Social work roles and activities regarding psychiatric medication: results of a national survey.
Despite the literature that calls for expanded roles, however, we found no earlier research that empirically assesses what social workers are doing in their daily practice with respect to psychiatric medication. This article is an initial attempt to fill that gap in our knowledge base.
We report the results of a 2001 national survey that examined social work practice roles and activities that relate in some way to psychiatric medications. Our explicit argument is that if clinical social workers are to embrace expanded opportunities for enhancing interdisciplinary collaboration and serving clients more responsively with regard to medication-related issues, then they must start with a more accurate understanding and appreciation of their firsthand experiences. Specifically, we asked the following questions: What kinds of professional activities are clinical social workers doing that relate to psychiatric medication, and how frequently are they doing them? How appropriate do social workers think these roles and activities in medication management are, and how competent do they feel in carrying them out? Once we begin to answer these questions we can consider how social work practitioners and educators can better prepare for the tasks and challenges that lie ahead.
We used a cross-sectional survey design with a national random sample of NASW members who self-identified with "clinical" as their primary method of practice and "mental health" as their primary field of practice. Questionnaires, totaling 4,024, were mailed, and a reminder postcard was sent about a week later. Of the 3,790 questionnaires returned, 994 were usable, yielding a 26 percent response rate. A lower response rate was expected because of the length of the questionnaire (100 items, including two open-ended questions), and the recognition that some social workers still do not see medications as salient to their work. Length and perceived salience are key factors in lowering mailed survey response rates (Heberlein & Baumgartner, 1978; Yammarino, Skinner, & Childress, 1991). Under a contract, our University Survey Evaluation and Research Lab managed the formatting and distribution of the questionnaire, as well as data collection and data entry.
The heart of the questionnaire consisted of ratings of 31 possible tasks and activities related to psychiatric medication. (A copy of the questionnaire is available from the authors.) To ensure this list of tasks and activities was grounded in real-world practice, we first conducted three focus groups with local practitioners before developing the survey instrument. These sessions elicited information about the kinds of experiences social workers have across a range of settings with a range of clients taking medication, and with their prescribing physicians and psychiatrists. A draft questionnaire based on those focus groups was piloted with a different group of social workers from a local mental health facility. In addition to questions about roles and activities, the questionnaire contained sections on ethical dilemmas in medication management (Walsh, Farmer, Taylor, & Bentley, 2003), perceived supports and barriers to practice related to psychiatric medication (reported elsewhere), demographic information, and two open-ended questions. These two questions asked respondents to reflect on changes they might make in their practice related to roles in psychopharmacology and to offer their perspective on the most important thing they do that contributes to success with clients who take psychiatric medication. A research assistant transcribed the responses to the open-ended questions from the survey to a word processing file where they were coded and sorted using of content analysis techniques of data fracturing and conceptual ordering (Strauss 8: Corbin, 1998). Other data were analyzed using traditional methods of univariate, bivariate, and multivariate analysis using SPSS version 10 (.05 significance level).
Demographic Characteristics of Survey Respondents
The demographic characteristics of the respondents mirror those of NASW in that they reflect a largely white, female, experienced, and maturing subset of practitioners in the field of social work. Specifically, of the 994 social workers who completed the survey, 69.7 percent (n = 640) were female and 30.3 percent (n = 278) were male, with a mean age of 53 years (range 27 to 88), and an average of 25.1 years of practice experience. Eighty-eight percent (n = 874) have an MSW degree. Of the 92 percent (n = 914) of respondents who reported race or ethnicity, most were white (87.4 percent, n = 799). Other respondents identified as Hispanic (2.3 percent, n = 23),African American (1.6 percent, n = 16),Asian/ Pacific Islander (1 percent, n = 3), and American Indian/Alaska Native (.3 percent, n = 3). Two percent (n = 18) identified themselves as "other."
Half of the respondents (50.8 percent, n = 455) work in urban settings compared with 35 percent (n = 319) who work in suburban areas, and 13.6 percent (n = 122) who work in rural settings. Work settings include a large contingent in private practice (54.7 percent, n = 479),but also many in community mental health centers (14.7 percent, n = 129), state psychiatric hospitals (3.2 percent, n = 28), private psychiatric and general hospitals (3.0 percent each, n = 26 for each), social services agencies (2.9 percent, n = 25), state or federal mental health organizations (2.5 percent, n = 22), residential-group homes (2.2 percent, n = 19), psychosocial clubhouses or drop-in centers (.2 percent, n = 2), and mental health advocacy organizations (.1 percent, n = 1). Most respondents reported providing clinical services to adults (97.8 percent, n -859) and to children (83.0 percent, n = 474). Furthermore, virtually all respondents (98.6 percent; n = 840) indicated that at least some of their clients were using psychiatric medications.
Frequency of Carrying Out Roles and Activities Related to Psychiatric Medication
To provide insight into the meaning of the results, the presentation of findings is loosely organized around the type of activity required of social workers: discussion, collaboration, information sharing, or case management. (The original list of activities in the questionnaire was not organized by category.) The most frequently performed tasks (in a typical month) were talking with clients about their feelings about taking medication, making referrals to physicians, and discussing with clients how medications may work in combination with psychosocial interventions (Table 1). These are the only three activities in which more than 70 percent of respondents said that they performed them "often" or "very frequently" in a given month (these two responses were combined for presentation of results). About half the respondents "often" or "very frequently" helped clients weigh the pros and cons of taking medication or discussed medication issues with physicians. Numerous tasks are rarely performed by social workers in a typical month, including suggesting changes in medications to physicians, providing psychoeducation, and delivering medications to clients.
Perceived Competence and Appropriateness of Social Work Roles
In general, perceptions of competence and appropriateness are positively associated with frequency of roles performed (Table 1). That is, as frequency increases or decreases, so does reported perceptions of both professional competence with a given task and its disciplinary appropriateness. Almost everyone who responded to the survey (96 percent) said it is quite appropriate for social workers to talk to a client about his or her feelings about taking medication, ranking it as both the most appropriate social work activity with respect to psychiatric medication, and the one about which they feel most competent. The second most appropriate role is making a referral to a physician for a medication evaluation (95.1 percent "quite appropriate"),which also ranks second in terms of perceived competence with the task. Respondents (75.8 percent) said it is quite appropriate for social workers to help clients make decisions about medication--that is, help clients weigh "pros" and "cons," yet, only 51.6 percent reported doing it often. Given social work's long association with problem solving, it may be surprising that only 68.1 percent of respondents felt competent to carry out this activity. Similarly, whereas 85 percent of respondents reported that preparing a client for an interview with a physician is appropriate, only 38 percent reported doing it often or very frequently.
Desired Changes in Standard Practice
The participants were asked to respond to an open-ended question on the survey instrument: "If you were in charge of your agency/department, what one change would you make in standard practice regarding social workers and psychiatric medication?" Twenty-eight respondents indicated that they were happy with their collaborative relationships and related work policies and practices, and would therefore not offer suggested changes. However, three clear themes emerged from the content analysis of the 598 written responses to this question that did offer possible changes.
More Thorough and In-Depth Education for Social Workers about Psychiatric Medication. A total of 249 respondents called for educational forums, workshops, seminars, short courses, in-service training, and opportunities for case discussions on a more routine or regular basis, including education on specific purposes and types of medications, side effects, drug interactions, considerations for prescription choices, statistics on effectiveness, and alternatives to traditional medicine. Respondents wanted printed information geared towards non-medical professionals and training on the use of resource and reference materials like The Physician's Desk Reference. Respondents specifically suggested wider use of client testimonials, in which clients would share their personal experiences with psychiatric medication. They indicated a desire for more skills-based education on such topics as referring clients for medication, advocating for access to medication, exploring the emotional impact of medication on clients, the interplay between psychotherapy and medication, and general medication management, including how to differentiate side effects from symptoms. A dozen respondents suggested that advanced training and education on medications be mandatory, perhaps complete with development of certificate programs. Many suggested that psychiatrists could ideally provide education on medications, but others noted that pharmacists, nurses, or psychopharmacologists could provide ongoing medication education. The data reflect mixed opinions about the potential role of the drug representatives from pharmaceutical companies. An argument is made that the quest for more education on psychiatric medication needs to be balanced by an acceptance that social workers are not "medical" professionals.
More Extensive Interaction with the Medical Community. Two hundred and thirty-seven respondents suggested that collaboration between social workers and prescribing physicians is essential and that collaboration needs to be close, continual, better, and more frequent. Respondents also wanted to see easier access for themselves and clients to psychiatrists and other physicians and immediate access in the case of emergency or urgent need. Specific ideas about achieving that level of collaboration included better use of team approaches in prescribing and monitoring medication and more social worker participation in client appointments with physicians. Respondents focused on activities that improve communication with prescribing physicians, such as creating more opportunities for either formal or informal interaction or dialogue or designing some form or checklist for the client's chart to better monitor medication side effects and other medication issues. Finally, respondents noted that they would like physicians to be more open to social workers' expertise and to respect the input of social workers regarding medication. This might require more training of physicians and nurses about specific social work roles and models.
Better Definition of Appropriate Role of Social Work Regarding Psychiatric Medication. One hundred and twelve respondents called for more explicit policies or guidelines regarding social worker responsibilities with respect to medication, including more detailed procedures for making referrals for medication evaluation and for dealing with ethical and legal issues. Two dozen responses suggested instituting policies that require minimal use of medication or require mandatory psychotherapy when psychiatric medications are used. These respondents advocated a separation of social work roles from medical roles, noting that the social worker's role is that of therapist. They suggested that all specific medical questions be referred to the physician, with social workers having no responsibility for medication education, assessment of side effects, or monitoring, managing, or prescribing medication. A subset of eight respondents suggested that social workers limit their discussion with clients to general medication issues or to monitoring adherence only, and raised questions about whether social workers should be involved in "pushing drugs" at all. A few warned against using medication knowledge as a status symbol and voiced concern about clients' rights to refuse medication and the right to pursue alternatives to medication. On the other hand, 23 suggested encouraging social workers to take a more active role in psychiatric medication and called for equality between social workers and physicians, with several advocating the availability of optional training that would allow social workers to adjust, prescribe, dispense, or authorize refills of medication (and be appropriately compensated for it).
Practitioner Keys to Success with Clients The second open-ended question posed was: "What do you think is the most important thing that you do personally that contributes to a successful outcome with your clients who take psychiatric medication?" Responses totaling 758 were coded on this question. Again, content analysis of responses yielded three categories of themes.
Collaborative Interaction with Physicians. Responses totaling 236 suggested that engaging in productive collaborative interactions with medical staff is among the most important things social workers do to ensure a successful outcome with clients taking psychiatric medication. Respondents connected effectiveness of their interactions with physicians with a range of strategies: frequently communicating with the physician; "supporting" her or him; taking a proactive stance by calling physicians; asking questions; setting up meetings; visiting physician's offices; seeking or giving feedback; discussing diagnosis, symptoms, and outcomes; making good referrals; sending along client histories; discussing prescriptions; sitting in on medical consultations with clients; and following up with physicians after referrals. One respondent described her role as being the "eyes and ears for the doctor" and another said she sees herself as simply the "liaison" between client and doctor. As such, respondents emphasized the importance of finding competent, reliable, and accessible physicians to refer to, ones whom they can trust, who respect social workers, and understand the value of psychotherapy and other psychosocial interventions.
Use of Specific Practice Strategies and Skills in Referral, Adherence, and Medication Monitoring. The largest numbers of respondents, 399, related their success with clients to specific practices and techniques with clients and families themselves. Indeed, 139 respondents said that the most significant thing they do for clients is help them prepare for physician visits and gain skills in self-advocacy. Respondents noted that they are instrumental in encouraging clients to see a physician in the first place, and in making a referral for medication evaluation. They mentioned the importance of being able to accurately assess a need for medication and assist clients and their families in evaluating the pros and cons of medicine, or help obtain a second opinion.
Especially in the face of reluctance, respondents said they coach clients in asking questions, talking more openly, and taking a more active, assertive part in their treatment. Key factors for success in working with more passive or reluctant clients included providing a safe place for open discussion; building a trusting, supportive, respectful, and empowering relationship; giving clients time and permission to talk about their medication experiences; normalizing ambivalence, fears, and concerns about medication; reducing shame and stigma; working through and validating strong feelings; and openly acknowledging issues related to control and authority. Several respondents noted the use of self-disclosure regarding their own medication use as part of the therapeutic relationship. Additional keys to success were encouraging client's own self-education and decision making, and supporting clients' self-determination regarding medication.
Respondents also engaged with family members and provided them with needed information, education, and support. Supporting and encouraging adherence means tying it to positive life changes and emphasizing the role of taking medication, self-care, and the prevention of relapse. Respondents identified the negative consequences often associated with nonadherence and highlighted the potential positive outcomes associated with medication. In addition, they were alert to overmedication, polypharmacy, and cultural views that might inhibit compliance. General strategies in medication monitoring skills and strategies reported by respondents also included observing and documenting client reactions, side effects, and changes in behaviors and moods; assisting clients in monitoring their own experiences such as journaling; and helping clients make informed decisions at major treatment junctures.
Holding Positive Attitudes and Beliefs that Support Use of Medication. The last category of responses, reflecting 123 comments, connected successful outcome to the communication of positive social work attitudes and beliefs about the role of medication in treatment. In general, communicating hope and sharing professional experiences of other clients' positive outcomes were activities thought to contribute to positive outcomes. Respondents indicated that overall they supported the appropriate use of medication. Although "appropriate" was not always clearly defined, respondents seem to equate it with being diagnostically indicated, such as with psychosis, depression, or anxiety, or when talk therapy is seen as not enough. On the other hand, 11 respondents wrote that social workers still needed to come to grips with beliefs and feelings regarding psychiatric medication. They discouraged medication or helped clients take as low a dosage as possible, and they believed that skilled psychosocial work contributed most to successful outcomes with clients. Eighteen respondents noted that they either treated clients regardless of their personal decision about medication, adopted a "neutral stance" regarding medication, or stated that they support clients following prescribed medication regimes even if they disagreed with them. Not surprising, respondents believed that it is rare that medication alone is optimal, and were likely to see medication as positive in conjunction with psychotherapy. To maintain a positive, informed view of the role of medication, more than 24 respondents explicitly emphasized the importance of keeping up-to-date on literature and research, owning handbooks, consulting with other professionals, and of course, listening to their clients, supervisors, and collaborating physicians.
DISCUSSION AND IMPLICATIONS FOR SOCIAL WORK PRACTICE AND EDUCATION
The study's purpose was to begin to build a database on the real world activities and roles of social workers regarding psychiatric medication. We used both quantitative and qualitative data collected from surveys mailed to a randomly selected group of members of the largest professional social work organization in the United States. As stated earlier, however, NASW membership, particularly those describing their practice as "clinical," is somewhat constrained demographically in that it is largely female, white, experienced, and with high levels of private practice involvement. To conduct research on social work roles in psychopharmacology, there is certainly a desire to sample social workers who represent a younger, more diverse group of practitioners who are working, for example, in entry and mid-level line positions in public mental health, social services, or school settings, often with those who suffer from serious mental illnesses or emotional difficulties. Yet, the lack of a formal (or informal) network or organization of such a targeted group of social workers serves to restrict accessibility, especially on a national scale. Although there are limits to using an NASW sampling frame, this was an appropriate, logical, and useful place to start building the database on social work roles in medication-related activities. Along those lines, our modest return rate may actually exaggerate positive opinions about medication or falsely inflate the reported frequency of activities, as those positively engaged in medication-related roles might be more likely to have completed the mailed survey. Although ethical concerns and resource limits prevented a follow-up with nonrespondents, the return rate may suggest a perceived lack of relevance of the topic by nonrespondents, insufficient incentives to participate (especially in light of the survey's length), and, as discussed earlier, a need to more creatively gain access to hidden dimensions of our practice community.
The findings suggest that some traditional and familiar social work roles are very frequently carried out by social workers, such as talking about feelings and problems related to medication, discussing treatment effects, and making referrals to prescribers. In addition, these were seen as appropriate activities to engage in, and social workers perceived themselves as having adequate levels of competence in carrying them out. Some roles and activities regarding psychiatric medication were not performed as frequently as might be expected. For example, although it is not surprising that a large majority of respondents said it is quite appropriate for social workers to help clients with medication decision making, in this study only half of respondents said they often or very frequently helped clients weigh the pros and cons regarding medication-related issues in particular. Only about two-thirds of respondents felt competent to do it. These results are in spite of the fact that problem solving--helping clients weigh the pros and cons of issues--is long associated with counseling and the basic social work method. Other roles that seem to be underperformed given their historical centrality to social work practice include talking to clients' families about medication and communicating with treatment team members. These are all roles that seem to require more assertive interaction with others on the part of the social worker.
Similarly, whereas 85 percent of respondents reported that preparing a client for an interview with a physician is appropriate, only 38 percent did it often or very frequently. Given that actually making a referral is the second most frequent task, this finding that slightly less than two-thirds occasionally, rarely, or never prepared clients for meeting with the physician is a surprise. In her classic metaanalysis, Videka-Sherman (1988) noted that client preparation is a key characteristic of successful mental health practice, yet also noted that it is an underused practice. Our data suggest that trend may be continuing. And the qualitative findings document that several individual respondents identified client preparation for a referral to a physician, including coaching on what to say and what to expect, as a key to their own individual "success" in practice.
Other implications emerge from this discussion. First, it is especially important that social workers better recognize opportunities to apply their skills in problem solving to issues involving psychiatric medication. Given the relatively low competence rating with this activity, it could be that social workers exaggerate the depth of psychopharmacological knowledge needed to help clients with basic problem solving and decision making. Although knowledge of drug efficacy and side effects is desirable, client decisions to be assessed for medication or to discontinue medication are often centered in the client's subjective experience, not with complicated pharmacological facts and figures. Second, social workers have to be more assertive in taking action on medication-related problems, including taking responsibility for increasing direct collaborative activities with physicians and family members in particular. Qualitative data suggest social workers very much value these activities, but the nature of practice today may be making collaboration and collateral contacts more challenging. In the face of admitted barriers, practitioners and educators must figure out ways to institutionalize true interdisciplinary teamwork. This could mean anything from simply restructuring field internships to completely revisioning professional education and practice.
A third implication for social work practice and education is for social workers to dramatically increase activities related to client preparation and referral. A first step may be greater recognition and dissemination of the importance of this role in the first place. But more specifically there is a need for greater emphasis in social work practice and education on the emotional impact of a referral for medication, more training in, and validation for coaching clients, teaching skills in negotiating with physicians, and sharing research knowledge about medication. The number-one activity of social workers related to psychiatric medication was discussing a client's feelings about medication. Although current training in social work includes content on drawing out client emotions, there seems to be little content on understanding the lived experiences of clients related to psychiatric medications in particular. We know little of how people make sense of their medication, or what effect it has on their sense of self. An increased understanding of the subjective experiences of clients, both adults and children, is called for here to improve our responsiveness and build on our disciplinary strengths (Bentley & Walsh, 1998; Floersch, 2003; Longhofer, Floersch, & Jenkins, 2003). This may call for a dramatic reorientation of our educational emphasis in teaching human behavior and the mental, emotional, and behavioral disorders with which our clients struggle.
A final note concerns the views expressed and implied in the data about the appropriate stance of a social worker regarding medication. Participants identified holding "positive attitudes and beliefs" about medication as another key to successful practice. A consensus seems to be emerging in the literature that, in general, a critical perspective about medications is appropriate for social workers (Bentley & Walsh, 2006; Cohen, 2002; Lacasse & Gomory, 2003; Morley, 2003). This is where social workers understand the beneficial therapeutic effects and the sometimes dramatic improvement in the quality of life for clients who use medication, but who also understand the strong influences of economic and political forces in prescription writing in the United States, and the possibility of related bias in research and marketing. In that regard, it may be of some concern that several respondents in the study identified drug company representatives as a significant and potentially biased source of knowledge about medication. This is in addition to physicians, the number-one source of knowledge about medication, who largely get their information from pharmaceutical companies.
Achieving greater role breadth and fluency related to psychiatric medications and increasing perceptions of social workers' competence may be best achieved by increasing knowledge about psychiatric medication, increasing the use of specific intervention skills, and, especially, increasing the amount of contact between social workers and prescribing physicians. We must close the gap between what we know to be important and what we do on a day-to-day basis with clients, families, and other collaborators.
Original manuscript received May 5, 2003
Final revision received May 17, 2004
Accepted July 12, 2004
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Kia J. Bentley, PhD, LCSW, ACSW, is professor and director, doctoral program ix social work, Virginia Commonwealth University, School of Social Work, 1001 West Franklin Street, Richmond, VA 23284-2027; e-mail: firstname.lastname@example.org. Joseph Walsh, PhD, is associate professor, and Rosemary L. Farmer, PhD, LCSW, is associate professor, School of Social Work, Virginia Commonwealth University, Richmond. An earlier version of this article was presented at the Council on Social Work Education Annual Program Meeting, February 28, 2004, Anaheim, CA. This research was funded by a grant from the Ittleson Foundation. The authors would like to enthusiastically thank Ms. Kate Didden, MSW, and Dr. Patrick Dattalo, also at VCU, for their assistance with, and advice on, the data analysis in this study.
Table 1: Frequency, Competence, and Appropriateness of Social Work Roles and Activities with Regard to Psychiatric Medication Very Frequently/ Quite Quite often Competent Appropriate Activity (%) (%) (%) Discussion-Focused Activities with Clients Discussing with a client his or her feelings about taking medication 80.0 90.9 95.9 Discussing with a client the desired combined effects of medication and psychosocial interventions 70.1 79.4 88.0 Discussing a problem about medication with a client 61.2 48.2 72.7 Monitoring a client's compliance with a medication 60.8 73.1 80.4 Helping a client consider the "pros" and "cons" of taking medication 51.6 68.1 75.8 Checking for the possibility of adverse side effects 51.4 38.5 67.2 Encouraging a client to take medication 44.2 79.9 76.7 Documenting the effects of medication in a client's chart 39.6 57.1 62.3 Preparing a client for an interview with a prescribing physician 0.4 82.1 84.6 Monitoring a client for prevention of medication abuse 36.5 47.3 66.4 Assessing the severity of any adverse side effects 30.1 22.7 43.9 Prompting a client to remember to take his or her medication 24.7 75.2 64.0 Direct Collaborative Activities with Others Making referrals to a physician for a medication assessment with a client 71.9 89.2 95.1 Discussing a client's medication problem with a physician 48.2 63.6 86.6 Consulting with the physician about the effectiveness of a clients medication 46.0 66.2 83.0 Communicating a client's lack of medication compliance with the physician 44.6 82.7 82.6 Communicating with members of client's treatment team 28.5 62.2 68.7 Talking with a client's family about medication issues 27.1 55.6 60.8 Helping a family contact a physician about a client's medication 19.9 75.9 70.5 Suggesting to a physician that he or she adjust client's medication dosage 15.4 32.8 45.7 Suggesting to a physician that he or she change type of medication 11.3 29.8 45.1 Assessing the severity of any adverse side effects 30.1 22.7 43.9 Prompting a client to remember to take his or her medication 24.7 75.2 64.0 Teaching or Information- Sharing Activities Providing information to a client about the ways that medication works in the body 31.7 26.4 43.8 Presenting data or other information to a client about a medication's effectiveness 22.2 35.2 44.4 Facilitating a 37.3 medication education group with clients 3.5 22.8 Facilitating a medication education group with families 2.2 23.7 Hands-on Case Management-Related Activities Assessing a client's ability to pay for medication 21.2 59.0 64.5 Helping a client locate financial and other resources for medication 19.0 51.8 71.4 Ensuring that a client's medication blood levels are checked when indicated 13.6 27.5 33.2 Transporting a client to a prescribing physician's office 2.9 51.8 15.0 Delivering medications to client 1.8 43.1 11.9 Filling client's medication pillbox 0.8 35.9 8.5
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|Author:||Bentley, Kia J.; Walsh, Joseph; Farmer, Rosemary L.|
|Date:||Oct 1, 2005|
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