Social Work in Health Care
ISSN: 0098-1389 (Print) 1541-034X (Online) Journal homepage: http://www.tandfonline.com/loi/wshc20
Observations on the Scientific Base of Health Social Work Hans S. Falck PhD, FRHS To cite this article: Hans S. Falck PhD, FRHS (1990) Observations on the Scientific Base of Health Social Work, Social Work in Health Care, 15:1, 9-19, DOI: 10.1300/J010v15n01_03 To link to this article: http://dx.doi.org/10.1300/J010v15n01_03
Published online: 26 Oct 2008.
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Citing articles: 1 View citing articles
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Date: 07 November 2015, At: 22:54
Observations on the Scientific Base of Health Social Work Downloaded by [University of Cambridge] at 22:54 07 November 2015
H a n s S. Falck, PhD, F R H S
ABSTRACT. This article examines aspects of social work in health care from a philosophy of science perspectivc, which suggests different ways of conceptualizing and defining variables ranging from service recipients to principles undergirding social work intcrvention. Focus is given to the relationships among theory, practice, and research in social work by considering the nature of clinical theory; health social work theory; and theory grounded rcsearch.
Investigation of the scientific basis of social work in health care always has been and remains a most fruitful undertaking. T w o aspects of science in such investigations are: (a) inquiry into practice, or the process of social work intervention; and (b) the evaluation of practice, or whether social work in health care settings "works." Recently, the prospects of such investigations have been strengthcned b y the publication of an extensive, well-organized, annotated bibliography categorized according to eighteen dimensions of social work in health care (Berkman et al., 1988). Motivations for evaluative studies of practice include not only the traditional desire of professional social workers to track their work, but in morc recent years the need to assess their work in light of the drastic changes on the availability of that care to the American people in general and those in immediate need of health care in particuHans S. Falck is Professor of Social Work and Professor of Psychiatry, Virginia Cnmmonwealth University, 1001 West Franklin Street, Richmond, VA 23284-2027. The author wishes to acknowledge the contributions to this article of Thomas 0. Carlton, DSW. Social Work in Health Care, Vol. 15(1) 1990 0 1990 by The Haworth Press, Inc. All rights reserved. 9
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lar (Christ, 1982: Coulton, 1980: Coulton & Butler, 1981; Rosenberg, 1980; Volland & German, 1979). A third, gradually developing field of inquiry has to do with epistemological and theoretical investigations of social work. In such inquiries, emphasis is less on quantitative, data-bound research than on concepts, constructs, theories, and scientific laws. Investigations in this area focus on the way social workers think and the kinds of knowledge and methods of reasoning upon which their work rests. Not only is this effort a necessary one for the development of the health care specialty in social work, but for social work as a whole. It is demanded for the long range definition of what social work in health care is and how it relates to the practice of non-social work colleagues in health care (e.g., nurses, physicians, occupational therapists, rehabilitation therapists, patient advocates, and physical therapists), for each of these other disciplines also has and puts forward its own psychosocial claims. In recent years, a shift has developed in the attention of social work authors and researchers from concern about the uniqueness of social work in health care to an examination and explication of its central characteristics (Falck, 1982, 1984, 1988). The focus of this article is on philosophy of science aspects of social work in health care. The term, philosophy of science, as used here, is defined in its broadest sense to suggest that there are alternative ways of conceptualizing everything, from the way one defines recipients of service to the principles undergirding social work intervention. CONSIDERATIONS OF THEORY Members of most academic professional circles assume, usually without documentation, that theories of professional intervention are reflected in the work performed by practitioners. The basic question, however, is not whether theory is reflected in practice at all, but rather the extent to which such reflection takes place. The latter question cannot be answered with anything approaching definitiveness and, in fact, the tendency seems to be in the other direction. It may be, for example, that theory has little influence on the roles many practitioners perform and the work they do and that
Downloaded by [University of Cambridge] at 22:54 07 November 2015
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II
many social workers, like most Americans, favor "what works" over theory. There are exceptions of course. For example, the impression prevails that practitioners brought up in the behaviorist tradition are somewhat more effective at establishing the link between learning theory and what they actually do. Less likely to meet the standards of linking theory and practice are those social workers educated according to theoretical systems with high levels of abstraction and generalization in which the variables intervening between theory and practice can rarely bc operationalizcd. Ego-based social work is one example of this type of theoretical system. The point here is not to argue the advantages or validity of any specific theory pcr se, but rather to direct attention to: (1) the nature of clinical theory; (2) theory in health social work; (3) theory and theory-grounded research and social work practice. THE NATURE OF CLINICAL THEORY
The first and foremost observation to be made about any clinical social work theory is that it must be useable in the practice of social work, e.g., in this case, the practice of social work with identifiable health care clients and their families. Clinical theory rests on knowledge of the human condition. In fact, knowledge of the human condition is the most fundamental aspect of theory building and theory use. Since theory is always a matter of abstraction and generalization, it must have the potential for explaining the interventions of social workers with entire classes of clients and, by deduction, the intervention of a social worker with a particular client and histher family. Since generalization is an inherent attribute of theory, theory does not develop in terms of one case or one family alone, although theory-relevant insights may be gained from a few cases. To become theory, however, such insights must be able to stand the test of gencralizability. Theory aims at predictive power. Given certain kinds of clients and their families, and given certain kinds of sickness, injury or disability, a theory of social work practice ought to be such that it predicts the results of specific interventions with any given client and family or any number of clients and their families. A theory that does not predict outcomes is of limited usc. Thus, theory explains.
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Without theory, explanations are random, and, therefore, little more than observations of limited value among which any one observation might be as valid as another or none at all. The explanatory aspect of theory is usually causal in nature. That is, given the simultaneous presence of certain clients and family characteristics under stressful conditions, such as those that are found in disease, injury and disability, certain causal relationships will be observable under certain conditions of social work intervention. For example, if clients and families are characterized by B, D, and F, and if social work intervention I occurs, then X, Y, and Z can be expected as the outcome of intervention I. In turn, intervention I explains causally the relationships of all of the given variables to each other in time. Causation deals with antecedents (B, D, F) and postcedents (X, Y, Z), all of which can be studied empirically, analyzed, and reported. TRADITIONAL THEORY IN HEALTH SOCLAL WORK In any consideration of theory for social work in health care, it is important to note that until recently, specializations in social work practice and education derived their legitimacy from a generic body of social work theory. This is still largely the case, although the number of exceptions is growing. For most of its history, social work theory developed in terms of discrete practice methods. Because social casework, social group work, and community organization were conceptualized and taught as discrete methods, broadly applicable across settings and fields of practice, it was assumed that once social workers were educated in their use, they could apply them anywhere, in any setting. Methods, however, contain the biases of the practitioners who develop them and use them for specific purposes. At least since the publications of Hamilton's seminal text (1940), the notions of the individual and some larger social system have been the core theoretical concepts of each major social work practice (Falck, 1988). Consequently, these two core concepts have been taught and presumably used widely in social work practice in their original form or with slight modification, e.g., the individual is sometimes referred to as the person, while social structure has been designated as situation, society, environment, and more recently as ecology. In
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this large body of literature, moreover, no differentiations are made between the concepts of the individual and the person. In fact, the two terms are frequently used interchangeably, itself a questionable oractice. The use of terms in theory building implies the use of logic, i.e., vary the term and you vary the logic. Nevertheless, this process calls for circumspection, to say the least, because the application of terms developed within the practice field presumably makes a difference in how clients are perceived and dealt with, even if direct links between the one and the other are difficult to demonstrate. It may be argued that while social work academics, especially theorists, quibble over what to call clients (or patients), people suffer and that the intellectual effort would be better spent on helping. The counter-argument to such persuasive observations is that what one calls things does make a difference because naming people (as opposed to labeling people) determines who offers what to whom and what one expects in return. This is nowhere better illustrated than in health social work practice where use of the terms treatment and therapy are commonplace. Treatment has a common sense usc in that it depends on the presence of an identifiable condition, i.e., a sickness or injury. Following the same common sense logic, this fact requires that a diagnosis bc made, since a diagnosis is the basis upon which the clarity, accuracy, and efficacy of the treatment rests. There are four possible outcomes in the treatment of a sickness or injury. One is recovery. Another is stabilization, third is no effect, and the fourth is death. In addition, treatment, resting as it does on the basis of a diagnosable sickness or injury, is by its nature centered on one person, namely the patient. Even when several persons have the same sickness or injury, each is treated as a single case. The irresistible inference and conclusion affecting the use of terms such as diagnosis (even social diagnosis) and treatment is that social workers cure sickness. The social work client is conceptualized as a patient; the social worker, as is always the case in trcatmcnt oricntcd work, is presumed to know what is wrong with the patient, and consequently what the patient needs. The social worker, therefore, administers what the patient needs (treatment) and hopes for the results desired. But, is social work practice like
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the practice of medicine? Are the problems of social work clients who are sick comparable to those of medical patients? Nevertheless, clinical theory for health social work practice frequently uses the language of medicine. In doing so, it makes the identification and definition of the central characteristics of social work practice all the more difficult. When, as is often the case, such tendencies characterize the practice of social work in health care, the lines of demarcation between and among health professionals are diffused. No one is helped less than the client who stands the risk of wrong diagnosis (instead of social work assessment), wrong treatment (instead of social work intervention), and wrong outcome expectations (instead of improved feelings or behavior). In all likelihood the most serious of the negative costs paid by social work has been the partialization of client problems in the same way that medicine partializes the patient's body. This is a natural counterpart of the specialization and subspecialization of medicine that allows practitioners to focus on one specific organ alone, to understand its functions in great detail, and to treat its dysfunctions in depth. However, this approach breaks down when organism-wide diseases are present, as in the transfer of disease from primary to secondary sites when metastases occur in a variety of cancers. Medical specializations and subspecializations are based on a parts-whole logic derived from linking specific parts of the body to specific other parts. Social work thought often parallels this type of thinking. This parallel is a dialectic in which parts (individuals) are first contrasted with and then summoned up, linked, and integrated to make a whole. The whole is the environment. As a separate variable the environment becomes a subsuming umbrella; but under the umbrella are found separate individuals who, when added to each other, are said to form a totality. The result is the individual and the environment or its variations, all of which follow the same logic. The solution to both medical and social work manifestations of the problems under discussion lies in the a priori irreducibility of wholeness. Thus, the body is not the sum total of its parts. It is a whole by nature and the various aspects of it that the specialist and subspecialist diagnoses and treats are the body's components, not parts. Being components, there is nothing to add and integrate, and there is no dialectic to define each and synthesize all.
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The point is, that theory and the language of theory make an enormous difference, provided that social work claims to be a rational enterprise. Once this claim is dropped, however, it is necessary to rely on practice wisdom or intuition alone and no matter how sophisticated that wisdom or intuition may be, all argument about all language and all logic is unnecessary. But given such a stance, it is necessary to ask what it is that any generation of social work practitioners has to teach succeeding generations? Clinical theory, then,'consists of several components. The first component is a clear view of the human condition-biological, social, psychological, and symbolical (the assignment of meaning to human behavior). Another component of clinical theory is practice theory. This component is best expressed in testable propositions drawn from the underlying view of the human condition. These propositions are cxpressed in practice principles, the purpose of which is to understand client behavior and social work behavior. For example, a social worker who bases his or her work on the membership model (Falck, 1982, 1984, 1988) might say: The membership qualities of these family mcmbcrs arc such that the son plays a highly submissive role while relying on the parents to continue to make decisions for him in ways more appropriate to an earlier stage of his development. My aim will be to help change the ways thc mcmbers of this family deal with each other, thereby affecting the relationships of all with all. This example rcflccts how the social worker's interventions should depend on the propositions that underlic thcm. For cxamplc, the practice propositions that underlie this illustration, based as they arc on the membership perspective are:
1. Client and social worker behavior, as well as the behavior of all others involved, is to be viewed in membership terms; 2. The aim of social work intervention in membership behavior is not to achicvc clicnt independence; rather its goal to reinforce the creative and useful dependence inherent in human nature, while aiming simultaneously at the improvement of dysfunctional dependence.
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Dependence is inherent in the fact that people are never totally independent. Therefore, the question is not whether they can be independent or not, but what the nature of the connectedness (dependence) of all with all is and how that connectedness can be improved. From a theoretical and practice standpoint, the conceptual building blocks of the membership model, for example, point to a practice language of considerable significance to social work. The social worker assesses the needs of all members directly affected by the sickness, injury, or disability of one member because all are members of the same family or other group. The social worker determines whose interests are to be addressed and enters into the family or other group membership network. In doing so, the social worker becomes a component of a helping group which consists of the sick member, the other members affected by and affecting the management of the sick member's illness, and the social worker. Even when particular members are not physically present, choices are identified and decisions made with reference to how all the members will cope with the situation now and in the future. Thus, membership legitimates the dependency of clients, whether sick or not, on one another, subject only to qualitative variables that can be modified by the joint interventions of the social worker and other members. The social worker and the other members of the helping group are, by definition, members of larger membership groups. In fact, the resources of the larger community, the social worker being one of those resources, are identified and utilized in and through the helping group to increase the positive qualities of the ways the members deal with the stress inherent in conditions of sickness and injury and in finding ways to overcome or prevent permanent debilitation. Theory, Research Grounded in Theory, and Social Work Practice
Without carrying the description of one theoretical model too far, it should now be clear how the use of one or another theoretical model influences both social work thought and behavior. In many
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ways, social work in health care follows the same general theoretical approaches followed by social work in other fields of practice. The future of membership and other new conceptual and theoretical models of social work in health care will depend, at least to some degree, on their empirical testability under conditions of everyday social work practice. Currently, not even social work models based on ego psychology or systems theory, which predominate in the field, have been adequately tested for their effectiveness. Evaluation studies that do exist are mostly atheoretical or do not state their theoretical biases explicitly enough to identify them. Even when social workers claim to work with families, one of the oldest of claims in health social work practice, the available data casts some doubt about reality of this claim in cvcry day practice (Carlton, Falck & Berkman, 1984; Carlton, 1984). The resistance of social work practitioners to research and evaluation studies is legendary. No doubt the not uncommon lack of social work practice experience among social work researchers accounts for part of this problem. Biases by practitioners who insist that practice and research are fundamentally different procedures further complicate the situation and both the imprecision of clinical social work language and the obscurity of research language complete it. A more rational and detached view of the distortions inherent in social work's practiceiresearch dichotomy results in the identification of some remarkable parallels among practice, research, and theory development. The central, common element in all three is the use of reason. Reason in this connection is defined as any attempt at: systematic observation of human behavior in general as well as in specific situations; planned intervention; skill in the disciplined, technically adept asking of questions; and arrival at temporarily valid answers to questions about the nature and outcomes of that intervention. It is interesting to note, that nothing was found in the social work literature that challenged these observations. Indeed, practitioners, researchers, and theorists regularly claim that their thinking and their work is bound by reason. All claim the ability to present the results of their efforts in logical, even lawful terms. Nevertheless, all harbor suspicion of the others. Practitioners, for example, r e p -
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larly complain that researchers do not understand the non-empirical aspects of practice, e.g., the affective aspects of relationships among clients and social workers, empathy, informed clinical intuition. Researchers condemn the lack of discipline (rationalism) they perceive among clinicians, yet more than a few researchers publish their reports in the form. of quantitative data, without reference to grounded theory. Consequently, they leave unanswered questions that do not yield easily to tests of statistical significance. These unanswered questions, in turn, produce new criticisms from practitioners and the process begins again. Rationality, however, is not a singular quality. One can be rational in a variety of ways. Yet, there are certain givens that are applicable to all social work efforts, including practice, research, and theory building. Competent clinicians typically develop awareness of basic assumptions made about their clients. These assumptions are not untypically as theoretical in nature as those of the researcher who, provided no claims for eclecticism are made, undertakes theory-grounded investigations. Nor do theorists, by the very definition of the term, overlook the need for explicit statements about what it is that guides their work. CONCLUSION
Clinicians who can help clients know what intervention techniques work, and, therefore, address client needs with a sense of competence, at least hypothetically. The test of their adequacy lies in the effects, desired and undesired, predicted and unpredicted, of their interventions. Similarly, researchers aim at the use of the most efficacious study methodology and evaluate its adequacy and appropriateness by studying their findings in light of the research inputs that produced them. Logical reasoning, inductive and deductive, under maximally precise definitions of terms, governs the work of all three. Social work in health care, from its auspicious beginnings among the sick and poor of Boston at the turn of the century, to its more currently rarified intellectual efforts, needs to keep in mind that scientific practice, research, and theorizing supplement the humanism, the plainness of sympathy for those who suffer, the empathic
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understanding of the pain felt by members of families, social groups, or helping groups when sickness, injury, or disability is present.
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REFERENCES Berkman, B., Bonander, E., Kemler, B., Marcus, L., Rubinger, M-J. I., Rutchick, I., & Silverman, P. (1988). Social Work in Health Care: A Review of the Literature. Chicago: American Hospital Association. Carlton, T.O. (1984). Clinical Social Work in Health Settings: A Guide to Professional Practice with Eremplars. New York: Springer Publishing Company. Carlton, T.O., Falck, H.S., & Berkman, B. (1984). The use of theoretical constructs and research data to establish a base for clinical social work in health settings. Social Work in Health Care, 10 (2), 27-39. Christ, W.R.(1982). A method for setting social work staffing standards within a psychiatric hospital. Social Work in Health Care, 8 (Z), 87-104. Coulton, C.J. (1980). Approaches to quality assessment in social work. Qualip Review Bulletin, 6 (lo), 9-13. Coulton, C.J., & Butler, N. (1981). Measuring social work productivity in health care. Health and Social Work, 6 (3), 10-12. Falck, H.S. (1988). Social Work: The Membership Perspective. New York: Springer Publishing Company. Falck, H.S.(1984). The membership model of social work. Social Work, 29 (2). 154-159. Falck, H.S. (1982). What is central in social work? Health and Social Work, 7 (3), 235-237. Hamilton, G. (1940). Theory and Practice of Social Case Work. New York: Columbia University Press. Rosenberg, G. (1980). Concepts in the financial management of hospital social work departments. Social Work in Health Care, 5 (3), 287-297. Volland, P., & German, P.S. (1979). Development of an information system: A means for improving social work practice in health care. American Journal of Public Health, 69 (4), 335-339.
ISSN: 0098-1389 (Print) 1541-034X (Online) Journal homepage: http://www.tandfonline.com/loi/wshc20
Observations on the Scientific Base of Health Social Work Hans S. Falck PhD, FRHS To cite this article: Hans S. Falck PhD, FRHS (1990) Observations on the Scientific Base of Health Social Work, Social Work in Health Care, 15:1, 9-19, DOI: 10.1300/J010v15n01_03 To link to this article: http://dx.doi.org/10.1300/J010v15n01_03
Published online: 26 Oct 2008.
Submit your article to this journal
Article views: 18
View related articles
Citing articles: 1 View citing articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=wshc20 Download by: [University of Cambridge]
Date: 07 November 2015, At: 22:54
Observations on the Scientific Base of Health Social Work Downloaded by [University of Cambridge] at 22:54 07 November 2015
H a n s S. Falck, PhD, F R H S
ABSTRACT. This article examines aspects of social work in health care from a philosophy of science perspectivc, which suggests different ways of conceptualizing and defining variables ranging from service recipients to principles undergirding social work intcrvention. Focus is given to the relationships among theory, practice, and research in social work by considering the nature of clinical theory; health social work theory; and theory grounded rcsearch.
Investigation of the scientific basis of social work in health care always has been and remains a most fruitful undertaking. T w o aspects of science in such investigations are: (a) inquiry into practice, or the process of social work intervention; and (b) the evaluation of practice, or whether social work in health care settings "works." Recently, the prospects of such investigations have been strengthcned b y the publication of an extensive, well-organized, annotated bibliography categorized according to eighteen dimensions of social work in health care (Berkman et al., 1988). Motivations for evaluative studies of practice include not only the traditional desire of professional social workers to track their work, but in morc recent years the need to assess their work in light of the drastic changes on the availability of that care to the American people in general and those in immediate need of health care in particuHans S. Falck is Professor of Social Work and Professor of Psychiatry, Virginia Cnmmonwealth University, 1001 West Franklin Street, Richmond, VA 23284-2027. The author wishes to acknowledge the contributions to this article of Thomas 0. Carlton, DSW. Social Work in Health Care, Vol. 15(1) 1990 0 1990 by The Haworth Press, Inc. All rights reserved. 9
Downloaded by [University of Cambridge] at 22:54 07 November 2015
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lar (Christ, 1982: Coulton, 1980: Coulton & Butler, 1981; Rosenberg, 1980; Volland & German, 1979). A third, gradually developing field of inquiry has to do with epistemological and theoretical investigations of social work. In such inquiries, emphasis is less on quantitative, data-bound research than on concepts, constructs, theories, and scientific laws. Investigations in this area focus on the way social workers think and the kinds of knowledge and methods of reasoning upon which their work rests. Not only is this effort a necessary one for the development of the health care specialty in social work, but for social work as a whole. It is demanded for the long range definition of what social work in health care is and how it relates to the practice of non-social work colleagues in health care (e.g., nurses, physicians, occupational therapists, rehabilitation therapists, patient advocates, and physical therapists), for each of these other disciplines also has and puts forward its own psychosocial claims. In recent years, a shift has developed in the attention of social work authors and researchers from concern about the uniqueness of social work in health care to an examination and explication of its central characteristics (Falck, 1982, 1984, 1988). The focus of this article is on philosophy of science aspects of social work in health care. The term, philosophy of science, as used here, is defined in its broadest sense to suggest that there are alternative ways of conceptualizing everything, from the way one defines recipients of service to the principles undergirding social work intervention. CONSIDERATIONS OF THEORY Members of most academic professional circles assume, usually without documentation, that theories of professional intervention are reflected in the work performed by practitioners. The basic question, however, is not whether theory is reflected in practice at all, but rather the extent to which such reflection takes place. The latter question cannot be answered with anything approaching definitiveness and, in fact, the tendency seems to be in the other direction. It may be, for example, that theory has little influence on the roles many practitioners perform and the work they do and that
Downloaded by [University of Cambridge] at 22:54 07 November 2015
Hans S. Falck
II
many social workers, like most Americans, favor "what works" over theory. There are exceptions of course. For example, the impression prevails that practitioners brought up in the behaviorist tradition are somewhat more effective at establishing the link between learning theory and what they actually do. Less likely to meet the standards of linking theory and practice are those social workers educated according to theoretical systems with high levels of abstraction and generalization in which the variables intervening between theory and practice can rarely bc operationalizcd. Ego-based social work is one example of this type of theoretical system. The point here is not to argue the advantages or validity of any specific theory pcr se, but rather to direct attention to: (1) the nature of clinical theory; (2) theory in health social work; (3) theory and theory-grounded research and social work practice. THE NATURE OF CLINICAL THEORY
The first and foremost observation to be made about any clinical social work theory is that it must be useable in the practice of social work, e.g., in this case, the practice of social work with identifiable health care clients and their families. Clinical theory rests on knowledge of the human condition. In fact, knowledge of the human condition is the most fundamental aspect of theory building and theory use. Since theory is always a matter of abstraction and generalization, it must have the potential for explaining the interventions of social workers with entire classes of clients and, by deduction, the intervention of a social worker with a particular client and histher family. Since generalization is an inherent attribute of theory, theory does not develop in terms of one case or one family alone, although theory-relevant insights may be gained from a few cases. To become theory, however, such insights must be able to stand the test of gencralizability. Theory aims at predictive power. Given certain kinds of clients and their families, and given certain kinds of sickness, injury or disability, a theory of social work practice ought to be such that it predicts the results of specific interventions with any given client and family or any number of clients and their families. A theory that does not predict outcomes is of limited usc. Thus, theory explains.
Downloaded by [University of Cambridge] at 22:54 07 November 2015
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Without theory, explanations are random, and, therefore, little more than observations of limited value among which any one observation might be as valid as another or none at all. The explanatory aspect of theory is usually causal in nature. That is, given the simultaneous presence of certain clients and family characteristics under stressful conditions, such as those that are found in disease, injury and disability, certain causal relationships will be observable under certain conditions of social work intervention. For example, if clients and families are characterized by B, D, and F, and if social work intervention I occurs, then X, Y, and Z can be expected as the outcome of intervention I. In turn, intervention I explains causally the relationships of all of the given variables to each other in time. Causation deals with antecedents (B, D, F) and postcedents (X, Y, Z), all of which can be studied empirically, analyzed, and reported. TRADITIONAL THEORY IN HEALTH SOCLAL WORK In any consideration of theory for social work in health care, it is important to note that until recently, specializations in social work practice and education derived their legitimacy from a generic body of social work theory. This is still largely the case, although the number of exceptions is growing. For most of its history, social work theory developed in terms of discrete practice methods. Because social casework, social group work, and community organization were conceptualized and taught as discrete methods, broadly applicable across settings and fields of practice, it was assumed that once social workers were educated in their use, they could apply them anywhere, in any setting. Methods, however, contain the biases of the practitioners who develop them and use them for specific purposes. At least since the publications of Hamilton's seminal text (1940), the notions of the individual and some larger social system have been the core theoretical concepts of each major social work practice (Falck, 1988). Consequently, these two core concepts have been taught and presumably used widely in social work practice in their original form or with slight modification, e.g., the individual is sometimes referred to as the person, while social structure has been designated as situation, society, environment, and more recently as ecology. In
Downloaded by [University of Cambridge] at 22:54 07 November 2015
Ham S. Falck
13
this large body of literature, moreover, no differentiations are made between the concepts of the individual and the person. In fact, the two terms are frequently used interchangeably, itself a questionable oractice. The use of terms in theory building implies the use of logic, i.e., vary the term and you vary the logic. Nevertheless, this process calls for circumspection, to say the least, because the application of terms developed within the practice field presumably makes a difference in how clients are perceived and dealt with, even if direct links between the one and the other are difficult to demonstrate. It may be argued that while social work academics, especially theorists, quibble over what to call clients (or patients), people suffer and that the intellectual effort would be better spent on helping. The counter-argument to such persuasive observations is that what one calls things does make a difference because naming people (as opposed to labeling people) determines who offers what to whom and what one expects in return. This is nowhere better illustrated than in health social work practice where use of the terms treatment and therapy are commonplace. Treatment has a common sense usc in that it depends on the presence of an identifiable condition, i.e., a sickness or injury. Following the same common sense logic, this fact requires that a diagnosis bc made, since a diagnosis is the basis upon which the clarity, accuracy, and efficacy of the treatment rests. There are four possible outcomes in the treatment of a sickness or injury. One is recovery. Another is stabilization, third is no effect, and the fourth is death. In addition, treatment, resting as it does on the basis of a diagnosable sickness or injury, is by its nature centered on one person, namely the patient. Even when several persons have the same sickness or injury, each is treated as a single case. The irresistible inference and conclusion affecting the use of terms such as diagnosis (even social diagnosis) and treatment is that social workers cure sickness. The social work client is conceptualized as a patient; the social worker, as is always the case in trcatmcnt oricntcd work, is presumed to know what is wrong with the patient, and consequently what the patient needs. The social worker, therefore, administers what the patient needs (treatment) and hopes for the results desired. But, is social work practice like
Downloaded by [University of Cambridge] at 22:54 07 November 2015
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the practice of medicine? Are the problems of social work clients who are sick comparable to those of medical patients? Nevertheless, clinical theory for health social work practice frequently uses the language of medicine. In doing so, it makes the identification and definition of the central characteristics of social work practice all the more difficult. When, as is often the case, such tendencies characterize the practice of social work in health care, the lines of demarcation between and among health professionals are diffused. No one is helped less than the client who stands the risk of wrong diagnosis (instead of social work assessment), wrong treatment (instead of social work intervention), and wrong outcome expectations (instead of improved feelings or behavior). In all likelihood the most serious of the negative costs paid by social work has been the partialization of client problems in the same way that medicine partializes the patient's body. This is a natural counterpart of the specialization and subspecialization of medicine that allows practitioners to focus on one specific organ alone, to understand its functions in great detail, and to treat its dysfunctions in depth. However, this approach breaks down when organism-wide diseases are present, as in the transfer of disease from primary to secondary sites when metastases occur in a variety of cancers. Medical specializations and subspecializations are based on a parts-whole logic derived from linking specific parts of the body to specific other parts. Social work thought often parallels this type of thinking. This parallel is a dialectic in which parts (individuals) are first contrasted with and then summoned up, linked, and integrated to make a whole. The whole is the environment. As a separate variable the environment becomes a subsuming umbrella; but under the umbrella are found separate individuals who, when added to each other, are said to form a totality. The result is the individual and the environment or its variations, all of which follow the same logic. The solution to both medical and social work manifestations of the problems under discussion lies in the a priori irreducibility of wholeness. Thus, the body is not the sum total of its parts. It is a whole by nature and the various aspects of it that the specialist and subspecialist diagnoses and treats are the body's components, not parts. Being components, there is nothing to add and integrate, and there is no dialectic to define each and synthesize all.
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The point is, that theory and the language of theory make an enormous difference, provided that social work claims to be a rational enterprise. Once this claim is dropped, however, it is necessary to rely on practice wisdom or intuition alone and no matter how sophisticated that wisdom or intuition may be, all argument about all language and all logic is unnecessary. But given such a stance, it is necessary to ask what it is that any generation of social work practitioners has to teach succeeding generations? Clinical theory, then,'consists of several components. The first component is a clear view of the human condition-biological, social, psychological, and symbolical (the assignment of meaning to human behavior). Another component of clinical theory is practice theory. This component is best expressed in testable propositions drawn from the underlying view of the human condition. These propositions are cxpressed in practice principles, the purpose of which is to understand client behavior and social work behavior. For example, a social worker who bases his or her work on the membership model (Falck, 1982, 1984, 1988) might say: The membership qualities of these family mcmbcrs arc such that the son plays a highly submissive role while relying on the parents to continue to make decisions for him in ways more appropriate to an earlier stage of his development. My aim will be to help change the ways thc mcmbers of this family deal with each other, thereby affecting the relationships of all with all. This example rcflccts how the social worker's interventions should depend on the propositions that underlic thcm. For cxamplc, the practice propositions that underlie this illustration, based as they arc on the membership perspective are:
1. Client and social worker behavior, as well as the behavior of all others involved, is to be viewed in membership terms; 2. The aim of social work intervention in membership behavior is not to achicvc clicnt independence; rather its goal to reinforce the creative and useful dependence inherent in human nature, while aiming simultaneously at the improvement of dysfunctional dependence.
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Dependence is inherent in the fact that people are never totally independent. Therefore, the question is not whether they can be independent or not, but what the nature of the connectedness (dependence) of all with all is and how that connectedness can be improved. From a theoretical and practice standpoint, the conceptual building blocks of the membership model, for example, point to a practice language of considerable significance to social work. The social worker assesses the needs of all members directly affected by the sickness, injury, or disability of one member because all are members of the same family or other group. The social worker determines whose interests are to be addressed and enters into the family or other group membership network. In doing so, the social worker becomes a component of a helping group which consists of the sick member, the other members affected by and affecting the management of the sick member's illness, and the social worker. Even when particular members are not physically present, choices are identified and decisions made with reference to how all the members will cope with the situation now and in the future. Thus, membership legitimates the dependency of clients, whether sick or not, on one another, subject only to qualitative variables that can be modified by the joint interventions of the social worker and other members. The social worker and the other members of the helping group are, by definition, members of larger membership groups. In fact, the resources of the larger community, the social worker being one of those resources, are identified and utilized in and through the helping group to increase the positive qualities of the ways the members deal with the stress inherent in conditions of sickness and injury and in finding ways to overcome or prevent permanent debilitation. Theory, Research Grounded in Theory, and Social Work Practice
Without carrying the description of one theoretical model too far, it should now be clear how the use of one or another theoretical model influences both social work thought and behavior. In many
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ways, social work in health care follows the same general theoretical approaches followed by social work in other fields of practice. The future of membership and other new conceptual and theoretical models of social work in health care will depend, at least to some degree, on their empirical testability under conditions of everyday social work practice. Currently, not even social work models based on ego psychology or systems theory, which predominate in the field, have been adequately tested for their effectiveness. Evaluation studies that do exist are mostly atheoretical or do not state their theoretical biases explicitly enough to identify them. Even when social workers claim to work with families, one of the oldest of claims in health social work practice, the available data casts some doubt about reality of this claim in cvcry day practice (Carlton, Falck & Berkman, 1984; Carlton, 1984). The resistance of social work practitioners to research and evaluation studies is legendary. No doubt the not uncommon lack of social work practice experience among social work researchers accounts for part of this problem. Biases by practitioners who insist that practice and research are fundamentally different procedures further complicate the situation and both the imprecision of clinical social work language and the obscurity of research language complete it. A more rational and detached view of the distortions inherent in social work's practiceiresearch dichotomy results in the identification of some remarkable parallels among practice, research, and theory development. The central, common element in all three is the use of reason. Reason in this connection is defined as any attempt at: systematic observation of human behavior in general as well as in specific situations; planned intervention; skill in the disciplined, technically adept asking of questions; and arrival at temporarily valid answers to questions about the nature and outcomes of that intervention. It is interesting to note, that nothing was found in the social work literature that challenged these observations. Indeed, practitioners, researchers, and theorists regularly claim that their thinking and their work is bound by reason. All claim the ability to present the results of their efforts in logical, even lawful terms. Nevertheless, all harbor suspicion of the others. Practitioners, for example, r e p -
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larly complain that researchers do not understand the non-empirical aspects of practice, e.g., the affective aspects of relationships among clients and social workers, empathy, informed clinical intuition. Researchers condemn the lack of discipline (rationalism) they perceive among clinicians, yet more than a few researchers publish their reports in the form. of quantitative data, without reference to grounded theory. Consequently, they leave unanswered questions that do not yield easily to tests of statistical significance. These unanswered questions, in turn, produce new criticisms from practitioners and the process begins again. Rationality, however, is not a singular quality. One can be rational in a variety of ways. Yet, there are certain givens that are applicable to all social work efforts, including practice, research, and theory building. Competent clinicians typically develop awareness of basic assumptions made about their clients. These assumptions are not untypically as theoretical in nature as those of the researcher who, provided no claims for eclecticism are made, undertakes theory-grounded investigations. Nor do theorists, by the very definition of the term, overlook the need for explicit statements about what it is that guides their work. CONCLUSION
Clinicians who can help clients know what intervention techniques work, and, therefore, address client needs with a sense of competence, at least hypothetically. The test of their adequacy lies in the effects, desired and undesired, predicted and unpredicted, of their interventions. Similarly, researchers aim at the use of the most efficacious study methodology and evaluate its adequacy and appropriateness by studying their findings in light of the research inputs that produced them. Logical reasoning, inductive and deductive, under maximally precise definitions of terms, governs the work of all three. Social work in health care, from its auspicious beginnings among the sick and poor of Boston at the turn of the century, to its more currently rarified intellectual efforts, needs to keep in mind that scientific practice, research, and theorizing supplement the humanism, the plainness of sympathy for those who suffer, the empathic
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understanding of the pain felt by members of families, social groups, or helping groups when sickness, injury, or disability is present.
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REFERENCES Berkman, B., Bonander, E., Kemler, B., Marcus, L., Rubinger, M-J. I., Rutchick, I., & Silverman, P. (1988). Social Work in Health Care: A Review of the Literature. Chicago: American Hospital Association. Carlton, T.O. (1984). Clinical Social Work in Health Settings: A Guide to Professional Practice with Eremplars. New York: Springer Publishing Company. Carlton, T.O., Falck, H.S., & Berkman, B. (1984). The use of theoretical constructs and research data to establish a base for clinical social work in health settings. Social Work in Health Care, 10 (2), 27-39. Christ, W.R.(1982). A method for setting social work staffing standards within a psychiatric hospital. Social Work in Health Care, 8 (Z), 87-104. Coulton, C.J. (1980). Approaches to quality assessment in social work. Qualip Review Bulletin, 6 (lo), 9-13. Coulton, C.J., & Butler, N. (1981). Measuring social work productivity in health care. Health and Social Work, 6 (3), 10-12. Falck, H.S. (1988). Social Work: The Membership Perspective. New York: Springer Publishing Company. Falck, H.S.(1984). The membership model of social work. Social Work, 29 (2). 154-159. Falck, H.S. (1982). What is central in social work? Health and Social Work, 7 (3), 235-237. Hamilton, G. (1940). Theory and Practice of Social Case Work. New York: Columbia University Press. Rosenberg, G. (1980). Concepts in the financial management of hospital social work departments. Social Work in Health Care, 5 (3), 287-297. Volland, P., & German, P.S. (1979). Development of an information system: A means for improving social work practice in health care. American Journal of Public Health, 69 (4), 335-339.
