What Social Work Is Actually Like

When people hear "child welfare," what do they picture?

They picture me taking children away from their parents. That's what everyone thinks. And yes, that happens. I've done emergency removals. I did one six weeks ago. But removals are maybe 5% of the job. The other 95% is trying to prevent them. I show up at homes and I assess whether a child is safe. I connect families to services. Substance abuse treatment, parenting classes, domestic violence resources, housing assistance. I write case plans. I check in every two weeks, sometimes every week. I sit in Family Court and tell a judge what I've observed. I call therapists and teachers and pediatricians and try to build a picture of what's happening in a home based on what 8 different people can tell me, most of whom have incomplete information.

My caseload right now is 18 families. The state recommends 12. We're short-staffed. Everyone in this office is carrying at least 15. My supervisor, a woman named Portia, has been here 11 years and she says the caseload was 10 when she started. She's watched the numbers climb every year since 2018. Nobody new is coming in because the salary is $42,000 and you need a master's degree. Do the math on that and tell me why we can't recruit.

Walk us through how a case starts.

We get a report through the hotline. Could be a teacher, a doctor, a neighbor, sometimes a family member. The report comes to our intake unit and they screen it. If it meets the threshold for investigation, it gets assigned to a caseworker. Me, if it's in my zone. I cover a section of Durham that includes a few neighborhoods east of downtown, some suburban areas near Research Triangle Park, and a trailer park off Old Oxford Highway.

Last Thursday I got a report at 9:15 AM. Teacher at a Title I elementary school reported that a 7-year-old, I'll call her the child, had come to school three days in a row in the same clothes, hadn't had breakfast, and told her teacher that nobody was home when she woke up. The teacher called the hotline. Report came to me. I had 24 hours to make initial contact.

I drove to the school first. Talked to the teacher, a woman named Ms. Overby, who'd been at that school for six years. She gave me specifics. The child was wearing a pink hoodie with a stain on the front. She'd been taking extra milk cartons at lunch. She'd fallen asleep in class twice this week. Ms. Overby said the mother was engaged at the beginning of the year, came to conferences, signed the reading log. Something changed around November.

What happened when you went to the home?

I went that afternoon. Two-bedroom apartment in a complex off Angier Avenue. Knocked on the door. Nobody answered. Knocked again. A woman opened the door, maybe mid-30s, wearing scrubs. She looked tired. Not hostile, just tired. I introduced myself, showed my ID, explained that we'd received a report and I was there to check on the child's well-being. The mother, I'll call her the parent, let me in. The apartment was cluttered but not unsafe. There was food in the kitchen. The child's room had a bed with sheets. No obvious hazards.

What came out during the conversation was that the mother had started working nights at a nursing home in October. She was doing 11 PM to 7 AM shifts four nights a week. She'd been having her boyfriend watch the child at night but they'd broken up in late November and now there was no one. She was leaving the child alone from about 10:30 PM, when the child was asleep, until 7:20 AM when the child walked to the bus stop. The child is seven. She'd been doing this for about three weeks.

That's inadequate supervision. It's also a 34-year-old woman trying to keep a job that pays $16 an hour and not having any other options. She didn't have family in Durham. She'd moved from Fayetteville after the breakup with her ex. Her mom was in Lumberton, which is two hours away. She was alone, working nights, and she'd made a decision that she knew wasn't right because the alternative was losing the job and the apartment.

So what do you do with that?

I don't remove the child. This is not a removal situation. The child isn't in immediate danger. What I do is open a case, develop a safety plan, and connect her to services. The safety plan says: the child cannot be left unsupervised overnight. Period. The mother needs to arrange childcare or adjust her schedule. I gave her three referrals: a subsidized childcare program that covers odd hours, a community resource center that has a family support navigator, and a number for the local YWCA that runs a crisis childcare line.

Then I wrote the whole thing up. The initial assessment report is a 14-page document in our system, NC FAST. I documented the home visit, the observations, the conversation, the safety plan, the referrals. That took about two and a half hours. The home visit itself was 50 minutes. The documentation was three times longer than the visit. That ratio is, honestly, pretty standard. I spend more time writing about what I did than doing it.

You've been here three years. That's longer than average for child welfare.

The average tenure in our office is about 18 months. In the three years I've been here, I've watched maybe 20 people leave. Some went to other agencies. Some went to clinical work. Some left social work entirely. A woman I started with, Denise, she went to a medical device company doing sales. She makes $85,000 now. She told me she doesn't think about work at 11 PM anymore. I think about that sometimes.

I stay because, I don't know how to explain this without it sounding like a bumper sticker, but when I go back to that apartment two weeks later and the mother tells me the childcare program started and the child isn't alone at night anymore, that's real. That's a thing I did. The referral I made connected to a service that solved a problem that was putting a child at risk. The system worked. It doesn't always work. But when it does, you feel it in a way that, like, I don't think you feel in most jobs. Denise doesn't feel that selling medical devices. I asked her. She said, "No, but I sleep better." Fair enough.

What's a bad day?

A bad day is when I show up at a home and I know within 30 seconds that this child isn't safe, and I have to figure out in real time what to do about it. I did a removal in February. I can't give details. But the short version is: the report was for physical abuse, I arrived at the home, the child had injuries that were consistent with the report, and I had to call law enforcement and initiate an emergency removal. The child went to a foster placement that night. I filled out the paperwork until 9:30 PM. I drove home, ate cereal at my kitchen counter, and called my mom. My mom is a preschool teacher in Raleigh. She didn't say much. She just listened. That's all I needed.

The next day I had 17 other families to manage. The removal didn't stop the clock on anything else. That's the part nobody prepares you for. You do the hardest thing you've ever done professionally, and the next morning you're back in the Malibu driving to the next house. There's no debrief. There's no mental health day. Portia checks in. She asks, "Are you OK?" and I say yes because what am I going to say? No? She's carrying the same weight.

What's yours?

How much of the job is driving. I drive, like, 800 miles a month in that Malibu. From the office to homes to schools to the courthouse to service providers and back. Some of those drives are 40 minutes each way to get to a rural address outside the city. And in the car, alone, that's when the day hits you. Not in the home, because in the home you're in work mode. You're observing, you're documenting, you're staying professional. It's in the car, on the way back, when you replay what you just saw. The pink hoodie. The milk cartons. The seven-year-old walking to the bus stop alone in the dark. You can't talk to anyone about it because of confidentiality. You can't call a friend and say "let me tell you about my day." You sit in the car and you process it alone on I-85 and then you pull into the office parking lot and you walk in and you start the documentation. The driving is the only time the feelings are allowed to exist. The rest of the time, you're writing a report.

62 clients. How does that work?

It works badly. I'll be honest. The recommended caseload for outpatient clinical work is about 30 to 40 clients. I'm at 62. That happened gradually. Three years ago I was at 45, which was manageable. Then we lost two clinicians. One got a private practice going and left. The other moved to Colorado. The center didn't replace them for eight months because the salary, $54,000 for an LCSW in Tucson, doesn't attract a lot of candidates when private practice pays $90 to $120 an hour. So their caseloads got distributed to the remaining clinicians. I absorbed 12 of those clients, which put me at 57. Then new referrals kept coming in and the waitlist hit 14 weeks and the clinical director, a psychologist named Dr. Morales, asked if I could take a few more. I said yes because the alternative was telling a 19-year-old with suicidal ideation to wait three more months.

At 62, I see each client every two to three weeks instead of weekly. Some clients who need weekly sessions are getting biweekly. That's a clinical compromise. I'm providing adequate care, not optimal care. The difference between those two words is the thing I think about at night.

What does a typical day look like?

I see 7 to 8 clients a day, sometimes 9. Each session is 53 minutes. I have a 7-minute window between sessions to write a progress note, use the bathroom, refill my water, and mentally shift from one person's world to another's. That transition is, honestly, the hardest part of the day. At 10 AM I'm sitting with a woman in her 50s working through grief after losing her husband. At 10:53 I say goodbye. At 11 AM I'm sitting with a 24-year-old man who's on probation for a DUI and is court-mandated to attend therapy and does not want to be in my office.

Those are two completely different therapeutic relationships. The grief client needs warmth, reflection, space to feel. The court-mandated client needs structure, directness, someone who isn't going to judge him but also isn't going to let him coast. I have to shift between those two modes in 7 minutes. Sometimes I don't fully make the shift. I catch myself being too soft with someone who needs confrontation, or too direct with someone who needs gentleness. When that happens, I adjust mid-session. But the fact that it happens at all tells you something about the pace.

You said 14 of your clients are court-mandated. Is that different?

Very. Court-mandated clients don't choose to be there. Some of them are upfront about it. A guy I see on Tuesdays, I'll call him the Tuesday client, he told me during our first session, "My PO says I have to be here for six months. I'm going to sit in this chair and be pleasant and then I'm done." I said, "OK. Let's figure out how to make those six months useful." That was in August. We're eight months in and he's voluntarily extended. Not because I'm a genius therapist. Because I didn't fight him. I let him be resistant and I met him where he was and eventually, around month four, he started talking about his daughter and what it was like to miss her second birthday because he was in jail. He wasn't mandated to discuss that. He chose to.

That's the version that works. The version that doesn't work is the client who shows up, says as little as possible, watches the clock, and leaves. I have three or four of those. They complete the mandated hours and they leave and I never know if anything happened in that room that mattered. My supervisor when I was starting out, a woman named Corinne at a different agency, she told me, "You plant seeds. Some of them grow after they leave." I hold onto that. Some weeks more than others.

What about the documentation?

Each progress note takes about 8 to 12 minutes. I see 7 to 8 clients a day. That's roughly an hour and a half of notes. Plus treatment plan updates, which are due every 90 days for each client, and each one takes about 25 minutes. Plus intake assessments for new clients, which take 90 minutes for the session and another 45 for the documentation. Plus supervision notes for the two interns I supervise, Hana and Josue, which is another hour a week. Plus the crisis documentation when a client calls the crisis line and I have to follow up, which happens maybe twice a month.

Our documentation system is called Credible. It's an electronic health record. It's fine. It does what it does. But there are about 40 fields per progress note and some of them feel redundant. I have to document the client's presenting mood, the interventions used, the client's response to interventions, progress toward treatment goals, a plan for the next session, and a risk assessment. Every session. Even for the client I've been seeing for three years for mild generalized anxiety who is doing well and whose sessions are basically check-ins. I still have to document that I assessed for suicidal ideation. I did. The answer was no, as it has been for 36 consecutive sessions. But I document it because if I don't and something happens, the question will be "did you assess?" and my documentation is my only evidence.

Is this the career you expected when you got your MSW?

I thought I'd do more therapy and less paperwork. That's the honest answer. When I was in my MSW program at ASU, the clinical courses were about theories and techniques. Motivational interviewing, CBT, trauma-informed care. The courses were not about Credible and treatment plan updates and insurance pre-authorizations. I spend, realistically, about 55% of my day doing things that are not therapy. Documentation, coordination, phone calls to psychiatrists, calls to probation officers, supervision, staff meetings. The therapy part, the part I trained for and the part that drew me to this career, is about 45% of my time. I'm good at that 45%. I think I make a real difference in people's lives during that 45%. The other 55% is the infrastructure that allows the 45% to exist. I've accepted that. But I didn't go to grad school for the infrastructure.

What's yours?

How much of clinical social work is absorbing stories that you cannot share with anyone. I sit in a room and people tell me the worst things that have happened to them. Abuse, assault, loss, violence, the things they've done and the things done to them. And I hold those stories. That's, like, that's the job description. Hold the stories. Create a space where someone can say the unsayable. And then I go home and my partner, a guy named Felix who teaches sixth-grade science, asks me how my day was. And I say, "It was OK." Because I can't tell him what happened in that room. Not the specifics, not even the general themes most of the time, because if I start talking about trauma at the dinner table, I'm bringing it into our home. So the stories live inside me. I go to my own therapy every two weeks, and I process what I can. But there's a layer of other people's pain that just kind of accumulates over the years, like sediment. You learn to carry it. The people who don't learn to carry it leave. And the fact that the profession selects for people who can absorb suffering without breaking is, I don't know, I've thought about whether that's resilience or whether it's something else that we're calling resilience because the alternative label is less flattering.

What do people get wrong about hospital social work?

They think I'm a therapist who works in a hospital. I'm not. I do very little counseling. My primary function is discharge planning. A patient comes in, they receive medical treatment, and at some point the medical team says "this person is ready for discharge." My job is to figure out where they go. That sounds simple. It is not simple. Where a person goes after a hospital stay depends on their insurance, their housing situation, their support system, their mobility, their cognitive status, their substance use history, their immigration status, their ability to manage medications, and about 15 other variables that the medical team often doesn't have time to assess. I assess them. Then I make calls. A lot of calls.

Yesterday I worked on the discharge plan for a 58-year-old man who'd been hit by a car while walking on North Avenue. He came in by helicopter on a Saturday night with a traumatic brain injury, a fractured pelvis, and a broken femur. He was in the surgical ICU for six days, then transferred to a step-down unit. He'd been on my unit for four days when I got involved. The trauma attending, Dr. Okeke, told me the patient was medically stable and could be transferred to a rehab facility. My job: find a rehab facility that has a bed, accepts his insurance, and can handle his level of care. His insurance is Medicaid. And that's where the work begins.

What happens with Medicaid?

Medicaid covers inpatient rehab, but not every facility accepts it, and the ones that do have waitlists. In Baltimore, there are about eight skilled nursing facilities and three inpatient rehab centers that take Medicaid. I called all of them. Six had no beds. Two had beds but couldn't accept a patient with his level of TBI because they didn't have the neuro-rehab staffing. The inpatient rehab centers had beds but required a pre-authorization from Medicaid that takes 48 to 72 hours to process. So this man, who the doctors say is medically ready to leave, is going to stay in a hospital bed for three more days because the insurance authorization is pending and the facilities that don't require authorization don't have beds.

That's a $4,200-a-day hospital bed. Three days of it. $12,600 in hospital charges because the community infrastructure can't absorb him fast enough. I did not go to social work school to do health insurance logistics. But that is easily 40% of my job.

What about the patients who don't have anywhere to go?

That's the other 40%. The patient who was homeless before the accident. The patient whose family says they can't take them back. The patient who was living in a group home that won't readmit them because of new behavioral issues caused by the TBI. Last month, I had a 23-year-old gunshot wound survivor who'd been on my unit for three weeks. He was medically cleared for discharge on day 12. He stayed until day 21 because he was homeless, had no Medicaid yet because his application was pending, and no shelter in Baltimore could accept a patient in a wheelchair. I called 11 shelters. I called the Baltimore City Health Department. I called the VA even though he wasn't a veteran because sometimes they have overflow resources. Nothing.

On day 19, I got him into a transitional housing program through a nonprofit called Marian House that had a wheelchair-accessible unit. The intake coordinator there, a woman named Bev, had to pull strings to get him in because technically he didn't meet their eligibility criteria. Bev has taken my calls at least 30 times over the years. She knows when I call it means I've already tried everything else. She said, "How bad is it?" I said, "He's been in a hospital bed for 19 days because nobody has a ramp." She said, "Send me the paperwork." That's how it works. You build relationships with the Bevs. You call the Bevs. The Bevs are the system working in spite of itself.

You've been doing this for 16 years. How has it changed?

When I started at this hospital in 2010, the average length of stay for a trauma patient was about 5 days. Now it's closer to 7. The medical care hasn't gotten slower. The discharges have gotten harder. Fewer rehab beds, longer insurance authorizations, more patients with complex social situations. Homelessness in Baltimore is worse than it was in 2010. The opioid crisis created a population of patients who need both medical and substance treatment and there are almost no facilities that do both. The number of patients I see who have nowhere to go after discharge has, I'd estimate, tripled in 16 years.

The hospital has hired more social workers, I'll give them that. When I started, we had 6 covering the whole hospital. Now we have 14. But the acuity has outpaced the staffing. Each of us carries about 20 to 25 active patients at any time. I cover trauma and surgical ICU, which is the highest-acuity unit. My colleague Russ covers med-surg. Another colleague, Yael, covers the ED. Yael's job is the hardest in the building because she has to do assessments and disposition planning in real time, in a hallway, with no advance notice. I at least get a day or two to work a case. Yael gets 45 minutes.

What keeps you here?

The morning rounds. Every morning at 7:30, I join the trauma team for rounds. We go bed to bed. The attending, the residents, the nurses, the pharmacist, and me. They discuss the medical plan. Then they look at me and say, "Soledad, where are we with discharge?" And I give them the update. The bed is confirmed at the rehab facility. The Medicaid auth came through. The family is picking him up at 2 PM. Whatever it is. And when I say "the patient is going home today," there's this brief moment where the whole team nods. The bed frees up. A new patient can come in. The system moves forward by one person. That's not dramatic or cinematic. It's a nod. But 16 years of nods add up to a career. Every nod means a person left the hospital alive and went somewhere that could take care of them next. That's enough for me. Most days.

What's yours?

That the families are harder than the patients. The patients are usually medicated, or in too much pain to argue, or unconscious. The families are wide awake and terrified and they want answers I don't have. The wife who asks, "When can he come home?" and I have to say, "He's going to a rehab facility first, and we don't know for how long." The mother who asks, "Why can't he stay here until he's better?" and I have to explain that the hospital isn't a long-term care facility and that his insurance won't cover additional days once he's medically stable. The adult child who drives in from Philadelphia and says, "Nobody told me any of this," and they're right, because communication between the medical team and the family is fragmented and I'm often the first person who sits down and explains the full picture.

I've had family members scream at me. I've had family members cry on me. I've had a family member threaten to call a lawyer because I told them their father was being discharged to a skilled nursing facility instead of going home. Their father had a spinal cord injury and couldn't transfer out of bed independently. Going home wasn't safe. But telling a daughter that her father can't go home, that's a conversation that breaks something, and I'm the person who has that conversation. Not the doctor. The doctor says, "Your father needs a higher level of care." I'm the one who says, "Here are the three facilities that have beds. Let me walk you through the options." The doctor delivers the news. I deliver the reality. And the reality is the part people get angry about.