Social Work in Health Care
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Beyond Relationship Frances Nason MSW, LICSW To cite this article: Frances Nason MSW, LICSW (1990) Beyond Relationship, Social Work in Health Care, 14:4, 9-24, DOI: 10.1300/J010v14n04_03 To link to this article: http://dx.doi.org/10.1300/J010v14n04_03
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Beyond Relationship: The Current Challenge in Clinical Practice
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Frances Nason, MSW, LICSW
ABSTRACT. Clinical social workers in health settings have used
time and relationship and the understanding of individual and family dynamics, biophysiology, and larger systems issues to assist patients and families in resolving health related problems. The current economic crisis is limiting tlrne and focus and necessitating revisions in intervention techniques. Clinicians experience this as a threat to their identity as a caring profession and to their ability to support patient autonomy within the health care environment. Effective adaptation requires a different use of self, expanded diagnostic skills, greater use of networking and systems interventions, and more sophisticated clinical techn~ques.Often, engagement, assessment and intervention have to occur within the same session. To accomplish this shift in practice, there has to be strong clinical leadership and a conscious focus on adapting clinical models to meet the current economic restrictions. Social work programs in contemporary health care settings are faced with reduced levels of staffing, .shorter lengths of hospital stay for patients, restricted community resources, and a heightened administrative emphasis on discharge planning (Caroff, 1988; Dinerman et al., 1986; Patti and Ezell, 1988). These changes are experienced by direct care staff as a threat to the nature of their practice and to the integrity of their profession, even though administrators with an overview of hospital economics regard them as Frances Nason is Director of Social Work.and Discharge Planning at Massachusetts Eye and Ear Infirmary, 243 Charles St., Boston, MA 02114. Social Work in Health Care, Vol. 14(4) 1990 O 1990 by The Haworth Press, Inc. All rights reserved.
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critically important. Social workers are also feeling the impact of a shift in government policy away from ideals of welfare as a human right and toward ideals of limited state responsibility and increased self-reliance (Kohlert, 1989). The question confronting the profession today is: can clinical practice continue to exist within the current time and reimbursement constraints? Social work practice has always been closely integrated with the economic realities of the time and the changing needs of the population. To understand the impact of current changes and the potential for new solutions, it is helpful to survey the development of current social work practice models. BACKGROUND
Social work in health care began in the early 1900's when the country's resources were supporting the rise of large corporations, and government had not assumed responsibility for the social welfare of the poor, the ill, the elderly, or the disadvantaged. In this period of great disparity between the well-to-do and the poor, social support was often limited to private philanthropy and volunteerism. Confronted with many patients living in poverty, concerned physicians began to question social and economic impediments to effective medical care. As a first step, volunteers and nursing staff were asked to work with patients to help them locate appropriate community resources (Cannon, 1913). However, a real shift in understanding the psychosocial concomitants of illncss occurred in 1906 when Dr. Richard Cabot invited Ida Cannon to join the staff at the Massachusetts General Hospital. Cannon, who had previous experience as a visiting nurse, had come to Boston to study at the ncw School for Social Workers.* She brought to her role in the hospital an understanding of the medical and nursing professions, a strong community orientation, and a commitment to the valucs and knowledge of the newly developing profcssion of social work. She saw her challenge as one of identifying for the medical establishment the psychosocial problems that undermined good medical practice and then developing social work *Now Simmons Collegc School for Social Work
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interventions and treatments that integrated medical care, social and economic resources, and an understanding of the specific psychological vulnerabilities and strengths of the individual patient (Cannon, 1913). As I see it, the social worker's function does not lie especially in a sympathy with human nature in immediate distress of mind and body. Physician and nurse appreciate these phases of the patient's condition. Rather does the social worker's function lie in an enlarged understanding of any psychic or social conditions which may lie at the root of the patient's distress of mind and body. Faulty character, diseased community life, and unwholesome human relations are the fields of her study and constructive effort. Her knowledge of these factors, added to the doctor's knowledge of physical factors, gives a broad basis for action both medical and social. (Cannon, 1913) The problems, the challenges, and the solutions dealt with by this fledgling profession have striking similarities with the work that is done today, although the labels may be different. Patients for whom social work services were targeted included (as Cannon put it) those dumped by their family, the tuberculous, the convalescent, the physically disabled needing employment, victims of chronic disease, the unmarried mother, the syphylitic, the mentally unbalanced, the neurasthenic, the suicidal, and the feeble-minded. Interventions focused on the patient interview, a home assessment, collaboration with the physician, identification of community resources, counseling, education, and community referral (Cannon, 1913). Helping patients by directing them to appropriate sources of assistance was referred to as "steering," while "shoving" required a more aggressive intervention with resistant community agencies or unresponsive families. When there was concern about the continued success of a patientlcommunity agency connection, the social workers did "follow-up." Often, needed services were not available and the social work department found funding to establish its own patient service programs or pulled together a group of community
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agencies to document needs and develop community funded supports (Cannon, 1913).
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During this our second year's work we procured help for our patients through one hundred and sixty-four different charities, hospitals, district nursing associations, etc. We doubt whether any other distributing center is in a position to use more effectively the rich resources of Boston and its vicinity. (Cabot, 1907) In parallel with the heavy emphasis on linking patients to appropriate community services, there was an equally strong emphasis on the nature of the clinical intervention. The psychological elements, which the social worker must consider, are of fundamental importance. They include the patient's character, his temperament, his reaction to the experience of illness, and his attitude toward those endeavoring to help him. In the interplay of the physical, economic, and psychological factors, the psychological dominates; hence the understanding of this subtle reaction of human nature to circumstances should engage the most thoughtful efforts of the medical social worker. (Cannon, 1913) But there have been many changes between social work's initial entry into the field of health care and today's retrenchment of resources. Social work practice developed in response to fluctuations in the economy and changing models of medical care (Miller and Rehr, 1984). Starting with the rise of social welfare services in the 3OYs,and continuing into the years of postwar affluence, the decades of social liberalism, and the medicalization of society, hospitals and health care settings developed into relatively autonomous but expensive enterprises (Rehr, 1985; Star, 1982). At the same time, social work practice evolved a clinical approach that made use of government welfare programs and psychotherapy. The latter relied on a warm, sympathetic and gradually evolving therapeutic relationship as the key to the patient's self-discovery and resolution of problems (Bartlett, 1961; Feldman, 1960; Perlman, 1957). The new field of psychiatry and an expanding mental hcalth movement increased society's understanding of mental illness and
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adjustment reactions in everyday life. Social workers in health care settings eagerly incorporated the new modalities of ego psychology (Blanck and Blanck, 1979; Parad and Miller, 1963), crisis intervention (Parad, 1965), grief theory (Lindemann, 1944), family therapy (Caroff and Mailick, 1985; Kemler, 1985), alcohol dependency treatment (Corrigan, 1979), object relations theory (Horner, 1984), and self psychology (Elson, 1986) into their clinical practice. The identity of a medical social worker was replaced by the identity of a clinical social worker in a medical setting. Thus, from its inception, social work practice in health settings brought together a broad range of medical, psychological, and social constructs to achieve a comprehensive clinical approach to patient care. The early legacy from Ida Cannon was: (1) social work's leadership in developing new models of service; (2) its commitment to integrating advocacy for community services with psychosocial diagnosis and clinical case work; and (3) its appreciation of the importance of the relationship with other medical care providers in establishing an effective biopsychosocial model of care. During the second phase of the evolution of practice, social workers focused on integrating new psychological concepts into their clinical base. Family and individual therapy rather than larger systems interventions became the primary focus (Davidson, 1978; Nason and Delbanco, 1976). This was possible because medical establishments had become their own holistic service systems, and social workers in these settings had the opportunity to develop longterm relationships with their patients. Community resources were readily available, and social work no longer needed to emphasize its initial commitment to moving patients back into the community through a strong network of agencies and interagency problem solving. Departments began to split off the discharge function, often delegating it to less well trained workers (Peterson et al., 1979; Wattenberg and O'Rourke, 1978).
CURRENT CHALLENGES We are now facing the withdrawal of government supports from health, education, and welfare programs (Abramovitz, 1986; Day, 1989; Harrington, 1989). Administrators in health care settings are pressing staff to maximize efficiency and minimize waste. These
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changes are necessitating a new model of service that asks the individual patient or family to use personal resources rather than rely on lengthy reimbursable interventions by professionals. Because social work practice was originally established as a support for the physician, and its early survival was financed by physician reimbursement, there had been a tendency to turn to the physician as the team leader. Currently, however, physicians are also experiencing changes and restrictions in their traditional roles. Administration of hospitals and health settings is being taken over by business managers. As social work departments become less dependent on physicians and more dependent on administrators, there is some risk that administrators will set the standards for social work practice without understanding the implications of these changes (Levine, 1988). Just as social workers once integrated but redefined the medical model, so they will now need to integrate but redefine economic principles. This means initiating the necessary costlbenefit adaptations in their own practice. Patient needs in health care settings are becoming more complex than ever (McKinney and Young, 1985; Peterson, 1987). The challenge is to find cost effective methods for meeting these needs. As Bendor documents, engagement, diagnosis, treatment planning, and implementation often have to be done in a few days. "The cherished social work principle of 'starting where the client is' is challenged by the new principle of 'starting where the reimbursement is'" (Bcndor, 1987). In efforts to facilitate more timely planning for discharge needs while allowing patients to have maximal input into the decision making process, the clinical social worker must often be the one to confront patients and families with the harsh reality of their current social and medical situations. The opportunity for denial that is an early component of a normal grieving process becomes curtailed by the need for expedient discharge planning. Managing such cases takes a great deal of experience and clinical sophistication (Blumenfield and Rosenberg, 1988); in general it cannot be effectively done by casework assistants. Effective practice in today's health care setting involves: using clinical intuition and careful diagnostic judgment; accepting a leadership role and assisting other providers with clinical decision rnaking; relinquishing the long-term relationship in order to expedite patientlfamily problem solving; and integrating clinical skills and
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systemic techniques with the knowledge of community resources and networking options. As the following cases suggest, effective crisis intervention, short-term therapy, and discharge planning will be the signature of the most skilled clinician, not the least skilled. CASE ILLUSTRATIONS Case 1
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Presenting Problem A 57-year-old widower was admitted for emergency surgery in the middle of an acute psychotic episode in which he had lacerated both of his eyes. He had a previous history of brief hospitalizations for psychotic ideation, but had never been self-mutilating. He had recently expressed concern about difficulties his son was having in the armed services, but there was no obvious cause for his sudden decornpensation. Following surgery, the psychiatric resident saw the patient for medication management. The social worker met with the upset family to review family history and resources and to provide emotional support. The patient was medically ready for discharge from the surgical setting in less than a week. At that point he was just coming out of his psychosis, was in a state of shock, newly blinded, and unable to talk about what he had done to himself or how he felt. Efforts by the psychiatrist to transfer him to a psychiatric setting met with no success. No hospital would take him. His only local family, a sister and niece, were also not willing to take responsibility for him.
Assessment The social worker made a clinical decision that an immediate return to the community was unsafe, that he needed the opportunity to stabilize his psychological function in a psychiatric facility but then could potentially return home. With inpatient psychiatric hospitalization as the discharge focus, the social worker began to expand her function. She called the psychiatric settings that had turned him down in order to clarify their reasons for refusing admission. The nurses in those
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settings felt that they would be unable to meet the patient's activity of daily living needs because he had no mobility skills; the administrator feared an overstay.
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lntewention The social worker reassessed the patient and determined that he was anxious but not currently psychotic or suicidal. The social worker suggested the possibility of removing suicide precautions and initiating a process of mobility and activity of daily living training on the floor. Psychiatry and nursing agreed to participate with this plan and to help monitor the patient's mental status during this process. The social worker began to plan with the patient for the next stages of adaptation to his loss. With his knowledge, she contacted his son, who was stationed overseas, and initiated a family hardship discharge from the armed services for him. She met with thc sister and niece to help them to understand more about the process of an acute psychotic episode, to articulate their feelings of anger and guilt, and to engage their support in working with an inpatient psychiatry setting. As part of this process, she helped them to work out transportation so they could get to future meetings. The social worker negotiated with the Commission for the Blind to obtain the services of a mobility trainer while the patient was in the hospital. She contacted the neighborhood community mental health agency and reestablished their commitment to provide follow-up care. One week later, when all the pieces were in place, she again initiated referrals to the more promising inpatient psychiatry facilities. In her calls, she described the patient's current strengths and increased mobility and offered on-site inservice training to the facility's nursing staff by a nurse educator from her own hospital who was knowledgeable about working with newly blinded patients. She also spelled out the long range community supports that would be available when the patient was ready for discharge from the psychiatric facility. One inpatient psychiatry unit agreed to evaluate the patient. The worker reviewed the intake process with the patient and
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accompanied him and his sister when they went for the patient's initial evaluation. The patient was accepted for admission. A nurse and social worker went with the patient on the day of transfer to provide training to the inpatient staff and support to the patient during the transition. Case 2
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Presenting Problem A 53-year-old married woman with a 15-year history of advancing multiple sclerosis, was admitted in a sudden onset medical crisis. In spite of all medical efforts, her condition deteriorated rapidly and she was on multiple system supports. Her two adult children, their spouses, and her husband met with the physician but were unable to come to terms with her medical deterioration or her impending death. They could not accept a "do not resuscitate" order even though the patient had made it clear to her daughter that she would not want to be maintained in a vegetative state. She was struggling to say goodbye to her family members when she had lucid moments but they kept begging her to continue to fight to live.
Assessment The social worker asked to meet with the family as a unit to help them with their grief process. Each family member talked about what had been special and what was unfinished in his or her relationship with the patient. The social worker sensed that there was still something missing. She asked what their greatest fear was should the patient die. After much discomfort, the family revealed that the patient's husband had become psychotically depressed after the death of his mother twenty years before. Further discussion indicated that the husband was sad and anxious about being alone but was not having symptoms of either serious depression or psychosis.
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Once this family secret was out in the open, the family could begin to face the patient's impending death, and make appropriate plans for the husband and for themselves. They each said their goodbyes to the patient when they were with her and asked the doctor to do everything to make her comfortable but not to resuscitate her if she had a cardiac arrest. Two days later she had a cardiac arrest and died. The family met once with the social worker before the funeral. One daughter and son-in-law planned to move in with the patient's husband for six months while they were building their own home. The husband had been having some difficulty sleeping but felt connected to his children and planned to join a bereavement support group. He did not feel the need for further psychiatric support at this point. He and his children agreed to monitor his symptoms and contact the social worker or mental health agency if there were any changes. The social worker contacted the family several weeks later and the situation appeared stable. One year later, the family contacted the worker to say that things were going well. Case 3
Presenting Problem An army private and his Italian wife had been recently stationed in the states. The wife had difficulty leaving her parents and had encouraged them to visit. During the visit, her mother had a major stroke. There was no medical coverage for any of the mother's care. Her recovery was slow and six weeks after emergency admission to the hospital, she no longer required acute care but was still confused, unable to talk, unable to walk without assistance and unable to transfer from bed to chair by herself. The daughter was very distraught and was with her all the time. Physicians felt the patient could not return to her own country for at least six months because of the potential for further damage from the flight. No rehabilitation facility would accept her without payment. The family had no financial resources.
Frances Nason
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Assessment
The daughter thought she could care for her mother at home but the son-in-law was fearful that his wife and father-in-law would not be able to meet her needs. The father-in-law would not come to see the patient and had become very demanding of the family. The son-in-law indicated that he was having difficulties adjusting to this crisis and felt his marriage had always been endangered by his wife's dependence on her parents. Every community agency refused to become involved in caring for the patient or her family because of their fear that thcy would be left carrying all the costs of care. Intervention
The social worker requested an emergency meeting of all community agencies that could potentially help the family. Because there had been ongoing working relationships, all agencies agreed to send a senior staff representative. Prcscnt for the meeting were: the home health agency; the home care corporation; the family service agency; the community mcntal health center; a representative from the army basc; the hospital social worker; the chief physical therapist from the hospital; and a representative of the council for elders. After reviewing the critical needs of the family, the lack of available financial resources and each agency's concern that the costs of unreimbursed care would overwhelm already overdrawn budgets, the social worker proposed that each agency make a commitment to provide one piece of the care package that was needed. The time commitment would be for six months, when the patient could be returned safely to her own country. The social worker explained that the hospital had agreed to coordinate the patient's care and to provide free physical and occupational therapy on a twice a week basis as well as ongoing medical management. There was a long silence and then, one by one, each agcncy committed itself to provide one or another of the critically needed services that would make up a home based rehabilitation program for the patient. The family service agency had an Italian speaking social worker who agreed to try to work with
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the patient's husband. The council for elders agreed to locate Italian speaking volunteers to help with visiting and translating for the patient. The community mental health agency agreed to offer marital counseling to help the patient's daughter and sonin-law with the stresses this crisis was causing in their marriage. The army base agreed to provide all supplies and to work out transportation back to Italy when it was safe for the patient to fly. The home care corporation and home health agency agreed to provide home nursing assistance with personal care and homemaker services. The family was very responsive to the services that were offered to them and although the program had its difficult moments and times when there were disruptions in the coordination of services, the patient was able to be cared for in the community, made some gains in function, and did return to Italy five months later. The patient had a large extended family in Italy and the daughter and son-in-law went with her to assist with the transition, but returned to the states to continue to build their own life. Each of these cases illustrates the complex ways in which clinical social workers used their diagnostic, treatment, and systems intervention skills to work with the patient and family within the context of larger system issues. None of these cases involved a long-term treatment relationship with patient or family, but each required excellent clinical judgment, an empathic understanding of patient, family, and community agency issues, the willingness to take the lead in developing an appropriate intervention plan, and the clinical facilitation of patient and family decision making and problem resolution.
DISCUSSION Kapoport (3962) describes a crisis as a "catalyst that disturbs old labits, evokcs new responses and becomes a major factor in chartng new dcvelopments." It rcquires a solution which is new in relaion to an individual's previous cxperience. Current cost containnent pressures pose a crisis for the ficld of social work. In their rraditional role, social workers monitored the quality of care of dis-
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advantaged patients, provided ongoing individualized services, and advocated for legislative and regulatory changes when problems occurred. They are now asked as well to review their policies and procedures and determine the most cost effective means of providing services to patients. Combining efficiency and effectiveness in this climate requires changes in the nature of therapeutic interactions. The existence of a strong support network for hospital social work directors has enabled them to take the initiative in promoting effective administrative systems (Rosenberg and Clarke, 1987). Direct care staff, however, have felt more isolated in their efforts to modify their own style of practice. Consequently, there has been an attrition of good clinicians from the field and growing difficulty in filling vacant positions. Current clinical interventions often require a telescoping of engagement, assessment, and intervention into one or two sessions. The clinician's previous enjoyment of the developing relationship with the patient (Surrey, 1984) must now be replaced by his or her pleasure in effective diagnosis and in facilitation of the patient's own independent abilities to solve problems. This new approach necessitates a different meaning of "relationship" and a diffcrent use of the clinician as "self object." At this time of change, it is important to establish effective support networks for clinical social workers in these settings. Creative social work clinicians are already responding to this challenge. The profession is fortunate to have a broad base of knowledge and a tradition of integrating both individual and system perspectives. Rather than abandoning the clinical components of care and retrenching to the limited focus of only dispensing resources, these clinicians are expanding the efficiency and efficacy of diagnosis, problem focused intervention and network development. Social workers are now assuming responsibility for early identification of depression, dementia, psychosis, chemical dependencies, personality style, family function, and larger system issues. As health care institutions are being redefined as a component in a continuity-of-care system, social workers are taking the lead in developing interagency linkages and effective communication, coordination, and problem solving procedures. With the increased
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pressure for rapid decision making, patients and families are at risk of losing control of the decisions that affect their own well-being. Clinical social workers are responding by developing treatment models and psychoeducational programs that have the potential to increase the effectiveness of patient and family involvement in care planning and decision making. The evolution of new practice models requires strong clinical leadership, opportunities for an ongoing exchange of ideas between clinicians from different settings, and confidence in social work's ability to meet the challenges. Social work administrators will need to support the continued evolution of effective practice paradigms and encourage peer discussion and collaborative problem solving for particularly difficult cases. The schools of social work must acknowledge the need for expanded skills for the clinicians going into health care settings and work closely with these settings to develop more relevant practice guidelines. New clinical leadership needs to be supported. This is the time when clinical social work can and must make its greatest contribution to health care, but to do so, it must employ the imagination and vision required by extraordinary times. REFERENCES Abramovitz, M. (1986). The privatization of the welfare state: a review. Social Work, 31(4), 257-264. Bartlett, H.M. (1961). Social work practice in the health field. Washington, D.C.: NASW. Bendor, S.I. (1987). The clinical challenge of hospital-based social work practice. Social Work in Health Care, 13 (2), 25-34. Blanck,G.,& Blank,R. (1979). Ego psychology 11. New York: Columbia Press. Blumenfield,S., & Rosenberg,G. (1988). Towards a network of social health services in redefining discharge planning and expanding the social work domain. Social Work in Health Care, 13(4), 31-48. Cabot,R.C. (1907). Annual Report of the Social Service Department of Massachusetts General Hospital. Boston: The Fort Hill Press. Cunnon,l. (1913). Social work in hospitals. Philadelphia: The Russell Sage Foundation. Caroff,P., & Mailick,M. (1985). The patient has a family: reaffirming social work's domain. Social Work in Health Care, 10(4), 17-34. Caroff,P. (1988). Clinical social work: present role and future challenge. Social Work in Health Care, 13(2), 21-33.
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Corrigan,E. (1979). Alcohol knowledge and practice issues. Health and Social Work, 4(4), 9-40. Davidson,K.W. (1978). Evolving social work roles in health care: the case for discharge planning. Social Work in Health Care, 4(1), 43-54. Day, P.J. (1989). The new poor in America: isolationism in an international political economy. Social Work, 34(3), 227-233. Dinerman,M. et al. (1986). Surviving DRG's: New Jersey's social work experience with prospective payments. Social Work in Health Care, 12(1), 103-113. Elson,M. (1986). Self psychology in clinical social work. New York: W.W. Norton and Co. Fe1dman.Y. (1960). Integration of psychoanalytic concepts into casework practice. Smith College Studies in Social Work, 30, 144-156. Harrington,M. (1989). Socialism past and future. New York: Arcade Publishing. Horner,A.J. (1984). Object relations and the developing ego in therapy. New Jersey:Jason Aronson Inc. Kemler,B. (1985). Family treatment in the health setting: the need for innovation. Social Work in Health Care, 10(4), 45-53. Kohlert, N. (1989). Welfare reform: a historic consensus. Social Work. 34(4), 303-306. Levine,D.E. (1988). Letters. Health and Social Work, 13(2),83. Lindemann,E. (1944). Symptomatology and management of acute grief. American Journal of Psychiatry, 101, 141-148. McKinney,E.A., & Young, A.T. (1985). Changing patient populations: consideration for service delivery. Health and Social Work, 10(4), 292-299. Miller,R.S., & Rehr,H. (eds) (1983). Social work issues in health care. New Jersey: Prentice-Hall, Inc. Nason F. & Delbanc0,T.L. (1976). Soft services: a major, cost-effective cornpol nent of primary medical care.Social Work in Health Care, 1(3), 297-308. Parad,H. & Miller,R. (eds) (1963). Ego-oriented casework: New York: FSAA. Parad,H.(ed) (1965). Crisis intervention:selected readings. New York: FSAA. Patti,R.J., and Ezell,M. (1988). Performance priorities and administrative practice in hospital social work departments. Social Work in Health Care, 13(3),73-89. Perlman,H.H. (1957). Social casework:a problem-solving process. Chicago: University of Chicago Press. Peterson,C. et al. (1979). Paraprofessional role in a mental health continuing care program. Health and Social Work, 4(3), 65-81. Peterson,K.J. (1987). Changing needs of patients and families in the acute care hospital: implications for social work practice. Social Work in Health Care,, 13(2),1-14. Rapoport,L. (1962). The state of crisis: some theoretical considerations.SociaI Service Review,26, 213-222. Rehr,H. (1985). Medical care organization and the social service connection. Health and Social Work, 10(4), 245-257. Rosenberg,G. & Clarke,S.S. (eds) (1987). Social workers in health care management: the move to leadership.Social Work in Health Care, 12(3), 1-143.
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Star,P. (1982). The social transformation o f American medicine. New York: Basic Books. SurreyJ. (1984). Self-in-relation: a theory of women's development. Work i n Progress, Wellesley College, No.13,l-16. Wattenberg,S.H. & O'Rourke,T.W. (1978). Comparison o f task performance of master's and bachclor's degree social workers in hospitals. Social Work in Health Care, 4(1), 93-105.
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Beyond Relationship Frances Nason MSW, LICSW To cite this article: Frances Nason MSW, LICSW (1990) Beyond Relationship, Social Work in Health Care, 14:4, 9-24, DOI: 10.1300/J010v14n04_03 To link to this article: http://dx.doi.org/10.1300/J010v14n04_03
Published online: 26 Oct 2008.
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Beyond Relationship: The Current Challenge in Clinical Practice
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Frances Nason, MSW, LICSW
ABSTRACT. Clinical social workers in health settings have used
time and relationship and the understanding of individual and family dynamics, biophysiology, and larger systems issues to assist patients and families in resolving health related problems. The current economic crisis is limiting tlrne and focus and necessitating revisions in intervention techniques. Clinicians experience this as a threat to their identity as a caring profession and to their ability to support patient autonomy within the health care environment. Effective adaptation requires a different use of self, expanded diagnostic skills, greater use of networking and systems interventions, and more sophisticated clinical techn~ques.Often, engagement, assessment and intervention have to occur within the same session. To accomplish this shift in practice, there has to be strong clinical leadership and a conscious focus on adapting clinical models to meet the current economic restrictions. Social work programs in contemporary health care settings are faced with reduced levels of staffing, .shorter lengths of hospital stay for patients, restricted community resources, and a heightened administrative emphasis on discharge planning (Caroff, 1988; Dinerman et al., 1986; Patti and Ezell, 1988). These changes are experienced by direct care staff as a threat to the nature of their practice and to the integrity of their profession, even though administrators with an overview of hospital economics regard them as Frances Nason is Director of Social Work.and Discharge Planning at Massachusetts Eye and Ear Infirmary, 243 Charles St., Boston, MA 02114. Social Work in Health Care, Vol. 14(4) 1990 O 1990 by The Haworth Press, Inc. All rights reserved.
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critically important. Social workers are also feeling the impact of a shift in government policy away from ideals of welfare as a human right and toward ideals of limited state responsibility and increased self-reliance (Kohlert, 1989). The question confronting the profession today is: can clinical practice continue to exist within the current time and reimbursement constraints? Social work practice has always been closely integrated with the economic realities of the time and the changing needs of the population. To understand the impact of current changes and the potential for new solutions, it is helpful to survey the development of current social work practice models. BACKGROUND
Social work in health care began in the early 1900's when the country's resources were supporting the rise of large corporations, and government had not assumed responsibility for the social welfare of the poor, the ill, the elderly, or the disadvantaged. In this period of great disparity between the well-to-do and the poor, social support was often limited to private philanthropy and volunteerism. Confronted with many patients living in poverty, concerned physicians began to question social and economic impediments to effective medical care. As a first step, volunteers and nursing staff were asked to work with patients to help them locate appropriate community resources (Cannon, 1913). However, a real shift in understanding the psychosocial concomitants of illncss occurred in 1906 when Dr. Richard Cabot invited Ida Cannon to join the staff at the Massachusetts General Hospital. Cannon, who had previous experience as a visiting nurse, had come to Boston to study at the ncw School for Social Workers.* She brought to her role in the hospital an understanding of the medical and nursing professions, a strong community orientation, and a commitment to the valucs and knowledge of the newly developing profcssion of social work. She saw her challenge as one of identifying for the medical establishment the psychosocial problems that undermined good medical practice and then developing social work *Now Simmons Collegc School for Social Work
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interventions and treatments that integrated medical care, social and economic resources, and an understanding of the specific psychological vulnerabilities and strengths of the individual patient (Cannon, 1913). As I see it, the social worker's function does not lie especially in a sympathy with human nature in immediate distress of mind and body. Physician and nurse appreciate these phases of the patient's condition. Rather does the social worker's function lie in an enlarged understanding of any psychic or social conditions which may lie at the root of the patient's distress of mind and body. Faulty character, diseased community life, and unwholesome human relations are the fields of her study and constructive effort. Her knowledge of these factors, added to the doctor's knowledge of physical factors, gives a broad basis for action both medical and social. (Cannon, 1913) The problems, the challenges, and the solutions dealt with by this fledgling profession have striking similarities with the work that is done today, although the labels may be different. Patients for whom social work services were targeted included (as Cannon put it) those dumped by their family, the tuberculous, the convalescent, the physically disabled needing employment, victims of chronic disease, the unmarried mother, the syphylitic, the mentally unbalanced, the neurasthenic, the suicidal, and the feeble-minded. Interventions focused on the patient interview, a home assessment, collaboration with the physician, identification of community resources, counseling, education, and community referral (Cannon, 1913). Helping patients by directing them to appropriate sources of assistance was referred to as "steering," while "shoving" required a more aggressive intervention with resistant community agencies or unresponsive families. When there was concern about the continued success of a patientlcommunity agency connection, the social workers did "follow-up." Often, needed services were not available and the social work department found funding to establish its own patient service programs or pulled together a group of community
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agencies to document needs and develop community funded supports (Cannon, 1913).
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During this our second year's work we procured help for our patients through one hundred and sixty-four different charities, hospitals, district nursing associations, etc. We doubt whether any other distributing center is in a position to use more effectively the rich resources of Boston and its vicinity. (Cabot, 1907) In parallel with the heavy emphasis on linking patients to appropriate community services, there was an equally strong emphasis on the nature of the clinical intervention. The psychological elements, which the social worker must consider, are of fundamental importance. They include the patient's character, his temperament, his reaction to the experience of illness, and his attitude toward those endeavoring to help him. In the interplay of the physical, economic, and psychological factors, the psychological dominates; hence the understanding of this subtle reaction of human nature to circumstances should engage the most thoughtful efforts of the medical social worker. (Cannon, 1913) But there have been many changes between social work's initial entry into the field of health care and today's retrenchment of resources. Social work practice developed in response to fluctuations in the economy and changing models of medical care (Miller and Rehr, 1984). Starting with the rise of social welfare services in the 3OYs,and continuing into the years of postwar affluence, the decades of social liberalism, and the medicalization of society, hospitals and health care settings developed into relatively autonomous but expensive enterprises (Rehr, 1985; Star, 1982). At the same time, social work practice evolved a clinical approach that made use of government welfare programs and psychotherapy. The latter relied on a warm, sympathetic and gradually evolving therapeutic relationship as the key to the patient's self-discovery and resolution of problems (Bartlett, 1961; Feldman, 1960; Perlman, 1957). The new field of psychiatry and an expanding mental hcalth movement increased society's understanding of mental illness and
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adjustment reactions in everyday life. Social workers in health care settings eagerly incorporated the new modalities of ego psychology (Blanck and Blanck, 1979; Parad and Miller, 1963), crisis intervention (Parad, 1965), grief theory (Lindemann, 1944), family therapy (Caroff and Mailick, 1985; Kemler, 1985), alcohol dependency treatment (Corrigan, 1979), object relations theory (Horner, 1984), and self psychology (Elson, 1986) into their clinical practice. The identity of a medical social worker was replaced by the identity of a clinical social worker in a medical setting. Thus, from its inception, social work practice in health settings brought together a broad range of medical, psychological, and social constructs to achieve a comprehensive clinical approach to patient care. The early legacy from Ida Cannon was: (1) social work's leadership in developing new models of service; (2) its commitment to integrating advocacy for community services with psychosocial diagnosis and clinical case work; and (3) its appreciation of the importance of the relationship with other medical care providers in establishing an effective biopsychosocial model of care. During the second phase of the evolution of practice, social workers focused on integrating new psychological concepts into their clinical base. Family and individual therapy rather than larger systems interventions became the primary focus (Davidson, 1978; Nason and Delbanco, 1976). This was possible because medical establishments had become their own holistic service systems, and social workers in these settings had the opportunity to develop longterm relationships with their patients. Community resources were readily available, and social work no longer needed to emphasize its initial commitment to moving patients back into the community through a strong network of agencies and interagency problem solving. Departments began to split off the discharge function, often delegating it to less well trained workers (Peterson et al., 1979; Wattenberg and O'Rourke, 1978).
CURRENT CHALLENGES We are now facing the withdrawal of government supports from health, education, and welfare programs (Abramovitz, 1986; Day, 1989; Harrington, 1989). Administrators in health care settings are pressing staff to maximize efficiency and minimize waste. These
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changes are necessitating a new model of service that asks the individual patient or family to use personal resources rather than rely on lengthy reimbursable interventions by professionals. Because social work practice was originally established as a support for the physician, and its early survival was financed by physician reimbursement, there had been a tendency to turn to the physician as the team leader. Currently, however, physicians are also experiencing changes and restrictions in their traditional roles. Administration of hospitals and health settings is being taken over by business managers. As social work departments become less dependent on physicians and more dependent on administrators, there is some risk that administrators will set the standards for social work practice without understanding the implications of these changes (Levine, 1988). Just as social workers once integrated but redefined the medical model, so they will now need to integrate but redefine economic principles. This means initiating the necessary costlbenefit adaptations in their own practice. Patient needs in health care settings are becoming more complex than ever (McKinney and Young, 1985; Peterson, 1987). The challenge is to find cost effective methods for meeting these needs. As Bendor documents, engagement, diagnosis, treatment planning, and implementation often have to be done in a few days. "The cherished social work principle of 'starting where the client is' is challenged by the new principle of 'starting where the reimbursement is'" (Bcndor, 1987). In efforts to facilitate more timely planning for discharge needs while allowing patients to have maximal input into the decision making process, the clinical social worker must often be the one to confront patients and families with the harsh reality of their current social and medical situations. The opportunity for denial that is an early component of a normal grieving process becomes curtailed by the need for expedient discharge planning. Managing such cases takes a great deal of experience and clinical sophistication (Blumenfield and Rosenberg, 1988); in general it cannot be effectively done by casework assistants. Effective practice in today's health care setting involves: using clinical intuition and careful diagnostic judgment; accepting a leadership role and assisting other providers with clinical decision rnaking; relinquishing the long-term relationship in order to expedite patientlfamily problem solving; and integrating clinical skills and
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systemic techniques with the knowledge of community resources and networking options. As the following cases suggest, effective crisis intervention, short-term therapy, and discharge planning will be the signature of the most skilled clinician, not the least skilled. CASE ILLUSTRATIONS Case 1
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Presenting Problem A 57-year-old widower was admitted for emergency surgery in the middle of an acute psychotic episode in which he had lacerated both of his eyes. He had a previous history of brief hospitalizations for psychotic ideation, but had never been self-mutilating. He had recently expressed concern about difficulties his son was having in the armed services, but there was no obvious cause for his sudden decornpensation. Following surgery, the psychiatric resident saw the patient for medication management. The social worker met with the upset family to review family history and resources and to provide emotional support. The patient was medically ready for discharge from the surgical setting in less than a week. At that point he was just coming out of his psychosis, was in a state of shock, newly blinded, and unable to talk about what he had done to himself or how he felt. Efforts by the psychiatrist to transfer him to a psychiatric setting met with no success. No hospital would take him. His only local family, a sister and niece, were also not willing to take responsibility for him.
Assessment The social worker made a clinical decision that an immediate return to the community was unsafe, that he needed the opportunity to stabilize his psychological function in a psychiatric facility but then could potentially return home. With inpatient psychiatric hospitalization as the discharge focus, the social worker began to expand her function. She called the psychiatric settings that had turned him down in order to clarify their reasons for refusing admission. The nurses in those
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settings felt that they would be unable to meet the patient's activity of daily living needs because he had no mobility skills; the administrator feared an overstay.
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lntewention The social worker reassessed the patient and determined that he was anxious but not currently psychotic or suicidal. The social worker suggested the possibility of removing suicide precautions and initiating a process of mobility and activity of daily living training on the floor. Psychiatry and nursing agreed to participate with this plan and to help monitor the patient's mental status during this process. The social worker began to plan with the patient for the next stages of adaptation to his loss. With his knowledge, she contacted his son, who was stationed overseas, and initiated a family hardship discharge from the armed services for him. She met with thc sister and niece to help them to understand more about the process of an acute psychotic episode, to articulate their feelings of anger and guilt, and to engage their support in working with an inpatient psychiatry setting. As part of this process, she helped them to work out transportation so they could get to future meetings. The social worker negotiated with the Commission for the Blind to obtain the services of a mobility trainer while the patient was in the hospital. She contacted the neighborhood community mental health agency and reestablished their commitment to provide follow-up care. One week later, when all the pieces were in place, she again initiated referrals to the more promising inpatient psychiatry facilities. In her calls, she described the patient's current strengths and increased mobility and offered on-site inservice training to the facility's nursing staff by a nurse educator from her own hospital who was knowledgeable about working with newly blinded patients. She also spelled out the long range community supports that would be available when the patient was ready for discharge from the psychiatric facility. One inpatient psychiatry unit agreed to evaluate the patient. The worker reviewed the intake process with the patient and
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accompanied him and his sister when they went for the patient's initial evaluation. The patient was accepted for admission. A nurse and social worker went with the patient on the day of transfer to provide training to the inpatient staff and support to the patient during the transition. Case 2
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Presenting Problem A 53-year-old married woman with a 15-year history of advancing multiple sclerosis, was admitted in a sudden onset medical crisis. In spite of all medical efforts, her condition deteriorated rapidly and she was on multiple system supports. Her two adult children, their spouses, and her husband met with the physician but were unable to come to terms with her medical deterioration or her impending death. They could not accept a "do not resuscitate" order even though the patient had made it clear to her daughter that she would not want to be maintained in a vegetative state. She was struggling to say goodbye to her family members when she had lucid moments but they kept begging her to continue to fight to live.
Assessment The social worker asked to meet with the family as a unit to help them with their grief process. Each family member talked about what had been special and what was unfinished in his or her relationship with the patient. The social worker sensed that there was still something missing. She asked what their greatest fear was should the patient die. After much discomfort, the family revealed that the patient's husband had become psychotically depressed after the death of his mother twenty years before. Further discussion indicated that the husband was sad and anxious about being alone but was not having symptoms of either serious depression or psychosis.
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Once this family secret was out in the open, the family could begin to face the patient's impending death, and make appropriate plans for the husband and for themselves. They each said their goodbyes to the patient when they were with her and asked the doctor to do everything to make her comfortable but not to resuscitate her if she had a cardiac arrest. Two days later she had a cardiac arrest and died. The family met once with the social worker before the funeral. One daughter and son-in-law planned to move in with the patient's husband for six months while they were building their own home. The husband had been having some difficulty sleeping but felt connected to his children and planned to join a bereavement support group. He did not feel the need for further psychiatric support at this point. He and his children agreed to monitor his symptoms and contact the social worker or mental health agency if there were any changes. The social worker contacted the family several weeks later and the situation appeared stable. One year later, the family contacted the worker to say that things were going well. Case 3
Presenting Problem An army private and his Italian wife had been recently stationed in the states. The wife had difficulty leaving her parents and had encouraged them to visit. During the visit, her mother had a major stroke. There was no medical coverage for any of the mother's care. Her recovery was slow and six weeks after emergency admission to the hospital, she no longer required acute care but was still confused, unable to talk, unable to walk without assistance and unable to transfer from bed to chair by herself. The daughter was very distraught and was with her all the time. Physicians felt the patient could not return to her own country for at least six months because of the potential for further damage from the flight. No rehabilitation facility would accept her without payment. The family had no financial resources.
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Assessment
The daughter thought she could care for her mother at home but the son-in-law was fearful that his wife and father-in-law would not be able to meet her needs. The father-in-law would not come to see the patient and had become very demanding of the family. The son-in-law indicated that he was having difficulties adjusting to this crisis and felt his marriage had always been endangered by his wife's dependence on her parents. Every community agency refused to become involved in caring for the patient or her family because of their fear that thcy would be left carrying all the costs of care. Intervention
The social worker requested an emergency meeting of all community agencies that could potentially help the family. Because there had been ongoing working relationships, all agencies agreed to send a senior staff representative. Prcscnt for the meeting were: the home health agency; the home care corporation; the family service agency; the community mcntal health center; a representative from the army basc; the hospital social worker; the chief physical therapist from the hospital; and a representative of the council for elders. After reviewing the critical needs of the family, the lack of available financial resources and each agency's concern that the costs of unreimbursed care would overwhelm already overdrawn budgets, the social worker proposed that each agency make a commitment to provide one piece of the care package that was needed. The time commitment would be for six months, when the patient could be returned safely to her own country. The social worker explained that the hospital had agreed to coordinate the patient's care and to provide free physical and occupational therapy on a twice a week basis as well as ongoing medical management. There was a long silence and then, one by one, each agcncy committed itself to provide one or another of the critically needed services that would make up a home based rehabilitation program for the patient. The family service agency had an Italian speaking social worker who agreed to try to work with
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the patient's husband. The council for elders agreed to locate Italian speaking volunteers to help with visiting and translating for the patient. The community mental health agency agreed to offer marital counseling to help the patient's daughter and sonin-law with the stresses this crisis was causing in their marriage. The army base agreed to provide all supplies and to work out transportation back to Italy when it was safe for the patient to fly. The home care corporation and home health agency agreed to provide home nursing assistance with personal care and homemaker services. The family was very responsive to the services that were offered to them and although the program had its difficult moments and times when there were disruptions in the coordination of services, the patient was able to be cared for in the community, made some gains in function, and did return to Italy five months later. The patient had a large extended family in Italy and the daughter and son-in-law went with her to assist with the transition, but returned to the states to continue to build their own life. Each of these cases illustrates the complex ways in which clinical social workers used their diagnostic, treatment, and systems intervention skills to work with the patient and family within the context of larger system issues. None of these cases involved a long-term treatment relationship with patient or family, but each required excellent clinical judgment, an empathic understanding of patient, family, and community agency issues, the willingness to take the lead in developing an appropriate intervention plan, and the clinical facilitation of patient and family decision making and problem resolution.
DISCUSSION Kapoport (3962) describes a crisis as a "catalyst that disturbs old labits, evokcs new responses and becomes a major factor in chartng new dcvelopments." It rcquires a solution which is new in relaion to an individual's previous cxperience. Current cost containnent pressures pose a crisis for the ficld of social work. In their rraditional role, social workers monitored the quality of care of dis-
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advantaged patients, provided ongoing individualized services, and advocated for legislative and regulatory changes when problems occurred. They are now asked as well to review their policies and procedures and determine the most cost effective means of providing services to patients. Combining efficiency and effectiveness in this climate requires changes in the nature of therapeutic interactions. The existence of a strong support network for hospital social work directors has enabled them to take the initiative in promoting effective administrative systems (Rosenberg and Clarke, 1987). Direct care staff, however, have felt more isolated in their efforts to modify their own style of practice. Consequently, there has been an attrition of good clinicians from the field and growing difficulty in filling vacant positions. Current clinical interventions often require a telescoping of engagement, assessment, and intervention into one or two sessions. The clinician's previous enjoyment of the developing relationship with the patient (Surrey, 1984) must now be replaced by his or her pleasure in effective diagnosis and in facilitation of the patient's own independent abilities to solve problems. This new approach necessitates a different meaning of "relationship" and a diffcrent use of the clinician as "self object." At this time of change, it is important to establish effective support networks for clinical social workers in these settings. Creative social work clinicians are already responding to this challenge. The profession is fortunate to have a broad base of knowledge and a tradition of integrating both individual and system perspectives. Rather than abandoning the clinical components of care and retrenching to the limited focus of only dispensing resources, these clinicians are expanding the efficiency and efficacy of diagnosis, problem focused intervention and network development. Social workers are now assuming responsibility for early identification of depression, dementia, psychosis, chemical dependencies, personality style, family function, and larger system issues. As health care institutions are being redefined as a component in a continuity-of-care system, social workers are taking the lead in developing interagency linkages and effective communication, coordination, and problem solving procedures. With the increased
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pressure for rapid decision making, patients and families are at risk of losing control of the decisions that affect their own well-being. Clinical social workers are responding by developing treatment models and psychoeducational programs that have the potential to increase the effectiveness of patient and family involvement in care planning and decision making. The evolution of new practice models requires strong clinical leadership, opportunities for an ongoing exchange of ideas between clinicians from different settings, and confidence in social work's ability to meet the challenges. Social work administrators will need to support the continued evolution of effective practice paradigms and encourage peer discussion and collaborative problem solving for particularly difficult cases. The schools of social work must acknowledge the need for expanded skills for the clinicians going into health care settings and work closely with these settings to develop more relevant practice guidelines. New clinical leadership needs to be supported. This is the time when clinical social work can and must make its greatest contribution to health care, but to do so, it must employ the imagination and vision required by extraordinary times. REFERENCES Abramovitz, M. (1986). The privatization of the welfare state: a review. Social Work, 31(4), 257-264. Bartlett, H.M. (1961). Social work practice in the health field. Washington, D.C.: NASW. Bendor, S.I. (1987). The clinical challenge of hospital-based social work practice. Social Work in Health Care, 13 (2), 25-34. Blanck,G.,& Blank,R. (1979). Ego psychology 11. New York: Columbia Press. Blumenfield,S., & Rosenberg,G. (1988). Towards a network of social health services in redefining discharge planning and expanding the social work domain. Social Work in Health Care, 13(4), 31-48. Cabot,R.C. (1907). Annual Report of the Social Service Department of Massachusetts General Hospital. Boston: The Fort Hill Press. Cunnon,l. (1913). Social work in hospitals. Philadelphia: The Russell Sage Foundation. Caroff,P., & Mailick,M. (1985). The patient has a family: reaffirming social work's domain. Social Work in Health Care, 10(4), 17-34. Caroff,P. (1988). Clinical social work: present role and future challenge. Social Work in Health Care, 13(2), 21-33.
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Corrigan,E. (1979). Alcohol knowledge and practice issues. Health and Social Work, 4(4), 9-40. Davidson,K.W. (1978). Evolving social work roles in health care: the case for discharge planning. Social Work in Health Care, 4(1), 43-54. Day, P.J. (1989). The new poor in America: isolationism in an international political economy. Social Work, 34(3), 227-233. Dinerman,M. et al. (1986). Surviving DRG's: New Jersey's social work experience with prospective payments. Social Work in Health Care, 12(1), 103-113. Elson,M. (1986). Self psychology in clinical social work. New York: W.W. Norton and Co. Fe1dman.Y. (1960). Integration of psychoanalytic concepts into casework practice. Smith College Studies in Social Work, 30, 144-156. Harrington,M. (1989). Socialism past and future. New York: Arcade Publishing. Horner,A.J. (1984). Object relations and the developing ego in therapy. New Jersey:Jason Aronson Inc. Kemler,B. (1985). Family treatment in the health setting: the need for innovation. Social Work in Health Care, 10(4), 45-53. Kohlert, N. (1989). Welfare reform: a historic consensus. Social Work. 34(4), 303-306. Levine,D.E. (1988). Letters. Health and Social Work, 13(2),83. Lindemann,E. (1944). Symptomatology and management of acute grief. American Journal of Psychiatry, 101, 141-148. McKinney,E.A., & Young, A.T. (1985). Changing patient populations: consideration for service delivery. Health and Social Work, 10(4), 292-299. Miller,R.S., & Rehr,H. (eds) (1983). Social work issues in health care. New Jersey: Prentice-Hall, Inc. Nason F. & Delbanc0,T.L. (1976). Soft services: a major, cost-effective cornpol nent of primary medical care.Social Work in Health Care, 1(3), 297-308. Parad,H. & Miller,R. (eds) (1963). Ego-oriented casework: New York: FSAA. Parad,H.(ed) (1965). Crisis intervention:selected readings. New York: FSAA. Patti,R.J., and Ezell,M. (1988). Performance priorities and administrative practice in hospital social work departments. Social Work in Health Care, 13(3),73-89. Perlman,H.H. (1957). Social casework:a problem-solving process. Chicago: University of Chicago Press. Peterson,C. et al. (1979). Paraprofessional role in a mental health continuing care program. Health and Social Work, 4(3), 65-81. Peterson,K.J. (1987). Changing needs of patients and families in the acute care hospital: implications for social work practice. Social Work in Health Care,, 13(2),1-14. Rapoport,L. (1962). The state of crisis: some theoretical considerations.SociaI Service Review,26, 213-222. Rehr,H. (1985). Medical care organization and the social service connection. Health and Social Work, 10(4), 245-257. Rosenberg,G. & Clarke,S.S. (eds) (1987). Social workers in health care management: the move to leadership.Social Work in Health Care, 12(3), 1-143.
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Star,P. (1982). The social transformation o f American medicine. New York: Basic Books. SurreyJ. (1984). Self-in-relation: a theory of women's development. Work i n Progress, Wellesley College, No.13,l-16. Wattenberg,S.H. & O'Rourke,T.W. (1978). Comparison o f task performance of master's and bachclor's degree social workers in hospitals. Social Work in Health Care, 4(1), 93-105.
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