× Expand Erasing anxiety by Jonathan B. Singer, Ph.D., LCSW, and Claudia Dewane, D.Ed., LCSW, BCD The one thing that concerns me following graduation is I want to know that I am experienced enough and have the knowledge about skills and theories to effectively work with someone. It is important to be more than someone who sits in an office and gives someone a person to talk to. There is more to therapy than talking; one must know how to do talking with a purpose and an end result. MSW student After years of school, you’ve finally graduated with your master’s degree in social work. You are relieved, ecstatic, and...petrified! You are plagued by the thought that you didn’t learn enough and that you really don’t know what you’re doing! You might have “New Social Worker Anxiety Syndrome” (see sidebar on page 12 for diagnostic criteria). The good news is that some of this anxiety is going to help you be a better clinician. The bad news is that too much anxiety can interfere with providing effective clinical services. The purpose of this article is to identify and address situations that clinical MSW students anticipate causing anxiety. Our hope is that by addressing these concerns, we can reduce unnecessary anxiety, so that new social workers can focus more of their energy on their clients. You are not alone As a graduate student, you’ve had to learn to cope with a variety of anxiety-provoking situations. Dziegielewski, Turnage, and Roest-Marti (2004) identified three sources of stress for social work students: role diversity (e.g., “how can I juggle course work, field, and my personal/work life?”), interpersonal relationships (e.g., “why are my group assignments always with Jen—we don’t get along at all”), and academic requirements (e.g., “why does every professor have a different expectation for APA format?”). These stressors are most apparent in the first year of an MSW program, when students are adjusting to the demands and expectations of their graduate program. Luckily, first-year MSW students have the time and space to address those concerns with other students, field instructors, and faculty. Furthermore, most college campuses have counseling centers that offer “stress management” or “burnout prevention” classes and seminars that help new students with time management, study skills, and relaxation techniques. Graduating MSW students have to cope with a new set of anxiety-provoking situations, but no longer have the same group of students, field instructors, and faculty with whom to address their concerns. Gone are the concerns about writing lit reviews, policy papers, and seeing your first client. Graduating students are now concerned with finding a job, knowing job-related skills, and being successful as a professional. If these concerns sound familiar, you’re not alone. One study found that 88% of graduating MSW students reported feeling anxious about entering the profession (Mathias-Williams & Thomas, 2002). Despite the near ubiquity of graduation-related anxiety, we were unable to find any articles that directly addressed the specific anxieties that clinical social work students experience upon graduation. Survey of student anxiety Our students were becoming anxious about their impending graduation. In the last semester of an MSW clinical practice course, we did an informal poll of 43 graduating clinical MSW students and asked them to anonymously write down their most feared intervention or situation, or a counseling issue that makes them most anxious or hesitant. We found that students shared many of the same anxieties. Their responses fell into four broad categories: working in a certain modality (individual, family, or group therapy)

what to say in a specific situation

how to intervene with a specific problem

professional use of self Although there is overlap among categories, each category represents a different type of anxiety and consequently suggests a different approach to addressing that anxiety. Student responses indicated that their anxiety was due to a perception that they lack specific knowledge or skills. Thus, this article provides some information on specific knowledge or skills that might reduce anxiety. The remainder of this article is divided into four sections, one for each category. In each section, we explain the category, use student quotes to illustrate the anxiety or concern, and recommend specific approaches to address specific anxiety-provoking situations. We end with general recommendations that students and schools of social work can implement to address practice-related anxiety Category One: Modality Clinicians use the term “modality” to refer to whether treatment is done in an individual, family, or group mode. Although some students reported anxiety related to work with individual clients, the majority of students expressed anxiety about working with families and groups. Students reported two primary concerns, both related to the experience of being overwhelmed. First, students were concerned that they would be overwhelmed by group dynamics, expressing fears about being outnumbered, and how they could control, structure, or redirect family/group therapy sessions. For example, one student wrote, “How do I deal with being in an unfamiliar situation with unfamiliar family dynamics?” Second, students were concerned that they would become overwhelmed by too much information or at a loss because they did not pick up on the “right” information. For example, one student wrote, “I’m afraid of not picking up the subtle themes of the problem to be effective with the intervention.” A few students reported concerns about how to deal with a lack of information. For example, one student wrote, “What do I do if no one is talking, or if they are not talking about what is important?” Recommendations Concerns about feeling overwhelmed in family and group settings are appropriate, because social workers have to manage a huge amount of information, even when participants are not saying much. Most people cannot process more than a few pieces of information at a time. Remember the professor who lectured for an hour without a break? You stopped absorbing the information after 20 minutes. The family that overwhelms you with information is doing the same thing. And, just like in a lecture, your brain will shut down. Unlike a lecture, you can’t manage the overload by doodling or thinking about something else. The good news is that the vast amount of information that causes concern is also going to be the source of relief for anxious new social workers. Families and groups tell you everything you need to know about the problem; you just need to know what to do with that information. There are some simple and effective techniques for dealing with information overload in therapy sessions.

Everyone speaks at once: This dynamic often comes up in a first session, and is often attributable to the family’s or group’s anxiety about being in treatment. You can diffuse the dynamic by establishing a rule for who speaks when. Your job then is to enforce the rule with the adults, and in a family situation support the adults to enforce the rule with the kids. If the family or group won’t abide by the rule, then you can leave the session and tell the family or group that they should come get you when they are able to follow the rule (Brock & Bernard, 1992). No one speaks: First, you have to figure out why there is silence. Is the silence due to not knowing what is expected in therapy, is it due to deficits in information or cognitive abilities, or is it the family or group’s effort to maintain homeostasis? Once you’ve identified the reason, you can verbalize your thoughts about why there is silence and invite participants to comment on your ideas (Brock & Bernard, 1992). Slow things down. Families are just catching you up to speed on their problems. Instead of allowing the family to move from one problem to the next, focus on one problem at a time. Slow things down by having the family “unpack” the problem by asking for details. “I’d like to hear more about what your mom does when you come home after curfew.” Have each family member give his or her version of the problem. “I’m wondering if mom would like to share her version of what happens when you come home after curfew.” Slowing things down might be strange in a social conversation, but it is essential in a therapeutic conversation. Managing the information will ultimately help you establish rapport with the family and help them to address whatever process or content issue is most important. Have an a priori idea of what information is important. Your theoretical frame will help you to filter out the information. Some therapists focus more on the process (e.g., patterns of interaction, who is talking, how the dynamics are structured). Others focus more on the content (e.g., what was said, how it was said, what key ideas are repeated over and over again). For example, in families where there is parent-child conflict, it is easy to get overwhelmed by the in-session arguing, or unspoken anger. One way of limiting information is by knowing that you are listening for either the process of the conflict (how the conflict develops, what happens before and after, who is involved) or the content of the conflict (what is it about, what words are important triggers, and so forth). Although you have to recognize both process and content, it is perfectly legitimate to focus on one at a time in order to reduce the amount of information you have to process. Category Two: What to say when The second category reflects students’ concern that they would not know what to say to clients in a specific situation. Students said they would not know what to say if their client: appeared to have abused his or her child, was visibly upset by the death of a loved one, presented in crisis, reported illegal activity, was silent, confronted the clinician, asked the social worker personal questions, or said “I don’t know” when he or she clearly did know. Recommendations Although it is impossible to come up with responses for every anticipated situation, we have three recommendations that will help new social workers manage anxiety about not knowing what to say to a client. Make an “I wish I had said that” list. You cannot know what to say in every situation. If you are like most people, you will come up with the perfect response later, either through research, consultation, or individual processing. When you come up with the perfect response, write it down. Then practice it with a colleague or in supervision. You’ll find that clients will bring up the same issues, questions, or comments time after time. The next time they do, you’ll be ready. Adopt a “beginner’s mind.” If you find yourself feeling anxious because you think your client is looking to you for an answer, or is challenging the information you have, go with it rather than fight against it. Allow yourself to have a “beginner’s mind,” which is a Zen Buddhist concept that assumes that beginners come up with more options than experts. If you think you are supposed to know the answer, then you’ll force yourself to come up with something and cut off the possibilities. If instead you allow yourself to say, “I don’t know, but let’s figure it out,” then you’ve done yourself and your client a real service. Client says “I don’t know.” When you ask a question and your client responds, “I don’t know,” you want to avoid falling into a question-answer trap (Miller & Rollnick, 2002), or ignoring important information. One way to do this is to respond: “When you say, ‘I don’t know,’ is it that you don’t know the answer, or you don’t want to tell me? Both are fine. If you don’t know the answer, then we can use this time to figure it out. If you don’t want to tell me, be honest so that I can respect your wishes.” If your client responds, “I don’t want to tell you,” thank the client for trusting you with the truth, and then say, “The way we build trust in each other is by being honest. Since we’re being honest, I’m wondering what you think might happen if you tell me.” This response respects the client’s privacy, allows the therapist to reinforce the idea that honesty and trust are central to an effective treatment relationship, and opens the door to processing client thoughts and feelings that might otherwise have been barriers to treatment success. Category Three: Working with specific populations or problems Students mentioned several populations or problems that gave reason for concern. Among the situations that students found anxiety-provoking were: abuse and neglect (e.g., childhood rape, domestic violence, perpetrators, neglectful parents, PTSD), substance abuse, cognitive impairment, grieving families, clients in a suicidal crisis, and suicide survivors. Students felt ill-prepared to diagnose or treat adult psychopathology. In addition, students reported anxiety when imagining resistant, controlling, or dominating clients.

Recommendations Anxiety around working with specific populations or problems is perhaps the easiest of the four categories to address. Anxiety surrounding populations and problems is appropriate, because new social workers are not expected to be specialists in any specific population or problem! Remember that even as a master’s level social worker, you have received a generalist education. As a comparison, physicians who have completed medical school are not yet specialists until they have completed a residency. If you think about your first jobs as unofficial residencies (i.e., on-the-job training), then you’ve bought yourself three to four years to become experts. If you combine your work experience with continued education through course electives, post-graduate certificate programs, trainings, or workshops, then you can become a specialized practitioner in family therapy, group therapy, CBT, REBT, psychoanalysis, or any of the other myriad of therapeutic approaches, problems, or populations that exist. Additionally, there are some situations regarding specific populations or problems that should raise anxiety, particularly those that put the client at risk for harm or the social worker at risk for liability, including misdiagnosis, suicidal behavior, duty to warn, and mandated reporting. The following are four general recommendations for addressing anxiety and one specific recommendation for working with suicidal clients. Is it personal or professional? Figure out if your anxiety around working with a certain problem or population is related to a personal issue or lack of professional preparation. We are human, and reacting to a client emotionally is to be expected. It does not necessarily mean you can’t be effective. Is there a value conflict? Are you anxious because there are conflicting values (e.g., calling child welfare while trying to establish a trusting relationship)? Identifying your blind spots in working with specific problems or diagnoses helps master visceral or inhibiting reactions. Remember that value conflicts are normal. What are the best practice approaches? Remember all of those literature reviews you were asked to do in grad school? The answers to how to treat certain problems and populations are probably in one of those papers (if not yours, someone else’s). Become familiar with online sources like the Campbell Collaboration (http://www.campbellcollaboration.org/), or SAMHSA’s National Registry of Evidence-based Programs and Practices (http://www.nrepp.samhsa.gov/). Books are particularly useful in learning about best-practice approaches, because authors have the space to go into detail about the treatments. Three social work-specific resources are the Evidence-Based Practice Manual (Roberts & Yeager, 2004), the Social Workers’ Desk Reference, Second Edition (Roberts, 2009), and the Encyclopedia of Social Work, 20th Edition (Mizrahi & Davis, 2008). Who are the (local) experts? Talk with professionals in the field who specialize in the population or problem. They might be local or not. Phone supervision provides access to experts from around the country (Singer, 2008). Join a supervision support group to help you validate and work through your reactions or concerns. Supervision shouldn’t end when you get your license. Working with suicidal clients: Social workers should know what information to gather during a basic suicide assessment. These data include the client’s suicidal thoughts (ideation), how serious and/or willing they are to follow through (intent), and how they are going to do it (plan). When your client is suicidal, you are expected to consult early and often. You are also expected to document your assessment and intervention immediately and more thoroughly than you would a regular progress note. Two free resources for more information on working with suicidal clients are: 1) a two-part series on crisis intervention and suicide assessment on The Social Work Podcast (Singer, 2007), and 2) an excellent chapter on Responding to Suicidal Risk by Pope and Vasquez (2007; http://kspope.com/suicide/). Category Four: Professional use of self Melding the professional self of what one knows from training, literature, and practice with the personal self of who one is (personality, belief system, and life experience) is a hallmark of skilled practice. This combination of person and practice is the essence of “professional use of self” (Dewane, 2006). Many students reported concerns about a client asking personal questions (e.g., “how old are you?” or “do you have kids?”). Some students expressed concern that they wouldn’t be able to relate to or connect with clients, for example, “The fact that I don’t have children; I am afraid of telling parents how to interact with children in a manner that deviates from their norm, but I see as beneficial for their mutual relationships.” One student was even brave enough to admit, “I’m nervous about not liking my clients.” Category three was perhaps the easiest to address. Category four is perhaps the most difficult, because it is the most personal. The good news is that one of us (Claudia Dewane) is a recognized expert in “use of self” (Dewane, 2006). Before we provide our recommendations, we thought it would be useful to briefly describe some typical ways of using the “self” in a therapeutic relationship. Practitioners mistakenly believe that self-disclosure is the definition of “use of self,” but it is much more than simply pondering whether to answer a personal question. Self-disclosure is only one of the operational categories of use of self that Dewane (2006) proposes. Another way of using your “self” appropriately is by addressing any anxiety in the treatment relationship. Addressing tension or acknowledging a reaction you or your client had taps into the “relational dynamics” (what is going on between you and the client relationship). For example, “I’m sensing a type of tension between us and I’m wondering if you are, too...let me be specific. I feel a little uncomfortable each time you raise your voice. Do you find other people react that way to you also?” Addressing the anxiety serves to strengthen the therapeutic relationship, and conveniently, reduce your anxiety. Recommendations Learn to respond to personal questions. Ask yourself, “What is behind the question?” When clients ask if you have children, are divorced, have been unemployed, or any other of the myriad of situations our clients experience, what they are really asking is whether you can understand and help them. As an example, if you don’t have children, you can reply, “No, I don’t have children. Are you concerned we might not be able to work together?” or, “No, I don’t. Can you tell me what the best part of being a parent is for you?” You have answered the question, but you have also switched the focus to where it belongs—on the client. Avoid using the “yes, but...” or “no, but...” defense. This response may sound hollow. For example, “No, I’m not married, but my parents still are.” If you do share an experience with your client, the need to shift the focus back to your client still applies: “Yes, I do, and I know parenting/divorce/unemployment is different for everyone. My experience might not be the same as yours. Tell me more about your _______.”