Between social and somatic disorders: The promotion of health as part of general social work practice

0277-9536190 S3.00 + 0.00 Copyright %;,1990 Pergamon Press plc

Sot. Sci. Med. Vol. 31. No. I, pp. 3542. 1990 Printed in Great Britain. All rights reserved

BETWEEN SOCIAL AND SOMATIC DISORDERS: THE PROMOTION OF HEALTH AS PART OF GENERAL SOCIAL WORK PRACTICE WOLF

RAINER

WENDT

Vocational Academy Stuttgart, Department of Social Work, P.O. Box 100563,700O Stuttgart 10, F.R.G. Abstract-The population of the highly industrialized countries have access to an increasing range of possibilities for influencing their own state of health in both positive and negative ways. Health maintenance behavior is part of a general ‘way of life’ which is determined by chosen life styles. While the clients of professional social work may have a more restricted range of options, the interdependence of their individual life situations and health disposition remains a factor in their case as well, usually with negative results. There is a constant mediation of social disorders in somatic disorders (and vice versa, especially in cases of chronic illness, disability and addiction). This paper discusses aspects of assessment, coping styles and social support along the socio-psycho-somatic axis. There are many arguments for a conscious integration of health promotion into social work practice in general. Key words-health

status, immunological model, promotion of health

insurance is available) with varieties of functional and chronic ailmenfs-and little in the way of self-help. Also, there occurs at least partial neglect of necessary health concerns. This is due to stressful work and living conditions as well as problems in interpersonal relations. As corollary, points of departure of primary, secondary, and tertiary prevention are varied in their nature, while professional social work is indicated primarily in those cases where one would expect to find either chronic illness or special complications needing special treatment. Health focused social intervention cannot, therefore, be confined to addressing acute illness or to rehabilitation efforts alone, while exclusively psychosocially centered social services often obscure the physical side of their clientele’s suffering. Increased knowledge and more comprehensive as well as more exact assessment can work together to reduce the tendency to ignore the latter. It is, therefore, the thesis of this article that social work can contribute, if it so chooses, to the promotion of the general health state of the population, conceived of and conceptualized in terms of broad societal supports. While it will remain necessary and legitimate to address the personal and social issues contiguous to strictly health concerns, a more universal view of health and health directed services by social work and social workers is legitimate, necessary, and well within the realm of social work to address.

INTRODUCI’ION

of highly industrialized countries and regions have access to an ever-increasing range of life styles, many of them directly related to health issues. The inhabitants of such countries are often supported by highly developed health-care systems, by athletic and recreational resources, as well as by highly sophisticated pharmaceutical industries and their products. All of these favor the differentiation and modification of needed health-maintenance behavior as well as illness behavior. In addition, new movements have sprung up from those interested in advocating for environmental protection; and the increasing frequency with which self-help groups appear results in further impact on the health status of millions. Yet, by no means do all citizens exploit these options in ways beneficial to their health. To cite only two examples, medication abuse and damage ensuing from misuse of recreational sports document the point. Well-educated and gainfully employed members of the middle-class tend to make relatively moderate use of health services, unless such people are consciously aware of the benefits of active attendance to their personal health needs. Thus, they might contribute to the maintenance of their own health by eating well and healthfully, and as a further example, through participation in physical fitness programs. The emphasis is typically on what the person can do for herself or himself without reliance on the organized social services, although it is often the case that the demands of the work place may hinder or discourage regular health check-ups as well as physical exercise, particularly among the ‘upwardly mobile’ population. In other words, even where services and choices exist, they are not always utilized. It is a mixed picture. Among lower-class persons one may observe that people pay frequent visits to the physician (as long as The populations

THE ASSESSMENT OF LIFE STATUS

An important contribution to the conceptualization of social work in care health, broadly understood, is the life style approach to health promotion, as exemplified in a paper published by the Regional Office for Europe of the World Health Organization [l]. The aim here is more than a merely preventive one in terms of carefully selected factors, but rather the 35

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holistic promotion of well-being and good health. Both come about-or fail to do so-under the influence of social conditions, psychological and mental factors. Because this approach takes into account all circumstances of importance to the conduct of life, it leads to an ecological (or eco-social) understanding of the individual’s bio-psycho-social status in life [2]an understanding which can be especially important for community social work. The individual shapes a certain life style within the framework of his or her own situation, played out with more or less healthy or unhealthy effects. In the case of an unhealthy life style no preventive efforts will be rewarded by success unless that life style is modified. In the debates about this approach the complexities involved in the mediation of social and somatic conditions have become quickly apparent. The term life style is only in part suited for comprehending the shaping of individual behavior by socio-economic and psycho-cultural forces. Their supra-individual characteristics are portrayed more faithfully by the term ‘way to life’; while the individually determined characteristics involved are called a ‘way of living’. Life styles, on the other hand, contain the qualities of having been chosen, of electiveness, and are, so to speak, played out within socio-economic circumstances. The term is often used in the medical context as synonym for risk-taking behavior. One’s manner of living is the result of adaptation to the outer and inner conditions of an individual life, and an adaptation as well to the collective way of life. The personal ‘way of living’ also encompasses the way of working, of housing, the patterns of dealing with others, the way of interpreting social situations, and modes of coping. The term is also used as a synonym for life style in the papers of WHO of which we referred to above. It should relate to “the interplay between living conditions in the wide sense and individual patterns of behavior as determined by socio-cultural factors and personal characteristics” [ 1, p. 1181.This is where social work comes into play, precisely because it makes constructive contributions to the shaping of ways of living. This chance is provided in the problematic situations of the clientele of social workers. The latter discuss the ‘statuses’ of their clients with the clients themselves within the present coordinates of their way of living. A conceptual model of this ‘status in life’ incorporates outer and inner aspects of life and the process-dimension of time [3]. To assess this status in terms of case management, we have to consider the whole range of ecological relationships. This is more than a situational approach, more then observing personenvironment transactions. For the determination and understanding of the idea ‘status in life’ we shall now return to the already mentioned differentiations of human behavior. Socioeconomic development provides increasingly varied options for individuals; and technical innovation in all areas of life change the conditions of individual existence. The ‘status’ in which an individual or a family finds itself can be circumscribed by a series of objective indicators; the subjective self-assessment of an individual or family are what constitutes any given situation in any case. Thus, a given status in life embraces both the objective and subjective

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perceptions of the given situation. The basis for this unity lies in the self-and proactive process of human development-in the bio-psycho-social way of living. Viewed schematically, four dimensions determine the status of the process (Fig. 1). The first dimension is the life history, in which background, traditions, and the individual dynamics of motives and ambitions represent those factors that regulate the way of living along the time axis. The client belongs to a certain development stage of life and has attained a certain level of social functioning [4]. One’s social development goes hand in hand with the career of the body; and life changes are Seen as stressors which necessitate physiological adaptation. The status of any given individual changes in the course of time simply because the person ages somatically, psychologically, mentally. In the family, the entire set of social relationships shifts with the aging of its various members. Their state of health does not, of course, remain unaffected by these changes with the accompanying shifts in the ability to function. When viewed in macro-social terms, it is important for society that the increasing life expectancies of populations and the accompanying generative behavior create new types of relationships among its members. Secondly, the history of the individual undergoes continuous change in the environment within which it occurs. The relationship to the environment has soci-ecological, socio-economic, political, and sociocultural traits. In this respect the subject is an active participant in his or her context as it is perceived. Each individual adapts occupationally, possibly in the circumstances under which he or she is housed, and micro-politically as a citizen in community and neighborhood-with people very much like himself or herself. The person suffers impairments and enjoys successes; experiences the advantages and disadvantages of his or her situation in its context. Where and how the individual fits as a member of his or her environment is objectively observable. It indicates whether a person is regarded as socially integrated, marginal, as rising or descending in the social hierarchy. The person thus belongs to his more limited and wider milieu; he is ever a member of the milieu in both specific and in varying ways [S]. To the extent that other people, including professional, also are

Between social and somatic disorders members of this social context (or are able to place themselves within it), it becomes possible to assess the status of a person’s life intersubjectively. Third, the environmental relationship is not to be conceived of in static terms. The self-activating person anticipates its processes by planning, and thus changing it. He assures himself of perspectives and therefore, of the availability of options in his environment; his chances and opportunities to attain life goals. His future is uncertain. Negative prospects and results have to be taken into consideration; and where the individual usually responds with a strategy of avoidance. Yet, even in difficult circumstances a person may be able to mobilize previously unimagined powers and a wide range of abilities to cope. Thus, a person’s perspectives influence the way in which life history is projected into the future and, thereby also its direction. However life develops, it is always accompanied by loss, danger, as well as the potential for new adaptation. The fourth dimension of the status in lifeas opposed to the individual’s relationship to the environment-is its foundation in the psychic and somatic interior of the individual. This inner milieu is perceived subjectively in good or bad ways. The individual responds actively, psychologically and physiologically. Social motivation and membership [5] are internal to the person and are, therefore, manifestations of neural circuitry and opioid systems located in the brain [6]. The same inner disposition of which we have been speaking describes genetic predisposition as well; yet it, too, is not fixed but plastic and open to influence. In the pop-psychological and somewhat esoteric scene so popular in this day, we are confronted by a widespread view that deepreaching changes in the situations of people can be brought about by the mere manipulation of psychic traits. In fact, the clients of psychosocial intervention services often do have fewer external, interpersonal difficulties than internal ones. Also, this population does not typically include those on welfare because of socioeconomic problems. Even their state of distress does not consist primarily and one-sidedly of material need and environmental deprivation as one might assume, viewing them from some distance. The need for material and social support turns people into the clients of the social services, while health problems move somewhat into the background to be noticed only in passing. Sufferers from somatic disorders go to the physician-where the patient’s psychosocial problems receive marginal attention. The preoccupations of the professions with their own specialization patterns make it difficult for them to address the matter of prevention. Therefore, before social and medical services are combined in order to attack the re-enforcement of one by the other, both tend to be fixed by way of stereotyped coping by the patient and client. There are social factors in the etiology of illness and somatic factors in the etiology of psychosocial problems. These factors pre-exist and work subliminally prior to the time that an illness becomes manifest and results, in turn, in psychosocial difficulties. A lessening in the ability to cope and/or neuroendocrine and neuroimmunological disturbances occur. The sociosomatic gray area between health and sickness is of interest to us,

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necessarily so, both in the individual as well as in the case of the many who do not yet receive professional help. Even if these people are already clients or patients, in their inner milieu they continue to incubate the symptoms of ailments with their somatic and psychological consequences. Their history and the relation of the individual to the environment influence, prospectively, their status in life. Status in life is a multidimensional construct, It involves dealing with objective reality as well as subjective systems of perceiving and evaluation in order to grasp its significance. The individual finds ways to manage his life and its vicissitudes by either confronting its reality or by attempting to escape from it. Both external and inner activities by any given person contribute to this. For this reason one should avoid placing psychologically explainable conditions ahead of physical ones. Social workers observe the unity and interplay of social conditions and clients’ states of health every day. On the other hand, a purely social definition and reconceptualization of health is equally inadequate. It tends to render too great priority to macro-social and micro-social relations together with inner-outer causal reasoning. The micro-social conditions and the biological mechanisms of bodily functions enjoy exceptionally complex relationship. This results in the need for a unitary conception of the social management of life and of the personal management of health. THE STATE OF HEALTH AND ITS INTEGRATION INTO THE STATUS OF LIFE

The way in which the external situation is mediated into the inner milieu of the somatic state can be observed with increasing precision in the psychoendocrine and psychoneuroimmunological connection [7]. Emotions are associated with endocrine patterns of response in catecholamine and corticoid systems [8,9]. The regulatory systems of the central and visceral nervous system, the endocrine system, and the immune system are linked into mutual dependence through a multitude of intercellular transmitters. Specific patterns for the distribution of nervous, hormonal, and immunological activity are formed in their internal interrelationship. The immunological state is continually modulated by nervous and endocrine activity as mediated by neuropeptides and other substances, and vice versa [lo]. In the case of stress or under the impact of critical life events, the power of resistance decreases, and thus the degree of general susceptibility to disease [ll] increases, as well as the special vulnerability to sociosomatic and somatopsychic disorders [12]. In his regulatory system the individual undergoes a process of adjustment which has equally differentiated consequences somatically as the life history itself may have for individual assessment of the social situation. The individual nervous, endocrine, and immunological regulatory process is sufficiently plastic in its internal autopoiesis [13] for self-active adjustment to all life-connected situations. The involvement of the limbic system and his attitudes regulate the person’s emotions: joy, fear, hope. Hopelessness is associated with negative consequences, from chronic depression

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to death. The prospect of the lack of hope is preconditioned by earlier experiences. Yet, we are not justified in assuming linear causality to operate in these situations. The autopoiesis of mental and psychic processing can subsume the large majority of external adversities with no visible harm. In general it is also capable of meeting challenges by incorporating objectively negative events and conditions into positive physical and emotional states. This process of mental and physical self-determination should not be neglected-and this applies in particular to social work. The way people think, feel, and act are crucial resources for the desired promotion of social health. Partly from not knowing, partly for reasons of ideological bias, social workers (and physicians) have often dismissed problems in the conduct of life from the realm of individual responsibility with justifications such as (1) macro-systemic problems (unemployment, housing problems, exploitation at work, and social discrimination); (2) purely physical problems (illness, physical wear and tear, endogenous physical processes, physical exhaustion); and, (3) psychogenesis lying far off in the patient’s past (early childhood, faulty upbringing by parents, inadequate social integration). Aside from psychodynamically oriented treatment, the only remedy to external stress factors such as these is compensatory social and medical support: provision of public welfare services, the procurement of housing and work, and medical care. As helpful as these services may be at a given point in the client’s life, they bring no improvement in the competence of individuals in their own situation. In time new crises will result; and one cannot simply wait until the broader economic, political, and cultural structures have changed as suggested by Alonzo [ 141. The most suitable alternative appears to lie in the assessment of the sociosomatic conditions within that same framework that serves as the day-to-day source of orientation for individuals. In the self-organization of their lives they are simultaneously bound in a double recursivity to the patterns of their internal bodily systems of processing and the patterns of their external and social processing of situational circumstances. The social conception of the status in life does justice to the latter process, but also holds it open for the nervous, endocrine, and immune states. These statuses are internally interrelated and linked, and in such ways that the processes of the social as well as the somatic states of living shape their own dispositions. Nor is it a matter of accounting for them in linear, causal terms. Health will be disturbed by external and internal modifications. Nor can it be restored by external agents alone. Immunological research has shown that the maintenance and restoration of internal states of equilibrium represents an internal achievement to which internal-external relations remain subordinate. The immune system is self-referential and autonomous in nature [15, 161. We find these same systemic traits in the social field as well as in the psychological make-up of people. In the ways of living of a certain percentage of the homeless, for example, we observe that the texture of their real relationships and psychological assumptions is so firmly established that external changes such as a procurement of housing or work by no

means result in permanent changes in their status in life. The rootedness of extant systems of selfregulation is pronounced among groups manifesting deviant behavior (and even more in the case of normal behavior because of the social support it receives). Among addicts there is the additional problem that their behavior is subject to both somatic and social re-enforcement. Among such and other groups it is difficult to determine causal relationships epidemiologically speaking, be they social, mental, or physical disorders [17]. In each individual case it is precisely the interplay of these factors that becomes the focus of the clinical social work process. A feeling of minor disequilibrium occurs among many people due to a sense of social disorder, conflicts, or simply the discomfort of an identifiable situation. On an individual basis this kind of reaction takes on different forms, in part due to physical constitution, in part tracable to earlier experiences. The sense of weakness one experiences in such conditions permits an increased sense of dependency on others which, in turn, intensifies the body’s response to the events that triggered them in the first place. Depressive changes in mood lead through a decrease in the effectiveness of immune reactions to heightened susceptibility to illness. Intermittent diseases, e.g. with rheumatic symptoms, occur with greater intensity than ‘otherwise might be the case. Palliative medicating supports the palliative coping of the patient [18]. Social work clients often move in this transitional zone between health and sickness. Should the individual be employed, he will report himself sick and attempts to improve in a period of rest that follows. Should he have lost his work place, the by now chronic illness will complicate recovery. In such cases it will be of little help to enlighten the sufferer about the mechanisms of somatization, so long as he possesses no other ways to maintain an inner and outer equilibrium. The internal balance of the effects of one’s life history, attitudes, circumstances and available resources, all related to the total of his status in life make for illness. The individual loses the competence to cope and learns to become helpless, resulting in disease and/or dependency [19]. It cannot reasonably be expected that research conducted in human biology will furnish immediately available supplies of suggestions for application in the professional social services. The conceptualization of health social work and its methodological application must take place within social work itself. The research findings and concepts from biological and medical science do, however, offer rich materials for informational efforts in the area of health promotion-within social work practice. Of special significance in this regard is the investigation of coping behavior. Doing so leads to the reconciliation of social and of health related efforts and of the selfregulatory apparatus of social work clients. It would enhance the profession’s methodological application. Coping, i.e. “to manage specific external and/or internal demands that are appraised as taxing or exceeding the resources of the person” [20, p. 1411 is learned at all levels of the physiological system of regulation. Concentrated in the individual will to self-assertion, it then influences those levels in its turn. Socio-epidemiologically it has been studied

Between social and somatic disorders primarily in respect to the management of stress created by serious illness or which the social environment has inflicted on the conduct of a person’s life. Moos [2] has identified nine major types of coping responses used in crisis situations. An evaluation or re-evaluation of the client situation can occur by utilizing the following dimensions. These are: (1) logical analysis and mental preparation, involving review of past experience in the management of difficult situations; (2) cognitive redefinition, embracing strategies that emphasize the advantage of a situation; (3) cognitive avoidance or denial which is to play down the seriousness of a situation in time of crisis. In addressing the problematic nature of a situation which, according to Moos, involves the following mechanism are available such as (4) seeking new information and support, a core element of social management; (5) taking problem-solving action that holds out the promise of new adaptation within a given situation; (6) pursuing alternate reward with the intention to achieve psychological compensation; (7) the regulation ofaffect by, for example, preserving calm; (8) emotional discharge, a form of stress reduction which the social environment supports to permit limited resonation of strong feelings; (9) resignation and acceptance, i.e. submission to fate; and (10) “behavioral withdrawal” [21, p. 2121. By taking stock of a single person’s preferred modes of dealing with a demanding situation, profiles may be created which provide important contributions to the assessment of an individual case as well as to clinical or social treatment. Moos further discusses the relationship of coping within the professional and in the familial milieu and the manifestations of personal coping strategies. Most of the named coping styles correspond to the tendency of many social workers to emphasize the psychological aspects of their clients’ problems. These, in turn, offer access to interpersonal resources. The hard facts, however, lie in their material situation, in their social status, and in their material physical disposition. The latter is part of conflict and of adaptation to their overall circumstances and milieu. Considering that people find themselves in situations with an uncertain future, misapprehension and wishful thinking, even misguided judgment, social workers might well look to psychological concomitants in order to be of help. The primary object of their concern, however, needs to lie outside psychological processing of feelings and thoughts. It is for this reason also that we avoid the use of the term ‘psychosomatic’ for difficulties in the kinds of adaptation called for when their causes are material and social rather than of the mind. One ought to look at external reality in such cases. To put it bluntly, the sociosomatic context is asserted in formulation such as: ‘you are not getting along with people’/‘work is making you sick’/‘you are not up to it’/‘your family’s expectations are overtaxing you’/‘you cannot see yourself out of an oppressive situation’/‘poverty is weighing you down’/‘you are isolated’. Clients of social work often display coping profiles deviating from social norms. The causes for this deviation should not, however, be seen as one-sided. Assumptions about them need to be based on the inherent problems of the social environment and

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the individual’s efforts to address it, that is, on the burdens they posit for each other. The fact that the individual is often wanting of the competence to deal with it positively is already the effect of the discontinuities besetting both. Competence is based on both having the skills to act and having the opportunity to act skillfully. The lack of ability to planfully conduct one’s life, including health behavior, keeping in mind one’s life history, the socio-economic environment in which one lives and, one’s attitudinal set, affect the state of one’s health. Just as in social work, health workers must address client’s problems in a compensatory style. Outpatient and inpatient treatments are performed and where indicated, medication may be prescribed. Where people’s ailments are chronic ones, the indicated treatments cannot prevent the accompanying process of chronicity itself. More helpful approaches to health management are those that expand and strengthen the competence and coping capabilities of people and that make use of existent resources in so doing. Competence is based on the individual’s interactions with the environment. These interactions form patterns of appropriateness and responsibility. Within these patterns individuals are capable of handling situations effectively or ineffectively [22, p. 1611. Goodness of fit is an explanatory concept in the competence literature which helps explain the interrelationships of social and somatic management as well as autonomous and self-focused control on the side of the individual in the context of the social structures within which his life takes place. A pre-condition for the effective provision of help is the assessment of the overall status of a person’s life. Social workers and clients engage in mutual discussion of as many aspects of these as possible, and especially those that contribute to the problematic situation at hand, and finally, what may be done about it. The result may be a fairly long process; and if as many other professionals and others participate in it, so much the better. One’s status in life does not arise in isolation and without comparison to that of others. The discussions about one’s life and its problems in the client’s informal network and within the social service agency are in themselves effective forms of social support. We regard the ever-increasing quality of health counseling as an important aspect of community social work-with its application of the status-in-life concept. INCLUDING THE PROMOTION OF HEALTH IN CASE MANAGEMENT

An individual with problems of living and the associated physical reactions to them frequently experiences palliative medical intervention. Such treatment and the use of medication may be counterindicated, if not harmful, when it prevents the patient from understanding the extent to which his behavior produces his own illness. In such an event medical treatment fails to contribute to a problem-solving mode for coping, but rather to a palliative strategy aiming at relief of symptoms, subjectively experienced. Problem-solving or instrumental coping aspires to changes in the whole of the stressful situation through appropriate action [ 18). The coping behavior is directed both externally and internally and requires

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social support not only in terms of problem-solving using others; but also internally, i.e. psychologically. Therefore, the modern general practitioner of medicine is challenged to become, being assisted by an ecological view of human life, a manager of living [23]. This applies even more strongly to those practitioners who from the very beginning of life influence the ever more complex social situation of the growing person. Professional case management that organizes support within the network of internal+xtemal relations directs its efforts to status-of-life as subjectively perceived by patients and by others. This is particularly the case during the assessment phase. The individual process of balancing what the patient perceives and what he brings to the social worker should at first be taken as presented. It becomes elaborated over the course of social work intervention, perhaps even modified, and serves as the basis for further social work help and eventually results in changes in the patient’s ways of living. However, the new arrangement will be of little lasting benefit if its internal and external aspects fail to be considered simultaneously. The pursued changes must lead to a new equilibrium, for otherwise the crisis that brought the patient into the helping relationship would only become worse. Case management is successful when it creates arrangements in which the individual (or family) copes according to his own development experiences, attitudes and perspectives, environment, and other internal resources. In the case of a behaviorally disturbed and/or psychosomatically reacting child with problems of self-assertion with his peers, the social worker will try to strengthen supports within the family, motivate teachers to provide increased encouragement, and possibly have the child attend karate classes and learn personal fitness techniques. In the case of a stressed single mother the proper solution may be involvement in a support group (for social reorientation), autogenic training, together with the temporary support of a family social worker. Normally, supporting both mother and child will be combined; and case management will expand to social health services. Each individual is dependent, under the influence of the superstructural conditions of his social environment, on the consensual agreements created by the interaction of a community’s citizens and their institutions. That people expose themselves to health risks due to a lack of knowledge is less of a problem today in the developed countries than it is elsewhere. It is of much greater importance that people protect their health on a self-active basis, with desirable or undesirable consequences as the case may be. The opinion makers in the media as well as in smaller social circles, including families, also influence selfactivated health protection. Social work, too, must be sufficiently motivated to work for the proper allocation of health services as well as the attitudes of individual patients. The patient regulates his own life; and it is for this reason that the person’s internally derived impact on his own health condition remains crucial. The responsibility for this is clearly his. The context of self-orientation and the taking of selfresponsibility can be backed up through measures of social support (i.e. in the direction of developing increased awareness of his responsibility).

In order to provide efficient social work health services, the profession has to change its dominant patterns of thought about practice. The linear tracing of somatic disorders to social conditions is unproductive. We are confronted on both sides of the equation with highly complex circumstances whose internal feedback and interrelationships demand situation-specific and person-specific reasoning. The wide-spread ‘psychologization’ of behavior is more inclined to weaken individual coping behavior than to strengthen it. For example, to attribute addiction to disorders of the ego ignores the system of self-regulation intrinsic to the concept ego and thereby implies diminished or suspended competence. It would be more accurate to observe that the move to addiction equals ego weakness or disorder, that is, the loss of the social and ecological stewardship of the ego. The cause for this should be sought in the entire status in life-including the disposition of the subject-and helping himself by addictive means. The object of preventive action must be the ego in context, this being the best way to strengthen it. A therapy aimed merely at the psychological ego will fail due to the fact and weight of unchanged reality. Therapeutic interventions aimed solely at social conditions will also fail because of life style considerations and individual will. He, in his circumstances and in a social and somatically focused dual treatment milieu we discussed earlier, requires a consensus between the agenda of help he has agreed to, and indirectly on a meta-level, of consent to the socially arranged promotion of health. The creation and use of this remains an incremental undertaking. Social workers obtain the skills to handle it the more they learn to think and act simultaneously in social and somatic terms. A life crisis (parallel to a crisis of life style) is sustained on many levels: in the quality of the differences between the claims on life and their chances of fulfillment; in the discrepancy between physical and social skills (in the crises of youth and age); in the quality of difference among the members of a community, each of whom both want and are compelled to come to terms with these various discrepancies. If, in a crisis between partners, a relationship-related crisis, mutual dependency is the major issue-precisely because it is an expression of a membership quality (51, individual somatic disorders should also be subjects of joint discussion-including feelings and interpersonal problems, for they are de facto components of physical problems. Thoughtful assessment of clients by social workers points rather clearly to those who purvey a pessimistic and passively entrenched attitude toward their situation. If neurasthenia or other functional syndromes, or alcoholism is a factor, it is unimportant which preceded the other, since in the present both re-enforce the other. In order to deal with them in combined form, the practitioner is best advised to concentrate on intermediary variables of the sociosomatic relationship. Clearly important is the client’s perceived self-efficacy as defined by Bandura [24]. Relative lack of self-efficacy means psychic and physical stress. In the process of offering the client social support one should attempt to strengthen individual self-efficacy. Yet, to the extent that the helper avoids doing ‘for’ the client, he might well activate the

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network of the client’s other relationships encouraging family group interaction. The individual will thus be rendered the opportunity to give as well as to receive, thus enabling the client to re-obtain and re-experience the lost or minimized self-efficacy. The individual needs to be reminded that he can change his situation through his own actions. The realization of this experience obviously correlates with an active approach in the modes of confrontative coping, problem solving, positive reappraisal, and the acceptance of responsibility for behavior [25,26]. If the management of the helping relationship results in these behaviors occurring with increasing frequency and within the network of the client’s relationships, there will be benefit to all involved. This, then, prepares the way for increased self-efficacy. One would expect clients to gain in optimism, leading in turn to increased ability to cope well and once more simplifying further access to further social supports [27]. The interaction of utilizable social resources and improved cognitive orientation toward desired change pave the way to higher levels of usable stamina. Conversely, helplessness and hopelessness bring the risk of poor health and low stamina [28]. The aim of social work in health care is to appraise the social and somatic situation of persons and to help master it. Social workers are often inadequately trained to do this. Because of the limited ways of defining their functions, particularly in hospital social work, the somatic aspects of the work are often neglected. In such cases, their functions tend to be confined to addressing the external realities of their illness. If the demarcation of medical activity is rigidly maintained, social workers find themselves in a situation comparable to that of sufferers of psychosomatic illness. The patient is unable to express emotion, a condition called alexithymia. The analogous failure of social workers to perceive, describe, and communicate about somatic implications of the overall life situation of clients may be called alexisomia. The mentioned shortcomings turn into significant restrictions on the professional competence of social workers. The task of social work everywhere consists of enabling people confronted with average life events to control and better their life situation. The loci of control are inside as well as outside the body. The client needs the experience of a controllable situation. Otherwise, the threat of fatalism and resignation will come to dominate his or her situation [29]. The social worker needs to be a companion to the client in backing up the latter’s efforts in word and in deed. The issue is one of social and health maintenance as inseparable constituents of the mastery of life. When attention is centred exclusively on the psychosocial context in mutual dependency on each other, observations of what is happening to clients will be superficial and inferences incorrect. The drives and inner conflicts of clients viewed psychodynamically are one aspect of the total picture, but it is quite another to become aware of the relational aspects of social efficacy and of somatic efficacy in individual life performance. The individual should be fully aware of how his or her strategies for the conduct of life affect the physiological system (and vice versa). The knowledge is needed not only after problems

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have manifested themselves, as in drug addiction of physical handicaps. In rendering psychosocial services to families, young people, and the elderly it is a matter of prevention and of the competence needed to monitor and manage social and physiological functioning at the same time. MODI

VIVENDI

Elderly people, respecting their developmental stage and adaptations, need to budget their physical and mental energies. We have learned from gerontology that this does not have to mean a retreat from social competence-assuming that the elderly person avoids the one-sideness of pre-occupation socially, psychologically, or mentally. Varieties of meaningful activity and an optimistic attitude are what is [30] and can exert positive influence on the person’s vitality. Physical lethargy is often the result of the lack of social and mental involvement. Socio-culturally learned habits contribute to this deficiency. Retirement of the elderly is frequently imposed on people by the society, and helplessness is re-enforced. Handicapped persons are treated similarly. This passivity and dependency needs to be countered systematically. In order to avoid the ‘easy way out’ of physical incapacity, the professional helper must be able to assess the individual’s limits of coping. These are not objectively fixed (and social support may even expand upon them). For this reason it is also necessary to understand each client’s capacity for coping in, if necessary, an extended relationship with him or her. This is not unlike that which takes place within the client’s family and in the raising of children: through positive acceptance encouragement, verbal instruction, and the non-verbal shaping of attitudes and cultivation of ways of communicating. In a family whose members are in a variety of life stages and statuses, as well as levels of health, it is the task of the relatives to find and maintain modi vivendi-of types appropriate and favorable to any given person in their common family situation. When there is a handicapped or chronically ill person among them, the creation of the modus uicendi will require special precaution and effort. Accustomed patterns of mastering the situation-over time-fail. When the services of a social worker are called upon in such situations, he can try to strengthen the capability to cope on the part of family members. This includes anticipating the need to cope, not only at any given moment, but in some cases well into the future. The capacities of the patient and the family to adapt adequately is reciprocal in nature. The chosen modus vivendi must prove its efficacy within the relationships of family members with each other. Therefore, the social worker must address the entire family network from the very outset of his or her interventions. Case management is accomplished, in part, by locating and processing resources in often complicated situations. It amounts to the management of membership in the family and in the wider social context [S]. It is important that the task be understood bio-psycho-socially. Social workers have from the beginning taken into account the socio-economic and cultural context of thier clients’ lives. In light of this fact there exists the

WOLF RAINER

42

choice of relying for explanations on the circumstances implicit in illness or to help the client place a distance between that and better ways of coming to terms with it. Our plea should be for a third and also more comprehensive procedure. In the web of one’s social existence there are always large numbers of others who are involved in the distribution of life stresses, of social order and disorder, of healthy and unhealthy living. Social workers can work within this distributive social structure and as responsive agents for a better life or for the more responsible allocation of life chances. Thus social workers do not assume the role of the paramedical expert; rather, they take into account the bio-psycho-social context of their clients’ ways of life.

WENDT

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