necessary to be helpful to survivors. In fact,

strategies that are traditionally used in social work practice

have been found to be effective when working with sur-

vivors. Most fundamentally, the ability to convey empathy

and understanding affirms and validates the survivor’s

feelings and experiences, reducing isolation and feelings of

being alone and different. Cognitive-behavioral strategies

challenge core beliefs and assist survivors in recognizing

and challenging their distortions in thinking; they also

serve to normalize and manage experiences, feelings, and

reactions, and assist survivors in seeing the connection

between present difficulties and the past trauma (Febbraro

2005; Messman-Moore and Resick 2002). Solution-

focused techniques strengthen self-capacities by helping

survivors identify positive ways they have coped in the past

(Knight 2006; Brun and Rapp 2001; Fleming 1998; Tam-

bling 2012). Techniques like writing, art, and other phys-

ical activities allow survivors to express feelings in

alternative, non-verbal ways (Huss et al. 2012; Park and

Blumberg 2002; Pifalo 2009).

More specialized strategies including guided imagery,

hypnosis, and eye movement desensitization and repro-

cessing (EMDR) have been employed with survivors of

childhood trauma. However, these are used most appro-

priately in trauma-centered intervention; they can be

empowering to survivors by helping them learn to relax,

self-soothe, and both express and manage feelings (Bisson

2005; Edmond et al. 2004; Harford 2010; Peace and Porter

2004; Solomon et al. 2009; Struwig and van Breda 2012).

They do require specialized training and an understanding

of the neurophysiological changes in the brain that have

been found to result from childhood trauma (Delima and

Vimpani 2011; Harford 2010). It is critical to note that the

worker should never use any techniques, particularly those

that require this more advanced knowledge, without

appropriate training (Thayer and Lynn 2006; van Minnen

et al. 2010).

Regardless of the techniques to be employed, the clini-

cian should work in partnership with the client, informing

her or him of what strategies the worker intends to utilize

and why (McGregor et al. 2006). The practitioner also

should avoid using any strategy for which there is little or

no evidence of effectiveness or a sound theoretical foun-

dation. While this would seem to go without saying, such

techniques abound in treatment with survivors (Arbuthnott

et al. 2001; Thayer and Lynn 2006). Finally, the worker

must be prepared to help survivors either express or contain

feelings, depending upon what is required to enhance self-

capacities.

In the following example from a 30-day inpatient drug

treatment program, the worker demonstrated her willing-

ness to consider that the client may have a history of

trauma, without jumping to firm conclusions. Notably, she

uses basic skills of social work practice to address the

client’s relatively spontaneous disclosures. The client,

thirty-year-old Rose, was meeting with the intake worker,

Claire, for her initial introduction to the program. After

Claire introduced herself and explained the policies and

treatment options of the inpatient program, she asked Rose

to describe her history of substance abuse. The following

exchange then took place.

Rose: I started using when I was about 10 or 11. I

would sneak into my parents’ liquor cabinet and drink

whatever I could find. I would try to cover it up by

adding water, and I guess it worked, ‘cuz they never

said anything. Of course, they were alcoholics

themselves, and didn’t give a damn about me.

Claire: Wow…that’s pretty young. Sometimes when
children use at such a young age it means that they

are trying to escape something. I am wondering if that

might be the case for you?

Silence.

Claire: It appears as if I have struck a chord with you.

I know it can be hard to talk about stuff that happened

in the past, but we can be more helpful to you now if

we know about anything that may have happened to

you when you were little.

Rose: Well, uh, my father would mess around with

me, you know, touch me and stuff.

Claire: I am so sorry to hear this, Rose. This must

have been very difficult for you, very painful.

Rose: (teary-eyed): I have always felt so dirty, so

ashamed about what he did to me…
Silence.

Claire: So many of our clients, particularly our

female clients, have had similar experiences. Using

drugs and alcohol becomes a way to escape the pain,

the sadness, the anger, all those feelings that go along

with what your father did to you.

In this brief exchange, Claire normalized and validated

her client’s feelings and experiences through empathy but

did not lose sight of her primary purpose which was to

conduct an initial intake. She allowed Rose to give voice to

what happened to her at the hands of her father, which was

a critical first step towards coming to terms with the vic-

timization. Yet, Claire did not press for a lot of detail or

encourage Rose to engage in in-depth self-disclosure. This

would have been counterproductive and undermined

Clin Soc Work J (2015) 43:25–37 29

123

Rose’s self-capacities, particularly her ability to manage

her feelings. It also would have been inconsistent with

Claire’s role as an intake worker.

As Claire sensitively observed, there is a strong corre-

lation between substance abuse and a history of sexual

abuse, particularly for women (Resnick et al. 2013; Ullman

et al. 2013). This enhanced Rose’s feelings of self-efficacy

by helping her better understand her current behavior.

Armed with this information, Rose, Claire, and Claire’s

colleagues could develop a treatment plan that took into

account Rose’s history but also focused on her current

problems with addiction.

In contrast, in this next example, the worker, Joan,

completely ignored the client’s thinly veiled hints about his

history. By doing so, she reinforced feelings of isolation

and deep shame, which are common, particularly among

male survivors (Alaggia and Millington 2008; Clark et al.

2012). The setting was a halfway house for men recently

released from prison. Joan was assigned to work with

Victor throughout his ninety day stay in her program.

Victor had been incarcerated for 10 years for possession of

drugs with the intent to distribute and for breaking and

entering. Joan’s role was to assist Victor in finding housing

and employment once he was released from her program.

The following exchange occurred in their sixth meeting

together.

Joan: So, last week, we were talking about your

introduction to your drug of choice [cocaine]. I

wonder how that was for you that your mother is the

one who encouraged you to use with her?

Victor: Well, at the time, I thought it was cool, you

know? I mean, I was 14, and here I was allowed to

snort coke.

Joan: It must have been confusing for you…
Victor (interrupts): Even at the time, when I was a

kid, I guess I knew it was screwed up, that my mom

shouldn’t be using with her kid. But, it was a good

escape from the craziness going on around me.

Joan: So when do you think that it became a problem

for you, when you couldn’t stop anymore?

Victor: From the beginning! The first time I got high,

I was, like, WOW, this feels great! I just numbed

myself out, when all the shit was going down with my

mother’s boyfriends.

Joan: Sounds like a rough time for you, and the coke

provided you with just the escape you needed. Before

you knew it, you were hooked.

On two occasions, Victor offered Joan the opportunity to

inquire about his past. But at neither point did she ask him

for more information. When asked about this, Joan

acknowledged that she picked up on Victor’s hints, but

wasn’t sure what to do with them. She questioned whether

it was ‘‘appropriate’’ for her to ask him about his past,

given the need to help him transition back into the com-

munity. She worried that she would be opening a ‘‘can of

worms’’ if she asked him what he meant by ‘‘the craziness’’

and the ‘‘shit’’ with his mother’s boyfriends. Joan further

conceded that she wasn’t sure what she would do if Victor

were to admit to a history of maltreatment, suggesting that

countertransference also may have been a factor.

With help, Joan came to understand that exploring

Victor’s past in a purposeful way would provide her with

valuable information about what he needed in the present.

In the session that followed, Joan did follow-up on the

comments Victor made previously; he reported that several

of his mother’s boyfriends had sexually and physically

abused him over a five year period. For the remainder of

his stay at her program, Joan assisted Victor in seeing the

connection between his past and present problems. She also

helped him better understand what happened to him when

he was a child, a particularly important strategy since men,

more so than women, are likely to assume their victim-

ization was related to homosexuality (Alaggia and Mil-

lington 2008). She acknowledged and empathized with his

feelings, encouraging him to express what it had been like

for him. Since it often was difficult for Victor to put his

feelings into words, particularly his anger, Joan suggested

alternative strategies, including punching pillows and

working with clay, examples of non-verbal techniques that

have been found to be effective in helping survivors- and

other clients- better manage and control feelings (Baljon

2011; Worthington 2012).

It is empowering for survivors to be able to put into

words their experiences and feelings. But, they also need to

remain in control of their emotions, since this enhances

self-capacities (McGregor et al. 2006; Sweezy 2011).

Further, clinicians need to be mindful of their professional

role and function when encouraging clients to share their

affective reactions. In the previous case involving Rose’s

intake interview, Claire empathized with the client without

encouraging a great deal of self-disclosure, consistent with

the fact that this was a one-session intake interview. In

contrast, once Joan gained an appreciation for how she

could be helpful to Victor during his ninety day stay, she

adopted an interdependent focus on encouraging Victor to

talk about and manage his feelings so they didn’t under-

mine his ability to secure employment and permanent

housing.

Trauma Informed Practice: Challenges

Three particularly noteworthy challenges face clinicians

who work with clients with histories of childhood trauma.

First, there will be instances when the client doesn’t report

30 Clin Soc Work J (2015) 43:25–37

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a history of childhood trauma because of the shame and

embarrassment that such a history engenders; this is

reflected in Victor’s indirect way of addressing his past

victimization. With sensitive, informed questioning like

that conducted by Claire in an earlier example, however,

the worker is likely to elicit relevant information about a

past history of trauma. Directly asking the client about

possible childhood trauma, subtly but powerfully conveys

to the client that she or he can discuss it when ready and

also normalizes and affirms her or his experiences and

feelings.

A related challenge occurs when the client presents with

little or no memory of past trauma. A client’s symptom

cluster and presenting problem(s) may be strongly sug-

gestive of a history of childhood trauma, but don’t provide

conclusive proof. Survivors may not report a history of

childhood trauma because they simply don’t remember it.

One of the ways that these individuals cope with their

victimization is through repression, typically manifested

through memory loss (Ghetti et al. 2006; McNally et al.

2006; Nemeroff 2004). Survivors often have fragmented

and disjointed memories that are confusing to both them-

selves and the worker; this can make assessment and col-

lecting a social history difficult (Legault and Laurence

2007). Thus, the worker may have to tolerate a certain

amount of ambiguity when working with clients who dis-

play difficulties symptomatic of a childhood history of

trauma.

Specialized techniques discussed earlier such as guided

imagery have been used to ‘‘recover’’ (or, according to

some critics, create) memories of abuse, thus generating

much controversy (Alison et al. 2006; Arbuthnott et al.

2001; Thayer and Lynn 2006). The recovered memory

debate centers on the accuracy of memories that surface in

the present regarding abuse that allegedly occurred in the

past. Research supports the existence of such memories but

the findings of other studies call their veracity into question

(Bottoms et al. 2012; McNally 2003; Rubin and Boals

2010). There are documented cases in which memories of

abuse have been manufactured- intentionally or uninten-

tionally- by clients, often with the subtle encouragement of

the clinician (Ashmore and Brown 2010; Fusco and Platania

2011; McNally and Geraerts 2009; Takarangi et al. 2008).

In the following example, the practitioner’s preconceived

notions about what ‘‘must’’ have happened to the client,

Susan, resulted in her asking questions which confirmed

assumptions she- the practitioner- already held. In addition,

the clinician didn’t appreciate the need to assist Susan in

managing her feelings, which ultimately undermined the

client’s self-capacities and increased feelings of self-doubt.

Susan, 35, was being seen in an outpatient mental

health clinic for problems with depression. She

reported few memories of her childhood, but did

recall her parents’ alcoholism and constant fights.

During the course of therapy, Susan reported dis-

turbing memories of her parents’ bedroom and her

father in the bed, naked. The therapist suggested to

Susan that she was sexually abused by her father.

Susan reported later that while she was skeptical of

this, she assumed ‘‘the therapist knew what she was

doing’’. She began to accept that her father ‘‘must

have’’ abused her, even though she never remem-

bered this happening. This resulted in an increase in

her drug use, intensified her feelings of depression,

and led to estrangement from her family and rage.

Once Susan reached the agency’s limits for the

number of sessions she could be seen, she found

another clinician with a great deal of experience and

training working with adult survivors of childhood

trauma. Working together, Susan and her new worker

discovered, through the careful, informed use of

guided imagery, that Susan was not sexually abused

by her father. She recalled that she found her father in

bed, naked, with another woman while her mother

was at work. Her father warned her that she shouldn’t

tell her mother, as it would ‘‘kill’’ her. Further, he

threatened to harm Susan if she told anyone about

what she saw.

The prudent stance in a case such as this is for the

worker to maintain a position of neutrality. The second,

experienced clinician avoided making a priori assumptions

about what Susan’s disjointed memories might mean. After

discussing with Susan in advance what she intended to do,

the practitioner asked the client to describe what she saw

on a movie screen, while in a state of relaxation, a typical

strategy utilized in guided imagery (Leviton and Leviton

2004). The clinician avoided asking leading questions as

well as arriving at conclusions as to what the client’s

descriptions might mean. Working together, Susan and the

practitioner explored the possible meanings associated with

what the client had visualized.

When memories surface in the present and/or are frag-

mented, the worker accepts that memories of abuse may be

psychologically and affectively true, even though they may

not be historically accurate (Reimer 2010; Rubin and Boals

2010). In those instances when the client reports no history

of child maltreatment but presents with many of its

symptoms, the worker remains focused on the present-day

challenges the client faces. The clinician doesn’t ‘‘reach

for’’ memories that she or he assumes ‘‘must’’ be there.

Rather, she or he considers the possibility that there may be

a history of abuse and is prepared to respond should

memories begin to surface, as they often do, on their own

(Bottoms et al. 2012; Rubin and Boals 2010). This is

Clin Soc Work J (2015) 43:25–37 31

123

particularly important in those cases when the client has no

memories at all of her or his childhood, as this has been

found to be a common indicator of childhood victimization

(Crowley 2007; McNally et al. 2006).

The following example underscores yet again the need

for the worker to maintain a neutral stance and avoid

making a priori assumptions about what a client’s memo-

ries might mean.
2

Charles, a client in an inpatient psychiatric facility,

had unclear, fragmented memories of his childhood,

but believed that ‘‘something’’ happened to him in the

basement of his home. He had recollections of being

face down in a pile of laundry and had physical

sensations of being penetrated in his rectum. He also

was able to visualize the shadow of a man standing

over him. Finally, he recalled seeing a tool belt

hanging on the wall in the basement, and believed he

was sodomized with the handle of one of the tools by

his father, who was an abusive alcoholic.

Based upon these recollections, it would be easy for the

practitioner to come to the same conclusions as Charles. In

fact, as Charles talked further about his victimization in

group and individual therapy, his memories of what hap-

pened to him became clearer, a common phenomenon

(Colangelo 2009; Malmo and Laidlaw 2010; Raymaekers

et al. 2012). Charles ultimately was able to see the face of

the person who abused him, and it wasn’t his father. It was

an uncle who had lived with his family, something that he

had not remembered initially. Charles also came to believe

that tools were not inserted in him though he was sodom-

ized. Rather they were in his line of vision, and he focused

on them, so he did not have to think about or feel what was

being done to him by his uncle. This example should serve

as a cautionary tale to all practitioners. The client needs to

be able to tell and make sense of her or his story without

the worker assuming in advance what the story might mean

(Bedard-Gilligan et al. 2012).

A second challenge associated with working with a

client with a history of childhood trauma is related to

mandatory reporting requirements. In many jurisdictions,

mental health professionals must report disclosures from

adult survivors about their abuse as children (Morton and

Oravecz 2009). The worker actually can meet legal

requirements in ways that empower survivors, even though

clients’ initial reactions often include fear of exposure and

vulnerability (Farber et al. 2009). The practitioner should

adhere to three principles. First, the worker must be well-

versed in what her or his legal responsibilities actually are.

Second, the worker should uphold legal mandates in a way

that minimizes risk to survivors. Finally, the worker assists

the client in determining what courses of action to take and

avoids making those decisions for him or her. This, again,

implies that the worker adopt a neutral stance.

In this next example the practitioner handled the client’s

disclosures in a way that undermined his self-capacities

and, ultimately, re-traumatized him. George, the client,

reported the following experience:

When I went to the [outpatient mental health] agency,

they asked me a bunch of questions about my history.

They asked me if I had experienced any type of

sexual abuse. I was embarrassed, man, with them

asking about this shit. But I told them I thought a

neighbor might have fooled around with me when I

was about five or six years old. The person I spoke

with told me that she would need to report what I told

her to the authorities. I begged her not to do it! I

didn’t want anyone to know about what happened,

and I couldn’t really remember much of it anyway,

and now she was going to tell the police?! The guy

still lives next door to my parents! She said that this

was a good thing: that I should file charges against

the guy who molested me. She said I had a right to

get justice for what happened to me. She kept asking

me for more and more detail, and it got me really

upset, particularly since so much of it was really

fuzzy. All I want is to stay healthy!

The practitioner was required by her agency to ask about

possible childhood victimization, due to her state’s

reporting requirements. Therefore, she had to report what

George disclosed to her. What seems like an arbitrary

mandate that will undermine the therapeutic relationship

actually can become a way that the worker and client ini-

tially engage with one another and create a partnership (Oz

and Balshan 2007). What does undermine the working

alliance is when such a mandate comes, from the client’s

viewpoint, out of the blue, as it did for George. In other

words, it’s not the mandate itself that creates the problem,

it’s the way the worker presents it to and handles it with the

client (Morton and Oravecz 2009).

The author’s state is one that requires clinicians to report

an adult client’s disclosures of childhood abuse. The author

tells her clients about the mandatory reporting law at the

outset of the first interview. She and the client then craft a

statement together that satisfies the legal requirement, but

also protects the client, to the extent that is possible. This

strategy actually is empowering for the survivor, despite

the mandated intrusion into her or his privacy.

Another aspect of George’s experience that was coun-

terproductive was the practitioner’s continued questioning;

she really didn’t need additional information to do her job

as a case manager conducting an intake or to fulfill her

state’s mandatory reporting requirements. Collecting2 Adapted from Knight (2009).

32 Clin Soc Work J (2015) 43:25–37

123

detailed information about George’s past was de-stabiliz-

ing and undermined his self-capacities. Further, the clini-

cian’s persistence in encouraging George to take legal

action against his abuser was misguided, particularly given

his disjointed memories of what may have happened to

him. Recovered, fragmented memories are particularly

suspect from a legal perspective (Alison et al. 2006; Binder

and McNeil 2007). It is not up to the worker to decide how

or even whether the client should use the legal system or in

some other way confront abusers or others who may have

been complicit in the victimization (Regehr and Alaggia

2006). The worker’s position should be to provide support,

information, and guidance to the client about available

options but not to tell the client what to do. Given survi-

vors’ core feelings of powerlessness, this is an especially

important consideration.

The worker also should help clients identify what it is

they hope to get out of pursuing legal action or confron-

tation. It is very difficult for adult survivors to prove their

abuse in a court of law, and this is particularly true of

sexual abuse (Alison et al. 2006; Binder and McNeil 2007).

Survivors’ testimony about their recollections of what

happened will be subject to cross-examination. It is not

surprising that all of the author’s clients who have been

through the legal system referred to it as being ‘‘raped all

over again.’’

A final challenge when working with adult survivors

reflects the impact that this has on workers, themselves.

Survivors often present themselves as overwhelmed with

myriad problems and, as discussed, with heightened feel-

ings of mistrust and hostility towards the practitioner

(Bride 2004; Cunningham 2003; Harper et al. 2008; Shafer

and Fisher 2011). Further, their disclosures about what

happened to them, their ‘‘trauma narratives’’ (Etherington

2000), can be extremely hard to hear and their reactions to

the narrative can be hard to witness. Thus, countertrans-

ference is a common reaction among practitioners who

work with survivors (Cramer 2002; Pearlman and Sa-

akvitne 1995). Typical reactions range from disbelief and

avoidance such as that displayed by Joan, Victor’s worker,

to over-identification and rescuing behavior such as that

displayed by Margaret’s worker. While countertransfer-

ence is often assumed to be the result of the worker’s

unresolved issues, in the case of working with survivors, it

is best viewed as a natural consequence of working with

challenging, highly distressed clients (Walker 2004).

Workers also are at risk of being indirectly traumatized

through their work with survivors (Adams et al. 2006;

Knight 2009, 2013; Harr and Moore 2011; Thomas and

Wilson 2004). Three different manifestations of this phe-

nomenon have been distinguished: secondary traumatic

stress, which includes intrusive symptoms comparable to

those that accompany PTSD; vicarious trauma which refers

to the changes in the worker’s views of self and others

analogous to those that occur with survivors; and compas-

sion fatigue in which the worker is unable to generate

feelings of empathy for the client. Indirect trauma is viewed

as an inevitable consequence of working with clients with

histories of childhood trauma over time and witnessing their

pain and distress firsthand (Bride 2004; Baird and Kracen

2006; Jenkins and Baird 2002). Indirect trauma is not the

same as countertransference, which occurs in response to a

particular client (Berzoff and Kita 2010). Yet, each can

reinforce the other (Pearlman and Saakvitne 1995).

It is imperative that workers take steps to minimize the

impact countertransference and indirect trauma have on

them personally and on their work. This includes adopting

self-care strategies that focus on nurturing oneself, estab-

lishing fulfilling relationships, and being pro-active in

managing stress (Bell et al. 2003; Bober and Regehr 2006).

Clinicians need to be vigilant in assessing the impact their

work with survivors has on them. In the following exam-

ple, an intake worker in child protective services described

his reactions to a child client, revealing manifestations of

secondary traumatic stress and countertransference.

Now that I have my own child, I find it a lot harder to

turn off my thoughts about the kids on my caseload. I

just finished up an investigation involving allegations

of physical and sexual abuse of a 4 year-old boy.

Mom was a drug addict and lived pretty much on the

streets. Apparently, she left her son with a series of

boyfriends. The child has signs of having been

repeatedly sodomized. Also a lot of physical injuries.

I have a son who’s five. I look at my son and can’t

help but think of this little boy, and all the other kids

that I’ve seen over the years. My son is happy,

carefree. This little kid, he’s already gone in a lot of

ways. He’s got these dead eyes. I keep seeing those

dead eyes of his every time I look at my son.

I also find myself being so f…ing angry with this
boy’s mother. I need to work with her, but I blame

her for her son’s injuries. She doesn’t deserve to have

a child! It’s really hard for me to hide my feelings and

do my job, which is to work toward reunification.

The worker’s honesty in disclosing his feelings and

reaction was the first step towards managing them. His

feelings of anger towards the child’s mother were under-

standable; he is, after all, human. Having a son the same

approximate age as his child client only exacerbated these

feelings. Workers need a place to talk about their feelings.

Thus, agency culture and the supervisory climate should

encourage honest discussion in a way that normalizes,

validates, and helps clinicians manage manifestations of

indirect trauma and countertransference (Brockhouse et al.

2011; Stebnicki 2000).

Clin Soc Work J (2015) 43:25–37 33

123

Conclusion

Adult survivors of childhood trauma are a particularly

challenging group of clients given the long-term effects of

the victimization and the present-day difficulties they face.

In this article, trauma-informed practice is explained,

incorporating the most recent theoretical and empirical

literature. The purpose has been to educate and support

practitioners who encounter survivors of childhood trauma

in settings that are particularly likely to serve these indi-

viduals such as addictions, mental health, forensics/cor-

rections, and child welfare. The practitioner neither ignores

nor dwells exclusively on the trauma. Rather, trauma-

informed practitioners are sensitive to the ways in which

the client’s history affect her or his present-day challenges

and normalize and validate the client’s experiences, con-

sistent with their professional role. Trauma-informed

practice requires the practitioner to understand how the

working alliance, itself, can be used to address the long-

term effects of the client’s childhood trauma. Emphasis is

placed on helping survivors understand how their past

influences the present and on empowering them to manage

their present lives more effectively, using basic skills of

social work practice. Trauma-informed practitioners are, in

fact, well-served by their core training as social workers.

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Wright, D., Woo, W., Muller, R., Fernandes, C., & Kraftcheck, E.

(2003). An investigation of trauma-centered inpatient treatment

for adult survivors of abuse. Child Abuse and Neglect, 27,

393–411.

Dr. Carolyn Knight is a licensed social worker with 30 years of
experience working individually and in groups with survivors of

childhood trauma, particularly sexual abuse. She is the author of two

books, numerous articles, and book chapters on working with

survivors of childhood trauma in group and individual treatment.

Clin Soc Work J (2015) 43:25–37 37

123

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Trauma-Informed Social Work Practice: Practice Considerations and Challenges

Abstract
Introduction
Nature of Childhood Trauma
Trauma-Informed Practice: Definition
Importance of the Professional Relationship
Practice Considerations
Trauma Informed Practice: Challenges
Conclusion
References

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