- Email: [email protected]
Social work in health care: Directions in practice
Sot. Sci. Med.
Vol. 31, No.
1, PP. 19-26, 1990
0277-9536/90 S3.00 + 0.00
Printed in Great Britain. All rights reserved
Copyright (Q 1990 Pergamon Press plc
SOCIAL WORK IN HEALTH CARE: DIRECTIONS IN PRACTICE BARBARA BERMAN,’
EVELYN BONANDER,’ IRENE RUTCHICK,’
PHYLLIS SILVERMAN,’
BETH KEMLER,* LEONARD MARCUS~ and MOLLY-JANE ISAAC~~N-RUBINGER~ ‘Social Service Department, Massachusetts General Hospital, Boston, MA 02114, *Social Service Department, Children’s Hospital, Boston, MA 02115, )West Roxbury Veteran’s Administration, Human Resource and Development, West Roxbury, MA 02132 and 4Social Service Department, Massachusetts Eye and Ear Infirmary, Boston, MA 02114, U.S.A.
Abstract-As technological advances within biomedicine uncover more complex and confusing situations, social workers are forced to deal with the patient and family with greater uncertainty. To competently address today’s biomedical environment with an anticipation of tomorrow’s advances is an incredible challenge. The focus of the theoretical framework necessary as the foundation for health care practice has shifted from an emphasis on psychopathology to a focus on what people do well, on their adaptive capacities with the goal of preventing maladaptive behavior. Therefore, the focus of practice must be on factors that affect normal or typical growth and development in the course of living and must include an understanding of the interaction between the biological, psychological, cognitive, social, cultural, and environmental dimensions of social functioning.
Key words-theoretical
foundation, health, social work, therapies
INTRODUCTION The medical complex
problems
and
sophisticated,
which people present today are
frequently talented
alive under conditions
that evolved from these papers [3] examined competencies and knowledge needs for social workers in health care as conceptualized in three sophisticated educational programs. This work again demonstrated how educators, both school-based and agency-based, could collaborate to develop sound health-related social work curricula. However, these early efforts did not fully address what variables should guide curriculum development nor specifically delineate the unique characteristics of health care practice. From 1980 to 1987, the faculty of the Social Work in Health Care Program of the Massachusetts General Hospital Institute of Health Professions (IHP) were charged with the responsibility of developing specialized curricula for social work in health care [4]. The challenge was to focus on and revise the generic social work core curriculum to meet the needs of health specialists. A 2-year grant from the Lilly Endowment supported these curriculum development efforts. In 1986, the Society for Hospital Social Work Directors reconfirmed its commitment to the education of social workers in health by requesting the Institute’s faculty to update the earlier work on knowledge-base needs for social work in health. The results of those efforts have been published by the American Hospital Association in a book, Social
strange,
even
to the most
professionals.
People
are kept
never known
before.
As tech-
nological advances within biomedicine uncover more complex and confusing situations, health professionals are forced to deal with the patient and family with greater uncertainty. New roles and tensions are created for social workers and other health care providers. To competently address today’s biomedical environment with an anticipation of tomorrow’s advances is an incredible challenge. To meet the needs of continuously changing roles and practices for social workers in health care is equally challenging. The direction social work has taken to meet the demands of a dynamic health care system is clearly evidenced in the literature of the last 10 years. A brief overview of significant published works serves as background. In 1978, the Society for Hospital Social Work Directors of the American Hospital Association published a monograph titled ‘Knowledge base and program needs for effective social work practice in health’ [l]. That review delineated 13 areas of knowledge considered necessary to enable health care social workers to meet the demands of professional practice [I]. In 1980, the Society sponsored a national conference, in conjunction with the Council on Social Work Education, that addressed dilemmas schools and agencies face in education for social work practice in health care. The papers from that conference were published in a monograph [2] that reflected the commitment of academic and practice-based educators to raise the standard of practice of social workers in health. This commitment was still evident in a series of papers presented at the 1982 Annual Meeting of the Council on Social Work Education. The monograph
Work in Health Care: A Review of the Literature
[5].
Eighteen areas of knowledge needed for effective practice in health care are conceptualized. This paper draws extensively from this latest work, which explores the uniqueness of health care practice and the significant content needed within our knowledge base.
THEORETICAL FOUNDATION NECESSARY FOR PRACTICE The
theoretical
foundation
necessary
for practice
in health care must relate to the goals of that practice. 19
20
BARBARA BERKMAN~~
The goals of clinical social work in health care have been described on a global level of abstraction with specificity to health dependent on the generic or specific orientation of the author. In Bartlett’s seminal work [6], the concept of enhancing or improving social functioning appeared to dominate the conceptualization. Kahn [7] used Bartlett’s framework and emphasized the interrelation between social functioning and physical health status, stressing the individual’s need for help with coping tasks if a health problem created or exacerbated an imbalance between individuals and environment. Regensberg [S] presented the goals as helping “people to achieve their maximum status of social health. .” and to obtain maximum benefits from programs and services related to social health. More recently, a definition of clinical social work applicable to all social work practice was adopted by the Board of Directors of the National Association of Social Workers, the National Registry of Health Care Providers and the American Board of Examiners in Clinical Social Work (91. This statement speaks to the goals of clinical social work as “enhancement and maintenance of psychosocial functioning of individuals, families and small groups”. The emphasis of social work practice in health care is on the mutual interaction of the patient and the patient’s context [lo]. Depending on your theoretical perspective, that context may be the family [l I], social membership [lo, 12], the larger ecological system [ 131, or a specific disease entity [ 141. This shift in emphasis from the intrapsychic to the mutual interaction of the patient and his or her context has been important in helping the profession to develop clearer concepts and thus to intervene more effectively. In the health care system, the social worker provides services to individuals, and deals with their families and the social system during periods of stress usually associated with an illness, the development of a disabling condition, or the exacerbation of a physical handicap. The intervention is an outgrowth of the worker’s assessment of the client’s difficulty and need. This assessment is not made without value judgments, but is a product of the worker’s understanding of the etiology of the problem. There are many ways of understanding human behavior and people’s response to stress. One view largely examines their past behavior, focuses on deficits in psychological functioning, and assesses current reactions in terms of prior psychological difficulties. This is often described as a medical model, and includes a diagnostic assessment and a treatment intervention. An alternate approach, the adaptation model [ 131, examines the nature of the current stressor and the resulting alteration of an individual’s life. It directs attention to assessing what the individual needs to know to make an appropriate accommodation. In this view there is an assumption that most people in the situation would have similar reactions and similar needs specific to the critical event with which they are coping [151. For example, denial, anxiety, depression, and anger may be expected after a loss. Rather than seeing these as symptoms of malfunctioning, they can be understood as appropriate reactions that can facilitate coping.
al.
Most people have well-established ways of dealing with their feelings in normal circumstances. Difficulty often arises when old strategies for dealing with stress are not adequate for a new situation. The deficit is not in the person’s personality, but in his or her experience and knowledge. Individuals who have never previously experienced illness, bereavement, or disability may need to learn about the consequences of these new experiences and learn how to expand their repertoire of coping strategies. An awareness of different learning styles is therefore important in helping clients develop adaptive strategies. How people understand and appraise their situation will also affect the way they cope [16, 171. It is a matter of understanding how people make sense out of their world. Kegan [18] relates this process to the stage of cognitive development that an individual has reached. In this adaptation/education model the social worker is a facilitator, and the goal of intervention is change that reflects adaptation and accommodation to the new reality resulting from the altered situation. Get-main [13] contends that the adaptation model is most applicable to social work practice in the health care system. This perspective views human development and functioning, including health and illness, as outcomes of continuous exchanges between the individual and the social environment, the physical setting, and the cultural context. In contrast, Carlton [12] conceptualizes human behavior in terms of empirically observable patterns of affiliation or membership. Applying Falck’s model [19-221 to health care, he rejects the concepts of individual and environment in favor of the componential concepts of member and membership. He observes that people are social by nature and definition and that all people are members of families, communities, and a wide range of other groups. Membership can be identified by such observable criteria as blood relationships, marriage, occupation, common interest, and by such life stages as age and shared condition. Carlton underscores the social nature of human interaction and points out that memberships can be either positive or negative and that the affected person is the total of all of his or her social memberships and experiences, past and present, simultaneously internal in terms of psychological make-up and external in terms of social relationships. The ability to adapt, then, is not simply a function of personality. It reflects the social context of family, gender, race, social class, and ethnicity, as well as economic class memberships, to which is added the particular stressor with which the person is coping. All of these membership variables interact with each other to produce the person’s particular response to the health situation and facilitate the person’s ability to cope with it, positively or negatively. Get-main also emphasizes the need to understand the dynamic among stress, coping, and adaptiveness. She notes that people use an almost limitless variety of physiological, cognitive, emotional, social, and cultural processes to adapt. In Germain’s frame of reference, adaptation is a continuous process, because environments and people’s needs and goals continually change.
Social work in health care Social workers in health care must utilize a conceptual framework for understanding behavior that encompasses a view of people in a network constantly in motion: continuously reacting, interacting, and dealing with change in themselves and in their environments. Stressors can be internal and external. In the health care system stress is often the result of factors outside the individual, in the environment of the particular cultural, social, and political system of which the individual is a part. Therefore, the focus of the theoretical framework necessary as the foundation for health care practice has shifted from an emphasis on psychopathology to a focus on what people do well, on their adaptive capacities, with the goal of preventing maladaptive behavior. This is not to deny that, at times, psychological deficits or earlier emotional problems can lead to ineffective or impaired behavior. And although the emphasis of practice in health care is on enhancement of coping rather than on amelioration of already existing emotional problems, it is nevertheless incumbent on the social worker to have an understanding of psychopathology. This theoretical framework should direct us to a knowledge base which is related to the reality of practice in health care.
21
Health and Social Work.
of stress-related or psychosomatic illness, the course and management of any illness, and the impact illness has on family life. There is, however, strikingly little actual clinical work with families as a whole in health settings [24]. Because much of what social workers do involves helping patients and families cope with and adapt to changes brought about by illness and hospitalization, family therapy can be an effective framework for intervention. Many models of family treatment are short term, often task-centered, and aimed at adaptation to, rather than amelioration of, pathology. From a systems perspective, any change in the patient’s level of functioning or role within the family inevitably affects the entire family, which in turn has further effects on the patient. Family therapy is thus ideally suited for addressing such changes. helping family members adapt as required. These changes may include adjusting to a family member’s uncertain medical future or confronting a member’s imminent death. For other families the change may involve a loved one’s returning home from the hospital unable to resume prior roles or functioning, or not returning home but being placed in a long term care facility. During the past decade, there has been an abundance of material published about systemic family therapy in general, but only recently have there been attempts to adapt this model of intervention specifically to the health care setting. An area that deserves more attention is the use of systemic work to better understand and intervene more effectively with families stricken by chronic illness. Penn [25] has been writing about the generational patterns that are established in such families. Social workers in medical settings have yet to write about their experiences and ideas in this area. An important aspect of clinical work in the health field is the element of uncertainty with which increasing numbers of families are confronted as technological developments in medicine transform life-threatening diseases into chronic illnesses. Relatively little in the social work literature deals with this issue. Although more research is needed on how best to help families cope with the uncertainty, we already know some of the interventions that are helpful. These include being attuned to the medical situation of the particular patient in order to provide information that is honest and balanced in terms of positive reasons for hope and realistic causes for concern, and providing acknowledgement of how difficult ‘not knowing’ is, and being available to help. Moreover, it is important to remember that family members, including the patient, will deal with uncertainty in their own way and in their own time, which may result in lack of synchrony among members. Being out of sync can create greater stress for the family and impede successful coping [26,271. Working within a family systems perspective can be especially useful in opening lines of communication, helping family members support each other in the tension of the uncertainty, and dealing with lack of synchrony when it occurs.
Family practice
Group work practice
As a profession, social work has long appreciated the important role families play in terms of the onset
Group work has become a significant mode of social worker intervention in health care settings. Yet
PRACTICE CONSIDERATIONS
The focus of social work health care practice in this theoretical framework must be on factors that affect normal or typical growth and development in the course of living, and must include an understanding of the interaction between the biological, psychological, and cognitive. The ability to integrate physiological data may be as important to social work practice as the ability to integrate psychodynamic data. As in any practice setting, treatment interventions in health care are based on an assessment of the problems faced by a given individual or family within a specific context, taking into account both internal and external resources. If in a health setting, the emphasis is predominantly on enhancing coping with health problems, this may involve mobilizing external resources (via advocacy, provision of specific services, involvement of family and community resources) or strengthening internal resources (via support, clarification, education of the patient and family about the illness and its implications, helping to set priorities, and regulating the tempo of the coping activity). A recent trend in social work practice in health care is toward increased specialization, reflecting the specialization in medicine. One reason for the formation of social work specialty groups (for example, oncology social workers, renal disease social workers, emergency room social workers, and so forth) is the sense that specialized knowledge and skills are required. Yet it can be argued that social workers encounter the same psychosocial problems and do essentially the same things in spite of the diversity of programs [23]. Both sides of this debate are presented comprehensively in the November 1981 issue of
BARBARA BERKMAN et
22
the literature remains largely descriptive or anecdotal, with virtually no research on efficacy and little attempt to explore under what circumstances individuals benefit from their group experiences [28]. In addition, there is a lack of consistency regarding what is reported as well as variations in theoretical orientation, setting, and leadership dimensions, which make comparisons of reports difficult. Much of the available literature describes groups or group programs for patients and families who are coping with the psychosocial effects of a particular disease or life crisis such as aging or institutionalization. Most include a discussion of the special needs of the given population, the rationale for using a group approach, and the format or structure of the group. Frequently, the themes addressed by group members are also elaborated. The focus tends to be on the individual within the group and, with the exception of group curative factors or healing mechanisms, the application of group therapy to these special interest groups is not addressed. Although many of these groups are led by more than one person and often involved several disciplines, there is virtually no discussion of the complex dynamics involved in co-leadership. Type of group Although most groups in health care settings provide both information and support to their members, with the goal of increasing coping capacities and thereby fostering some behavioral change, the particular emphasis varies among groups. The types of groups identified in the health field include the following. Educational. The predominate focus is to provide information. The groups are conducted in a classroom-like manner with a didactic presentation and and answer discussion topic-centered question [29-341. Support. The predominant focus is to provide opportunities for ventilation and universalization of feelings, hope, identification, and other mutual-aid experiences [3 1,36,37,40-521. Psychoeducational or education/support. The educational and supportive foci are combined in one of two ways: structured didactic material presented by the group leader or a guest speaker, followed by an open discussion in which members share mutual concerns; or information presented more informally by an ‘expert’ leader, usually in response to specific questions from group members. Co-leadership is frequently used in the latter model in which one leader is more knowledgeable about human behavior and group dynamics and the other is more knowledgeable about the content or topic being addressed [53-66]. Behavioral change. This approach involves the use of group intervention to alter specific target behaviors such as noncompliance with medical treatment or the over-utilization of medical services [67-771. ORGANIZATIONAL
ISSUES
The social worker practicing in any health setting is confronted by a complex and changing system of authority, interaction, and communication. The com-
al.
plexity derives from the breadth of participants in service delivery and decision-making; that is, the multiple agencies serving each patient, the multiple disciplines arranged in a hierarchy of expertise and influence, and the numbers of payers for services from private insurers to governmental programs. The task for the social worker is not only to comprehend this intricate web, but also to be capable of working with it, to be able to explain it, and if necessary to be able to change it on behalf of clients being served. The nature of social work practice in all health settings, therefore, calls for a high degree of systemrelated activity. However, the intraorganizational and interorganizational experience of the inpatient in an acute care hospital may be far more pervasive and intrusive than that of clients in an ambulatory setting. The patient often lives in the organizational setting while in a stressful stage of transition. The hospital social worker concerned with psychosocial aspects of the illness experience must be sensitive to the issues the organizational setting poses for the patient [l3]. The demands on the social worker include frequent interdisciplinary collaboration, team meetings, and interorganizational relations as the social worker frequently participates in patient care conferences and in negotiations with other professionals and organizations. In recent years, social workers have been writing more about their role in the collaborative process. The literature discusses several issues that can be divided into two categories: those that are pertinent to the process of establishing collaborative practice and those that are relevant to the practitioner actually doing the work. The first category of literature discusses issues such as team development [78], the administrative support and structure that are needed to create and use an interdisciplinary team conference [79], and interagency collaboration for health planning (801. The second category focuses on themes such as one’s professional identity [81], role overlap and conflict [82], boundaries and areas of professional expertise [83], the team as reflective of systemic and patient care problems (841, and ethical issues and decision-making [85]. In addition, the literature cites several studies on the amount and quality of contact and collaboration among disciplines [86,871. Also, several articles give detailed case examples of collaborative work with different groups of patients, for example, the elderly, cancer, chronic pain, stroke, and terminally ill patients [88-901. Finally, collaboration is discussed in the literature in terms of interdisciplinary education. Examples are articles dealing with objectives for interdisciplinary learning in a course about child abuse [91], and an overview of content, problems, and issues in team training [92]. The health care system is in a period of rapid change, motivated primarily by efforts to contain the rising cost of health care services. These efforts have had direct implications for the organization of health care services. New types of organizations have been developed, such as the health maintenance organization [70,93]; there has been continuing concern about access to health care services [94]; new methods of cost control have been introduced (951; and there has been a rise of corporate involvement in the system [96]. The social worker must therefore have an
Social work in health care understanding of these matters as they occur, and also a basic organizational conceptual framework for comprehending the system and the factors that promote change. A number of sources in the social work literature provide a general orientation to organizational theory [61, 97, 981. The following organizational concepts are particularly pertinent to the health care arena. Organizational goals are important, not only in terms of identified formal goals, but also in terms of the informal or underlying goals of the many groups and individuals associated with the organization. Depending on their relative power within the system, different groups will have more or less opportunity to promote their goals within the organization [99, 1001. Organizational technology, or the different methods used by organizations to effect change, and the standards used to evaluate the effectiveness of those change methods are important factors. Organizational structure, or the decision-making framework of the organization, helps the worker recognize both the formal and the informal systems of authority and power within the organization [lOI, 1021.The orgunizutionul environment encompasses other external organizations, policy bodies, and social trends that affect the internal operation of the organization [ 1031 and methods of orgunizutionul change can be applied when system problems amenable to intervention have been identified [104-1061. The political environment of health care practice, which is constantly in flux, dramatically affects practice by changing political priorities, through the push and pull of various constituencies, through the introduction of new ideas and technologies, and the advent of new policies around health crises, such as AIDS. The bulk of health care services are financed by monies derived from the public domain. Policy decisions are made that determine the availability of services, length of service, and type of services provided to patients. These issues must be incorporated in the social work health care knowledge base if workers are competently to meet the demands of practice. Policy issues
Social workers in the health care setting are a natural source of health policy information for patients and families as well as other professionals. They are confronted by questions regarding eligibility for entitlement programs such as Medicaid, insurance coverage of services by programs such as Medicare, and the availability of community services such as home care. The social worker must be able to provide referrals to sources of assistance and services that may be unknown to the patient. For example, discharge planning is inextricably tied to developing resources for the post-hospital care of the patient [107’J The social worker must be prepared to provide a broad range of services, much of which are related to post-hospital care planning, as this is fundamental to the patient’s continued recovery from illness. Many people cannot anticipate or plan for health crisis, and therefore are unprepared for the post-hospitalization contingencies they may face. The most appropriate focus of intervention may well be one of facilitating adaptation
23
to social systems and negotiating resources, not treating or curing psychological problems. In many cases, it is a matter of supporting the patient’s family or friends, the natural support system as it adjusts to a changing set of needs. Social work’s expertise regarding the relationship between social systems and people can be a major contribution to the policy process. There are several policy topics that deserve special attention: health care finances raise questions which have become the central issue of the 1970s and 198Os, and undoubtedly will remain so. Among the factors contributing to the rise in health care costs are the growing elderly population, the introduction of new and expensive medical technologies, and expanding expectations regarding health care services. Those who pay for services, including governmental agencies such as the Health Care Financing Administration, insurance companies such as Blue Cross/Blue Shield, and employers who provide costly health insurance as an employee benefit are looking for ways to slow the inflationary spiral. Some of the methods currently used to discourage unnecessary costs are set rates of reimbursement for services such as the diagnosis-related groups, and monitoring of services, through peer review organizations. No single issue has a greater effect on the availability of services, the quality of service. and the nature of service than the issue of cost [108]. Medicare and Medicaid raise questions of entitlement, eligibility, and implementation [109, 1IO]. Long-term health care issues include access to services, quality of services, alternative services, and the appropriateness of services [I 11, 1121. Policies as they affect special populations such as children, the elderly, and the handicapped are significant concerns [ 113-l 161. Policies as they affect social work services and the availability of funding to support social work services, education, and research results from decisions made in the public policy realm. In order to be effective in the pervasive arena of health care policy, the social worker must be versed in the particulars of a policy question and be skilled in policy analysis and intervention. Legal and ethical issues
In their work with patients and other professionals, health care social workers face a complex array of legal and ethical issues which impact on their practice decisions. There are two major areas of concern. The first are questions pertaining to the treatment of patients: such as questions on prolongation of life, the provision of information, and dilemmas created by specific types of illnesses or social concerns. There are also questions on the allocation of limited resources, such as when the demand for certain services exceeds the supply. In some cases, there are clear guidelines or standards to follow, for which violation would result in legal consequences. But in many cases, new medical technologies, new illnesses, or new resource restrictions pose questions for which there are no clear answers. For example, discharge planning is an area laden with ethical and legal questions with one of its major problematic issues being the equitable allocation of scarce resources 11171.
24
BARBARA BERKMAN et al. CONCLUSION
The unique challenge of social work in health is that there is not the luxury of limiting the number of variables to which a health professional must relate. If our goal as social workers is to support the social functioning of individual and family, care must be taken not to fall into a dogmatic single factor causality mode of thinking which has too frequently directed the practices of both biomedically-based and psychodynamically-based practitioners. And, while social work has placed greater emphasis in past years on the psychological and interpersonal elements of social functioning, there is a growing substantive argument for the inclusion of borh biomedical- and psychological-based knowledge as the necessary thrust of practice. Social work has probably errored on the side of too much emphasis on psycho-analytic and psychological explanations for human behavior. It is evident to those who practice in health care that in conceptualizing the content areas necessary for competent practice, a blend of cultural, social, psychological, environmental, and biological dimensions of social functioning must be encompassed. REFERENCES
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25
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BARBARA BERKMAN et al.
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103. Wilson P. Expanding the role of social workers in coordination of health services. Hlth Sot. Work 6, 57-64, Febr. 1981. 104. Foster Z. and Leader P. How social work can influence hospital management of fatal illness. In Fundamentals of social Work Practice (Edited by Sanders er al.), DD. 200-235. Wadsworth. Monterev. CA. 1982. 105. ‘iurdach A. Skills and tactics in hoipital practice. Sot. Work 28, 279-284, July-Aug. 1983. 106. McNamara J. Social work designs: a humanistic program to enhance patient care. In Social Work Admin&alion in Healih Care (Edited by Lurie A. and Rosenberg G.), pp. 229-238. The Haworth Press, New York, 1984. 107. Lurie A. The social work advocacy role in discharge nlannimz Sot. Work Hlth Care 8. 75-85. 1982. 108. ‘Noble J: Jr and Conley R. Cost containment. In Social Work and Health Care Policy (Edited by Lum D.), pp. 151-157. Allanheld, Osmun, Totowa, NJ, 1982. 109. Spring J. Medicare: an advocacy perspective. Sot. Work HIth Care 6, 77-89,
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116. Poole D. and Carlton T. A model for analyzing utilization of maternal and child health services. Health Sot. Work 11, 209-222, 1986. 117. Blazyk S. and Canavan M. Therapeutic aspects of discharge planning. Sot. Work 30,489-496, Nov.-Dec. 1985.
Vol. 31, No.
1, PP. 19-26, 1990
0277-9536/90 S3.00 + 0.00
Printed in Great Britain. All rights reserved
Copyright (Q 1990 Pergamon Press plc
SOCIAL WORK IN HEALTH CARE: DIRECTIONS IN PRACTICE BARBARA BERMAN,’
EVELYN BONANDER,’ IRENE RUTCHICK,’
PHYLLIS SILVERMAN,’
BETH KEMLER,* LEONARD MARCUS~ and MOLLY-JANE ISAAC~~N-RUBINGER~ ‘Social Service Department, Massachusetts General Hospital, Boston, MA 02114, *Social Service Department, Children’s Hospital, Boston, MA 02115, )West Roxbury Veteran’s Administration, Human Resource and Development, West Roxbury, MA 02132 and 4Social Service Department, Massachusetts Eye and Ear Infirmary, Boston, MA 02114, U.S.A.
Abstract-As technological advances within biomedicine uncover more complex and confusing situations, social workers are forced to deal with the patient and family with greater uncertainty. To competently address today’s biomedical environment with an anticipation of tomorrow’s advances is an incredible challenge. The focus of the theoretical framework necessary as the foundation for health care practice has shifted from an emphasis on psychopathology to a focus on what people do well, on their adaptive capacities with the goal of preventing maladaptive behavior. Therefore, the focus of practice must be on factors that affect normal or typical growth and development in the course of living and must include an understanding of the interaction between the biological, psychological, cognitive, social, cultural, and environmental dimensions of social functioning.
Key words-theoretical
foundation, health, social work, therapies
INTRODUCTION The medical complex
problems
and
sophisticated,
which people present today are
frequently talented
alive under conditions
that evolved from these papers [3] examined competencies and knowledge needs for social workers in health care as conceptualized in three sophisticated educational programs. This work again demonstrated how educators, both school-based and agency-based, could collaborate to develop sound health-related social work curricula. However, these early efforts did not fully address what variables should guide curriculum development nor specifically delineate the unique characteristics of health care practice. From 1980 to 1987, the faculty of the Social Work in Health Care Program of the Massachusetts General Hospital Institute of Health Professions (IHP) were charged with the responsibility of developing specialized curricula for social work in health care [4]. The challenge was to focus on and revise the generic social work core curriculum to meet the needs of health specialists. A 2-year grant from the Lilly Endowment supported these curriculum development efforts. In 1986, the Society for Hospital Social Work Directors reconfirmed its commitment to the education of social workers in health by requesting the Institute’s faculty to update the earlier work on knowledge-base needs for social work in health. The results of those efforts have been published by the American Hospital Association in a book, Social
strange,
even
to the most
professionals.
People
are kept
never known
before.
As tech-
nological advances within biomedicine uncover more complex and confusing situations, health professionals are forced to deal with the patient and family with greater uncertainty. New roles and tensions are created for social workers and other health care providers. To competently address today’s biomedical environment with an anticipation of tomorrow’s advances is an incredible challenge. To meet the needs of continuously changing roles and practices for social workers in health care is equally challenging. The direction social work has taken to meet the demands of a dynamic health care system is clearly evidenced in the literature of the last 10 years. A brief overview of significant published works serves as background. In 1978, the Society for Hospital Social Work Directors of the American Hospital Association published a monograph titled ‘Knowledge base and program needs for effective social work practice in health’ [l]. That review delineated 13 areas of knowledge considered necessary to enable health care social workers to meet the demands of professional practice [I]. In 1980, the Society sponsored a national conference, in conjunction with the Council on Social Work Education, that addressed dilemmas schools and agencies face in education for social work practice in health care. The papers from that conference were published in a monograph [2] that reflected the commitment of academic and practice-based educators to raise the standard of practice of social workers in health. This commitment was still evident in a series of papers presented at the 1982 Annual Meeting of the Council on Social Work Education. The monograph
Work in Health Care: A Review of the Literature
[5].
Eighteen areas of knowledge needed for effective practice in health care are conceptualized. This paper draws extensively from this latest work, which explores the uniqueness of health care practice and the significant content needed within our knowledge base.
THEORETICAL FOUNDATION NECESSARY FOR PRACTICE The
theoretical
foundation
necessary
for practice
in health care must relate to the goals of that practice. 19
20
BARBARA BERKMAN~~
The goals of clinical social work in health care have been described on a global level of abstraction with specificity to health dependent on the generic or specific orientation of the author. In Bartlett’s seminal work [6], the concept of enhancing or improving social functioning appeared to dominate the conceptualization. Kahn [7] used Bartlett’s framework and emphasized the interrelation between social functioning and physical health status, stressing the individual’s need for help with coping tasks if a health problem created or exacerbated an imbalance between individuals and environment. Regensberg [S] presented the goals as helping “people to achieve their maximum status of social health. .” and to obtain maximum benefits from programs and services related to social health. More recently, a definition of clinical social work applicable to all social work practice was adopted by the Board of Directors of the National Association of Social Workers, the National Registry of Health Care Providers and the American Board of Examiners in Clinical Social Work (91. This statement speaks to the goals of clinical social work as “enhancement and maintenance of psychosocial functioning of individuals, families and small groups”. The emphasis of social work practice in health care is on the mutual interaction of the patient and the patient’s context [lo]. Depending on your theoretical perspective, that context may be the family [l I], social membership [lo, 12], the larger ecological system [ 131, or a specific disease entity [ 141. This shift in emphasis from the intrapsychic to the mutual interaction of the patient and his or her context has been important in helping the profession to develop clearer concepts and thus to intervene more effectively. In the health care system, the social worker provides services to individuals, and deals with their families and the social system during periods of stress usually associated with an illness, the development of a disabling condition, or the exacerbation of a physical handicap. The intervention is an outgrowth of the worker’s assessment of the client’s difficulty and need. This assessment is not made without value judgments, but is a product of the worker’s understanding of the etiology of the problem. There are many ways of understanding human behavior and people’s response to stress. One view largely examines their past behavior, focuses on deficits in psychological functioning, and assesses current reactions in terms of prior psychological difficulties. This is often described as a medical model, and includes a diagnostic assessment and a treatment intervention. An alternate approach, the adaptation model [ 131, examines the nature of the current stressor and the resulting alteration of an individual’s life. It directs attention to assessing what the individual needs to know to make an appropriate accommodation. In this view there is an assumption that most people in the situation would have similar reactions and similar needs specific to the critical event with which they are coping [151. For example, denial, anxiety, depression, and anger may be expected after a loss. Rather than seeing these as symptoms of malfunctioning, they can be understood as appropriate reactions that can facilitate coping.
al.
Most people have well-established ways of dealing with their feelings in normal circumstances. Difficulty often arises when old strategies for dealing with stress are not adequate for a new situation. The deficit is not in the person’s personality, but in his or her experience and knowledge. Individuals who have never previously experienced illness, bereavement, or disability may need to learn about the consequences of these new experiences and learn how to expand their repertoire of coping strategies. An awareness of different learning styles is therefore important in helping clients develop adaptive strategies. How people understand and appraise their situation will also affect the way they cope [16, 171. It is a matter of understanding how people make sense out of their world. Kegan [18] relates this process to the stage of cognitive development that an individual has reached. In this adaptation/education model the social worker is a facilitator, and the goal of intervention is change that reflects adaptation and accommodation to the new reality resulting from the altered situation. Get-main [13] contends that the adaptation model is most applicable to social work practice in the health care system. This perspective views human development and functioning, including health and illness, as outcomes of continuous exchanges between the individual and the social environment, the physical setting, and the cultural context. In contrast, Carlton [12] conceptualizes human behavior in terms of empirically observable patterns of affiliation or membership. Applying Falck’s model [19-221 to health care, he rejects the concepts of individual and environment in favor of the componential concepts of member and membership. He observes that people are social by nature and definition and that all people are members of families, communities, and a wide range of other groups. Membership can be identified by such observable criteria as blood relationships, marriage, occupation, common interest, and by such life stages as age and shared condition. Carlton underscores the social nature of human interaction and points out that memberships can be either positive or negative and that the affected person is the total of all of his or her social memberships and experiences, past and present, simultaneously internal in terms of psychological make-up and external in terms of social relationships. The ability to adapt, then, is not simply a function of personality. It reflects the social context of family, gender, race, social class, and ethnicity, as well as economic class memberships, to which is added the particular stressor with which the person is coping. All of these membership variables interact with each other to produce the person’s particular response to the health situation and facilitate the person’s ability to cope with it, positively or negatively. Get-main also emphasizes the need to understand the dynamic among stress, coping, and adaptiveness. She notes that people use an almost limitless variety of physiological, cognitive, emotional, social, and cultural processes to adapt. In Germain’s frame of reference, adaptation is a continuous process, because environments and people’s needs and goals continually change.
Social work in health care Social workers in health care must utilize a conceptual framework for understanding behavior that encompasses a view of people in a network constantly in motion: continuously reacting, interacting, and dealing with change in themselves and in their environments. Stressors can be internal and external. In the health care system stress is often the result of factors outside the individual, in the environment of the particular cultural, social, and political system of which the individual is a part. Therefore, the focus of the theoretical framework necessary as the foundation for health care practice has shifted from an emphasis on psychopathology to a focus on what people do well, on their adaptive capacities, with the goal of preventing maladaptive behavior. This is not to deny that, at times, psychological deficits or earlier emotional problems can lead to ineffective or impaired behavior. And although the emphasis of practice in health care is on enhancement of coping rather than on amelioration of already existing emotional problems, it is nevertheless incumbent on the social worker to have an understanding of psychopathology. This theoretical framework should direct us to a knowledge base which is related to the reality of practice in health care.
21
Health and Social Work.
of stress-related or psychosomatic illness, the course and management of any illness, and the impact illness has on family life. There is, however, strikingly little actual clinical work with families as a whole in health settings [24]. Because much of what social workers do involves helping patients and families cope with and adapt to changes brought about by illness and hospitalization, family therapy can be an effective framework for intervention. Many models of family treatment are short term, often task-centered, and aimed at adaptation to, rather than amelioration of, pathology. From a systems perspective, any change in the patient’s level of functioning or role within the family inevitably affects the entire family, which in turn has further effects on the patient. Family therapy is thus ideally suited for addressing such changes. helping family members adapt as required. These changes may include adjusting to a family member’s uncertain medical future or confronting a member’s imminent death. For other families the change may involve a loved one’s returning home from the hospital unable to resume prior roles or functioning, or not returning home but being placed in a long term care facility. During the past decade, there has been an abundance of material published about systemic family therapy in general, but only recently have there been attempts to adapt this model of intervention specifically to the health care setting. An area that deserves more attention is the use of systemic work to better understand and intervene more effectively with families stricken by chronic illness. Penn [25] has been writing about the generational patterns that are established in such families. Social workers in medical settings have yet to write about their experiences and ideas in this area. An important aspect of clinical work in the health field is the element of uncertainty with which increasing numbers of families are confronted as technological developments in medicine transform life-threatening diseases into chronic illnesses. Relatively little in the social work literature deals with this issue. Although more research is needed on how best to help families cope with the uncertainty, we already know some of the interventions that are helpful. These include being attuned to the medical situation of the particular patient in order to provide information that is honest and balanced in terms of positive reasons for hope and realistic causes for concern, and providing acknowledgement of how difficult ‘not knowing’ is, and being available to help. Moreover, it is important to remember that family members, including the patient, will deal with uncertainty in their own way and in their own time, which may result in lack of synchrony among members. Being out of sync can create greater stress for the family and impede successful coping [26,271. Working within a family systems perspective can be especially useful in opening lines of communication, helping family members support each other in the tension of the uncertainty, and dealing with lack of synchrony when it occurs.
Family practice
Group work practice
As a profession, social work has long appreciated the important role families play in terms of the onset
Group work has become a significant mode of social worker intervention in health care settings. Yet
PRACTICE CONSIDERATIONS
The focus of social work health care practice in this theoretical framework must be on factors that affect normal or typical growth and development in the course of living, and must include an understanding of the interaction between the biological, psychological, and cognitive. The ability to integrate physiological data may be as important to social work practice as the ability to integrate psychodynamic data. As in any practice setting, treatment interventions in health care are based on an assessment of the problems faced by a given individual or family within a specific context, taking into account both internal and external resources. If in a health setting, the emphasis is predominantly on enhancing coping with health problems, this may involve mobilizing external resources (via advocacy, provision of specific services, involvement of family and community resources) or strengthening internal resources (via support, clarification, education of the patient and family about the illness and its implications, helping to set priorities, and regulating the tempo of the coping activity). A recent trend in social work practice in health care is toward increased specialization, reflecting the specialization in medicine. One reason for the formation of social work specialty groups (for example, oncology social workers, renal disease social workers, emergency room social workers, and so forth) is the sense that specialized knowledge and skills are required. Yet it can be argued that social workers encounter the same psychosocial problems and do essentially the same things in spite of the diversity of programs [23]. Both sides of this debate are presented comprehensively in the November 1981 issue of
BARBARA BERKMAN et
22
the literature remains largely descriptive or anecdotal, with virtually no research on efficacy and little attempt to explore under what circumstances individuals benefit from their group experiences [28]. In addition, there is a lack of consistency regarding what is reported as well as variations in theoretical orientation, setting, and leadership dimensions, which make comparisons of reports difficult. Much of the available literature describes groups or group programs for patients and families who are coping with the psychosocial effects of a particular disease or life crisis such as aging or institutionalization. Most include a discussion of the special needs of the given population, the rationale for using a group approach, and the format or structure of the group. Frequently, the themes addressed by group members are also elaborated. The focus tends to be on the individual within the group and, with the exception of group curative factors or healing mechanisms, the application of group therapy to these special interest groups is not addressed. Although many of these groups are led by more than one person and often involved several disciplines, there is virtually no discussion of the complex dynamics involved in co-leadership. Type of group Although most groups in health care settings provide both information and support to their members, with the goal of increasing coping capacities and thereby fostering some behavioral change, the particular emphasis varies among groups. The types of groups identified in the health field include the following. Educational. The predominate focus is to provide information. The groups are conducted in a classroom-like manner with a didactic presentation and and answer discussion topic-centered question [29-341. Support. The predominant focus is to provide opportunities for ventilation and universalization of feelings, hope, identification, and other mutual-aid experiences [3 1,36,37,40-521. Psychoeducational or education/support. The educational and supportive foci are combined in one of two ways: structured didactic material presented by the group leader or a guest speaker, followed by an open discussion in which members share mutual concerns; or information presented more informally by an ‘expert’ leader, usually in response to specific questions from group members. Co-leadership is frequently used in the latter model in which one leader is more knowledgeable about human behavior and group dynamics and the other is more knowledgeable about the content or topic being addressed [53-66]. Behavioral change. This approach involves the use of group intervention to alter specific target behaviors such as noncompliance with medical treatment or the over-utilization of medical services [67-771. ORGANIZATIONAL
ISSUES
The social worker practicing in any health setting is confronted by a complex and changing system of authority, interaction, and communication. The com-
al.
plexity derives from the breadth of participants in service delivery and decision-making; that is, the multiple agencies serving each patient, the multiple disciplines arranged in a hierarchy of expertise and influence, and the numbers of payers for services from private insurers to governmental programs. The task for the social worker is not only to comprehend this intricate web, but also to be capable of working with it, to be able to explain it, and if necessary to be able to change it on behalf of clients being served. The nature of social work practice in all health settings, therefore, calls for a high degree of systemrelated activity. However, the intraorganizational and interorganizational experience of the inpatient in an acute care hospital may be far more pervasive and intrusive than that of clients in an ambulatory setting. The patient often lives in the organizational setting while in a stressful stage of transition. The hospital social worker concerned with psychosocial aspects of the illness experience must be sensitive to the issues the organizational setting poses for the patient [l3]. The demands on the social worker include frequent interdisciplinary collaboration, team meetings, and interorganizational relations as the social worker frequently participates in patient care conferences and in negotiations with other professionals and organizations. In recent years, social workers have been writing more about their role in the collaborative process. The literature discusses several issues that can be divided into two categories: those that are pertinent to the process of establishing collaborative practice and those that are relevant to the practitioner actually doing the work. The first category of literature discusses issues such as team development [78], the administrative support and structure that are needed to create and use an interdisciplinary team conference [79], and interagency collaboration for health planning (801. The second category focuses on themes such as one’s professional identity [81], role overlap and conflict [82], boundaries and areas of professional expertise [83], the team as reflective of systemic and patient care problems (841, and ethical issues and decision-making [85]. In addition, the literature cites several studies on the amount and quality of contact and collaboration among disciplines [86,871. Also, several articles give detailed case examples of collaborative work with different groups of patients, for example, the elderly, cancer, chronic pain, stroke, and terminally ill patients [88-901. Finally, collaboration is discussed in the literature in terms of interdisciplinary education. Examples are articles dealing with objectives for interdisciplinary learning in a course about child abuse [91], and an overview of content, problems, and issues in team training [92]. The health care system is in a period of rapid change, motivated primarily by efforts to contain the rising cost of health care services. These efforts have had direct implications for the organization of health care services. New types of organizations have been developed, such as the health maintenance organization [70,93]; there has been continuing concern about access to health care services [94]; new methods of cost control have been introduced (951; and there has been a rise of corporate involvement in the system [96]. The social worker must therefore have an
Social work in health care understanding of these matters as they occur, and also a basic organizational conceptual framework for comprehending the system and the factors that promote change. A number of sources in the social work literature provide a general orientation to organizational theory [61, 97, 981. The following organizational concepts are particularly pertinent to the health care arena. Organizational goals are important, not only in terms of identified formal goals, but also in terms of the informal or underlying goals of the many groups and individuals associated with the organization. Depending on their relative power within the system, different groups will have more or less opportunity to promote their goals within the organization [99, 1001. Organizational technology, or the different methods used by organizations to effect change, and the standards used to evaluate the effectiveness of those change methods are important factors. Organizational structure, or the decision-making framework of the organization, helps the worker recognize both the formal and the informal systems of authority and power within the organization [lOI, 1021.The orgunizutionul environment encompasses other external organizations, policy bodies, and social trends that affect the internal operation of the organization [ 1031 and methods of orgunizutionul change can be applied when system problems amenable to intervention have been identified [104-1061. The political environment of health care practice, which is constantly in flux, dramatically affects practice by changing political priorities, through the push and pull of various constituencies, through the introduction of new ideas and technologies, and the advent of new policies around health crises, such as AIDS. The bulk of health care services are financed by monies derived from the public domain. Policy decisions are made that determine the availability of services, length of service, and type of services provided to patients. These issues must be incorporated in the social work health care knowledge base if workers are competently to meet the demands of practice. Policy issues
Social workers in the health care setting are a natural source of health policy information for patients and families as well as other professionals. They are confronted by questions regarding eligibility for entitlement programs such as Medicaid, insurance coverage of services by programs such as Medicare, and the availability of community services such as home care. The social worker must be able to provide referrals to sources of assistance and services that may be unknown to the patient. For example, discharge planning is inextricably tied to developing resources for the post-hospital care of the patient [107’J The social worker must be prepared to provide a broad range of services, much of which are related to post-hospital care planning, as this is fundamental to the patient’s continued recovery from illness. Many people cannot anticipate or plan for health crisis, and therefore are unprepared for the post-hospitalization contingencies they may face. The most appropriate focus of intervention may well be one of facilitating adaptation
23
to social systems and negotiating resources, not treating or curing psychological problems. In many cases, it is a matter of supporting the patient’s family or friends, the natural support system as it adjusts to a changing set of needs. Social work’s expertise regarding the relationship between social systems and people can be a major contribution to the policy process. There are several policy topics that deserve special attention: health care finances raise questions which have become the central issue of the 1970s and 198Os, and undoubtedly will remain so. Among the factors contributing to the rise in health care costs are the growing elderly population, the introduction of new and expensive medical technologies, and expanding expectations regarding health care services. Those who pay for services, including governmental agencies such as the Health Care Financing Administration, insurance companies such as Blue Cross/Blue Shield, and employers who provide costly health insurance as an employee benefit are looking for ways to slow the inflationary spiral. Some of the methods currently used to discourage unnecessary costs are set rates of reimbursement for services such as the diagnosis-related groups, and monitoring of services, through peer review organizations. No single issue has a greater effect on the availability of services, the quality of service. and the nature of service than the issue of cost [108]. Medicare and Medicaid raise questions of entitlement, eligibility, and implementation [109, 1IO]. Long-term health care issues include access to services, quality of services, alternative services, and the appropriateness of services [I 11, 1121. Policies as they affect special populations such as children, the elderly, and the handicapped are significant concerns [ 113-l 161. Policies as they affect social work services and the availability of funding to support social work services, education, and research results from decisions made in the public policy realm. In order to be effective in the pervasive arena of health care policy, the social worker must be versed in the particulars of a policy question and be skilled in policy analysis and intervention. Legal and ethical issues
In their work with patients and other professionals, health care social workers face a complex array of legal and ethical issues which impact on their practice decisions. There are two major areas of concern. The first are questions pertaining to the treatment of patients: such as questions on prolongation of life, the provision of information, and dilemmas created by specific types of illnesses or social concerns. There are also questions on the allocation of limited resources, such as when the demand for certain services exceeds the supply. In some cases, there are clear guidelines or standards to follow, for which violation would result in legal consequences. But in many cases, new medical technologies, new illnesses, or new resource restrictions pose questions for which there are no clear answers. For example, discharge planning is an area laden with ethical and legal questions with one of its major problematic issues being the equitable allocation of scarce resources 11171.
24
BARBARA BERKMAN et al. CONCLUSION
The unique challenge of social work in health is that there is not the luxury of limiting the number of variables to which a health professional must relate. If our goal as social workers is to support the social functioning of individual and family, care must be taken not to fall into a dogmatic single factor causality mode of thinking which has too frequently directed the practices of both biomedically-based and psychodynamically-based practitioners. And, while social work has placed greater emphasis in past years on the psychological and interpersonal elements of social functioning, there is a growing substantive argument for the inclusion of borh biomedical- and psychological-based knowledge as the necessary thrust of practice. Social work has probably errored on the side of too much emphasis on psycho-analytic and psychological explanations for human behavior. It is evident to those who practice in health care that in conceptualizing the content areas necessary for competent practice, a blend of cultural, social, psychological, environmental, and biological dimensions of social functioning must be encompassed. REFERENCES
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