_________ Terra Rosten, MSW, MPH, Linkage and Retention in Care Coordinator, University of Colorado Health Infectious Diseases Group Practice, Georgianna Gaitan, LMSW, MSW, Family Advocate II, Ron Wood Family Resource Center, Pari Shah, LCSW, PhD Candidate, Graduate School of Social Work, University of Denver, and N. Eugene Walls, PhD, Professor, Graduate School of Social Work, University of Denver, Denver, CO. Copyright © 2022 Authors, Vol. 22 No. 1 (Spring 2022), 110-132, DOI: 10.18060/25561 This work is licensed under a Creative Commons Attribution 4.0 International License. Social Work Practice in the Time of Quarantine: A Photo Elicitation Study of Experiences of Remote Work during COVID-19 Terra Rosten Georgianna Gaitan Pari Shah N. Eugene Walls Abstract: Using quantitative, qualitative, and photographic data that were collected early in the COVID-19 pandemic, this study examined the reflections of ten U.S. social workers on their experiences migrating to remote service delivery. Participants were asked to share strategies, opportunities, coping mechanisms, self-identified professional values, and pre- dictions for the future of social work. Three primary themes - professional flexibility and creativity, connection, and recentering generalist social work skills – emerged with nu- merous additional subthemes. The study’s findings underscore the critical importance of contextualizing service delivery moving forward – neither adopting a one-size fits all ap- proach for the sake of financial efficiencies nor failing to incorporate the lessons learned during the pandemic. As such, service delivery systems should adapt in such a way as to incorporate increased flexibility in meeting client needs. Keywords: Social work, COVID-19, pandemic, telehealth, remote service delivery, photo elicitation In the early spring of 2020, many Americans were overwhelmed with fear about their health and economic stability as a result of the COVID-19 pandemic. Confronted with quarantine regulations and isolation from others, U.S. residents were tasked with exercising protective behaviors and avoiding risk-related activities for their safety and the safety of those around them (Twenge & Joiner, 2020). In the months that followed, millions of U.S. residents lost income or employment resulting in hardship even meeting primary needs such as paying for housing or other essentials (Orgera et al., 2021). The onset of stress during disease outbreaks can result in the exacerbation of existing mental health conditions and chronic illnesses as well as an increase in the use of addictive substances (Panchal et al., 2021). Social isolation as a result of public health quarantines can additionally increase the risk of adverse mental health consequences, such as depres- sion and anxiety (Tulane University, 2020). During the current public health crisis, the drastic rise in mental health diagnoses, symptoms, and emergency healthcare usage has raised the question of whether sufficient resources have been deployed (Walter-McCabe, 2020). One way in which many health care providers can respond to community health and social service needs during pandemics is through a shift to remote service delivery. How- ever, for the delivery of efficient and effective health care and social services, scholars have emphasized the importance of therapeutic presence and its components (Crawford, about:blank Rosten et al./SWK PRACTICE 111 2021). To preserve therapeutic presence, the attributes of compassion, validation, and em- pathy must be integrated into remote practice (Crawford, 2021). Fortunately, technological advances have enabled social workers and other professionals to interface with clients through audio and visual expression that, at a minimum, can emulate these necessary at- tributes (Geller, 2020). Remote service delivery is not, of course, without its issues. While certain populations may find remote service delivery favorable, including individuals who struggle to arrange transportation for service visits or individuals living in rural areas (Cristofalo, 2021; Hedrick et al., 2022), other populations may not have the resources (i.e., internet), equip- ment (i.e., computer/phone), or environment (i.e., stable housing) to accommodate appoint- ments through remote delivery options (Cristofalo, 2021; Funk, 2021). Further, specific populations may have barriers relating to language and communication, such as individuals who are hard of hearing or individuals who rely on language interpretation services (Cris- tofalo, 2021; Lew et al., 2021). These populations may be burdened by the process of con- necting with social workers through electronic and distance mediums. There is the addi- tional concern that remote assessments can become more complicated if clients are man- aging crises relating to behavioral health or domestic violence (Cristofalo, 2021). As the rise in telehealth as a medium of service delivery is not expected to decline in the near future (Crawford, 2021), social workers have been encouraged to take on the perspective of populations in need when deliberating how remote service delivery should be facilitated (Cristofalo, 2021; Spelten et al., 2021). Social Work’s Role during the COVID-19 Pandemic As was the case with the current pandemic, national emergency response plans in the U.S. have historically included social workers in their frontline staff to implement mental health services, to manage distress, and to relay accurate information to community mem- bers (U.S. Department of Health & Human Services [US DHHS], 2005). As such, social workers – as part of the essential workforce – have continued to support clients and com- munities during the COVID-19 pandemic. In response to the pandemic, the National As- sociation of Social Workers (NASW, n.d.) strengthened the use of remote service options, such as telehealth appointments, to reduce the likelihood of virus transmission while also sustaining social workers’ ability to continue to deliver services. Policy amendments were necessary to enable telehealth to be utilized to expand service access and to avoid service disruption (US DHHS, 2020). Consequently, the discipline is beginning to understand the potential of telehealth to advance service delivery, when its use is suitable, and how it should be delivered. In addition to remote service delivery during the COVID-19 pandemic, social workers have not lost sight of vulnerable communities and have continued to offer care and respond to critical client and community needs (Redondo-Sama et al., 2020). Many social workers have been a lifeline to older patients living in facilities with visiting restrictions as well as to hospice patients. Social workers have continued to visit these patients as permitted, of- fering connection and comfort (Gewirtz, 2020). To address the issue of food insecurity among children and youth, social workers have organized alternative lunch programs for ADVANCES IN SOCIAL WORK, Spring 2022, 22(1) 112 students who previously depended on school-provided meals (Gewirtz, 2020). As scholars have highlighted and these examples demonstrate, social workers are applying the values of the profession (e.g., compassionate service, importance of human relationships, and so- cial justice) to continue to deliver essential services during the public health crisis brought on by the pandemic (Kamnitzer et al., 2020). Gaps in Current Research As the social work workforce has been preoccupied with attending to emergency con- ditions and the urgent needs of patients and clients, and many in the social work academy have been focused on shifting teaching and research to an online format, it is not surprising that the literature on the practice of social work and the experiences of social workers dur- ing the COVID-19 pandemic has primarily been commentary pieces (e.g., editorials and letters). Nevertheless, the lack of empirical studies limits the discipline’s ability to adapt practice for the current and future pandemic environments. The absence of studies address- ing the profession’s response to COVID-19, including representation and discussion of social workers employed in fields in numerous practice areas (e.g., child welfare and school-based social workers) also presents a gap within current literature (Redondo-Sama et al., 2020). Finally, even though many practitioners have been forced to migrate to remote service delivery by necessity, an evaluation of the ongoing utility of mechanisms (e.g., telehealth), particularly in response to the needs of diverse populations, is largely absent. The purpose of the current study was to investigate how social workers have adapted prac- tice during the pandemic, to explore how social workers perceive shifts in their professional role, and to understand what social workers are considering as the possible long-term out- comes of the response to COVID-19 on the discipline. Method As the pandemic necessitated drastic changes in the delivery of social work education in early 2020, one co-author who is a faculty member in a school of social work joined with colleagues in raising questions about how best to support practitioners and graduate level interns in continuing to deliver critical services when face-to-face contact was no longer an option. Extant literature on telehealth services was primarily limited to certain practice areas, and, even then, did not address how to effectively navigate required and urgent shifts to remote service delivery. This gap in the existing scholarship motivated one co-author to develop a research project to capture data as these processes were unfolding in the discipline to better inform social work practice, and to integrate students into the project to support their research skill development as well as to help inform these processes in their own emerging practice careers. Project co-authors represent one MSW student, one MSW-MPH student, one PhD student, and one faculty member. While the project team embodies diversity in terms of race/ethnicity, gender, sexual orientation, age, geographic location, years of practice experience, and practice area interests, all team members iden- tify as cisgender, non-disabled, and U.S. citizens. The use of photographic data to enhance qualitative interviewing is a methodological approach known as photo elicitation (Thomas, 2009) and has been used successfully in a Rosten et al./SWK PRACTICE 113 wide range of research studies (Mannay, 2013). Photo elicitation integrates visual images that capture metaphoric responses to the research questions into the interview process. The use of these visual images engages the parts of the human brain that process visual infor- mation which are different and evolutionarily older than the parts of the brain that process verbal information. This combination of images with words evokes “deeper elements of human consciousness than do words” alone (Harper, 2002, p. 13). As the goal of the project was to co-create knowledge with social work practitioners and to deepen those practitioners’ reflections on the issues they experienced as they under- took the migration to remote service delivery, the decision was made to use photo elicita- tion. Using this approach allowed the project to capitalize on photo elicitation’s benefits that result in strengthening the rigor of qualitative research. It allows for triangulation of data and can bring additional insights that interviews alone may not garner (Bigante, 2010). During the interview process, images can evoke powerful emotions and memories that add depth and layers to the engagement with the participant (Harper, 2002). Finally, the inter- view in photo elicitation is a collaborative process between the participant and researcher and fosters joint creation of knowledge (Glaw et al., 2017). While photographs can be generated by either the researcher or by research participants in this approach, having participants photographing their own images can increase partici- pant comfort in the interview process as they know beforehand what the content of the interview will be focused on (Glaw et al., 2017). This approach also gives respondents more power to direct the interview process (Noland, 2006). Methods and Procedures Data for the study were collected early in the COVID-19 pandemic, between March and July of 2020. Announcements about the study were posted on social media focused on social work and shared through the authors’ professional email lists. Interested participants were contacted by one of the project researchers and provided additional information about the study, given an explanation of what participation would entail, and given an opportunity to ask questions. From there, participants who agreed to proceed were emailed a link to an online survey that secured the informed consent, gathered basic demographic data, and collected information regarding the participant’s perspectives on shifting to remote service delivery. Once consent was received and the participant had completed the online survey, a 1:1 meeting was scheduled with a project researcher during which information regarding the primary research questions, logistics of taking photographs and developing captions were discussed, and information was shared about how to upload photographs and captions to a secured data storage site. We asked participants to take their photographs and develop their captions over the period of the two weeks following their 1:1 meeting. In terms of captions, participants were told, “For each of the photographs included in the project, you will decide on a caption or brief narrative about the photograph that explains how the photograph an- swers the research question to you.” ADVANCES IN SOCIAL WORK, Spring 2022, 22(1) 114 Once participants completed the process of taking and uploading photographs and had developed captions for each photograph, an open-ended interview was scheduled. In the qualitative interviews, participants were debriefed on their experience and invited to dis- cuss their photographs and finalize their captions. The photographs were used as prompts around which to engage the participant. The debriefing interviews lasted from 30 to 90 minutes, were conducted by the two MSW coauthors, and recorded via Zoom. The Zoom meeting recordings were automatically transcribed by the software, but pro- ject researchers reviewed the transcripts while viewing the recorded interviews to correct any mistakes in the transcription. Data for the study included the completed online survey that captured both demographics and general perspectives about shifting to remote service delivery, the photographs taken and their corresponding captions, and the transcripts from the interviews. The University of Denver institutional review board approved the study. Analytic Sample A total of 14 social workers indicated interest in participating in the study. Of those, 2 did not complete the consent process, while 2 others completed the consent process and online demographic survey but did not respond to requests for the initial 1:1 project meet- ing. The final analytic sample for the project consists of ten social workers whose modality of service delivery was primarily face-to-face prior to the advent of the COVID-19 pan- demic and whose modality shifted to at least some remote service delivery in response to the pandemic. While the authors’ networks include professionals involved in many areas of social work practice, most are employed in community-based service delivery with sig- nificant representation in health-related and child welfare-related areas of practice. This pattern of representation is reflected in the final analytic sample where 60% (n=6) of re- spondents were in a health-related sector, 30% (n=3) in child welfare, and 10% (n=1) in services for older adults. All respondents are U.S.-based practitioners. Measures A number of closed-ended questions were asked on the online survey to understand the context of service delivery. To capture the modality in which services were primarily delivered prior to the COVID-19 pandemic, participants were asked, “Prior to the COVID- 19 pandemic and quarantine, which of the following best describes the format that you provided services? Online/remote format can include delivery of services by telephone, videoconferencing, and other online platforms such as Zoom, Skype, etc.” Next, partici- pants were asked, “Prior to the COVID-19 pandemic and quarantine, which describes your plans for the future format of delivery of social work services?” To understand how pre- pared the participants felt, they were asked, “How prepared would you say you were to shift services to an online/remote service delivery format?” Finally, to assess the ease at which the shift in service delivery was made, participants were asked, “Now that you have been required to shift to an online/remote service delivery format because of the COVID- 19 pandemic and quarantine, which best describes how you would rate that experience?” All questions had Likert-type scale response sets (e.g., ranging from (1) not at all prepared Rosten et al./SWK PRACTICE 115 to (4) very prepared, and ranging from (1) much easier than I thought it would be to (7) much harder than I thought it would be). Four open-ended survey questions were also asked initially of participants. They in- cluded, “Briefly describe your perspective on shifting to an online/remote service delivery format PRIOR to the COVID-19 pandemic and quarantine. For example, when you thought about shifting to an online/remote service delivery format or increasing your use of online/remote formats for service delivery, were you excited about it, anxious about it, resistant to it, etc.?”, “Briefly, what has been the most POSITIVE aspect of shifting to an online/remote service delivery format for you?”, “Briefly, what has been the most NEGA- TIVE aspect of shifting to an online/remote service delivery format for you?” and “Are there any things that you would like us to know about your shift to an online/remote service delivery format?” Finally, during the initial information session, participants were given the five primary research questions that they were to answer using photographs and cap- tions (see Table 1). Table 1. Photo Elicitation Guiding Questions 1. What strategies have you used to shift your in-person delivery models to distance/ remote/ online delivery models? 2. How has the shift to distance/remote/online delivery affected your understanding of your role in the lives of your clients and your value as a social worker? 3. What unique opportunities have presented themselves either directly or indirectly related to the changes you have had to make to deliver services in a distance/remote/online approach? 4. How have you coped with the experience of migrating to distance/remote/online services in such a quick manner? 5. What long-term impact do you think the required changes related to the COVID-19 pan- demic will have on the discipline of social work? Data Analysis Responses to the close-ended online survey questions were examined using descriptive statistics. Qualitative data from the online survey and from the debriefing qualitative inter- views (both photographic data as well as transcripts from the discussion) were organized by questions asked prior to coding. All four co-authors were involved in data analyses. We used a domain analysis (Spradley, 1979) methodology to code and highlight themes found in the qualitative and open-ended survey data. Domain analysis is a qualitative approach that emerged out of ethnographic research and seeks to understand larger units or clusters of knowledge and is an approach that can be used for different source types of data (Onwuegbuzie et al., 2012). While the responses were organized by question asked, no a priori assumptions were made, and responses were examined for emergent themes across the various questions. Four total coders were involved to decrease researcher bias. All the qualitative and photo- graphic data from each question were reviewed and coded independently by a combination ADVANCES IN SOCIAL WORK, Spring 2022, 22(1) 116 of two of the four research team members. From there, each pair met to identify any dis- crepancies in their coding, combine coding categories that were similar, and identify pre- liminary themes and theme definitions. Following that process, the full research team met to discuss the codes and preliminary themes that emerged to identify commonalities across respondents until consensus was reached among team members on the final themes and their definitions. A clinical social worker was brought onto the team to support analysis and enhance clarity of the data and themes as they relate to practice. Photographic data were examined in relation to the textual themes that emerged, and exemplars were chosen to best illustrate those themes. Results Descriptive Characteristics of Sample All study participants identified as female, with experience in social work practice ranging from 6 to almost 27 years and a mean of 10.7 years. The majority of participants reported having an MSW degree (80%, n=8) with the remaining two having a BSW. Par- ticipants ranged from 30 to 49 years old with a mean age of 39.7 years. In terms of service delivery modality prior to the pandemic, 40% (n=4) indicated that all services were delivered in a face-to-face format, 30% (n=3) indicated that services were delivered mostly in a face-to-face format with minimal delivery in a remote format, and 20% (n=2) indicated a 50/50 split between face-to-face and remote service delivery. The participant in aging services indicated a response of other and noted that home visits were done once a year in each client’s home. All participants indicated that they were not plan- ning on any shifts in service delivery modality prior to the occurrence of the pandemic. In response to how prepared they felt to shift services to a remote delivery modality, the largest group (50%, n=5) indicated that they were “slightly prepared.” Twenty percent (n=2) reported they were “not at all prepared” and 20% (n=2) reported that they were “somewhat prepared.” Only one of the participants (10%) reported being “very prepared.” Finally, in response to how difficult they would rate the experience of having shifted to remote service delivery, the largest group (40%, n=4) reported that the shift was “much harder” than they had thought it would be, followed by 20% (n=2) reporting that the shift was “much easier” than they had thought it would be. The remaining four participants were evenly spread across the remaining four categories from “somewhat easier” to “somewhat harder.” Themes Turning now to the overarching themes that emerged from the narrative data, we iden- tified three primary themes across responses from the various questions: professional flex- ibility and creativity, connection, and recentering generalist social work skills. Within each of these overarching themes, a number of subthemes emerged. Some of these subthemes address the way in which social workers migrated to remote services and adapted service delivery, some addressed lessons that emerged in delivering services in a remote format, Rosten et al./SWK PRACTICE 117 and some raised concerns about the way in which the discipline moves forward. Themes and subthemes are summarized in Table 2. Professional Flexibility and Creativity Social workers in the study illustrated the importance of flexibility across numerous domains in their work during the shift to remote service delivery. This included being cre- ative and flexible in the way they assessed, intervened, and evaluated their work with their clients. Table 2. Summary of Themes and Subthemes Theme Subtheme Definition Professional Flexibility and Creativity Assessment Manner in which assessment of clients shifted, including who the primary client was and a needed shift to focus on primary needs Intervention Manner in which service delivery shifted as well as how resources needed for service deliv- ery were deployed Evaluation Critical questioning that emerged regarding complexity of system requirements that im- peded service delivery, including ideas about future of service delivery Connection With colleagues and other professionals Shifts that occurred in day-to-day relationships with one’s professional network With family and to self Shifts and increased flexibility that occurred as result of impact of remote service delivery With clients Shifts and boundary changes in social worker- client relationship that emerged as clients in- creased awareness of social worker’s life out- side of work context Recentering Generalist Social Work Skills Attending to basic needs Necessity of responding to increased client need around basic issues of living regardless of other job responsibilities Loss Prevalence of pandemic-related issues of grief and loss in work with clients Assessment. The participants shared that the ways in which they had to assess their clients shifted. First, for some, who they considered to be their client changed due to the pandemic. For example, if a social worker’s primary client was a patient in the healthcare setting and the pandemic created a barrier between the social worker and patient, the pri- mary client shifted to the family members. One participant noted, “Right now our role has shifted, you know, we're not able to really provide patient care. It shifted to more mostly...family support as most of...our patients have cognitive impairments.” Next, assessment shifted from mental health work to a prioritization of clients’ basic needs and physical health safety. For example, one social worker reported, “I would say linking patients to food in record numbers," and also noted, “I am getting multiple calls a ADVANCES IN SOCIAL WORK, Spring 2022, 22(1) 118 day to help with linkage to unemployment claims, insurance claims, and I'm getting them from a lot of doctors who are feeling overwhelmed.” Intervention. The way in which social workers were intervening with their clients during the transition to remote delivery of services required the social workers to be flexi- ble and creative due to the limited availability of resources as well as shifts in service needs and delivery modalities. This included aspects of both deployment of resources as well as delivery of services. Deployment of Resources. There was variability across participants in terms of how their agencies supported the shift to remote services. For some, the agency’s response sug- gested that social work services were not a priority for the organization, while others ex- perienced their agency deploying significant agency resources to support the shift. This included technology (e.g., cellphones, computers, digitization of files, access to Zoom), as well as protective equipment to enable safe interaction with clients. One participant noted, [U]nfortunately, [health agency] was not able to provide any equipment to me or anything for work from home. So that is all the things I've had to purchase or just using what we have right at home and then hav- ing to like purchase other things because we were not given priority for...like the loaner laptops. But I just was told that in my role that I was not on the list…to get a laptop. They said they didn't have enough resources. Across the participants, sacrificing space in their homes and being creative in using per- sonal resources that were purchased or that al- ready existed were commonplace (see Figure 1). Some participants expressed that offering services from their home was a positive in the shift to remote service delivery. Responding to what she liked about working from home, a participant noted, “It’s just the comfort of be- ing home and being surrounded by things that make you happy.” Another chuckled, reporting, “The commute is wonderful from home.” Other participants discussed making homemade masks until their agency was able to provide PPE (see Figure 2). One participant reported, You know, our clinic went without PPE for, like masks, for about three days. This was a few weeks ago, this was not this week, but still. It's just, when they're asked, like ‘Why can't we get more masks’, ‘No, you already got masks. You should have been able to make do with what you had’. Figure 1. The home office will become a more re- lied upon workspace. Rosten et al./SWK PRACTICE 119 The lack of PPE equipment was a common experience: It was the wild, wild, West, and there was no PPE. There were only gloves. Like, I took gloves out of patients’ rooms and stuck them in my backpack, like just didn’t take their whole box, but I took some...I re- member one of the nurses gave me like four masks one time because I just didn’t have any, and those were not the N95, they’re just paper surgical masks. That’s all we had at the be- ginning…Lysol wipes…my best friend brought those to me because I couldn’t find any. She just brought them. She told me, she called me and said, ‘I’m bringing these over’, and I burst into tears. I was so grateful that she was bringing them to me. I was going out and going into places that I didn’t have anything to clean my tablet or phone with. Delivery of Services. The shift to remote service delivery required creativity on the part of the social worker and while the requirement for how quickly shifts had to occur was not seen as positive, some of the actual modifications were ultimately viewed in a positive light. Participants talked about converting face-to-face trainings to online trainings using technology which enabled efficient delivery of training content to a geo- graphically dispersed audience, and how the elimination of the need to travel enabled social workers to better reach clients who had difficulty or were unable to travel to the agency’s office as well as freeing up time in the workday for other services. Home visits became porch and window vis- its and at times social workers were able to bypass some systems that had historically been obstacles. A health agency social worker described, ...we've had unique opportunities for some of our patients. That we can't physically go into their home or see them, but we've been Figure 2. There's different mask for different situations. That's why I put all the different ones we have. Figure 3. I’m still connected with the outside and with cli- ents through technology, but there is still a barrier, so I can’t always get the full picture. ADVANCES IN SOCIAL WORK, Spring 2022, 22(1) 120 able to arrange with the family to like visit while we sit on the porch and they sit on the other side of the screen door or another side of the window to still kind of have face-to-face visits. On the other hand, the shift to remote service delivery had negative impact for some on the quality of the work and on certain clients. For example, working with clients who needed support in understanding and completing forms became significantly more difficult than it had been when done in person. Because of language differences, difficulty with using technology, or being hard of hearing, communication with some clients was quite challenging, creating frustration and decreasing the quality of the interactions (see Figure 3). Describing one example of those difficulties, one social worker noted, “So communi- cation has been a little difficult…you know, trying to translate things and then the call gets choppy. So, we have to start over...it definitely can be a challenge to, you know, the flow of our communication.” Additionally, the inability to meet with clients face-to-face created significant limits in monitoring clients’ well-being and in gathering assessment data (see Figure 4): I'm not being able to see the client because of the type of interviews that we do…a lot of it is based off of like behavioral [observations]. You know, the client is acting out at the moment, or he's unable to do like a daily skill. So, we see that in person. We kind of work off of that with the home visit suspended, it's made our reports a little less detailed, I would say just because we're not able to see the child there. Evaluation. The participants in the study critically questioned the complex systems and processes that had been in place for social workers and clients to implement and access some services. They described many situations in which the requirement of systems in place to provide services for their clients were overly complex or served as gatekeepers to services rather than making services easy to streamline and implement. “It opens up a lot of ways to deliver services in a non-traditional way...like being creative in the way that we ser- vice our families and…being efficient…we don't even have DocuSign…we need DocuSign, we have too many documents.” For example, insur- ance policies for Medicare and Medicaid require face-to-face visits, which became impossible during quarantine. Given some of the successes of remote service delivery, the social workers be- gan to recognize overkill in bureaucratic require- ments and to question the way they had always done things. “[administrators] write policy, but have no idea how it's going to pan out, you know. It's very honestly like, you're not listening to the people that do the job. That's the one thing, I hate it.” Figure 4. I think that there're barriers with us- ing Zoom or phones for that matter when you are talking about the population that I work with. Rosten et al./SWK PRACTICE 121 The participants additionally shared ideas on the future of social work and how the experience of remote service delivery during the pandemic might inform future practices. Some expressed concern that agencies will focus solely on efficiencies that emerged during remote service delivery, failing to contextualize and, as such, offer models of service de- livery that are not effective at serving all clients. Others raised concern that services will return to pre-pandemic models without taking advantage of the lessons learned. While the reliance on technology offers one of those efficiencies, without considering the type of clients served, social workers expressed concern moving forward: “[when t]here’s some cognitive decline and so people look at the video screens, even if the most familiar people are there on the screens, their families, they can’t figure it out. So, there’s barriers…it doesn’t work for everybody.” Contextualizing is critical moving forward so that the prac- tice and service models that emerge address efficiencies along with appropriateness based on the client’s needs. Connection The second theme that emerged is that of connection and how connections have changed during the pandemic. Included under this theme are connections with other social workers and professionals, connections to self and with family, and the shifting of connec- tion with clients. Connections with Other So- cial Workers and Professionals. Many participants reflected on the way in which the shifts in service delivery changed their relation- ships with their day-to-day col- leagues and their broader network of colleagues. For some, this man- ifested in a stronger sense of soli- darity on their work teams, and they worked to find the best ways in which to support clients, fre- quently in a way that was more col- laborative. The importance of cel- ebrations and food as well as the staff spaces were underscored by some participants. The shift to re- mote offerings of professional de- velopment trainings broadened the reach of some organizations and expanded their work- ing network. A social worker responsible for training in the child welfare system reported: What’s been an unintended benefit, I guess you could say, is now that we're doing Zoom training, any worker from any region can attend any class. So, with that, we've increased the diversity of who's in the classroom because now we have peo- ple from all over the state like interacting and learning together. Figure 5. I am able to be more present for my daughter and my dog. It has helped that I can be here to help her through dis- tance learning and work at the same time. My dog is loving the extra attention as well. ADVANCES IN SOCIAL WORK, Spring 2022, 22(1) 122 Connection to Self and With Family. The time saved in commuting and making visits to clients’ homes along with the flexibility in scheduling that emerged provided opportunities for increased self-care. For some this resulted in the ability to take a walk in the middle of the day, or to pursue personal aspirations in terms of growth or hob- bies. One participant reported, Now, I’m able to go out every morning and stretch. I haven’t started yoga, but I’ve been kind of easing my way back and doing stretches every morning. Sometimes, I’ll wake up my daughter, and she’ll come out and do that with me and my dogs out here running around, so it’s nice to start off the day like that because you get some fresh air and it’s calm. The flexibility has allowed them to spend more time in a space with their fam- ily even as family members worked on their own activities or took care of their own responsibilities (see Figure 5). One parent reported, “This has actually helped a lot with my daughter being home schooled or distance learning.” Similarly, an- other noted, “It’s an opportunity to spend more time with kids in their school but also working at the same time.” Finally, the flexibility allowed them to attend to household responsibilities: “I am able to be working and doing my laundry like throwing in some laundry at the same time, and now the thing is that usually my weekends are packed with things that I can’t get done during the week.” Shifting of the Connection with Cli- ents. In many ways, the shift to remote ser- vice delivery seemed to humanize the social worker to clients. Clients got a glimpse into the homes of social workers, met their ani- mal companions, and at times witnessed in- teractions with participants’ family mem- bers. The ubiquitous experience of grief and loss, frustration, anxiety, and uncertainty that are part of living in the pandemic fos- tered a shared connection between social workers and clients. Clients frequently in- quired as to how the social worker was do- ing and reciprocity developed in a way that was not previously a part of the relation- ship. For some participants, this moved the relationship to one that was more meaning- ful and that reached beyond just providing resources to clients (see Figure 6). Recentering Generalist Social Work Skills The final theme that emerged under- scored some of the central aspects of social Figure 6. This represents the word, ‘intertwined’ where the roles are blurred. This experience has al- lowed me to connect with my foster parents in a new way. We are finding connection beyond our occa- sional in-person visits. Rosten et al./SWK PRACTICE 123 work practice and, at times, a return to these foundational skill sets for the participants. This included the need for practitioners to attend to some of the very basic human needs of their clients, the importance of active listening to support the relationship with the client, and the centrality of addressing loss as part of the human experience. Attending to Basic Human Needs. The pandemic created a high demand for basic needs to be met for the clients that were being seen by social workers. The concerns sur- rounding clinical interventions and support services, while still relevant, often took a back seat as client needs around food, housing, transportation, insurance, and connection to ser- vices became more pressing. Social workers whose jobs did not typically entail a focus on case management or connecting clients to com- munity resources to meet their basic needs found themselves called upon to center the brokering as- pects of social work practice (see Figure 7). One participant commented, It's like the linkage to some resources that I am using and I mean, using in record num- bers like I'm not used to using food resources. I mean, you know, food stamps, sure we refer. But this I feel like, this is food bank, like in record numbers. People that do not have food to get through the day. So that's what I'm see- ing…a lot of seniors. Active Listening. The fundamental skill of building rapport is frequently one of the first skills that social work students learn and it became even more critical as service delivery shifted to rely on remote strategies. Participants discussed the power of a single telephone call in building con- nection and trust, often reminding them of how central active listening and conveying their ability to hear and reflect clients’ experience was in solidifying their connection and building a working alliance. As the pandemic took away many resources and strategies for interven- ing with clients, social workers relied on active listening to support clients in a time of heightened fear and uncertainty. Illustrating this theme, one social worker talked about her calls with clients: My phone calls and my communication was a little bit deeper. I was asking more questions. I've stayed in the home for two hours, and I should have been there an hour or 45 minutes...I found myself just having more thoughtful conversations and being able to connect with people in that way during these last two months. So that's kind of a good thing just making them feel, I think, just taking the extra step, help them feel a little bit more supported. Addressing Loss. Clinical interventions around grief and loss became very relevant for social workers during the pandemic (see Figure 8). Many clients were experiencing Figure 7. I'm getting them from a lot of doctors who are feeling overwhelmed …they're like, is there anything you can do to help them get connected to unemployment. ADVANCES IN SOCIAL WORK, Spring 2022, 22(1) 124 some aspect of loss. One respondent identified much of the grief that was experienced during the pandemic as disenfranchised grief, that is, the grief that one experiences that goes unacknowledged or unaccepted by societal norms. The idea can be mapped onto the narratives shared by many of the clinicians about their work with their clients. Despite the public health concerns of the pandemic overshadowing issues of grief and loss, grief was ever-present in the social workers’ practice. These losses included loss of employment, shifts in the meaning of one’s home, isolation, and loss of loved ones to death. Knowledge about and skills in using trauma-informed (Knight, 2015; Levenson, 2014) strategies were relied upon heavily. A participant noted, So, I think that I've heard a lot about, in the social work field, about how like the trauma that people are ex- periencing, espe- cially like medical social workers and doctors and nurses and things like that. But...I think kind of some of the trauma has been focused on, but I don't believe that people have really focused on the grief and loss component of how much people have had to lose, both tangible and intangible losses that we may never get back. And how even when it goes back to quote un-quote normal, it won't be the same normal, it's going to be a new normal. And we're all going to have to deal with all the losses of what used to be and that's not going to be that way anymore. And so, I think that that is something that, within me, within my team, within our learning community, within the world, is all of this related to grief and loss. Discussion and Implications The findings from our study provide insight into the experience of social workers tran- sitioning their practices to remote service delivery early during the COVID-19 pandemic and quarantine. The consequences and implementation of this transition were captured in this photo elicitation study. The social workers had to shift the way they conducted their work through adapting the assessment, intervention, and evaluation perspectives and pro- cedures. The participants shared the importance of relying on foundational social work skills in times of crisis and how this continually appeared in their practices during quaran- tine. Through their images, the social workers further shared the importance of connection. Figure 8. Grief and loss is universal and it is one thing we all have in common from living through this pandemic. Rosten et al./SWK PRACTICE 125 In short, the pandemic has forced social work to evolve as a profession in reconsidering and recrafting our understanding of our clients’ needs. These findings have implications for practice, policy, and research. Specifically, the implementation of telehealth and other remote practices is central to the understanding of how social workers shifted their practices rapidly during a global cri- sis. Prior to the pandemic, there had been discussion surrounding the need for remote ser- vices; the COVID-19 pandemic accelerated the implementation of these services. The par- ticipants shared how the shift happened almost overnight, which led to minimal or no train- ing in how to adapt their practices to be suitable for an online delivery model. Many of the participants later discussed receiving ongoing training from their organizations or nation- ally on how to most effectively implement social work services online. However, the initial implementation of remote services occurred haphazardly due to the urgency of the global crisis. Moving forward, social work remote practices will likely remain as a modality of providing services, and emerging research and evaluation has suggested who may benefit most from remote services. Preliminary studies have demonstrated success of remote social work and mental health services with young people, adults, couples, and families (Sansom- Daly & Bradford, 2020). Further, remote services are an important resource in accessing services for individuals coping with chronic illness or health concerns (Jhaveri et al., 2020), who have parenting or caregiving responsibilities (Sharma & Vaish, 2020), or who live in rural areas (Nagata, 2021). While we are seeing many benefits of remote services for social work practice, we are also seeing how remote services are not always beneficial with chil- dren when play therapy and kinesthetic application is important (Hoffnung et al., 2021). Similarly, the provider should evaluate each individual’s ability to use technology, as re- mote services vary in effectiveness based on the ability to use and access technology (Sorinmade et al., 2020). Further, equity in practice must be considered when implementing remote social work interventions. From a practice sense, when an individual is accessing remote services from home, we must remember that they may not have the same privacy or safety that they would when coming into a social work setting. Many social work services are most effica- cious when the individual feels safe and understands that their information is confidential. We must also consider accessibility to technology when implementing remote services. Questions that social workers might ask include, “Who am I excluding when implementing remote services?”; “What unintended costs am I placing on my clients with remote ser- vices?”; and “What will I miss from not having face-to-face interactions with this client?” The social work participants in this study have indicated that remote mental health and other social services are likely not going away. The pandemic has forced the technology evolution to quickly be integrated into the way in which we work. Thus, a large gap remains in research that needs to be conducted to not only further understand when remote service delivery is best indicated and in what contexts, but also how remote service delivery can be implemented in an effective way. Further, the content and structure of social work ser- vices in an online setting must be better understood. For example, one study found that as one parenting support group moved to an online setting, the facilitator felt that the core ADVANCES IN SOCIAL WORK, Spring 2022, 22(1) 126 lessons were not being conveyed in the online setting. Participants however felt that they not only received the core elements of the program but the barrier of finding transportation or childcare to access these services were eliminated, allowing them to focus on the ser- vices being offered (Cook et al., 2021). The incongruence between the facilitators’ and participants’ perspectives warrants a need for further research to understand how services are best implemented and received in online modalities. Additionally, the efficacy of our study demonstrates how photo elicitation as a methodology may be beneficial for studying the effectiveness of remote service delivery modalities in social work. Regarding service delivery, the participants highlighted that many policies had to be immediately changed for social workers to implement their services without violating ex- isting rules and regulations. The participants also noted that many policies that were in place made services more bureaucratically difficult to implement rather than streamlining service provision. For example, one social worker said that the required signatures on doc- uments often delayed services from being implemented. Another explained that face-to- face mental health visits required by Medicare and Medicaid made implementation and billing of services difficult. In November of 2020, the Congressional Research Service released a report summa- rizing the behavioral health treatment policy changes that occurred due to the pandemic (Duff et al., 2020). This report summarized the policies that removed barriers preventing telehealth services from being implemented, such as requirements of face-to-face visits for both mental health services as well as substance use disorder medication treatments. Fur- ther, the Centers for Medicare and Medicaid Services (CMS) updated their reimbursement policies to include telemedicine modalities for individuals receiving services with these insurance plans (Duff et al., 2020). Policy amendments were made to the HIPAA Privacy Rule to include clear protection of patient health information in an online service modality (Duff et al., 2020). While all these policy changes were rapidly made, they are considered temporary, creating an obstacle for future telehealth services to be implemented should these provisions go away. Further policy advocacy is needed to create permanent legisla- tion that reduces or eliminates the barriers to accessing telehealth services from social workers. Beyond the remote services implications of COVID-19, social workers must re-evalu- ate the core of their practices moving forward. This collective traumatic event will be a part of many individuals’ narratives moving forward, and social workers, as they have been doing during the pandemic, must incorporate trauma-informed practices into their work. Additionally, social workers must lean on the values of flexibility and adaptability in their future work, since we are unsure of the long-term mental health implications of the global pandemic. To proactively address the shortcomings of remote service delivery, social workers should examine a multitude of approaches to acclimate their clients to the most beneficial modality of receiving services. For instance, the use of supportive technology trainings for older adults has been proposed as helpful (Gibson et al., 2020; Leedahl et al., 2018). Indi- viduals residing in restricted living arrangements, such as long-term care residents, have also been identified as benefitting from telehealth when visits from loved ones have been Rosten et al./SWK PRACTICE 127 limited (Tsai et al., 2010). As previously mentioned, recent literature has cautioned the use of telehealth when assisting individuals experiencing urgent mental health issues (Cris- tofalo, 2021). To ensure that remote service delivery is in the best interest of clients, social workers should evaluate the use of the modality on a case-by-case basis. The pandemic and the findings of this study further highlight the critical importance of social work’s commitment to social justice and to understanding the structural nature of inequalities. To this end, U.S. society has recognized that social workers are indeed essen- tial workers, connecting populations in need to health treatment and primary resources such as food assistance in the time of the pandemic (Fraher et al., 2020). Social workers have also been credited with performance beyond these duties, and as telehealth and remote services expanded, members of vulnerable groups who have critical needs have received behavioral health care because of social workers (Abrams & Detlaff, 2020). In the interest of their own health and the health of clients and patients, social workers have adopted re- mote technology and advanced the use of remote service delivery for the profession’s fu- ture (Gewirtz, 2020). The universal nature of COVID-19 is also an opportunity to challenge the individualist narratives of social problems that frequently monopolize sociopolitical discourse in the U.S. and run counter to the values and ethics of our profession. New narratives and imagery can have the power to challenge society to conceive of and construct new ways of living (Boggs et al., 2012). If history can teach us anything, it is in the context of widespread crisis – such as that of the Great Depression (Martin, 2012) – where opportunities exist to challenge the rootedness of explanations that pathologize individuals and to reimagine and humanize social structures. While early evidence suggests some attitudinal shifts from in- dividualistic to structural understandings of social problems as a result of COVID-19 are occurring, that shift is small and uneven across demographics (FrameWorks Institute, 2020). Even so, it is an opportunity for the profession to further our commitment to equity through policy advocacy and social movement support. Lastly, this study highlights the impact that photo elicitation as a methodology can have on shaping the discourse that emerges between researcher and study respondent as well as vividly illustrating the study findings. The photographs taken by the social workers participating in the study engaged their creativity in answering the research questions, deepening the thoughtfulness of their responses and, at times, clarifying tensions and nu- ances in their responses that strengthened the study’s results. The photographic data gave dimension to the social workers’ responses and enabled the interviewer to more fully en- gage the research respondent in the co-creation of knowledge. Given the time of the data collection occurring at the beginning of the pandemic, photo elicitation provided an addi- tional avenue of communication in a context when finding words to describe personal ex- periences could be challenging. Limitations As the sample size for this study was small and non-random, and the goal of qualitative research is not generalizability, the findings should be interpreted in that light. Addition- ally, the social workers who participated in the study are primarily from health-related and ADVANCES IN SOCIAL WORK, Spring 2022, 22(1) 128 child welfare practice areas and the themes that emerged may not translate to other fields of social work practice. Given the context of the study is specifically about the COVID-19 pandemic, the findings may be unique to this specific health crisis and may not be applica- ble to other motivations for shifting to remote forms of social work practice in other con- texts. Finally, all study participants were social workers, and the responses were likely shaped by the values of the discipline as well as the educational training of practitioners. Conclusion The social workers in this study offered varied responses about the opportunities, strat- egies, and coping mechanisms that emerged as part of the shift to increased remote service delivery. These social workers also shared varied perspectives on future implications for practice based on the experience of the pandemic. Social work values were central as the participants emphasized the importance of flexibility and creativity in service, as well as concerns about how remote service delivery differentially impacts vulnerable populations. Their reflections also reinforced that existing privilege and disparities have been further amplified during the COVID-19 pandemic. To bolster the national workforce of social workers and other health professionals de- livering care in this state of emergency, several sectors of society repealed bureaucratic regulations (Fraher et al., 2020). Permanent legislation is needed to prevent pre-existing limitations on remote service delivery from returning. Social workers should be able to reach their clients, patients, and communities by various methods rather than operating within an antiquated, one-size fits all approach. Conversely, social workers across the globe have argued that local and national governments have implemented pandemic regulations that are impractical, inadequate, and not clearly understood (Banks et al., 2020). To remedy undesirable policies from being enacted in response to emergency conditions, the social work profession should play a role in informing policy development. Social workers are highly aware of disparities at the individual and community level (Banks et al., 2020). The discipline may advance by examining the perspectives of vulnerable populations and their attitudes about remote delivery of services (e.g., telehealth) and leverage these findings to dismantle inefficient approaches. 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Social Work in Public Health, 35(3), 69-72. https://doi.org/10.1080/19371918.2020.1751533 Author note: Address correspondence to N. Eugene Walls, Graduate School of Social Work, University of Denver, Denver, CO, 80208. Email: eugene.walls@du.edu.edu https://doi.org/10.1080/13607863.2010.501057 https://publichealth.tulane.edu/blog/effects-of-social-isolation-on-mental-health/ https://publichealth.tulane.edu/blog/effects-of-social-isolation-on-mental-health/ http://doi.org/10.1002/jclp.23064 https://www.cdc.gov/flu/pdf/professionals/hhspandemicinfluenzaplan.pdf https://www.hhs.gov/coronavirus/telehealth/index.html https://doi.org/10.1080/19371918.2020.1751533 mailto:eugene.walls@du.edu.edu