Diagnosis in Social Work

New Imperatives

Francis J Turner

• Publisher: Routledge
• Year: 2013
• ISBN:
  9781136388033
• Edition: 1
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

How can you make necessary professional judgments without being judgmental?Assessment and diagnostic skills are essential professional tools for the social worker, but all too often they are neglected or downplayed. Diagnosis in Social Work argues for the reinstatement of social diagnosis to its former place as an essential concept in social work. This courageous book demonstrates the detrimental impact of the loss of diagnostic skills on the quality of social work intervention.Combining meticulous history with insightful analysis, Diagnosis in Social Work shows how the concept of diagnosis in social work has been misunderstood. It examines the negative, narrow definition of diagnosis offered in commonly used texts. Diagnosis in Social Work includes the tools you need to use the power of correct, careful diagnosis, including:

• case examples of social work diagnoses
• a thorough profile of the judgments constituting a social work diagnosis
• suggestions to enhance diagnostic acumen
• an analysis of diagnosis as a process and a fact
• ways to use computers in diagnosis
• an assessment of the risks of diagnosis

Diagnosis in Social Work includes everything social work practitioners need to know about the process and meaning of this sorely neglected part of the field. It is an ideal textbook as well, and it offers suggestions for further research.

Chapter 1

Introduction

The organizing thesis behind this work is that unless our profession turns once again to a broad acceptance of the concept and content of diagnosis as the heart of social work practice, we deprive our clients of a powerful helping resource and thus fail in our responsibility to them.

Although the project had been germinating in my mind for some ten years, it came to conceptual fruition one January morning in Cleveland during a snowstorm. I had just left Case Western Reserve University and was headed home to Kitchener, Ontario, about a seven-hour drive, when I discovered that the windshield wipers on my car would not work. I stopped at a nearby auto mechanic's shop seeking assistance. The mechanic on duty listened sympathetically and then informed me in all seriousness that he would not be able to tell me if he could help until he “carried out a diagnosis of the situation.” His friendly professionalism conveyed an air of confidence. After about fifteen minutes, he reported to me both the good news and bad news, and what he would be able to do and with what level of assurance as to the prognosis for my next few hours of driving.

Here was an instance of the use of the term, concept, and application of diagnosis that was of considerable assistance to me as a driver. As I later thought about our conversation, it reinforced my long-held conviction that no one profession owns this term. It is a generic term that brings security to clients and practitioners in all professions.

Just two days after I had begun writing the first chapter of this book, the six o'clock news reported that during that afternoon a social worker in a distant city, in the course of making a home visit by herself to a single woman client, had been brutally murdered by this client. The client, according to the news broadcaster, was reported to have had a history of “mental upset.”

Without knowing more about this tragic situation, I wondered whether this social worker had made a conscious judgment about her own safety in deciding to carry out this visit alone, or was she like so many social workers I meet who state they never make judgments or assign labels or diagnose?

Perhaps the question of her own safety, or lack thereof, had not entered her mind. Yet another possibility, one to which we must all pay heed, is that she indeed had carefully weighed all the available information and made the judgment that no risk was involved. It is important to know when a misdiagnosis has been made, for it then pushes us as a profession to ask if the deficit was in us or in a lack of available knowledge.

Objectives

I have a threefold objective in writing this book. The first is to review the development of the concept of diagnosis in social work since it first formally became an essential part of the profession's lexicon. This occurred with the publication of Mary Richmond's book Social Diagnosis in 1917. The second objective is to put forward an argument that this concept's change in status over the decades from an object of pride to a pejorative word stems from a serious misunderstanding of the term diagnosis. This misunderstanding led to a sociopolitical conviction of the need for our profession to separate itself from terminology presumed to be the property of another profession. My third objective: I suggest that this reluctance to incorporate the term has had a negative impact on the profession and its commitment to accountability and, in so doing, has deprived clients of the quality level of service that we are capable of providing. If this point can be validated, then this discussion of terminology moves beyond the halls of academic debate into the realm of professional ethics.

The discussion focuses principally on those aspects of social work practice that emphasize direct work with clients—that is, that component of practice sometimes called casework, clinical work, micropractice, direct intervention, or therapy. This discussion does not presume a dichotomy in practice between large and small systems work. Rather, it assumes that social work practice, as it moves into its second century with the new millennium, represents a unified spectrum of theory, knowledge, and skills that cannot be divided. Certainly, the field of contemporary practice is so wide that individual social workers need to find their own specific component or components of the spectrum on which each will focus his or her attention, but this must never be to the conceptual exclusion of the total range of the profession's scope of practice. Thus, much of the discussion about diagnosis rightly focuses on one facet of the spectrum and is of less relevance to other components. Nevertheless, the conceptual basis of diagnosis—being understood as that process of a consciously formed series of judgments made during the life of a case, judgments upon which a practitioner bases his or her interventions, and for which each is prepared to take responsibility—does have application across all aspects of social work practice.

This matter of accountability is the most important objective of all. That is, it is interesting and important to understand how the term came to be a part of the profession and equally interesting and important to understand the history, politics, and sociology of the concept; the relationship of this change in terminology to practice is the heart of this project. Changes in a profession's terminology are bound to occur as we exist in a dynamic, change-seeking system. It is also expected that as a human service profession with a service element, unlike more abstract professions, our terminology will change frequently. However, as terminology does change, we have an ongoing responsibility to be vigilant as to the impact of professional lexicons on service.

I mention this need to be watchful as a form of self-confession. Although my early identification in the profession was with “the diagnostic school of practice,” I moved to a wider focus on a broad-based interlocking theoretical approach to practice. In this growth process, I initially accepted the criticisms of others that the concept of diagnosis could be a limiting one for us and hence needed to be replaced by what was viewed as a less pathology, and more holistically based one. Therefore, although reluctantly, I did decide that the more politically correct term assessment, the one that came to replace diagnosis in much of North American social work practice, was acceptable. In so doing, both in my teaching and writing, I understood that this apparently greater comfort with the term assessment in the major practice textbooks was helpful, as long as it did not alter the practice concepts included in the term diagnosis —formal judgments leading to action.

However, in recent years, it has become increasingly evident to me that this shift in terminology was indeed more than word substitution. As I viewed practice, read case records in many settings, worked with clients, consulted with practitioners, and became involved in cases involving allegations of inappropriate social work service, I became more and more aware that as we moved to get rid of the term diagnosis we also seemed to be getting rid of the true meaning of diagnosis. I also became aware of the negative implications of this for practice.

As is discussed later, it appears that for a variety of very interesting sociological reasons, the term diagnosis was given a highly restricted meaning in the profession, one that emulated what were seen as the limitations of other professions. This misunderstanding and distortion permitted us to scapegoat the concept, legitimize our driving it out of the profession, and believe that by so doing we had “fixed” the deficits in our practice. We then saw ourselves as having achieved some type of maturational victory, which was presumed to ensure that clients were better served.

After long study, it is my conviction that the clients are not better served by the terminological change. Indeed, they suffer from it. Because of this, we need to readdress this discussion, and if my arguments appear to have validity we need to reinstate diagnosis to its rightful place of honor, the heart of social work practice.

I began this book, and the first draft of this chapter, out of a conviction that the term diagnosis had all but disappeared from the profession, apart from being alluded to as an interesting relic from our past. The basis for my argument was that it has clearly disappeared from the majority of social work textbooks. It has not only disappeared but clearly has explicitly been rejected by various authors. I will return to this in my later review of the literature.

However, as I talked about my interest in this problem to various groups as I traveled around, I found an interesting reality that contradicted what was being proffered in textbooks. What I found was that, indeed, many practitioners, for the most part senior practitioners, were very comfortable with the term and saw it as essential in their practice and discussions of practice. However, these colleagues were and are very aware that the apparent approved practice style was not to use the term. Its usage had been relegated to a form of underground vocabulary. Indeed, this reality that many in practice still viewed the term as important gave me further encouragement to address this matter in print. In the following chapters, I examine the place of diagnosis in social work and argue that it is important that we make it once again an essential part of our practice.

Chapter 2

The History of Diagnosis in Social Work

The history of diagnosis in social work is important, complex, and intriguing. It is important because its place in the profession's development is closely connected to our sociology and politics. It is complex because how it developed in social work has less to do with the concept of diagnosis than with other factors and struggles that made use of this concept to argue various positions about the nature and mandate of the profession. It is intriguing because it is a concept that has changed in a few decades from being the essential base of social work practice to being the object of scorn and rejection by many within the profession. As I examined the literature, I became aware that it is not possible to compact into a single chapter what is indeed an intriguing odyssey in our profession, one that deserves a full book in itself. What follows is a condensation of what in my opinion are the major components of this odyssey, with the understanding that my comments may not fully present the entire picture and certainly fail to mention some of the rich contributions of many colleagues over the years. What is evident is that a considerable body of literature exists that can serve as the basis for such an undertaking.

1920s

Clearly, in attempting an overview of the development of the concept of diagnosis in social work, the starting point needs to be the publication of Mary Richmond's still famous, outdated, yet still relevant book Social Diagnosis in 1917. Here is not the place to analyze its place in social work history. This was done well by William Berleman on the occasion of its fiftieth anniversary in 1968 and undoubtedly will be done again on its centennial. For this purpose, I need only to identify that it is the work that in the sociology of the profession committed social work to a mission to base its activities with clients on a structured, testable, and accountable process.

For Richmond, diagnosis was the essential responsibility of a social worker. The process was viewed as highly structured, in which the social worker gathered large amounts of data about the client's personality, history, and social situation so as to come to a conclusion about the nature of the problem and the proposed structure of the interventive process. Diagnosis clearly was seen as a highly intellectual process and involved the assessment and categorization of each client. Richmond's (1917) formal definition of diagnosis was “the attempt to arrive at as exact a definition as possible of the situation and personality of a given client” (p. 51).

Diagnosis for Richmond was closely identified with casework and its tripartite conceptual base of history, diagnosis, and treatment. As a concept, it predated structured psychodynamic thinking and tended to be much more sociological than psychological in its presentation. However, it also had a strong research value orientation, a point that is often overlooked.

The much later view that diagnosis was more properly a medical term than a social work term had some of its origins in this early work. Much social work practice of the day dealt with public health issues and thus brought early social workers into closer contact with physicians and public health nurses than with other professions. Hence some, but certainly not all, of the early conceptual thinking was influenced by health concepts, including the understanding of the meaning of diagnosis. Richmond was adamant in insisting that her term social diagnosis was distinct from the term as used in other health disciplines and that other perceptions of the term diagnosis were not to be confused or interchanged. This idea was reinforced in her later book, What Is Social Case Work? (1922).

1930s

Literature about diagnosis seems to be almost nonexistent for the next ten or fifteen years after Richmond's writing. However, this may only show that I was not able to locate it. It appears that during these years the concept of diagnosis as a distinct and time-bound process that preceded treatment stood as the base for the teaching and practice of casework. Indeed, it was this close relationship to casework that in later years partially brought the concept into question.

In the literature of the 1930s that I was able to locate, there appear to be two themes, both of which are of current interest. The first is a criticism of a style of recording that seemed to be emerging in which emphasis was being put on verbatim accounts of what clients had said. This was being attributed to the impact of psychoanalytic thinking. The second theme is a resultant lack of adequate historical data from which a clear diagnosis could be made. Again, this demonstrates the idea that diagnosis was a fact and was time-fixed in the life of a case.

However, an interesting new concept is observable that began to address the process of diagnosis. That is, practitioners were becoming aware that as a relationship developed and as more material from the client's life was better understood, it was necessary to adjust, when appropriate, earlier diagnostic formulations (Finlayson, 1937). However, the theme from earlier days continued that the concept of diagnosis implied understanding the client's problems and their interactive dimensions. There was a strong problem orientation to the concept of diagnosis and treatment.

In looking at the proceedings of the early Charities Conferences of this period, it is interesting to observe that they were highly multidisciplinary, looking at issues, as mentioned earlier, of a public health nature such as nourishment, housing, safety, abuse, health, and poverty. Thus the papers presented came from a wide range of disciplines in which social workers played an important role. In this regard, there was much unchallenged cross-borrowing of concepts and terminology, including diagnosis.

Fern Lowry (1938) further developed the concept of diagnosis as a process and strongly criticized the trend to see history, diagnosis, and treatment as three time-sequential processes. “Instead of visualizing them as three portions of a straight line, we can visualize them as three strands of rope, interwoven from one end to the other, so that no matter at what point the rope is cut, we cut across all three” (p. 572). Diagnosis remained the essence of practice. Its definition remained the same: a thinking process aimed at deriving meaning. Lowry continued to see the term as generic to all professions and not the prerogative of any one. She used examples from engineering to support her views of its nature and definition.

A later article in 1939 by Taussig further criticized the idea of diagnosis as a one-time process and discussed how diagnosis can and should develop through the life of the treatment process and how all aspects of the process influence one another.

1940s

In the 1940s, I found a continuation of the development of the concept of diagnosis and an increasing understanding of its complexity and its interconnection with all casework processes. Authors were again underscoring the risks of separating processes. Charlotte Towle (1941) emphasized the interactive skill component of diagnosis and treatment:

Diagnostic and treatment skills imply a capacity for precise analysis of a case situation into its parts, for comparative thinking of the parts in relation to the whole, and for synthesizing the parts into a comprehensive interpretive statement in which the essential elements of the case situation are still discernible and, therefore may serve as a treatment focus. (p. 458)

Later writings in the 1940s seem to move away from discussions of the nature and essence of diagnosis and toward the act of diagnosis, including the implications of the process for specific kinds of cases. The literature appears to take for granted the concept of both process and fact of diagnosis and emphasizes that as the treatment relationship develops, so too does the diagnosis change and develop (Simcox, 1947). In 1949, Hollis stressed the complexity of the diagnostic process and the need to take into account a wide purview of the client's life. There was no discussion of assigning labels (which emerged at a later date) but of attempting to understand the various dimensions of the personality and the situation of the client. It is clear in Hollis's writings that she was talking about a casework that is a form of therapy heavily influenced by psychodynamic theory. It appears that it was during the 1940s that the four concepts of casework, psychodynamic theory, psychotherapy, and diagnosis came to be seen as a unified concept. This perception later brought all four into question as various concepts were challenged from different perspectives.

These concepts were seen as a unified whole at the same time that much of casework practice was moving into family and mental health areas where many of the clients were highly motivated and where clients and workers perceived and expected treatment to be long term. This seems to be reflected in the literature on diagnosis, in which many examples were drawn from marriage adjustment problems. The stress here was still on diagnosis as a process of systematically understanding person and situation and on assessing potential for change (Sacks, 1949). In this literature concerning marital problems, a shift in the concept of diagnosis can be seen, from person and situation to person only. This is not a total shift; however, much of the discussion in the literature and many of the case exampl...

Table of contents

• Front Cover
• Half Title
• Title Page
• Copyright
• Dedication
• ABOUT THE AUTHOR
• CONTENTS
• Chapter 1. Introduction
• Chapter 2. The History of Diagnosis in Social Work
• Chapter 3. What Led Us Astray?
• Chapter 4. Diagnosis: What It Is Not
• Chapter 5. Diagnosis: What It Is
• Chapter 6. Our Ethical Responsibility to Diagnose
• Chapter 7. Our Ethical Responsibility to Label
• Chapter 8. A Spectrum of Critical Judgments
• Chapter 9. Diagnosis As a Process and a Record
• Chapter 10. Diagnosis and Gut Reaction
• Chapter 11. Diagnosis and Assessment
• Chapter 12. Diagnosis and Theory
• Chapter 13. Diagnosis and the Computer
• Chapter 14. The Risks of Diagnosing
• Chapter 15. Diagnosis and Research: A Contemporary Challenge
• Chapter 16. Enhancing Diagnostic Skills
• Chapter 17. Final Comments
• Appendix: Some Examples of Social Work Diagnoses
• Bibliography
• Index