8 minute read
Reclaiming our Place
Successful social work practice in medical model settings
BY ANNE PIRIE, MSW & JIM MORTON, MSW
During the last several decades the contexts within which social workers practise have become laden with contradictions: restrained funding while faced with burgeoning demand; prepackaged interventions intended to target problems as unique as the clients who register for service; increased reliance on cause-and-effect, medical-model approaches to complex human problems; and time-limited service for conditions that unfold over a lifetime. These contradictions have led the Nova Scotia College of Social Workers to commission research to investigate mental health experience in the province, to advocate for child welfare reforms, and to make mental health the theme of the College’s conference in May 2020.
This context inspired our article. We have decades of diverse experience in psychiatric and acute care hospitals, addictions services, mental health clinics, private practice, child welfare, and family service settings where they have worked in clinical, supervisory, leadership and consulting roles. We are hopeful that this article will stimulate both reflection and discussion within the social work and larger professional community, and are encouraged by the College’s proactive responses to the issues that social workers face every day.
In a clinical world where interventions focus on individuals, social workers know that people are best understood within the context of their lives. “Social work’s legitimacy and mandate lie in its intervention at the points where people interact with their environment, which includes the various social systems that people are embedded in and the natural, geographic environment…which has a profound influence on the lives of people.” 1
What are the implications for social workers in practice settings where the medical model predominates, where complex social problems are reduced to a diagnosis, and where treatment tends to concentrate on individuals? 2
Our experience tells us that social workers are often unsure about how best to assert their knowledge of intersectionality when under team pressure to adopt the dominant model.
Social work education may contribute to this discomfort. Our online review of MSW courses in schools of social work in Canada shows that many emphasize larger systems over direct practice models. Few offer in-depth study of the family, despite the International Federation of Social Work’s (IFSW) assertion that “human health and symptoms are closely connected with the environment and the intersections of significant relationships.” 3
The following scenario illustrates the tensions many social workers experience in clinical settings.
Ashley, a social worker, recalls the initial weeks of work in a mental health clinic. The office had two chairs—not sufficient to accommodate a family. A psychologist wondered aloud how social workers could do therapy and Ashley needed to explain that social workers are skilled in counselling individuals, families, and groups.
Then, at the weekly intake meeting with nurses, psychiatrists, social workers, psychologists and an occupational therapist, Ashley tried to sketch a family diagram, but there were big information gaps regarding who lived in the household, the nature of family functioning and their socioeconomic status. Referral information described problems in biomedical terms such as depression, anxiety, and sleep/appetite challenges, with scant information on drug and alcohol use. Team discussion revolved around diagnoses and medications.
Ashley soon realized that a commitment to contextual understanding and client empowerment was going to be challenging in this work setting. After an initial assessment, a psychiatrist was assigned to evaluate diagnosis and medications. Ashley agreed to conduct a psychosocial assessment and began to think about how the client and family may already have tried to address the problem, but a team member suggested that Ashley consider this client for Dialectical Behaviour Therapy.
Addressing the relational axis of person-problem-environment poses a challenge for social workers like Ashley, because differing perspectives between social work and the medical, cause-and-effect model are profound. What theoretical framework can give clinical social workers the clarity and confidence required to assert their professional responsibility to focus on context? 4
BOWEN SYSTEMS THEORY
One way out of this dilemma is Bowen Family Systems Theory. This framework describes the relationship between individuals and their social and physical environments. Bowen Theory suggests “that human behaviour…is not only self-regulated by individuals, but co-regulated in the highly interdependent systems in which individuals are embedded.” 5 Since the 1950s Bowen Theory 6,7,8 has been influenced by broad exposure to “…sociobiology, genetics, cell-biology, cancer research, physiology, biofeedback…”, 9 and more recently, neurological research. It offers a set of concepts derived from direct observation of human systems. Social workers have played leading roles in this endeavour in fields as diverse as clinical practice, 10,11 substance abuse, 12 family business, 13 and child protection. 14
To learn more about Bowen Family Systems Theory and its eight concepts visit: thebowencenter.org/theory
Like social work, Bowen Theory replaces cause-and-effect thinking with an emphasis on intersections or systems. “A system is an organized whole made up of interdependent elements that can be defined only with reference to each other and in terms of their position in the whole” (de Saussure). 15 Examples of human systems include health care teams, government departments, communities, and the diverse, multigenerational family, which appears “…to have an emotional centre or nucleus to which family members (and other non-related individuals) are responsively attached.” 16 This responsiveness has evolved to make the family an emotional unit, 17 with members both highly reactive to each other, yet also capable of exercising profoundly valuable leadership which Bowen Theory refers to as differentiation of self. 18
Why is systems thinking significant? It is significant because it fits within social work’s mandate to focus assessment and intervention on the intersection connecting person and environment.
Bowen Theory describes, in observable detail, how human systems actually work, offering insights that can empower social work practice. Social workers who own a solid understanding of system processes add value to interdisciplinary teams, especially when other professionals are concentrating on symptoms such as diabetes, child abuse, or psychosis. And importantly, a systems lens offers choices for targeting interventions, rather than focusing solely on the symptomatic person.
The following example illustrates how systems thinking influences clinical practice.
MEDICAL MODEL APPROACH:
In desperation, Mariam telephones the Family Services Centre, seeking help for her son Brent, age twenty. The duty worker learns that Brent dropped out of community college six months ago, is unemployed, living at home, sleeping late and always out at night. Mariam suspects he’s drinking, maybe using other drugs. Last night when his father ordered Brent to get a job, things nearly came to blows. The duty worker concurs that Brent needs help, but clarifies that he will need to call himself to arrange an appointment. Mariam sounds discouraged but agrees to try.
Brent ignores his mother’s pleas to call Family Services and tensions between Brent and his father intensify. Three weeks later, after another argument, Brent storms out and hasn’t returned. The Family Service Centre, not hearing from Brent, moves its intake document to the inactive file.
SYSTEM-FOCUSED APPROACH
In desperation, Mariam telephones Family Services. The duty worker reflects that the situation must be distressing. She offers an appointment for Brent, Mariam, her husband and Brent’s older sister. “I don’t know if Brent will come,” worries Mariam. “Hopefully he will,” says the intake worker, “But if not, come yourself. Bring whomever you can. These troubles are affecting everyone.”
A week later the social worker finds Mariam and her partner Redge in the waiting room. “Brent refused to come and Meghan had an exam today,” reports Mariam. “To be honest, Redge wonders how this can help when it’s Brent who has the problem.” “Let’s talk about it,” says the social worker. “From what I’ve understood, life hasn’t been much fun for anyone this past while. Don’t be discouraged that Brent is not here. Let’s explore what’s going on with Brent and with your family to see what we can learn. That’s the first step toward making a plan and to seeing how you can make a difference.”
Why does it matter to recognize families as emotional units? It matters because a change in any one member influences everyone else in the system. If one member takes charge of their own emotional functioning, the whole family, including those with symptoms, will adjust in response. In the above example, helping the parents deal with the situation may ultimately help Brent. From a practice perspective, this is what IFSW is getting at when it argues our mandate is to intervene “at the points where people interact with their environment.” 19
CONCLUSION:
As social workers, we need to focus our attention on the space between and among individuals and their contexts. Bowen Family Systems Theory, backed by decades of research, offers a way to conceptualize that emotional space.
Bowen Family Systems Theory offers a framework that can guide both practice and interactions with clinical teams. In the systems-focused example just described, the social worker accepts the family as an emotional unit, shows empathy for the parents’ experience, and sets the stage to explore opportunities for creative leadership in this troubled relationship system. Working this way reduces stress for the social worker because it provides a clinical approach that is compatible with professional values.
Imagine a future where a social worker is describing how the identified patient is caught in a family pattern, where family diagrams are commonplace and colleagues from other disciplines lean forward to listen and ask questions about the social work perspective.
Bowen Family Systems Theory provides a useful framework from which we can explore that future with confidence and clarity.
ANNE PIRIE is a social worker living in Sackville, NB. Anne worked in various clinical settings: mental health, hospitals, family services, child protection. Bowen Family Systems Theory enhanced her understanding of her own family, parenting, practising family therapy and designing intergenerational gatherings.
JIM MORTON is a social worker living in Kentville Nova Scotia with interests in mental health, family systems theory, politics, and social change. After a decade of practicing and teaching family therapy, he explored Bowen Family Systems and discovered a new way of thinking.
REFERENCES:
1. International Federation of Social Work: https://www.ifsw.org
2. Ambrose-Miller, Wayne and Ashcroft Rachelle. (2016). Challenges Faced by Social Workers as Members of Interprofessional Collaborative Health Care Teams Health Soc Work. p.6
3. International Federation of Social Work: http://www.ifsw.org
4. Morley, Christine and Dr. Selma Macfarlane. (2008) Repositioning Social Work in Mental Health: Challenges and Opportunities for Critical Practice. Paper presented at Australian Association of Social Workers, Strength in Unity Conference, Sydney
5. Noone, Robert J. & Daniel V. Papero. (2015). The Emotional Family System: An Integrative Concept for Theory, Science and Practice. New York: Lexington Books, p. 10
6. Bowen, Murray. (1978). Family Therapy in Clinical Practice. Northvale, Jersey: Jason Aronson.
7. Kerr, Michael E. and Murray Bowen. (1988) Family Evaluation: An Approach Based on Bowen Theory. New York: W.W. Norton & Company.
8. Butler, J. (Editor) (2013). The Origins of Family Psychotherapy: The NIMH Family Study Project. Toronto: Jason Aronson
9. Kerr, Michael E. (1991). Family Systems Theory and Therapy (pps. 226-264) in Gurman, Alan S. & Davis S. Kniskern (Editors) Handbook of Family Therapy Volume I. New York: Brunner/Mazel, p. 264
10. Brown, Jenny. (2012). Growing Yourself Up: How To Bring Your Best To All Of Life’s Relationships. Wollombi, Australia: Exisle Press.
11. Donley, Margaret G. (2015). Mating and Parental Care: The Influence of Gender on the Primary Triangle (pps. 219-235) in Noone, Robert J. & Daniel V. Papero (Editors). The Emotional Family System: An Integrative Concept for Theory, Science and Practice (pp. 185-198). New York: Lexington Books.
12. White, Charles M. (2011). Learners Without Teachers: The Simultaneous Learning About Self-Functioning and Bowen Theory by Supervising Staff, Interns, and Clients in an Outpatient Treatment Program (pp. 117-136). In Ona Cohen Bregman and Charles M. White, (Editors) Bringing Systems Thinking To Life: Expanding The Horizons For Bowen Family Systems Theory. New York: Routledge.
13. Baker, Katharine Gratwick and Leslie Ann Fox (2009). Leading a Business in Anxious Times: A Systems Approach to Becoming More Effective in the Workplace. Chicago: Care Communications Press.
14. Smith, Walter Howard, Jr. (2001) Child Abuse in Family Emotional Process in Family Systems: A Journal of Natural Systems Thinking in Psychiatry and the Sciences. Volume 5, Number 2.
15. Selvini Palazzoli et al. (1986). The Hidden Games of Organizations. New York: Panthion Books, p.175
16. Papero, Daniel V. (1990). Bowen Family Systems Theory. Toronto: Allyn and Bacon, p.26
17. Kerr, Michael E. (2019) Bowen Theory’s Secrets: Revealing the Hidden Life of Families. New York: Norton
18. Titelman, Peter (Editor). (2014). Differentiation of Self: Bowen Family Systems Theory Perspectives. New York: Routledge.
19. International Federation of Social Work: https://www.ifsw.org/
