Tag: therapy

Healing the Invisible Wounds: Understanding and Treating PTSD Among Military Veterans

Post-traumatic stress disorder (PTSD) has become one of the most pressing mental health issues among military veterans, particularly in the wake of modern conflicts in Iraq and Afghanistan. Years of exposure to intense combat, guerrilla warfare, and constant danger have left many veterans struggling with lasting psychological trauma. Despite increased public awareness and advances in treatment, PTSD continues to impose severe emotional, social, and economic burdens, both on individuals and on the healthcare system (Reisman, 2016).

PTSD among veterans is not a new phenomenon – it is a modern understanding of a condition that has existed as long as warfare itself. Historical records describe symptoms akin to PTSD as far back as ancient Greece, and over the centuries it has been labeled by many names, from “shell shock” during World War I to “battle fatigue” in World War II. The diagnosis of PTSD became formalized only in 1980, after the Vietnam War made clear the long-term psychological cost of combat. Contemporary studies estimate that between 13% and 30% of Iraq and Afghanistan veterans have experienced PTSD, with as many as half a million diagnosed cases over the past two decades (Reisman, 2016).

The condition rarely exists in isolation. Many veterans with PTSD also suffer from depression, anxiety, substance use disorders, and chronic pain, which together complicate both diagnosis and treatment. Depression is the most common comorbidity, and substance use is widespread among those attempting to cope with symptoms of trauma. Such overlapping conditions lead to higher rates of suicide, social isolation, and medical complications, making recovery a complex process requiring integrated care. Women veterans are particularly vulnerable, not only because of combat exposure but also due to the high prevalence of military sexual trauma, which can heighten the risk of developing PTSD (Reisman, 2016).

Diagnosis of PTSD involves both clinical interviews and self-report tools. Instruments such as the Clinician-Administered PTSD Scale (CAPS-5) and the PTSD Checklist (PCL-5) help determine symptom severity and functional impairment. The DSM-5 defines PTSD through four main symptom clusters—intrusion, avoidance, negative mood and cognition, and arousal—which reflect the range of ways trauma manifests in the mind and body. These diagnostic criteria guide clinicians toward evidence-based treatment approaches.

Cognitive-behavioral therapy (CBT) remains the most effective psychological treatment for PTSD. In particular, cognitive processing therapy (CPT) and prolonged exposure (PE) therapy are strongly supported by clinical evidence and widely used in veteran care. CPT focuses on identifying and restructuring distorted thoughts about the traumatic event, while PE encourages controlled and repeated engagement with trauma memories to reduce fear responses. Another therapy, eye-movement desensitization and reprocessing (EMDR), once met with skepticism, is now recognized internationally as an effective intervention that helps patients process trauma through guided eye movements and attention refocusing (Reisman, 2016).

While psychotherapy is the preferred first-line approach, pharmacological treatments are also important, particularly for those who do not respond fully to therapy. Selective serotonin reuptake inhibitors (SSRIs) such as sertraline and paroxetine are the only FDA-approved drugs for PTSD, although others like fluoxetine and venlafaxine are used off-label. These medications help regulate mood and anxiety symptoms but rarely lead to full remission. Researchers are increasingly investigating alternative pharmacological pathways, such as those involving GABA and glutamate neurotransmission. New drugs like vortioxetine, vilazodone, and even certain anticonvulsants such as topiramate are under study for their potential to modulate fear and memory processes. Some veterans also report relief from cannabis use, though its medical application remains controversial and tightly regulated (Reisman, 2016).

Combined treatment approaches – using both medication and psychotherapy – are often the most effective, particularly for veterans with severe or treatment-resistant PTSD. However, benzodiazepines, once commonly prescribed to manage anxiety, are now discouraged due to their limited efficacy and potential for dependency. The Veterans Affairs (VA) system has begun implementing education and shared decision-making programs to reduce benzodiazepine use and encourage evidence-based alternatives.

Beyond treatment, systemic and social barriers continue to hinder recovery. Many veterans face long wait times at VA facilities, limited access to mental health providers- especially in rural areas – and the persistent stigma associated with seeking psychological help. Cultural attitudes within the military often equate mental illness with weakness, deterring individuals from pursuing care. The VA has responded through public awareness campaigns like “About Face,” which normalizes PTSD treatment, and through telehealth services that provide remote therapy options. Studies indicate that telemedicine not only increases accessibility but also improves engagement and treatment adherence among veterans living far from urban centers (Reisman, 2016).

As more veterans seek care outside the VA system, the preparedness of community-based mental health providers has become a growing concern. Many civilian clinicians lack the training to address combat-related trauma effectively. To bridge this gap, the VA established the PTSD Consultation Program for Community Providers and partnered with organizations such as the Center for Deployment Psychology and Star Behavioral Health Providers, which train professionals in veteran-specific mental health care.

Despite ongoing research and program development, PTSD remains one of the most significant public health challenges facing veterans. Its economic cost exceeds billions of dollars annually, and its human cost is measured in the thousands of suicides that occur each year among former service members. Continued investment in both psychological and pharmacological research, alongside improved access to culturally competent care, is essential. Addressing PTSD requires not only medical intervention but also systemic reform and societal understanding to ensure that those who have endured the traumas of war receive the comprehensive care and dignity they deserve (Reisman, 2016).

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Trauma informed Social Work Practice

Trauma-informed social work practice is an approach to social work that takes into account the impact of trauma on the lives of individuals, families, and communities. This approach recognizes that trauma can have long-term effects on a person’s mental health, physical health, and well-being, and that individuals who have experienced trauma require specialized care and support.

The goal of trauma-informed social work practice is to create a safe and supportive environment for individuals who have experienced trauma. This approach emphasizes the importance of building trust and collaboration with clients, as well as empowering clients to make decisions about their own care. Trauma-informed social work practice also recognizes the role that societal and institutional trauma can play in the lives of individuals, and seeks to create change at a systemic level.

One of the key principles of trauma-informed social work practice is understanding the prevalence of trauma. Research has shown that a significant percentage of the population has experienced some form of trauma in their lives. This trauma can range from individual experiences, such as physical or sexual abuse, to collective experiences, such as discrimination or systemic oppression. Understanding the prevalence of trauma is essential in creating an environment that is sensitive to the needs of individuals who have experienced trauma.

Another principle of trauma-informed social work practice is the importance of safety. Trauma can create feelings of fear, anxiety, and vulnerability, which can make it difficult for individuals to engage in social work services. Trauma-informed social work practice emphasizes the importance of creating a safe environment for clients, both physically and emotionally. This may involve providing privacy and confidentiality, ensuring that clients have control over their own care, and creating a space that is calm and welcoming.

Trauma-informed social work practice also emphasizes the importance of empowerment. Clients who have experienced trauma often feel disempowered and may have difficulty trusting others. Trauma-informed social work practice seeks to empower clients by providing them with information, support, and tools to help them make decisions about their own care. This may involve working collaboratively with clients, recognizing their strengths and resources, and supporting them in setting goals that are meaningful to them.

Cultural humility is also a key aspect of trauma-informed social work practice. Social workers must recognize the ways in which cultural differences can impact the experience of trauma, as well as the ways in which cultural beliefs and practices can be a source of strength and resilience. Cultural humility involves recognizing one’s own cultural biases and limitations, and working to create a culturally responsive and inclusive environment for clients.

Finally, trauma-informed social work practice recognizes the importance of collaboration and partnership. Addressing the impact of trauma requires a multidisciplinary approach, and social workers must work collaboratively with other professionals, such as mental health providers, medical professionals, and educators. Trauma-informed social work practice also recognizes the importance of community partnerships, and seeks to create partnerships with community organizations and leaders to create a more supportive and responsive environment for individuals who have experienced trauma.

In conclusion, trauma-informed social work practice is an approach to social work that recognizes the impact of trauma on the lives of individuals, families, and communities. It emphasizes the importance of understanding the prevalence of trauma, creating a safe and empowering environment for clients, practicing cultural humility, and collaborating with other professionals and community partners. By adopting a trauma-informed approach, social workers can provide more effective care and support to individuals who have experienced trauma, and contribute to creating a more just and equitable society.

Adverse Childhood Experiences (ACEs)

What are ACEs

Adverse Childhood Experiences (ACEs) are stressful or traumatic experiences that can have a huge impact on children and young people throughout their lives.

The ten widely recognised ACEs, as identified in a US study from the 1990s, are:

Abuse:

  • physical
  • sexual
  • verbal

Neglect:

  • emotional
  • physical

Growing up in a household where:

  • there are adults with alcohol and drug use problems
  • there are adults with mental health problems
  • there is domestic violence
  • there are adults who have spent time in prison
  • parents have separated

As well as these 10 ACEs there are a range of other types of childhood adversity that can have similar negative long term effects. These include bereavement, bullying, poverty and community adversities such as living in a deprived area, neighbourhood violence etc.

We are committed to addressing all types of childhood adversity, and this is anchored in our long-standing, national approach of Getting it right for every child.

Why ACEs matter

Childhood adversity can create harmful levels of stress which impact healthy brain development. This can result in long-term effects on learning, behaviour and health.

Evidence from ACE surveys in the US, UK and elsewhere demonstrates that ACEs can exert a significant influence throughout people’s life.

ACEs have been found to be associated with a range of poorer health and social outcomes in adulthood and that these risks increase as the number of ACEs increase.

Research from Wales found that people who reported experiencing four or more ACES are:

  • 4x more likely to be a high-risk drinker
  • 16x more likely to have used crack cocaine or heroin
  • 6x increased risk of never or rarely feeling optimistic
  • 3x increased risk of heart disease, respiratory disease and type 2 diabetes
  • 15x more likely to have committed violence
  • 14x more likely to have been victim of violence in the last 12 months
  • 20x more likely to have been in prison at any point in their life

Consideration of ACEs is therefore crucial to thinking about how to improve the lives of children and young people, to support better transitions into adulthood, and achieve good outcomes for all adults.

What are we doing to address ACEs

As set out in the Programme for Government 2018 to 2019, we are committed to preventing ACEs and helping to reduce the negative impacts of ACEs where they occur and supporting the resilience of children, families and adults in overcoming adversity.

We are take forward action in four key areas:

1. Providing inter-generational support for parents, families and children to prevent ACEs

2. Reducing the negative impact of ACEs for children and young people

3. Developing adversity and trauma-informed workforce and services

4. Increasing societal awareness and supporting action across communities 

We held an ACEs ministerial event in March 2018 in Glasgow involving people working across a wide-range of related sectors and Year of Young People Ambassadors. This explored what was working well, where further action is needed and opportunities for collaboration.

Through our Getting it right for every child approach, families and children can be supported by services to prevent and reduce adversity and the negative outcomes associated with it.

We will build on our existing policies, including:

Our policies in the following areas are also relevant:

Addressing ACEs is also about better supporting adults who have been through adversity and trauma.

We are working with NHS Education for Scotland and have announced £1.35 million funding to deliver a national trauma training programme. This will help Scotland’s current and future workforce develop skills and services that respond appropriately to people’s adverse childhood experiences and other traumatic experiences.

Consideration of ACEs is increasingly informing the development of national policy. For example, the Justice in Scotland: Vision and Priorities 2017 to 2020 identified ACEs as a key issue. A range of actions are being taken to reduce their impact e.g. measures to reduce parental incarceration by moving to a presumption against short prison sentences.

We are also working with the Scottish ACEs Hub (co-ordinated by NHS Health Scotland) which aims to raise awareness and understanding about ACEs and progress national action. For example, the Scottish ACEs Hub, in conjunction with Education Scotland, held a conference in March 2018 on addressing childhood adversity to support children’s learning and wellbeing.

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Read more: NHS Health Scotland

Working with Involuntary Clients in Social Work: Theory, Practice and Ethical Considerations

Introduction

Social work is often associated with helping individuals and families who seek help and support voluntarily, motivated by their own recognition of problems and desire for change. However, a significant proportion of social work practice involves involuntary clients, individuals whose engagement with social workers is mandated or influenced by legal, institutional, or external pressures (Wilkinson, Smith & Gallaher, 2010; Smith, 2020). These clients include families involved in child protection, offenders in the criminal justice system(CJS), people with mental health conditions under compulsory treatment, or young people who are referred due to truancy or behavioural issues.

Working with involuntary clients presents a unique set of challenges for practitioners. They may resist intervention, lack trust in professionals, or deny that any problem exists. The power imbalance between worker and client is often sharper than in voluntary relationships, as the worker may hold statutory authority and the ability to enforce compliance. As a result, social workers must balance legal responsibilities with ethical principles of respect, empathy, and empowerment.

Defining Involuntary Clients

The term “involuntary client” describes individuals who engage with social workers under compulsion or pressure, rather than through free choice. Wilkinson, Smith and Gallaher (2010) distinguish between:

  • Mandated clients: those compelled to work with practitioners due to legal mandates, such as offenders on probation or families in child protection investigations.
  • Non-voluntary clients: those who engage due to external pressure from institutions, family, or circumstances, for example, students referred for persistent non-attendance at school.

Trotter, Rooney and Rooney (2020) argue that these categories exist along a continuum between voluntary and involuntary engagement. While some clients may be entirely mandated, others may initially resist but later engage willingly once trust is established. Recognising this spectrum is essential for practitioners, as it underlines the potential for movement from resistance to collaboration.

Challenges in Working with Involuntary Clients

Social work with involuntary clients is fundamentally complex. De Jong and Berg (2001) highlight that these relationships emerge from broader political and professional ideologies that define some individuals as needing surveillance or compulsory intervention. This places social workers in positions of power, compelled to enforce compliance while simultaneously attempting to build rapport.

Smith (2020) argues that traditional social work methods—such as active listening and client-led problem identification—are often insufficient in involuntary contexts. Instead, the work becomes more relational and adaptive, requiring practitioners to navigate hostility, denial, or mistrust. Engagement is less a linear process and more an art of improvisation, where workers respond to cues and shifting circumstances while prioritising relationship-building.

Key challenges include:

  • Resistance and reluctance: clients may refuse to engage, deny problems, or comply superficially.
  • Mistrust: many clients have negative past experiences with authority or institutions, making them sceptical of workers’ intentions.
  • Conflicting agendas: clients may prioritise different outcomes/ goals from those mandated by law or agency policy.
  • Time pressure: bureaucratic demands may conflict with the time required to build authentic relationships.

These challenges demand innovative, flexible, and ethically sensitive approaches.

The Engagement Process

Engagement is the foundation for effective work with involuntary clients. Jacobsen (2013) identifies four dimensions of engagement:

  1. Receptivity – the client’s openness to recognising problems and accepting help.
  2. Expectancy – belief in the possibility of benefit from intervention.
  3. Investment – willingness to take responsibility for their role in the enagement/ treatment.
  4. Working relationship – mutual trust, fairness, and open communication between worker and client.

Resistance, reluctance, and mistrust often undermine engagement. However, Jacobsen argues that motivation can be enhanced by support networks and by workers adopting a person-centred approach. Similarly, Smith (2020) emphasises recognition—treating clients with humanity and respect—as the starting point for engagement. Trust, built gradually, is fundamental to overcoming initial barriers. Workers may need to set aside their rigid timetables, acknowledge mistakes, and demonstrate authenticity to establish credibility.

For example, in child protection, a parent accused of neglect may initially view the social worker as a concern. However, consistent honesty, empathy, and transparency—such as acknowledging the parent’s fears while explaining the legal requirements—can slowly shift the relationship from hostility to provisional collaboration.

Practice Approaches

Motivational Interviewing

Motivational interviewing (MI) provides a structured yet flexible approach to working with ambivalence. Based on the stages of change—precontemplation, contemplation, preparation, action, maintenance, and relapse—MI recognises that clients may not be ready for change at the outset (Jacobsen, 2013). For involuntary clients, MI techniques such as exploring discrepancies, affirming autonomy, and reinforcing small successes can increase engagement and commitment.

For instance, an offender mandated to attend anger management may initially deny having a problem. Through MI, the social worker might highlight inconsistencies between the client’s stated desire for stable relationships and their aggressive behaviours, encouraging self-reflection without imposing judgement.

Solution-Focused Approaches

De Jong and Berg (2001) propose a solution-focused model, treating clients as experts in their own lives. This involves asking clients what they believe the agency expects of them, affirming their strengths, and collaboratively identifying strategies. This approach can empower clients who feel stripped of control by external mandates, giving them agency within the constraints of the system.

Cognitive-Behavioural Techniques

Cognitive-behavioural strategies are increasingly used with involuntary clients, particularly in criminal justice. These involve identifying irrational or harmful thought patterns and promoting pro-social alternatives (Trotter, Rooney & Rooney, 2020). Workers can model desired behaviours, reinforce positive change, and respectfully challenge harmful thinking.

Trotter’s Four Principles

Trotter (2006) outlines four principles for effective practice:

  1. Role clarification – being transparent about the worker’s dual role as helper and authority figure, clarifying negotiable and non-negotiable aspects, and explaining confidentiality.
  2. Pro-social modelling and reinforcement – promoting and rewarding constructive behaviours while discouraging harmful ones.
  3. Problem-solving – collaboratively identifying, ranking, and addressing problems with achievable goals and regular review.
  4. Relationship – maintaining empathy, optimism, honesty, and appropriate humour to foster trust.

These principles emphasise the balance between authority and empathy, accountability and support.

Good Practice Strategies

The Good Practice Guide developed in Scotland (Wilkinson, Smith & Gallaher, 2010) offers practical strategies for engaging involuntary clients, many of which remain highly relevant:

  • Building relationships: show humanity by sharing common interests or going the extra mile.
  • Trust-building: be consistent, keep promises, apologise when necessary.
  • Persistence and patience: recognise that progress is slow and requires flexibility.
  • Clear communication: explain roles, expectations, and consequences transparently.
  • Managing emotions: acknowledge hostility without personalising it; understand clients’ emotional histories.
  • Support for workers: avoid burnout by seeking peer support and resisting bureaucratic box-ticking.

These strategies highlight that effective practice is not only about methods but also about the personal qualities and resilience of the social worker.

Ethical Considerations

Working with involuntary clients raises profound ethical questions.

  • Power and authority: The worker’s statutory authority can create fear, mistrust, and resistance. Ethical practice requires transparency about power and efforts to minimise coercion where possible.
  • Autonomy vs protection: Clients may resist interventions designed to protect themselves or others. Social workers must navigate the tension between respecting autonomy and fulfilling legal duties.
  • Respect and dignity: Regardless of their circumstances, involuntary clients deserve recognition of their humanity (Smith, 2020). Small acts of respect—listening, apologising, validating experiences—can counteract the dehumanisation often felt by these clients.
  • Cultural sensitivity: Involuntary clients may come from marginalised communities disproportionately subject to surveillance and intervention. Workers must be mindful of systemic inequalities and avoid reinforcing oppression.

For example, a young person from a minority ethnic background in the youth justice system may view intervention as yet another example of systemic bias. The social worker must acknowledge these perceptions and aim to build trust while fulfilling statutory responsibilities.

Application to Practice

Child Protection

Parents investigated for neglect often experience shame, anger, and fear. They may resist workers’ involvement, perceiving them as threats to family unity. Building trust requires clear communication about the purpose of intervention, acknowledgment of parents’ strengths, and practical support—such as advocacy for housing or financial aid—alongside risk assessment.

Criminal Justice

Offenders on probation often demonstrate resistance, minimisation, or hostility. Using Trotter’s principles, workers can clarify roles, reinforce pro-social behaviours (e.g., punctuality, honesty), and use collaborative problem-solving to address criminogenic needs. Humour, empathy, and respectful challenge can help shift clients from compliance to genuine engagement.

Mental Health

Clients subject to compulsory treatment orders may mistrust professionals due to past (negative) experiences. Engagement requires recognising clients’ perspectives, involving them in care planning where possible, and validating their autonomy within legal constraints. Patience and consistency are crucial, as mistrust may take time to overcome.

In each context, the social worker must balance legal authority with relational ethics, adapting approaches to each individual circumstances.

Conclusion

Working with involuntary clients is among the most challenging yet essential aspects of social work practice. These clients often engage reluctantly, under compulsion or pressure, and bring with them mistrust, resistance, and conflicting agendas. However, effective practice is possible when social workers adopt approaches that combine clarity of role, respect for autonomy, pro-social modelling, and collaborative problem-solving.

Theories such as motivational interviewing and solution-focused practice provide useful frameworks, while Trotter’s principles and the Good Practice Guide offer practical strategies. Above all, successful engagement depends on relationships characterised by recognition, trust, and respect.

The ethical dilemmas of authority, autonomy, and systemic inequality require constant reflection. Social workers must strive to balance their statutory duties with their professional commitment to empowerment and justice. While progress may be slow and messy, the potential for positive change remains significant.

Ultimately, the work with involuntary clients exemplifies the dual nature of social work: at once constrained by law and bureaucracy, yet grounded in human connection, empathy, and the belief in people’s capacity for change.

Dialectical Behaviour Therapy: A social work intervention?

Dialectical Behaviour Therapy (DBT) has emerged as a pivotal intervention in addressing the complex challenges associated with Borderline Personality Disorder (BPD), particularly within the field of social work. As a modified form of Cognitive Behaviour Therapy (CBT), DBT integrates cognitive and behavioural strategies with mindfulness and dialectical philosophy, making it uniquely suited to the emotional dysregulation and interpersonal instability characteristic of BPD. The therapeutic approach was developed by Marsha Linehan, initially as a treatment for individuals experiencing chronic suicidality and self-harming behaviours. Over time, DBT has evolved into a comprehensive psychosocial treatment, combining individual therapy, skills training groups, phone coaching, and team consultation to support both clients and therapists.

Social work practice is deeply rooted in values of client-centred care, empowerment, and the therapeutic alliance. DBT aligns well with these principles by emphasizing validation, collaboration, and skill-building. The therapy does not pathologize emotional suffering but instead recognizes the dialectical tension between acceptance and change. Clients are encouraged to accept their current realities while simultaneously working towards behavioural and emotional improvements. This dual emphasis supports social work’s commitment to both respecting clients’ lived experiences and fostering meaningful transformation.

Central to DBT is the biosocial theory of BPD, which posits that the disorder arises from a transactional relationship between an emotionally vulnerable individual and an invalidating environment. Emotional vulnerability includes heightened sensitivity to emotional stimuli, intense emotional responses, and a slow return to baseline. An invalidating environment dismisses or punishes emotional expression, leading individuals to doubt their internal experiences and seek external validation through extreme behaviours. This conceptual framework resonates with social work’s ecological perspective, which views human problems within the context of systemic and environmental influences. It also invites practitioners to address broader social and relational dynamics rather than focusing solely on intrapsychic pathology.

The structure of DBT involves several interlocking components. Individual therapy sessions are designed to help clients apply DBT skills to specific challenges and to work through motivational issues that may hinder progress. Skills training groups, which often function more like psychoeducational classes than traditional group therapy, teach core skill sets in four modules: mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness. Phone coaching offers in-the-moment support, helping clients generalize skills to real-life situations, while therapist consultation teams ensure practitioners receive ongoing support and supervision. This multifaceted structure enhances treatment fidelity and helps social workers manage the emotional toll of working with high-risk populations.

Mindfulness, the foundational skill in DBT, draws heavily from Zen Buddhist practices and emphasizes nonjudgmental awareness of the present moment. In the context of social work, mindfulness supports both clients and practitioners in cultivating emotional awareness, self-regulation, and a grounded therapeutic presence. Distress tolerance skills help clients survive emotional crises without resorting to self-destructive behaviours. These include distraction techniques, self-soothing strategies, and radical acceptance. Emotion regulation skills aim to reduce emotional vulnerability by increasing positive emotional experiences and decreasing emotional reactivity. Finally, interpersonal effectiveness skills teach assertiveness, boundary-setting, and strategies for maintaining self-respect in relationships.

For social workers, the integration of DBT into practice offers several advantages. The structured nature of the therapy provides a clear roadmap for treatment, while the emphasis on validation and nonjudgmental stance aligns with social work values of empathy and respect. Moreover, DBT’s evidence base is robust. Research demonstrates its effectiveness in reducing self-harm, suicidality, psychiatric hospitalizations, and treatment dropout rates. DBT has also been adapted for various populations beyond BPD, including adolescents, individuals with substance use disorders, and clients with eating disorders or post-traumatic stress.

However, implementing DBT within social work settings also presents challenges. The comprehensive nature of the therapy requires significant training, time commitment, and organizational resources. Many community-based agencies may lack the infrastructure to support all components of the DBT model, such as skills groups or consultation teams. Additionally, the emphasis on behavioural analysis and structured interventions may be unfamiliar to social workers trained primarily in psychodynamic or client-centred approaches. Bridging this gap requires ongoing professional development and interprofessional collaboration.

Despite these barriers, adaptations of DBT have made it more accessible to social work contexts. For instance, some programs offer abbreviated or skills-only versions of DBT, which retain core elements while reducing intensity. These adaptations can still be effective, particularly when delivered with fidelity to the therapy’s principles. Social workers can also incorporate DBT-informed strategies into their broader practice, such as using validation techniques, teaching emotion regulation skills, or encouraging mindfulness.

Furthermore, the relational aspects of DBT—especially the therapeutic alliance—are critical to its success and align closely with social work practice. Therapists are encouraged to balance acceptance and change strategies in their interactions with clients. This dialectical stance involves being warm, validating, and supportive while also setting limits, challenging behaviours, and fostering accountability. Such a balance is particularly important when working with clients who experience intense fear of abandonment, emotional lability, and chronic interpersonal difficulties.

The DBT approach also invites social workers to reflect on their own emotional responses and boundaries. Working with clients who self-harm or express suicidal ideation can evoke fear, frustration, and helplessness. DBT addresses this through consultation teams that provide peer support, case discussion, and skill development. This component fosters sustainability and reduces burnout among practitioners, reinforcing the importance of self-care and supervision in social work practice.

In conclusion, Dialectical Behaviour Therapy represents a powerful intervention for clients with Borderline Personality Disorder, particularly within the field of social work. Its structured, skill-based approach, combined with a compassionate and validating therapeutic stance, makes it both effective and congruent with social work values. While challenges in implementation remain, adaptations and DBT-informed practices allow social workers to integrate its principles in diverse settings. By doing so, they can enhance their capacity to support emotionally vulnerable clients, promote resilience, and foster meaningful change in the lives of those they serve.

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DBT tools

The Transformative Potential of Gestalt Therapy in Social Work Practice

Evan Senreich’s article, “A Gestalt Approach to Social Work Practice,” offers a detailed exploration of how Gestalt therapy theory can serve as a comprehensive and integrative framework for social work. By synthesizing the ecological and strengths-based perspectives central to social work, this approach aligns seamlessly with the core values of the profession, including social justice, the importance of human relationships, and respect for the dignity and worth of individuals.

Gestalt therapy, a humanistic psychotherapy developed in the mid-20th century, emerged in reaction to the limitations of psychoanalytic traditions. The founders of Gestalt therapy, including Fritz and Laura Perls and Paul Goodman, rejected the passive, hierarchical dynamic of classical psychoanalysis, instead emphasizing immediate experience, relational authenticity, and the interconnectedness of individuals and their environments. Gestalt therapy draws upon a variety of influences, such as Kurt Lewin’s field theory, Gestalt psychology, existential philosophy, and even Zen Buddhism, resulting in an approach that prioritizes self-actualization, creativity, and human potential.

Central to this framework are four key theoretical concepts that resonate deeply with contemporary social work practice: field theory, the “I-Thou” relationship, creative adjustment, and the phenomenological perspective. Each concept provides unique insights into human behavior and offers practical applications for social workers at both micro and macro levels.

Field theory, rooted in Kurt Lewin’s work, forms the foundation of Gestalt therapy’s emphasis on interconnectedness. This perspective asserts that individuals do not exist independently of their environments; rather, they are inseparable from the larger field that includes cultural, social, and environmental factors. Field theory builds upon social work’s ecological perspective by emphasizing how subjective experiences shape perceptions of reality. For example, Gestalt therapy employs the concepts of “figure” and “ground” to describe how individuals focus on specific needs or wants (the figure) within the broader context of their life experiences (the ground). Social workers are encouraged to consider these dynamics when assessing clients’ situations, ensuring that interventions address both individual needs and systemic influences.

The “I-Thou” relationship, inspired by Martin Buber’s existential philosophy, underscores the importance of authentic, mutual interactions between social workers and clients. In contrast to “I-It” relationships, which are goal-oriented and objectify the other person, “I-Thou” relationships emphasize presence, empathy, and genuine connection. This approach fosters trust and respect, enabling clients to feel truly seen and understood. Social workers practicing from an “I-Thou” perspective adopt a horizontal rather than authoritarian stance, collaborating with clients as equals. This relational authenticity aligns with social work values such as self-determination and the dignity of the individual, creating a foundation for meaningful change.

Creative adjustment, another core concept of Gestalt therapy, offers a non-pathological framework for understanding human behavior. It posits that all actions, even maladaptive ones, represent attempts to meet needs based on available resources and life history. By framing behaviors as creative adjustments, social workers can adopt a strengths-based perspective, recognizing clients’ resilience and resourcefulness. For instance, a teenager joining a gang to find belonging or a person using substances to cope with trauma can be understood as making the best possible choices within their circumstances. This perspective encourages social workers to avoid judgment and instead focus on helping clients develop new, more fulfilling ways to meet their needs.

The phenomenological perspective complements these concepts by emphasizing the importance of understanding clients’ subjective experiences. Based on Edmund Husserl’s philosophy, phenomenology rejects the notion of a single objective truth, instead asserting that each individual interprets reality uniquely. Social workers are encouraged to “bracket” their assumptions and biases, focusing instead on the client’s lived experience. This approach not only enhances empathy but also ensures that interventions are culturally responsive and client-centered.

Senreich illustrates these theoretical principles through compelling case examples that highlight their practical application. One such case involves Adam, a social worker in a psychiatric day treatment program, and Rosa, a student intern. Both were assigned to work with Lisa, a young woman diagnosed with schizophrenia. Adam, influenced by his professional training and personal background, focused on Lisa’s psychiatric symptoms, limiting their interactions to brief, task-oriented sessions. Rosa, on the other hand, approached Lisa with openness and curiosity, fostering a deeper, more authentic connection. Through this “I-Thou” relationship, Lisa began to engage more fully in the program, eventually addressing painful childhood experiences and moving toward greater independence. This example underscores how field theory, relational authenticity, and cultural humility can transform social work practice, enabling deeper client engagement and more effective interventions.

Another case highlights the consequences of failing to adopt a phenomenological approach. Yvette, a social worker in a substance abuse treatment program, struggled to connect with Peter, a gay man in recovery from cocaine and alcohol dependence. While Yvette supported Peter’s sobriety, she dismissed his preference for anonymous sexual encounters, insisting that it was unhealthy and urging him to pursue monogamous relationships. By failing to bracket her biases and explore Peter’s perspective, Yvette undermined their therapeutic alliance, leaving Peter feeling misunderstood and disengaged. This example demonstrates the critical importance of attuning to clients’ subjective realities, particularly when addressing sensitive or culturally nuanced issues.

Gestalt therapy’s applicability extends beyond individual and family practice, offering valuable insights for organizational and community work. Field theory, for example, can inform program development and policy advocacy by encouraging social workers to consider the complex interplay of cultural, economic, and political factors shaping systemic issues. Creative adjustment provides a lens for understanding how communities respond to challenges such as poverty, discrimination, or environmental crises, highlighting opportunities for collective resilience and empowerment. Additionally, the “I-Thou” relationship and phenomenological perspective can enhance collaboration among stakeholders, fostering authentic dialogue and mutual understanding.

By integrating Gestalt principles into their practice, social workers can address systemic inequalities while empowering individuals and communities to creatively adjust in ways that promote self-actualization and social justice. This holistic approach aligns with the National Association of Social Workers’ Code of Ethics, which emphasizes access to resources, equality of opportunity, and respect for human diversity.

In conclusion, Senreich’s article underscores the transformative potential of Gestalt therapy as a unifying framework for social work. Its alignment with the profession’s core values, coupled with its adaptability across diverse practice settings, makes it a powerful tool for fostering relational authenticity, systemic change, and human flourishing. By embracing the principles of field theory, “I-Thou” relationships, creative adjustment, and phenomenology, social workers can deepen their practice, enhance client outcomes, and contribute to a more just and compassionate society.

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Addressing Self-Harm: Assessment, Management, and Prevention

Introduction
Self-harm, defined as intentional self-poisoning or injury irrespective of intent, remains a significant public health issue affecting individuals across all age groups and demographics. The behavior is often associated with underlying mental health conditions, emotional distress, or adverse social circumstances. To address this, the National Institute for Health and Care Excellence (NICE) released guideline NG225, offering evidence-based recommendations for assessing, managing, and preventing recurrence of self-harm. This article delves deeply into the key aspects of the guideline, designed for healthcare professionals, educators, social care practitioners, and others involved in supporting those who self-harm.

Understanding Self-Harm
Self-harm includes a wide range of behaviors, such as cutting, poisoning, or other acts of self-injury, that are intentional but may not always be intended to end life. Unlike stereotypical self-injurious behaviors seen in some developmental disorders, self-harm in this context often arises from emotional dysregulation, mental health disorders, or environmental stressors. It requires a holistic understanding that respects individual circumstances and avoids stigmatization.

Core Principles of Care
Providing care for individuals who self-harm must be grounded in respect, dignity, and empathy. Practitioners are encouraged to address the stigma surrounding self-harm and to adopt a collaborative approach with patients and, when appropriate, their families or carers. This collaboration should focus on shared decision-making, enabling individuals to have control over their care plans and fostering a sense of empowerment. Special attention should be given to inclusivity, ensuring care strategies are adapted to meet the needs of underserved or marginalized populations, such as those with disabilities, neurodevelopmental disorders, or from minority ethnic and LGBTQ+ backgrounds.

Assessment and Psychosocial Care
Timely and thorough psychosocial assessments are crucial in understanding the context of self-harm and addressing underlying issues. Mental health professionals should prioritize building a therapeutic relationship with the individual, exploring the functions and reasons for their self-harming behavior. Assessments should be conducted in private settings that promote confidentiality and are sensitive to the individual’s preferences and needs.
Key considerations include:

  • Assessing the individual’s emotional and mental state, social circumstances, and immediate safety.
  • Understanding the specific triggers and personal values associated with the behavior.
  • Tailoring assessments for specific populations, such as children, older adults, and individuals with learning disabilities, ensuring age-appropriate and context-sensitive approaches.
    For children and young people, professionals should explore social, educational, and home environments while addressing potential safeguarding concerns. In older adults, factors such as loneliness, cognitive impairments, and physical health issues should be prioritized.

Prevention Strategies and Interventions
Preventing self-harm recurrence requires a multi-faceted approach that combines psychological support, safety planning, harm minimization, and coordinated care across services. Psychological interventions, particularly those informed by cognitive-behavioral therapy (CBT), are the cornerstone of treatment for individuals who self-harm. For children and adolescents experiencing emotional dysregulation and frequent self-harming episodes, dialectical behavior therapy adapted for adolescents (DBT-A) is recommended.
Collaboratively developed safety plans are integral to prevention. These plans should help individuals identify triggers, develop coping mechanisms, and access support during crises. Safety measures may include removing access to means of self-harm and providing practical tools for managing distress. Harm minimization strategies, such as education on wound care and safe practices, can also play a role when individuals are not yet ready to completely stop self-harming.
Safer prescribing is critical in minimizing risks for individuals at high risk of overdose. This involves reviewing medications, limiting quantities, and maintaining open communication with other healthcare providers. Pharmacological interventions, however, are not recommended as primary treatments for self-harm.

Role of Professionals in Various Sectors
Healthcare professionals, educators, and staff in social and criminal justice settings all play vital roles in supporting individuals who self-harm.
Healthcare settings must adopt integrated care models that bring together mental and physical health services. Emergency departments should ensure access to private spaces for assessments, maintain clear protocols for managing frequent attenders, and prioritize collaborative decision-making. Schools and educational institutions should have designated leads for mental health who ensure the implementation and regular review of self-harm policies. These policies should provide guidance on identifying self-harming behaviors, supporting affected students, and addressing the needs of their peers.
In criminal justice settings, staff should be equipped to identify and respond to self-harm, ensuring access to appropriate healthcare and safeguarding resources. Secure environments, such as immigration removal centers, must address the heightened risks of self-harm and suicide among their populations while providing staff with adequate support for their own mental well-being.

Training and Supervision
The guideline underscores the importance of regular training for all professionals working with individuals who self-harm. This training should address the psychological and emotional complexities of self-harm, cultural competency, de-escalation techniques, and the development of compassionate communication skills.
Staff in specialist roles, such as mental health professionals, should receive additional training in conducting psychosocial assessments and risk formulation. Regular supervision and emotional support for staff are essential to help them manage the challenges associated with working in this field, ensuring they can provide compassionate and effective care without burnout.

Conclusion
The NICE guideline NG225 provides a comprehensive framework for addressing self-harm through respectful, evidence-based care. By prioritizing timely assessments, tailored interventions, and collaborative prevention strategies, professionals can significantly improve outcomes for individuals who self-harm. This requires coordinated efforts across healthcare, education, and social sectors, supported by ongoing training and robust policies. Ultimately, fostering a culture of understanding and compassion is crucial in reducing the prevalence and impact of self-harm while ensuring that affected individuals receive the support they need to recover.

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Psychodynamic Social Work: A Revival of an Overlooked Approach

In contemporary social work, many practitioners may overlook psychodynamic therapy, seeing it as an outdated relic in a field increasingly dominated by short-term, manualized interventions. Yet, this is precisely what Faye Mishna, Melissa Van Wert, and Kenta Asakura explore in their article “The Best Kept Secret in Social Work: Empirical Support for Contemporary Psychodynamic Social Work Practice.” They argue that psychodynamic approaches remain not only relevant but empirically supported and well-suited for addressing complex, real-world cases.

Psychodynamic Therapy: More Than Freud

Historically linked to psychoanalysis, psychodynamic therapy has evolved considerably since the days of Sigmund Freud. The approach now encompasses several theories, including self psychology, intersubjectivity, and relational theory. These contemporary frameworks focus on the therapeutic relationship as the primary tool for change, positioning the service user within their broader social environment. This aligns well with social work’s commitment to person-in-environment and relational practice, emphasising that individuals cannot be understood in isolation from their relationships and societal contexts (Mishna et al., 2013).

Relevance to Social Work Practice

One of the strongest arguments made by Mishna and her colleagues is that psychodynamic practice resonates deeply with the core principles of social work. The therapeutic relationship—central to psychodynamic theory—is the very foundation of social work practice. Whether practitioners are working with children, adults, or families, establishing a strong, empathic connection is key to facilitating personal growth and change (Mishna et al., 2013).

Moreover, psychodynamic approaches go beyond symptom management to address the complex interplay between a service user’s internal world and their external relationships. For example, self psychology emphasizes the importance of “self-object” experiences, where individuals develop a cohesive sense of self through empathic connections with others (Kohut, 1977). This mirrors social work’s holistic approach to understanding the client’s needs in their full context.

Empirical Support for Psychodynamic Therapy

Contrary to the misconception that psychodynamic therapy lacks empirical backing, a growing body of evidence supports its efficacy. Mishna and her co-authors review multiple studies demonstrating the effectiveness of psychodynamic therapy in treating a variety of mental health conditions, including depression, anxiety, eating disorders, and substance abuse disorders. For instance, research by Leichsenring et al. (2006) and a meta-analysis by Abbass et al. (2006) revealed that both short-term and long-term psychodynamic interventions can significantly improve mental health outcomes (Mishna et al., 2013).

Moreover, research has shown that the benefits of psychodynamic therapy often endure long after the treatment concludes. Unlike some brief therapeutic interventions, which may offer only temporary symptom relief, psychodynamic therapy aims to facilitate deeper, more lasting changes in service users’ psychological functioning (Town et al., 2012).

Addressing Complex, Real-World Cases

One of the strengths of psychodynamic practice is its ability to accommodate the complexity of real-world cases. Social workers often encounter clients dealing with intersecting oppressions and multiple, co-occurring issues—ranging from trauma and mental illness to systemic barriers such as poverty and discrimination. Psychodynamic therapy, with its focus on deep relational work and long-term change, is well-suited to this context (Mishna et al., 2013).

While manualised treatment models like cognitive-behavioral therapy (CBT) may offer clear pathways to symptom reduction, they may fall short in addressing the broader relational and social contexts of service users’ lives. Mishna et al. argue that social work education should incorporate psychodynamic theory more robustly to prepare future practitioners for the multifaceted challenges they will face in the field (Mishna et al., 2013).

Conclusion

In revisiting psychodynamic approaches, Mishna, Van Wert, and Asakura offer a timely reminder that psychodynamic social work is far from obsolete. The therapeutic relationship, person-in-environment perspective, and focus on deep psychological change make this approach especially relevant in today’s practice. As evidence continues to support the effectiveness of psychodynamic therapy, it is time for social work to rediscover its potential and integrate it into both practice and education.

By raising awareness of psychodynamic theory’s relevance and its empirical foundation, we can ensure that this “best-kept secret” in social work becomes widely known and utilised for the benefit of service users and practitioners alike.

References

Abbass, A. A., Hancock, J. T., Henderson, J., & Kisely, S. (2006). Short-term psychodynamic psychotherapies for common mental disorders. Cochrane Database of Systematic Review, (4).

Kohut, H. (1977). The restoration of the self. International Universities Press.

Leichsenring, F., Hiller, W., Weissberg, M., & Leibing, E. (2006). Cognitive behavioral therapy and psychodynamic psychotherapy: Techniques, indications and empirical evidence. American Journal of Psychotherapy, 60(3), 233–260.

Mishna, F., Van Wert, M., & Asakura, K. (2013). The best kept secret in social work: Empirical support for contemporary psychodynamic social work practice. Journal of Social Work Practice, 27(3), 289–303.

Town, J. M., Diener, M. J., Abbass, A., Leichsenring, F., Driessen, E., & Rabung, S. (2012). A meta-analysis of psychodynamic psychotherapy outcomes: Evaluating the effects of research-specific procedures. Psychotherapy, 49(3), 276–290.

Risk, Assessment and Intervention

Risk, assessment, and intervention are essential components of social work practice. Social workers are tasked with the responsibility of identifying, assessing, and intervening in situations where individuals, families, and communities are at risk. Risk, in social work, refers to situations where there is potential harm to an individual or group of individuals. This harm may be physical, emotional, or social, and may be caused by various factors, including poverty, abuse, neglect, discrimination, mental illness, and substance abuse.

Assessing risk is a crucial first step in social work practice. It involves gathering information about the situation and the individuals involved, analyzing the information, and determining the level of risk. Social workers use a range of tools and techniques to assess risk, including interviews, observation, and assessment scales. The assessment process is ongoing, and social workers regularly review and update their assessments to ensure that interventions are appropriate and effective.

Once risk has been assessed, social workers develop and implement interventions to reduce or eliminate the risk. Intervention may involve direct work with individuals, families, or communities, or it may involve advocacy and policy work. Interventions may be preventative, early intervention, or crisis intervention. Preventative interventions are aimed at addressing risk factors before they become significant problems. Early intervention is targeted at addressing problems in their early stages before they become more severe, while crisis intervention is aimed at addressing immediate risks and ensuring safety.

Interventions in social work may take many forms, including counseling, therapy, advocacy, education, and practical support. The choice of intervention will depend on the specific needs of the individual or group, as well as the resources available. Social workers may work collaboratively with other professionals, such as health care professionals, educators, and law enforcement officials, to ensure that interventions are effective and appropriate.

It is essential that social workers are skilled in managing risk and developing effective interventions. Social work training programs and professional development opportunities provide social workers with the knowledge and skills they need to assess risk and intervene effectively. Social workers must also be aware of the ethical and legal considerations when working with individuals, families, and communities at risk. They must respect the autonomy and dignity of the individuals they work with and ensure that their interventions are culturally sensitive and appropriate.

In conclusion, risk, assessment, and intervention are critical components of social work practice. Social workers must be skilled in identifying and assessing risk, developing and implementing effective interventions, and working collaboratively with other professionals. Social workers play a vital role in promoting the well-being of individuals, families, and communities by addressing risk factors and reducing harm. Effective risk management and intervention are key to promoting positive outcomes for those at risk and ensuring that social work practice is effective and ethical.

CBT in Social Work

Cognitive Behavioral Therapy (CBT) is a well-established psychotherapeutic approach that has been shown to be effective in treating a range of mental health disorders. CBT is based on the idea that our thoughts, feelings, and behaviors are interconnected, and that changing our thoughts and behaviors can lead to a positive change in our emotions and overall well-being. As a social worker, CBT can be an effective tool in helping clients manage their mental health concerns and achieve their goals.

CBT is a highly structured and goal-oriented therapy that typically involves a specific number of sessions. A social worker using CBT would first work with the client to identify the negative thoughts and behaviors that are causing distress. This may involve conducting a thorough assessment of the client’s mental health history, as well as their current thoughts and behaviors. Once these negative thoughts and behaviors are identified, the social worker would work with the client to challenge and reframe them in a more positive and constructive way.

CBT is also highly collaborative, and the social worker would work closely with the client to develop specific strategies and techniques to manage their thoughts and behaviors. This may involve teaching the client relaxation techniques such as deep breathing or progressive muscle relaxation, as well as problem-solving skills to help them cope with difficult situations. The social worker may also use homework assignments and other exercises to help the client practice these techniques outside of therapy sessions.

CBT is highly effective in treating a range of mental health concerns, including depression, anxiety, post-traumatic stress disorder (PTSD), and obsessive-compulsive disorder (OCD). As a social worker, CBT can be an effective tool in helping clients overcome these issues and achieve their goals. For example, a client struggling with depression may benefit from CBT techniques that help them challenge their negative thoughts and behaviors, develop coping strategies, and improve their overall mood and sense of well-being.

In addition to its effectiveness in treating mental health concerns, CBT is also highly adaptable and can be tailored to meet the specific needs of individual clients. This may involve modifying the therapy to address cultural or linguistic barriers, as well as addressing any co-occurring mental health or substance use issues that the client may be experiencing.

In conclusion, CBT can be a highly effective tool for social workers in helping clients manage their mental health concerns and achieve their goals. By identifying negative thoughts and behaviors, challenging and reframing them, and developing specific strategies and techniques to manage them, social workers can help their clients overcome a range of mental health concerns and improve their overall well-being.