The history and metamorphosis of the National Registry of Health Care Providers in Clinical Social Work

Clinical Social Work Jou rna l Vol. 16, No. 4, Winter 1988

THE HISTORY AND METAMORPHOSIS OF THE NATIONAL REGISTRY OF HEALTH CARE PROVIDERS IN CLINICAL SOCIAL WORK

Ann F. Farwell

ABSTRACT: This paper traces the history and metamorphosis of the National Registry of Health Care Providers in Clinical Social Work. It was created in 1975 to credential qualified clinical social workers, and to identify them through a published directory. In 1987 it became the National Institute for Clinical Social Work Advancement. Its objectives and purposes moved from credentialling to advancing the speciality of clinical social work through research, education and marketing.

The National Registry of Health Care Providers in Clinical Social Work, established in 1975, has achieved a place of importance and significance in the history of the clinical social work movement. It is fasci- nat ing to recall and review its origins, early days, and progress. Since nothing is created in a vacuum, however, some account of the develop- ments in social work nationally which produced the climate that led, in the late '60s and early '70s, to the beginning of the clinical movement is indicated. This account will then place the Registry and its history in perspective.

In the beginning, many years ago, social worl~ers were organized into six separate specializations within the profession. Among these psychiatric social work had the greatest influence. The mental health focus became the "generic" theme which referred to the commonalities inherent in the practice of "casework" in various settings. This theme prompted support, i n 1955, of the merger into one parent organization, the National Association of Social Workers. It was considered a step in

The author is indebteJ to Estelle Gabriel, Mary Montague, Edna F. Roth, Crayton E. Rowe, Jr., and Wright Williamson for their personal reminiscences and early minutes of the NRHCPCSW.

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the development of social work as an autonomous profession that would advance practice and improve standards, facilitating a basic, generic t raining for all social workers. Unfortunately, as t ime went on, the orig- inal philosophy and intent of the new organization was not realized. Florence Hollis notes, "In the fifties with the expansion of the Ameri- can Association of Social Workers to the National Association of Social Workers and the gradual abandonment of the smaller soc i e t i e s . . , the pendulum swung, under new leadership, to an emphasis on social change. For a number of crucial years when other professions were growing in their contributions to the field of psychotherapy, NASW gave little support to the concerns of direct practice."

This stance became evident in the erosion of education in preparation for clinical practice, as social change, also, became the emphasis of the Council for Social Work Education. Education for direct practice at the Master's level was virtually nonexistant or not valued. Social change was considered the panacea and solution for society's psychologi- cal as well as social ills. Parallel to this, Bachelor of Social Work programs were developing and in 1967 CSWE began to acknowledge their existence through "approving" them. In 1974 CSWE undertook the for- mal accreditation of BSW curricula whose major focus, especially in the beginning, was on social welfare and social policy with little attention to direct practice. This was followed in 1969, by NASW formally recog- nizing the BSW as the first professional degree for social work. The entry level for the profession was no longer the Master's degree. Thus ac- ceptance and status were accorded the BSW qualified social workers by both the national professional social work organization, and the standard setting body for social work education.

Beginning in the '50s and growing during the '60s, a number of clinical social workers were moving into private practice. Early on NASW denied them recognition since it did not consider private practice a legitimate function of social work. Social workers in agency settings, too, were not receiving much support for direct practice from their national organization. Their interests and concerns were not being ad- dressed and they felt disenfranchised.

It was this climate that gave impetus to the "clinical movement" demonstrated by the efforts and push for validation of clinical social work through gaining state licensure, the development of state societies for clinical social work and the organization of the National Federation of Societies for Clinical Social Work. It was truly a grass roots movement that spread rapidly with enthusiasm, and brought a sense of hope to those who had come to feel that clinical practice was in its "death throes." In 1970, representatives from six states that had formed societies for clinical social work met and organized the National Federation of Societies for Clinical Social Work. Its purpose would be "to support all

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clinical social workers, to encourage high standards for education and practice, and to promote clinical social work and speak on its behalf." State societies and the Federation grew and flourished because they clearly filled the void clinical social workers had felt professionally for some time.

And, now, against this background, the history of the National Reg- istry of Health Care Providers in Clinical Social Work. As the clinical movement grew, by 1975, there was a sense of urgency about the ne- glect and erosion of educational preparation for clinical social work practice. Discussions had been continuing also about the need for a ref- erence guide for clinical social workers who would meet the professional criteria. This directory would serve to identify qualified clinical social workers "to the world" which until now had little way of distinguishing those specialists within the broad spectrum of social work. These concerns were the unifying force that gave rise to the proposal for a national registry. Although NASW undertook the process of publishing a registry, because of the prevailing attitude within their organization, however, applications for inclusion were restricted to clinical social workers who held NASW membership. The National Federation of Soci- eties for Clinical Social Work, on the other hand, wished to support a registry open to all qualified clinical social workers irrespective of organizational membership.

Publication of a National Registry was proposed at the January 1975 Board meeting of the National Federation of Societies for Clinical Social Work with the "goal of developing an independent national compendium of social workers, who by education and experience qualified as health care providers in clinical social work." This proposal by Wright Williamson was enthusiastically received and a task force appointed to explore avenues of organization and implementation of such a registry. It was natural for the NFSCSW to provide the genesis for a registry since one of its objectives was to encourage adherence to high professional standards of education and practice. Although the Registry received support from the Federation, from the beginning it was concep- tualized as autonomous and independent from the Federation or any other professional association. Qualification was the sole criterion for membership.

By late March 1975, The Registry Task Force, with Mary Montague as Chairperson, had developed a plan for implementation, and had be- gun the design of the application and materials necessary for the beginnings of the Registry. In April 1975 the first Board of Directors of the National Registry of Health Care Providers in Clinical Social Work was established with Mary R. Montague, M.S.W., Philadelphia elected president. Others, including members of the Task Force, named to the Board were Jeanne D. Caughlin, M.S.W., California, secretary; Wright

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Williamson, M.S.W., Maryland, treasurer; Bill Jett, M.S.W., Kentucky; Arnold Levin, M.A., Illinois; Helen Pinkus, D.S.W., Virginia; Crayton E. Rowe, Jr., M.S.W., New York; George Mace Summers, D.S.W., Mary- land; and Melvin Q. Thorne, Jr., M.S.W., Texas. Incorporation of the Registry was completed in June 1975, and the pioneer undertaking was officially ready to begin full scale operation. An office was established in Lexington, Kentucky. Response to the Registry was swift, greater than ever anticipated, overwhelming and certainly rewarding. There was little doubt that the need for such was timely, and the decision to publish a registry accurate. The first edition of the NRHCPCSW was published in June 1976, an Addendum in January 1977, and the second edition in August 1977. It has been published annually since then.

The first Board of Directors undertook to "chart the course" for a group to be identified as "specialists" within the broad spectrum of social work. There were philosophical considerations and decisions to be made in determining who was a "qualified clinical social worker." In ar- riving at the definition of a clinical social worker and in developing the criteria the board made several basic decisions. First, as reflected in the title, was the decision that clinical social workers are health care providers. This decision was derived from the World Health Organization definition of health as a "healthy person in a healthy society." This stance reflected a basic value of the social work profess ion. . , that of a bio-psycho-social approach to individuals, couples, families, and small groups. Since the health and welfare field are differentiated in the United States the clinical social worker operates with other health professionals as a peer. Secondly, the decision was reached that clinical social workers are differentiated from other members of the social work profession by a particular knowledge base obtained through graduate professional education that included theoretical knowledge specifically related to clinical social work with individuals, couples, families and small groups. The Board agreed that the process of becoming a clinical social worker is an arduous, time-consuming one that would not be well served by shortened educational programs, particularly in view of the ever-increasing theoretical base required for skilled clinical practice. Thirdly, the Board believed that supervised clinical experience following graduate education was essential for autonomous practice. It was further agreed that Clinical Social Work is not determined solely by the setting in which the clinician practices, but rather by the knowledge, values and competence possessed and the services rendered. These philosophical decisions became and continued to be the foundation upon which criteria for membership rested.

The early days were exciting, gratifying and arduous. There was a fervor, zeal and commitment to develop a creditable and useful directory to serve clinical social workers and consumers. We are indebted to those

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who "put their shoulders to the wheel." Particular mention must be made of the contribution of Helen Pinkus to the development of criteria for Registry eligibility. As Chairperson of the Standards Committee, she was a strong advocate for the necessity and importance of clinical education and a sound knowledge base for practice. Before her untimely death in 1978, she was instrumental in developing the educational re- quirements and standards. These were a further outgrowth of a position paper she had written earlier on "Education for Clinical Social Work at the Master's Level." Mary Montague reminds us of the efforts and contribution of the Pennsylvania Society for Clinical Social Work in getting the Registry off the ground; t ime and money were given to develop and mail brochures and design ads for social work journals. The entire board of the Pennsylvania Society volunteered to process applications, spend- ing hours and hours dealing with the excellent response due to the efforts of the Task Force. The Registry was launched and ready to move forward. A Board was appointed by the NFSCSW and "seed" money pro- vided. Wright Williamson, who was a prime mover in efforts to publish a directory, carried out his duties as first treasurer admirably; he even loaned money to the Board to move its work forward. The Board could no longer handle the growing number of applications. An executive secretary was needed. Jeanne Pollock, Philadelphia, became the first executive secretary, working out of her home. Later, as indicated, an office was opened in Lexington, Kentucky.

Of great significance, and remembered most, is the dedication of the founders, and the meaning of establishing the Registry. Crayton E. Rowe, Jr. describes "the survival feeling of hope the Registry offered." Standards had been crumbling. Clinicians worked very hard with NASW on this issue. At that time, however, NASW did not wish to support re- quirements for clinical education and verified clinical practice standards within the Master's degree. "The Registry was a symbol," accord- ing to Rowe, "from which we can learn changes come about only if you make them yourself. To sum up," he says, "the Registry was a symbol of the preservation of the profession of clinical social "work. It symbolized a prototype of how impact can be made on a profession within a profession." His memories are, as a founding member, of being part of a single-minded group of professionals. He states, "We were not discour- aged by the backward and forward steps. Failure was not considered for our efforts meant t h e survival of a profession." And thus the Registry was created, survived and grew.

As indicated earlier, NASW was in the process of publishing a register restricted to NASW membership. The National Federation of Soci- eties for Clinical Work wished to support a registry open to all qualified clinical social workers independent of organizational membership. The two were published within a few months of each other. The National

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Registry of Health Care Providers in Clinical Social Work appeared in June 1976 and the NASW Clinical Register during the summer of 1976. There were two crucial distinguishing differences in eligibility require- ments. NASW had standards for generic casework, omitting emphasis on basic clinical educational preparation and practice. Over the years the NRHCPCSW has held firmly to its standards, requiring documentation to support the clinical emphasis. Another distinguishing factor was the autonomy and independence of the NRHCPCSW. Listing in the NASW Clinical Register was tied to membership in NASW. It was not an independent entity and the ACSW was required except in states hav- ing legal regulation of social work. It should be noted that the ACSW as well as the majority of licensure laws are not indicative of clinical specialty. Licensure laws are geared toward entry-level practice and by law, the ACSW is considered a generic examination (People vs. Scala, 419 NYS 2d 555, June 20, 1985).

Over the years, the Registry Board has been sensitive to the importance of publishing a viable and useful document and serving its members well. This involved careful review of applications, review and re- finement of standards, and an evolving format giving more comprehen- sive information about its members. In the beginning, information about registrants was sparse: only name, address, telephone and Regis- try number. In the past few years, based upon the registrant's "Clinical Vitae," listings include: name of graduate school; prior and present em- ployment; state licensure, certification or registration; designation of preferred clients, methods of practice, and specialized areas of interest; post-master's clinical education; specialty certification; and membership in clinical organizations. It is a wealth of information which identifies the qualified practitioner. With the ever-increasing passage of legal regulation, it has become even more important to clearly identify clinical social workers since legal regulation identifies the social worker but not the specialist in all but two states. Standards were constantly reviewed and refined to remain in concert with changing patterns in health care delivery and educational preparation, without eroding or compromising the basic standards required for Registry membership. Edna F. Roth, Credential Review Chairperson, remarks on this in her reminiscences, along with commenting on the efforts to insure that standards were met through an extremely careful review and processing of every application and documentation of qualifications.

In January 1985, upon the occasion of its tenth anniversary, the Board reviewed its history, discussed future purposes and goals, and considered how it could best serve the needs facing clinical social workers, over the next decade, in the rapidly changing health care delivery patterns, and in the pursuit of their practice. A questionnaire was developed asking members to indicate, in order of priority, needs as they

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saw them. The responses would serve as future direction to the Board. Simultaneously 50 major corporations were also surveyed in terms of their knowledge and use of clinical social work services. The results of both surveys clearly indicated the need for a national independent certification program as the number one priority. There was also an increasing demand for a uniform standard from other users of mental heal th services, including HMO's, PPO's and other large third-party payors. To this point in the development of clinical social work there had not been a uniform national certification program. Standards ex- isted only through legal regulation on a state-by-state basis with wide variations from state-to-state.

In June 1985, the NRHCPCSW Board made a landmark decision by voting unanimously to pursue the establishment of a national certification program for clinical social workers who had achieved an advanced level of practice. In addition to lacking a uniform national standard the profession of social work did not have a national examination developed specifically for the purpose of testing advanced clinical social work practice since legal regulation primarily focused on entry-level competence. An examination would complete the "three E" t r i a n g l e . . , that of education, experience, and examination. During the next year the Board worked arduously to fulfill this commitment. Education and experience standards for advanced practice were defined and refined. The essential elements in developing an examination to measure advanced clinical practice were considered, and a contract for test development negotiated. The implementation and operation of this certification program was planned. It is sometimes difficult to imagine how the Board could ac- complish so much in such a short time, just as it is breath-taking to imagine how the first Board organized and published the first Registry in such a short time. The fervor and enthusiasm was in response to an urgent need, just as originally. Everyone worked and w o r k e d . . , dedicated and committed. On May 1, 1986, the Registry Board announced the establishment of a new e n t i t y . . . The National Board of Examiners in Clinical Social Work. This new organization would award board certification in Clinical Social work Status. to those considered advanced clinical practitioners by virtue of education, experience, and examination. This undertaking represented another historic step in the development of clinical social work as a unique health care specialty. The response to the new program was one of enthusiasm and excitement, just as when the Registry was announced.

On May 2, 1986 representatives of the National Registry of Health Care Providers in Clinical Social Work met with NASW national staff representatives to inform them of this new credential, and to seek a cooperative engagement with NASW, in the best interests of the clinical social work profession, on advanced credentialling. The NRHCPCSW

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also communicated in writ ing its interest in cooperative engagement immediately following the meeting. Shortly afterwards, in late June 1986, NASW announced its own new advanced credential, the clinical diplomate, for those listed in the NASW Clinical Register who qualified.

This led to an immediate "hue and cry" from the field objecting to the establishment of two advanced status certifications. The tenor was that there should be only one in order not to split the field and that it should be a joint effort of both the National Registry of Health Care Providers in Clinical Social Work and the National Association of Social Workers. Beginning in October 1986 and over the next several months historic meetings were held between the two organizations to explore the establishment of a new credentialling body for advanced clinicians, jointly sponsored but independent of either, to carry this program forward. It was an exciting, t ime-demanding and exhausting period. The amount of work was unbelievable, hours and hours, documents and documents, compromises and holding firm. Judi th M. Holm, President of NRHCPCSW and Co-Chair of the Joint Negotiating Team deserves a special commendation for her tireless efforts and vision in her leadership role through this period. In September 1987, another historic landmark was reached. Both the NRHCPCSW Board and the NASW Board ratified agreements establishing the American Board of Examiners in Clinical Social Work which would award the Board Certified Diplomate status to advanced clinical practitioners. It would be an independent Board administered jointly by representatives appointed from both NRHCPCSW and NASW. The first meeting of this newly created board was held in October 1987. This marks a milestone in efforts by two national social work organizations to act in concert toward the best interests of the profession.

These months were critical for The Registry Board. Primarily, it was essential to safeguard standards for clinical social work. That con- cern with standards had brought the Registry into existence and remained a hal lmark of its being over the years. To a one the Board held firmly to the essential need for standards. Compromises in high standards came around the grandparenting period, since members of both the NRHCPCSW and the NASW Clinical Register would be eligible for grandparenting and waiver of examination. There would be a group now in the NASW register who would not meet the requirement for clinical education. These people will be grandparented. Following that the National Registry of Health Care Providers in Clinical Work standards are to hold and even be strengthened.

Equally crucial, was the future of the National Registry of Health Care Providers in Clinical Work. If we were no longer to credential qualified clinical social workers which had been our "raison d'etre" what were we to do? What would be the purposes and goals of our continued

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existence? What were the needs of the clinical Social work profession? The Board seriously considered its options, and determined there were needs, other than credentialling, that, if met, could bring fuller meaning and recognition to the specialty of clinical social work and the social work profession over all. Over the years, the words research, education, and marketing visibility were repeated as unmet needs. It is important and interesting to note that the proposal to establish a registry for clinical social workers, as formulated by Wright Williamson, states that as one of its objectives, in addition to credentialling, "the Registry shall conduct research and education programs for the furtherance and pro- motion of clinical social work." Since the urgency of identifying qualified clinical social workers and setting standards was the first priority, this objective was not included in the final objectives of the Registry in order not to dilute those efforts. As time went on, the credentialling as- pects with attention to standards, and marketing, expanded information to continue its viability, and careful review did not allow the Board to add these dimensions to its purposes. However, Edna Roth frequently reminded us that there was a need for research and that the information we had collected from and about our members related to their education and practice possessed a wealth of material for research purposes. Although market ing efforts were being made constantly, the need to un- dertake a really concerted program to make clinical social work visible nationally still remained. We could consider assuming leadership not only through our own efforts, but by working in cooperation with other clinically oriented organizations toward this end. Coupled with the need for visibility is the need for education for clinical social workers and about clinical social work for others, other professions, consumers, third-payors. In summer 1987, the NRHCPCSW Board endorsed these objectives along with the major purpose to maintain and elevate the ethical, professional, and clinical standards of the specialty of clinical social work.

In November 1987, coming full circle so to speak, the Board moved to establish another new entity. The National Registry of Health Care Providers in Clinical Social Work would become the National Institute for Clinical Social Work Advancement. The purposes and objectives would be: maintaining and elevating clinical social work standards, research, visibility and marketing, and education both within and without the profession. And thus we enter the second decade of our beginnings with a new purpose and focus, but with the same underlying principles and commitment.

It is impossible to end this history without special words of recognition and appreciation to our founders and those dedicated practitioners who served on the Board over the years. Without their steadfastness of purpose, commitment and tireless efforts we could not have become a symbol for clinical social work and a unifying force.

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REFERENCES

Hollis, F. (1982). Forward in F. Lieberman (Ed.), Clinical social workers as psychother- apists. New York: Gardner Press.

Lieberman, F. (1985). National Federation of Societies for Clinical Social Work, Newslet- ter, Vol. 5, No. 5, Summer, 1985.

Documents

The history and metamorphosis of the National Registry of Health Care Providers in Clinical Social Work