Social Work in Health Settings

Practice in Context

Judith L.M. McCoyd, Toba Schwaber Kerson, Judith L.M. McCoyd, Toba Schwaber Kerson, Judith L.M. McCoyd, Toba Schwaber Kerson

• Publisher: Routledge
• Year: 2016
• ISBN:
  9781317409113
• Edition: 4
• Topic: Sciences sociales
• Subtopic: Travail social

Social Work in Health Settings: Practice in Context maintains its use of the Practice in Context (PiC) decision-making framework to explore a wide range of social work services in health care settings. The PIC framework is used to cover a broad range of social work practice sites, settings and populations over 30 case chapters.

Fully updated to reflect the landscape of health care provision in the US since the Affordable Care Act was passed, the cases are grounded by 'primer' chapters to illustrate the necessary decisional and foundational skills for best practices in social work in health settings. The cases cover working with both individuals and groups of clients across the life course and the PiC framework helps maintain focus on each of the practice decisions a social worker must make when working with a variety of clients from military veterans to HIV positive children.

The ideal textbook for social work in health care and clinical social work classes, this thought-provoking volume thoroughly integrates social work theory and practice, and provides an excellent opportunity for understanding particular techniques and interventions.

Chapter 1

Practice in Context

The framework

Toba Schwaber Kerson, Judith L. M. McCoyd, and Jessica Euna Lee

Social Work in Health Settings presents a framework called “Practice in Context,” which the first author has used for the past 40 years as a tool for teaching and evaluation. The primary subject of the framework is the relationship between social worker and client because it is through trustworthy, strong, knowledgeable, and skill-based relationships with clients and others that social workers help clients to reach their goals (Beresford, Croft, & Adshead, 2007; Kerson & McCoyd, 2002). As a concept, “relationship” can be interpreted in diverse ways. It is an association or involvement, a connection by blood or marriage, or an emotional or other connection between people.

The definition of the social worker/client relationship used here is based in the work of others. Sociologist Erving Goffman, and anthropologist Gregory Bateson, theorize about some structural aspects of relationship such as the interactional focus, the connection of a relationship to its milieu, and the rules that inform or govern a relationship. Bateson uses the word interaction, and Goffman the word encounter, to be as precise as possible about their subjects. For this framework, interaction and encounter are seen as factors in a broader concept.

Goffman suggests that when studying interaction, the proper focus is not on the individual and his or her psychology, but rather the syntactical relations among the acts of different persons who are mutually present to one another (Goffman, 1981). To understand interaction, one must understand not the separate individuals but what occurs between them. Goffman (1966) further alludes to the special mutuality of immediate interaction:

When two persons are together, at least some of their world will be made up out of the fact (and consideration for the fact) that an adaptive line of action must always be pursued in this intelligently helpful or hindering world. Individuals sympathetically take the attitude of others present, regardless of the end to which they put the information thus acquired. (p. 16)

Thus, in interaction, there is always a shared sense of situation and a capacity, in some way, to be in the place of the other, no matter what each participant’s purpose in the interaction.

Goffman places relationship in context when he develops the notion of a “membrane” that “wraps” the interaction and, to some extent, separates it from its surroundings. “Any social encounter,” he writes, “any focused gathering is to be understood, in the first instance, in terms of the functioning of the ‘membrane’ that encloses it cutting it off from a field of properties that could be given weight” (Goffman, 1961, p. 79). Still, while the relationship can be viewed and defined in its own right, it remains intimately related to the world outside of it. Thus, Goffman says, “An encounter provides a world for its participants, but the character and stability of the world is intimately related to its selective relationship to the wider one” (Goffman, 1961, p. 80).

The rules that inform a relationship and the uses that the participants make of those rules are also part of Goffman’s and Bateson’s analyses of relationship. According to Bateson, interaction is the “process whereby people establish common rules for the creation and understanding of messages” (Bateson, 1971, p. 3). Goffman adds to this definition by noting that in encounters, rules are considered and managed rather than necessarily followed; that is, rules may shape interaction, but they also may be influenced by the participants. He writes:

Since the domain of situational proprieties is wholly made up of what individuals can experience of each other while mutually present, and since channels of experience can be interfered with in so many ways, we deal not so much with a network of rules that must be followed as with rules that must be taken into consideration, whether as something to follow or carefully to circumvent. (Goffman, 1966, p. 42)

Social workers add a psychological dimension to these more structural views of relationship. We say that relationship has to do with people’s emotional bonding. Also, the relationship between social workers and clients is a catalyst in that through understanding, support, nurturing, education, and the location of necessary resources, we help clients to address problems. Thus, the relationship affirms and motivates the client. In the same way, this forming of a helping relationship is not an end in itself but a means to help clients to reach their goals. In this book, the word client stands for any notion of a client unit, that is, an individual, family, program, organization, city, state, country, or advocacy effort that engages the services of a social worker who will help this entity to reach its goals.

Thus, for this framework, the relationship between social worker and client is defined using both sociological and psychological concepts. The sociological contributions have to do with structure; the focus is on interaction rather than on individual participants, on the use of rules, on the relationship’s connection to (or separation from) its surroundings or context. The psychological contributions are the purposive, feeling, catalytic, and enabling dimensions. Here, the relationship of social worker and client means one or more purposive encounters intended to be catalytic and enabling whose structure and rules for interaction are set by dimensions of context as well as by decisions made by the participants.

Practice in Context framework

According to the Practice in Context (PiC) framework, the two basic elements that structure the relationship between social worker and client are (1) the “context” in which the relationship occurs and (2) the “practice decisions” that social worker and client make about the form and nature of the relationship. Context and practice decisions act as a matrix for the relationship, a supporting and enclosing structure. By determining many of the rules by which the work of social worker and client proceeds, context and practice decisions define the possibilities for relationship. Although elements such as personality, nature and degree of illness, psychosocial assessment, and cultural background contribute to the relationship, they are characteristics of the individuals involved and not the interaction.

This approach or framework is not a generic practice theory because it is not a system of ideas meant to explain certain phenomena or relations. Nor is it a model, because it does not show proportions or arrangements of all of its component parts. Here are simply described elements of context and practice that structure the relationship of social worker and client. Three overarching purposes help the social worker to: (1) clarify the work, (2) understand alterable and unalterable dimensions of practice and context, and (3) evaluate work in light of these dimensions. Each is meant to help the social worker reflect upon the decisions and actions of the social worker. With client participation, the social worker understands and tries to influence context and constructs the relationship in ways that will help meet client goals. Thus, PiC is about the craft of social work – the skills with which social workers manage dimensions of practice.

Context

To assume that possibilities for the work are completely determined within the social worker/client relationship is unrealistic, and may contribute to disappointment and a sense of failure on the part of the participants, evaluators of service, and funding sources. To a great extent, dimensions of context determine many of the rules for the helping relationship (Kerson, 2002). Context means the set of circumstances or facts that surround a particular event or situation, the surrounding conditions that form the environment within which something exists or takes place. Bateson defines context as a “collective term for all those events which tell the organism among what set of alternatives he must make his next choice” (Bateson, 1975, p. 289). He adds to this the notion that “however widely context be defined, there may always be wider contexts a knowledge of which would reverse or modify our understanding of particular items” (Bateson, 1971, p. 16). Although context is a limitless concept, and focusing on certain dimensions means ignoring others, to intervene effectively means that one has to be able to consider and assess the circumstances that constitute the situational conditions under which one is working.

The present framework addresses three dimensions of context that we continue to think have the most direct and describable consequences for the relationship between social workers and clients in health care settings: policy, technology, and organization. These elements are considered most important because of the ways each affects the structure of and possibilities for the social worker/client relationship. Policies increasingly provide rules specifying the services that clients may receive, who may provide them and under what conditions, and how services are to be evaluated. Organizations are also rule makers, setting the structure for service delivery and defining the nature of service often at the behest of policymakers. Finally, in this era when the means of communication continue to expand and change and technological interventions have us questioning definitions of life, death, gender, parenthood, etc., the impact of technology on the relationship between social worker and client is enormous. Social workers’ understanding of and comfort with a great range of technologies enhance their roles as “translators” for their clients, their opportunities for empathy, as well as their general relational capacities. In addition, computer-assisted technologies and the internet have altered and expanded the ways in which social workers communicate, receive, and collect information. Thus, technology contributes to the content of the relationship, expands possibilities, and may also constrain it. The salience of each dimension and the ways those dimensions are related depend on the particular setting. In effect, these contextual factors may at most determine, or at least contribute to, the rules of the game, and as they change, the constraints and possibilities for action are altered as well.

Policy

Policies are explicit and definite sets of principles or courses of action that guide a range of actions in specific situations. They are always related to the political economy, that is, the ways by which a government manages its material resources. Policies address entitlements and restrictions; that is, they provide rightful claims, privileges or prerogatives, and/or they impose limitations and constraints. To think of policies in these ways demonstrates the need for social workers to understand the policies that may affect their clients. This understanding can help clients interpret policies and gain access to services. To be an effective client advocate one must excel at understanding the policies that shape clients’ entitlements and restrictions.

The status of the populations with which social work is most concerned and the status of the social work profession itself are, to a great extent, reflections of the political economy and the social policies of any particular period in U.S. history (Mechanic, 2005). Understanding health disparities is critical in this regard (Barr, 2014; Schlesinger, 2011). Peter Drucker notes that every 10 years or so, society reorganizes its world view, basic values, political and social structure, arts, and major institutions (Drucker, 2004). Thus, social policy is dynamic, fluid, and responsive to many powerful forces within and outside of a particular community or society. This seems to be a time of enormous social reform in the United States, and hopes are high for reforming the health care system (Barr, 2011, 2014; Blank & Burau, 2014; Little, 2007).

For example, the Patient Protection and Affordable Care Act (ACA) was signed into law in 2010 (Congress, 2010). An aim of the ACA is to not only expand access to public health insurance but also improve the quality of health care provided through Medicare and Medicaid. Also referred to as ObamaCare, the ACA expands health care coverage to all U.S. citizens and aims to reduce U.S. health care spending. Many of its provisions took effect in 2014 and key enactments relevant to social work include:

• individual mandate to purchase insurance and requirement for most employers to offer coverage to workers;

• improved access to public health insurance (e.g., expanding Medicaid to people below 130% of the federal poverty line);

• reforms to improve health care quality and reduce health spending;

• regulation of the health insurance industry (e.g., setting minimum benefit standards for qualified health benefit plans and prohibiting health insurers from refusing coverage based on patients’ medical histories (Congress, 2010; ObamaCare Facts, n.d.; Gorin, Pollack, Darnell, & Allen, 2014).

The base for policy is the law which in the form of legislation, administrative regulations, and/or court decisions affects every dimension and nuance of social work practice in any health setting (Kerson, 2002). Dickson (2014) identifies the following aspects of the health and human services that are permeated by the law:

1 the entrance into and exit from health and human services delivery systems;

2 the criteria used to determine eligibility for treatment, benefits, or services;

3 the rights to which patients and clients are entitled;

4 the rights to which professionals and staff are entitled;

5 the way in which health and human services programs are administered and regulated;

6 the relationship between the professional and the patient or client;

7 the practice of the health and human services professional (p. 3).

Therefore, in order to understand the policies that shape their practice, social workers must be able to understand the laws that affect the policies.

Another critical policy for social workers in health care settings is the Health Insurance Portability and Accountability Act of 1996 (HIPAA) that recognizes the importance of privacy of medical records. HIPAA regulations aim to assure the privacy and confidentiality of consumers’ health information by defining (1) the rights of individuals, (2) administrative obligations of covered entities, and (3) the permitted uses and disclosures of protected information (NASW, 2001; U.S. Department of Health and Human Services, 2015). HIPAA defines “protected health information” as individually identifiable health information in any media that is held or transmitted by a covered entity (U.S. Department of Health and Human Services, 2015). Social workers are considered covered entities if they transmit protected health information for which HHS has a standard. HIPAA has implications for social workers working in public health, research, and direct practice. Such information can be as obvious as medical records and diagnoses or as seemingly “common” as whether a patient is indeed at the medical facility. The 2013 Omnibus rule provides updated guidance on HIPAA compliance. The revisions that HIPAA has undergone in the last decade demonstrate the need to respond to ever changing dimensions of technology (Morgan, 2013) and to be aware of the limits to information that can be shared when making referrals.

No matter what level they work on, social workers must be able to contribute to, interpret, and influence policy in order to advocate for their clients and the profession. Decisions regarding which populations to serve, allocation of resources, planning, and programming are too often made before social work practitioners become involved, and it is far easier to affect the structure of a program before it is instituted rather than after. These activities are also most beneficial to clients when clients and social workers advocate together. In addition, involvement in policy formulation...

Table of contents

• Cover Page
• Social Work in Health Settings
• Praise
• Title
• Copyright
• Contents
• List of Figures
• List of Tables
• List of Contributors
• Acknowledgments
• 1 Practice in Context: The Framework
• Part 1 Individual And Family Work in Health Settings
• Part 2 Social Work and Public Health
• Index