Social Work in Health Settings

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“The new edition of this classic text offers the most comprehensive and insightful analysis
of social work practice in health care found in any textbook. The cases are new and discuss
cutting-edge issues including transgender health, genetic testing and counseling, immigrant
health, and international public health. Of particular value are the discussions of each case
that identify new learning and that model reflective practice skills. Because it presents con-
temporary issues influencing the context for, and the process of, social work decision-making
in the accessible form of case studies, Social Work in Health Settings is strongly recom-
mended as a textbook for students as well as advanced practitioners.”
Goldie Kadushin, University of Wisconsin-Milwaukee, USA

“The fourth edition of McCoyd and Kerson’s Social Work in Health Settings makes a strong
case for its impact and utility for social workers in health care. This well-written and consist-
ently edited book allows each contributor to speak in her own voice. The range of settings
and social work roles presented expands our understanding of social work in health care
while the casebook format helps the reader to see reflective social workers in action. Social
work educators will also find the book useful for teaching generalist social work practice.”
Julie S. Abramson, University at Albany, SUNY, USA
Social Work in Health
Settings

Practice in Context

Fourth edition

Judith L. M. McCoyd,
Toba Schwaber Kerson,
and Associates
First edition published 1989 (revised) by Haworth Press Inc
Second edition published 1997 by Haworth Press Inc
Third edition published 2010 by Routledge
This edition published 2016
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Contents

List of figures ix
List of tables xi
List of contributors xii
Acknowledgments xvi

1 Practice in Context: the framework 1

T O B A S C H WA B E R K E R S O N , J U D I T H L . M . M C C O Y D , A N D J E S S I C A E U N A L E E

PART 1
Individual and family work in health settings 23

2 Primer on micro practice in social work in health care: context,

skills, interventions, and best practices 25
J U D I T H L . M . M C C O Y D A N D T O B A S C H WA B E R K E R S O N

Section 1.1
Maternal and child health settings 37

3 Barriers for a mentally ill mother’s adoption plan 39

DASI SCHLUP

4 Fetal surgery 52
J E N N I F E R D I E M I N G L I S , J E S S I C A H E RT Z O G , A N D H E AT H E R K . O U S L E Y

5 Getting there: decision-making in the NICU 64

L A U R I E S T E WA RT

Section 1.2
Children and youth 77

6 Working with families with HIV-positive children 79

J U L I E . B I R M I N G H A M , D E B O R A H A . C A LV E RT, J E N N I F E R D . G R E E N M A N ,
J O H N K R A L L , A N D R A C H E L WA R N E R
vi Contents

7 Social work in a pediatric hospital: managing a medically

complex patient 90
JENNIFER FENSTERMACHER

8 Assistive technology and developmental disability: helping Gina

find her voice 102
B O N N I E FA D E R W I L K E N F E L D

9 Genetic testing following a pediatric cancer diagnosis: a role for

direct practice social workers in helping families with
Li–Fraumeni syndrome 113
ALLISON WERNER-LIN AND SHANA L. MERRILL

10 Family-focused care of an adolescent with a burn:

a multi-disciplinary approach 126
ANNE HAHN

11 The Young Women’s Program: a health and wellness model to

empower adolescents with physical disabilities in a
hospital-based setting 137
NANCY XENAKIS

12 The role of the social worker in transgender health care 149

R U S S E L L H E A LY

Section 1.3
Adults 161

13 The social worker on the genetic counseling team: a new role in

social work oncology 163
S U S A N S C A RVA L O N E , J U L I A N N E S . O K TAY, J E S S I C A S C O T T,
A N D K AT H Y H E L Z L S O U E R

14 Woman to Woman: a hospital-based support program for women

with gynecologic cancer and their families 175
A R D E N M O U LT O N

15 Liver Transplant 2015 187

R E G I N A M I L L E R A N D S E N AY I S H A D D I S

16 Returning veterans, constrictive bronchiolitis, and Veterans

Administration services: a war-related illness and injury study center 199
K AT H L E E N R AY A N D R A C H E L E . C O N D O N
 Contents vii

17 Work with undocumented immigrants: when serious illness intersects

with no insurance 210
PAT R I C I A A . F I N D L E Y

18 An integrated health care approach to promote smoking cessation

for persons with serious mental illness 221
JUDITH A. DEBONIS, LISA DE SAXE ZERDEN, AND ANNE C. JONES

Section 1.4
Aging 235

19 In-home support for Junior: a study of collaboration, boundaries,

and use of self 237
RENEÉ C. CUNNINGHAM

20 Geriatric social work in a community hospital: high-touch, low-tech

work in a high-tech, low-touch environment 249
S A R A H M A U S A N D T O B A S C H WA B E R K E R S O N

21 A framework for working with people with early-stage dementia:

a relationship-focused approach to counseling 260
P H Y L L I S B R A U D Y H A R R I S A N D K AT H L E E N “ C A S E Y ” D U R K I N

22 The future of end-of-life care: as palliative care gains momentum,

what is the future of hospice? 273
MICHELLE K. BROOKS AND JUDITH L. M. MCCOYD

PART 2
Social work and public health 285

23 Public health social work primer 287

T O B A S C H WA B E R K E R S O N A N D J E S S I C A E U N A L E E

Section 2.1
Work with special populations 299

24 Social work practice in an adolescent parenting program 301

T R A C I W I K E , K AT H L E E N R O U N D S , A N D H E L E N D O M B A L I S

25 Screening for perinatal depression in an inner-city prenatal setting 313

LAUDY BURGOS
viii Contents

26 Social work in the pediatric endocrinology and diabetes setting:

fighting the new epidemic of type 2 diabetes in children 325
HELAINE CIPOREN

27 Managing asthma from a social work perspective in a center for

children with special health needs 337
L A U R A B O Y D A N D T O B A S C H WA B E R K E R S O N

28 Camp Achieve: a week-long overnight camp for children and

teens with epilepsy 349
S U E L I V I N G S T O N , E M I LY B E I L D U F F Y, M A R I K AT E TAY L O R , A N D
T O B A S C H WA B E R K E R S O N

29 Following her lead: a measured approach to working with

homeless adults 359
ANNICK BARKER

30 Pediatric public health: educating professionals and communities

about children’s health and environmental exposures 371
BAMBI FISHER

Section 2.2
Internationally related public health 383

31 Community-based health and social services for Bhutanese refugees 385

J E S S I C A E U N A L E E A N D PA R A N G K U S H S U B E D I

32 Research for health efforts in the West Bank, Palestine 397

CINDY SOUSA

Section 2.3
Summary 409

33 Conclusion 411
J U D I T H L . M . M C C O Y D A N D T O B A S C H WA B E R K E R S O N

Index 421
Figures

1.1 Ecomap for Andy Long 16

1.2 The Practice in Context differential discussion grid 18
3.1 Ecomap of case study 48
4.1 Level of anxiety during and after pregnancy 61
5.1 Ecomap of Brooklyn’s family 71
6.1 Christina’s ecomap 85
7.1 Ecomap for Ned 94
8.1 Ecomap for Gina 105
9.1 Genogram of Jack’s family 121
11.1 Young Women’s Program organigraph – a hub with a web 144
13.1 Pedigree for Carla’s family 171
14.1 Ecomap for Irma and Sofia during Irma’s cancer treatment 184
15.1 Ecomap for Mark 194
15.2 Community of support worksheet 196
16.1 World Health Organization Framework of Reintegration 203
17.1 Ecosystem map for Vilma 217
18.1 Healthy Inglewood Project’s (HIP) integrated services for persons
with serious mental illness: a “medical home” 226
19.1 Ecomap for Junior 245
20.1 Ecomap for Mrs. Esposito 253
21.1 Ecomap for Mr. Adams 270
22.1 Pathway oncology patient – Palliative Care to hospice 276
23.1 Influences on public health of demographics 288
24.1 Ecomap for Tanya Smith 307
25.1 Points of screening in the OB/GYN diagnostic and treatment center 317
26.1 Intervention options for diabetes care 330
27.1 Ecomap for José 343
28.1 Organigraph for Camp Achieve 351
29.1 Ecomap of Ms. Harper’s social network before intervention 364
29.2 Ecomap of Ms. Harper’s social network after intervention 364
30.1 What is a message map? 374
30.2 Example of a message map for Suffolk County exposures 375
31.1 Overview of U.S. refugee resettlement process 386
x Figures

31.2 Resettlement timeline for Ansari and Dorji families 389

31.3 Ansari family genogram 392
31.4 Genogram for Dorji family 392
32.1 Timeline of project 401
Tables

9.1 
Suggested surveillance strategy for individuals with germline
TP53 mutations 114
11.1 Table of activities: after-school program structure 141
18.1 Supporting client’s progression through the early stages of change 228
Harris and Durkin’s relationship-focused approach to develop positive
21.1 
coping strategies 265
31.1 Overview of Bhutanese American Organization-Philadelphia’s programs 387
Contributors

Senayish Addis, M.S.S., has been a social worker at the Hospital of the University of
Pennsylvania, USA, for the past 9 years and a Liver Transplant Social Worker for the
past 7 years.
Annick Barker, M.S.S., L.C.S.W., is a mental health therapist at Health Care for the
Homeless, a Federally Qualified Health Center in Baltimore, MD, USA.
Juli E. Birmingham, M.Ed., is a counselor at the Special Immunology Family Care Center
at the Children’s Hospital of Philadelphia, USA.
Laura Boyd, M.S.W., is a Team Lead in the EPSDT Department at Health Partners Plans
in Philadelphia. She was formerly a social worker in the Center for Children with Special
Health Care Needs at St. Christopher’s Hospital for Children, also in Philadelphia, USA.
Michelle K. Brooks, M.S.S., L.C.S.W., is the Director of Psychosocial Services for Penn
Homecare and Hospice, an entity of the University of Pennsylvania Health System. Ms.
Brooks’ social work practice focus has been working with patients and families at the end
of life and in bereavement.
Laudy Burgos, M.S.W., L.C.S.W., is a social worker at Mount Sinai Hospital in New York
City, USA, where she works in the OB/GYN unit. She is also faculty for Icahn School of
Medicine at Mt. Sinai Hospital.
Deborah Calvert, M.S.W., L.S.W., is a social worker at the Special Immunology Family
Care Center at the Children’s Hospital of Philadelphia, USA.
Helaine Ciporen, M.S.W., M.Ed., L.C.S.W., is a social worker at Mount Sinai Hospital in
New York City, USA. She works in the Pediatric Endocrinology and Diabetes department.
Rachel E. Condon, B.A., is a graduate student in social work at Boston University, USA.
Reneé C. Cunningham, M.S.S., is the Associate Director at Center in the Park, USA, where
she is responsible for general operations, strategic planning, and evaluation, as well as
supervising key staff and managing contractual obligations for major contracts.
Judith A. DeBonis, Ph.D., L.C.S.W., is an assistant professor at the California State
University, Northridge, USA, and is the Principal Investigator for the Garrett Lee Smith
Suicide Prevention Campus Grant. As part of the CSWE Social Work and Integrated
Behavioral Healthcare Project, she is working to infuse integrated behavioral health and
primary care into master’s level social work education.
 Contributors xiii

Helen Dombalis, M.S.W., M.P.H., is the Director of Programs for the National Farm to
School Network in Washington, DC, USA.
Emily Duffy, L.C.S.W., served as the Camp Achieve coordinator from 2005 to 2007 and has
continued to work with children and families as a pediatric behavioral health consultant,
and most recently as a school social worker.
Kathleen “Casey” Durkin, M.S.S.A., L.I.S.W.-S., is a clinical social worker with over
30 years’ experience, and has a private practice serving individuals aged 3–93: groups,
couples, and families.
Jennifer L. Fenstermacher, M.S.S., L.C.S.W., is a social worker at the Nemours/A. I.
duPont Hospital for Children in Wilmington, DE, USA, where she works on the general
pediatrics short stay unit.
Patricia A. Findley, Dr.P.H., M.S.W., L.C.S.W., is Associate Professor of Social Work at
the Rutgers University School of Social Work, USA, the Special Assistant to the Dean for
Interprofessional Health Initiatives, and the Newark MSW Campus Coordinator.
Bambi Fisher, L.C.S.W., is a social work manager in pediatrics at Mount Sinai Medical
Center and on the faculty at the Icahn School of Medicine at Mount Sinai, USA.
Jennifer D. Greenman, M.S.W., L.S.W., is a social worker at the Special Immunology
Family Care Center at The Children’s Hospital of Philadelphia, USA.
Anne P. Hahn, Ph.D., L.C.S.W.-C., is a social worker at Johns Hopkins Bayview Medical
Center in Baltimore, MD, USA, where she works on the burn unit.
Phyllis Braudy Harris, Ph.D, A.C.S.W., L.I.S.W., is Professor and Chair of the Sociology
& Criminology Department, Director of the Aging Studies at John Carroll University,
USA, and is the founding co-editor of Dementia: The International Journal of Social
Research and Practice.
Russell Healy, M.S.W., L.C.S.W., is a clinical social worker in private practice in cen-
tral New Jersey, USA, and a doctoral student in the Rutgers School of Social Work’s
D.S.W. program.
Kathy Helzlsouer, M.D., M.H.S., is a medical oncologist and epidemiologist with a prac-
tice focus on cancer prevention and cancer survivorship. She is an adjunct professor at
the Johns Hopkins University Bloomberg School of Public Health, USA, and founding
Director of the Prevention and Research Center at Mercy Medical Center, Baltimore, MD,
USA.
Jessica Hertzog, M.S.W., is a social worker at the Children’s Hospital of Philadelphia, USA,
and works in the Center for Fetal Diagnosis and Treatment, the Garbose Special Delivery
Unit, and the NIICU.
Jennifer Diem Inglis, M.S.W., is a social worker at the Children’s Hospital of Philadelphia,
USA, and and works in the Fetal Heart Program and in the Garbose Special Delivery
Unit.
Anne C. Jones, Ph.D., L.C.S.W., is a clinical professor at the University of North Carolina at
Chapel Hill, USA, and and currently serves as the Co-Principal Investigator for the UNC-
PrimeCare, an integrated behavioral health training grant funded by HRSA.
xiv Contributors

Toba Schwaber Kerson, D.S.W., Ph.D., is Mary Hale Chase Professor Emeritus in Social
Science at the Graduate School of Social Work and Social Research, Bryn Mawr College,
Bryn Mawr, Pennsylvania, USA, and a Fulbright Specialist.
John Krall, L.C.S.W., is the Program Manager of the Special Immunology Family Care
Center at the Children’s Hospital of Philadelphia, USA.
Jessica E. Lee, M.S.S., L.S.W., is a Ph.D. candidate at Bryn Mawr College Graduate School
of Social Work, and she conducts research with and serves refugee communities in
Philadelphia, USA.
Sue Livingston, B.S., began her career in education, teaching preschool, elementary,
and middle school. She has spent the past 19 years at the Epilepsy Foundation Eastern
Pennsylvania, USA, as education coordinator, and was instrumental in the development
and management of Camp Achieve.
Sarah L. Maus, L.C.S.W., A.C.S.W., is a social worker at Abington Memorial Hospital,
Jefferson Health, USA, where she is the manager of the Muller Institute for Senior Health.
Judith L. M. McCoyd, Ph.D., Q.C.S.W., L.C.S.W., is Associate Professor of Social Work
at Rutgers University, The State University of New Jersey, School of Social Work, USA,
with focus on clinical practice, loss and grief, and interprofessional education.
Shana L. Merrill, M.S., L.C.G.C., is a clinical genetic counselor at the Hospital of the
University of Pennsylvania in Philadelphia, PA, USA, who specializes in rare tumor predis-
position syndromes, cardiovascular genetic predispositions, and neurogenetic counseling.
Regina Miller, M.S.S., L.C.S.W., C.C.T.S.W., is a Social Work Team Leader at the Hospital
of the University of Pennsylvania, USA, where she has worked for the past 11 years in
Solid Organ Transplantation.
Arden Moulton, L.M.S.W., M.P.S., is a social worker at the Mount Sinai Hospital in New
York City, USA, and Program Coordinator of the Woman to Woman Program.
Julianne Oktay, M.S.W, Ph.D., is Professor Emeritus at the University of Maryland, USA,
School of Social Work. Dr. Oktay has done extensive research in social work in health,
and has published two books on breast cancer: Breast Cancer in the Life Course and
Breast Cancer Daughters Tell Their Stories.
Heather K. Ousley, M.S.S, M.S., is a social worker at the Children’s Hospital of Philadelphia,
USA, and works in the Center for Fetal Diagnosis and Treatment, the Garbose Special
Delivery Unit, and the NIICU.
Kathleen Ray, Ph.D., L.C.S.W., is a social worker at the War Related Illness and Injury
Study Center at the Veterans Administration in East Orange, NJ, USA.
Kathleen Rounds, Ph.D., M.P.H., M.S.W., is professor at the University of North Carolina,
USA, at Chapel Hill School of Social Work.
Susan Scarvalone, M.S.W., L.C.S.W.-C., is a clinical research therapist at the Prevention
and Research Center, Mercy Medical Center in Baltimore, MD, USA, where she works
with cancer patients and their families to promote quality of life during and after treat-
ment, and participates in clinical research initiatives.
 Contributors xv

Dasi Schlup, M.S.W., L.C.S.W., is a clinical social worker at Women’s and Children’s
Hospital of the University of Missouri Health Care, USA. Her practice covers the Newborn
Intensive Care Unit and High Risk Obstetrics.
Jessica Scott, M.G.H., C.G.C., is a certified genetic counselor specializing in hereditary
cancer genetics at the University of Maryland Medical Center in Baltimore, MD, USA.
Cindy Sousa, Ph.D., M.S.W., M.P.H., is an assistant professor at the Graduate School of
Social Work and Social Research at Bryn Mawr College, USA, where her work focuses
on local and global dimensions of trauma, resilience, and health.
Laurie Stewart, M.S.S., L.S.W., is a social worker in the NICU at St. Christopher’s Hospital
for Children, USA.
Parangkush Subedi, M.S., M.P.H., is a resettled Bhutanese refugee and works at
Philadelphia’s Health Department. He initiated the Health Focal Point project with the
Bhutanese American Organization Philadelphia.
Marikate Taylor, B.A., M.A., started her career in the nonprofit sector in 2012. She serves
as the Information and Communications Coordinator for the Epilepsy Foundation Eastern
PA, USA, contributing to efforts to improve qualitative measurement, reporting, and mar-
keting efforts.
Rachel Warner, M.S.W, L.C.S.W., is a social at the Special Immunology Family Care
Center at The Children’s Hospital of Philadelphia, USA.
Allison Werner-Lin, Ph.D., L.C.S.W., Ed.M., is assistant professor at the School of Social
Policy and Practice at the University of Pennsylvania, USA, where she conducts research
addressing psychosocial aspects of genomic testing. She maintains a private practice with
families affected by hereditary cancer syndromes and bereavement.
Traci Wike, Ph.D., M.S.W., is an assistant professor at Virginia Commonwealth University
School of Social Work, USA.
Bonnie Fader Wilkenfeld, Ph.D., L.C.S.W., has extensive experience working in a vari-
ety of health care settings, most recently as a clinical social worker at a medical center
consisting of a hospital, residential facility, and school for individuals with severe and
profound multiple disabilities.
Nancy Xenakis, L.C.S.W., M.S., is Associate Director, Social Work Services at the Mount
Sinai Hospital, New York City, USA.
Lisa de Saxe Zerden, M.S.W., Ph.D., is the Associate Dean for Academic Affairs at the
University of North Carolina at Chapel Hill School of Social Work, USA, and is the
Principal Investigator for UNC-PrimeCare, an integrated behavioral health training grant
funded by HRSA.
Acknowledgments

Our immense gratitude goes first and foremost to our chapter contributors who shared their
practice decisions with humility, humor, and honesty – this book obviously could not exist
without these seasoned professionals. I am deeply grateful for Toba S. Kerson’s mentorship
and willingness to trust me to carry on her work with this casebook. My parents, Kathleen
J. Moyer and Ivan W. Moyer, also deserve acknowledgment as they taught me by experi-
ence about many of the health issues covered here during the time we were working on this
edition. Finally, I thank my “home team” – sons Ryan and Ian, Jim, the M.o.B., Anne and
Corey – I could not have survived this year without you all.
Judith L. M. McCoyd

In some form, Social Work in Health Settings: Practice in Context has been a part of me since
I became a social worker 50 years ago. It was a way to marry my sociological world view, my
social worker’s sensitivity to the pain of others, and my need to intervene in the most respect-
ful ways possible. Also, it was a means to keep valued colleagues and former students with
me. Many years ago, the excellent Judith L. M. McCoyd, then a doctoral student, assisted me
the third time I wrote the book and contributed a case. Now, the book is hers.
This time around, edition four is for Jennie who sparkles plenty, Larry who loves a lot,
and Leo who loves to learn.
Toba Schwaber Kerson
Chapter 1

Practice in Context
The framework
Toba Schwaber Kerson, Judith L. M. McCoyd,
and Jessica Euna Lee

Social Work in Health Settings presents a framework called “Practice in Context,” which the
first author has used for the past 40 years as a tool for teaching and evaluation. The primary
subject of the framework is the relationship between social worker and client because it is
through trustworthy, strong, knowledgeable, and skill-based relationships with clients and
others that social workers help clients to reach their goals (Beresford, Croft, & Adshead,
2007; Kerson & McCoyd, 2002). As a concept, “relationship” can be interpreted in diverse
ways. It is an association or involvement, a connection by blood or marriage, or an emotional
or other connection between people.
The definition of the social worker/client relationship used here is based in the work of
others. Sociologist Erving Goffman, and anthropologist Gregory Bateson, theorize about
some structural aspects of relationship such as the interactional focus, the connection of a
relationship to its milieu, and the rules that inform or govern a relationship. Bateson uses
the word interaction, and Goffman the word encounter, to be as precise as possible about
their subjects. For this framework, interaction and encounter are seen as factors in a broader
concept.
Goffman suggests that when studying interaction, the proper focus is not on the individual
and his or her psychology, but rather the syntactical relations among the acts of different per-
sons who are mutually present to one another (Goffman, 1981). To understand interaction,
one must understand not the separate individuals but what occurs between them. Goffman
(1966) further alludes to the special mutuality of immediate interaction:

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

Thus, in interaction, there is always a shared sense of situation and a capacity, in some way,
to be in the place of the other, no matter what each participant’s purpose in the interaction.
Goffman places relationship in context when he develops the notion of a “membrane” that
“wraps” the interaction and, to some extent, separates it from its surroundings. “Any social
encounter,” he writes, “any focused gathering is to be understood, in the first instance, in
terms of the functioning of the ‘membrane’ that encloses it cutting it off from a field of prop-
erties that could be given weight” (Goffman, 1961, p. 79). Still, while the relationship can be
viewed and defined in its own right, it remains intimately related to the world outside of it.
2 T. S. Kerson et al.

Thus, Goffman says, “An encounter provides a world for its participants, but the character
and stability of the world is intimately related to its selective relationship to the wider one”
(Goffman, 1961, p. 80).
The rules that inform a relationship and the uses that the participants make of those rules
are also part of Goffman’s and Bateson’s analyses of relationship. According to Bateson,
interaction is the “process whereby people establish common rules for the creation and
understanding of messages” (Bateson, 1971, p. 3). Goffman adds to this definition by noting
that in encounters, rules are considered and managed rather than necessarily followed; that is,
rules may shape interaction, but they also may be influenced by the participants. He writes:

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

Social workers add a psychological dimension to these more structural views of relationship.
We say that relationship has to do with people’s emotional bonding. Also, the relationship
between social workers and clients is a catalyst in that through understanding, support, nurtur-
ing, education, and the location of necessary resources, we help clients to address problems.
Thus, the relationship affirms and motivates the client. In the same way, this forming of a
helping relationship is not an end in itself but a means to help clients to reach their goals. In
this book, the word client stands for any notion of a client unit, that is, an individual, family,
program, organization, city, state, country, or advocacy effort that engages the services of a
social worker who will help this entity to reach its goals.
Thus, for this framework, the relationship between social worker and client is defined
using both sociological and psychological concepts. The sociological contributions have to
do with structure; the focus is on interaction rather than on individual participants, on the
use of rules, on the relationship’s connection to (or separation from) its surroundings or
context. The psychological contributions are the purposive, feeling, catalytic, and enabling
dimensions. Here, the relationship of social worker and client means one or more purposive
encounters intended to be catalytic and enabling whose structure and rules for interaction are
set by dimensions of context as well as by decisions made by the participants.

Practice in Context framework

According to the Practice in Context (PiC) framework, the two basic elements that structure
the relationship between social worker and client are (1) the “context” in which the rela-
tionship occurs and (2) the “practice decisions” that social worker and client make about
the form and nature of the relationship. Context and practice decisions act as a matrix for
the relationship, a supporting and enclosing structure. By determining many of the rules by
which the work of social worker and client proceeds, context and practice decisions define
the possibilities for relationship. Although elements such as personality, nature and degree of
illness, psychosocial assessment, and cultural background contribute to the relationship, they
are characteristics of the individuals involved and not the interaction.
This approach or framework is not a generic practice theory because it is not a system of
ideas meant to explain certain phenomena or relations. Nor is it a model, because it does not
 Practice in Context 3

show proportions or arrangements of all of its component parts. Here are simply described
elements of context and practice that structure the relationship of social worker and client.
Three overarching purposes help the social worker to: (1) clarify the work, (2) understand
alterable and unalterable dimensions of practice and context, and (3) evaluate work in light
of these dimensions. Each is meant to help the social worker reflect upon the decisions and
actions of the social worker. With client participation, the social worker understands and tries
to influence context and constructs the relationship in ways that will help meet client goals.
Thus, PiC is about the craft of social work – the skills with which social workers manage
dimensions of practice.

Context
To assume that possibilities for the work are completely determined within the social worker/
client relationship is unrealistic, and may contribute to disappointment and a sense of failure
on the part of the participants, evaluators of service, and funding sources. To a great extent,
dimensions of context determine many of the rules for the helping relationship (Kerson,
2002). Context means the set of circumstances or facts that surround a particular event or
situation, the surrounding conditions that form the environment within which something
exists or takes place. Bateson defines context as a “collective term for all those events which
tell the organism among what set of alternatives he must make his next choice” (Bateson,
1975, p. 289). He adds to this the notion that “however widely context be defined, there may
always be wider contexts a knowledge of which would reverse or modify our understand-
ing of particular items” (Bateson, 1971, p. 16). Although context is a limitless concept, and
focusing on certain dimensions means ignoring others, to intervene effectively means that
one has to be able to consider and assess the circumstances that constitute the situational
conditions under which one is working.
The present framework addresses three dimensions of context that we continue to think
have the most direct and describable consequences for the relationship between social
workers and clients in health care settings: policy, technology, and organization. These
elements are considered most important because of the ways each affects the structure
of and possibilities for the social worker/client relationship. Policies increasingly provide
rules specifying the services that clients may receive, who may provide them and under
what conditions, and how services are to be evaluated. Organizations are also rule mak-
ers, setting the structure for service delivery and defining the nature of service often at the
behest of policymakers. Finally, in this era when the means of communication continue
to expand and change and technological interventions have us questioning definitions of
life, death, gender, parenthood, etc., the impact of technology on the relationship between
social worker and client is enormous. Social workers’ understanding of and comfort with a
great range of technologies enhance their roles as “translators” for their clients, their oppor-
tunities for empathy, as well as their general relational capacities. In addition, computer-
assisted technologies and the internet have altered and expanded the ways in which social
workers communicate, receive, and collect information. Thus, technology contributes to
the content of the relationship, expands possibilities, and may also constrain it. The sali-
ence of each dimension and the ways those dimensions are related depend on the particular
setting. In effect, these contextual factors may at most determine, or at least contribute to,
the rules of the game, and as they change, the constraints and possibilities for action are
altered as well.
4 T. S. Kerson et al.

Policy
Policies are explicit and definite sets of principles or courses of action that guide a range of
actions in specific situations. They are always related to the political economy, that is, the
ways by which a government manages its material resources. Policies address entitlements and
restrictions; that is, they provide rightful claims, privileges or prerogatives, and/or they impose
limitations and constraints. To think of policies in these ways demonstrates the need for social
workers to understand the policies that may affect their clients. This understanding can help
clients interpret policies and gain access to services. To be an effective client advocate one
must excel at understanding the policies that shape clients’ entitlements and restrictions.
The status of the populations with which social work is most concerned and the status of
the social work profession itself are, to a great extent, reflections of the political economy and
the social policies of any particular period in U.S. history (Mechanic, 2005). Understanding
health disparities is critical in this regard (Barr, 2014; Schlesinger, 2011). Peter Drucker notes
that every 10 years or so, society reorganizes its world view, basic values, political and social
structure, arts, and major institutions (Drucker, 2004). Thus, social policy is dynamic, fluid,
and responsive to many powerful forces within and outside of a particular community or society.
This seems to be a time of enormous social reform in the United States, and hopes are high
for reforming the health care system (Barr, 2011, 2014; Blank & Burau, 2014; Little, 2007).
For example, the Patient Protection and Affordable Care Act (ACA) was signed into
law in 2010 (Congress, 2010). An aim of the ACA is to not only expand access to public
health insurance but also improve the quality of health care provided through Medicare and
Medicaid. Also referred to as ObamaCare, the ACA expands health care coverage to all U.S.
citizens and aims to reduce U.S. health care spending. Many of its provisions took effect in
2014 and key enactments relevant to social work include:

•• individual mandate to purchase insurance and requirement for most employers to offer
coverage to workers;
•• improved access to public health insurance (e.g., expanding Medicaid to people below
130% of the federal poverty line);
•• reforms to improve health care quality and reduce health spending;
•• regulation of the health insurance industry (e.g., setting minimum benefit standards for
qualified health benefit plans and prohibiting health insurers from refusing coverage
based on patients’ medical histories (Congress, 2010; ObamaCare Facts, n.d.; Gorin,
Pollack, Darnell, & Allen, 2014).

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

1 the entrance into and exit from health and human services delivery systems;
2 the criteria used to determine eligibility for treatment, benefits, or services;
3 the rights to which patients and clients are entitled;
4 the rights to which professionals and staff are entitled;
5 the way in which health and human services programs are administered and regulated;
6 the relationship between the professional and the patient or client;
7 the practice of the health and human services professional (p. 3).
 Practice in Context 5

Therefore, in order to understand the policies that shape their practice, social workers must
be able to understand the laws that affect the policies.
Another critical policy for social workers in health care settings is the Health Insurance
Portability and Accountability Act of 1996 (HIPAA) that recognizes the importance of pri-
vacy of medical records. HIPAA regulations aim to assure the privacy and confidentiality
of consumers’ health information by defining (1) the rights of individuals, (2) administra-
tive obligations of covered entities, and (3) the permitted uses and disclosures of protected
information (NASW, 2001; U.S. Department of Health and Human Services, 2015). HIPAA
defines “protected health information” as individually identifiable health information in any
media that is held or transmitted by a covered entity (U.S. Department of Health and Human
Services, 2015). Social workers are considered covered entities if they transmit protected
health information for which HHS has a standard. HIPAA has implications for social workers
working in public health, research, and direct practice. Such information can be as obvious as
medical records and diagnoses or as seemingly “common” as whether a patient is indeed at
the medical facility. The 2013 Omnibus rule provides updated guidance on HIPAA compli-
ance. The revisions that HIPAA has undergone in the last decade demonstrate the need to
respond to ever changing dimensions of technology (Morgan, 2013) and to be aware of the
limits to information that can be shared when making referrals.
No matter what level they work on, social workers must be able to contribute to, inter-
pret, and influence policy in order to advocate for their clients and the profession. Decisions
regarding which populations to serve, allocation of resources, planning, and programming
are too often made before social work practitioners become involved, and it is far easier to
affect the structure of a program before it is instituted rather than after. These activities are
also most beneficial to clients when clients and social workers advocate together. In addi-
tion, involvement in policy formulation helps the social work profession to broaden and
strengthen its influence. When policy has a negative effect on clients or the profession, a
united and concerted lobbying effort can stem the tide.
Historically, the presence of social work has been strongest in areas such as maternal
and child health, as well as services to veterans, where social workers have been involved
in developing policy on national, state, and local levels (Margolis & Kotch, 2013; Kerson,
1981, 1985). To a great extent, the policies social workers must familiarize themselves with
depend on the populations with whom they work and the institutions for whom they work.
Current foci of health-related social policy are on trying to control and/or cap costs and to
incorporate new knowledge and the development of new technologies into the notion of cost
control (Arrow et al., 2009; Mas & Seinfeld, 2008; Miller & West, 2009).

Controlling the costs of health care

In order to try to control health care costs, the federal government has created a series of
responses. Many responses can be understood under the rubric of managed care. For several
decades, managed care, which promises both service efficacy and cost containment, has been
a focal point for influencing policy formulation and advocating for clients (Acker, 2010;
Acker & Lawrence, 2009; Emanuel, 2012). At this point, the term managed care is used for
almost any strategy or structure put forth to manage the quality or cost of health care. Broadly
defined, managed care encompasses any measure that, from the perspective of the purchaser
of health care, favorably affects the price of services, the site where the services are received,
or their utilization. As such, it represents a continuum – from plans that, for example, do no
6 T. S. Kerson et al.

more than require prior authorization of inpatient stays, to the staff model health maintenance
organization that employs its doctors and assumes risk for delivering a comprehensive ben-
efit package. Ideally, managed care should not simply seek to reduce costs; rather it should
strive to maximize value, which includes a concern with quality and access.
A managed care system integrates the financing and delivery of appropriate medical care
by contracting with selected providers who offer comprehensive health services to enrolled
members for a predefined yearly or monthly premium, providing financial incentives for
patients to stay within system for their care, instituting utilization and quality controls to
which providers have agreed (and which increasingly seem to relate to patient satisfac-
tion), and by requiring that the providers assume varying degrees of financial risk. More
and more, providers are asked to balance the patients’ needs with cost control (Summer &
Hoadley, 2014).
Now, managed care is forcing social work to reexamine our practices and the values that
support the missions of organizations. It is critical that social workers in health care see
this current panacea-like solution as a series of complex strategies viewed by important and
powerful interest groups as ways to control the costs of health care. Managed care is not the
enemy of social work, nor is it a simple way to solve deep, complicated problems; in fact,
it is not even an it. The fact that managed care is altering roles and tasks for social workers
in many settings again underscores the importance of social workers being able to interpret
policy and advocate for clients.
One early managed care schema was the development of diagnosis-related groups
(DRGs). Formerly, the hospital charged the insurer what it decided it had spent to care for
the patient, plus a small percentage in addition. Now, the insurer pays the hospital based
on the patient’s diagnosis (DRG). According to the DRG classification, if the diagnosis
indicates 4 days of hospitalization, the hospital will be paid for 4 days of hospitaliza-
tion only, even if the patient stays in the hospital longer. When the patient is hospitalized
beyond the number of days indicated in the schema, the hospital must absorb the extra
cost. Consequently, there is great pressure on the hospital to discharge the patient and great
pressure on the social worker to make prompt and appropriate arrangements for the patient
to return to the community. Thus, a social worker who previously may have had weeks to
develop a relationship with, and an adequate discharge plan for, a patient, now may have a
matter of days or hours in which to accomplish the same task. More and more, the focus of
the health care facility is for the social worker to expedite the patient’s discharge as soon as
the physician can no longer justify the stay, or, even more important now, before the insurer
denies payment for services rendered. However, an aim of the ACA is to expand access to
public health insurance while also improving the quality of health care provided through
Medicare and Medicaid.

Technology
For contemporary health care, the development and cost of technology relate directly to
policy formulation. Technology and the organizations that house and/or distribute it account
for a good deal of the astronomical costs of medical care today. The United States’ passion
for, rapid acceptance of, and diffusion of “high-tech” solutions means that hospitals, health
professionals, patients, and families demand the best possible high-tech care, no matter what
the cost. Technology circumscribes practice just as policy and the law provide parameters for
practice. As Jasanoff (2008) says:
 Practice in Context 7

As prime custodians of the “is” and the “ought” of human experience, science and the
law wield enormous power in society. Each plays a part in deciding how things are in
the world, both cognitively and materially; each also helps shape how things and people
should behave, by themselves and in combination. (p. 767)

Technology is applied science – the ways in which a social group satisfies its material needs.
In the broadest sense, technology means the concrete, practical solutions people invent or
discover; this can mean mechanical ventilation or Motivational Interviewing techniques,
computer systems or new consumer-marketed genetic testing, anything that involves solving
problems with specific techniques. In the present framework, technology primarily refers to
medical/scientific inventions that are used for diagnosis or treatment: medication, surgical
techniques, life-sustaining machinery, or ways of viewing or measuring bodily functions
and, in addition, ways in which we collect, manage, and disseminate information and new
possibilities for interaction in relation to both diagnosis and treatment. It is through the
development of technology as well as management of lifestyle issues that we are expanding
possibilities for treating illness and extending life (Steinbrook, 2009). Because of techno-
logical development, for example, we are able to respond to conditions in-utero, keep people
alive who would otherwise die, and redefine many conditions from fatal to chronic.
Technology also means information management, the rise of electronic record keeping,
and the computerization of all imaginable kinds of data (Tjora & Scambler, 2009). It can also
be said that new communication technology is transforming the social work profession just
as it is affecting many others. For example, one only has to think of the enormous amount
of research that Gary Holden has been able to present to social workers in health care from
Gopher Resources for Social Workers to World Wide Web Resources for Social Workers,
to the present day professional news services – Information for Practice (IP) (Holden, 2009).
As National Association of Social Workers (NASW) web designer Ebony-Jackson says,
“Social media technology, texting via phone and e-mail messaging are revolutionizing the
way people communicate” (Sfiligoj, 2009). This means e-clinical work, e-therapy, social
networking websites, chat rooms, distance learning, as well as other virtual efforts, etc.
(Serafini, Damianakis, & Marziali, 2007) and new learning techniques such as e-health, tele­
health, interactive video, video conferencing, and social work rooms on the Web (Groshong &
Phillips, 2015; Matusitz & Breen, 2008).
Meanwhile, the development of life-sustaining and other technologies raise perplexing
ethical and legal problems in health care (Morrison & Monagle, 2013). Sometimes, the
extension of life can mean greatly diminished life quality. Invariably, life-sustaining technol-
ogies and interventions develop prior to the development of ethical and normative guidance
for dealing with outcomes of such technologies (full body scans and personalized genetic
testing are examples; see McCoyd, 2009 for analysis of fetal diagnosis). In other situations,
medical solutions may be dehumanizing and/or produce negative side effects. Each raises
new questions related to confidentiality, privacy, and record keeping. Current concerns about
confidentiality stem from these technological developments. Determining who has the right
to access information – the individual or group paying for the care, the individual receiving
the care, the individual with access to the computer system, etc. – has yet to be resolved
satisfactorily. (See above for discussion of how the HIPAA Privacy Rule helps.)
For social workers, sometimes the lack of medical means to intervene in an illness cre-
ates opportunities for psychosocial intervention. Historically, social workers had important
roles in the care of people with venereal diseases and tuberculosis, in part because medical