Advancing Social Work Practice in the Health Care Field

Emerging Issues and New Perspectives

Gary Rosenberg, Helen Rehr, Helen Rehr, Dsw

• Publisher: Routledge
• Year: 2012
• eBook ISBN: 9781136565717
• Topic: Medicine
• Subtopic: Health Care Delivery

Commemorating the 75th anniversary of the Department of Social Work at the Mount Sinai Medical Center in New York City, this innovative and exciting book traces the growth of the social work mission and the development of vanguard social work programs at Mount Sinai. Leading social work educators and practitioners look at where the profession is today and speculate on where it might be going. Each article is new and original to this book, and each contributor is a distinguished representative from his specialty in the field. Advancing Social Work Practice in the Health Care Field, with its wealth of historical, practical, and theoretical information, reflects today's state of the art in selected areas and should serve as an information source not only for practitioners and administrators, but also for educators who are committed to enhancing the social work services and the quality of social health care.

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Introduction: Posing the Issues

Helen Rehr, DSW

The times are inhospitable now, and they will remain so in the near future for the social services, for social welfare, and for social health policy. The next five years, and perhaps the entire decade of the 1980s, will be years of major constraints, certainly of conservative and perhaps regressive social health policies. It is true that we have seen a progressive and conservative ebb and flow over time in which we have lost some social programs and gained others. If we think back, we are aware that history has shown uphill but steady advances in this country’s social philosophy. The climate of today is at best that of a steady state of fiscal constraint and no change. History, however, has demonstrated that neither “no change” nor “regressive” policies are compatible for long with the public’s underlying belief in American social democracy.

This, then, becomes the time for stock-taking. Where and under what auspices will social work practice? Where should social work in health care place its emphasis? Should it concentrate on enhancing services to individuals through a range of modalities? Should it concentrate on social health policy and planning of services for targeted populations? Should it review present institutional arrangements in the way they reach out to and serve those in need? Are these issues in conflict? Are they reconcilable? The old social work dilemma resurfaces but with new and fresh perspectives.

Social Epidemiology

Bess Dana poses the key issue of the contribution of social epidemiology to social work practice in Chapter 2 of our book, “The Social Work-Community Medicine Connection.” Epidemiology is community medicine’s contribution to medicine’s way of studying the occurrence of disease in populations and in communities. Social epidemiology can offer social work the means to uncover a population’s and/or a community’s social health needs, its social diseases and disorders. With this approach, social work could direct its efforts more effectively not only in the formulation or policy planning but also in the projection of needed services.

In introducing community medicine’s potential for use by social work, Dana likens its present-day relevance to the impetus that psychiatry gave to a social work in the past. Drawing on community medicine approaches can expand social work practice and its educational bases. Augmenting the clinical case problem-resolution emphasis, community medicine emphasizes problem-identification and -solving for population groups. Dana’s emphasis is on health maintenance and on responsibilities that the health care establishment needs to assume. She sees the need to address wellness rather than disease.

Community medicine has two major functions: the promotion and the protection of the public’s health and the identification and solution of health problems in population groups. These can be likened to social work’s social planning and action functions. Community medicine underpins the biological sciences and draws on a multifacted interdisciplinary and interprofessional faculty, who represent the social, behavioral, and environmental sciences. Essentially, its focus is on the person-made social and health problems in the environment. In addition, biopsychosocial teachings are directed toward affecting the clinical attitudes and behaviors of tomorrow’s physicians. Community medicine’s formulations in promoting the community’s health include evaluation of existing programs and planning for changes. The philosophy that guides community medicine is that it serves as the catalyst among a number of constituencies, consumers, providers, and others in promoting synergistic approaches to solving problems. One of the challenges to social work is that it sometimes appears as if it has lost its social mission. Its major concentration has been on the sick patient in a hospital-based practice; it has focused on the impact of illness and hospitalization on the individual and his family. Dana credits the growth of quality social services and the development of high-social-risk screening and case-finding programs but claims that social work has remained tied to the medical model of care, in this way safeguarding its place in the medical care system. This has meant that in its programs, social work may have been serving providers’ needs first and those of consumers second.

In spite of the growth of its programs in health care, social work has had no major influence on health promotion, on health maintenance, on prevention, or on the development of new programs to meet needs evidenced by given populations. Implied in Dana’s projections is that social work will have to go outside its institutional base into the social environments that affect people. Whether institutional services are meeting needs is a question that requires assessment. Emphases now largely placed on secondary and tertiary care probably will have to be extended to include primary care and primary prevention.

Can a profession that has placed its major efforts in health care on clinical enterprises and that has demonstrated its effectiveness in direct social services to individuals, families, and small groups take on a totally new function? Can social work, which has served individuals and small groups, assume a target population approach without losing its clinical expertise? Why should social work not continue to do what it does best? Can social work take responsibility for all the social-health problems we see in this country? Can it be all things to all people? The conflict, one of long standing in social work, is raised again by the introduction of the social epidemiology connection to social work. We are reminded of the Flexner Report on the state of medicine over seventy years ago, which resulted in the separation of the public health from medicine.

Where should social work place its major emphases: on the individual good (needs- or service-oriented) or on the public good (policy- and planning-oriented)? If social work concenrates on one, does the other get lost? Is this polarization inevitable? Dana needs to be read for her point of view which reconciles the clinical and the social epidemiological approaches into a partnership congruent with social work’s goals and values.

Education for Social Work Practice

Is social work education adequately preparing the graduate for practice? Is the emphasis on the generic social worker valid for social work practice in health care? How closely related is academic social work to the field of practice? These are the issues that underlie Neil Bracht’s writings in Chapter 3, “Preparing New Generations of Social Workers for Practice in Health Settings.”

In the last twenty years, a burst of new medical and social support services have developed that are relatively specialized in knowledge and in concentration. Almost all of these new programs have introduced a social work component in their services. We find new programs in perinatology, renal dialysis and transplant, health maintenance organizations, care of the developmentally disabled as well as the physically handicapped, in primary care, and in emergency medicine. There are also specialized services for patients with multiple sclerosis, amyotrophic lateral sclerosis, myasthenia gravis, and cystic fibrosis, for example. Social work is practicing in neighborhood health centers and in community outreach programs. Institutional delivery problems have brought social work into patient representative, ombudsman, and advocacy programs. Self-help groups, home health support services, long-term care programs, and services aimed at substance abuse, physical abuse, and sexual abuse have also drawn on social work for input. We are still active in the old working arenas of the hospital and clinic and still make adaptations to the fragmentation and discontinuities that persist in these settings. But advances suggest that social work will need to become ready for the future forms of practice presaged by the newer programs. Education today deals with the old and not with the new; changes are vitally needed in our educational curricula.

In his Health Belief Model, Bracht makes an exciting projection, which attempts to reconcile current needs at both the preventive and the clinical levels of care. Affluent and impoverished Americans face the same range of social health disorders, and these require new approaches in health promotion as well as in service delivery. Some of these are caused by emphysema, heart disease, certain liver disorders, hypertension, mental health problems, accidents, violence, and drug abuse. Most are caused by life-style disorders emanating from social, physical, psychological, and environmental risk factors. Studies and demonstrations indicate that groups can modify behaviors and reduce risk factors. The elimination of smoking and the reduction of stress are two such risk-prevention factors. Educators in formal medicine, public health, or the allied health care professions have yet come to tap the potential of the Health Belief Model or of the role of specialized social health services. Like Dana, Bracht uses a biopsychosocial frame of reference, which addresses health promotion as well as the clinical diagnosis and treatment of the individual. The skills that require development deal with enhancing motivation for self-responsibility for one’s own health maintenance and disease control. An illness-prevention and health-promotion focus is a natural one for social work concentration. Social work is well prepared in understanding the risk factors relevant to social health diseases; the understanding of the etiology of behaviors and attitudes is part of its armamentarium. It has developed skills in securing involvement of consumer groups. The use of group and self-help methods as well as community education programs may be ways of securing individuals’ investment in their own change behaviors.

Citing the many changes in health care and noting what he believes the future emphases will be, Bracht makes a strong case for educational specialization in health care social work. However, the worry is whether an alliance between field and academia can be achieved. Many leaders of existing social agencies are concerned that change may disrupt their programs. Yet if experimental programs are not developed, it will be difficult to project the development of a new generation of social workers with needed skills. Similarly, if academicians are not exposed to the burst of new social work endeavors in health care, the educational emphasis will remain on the old. What is needed is joint planning by the field and school for the education of tomorrow’s social health workers. Planners need to define new curricular content and the hows of implementation. How do we prepare a worker to achieve the multifaceted and flexible skills necessary to contribute to new programs and to invent them? Does generic social work lend itself to these requirements? Or is the social work health specialist essential? Bracht poses ways to reconcile education and practice, to modify their discrepancies while creating a specialist in health care who has the necessary flexibility and inventiveness, who is prepared for a pluralistic health care system, for working collaboratively with other health care professions, and who can use social epidemiological as well as evaluation techniques.

Knowledge-Building for Practice

Should a practitioner be expected to become sufficiently knowledgeable to assume evaluation and study functions? Practitioners have been troubled by the separation of the service and study processes, which leaves them to the mercy of researchers, who often find social work interventions inadequate and nonproductive. Studies are often undertaken by sociologists who have little or no understanding of the nuances or the intricacies of practice interventions and who fault social work for its lack of clinical rigor. When findings tend to denigrate their work, it is not surprising that social workers eschew involvement in social research. Does the social work practitioner have the responsibility for assuming a role in knowledge-building? Rosalie Kane (Chapter 4) avoids the term “research” in her title for the reasons noted and also because clinicians do not see its connection with the “art” of practice. Identifying the locus of practice for the health care social worker as the arena where clinical questions should be raised, Kane offers the strongest inducement to date for the practitioner’s investment in studies. The workers’ interests should determine the direction of knowledge-building efforts. If workers could learn to pose the questions arising from their primary practice interests, this step would spur their motivation to seek the information and facts needed to answer the questions.

What questions evoke the most interest for social workers in health care? Most frequently their quest is for clearer understanding of the psychosocial etiology of physical and mental health problems, of the criteria for use of specific treatment modalities, and of the effectiveness of social work interventions. Do these questions lend themselves to study? Would such knowledge be helpful? Social workers are specifically trained and particularly expert in making observations. Observations are the first step in the evaluation of studies. They are the bread and butter of practice for all social workers, which help them speculate about the possible patterns in one case or in a series. Getting the facts and establishing the relationships among them help social workers to look for explanations of what they have observed. If their observations can be explained, then social workers are on their way toward making predictions. Predictions are the rationale of any social worker’s interventions. Are we prepared to take the risk of making them explicit? Clinical social work is based on history-taking and assessment. Social workers test their speculations as they deliver services. Kane shows practitioners the many ways to become involved in self-study and how to join with social work researchers but retain a major piece of the study action.

Kane offers exciting suggestions to social work educators about their analyses of data, which could be useful to social work practice. She believes that practioners could then draw on these projections to test their practice against existing ideas. She opens up a wide avenue of questions where answers would affect social service programming and delivery. Social workers in health settings are especially well placed to answer some issues through their work with clients with a broad variety of illnesses. Their work with other health care professionals opens other opportunities to learn what happens to groups who have given disorders and receive specialized treatments. Applied studies of their own caseloads could be broadened to include groups who do not receive social work services in order to accentuate a social epidemiological approach. The exciting by-product of engaging in study is the opportunity to put new knowledge back into one’s practice. Kane’s insightful paper gives definitive guidelines for social workers in health settings to lead the field in professional knowledge-building.

Methods of Social Work Intervention

Chapters 5 and 6 deal with intervention issues for social work in health settings. Laura Epstein (Chapter 5) suggests that the short-term, task-oriented approach has high relevance for the problems posed by people using medical care. Helen Nor-then (Chapter 6) believes that the group modality can serve a significant number who cross hospital thresholds and other health care settings. Do acute and chronic illnesses lend themselves to a problem-oriented approach? Is that what our clients seek? Do our clients want to work on their problems with peers who have similar concerns? What do social workers value as the most helpful interventions to clients? What problems do they pose for social workers?

Task-Centered Casework in Health Settings

Epstein notes that the answers are not at hand as to what therapeutic interventions best help people in trouble; she also enunciates clearly the dilemmas that task- centered casework poses for social workers. Epstein restates all the questions that have been asked about task-centered casework since its beginning use by social work. She makes no claims for short-term therapy over and beyond what studies have validated. The work of Berkman and Rehr (1972), Volland (1977), Spano (1977), Meites (1976), Coulton (1978), Rehr (1979), and a host of others over the last fifteen years has documented the place of short-term treatment via problem-contract-outcome studies of social work services in hospitals. The task-centered model has been a valuable clinical one to health care social workers, who have used short-term treatment in their work with patients and families for many years.

However, problem-to-contract-to-outcome evaluations do not always resolve the value conflicts social workers experience with short-term treatment. Can social workers overcome their sense of frustration and lack of satisfaction with the limited opportunities to continue working with clients who, they believe, need further help? What part do the illness and its crisis impact play in governing the choice and extent of the treatment modality of patients and their families? Do institutional arrangements, such as the length of hospitalization, impose a specific and time-limited social work approach on practitioners? Can the task-centered approach deal with the client’s sufferings, feelings, and pain adequately? Epstein does not address these issues for social workers in health care, but she does outline the value of task-centered casework as shown in the results of extensive research on short-term therapy. She also offers a philosophical base and a step-by-step paradigm for initiating short-term task-centered treatment and lists a comprehensive bibliography.

Social Work Groups in Health Settings

Is illness an experience that binds people together? Is there comparability among them from which individuals can take solace and help from each other? Can group encounters serve in the promotion of health? Does the group method lend itself to health settings? Why has it been eschewed; why have individual and family services been preferred methods? In Chapter 6, “Social Work Groups in Health Settings: Promises and Problems,” Helen Northen sets forth the premise that group process can be utilized to affect the intrapersonal, interpersonal, and environmental situations of those with whom we work. To Northen, the group is not limited to the sociological definition of a unit or two or more people who share common goals over time. She projects a broader definition of group, which covers an aggregate of persons for whom neither time nor cohesiveness exist initially, i.e., just a number of people together. The excitement in this projection is that it acknowledges the range of endeavors social workers in hospitals are undertaking in one-time encounters, which may or may not continue in further sessions, when they work with people gathered together in waiting rooms, or with patients in a clinic, or with those patients who have a specific disease. These group encounters are targeted to people engaged in a common experience; the group’s purpose is situationally determined. Groups in a hospital setting form naturally and using them positively is well suited to the types of needs that patients and their families evidence. Illness, disability, and the impact of the hospital experience are disruptive and distressful to an individual and his family. While we know that reactions differ from individual to individual, the events may be conceived as common to those who experience them. The group acts as a mutual aid system with a give and t...

Table of contents

• Cover
• Half Title
• About the Editors
• Title Page
• Copyright
• Contents
• Contributors
• Preface
• 1. Introduction: Posing the Issues
• 2. The Social Work-Community Medicine Connection
• 3. Preparing New Generations of Social Workers for Practice in Health Settings
• 4. Knowledge Development for Social Work Practice in Health
• 5. Short-Term Treatment in Health Settings: Issues, Concepts, Dilemmas
• 6. Social Work Groups in Health Settings: Promises and Problems
• 7. Clinical Contributions to Administrative Practice
• 8. Advancing Social Work Practice in Health Care
• Index