social work

More on therapy referrals

whirling-ghost replied to your post“About making therapy referrals”
Make sure it’s the appropriate type too. Like I got referred for group, despite the fact I was terrified of being in a room with people I didn’t know. Obviously that wasn’t going to work
realsocialskills said:
Yes, this too. Therapy isn’t just one thing. It’s a lot of different things.  It also matters who is involved; therapists are not interchangeable. Even when someone unquestionably needs therapy, the wrong therapist can still make matters worse. 
Generically telling someone “get therapy” is not likely to be a helpful suggestion. Everyone knows that therapy exists; everyone will have had others tell them to get therapy. 
A useful referral has to be more specific and based on something. It also needs to involve respecting the person you’re working with, listening to what they think of your suggestion, and recognizing it as their decision.
  • “It sounds like you’re struggling with your sexual identity. I know a therapist who has a good track record of helping men think through that. Would you like their name?”
  • “Some people who find that talk therapy doesn’t help them have found that CBT does, since it is concrete and based on learning skills and changing your thinking. What do you think about trying that?" 
  • "A lot of students who have come to me with similar problems around finals have found the counseling center helpful. Is that something you feel comfortable trying?”
  • “It’s hard to go through that kind of loss when none of your friends can relate; I think that peer support might help you. There’s a grief support group; would you like to try that?”
  • “The problems you’re describing are often caused by clinical depression, which is often treatable. I think it might be a good idea to get evaluated in case that’s the problem. There is a doctor we recommend who is respectful and listens to patients. What do you think about that?”

About making therapy referrals

Content note: Today’s post is primarily directed at people who make therapy referrals and recommend therapy as part of their job (social workers, doctors, ministers, rabbis, school counselors, etc). This post is specifically about something that goes wrong when people make therapy referrals for the wrong reasons. If you haven’t been in a position to recommend therapy from a place of authority over someone you have a responsibility to help, this post might not make a lot of sense.

There’s something that can go wrong in therapy referrals. This is a thing that happens:

  • A social worker, doctor, teacher, clergyperson, chaplain or someone in a similar role is faced with someone suffering really serious problems
  • They don’t know how to help with most of them
  • And they are afraid of the magnitude of this person’s problems, and need to set a boundary to avoid becoming responsible for managing them
  • And, so, they default to making a therapy referral, as a way to assert boundaries and feel that they have done all that they could
  • Therapy referrals are often appropriate, but sometimes people make therapy referrals even when they are not appropriate as a way of asserting a boundary

This is how therapy referrals ought to work:

  • You assess that a person you’re working with might benefit from therapy
  • You make this suggestion to them, and you say why
  • You suggest specific therapists you think might work well with them
  • And you assume that they are the ones who should be making this decision
  • And therapy is one decision/referral among many; it might be the solution to finding space to work on emotions and relationships, but it doesn’t replace the need to find food stamps or medical insurance or housing or proper diagnosis of a medical condition

This is how therapy referrals often do work:

  • You assess that someone has problems that are much, much bigger than you can handle
  • You want to assert a boundary so the full brunt of their struggles do not become your problem
  • You don’t actually want to say flat-out to a person who is suffering that you’re not going to help them
  • So, you tell them that they should get therapy, and make that referral as a way to gracefully assert a boundary without having to say outright that you’re not going to help them even though you know they need help
  • Don’t do this. It isn’t good for anyone, including people who really need therapy.
  • Be honest about boundaries you’re asserting, and make sure that any referrals you are making are appropriate
  • Therapy referrals are for the client, not for you

It’s important that, when you make therapy referrals, you’re making them to meet the needs of the person you’re working with, not your own needs

  • You have to have boundaries in order to do your work. That means that you will be routinely faced with suffering people who you won’t be able to help
  • That’s awful, but it’s something you have to face and be honest about
  • There will be people you can’t help with most of what they need, and people who can benefit from therapy. These are overlapping, but not identical categories.
  • Recommending therapy to people who can’t benefit from it can sometimes just be a dishonestly comfortable way of saying “I’m not going to help you, and I’ want you to feel good about my refusal”
  • Whether or not someone should get therapy is a separate issue from whether or not you can or should try to help them yourself
  • Some people who you can’t help should go to therapy instead (eg: someone whose primary problem is probably treatable depression or learning certain classes of things about relationship dynamics)
  • Some people who you can help in some ways also ought to go to therapy (eg: someone who comes to you for prayer might need prayer, Bible study *and* a therapy referral)
  • Some people you can’t help should not go to therapy (eg: a gay person whose primary issues have to do with their coming out process who lives somewhere where all available therapists are homophobic probably should not go to therapy; that doesn’t mean that you are going to be able to help them through that in your role as a crisis center intake social worker)
  • Some people who ought to get therapy also need other help, and that might be the more pressing issue. Don’t imply that therapy is the solution to a broader range of things than it actually is. (eg: therapy might help a homeless person deal with their emotional issues, but it doesn’t provide housing; don’t use your therapy referral script as a way to avoid telling them that you aren’t offering help with housing)
  • Therapy is an important tool, but it’s not magic. Don’t treat it as universally important, or as the solution to all problems that you don’t know how to or can’t solve.

TL;DR when you’re reccomending therapy to someone, make sure that it is an appropriate referral and that it’s about meeting their need for care rather than your need for boundaries. To that end, make sure that making a therapy referral isn’t the only way you can assert a boundary; develop other ways to say no respectfully.

lanthir replied to your post“Anonymous asked realsocialskills: I’m really interested getting a…”
My mom has her MA in social work, so I called her up to ask. She needed a low level college math course, and a low level statistics course to get her BA. No math for the masters program. (This was at Virginia Commonwealth University from 2000-2005)

2ifbifrost replied to your post“Anonymous asked realsocialskills: I’m really interested getting a…”
Very likely a statistics class will be required. Some schools have a particular “stats for social work” class. Colleges almost always have free tutoring options, especially for math. It is worth it to find out what they are and use them.
realsocialskills said:
Yes. Most universities have free tutoring options for math classes (and writing), and they are often good.

I’m really interested getting a degree in Social Work…but I’m wondering how much math you need in order to get a degree. I know each school is different, but wouldn’t the amount of math you need be pretty much the same? I ask this because I have an extreme fear of math. I get severe anxiety whenever I have to do even simple math in front of teachers.
realsocialskills said:
I’m not sure. Here’s what I do know:
  • In order to become a licensed clinical social worker in the US, you will need an MA as well as an undergrad degree.
  • I think once you get to the MA part, it is possible to avoid math classes
  • It probably is not possible to avoid math entirely undergrad
  • But there are often classes that count as math which aren’t particularly mathy
  • And at some schools, math classes and science classes are considered interchangeable for purposes of meeting distribution requirements
  • It’s worth looking into exactly what will be required when you’re considering schools, because it’s not the same everywhere
  • Also, many colleges have online math classes. If your anxiety is about doing math in front of teachers, that might be a good option for you

Does anyone who knows more about math phobia or social work degrees want to weigh in?

Listening to friends vs listening to clients





I have a question and don’t know if you already answered something like it. How can you show support for someone without making it about yourself? like *someone talking about a crap thing that…

offsettheshakes said:

this so much. Taught in my Social Work classes. I approve. People learn this.

realsocialskills said:

Yes, this is a really important skill for social workers. That said, I think sometimes people see this as a social work skill, or a therapy skill, or otherwise professional in nature. I think that seeing it that way is kind of misleading.

There are all kinds of relationships in which it’s sometimes important to listen more than you talk, and to create space the other person can fill with what they need to say. Most of those relationships aren’t very similar to social work.

The listening method is the same, but the power dynamics and appropriate boundaries are often very different.

In a social work setting, you have some degree of mandate to respect autonomy, but push come to shove, you also have clinical goals, and it’s very likely that you control access to resources they care about. That matters. It affects how the dynamic plays out. It affects what you can and can’t offer.

Also, in a social work context, you have a mandate to maintain professional distance and avoid getting too involved. The way you listen as a social worker involves, in part, making sure that you’re always maintaining an appropriate distance. When social workers are taught the listening skills I am talking about, they are often taught simultaneously with distance skills, and for a lot of people these end up conflated.

So, to be clear, I am not saying that friends should act more like social workers. Friendship is different. Friendship is personal, and reciprocal. Between friends, the basic context of the conversation is that they *are* personally involved in the friend’s life. Some of the methods of listening are still the same, but some are really different, too.

Friends should not treat friends like therapists or social workers. But friends *should* listen to friends.


I’m a high school student in America. Recently I was called in to talk to a psychologist because the adults at the school noticed I was having problems. I’ve known I was autistic for about two years now, so I was relieved to finally have a chance to get my diagnosis. But I’m scared — what does…

annekewrites said:

My first social work internship was mostly doing educational advocacy services for kids with disabilities.  Here’s what I know, with the disclaimer that I’m in upstate New York and the educational landscape is a bit weird in this state, so check your local info:

- There are two different laws that you might get accommodations under: the Individuals with Disabilities Education Act (IDEA), under which you might get an Individualized Education Plan, or IEP; and Section 504 of the Rehabilitation Act of 1973, under which you might get a “504 plan”.  Generally speaking, an IEP is more extensive than a 504 plan, and is what you need if you need something about the curriculum itself modified. 

- New York also used to offer something called an “IEP Diploma”, which was a high school diploma with extensively modified requirements.  This isn’t offered anymore for a number of reasons.  But even when it was, having an IEP didn’t necessarily mean that you’d get an IEP diploma; standard and even honors diplomas could still be an option.

- IEPs and 504 plans are confidential and off-limits to anyone except you, your parents or guardians if you’re under 18 (21 in some situations), and the teachers and other staff who are involved in creating or implementing the IEP or 504 plan.  Depending on what’s in the plan, putting it into effect may make it obvious to others that you have one, but not your diagnosis or the specific reason for the plan.

- This specifically means that colleges won’t know anything you don’t tell them. 

- However, if you do have high school accommodations, I strongly recommend you keep a record of them and when you’re in college you go directly to the college’s disability services office so that stuff is on file BEFORE any kind of problems happen.  Colleges don’t do IEPs as such, but they are covered under Section 504 so you can request “reasonable accommodations” related to a disability.  This applies to classroom as well as residential life.

- As a high school student, especially if this is your first go-around with services, you absolutely should have input into your IEP or 504 Plan.  You also have the right to bring an advocate of your choice into meetings, and sometimes it’s helpful if the advocate is an adult with similar disabilities to your own (I did a lot of this for kids with ADHD, because I’m an adult with ADHD).

- The school needs to accommodate anything you need to effectively participate in the meeting.  I worked with a girl who couldn’t physically go to her IEP meeting for mental health-related reasons, so we set things up so she could Skype in.  If you need to call/Skype/text to participate effectively, they need to be able to accommodate that.

- School districts can be lazy about all of these things.  They often want to put together an accommodation that is close to things they’ve done before even if it’s not really what you need, that is less expensive, that is less “trouble”, or that tries to make you or your parents look like the bad guys.  Don’t buy into it.  It’s their JOB to do what you need to get through school, and it’s the LAW.


Some thoughts on clinical social work assessments


Your blog is a great resource. I have a question and was hoping you’d give me some insight. I’m a clinical social worker. In most places I’ve worked, I’ve had to do assessments. Even with the most neutrally-worded assessments, clients often…

tardis60 said:

I’m glad that someone in social work not only had this concern but took the time and effort to ask, and ask realsocialskills in particular. This answer articulates for me so much about what I and family members have run into in these situations and explores many issues I identify with. And also made me think about all the reasons why these questions might be asked, all the reasons why reactions can be so uncomfortable, and what it’s like for the asker.

realsocialskills said:

Social work is really, really hard to do well. There’s so much going on in the field that puts pressure on social workers to treat people poorly and take them over.

And assessments are often part of that. They contain a lot of questions that are cognitive cues for views-from-above thinking, and the ways social workers are expected to phrase reports contribute to that even more. (And that kind of thing is really the tip of the iceberg.)

But social workers also sometimes do really important work, and a lot of it is work no one else is doing (the same is true of therapists, which is a similarly problematic field). So I don’t mean this as a general condemnation of social workers - social work is important, and important to get right. (There are social work roles that are wholly bad. But not all social work roles are like that). It’s hard to be in that field without adopting some really dangerous kinds of thinking.

I wish I knew more about how to do it well. I’m trying to find out as much as I can. Because I really, really want to support people who are trying to be good social workers.

Some thoughts on clinical social work assessments

Your blog is a great resource. I have a question and was hoping you’d give me some insight. I’m a clinical social worker. In most places I’ve worked, I’ve had to do assessments. Even with the most neutrally-worded assessments, clients often become offended or embarrassed by at least one of the questions, with topics ranging from sexuality to family to criminal history. It pains me to ask people invasive questions, but sometimes they’re necessary. Any tips for breaking through this?

realsocialskills said:

I don’t have a good answer to this - assessments definitely create a lot of problems for pretty much everyone who has to do them. I have some theories, but they’re very tentative at this point:

Don’t see the assessment as an end in itself:
  • Some people believe in assessments with an almost religious fervor
  • But your work isn’t about doing assessments, it’s about serving your clients
  • The assessments are a means to an end, and keeping that in mind helps
Think about the purpose the assessment is serving (I can’t tell you in detail what to do with your conclusions, but keeping the purpose in mind can be helpful):
Is it giving you information that you or others on your team need to have in order to serve this particular person?
  • eg: In a medical office, team members need to know if someone has a latex allergy.
  • And in most contexts, people need to know if someone is a minor
  • It can also be important or helpful to know family members or emergency contacts.
Do you need the information for specific reasons, or is it about generally rounding out the picture of who this person is?
  • For instance, you might routinely ask someone where they grew up in order to get a sense of their background
  • But you might not actually need to know that for a particular purpose
  • These might be the kinds of questions that you stop asking if someone isn’t receptive to them, even if they’re often helpful with other people
Is it for the purpose of assessing demographic uses of your services?
  • For instance, an agency keeping data on equity in its services might want to ask people about race, sex, gender, national origin, disability, or sexual orientation in order to assess whether they’re providing services in an equitable way
  • These are all things that in *some* social work contexts can be important to know about individual clients, but in other contexts they’re not pieces of important information
  • For instance, a food pantry might want to keep data on race in order to determine whether people of all races have good access to their services, but they don’t need to know the race of a specific person in order to serve them
  • These, too, might be questions you don’t press sometimes
Does it serve some other research purpose?
  • For instance, if your agency trying to determine whether using one kind of consent form works better than another?
  • There are a lot of rules for research
  • I don’t know them well
  • But I think it’s important to notice when what you’re doing is research, even when it’s undeclared research (which shouldn’t happen but does)
Is it information you’re required to gather even though having the information serves no actual purpose?
  • It is very common for agency assessment forms to have questions or even whole sections that serve no purpose as far as anyone on the team can tell
  • It’s ok not to take these sections very seriously
  • You don’t have to pretend things are important when they’re not
  • That said, things can be important even when most people in power don’t take them seriously
  • So know for yourself which things you consider importance
Is it a matter of creating a paper trail for the purposes of legal compliance?
  • It’s important that paperwork comply with the law
  • But things done for the purposes of legal compliance do not necessarily need to be treated the same way as things done because you actually need the information
  • It depends on the situation

Are you trying to determine eligibility for services?

  • That tends to involve uncomfortable or even illegitimate questions
  • Which you tend to have to ask anyway
  • I think it’s important to know when questions are and are not necessary for this purpose
Is it information that is actually needed to protect the safety of clients?
  • For instance, if you’re trying to detect red flags for abuse, those might be questions to push more
  • Or if you need to know about drug use for safety reasons (eg: if a drug commonly recommended to treat an issue interacts with a commonly used illegal drug, knowing that person’s drug history might be important)
  • Or if a treatment can be harmful to a fetus or dangerous to a pregnant person, it’s important to know if that person is pregnant or likely to become pregnant
Be honest with the person you’re working with. If you need the information, tell them why. If they don’t have to answer the questions, tell them.

When you’re asking sensitive questions, it might help to be explicit about the fact that you have to ask everyone:

  • Because otherwise people will think that you are asking because you suspect something about them
  • This is particularly important if the thing you’re asking about is stereotypically associated with their group
  • (As it is likely that the stereotype has been used to belittle them or justify violence or denial of important services; hearing this question from a social worker can be really loaded even if you have the best of intentions. They can’t read your mind, and you might sound just like people who do not mean well when you ask that)
  • But don’t mock the idea that it might apply to them. Because it might, and you don’t want to prevent them from giving you that information, or to imply that it is shameful 
Respect the people you’re working with, and take the power dynamic involved seriously:
  • By the time someone gets to a clinical social worker, they’ve probably already lost a lot of autonomy and power
  • And they’ve probably been dealing with people they can’t say no to
  • And all kind of people invading their privacy on all kinds of levels
  • If they can say no, *make that clear*.
  • If you have to ask but they don’t have to answer, *tell them it’s ok not to answer your questions*.
  • It might be worth acknowledging that it’s uncomfortable and invasive
 Keep in mind that people have the right to be offended:
  • Don’t try to get them to tell you it’s ok
  • It might not be ok
  • And they’re allowed to be angry that a stranger is asking them a lot of invasive personal questions
  • It might not be your fault, but it’s not their fault either
  • Part of your job is to accept that some people you work with are going to be legitimately angry or offended
  • The skills for dealing with that can be hard to aquire
  • But it’s not ok to evade it by putting pressure on people to tell you it’s ok when they think it isn’t
  • This is something all social workers and people in related fields are at risk of falling into (particularly if you are at the bottom of your professional hierarchy and feel powerless because you are forced to follow policies you disagree with)
  • Even if you feel powerless in your work, it’s important to remember that you are exercising tremendous power over other people
  • At the end of the day, you get to go home and have a life outside of any social services involvment
  • People who depend on services don’t
  • Don’t forget that, and don’t pressure them into making you feel better. Your self-image is not their problem.

Does any of that help?

And do any of y'all with experience in either asking questions as a social worker or being asked questions by a social worker have thoughts?