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Core Competencies in this Chapter (Check marks indicate which competencies are covered in depth)
C H A P T E R O U T L I N E
An Introduction to Macro Practice
in Social Work
Macro Practice in Context 2
Experiences of Former Students 2
What Is Macro Practice? 5
Locus of Involvement in Social Work Practice 5 A Systematic Approach to Macro Social Work Practice 6 The Interrelationship of Micro and Macro Social Work Practice 8
The Foundation of Macro Practice 9
Theories, Models, and Approaches 9 Values and Ethical Dilemmas 12 Service 13 Social Justice 13 Dignity and Worth of the Person 14 Importance of Human Relationships 14 Integrity 15 Competence 15
Three Case Examples 16
Case Example 1: Child Protective Services 17 Case Example 2: Case Management with Elderly and Disabled Persons 19 Case Example 3: Chronic Homelessness 22
Surviving the Dilemmas 26
Professional Identity 27
Summary 29
Practice Test 31
MySocialWorkLab 31
Case Study / Golem, Albania Case Study / Professional Decision Making in Foster Care
Professional Identity
Ethical Practice
Critical Thinking
Diversity in Practice
Human Rights & Justice Research-Based Practice
Human Behavior
Policy Practice
Practice Contexts
Engage, Assess, Intervene, Evaluate
✓
✓
✓
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MACRO PRACTICE IN CONTEXT
This book is intended for all social workers, regardless of whether they spe- cialize or concentrate in micro or macro tracks within schools of social work. It is also designed to be an introduction to macro practice as a set of profes- sional activities in which all social workers are involved. Although some prac- titioners will concentrate their efforts primarily in one arena more than another, all social workers encounter situations in which macro-level interven- tions are the appropriate response to a need or a problem. Therefore, we define macro practice as professionally guided intervention(s) designed to bring about change in organizational, community, and/or policy arenas. This book is not designed to prepare practitioners for full-time agency administration, program planning, community organizing, or policy analysis positions. Social workers who assume full-time macro roles will need a more advanced understanding than this text provides. Nor is this a book on how to specialize in macro practice. Instead, it is designed to provide basic knowledge and skills on aspects of macro practice in which competent social work practi- tioners will need to engage at some time in their professional careers.
Experiences of Former Students
No matter what roles our former students assume after graduation, they are all involved in macro activities. Therefore, in preparation for each revision of this book, we talk with former students who are now practicing social workers, some of whom work directly with clients and some of whom are coordinators, plan- ners, managers, administrators, organizers, and policy analysts in the United States and in other parts of the world. We also save emails from former students who keep us up-to-date and pose questions to us. We then include comments that illustrate the differences between students’ expectations of social work prac- tice and their actual experiences once they are working in the field. For example, a social worker employed by a community-based agency on an American Indian reservation shared these thoughts: “Culture is so impor- tant to the work we do. I constantly have to ask indigenous people for advice so that I do not make assumptions about the people with whom I work. The concept of community and what it means to this tribe, even the value of the land as a part of their tradition, is so crucial. It is much more complex than I had assumed when I was in school.” In her position, this social worker has come to appreciate what we taught about the false dichotomy between micro and macro social work. Although she works directly with tribal members, she is constantly assessing their environment, asking for advice, and recognizing the cultural context in which all her actions are embedded. Another former student reinforced the importance of community. “The thing that has surprised me is how much I need to know about the community— people’s values, where funding comes from, how to assess community needs. Even though I do direct practice, I am constantly pulled onto task forces and committees that have to deal with the broader community issues.” This practi- tioner contacted us to share how the use of geographic information systems (GIS) was becoming critically important in her agency. She had learned to use GIS to locate pockets of need within the community, and she had used her find- ings to convince decision makers to re-target their programming to persons in greatest need.
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One of our former students, originally from Nigeria, returned to her country of origin to establish a mission house designed to improve the welfare of elders. She wrote, “From our preliminary studies here, poverty and health-related problems are the two most prevalent issues for elders. Then, add widowhood and you’ll have a grim picture. There are cases of neglect arising primarily from the economic situations of family members. It is a case of being able to share what you have. If you have no food to eat, you cannot offer another person food. This is what we are trying to address in our programs here.” Compare this to what the former director of a social services unit in a U.S. hospital told us about elder care: “I have been here long enough to see the advent of diagnostic-related categories. This is the Medicare system’s way of making sure older patients are discharged efficiently, and if they are not, the hospital has to pick up the tab.” She went on to explain how social workers in health care are struggling to understand their roles, which are often limited by the services for which funding sources will authorize reimbursement. Understanding the way in which health-care organizations are changing, diversifying, and turning outward to the community has become critical for social workers who are encountering other professionals in roles similar to their own. As social work departments in health care and other organizations are decentralized into cost centers, social workers must understand why these administrative decisions are being made and find ways to influence future decision making. Many of these social work- ers entered health-care systems with the idea of providing counseling, but what they are doing is advocacy, solution-focused and crisis intervention, case man- agement, and discharge planning. They are also encountering technological challenges in accessing and using large information systems. Another student had this to say: “What makes this profession worthwhile for me is that there is a core of very committed people who really live up to the ideals of the profession. They’re very talented people who could make a lot more money elsewhere, but they believe in what they’re doing, and it’s always a pleasure to work with them. Our biggest frustration has been that there are so many people (like state legislators, for example) who wield so much power over this profession but have no understanding of what social problems and human needs are all about. Even though professionals may have spent the better part of their careers trying to understand how to deal with people in need, their opin- ions and perspectives are often not accepted or respected by decision makers.” The clinical director of a private for-profit adoption agency added this view: “Unlike a lot of social workers, I work in a for-profit agency, and busi- ness considerations always have to be factored into our decisions. We have a fairly small operation, and I think the agency director is responsive to my con- cerns about how clients are treated, but I’ve still had to get used to the tension that can arise between making a profit and serving clients.” On a final note, a direct-practice student who graduated made this state- ment: “My education in social work taught me how little I know. I feel as if I have just scratched the surface. Learning is a long ongoing process. I work in a head injury center and what I learned from having had exposure to macro- practice roles is that you have to know the organization in which you work, particularly the philosophy behind what happens there. This is more impor- tant than I ever imagined.” These quotations tell a number of stories. First, the issues facing social workers in their daily practice are not limited to client problems. If social workers are to be effective in serving their clients, many problems must be rec- ognized and addressed at the agency, community, and policy levels. Some of
An Introduction to Macro Practice in Social Work 5
these problems require changing the nature of services, programs, or policies. Most require an understanding of funding issues and the complications caused by the economic recession since 2008. In social service programs, at least for now, social workers cannot look forward to additional funding or increased staff, but rather need to find ways to provide and hopefully even improve ser- vices with the same or fewer resources. Second, skills learned in classroom settings become critically important to practice success, whether they are writ- ing, interpersonal, assessment, evaluation, or other skills. Finally, practition- ers continue to learn as they move into their respective places of employment, often surprising themselves with their insights about policy intent, the use of technology, and knowing how to ask the right questions. We thank our former students for helping us illustrate the use of macro-practice skills across set- tings and arenas, and the importance of macro practice to the profession.
WHAT IS MACRO PRACTICE?
As defined earlier, macro practice is professionally guided intervention designed to bring about change in organizational, community, and policy are- nas. Macro practice, as all social work practice, draws from theoretical foun- dations while simultaneously contributing to the development of new theory. Macro practice is based on any of a number of practice approaches, and it operates within the boundaries of professional values and ethics. In today’s world, macro practice is rarely the domain of one profession. Rather, it involves the skills of many disciplines and professionals in interaction. Macro activities go beyond individual interventions but are often based on needs, problems, issues, and concerns identified in the course of working one- to-one with service recipients. There are different ways to conceptualize the are- nas in which macro social work practice occurs. Rothman, Erlich, and Tropman (2008) identify three arenas of intervention: communities, organizations, and small groups. We have selected communities and organizations as the arenas on which the majority of this text will focus, folding small group work in as a criti- cal part of most interventions in both communities and organizations. Small groups are seen as collections of people who collaborate on tasks that move toward agreed-upon changes. It is our contention that small groups are often the nucleus around which change strategies are developed in both communities and organizations, and they are therefore more logically conceptualized as part of the strategy or medium for change rather than the focus of change. Other writers focus on the policy context in which macro intervention occurs (Gilbert & Terrell, 2010; Jansson, 2011; Karger & Stoesz, 2009). The policy arena is well articulated in other social work textbooks that complement the content here (e.g., Cummins, Byers, & Pedrick, 2011). Organizational and community arenas are deeply embedded in political systems, which are typically the starting points for development of social policies. Although the creation and analysis of these policies is not our main focus, an understanding of how ideologies and values are manifested in local, state, and national politics is fundamental to macro change.
Locus of Involvement in Social Work Practice
Social work practice is broadly defined and allows for both micro (individual, domestic unit, or group) and macro interventions (organization, community, or policy). See Box 1.1. Social workers who undertake macro interventions
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within a neighborhood may present issues and concerns that need to be addressed. Issues in the workplace, such as the quality of service to clients, may surface and require organized intervention. Community problems may be so glaring that the need for change comes from many different directions. Regardless of how social workers identify change opportunities, they function in a political environment that cannot be ignored. The three overlapping circles in Figure 1.1 illustrate the focal points of the social worker’s efforts in undertaking a macro-level change episode. We will refer to these focal points as (l) problem, (2) population, and (3) arena. Good social work practice requires understanding. To engage in macro prac- tice to help a client who is addicted to alcohol, for example, the social worker must understand the problem (alcoholism), the background of the person addicted, the population (e.g., elderly, retired males), and the arena (community or organization) within which the problem occurs. Understanding communities and organizations adds a dimension of complexity to social work practice, but this understanding is a critical precursor to successful macro-level intervention. In the course of developing an understanding of problem, population, and arena, the social worker will inevitably focus on the areas of overlap depicted in Figure 1.1. Continuing with the example of alcoholism among elderly, retired males, it would be important to review theory about how alcohol addic- tion develops, research reports from studies testing various interventions, and literature on the target population. As the change agent builds a body of knowledge about the problem and population, it becomes especially important to focus on the overlap between the two areas: alcoholism and its unique impact on elderly, retired males. It is likewise important to understand how the phenomenon of alcoholism affects the local community (the overlap between problem and arena), and to what extent the needs of the population of elderly, retired males are understood and addressed in the local community (overlap between population and arena). Ultimately, in an episode of macro practice, the objective is to work toward an understanding of the area where all three circles overlap (alcoholism and its impact on elderly, retired males in a given neighborhood or town).
Figure 1. Macro Practice Conceptual Framework: Understanding Problem, Population, and Arena
Policy Practice Critical Thinking Question: What are some strengths of micro practice that also help address complex problems in macro practice?
P o l i t i c a l&Pol icyContext
Problem Population
Arena (Communities and Organizations)
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As the social worker and other change agents study the situation, they will gain at least some level of understanding of (1) basic concepts and issues sur- rounding alcoholism, (2) elderly, retired males, (3) the local community and/or relevant organizations, (4) alcoholism as it affects elderly, retired males, (5) alcoholism and how it is addressed in the local community, (6) how the needs of elderly, retired males are addressed in the local community, (7) avail- able interventions and their applicability to both the population and commu- nity of interest, and finally, (8) the problem and needs of elderly, retired males in the local community who are addicted to alcohol. Social and community problems and needs must also be addressed within a larger context that affects the problem, the population, and the community or organization. Dealing with social and community problems and needs effec- tively requires an awareness of the political environment within which the change episode will be undertaken. For these reasons, we have placed the three circles (problem, population, and arena) within a large dotted outer cir- cle intended to depict the political environment. The importance of and the need for understanding the political and policy contexts within which macro- practice tasks take place cannot be overemphasized.
The Interrelationship of Micro and Macro Social Work Practice
Given the complexity of macro interventions, practitioners may begin to feel overwhelmed. Is it not enough to do good direct practice or clinical work? Is it not enough to listen to a client and offer options? Our answer is that profes- sional practice focusing only on an individual’s intrapsychic concerns does not fit the definition of social work. Being a social worker requires seeing the client as part of multiple, overlapping systems that comprise the person’s social and physical environment. The profession of social work is committed to seeking social and economic justice in concert with vulnerable and under- served populations, and macro-practice skills are necessary in confronting these inequalities. For example, consider a woman reported for child neglect who lives in a run-down home with structural problems her landlord refuses to fix. A clinical intervention designed to strengthen her emotional coping skills might be useful, but that intervention alone would ignore the depth of the problem facing her. Social workers unwilling to engage in some macro- practice types of activities when the need arises are not practicing social work. Similarly, social workers who carry out episodes of macro practice must understand what is involved in the provision of direct services to clients at the individual, domestic unit, or group level. Without this understanding, macro practice may occur without an adequate grounding in understanding client problems and needs. One example might be a social worker who conducts a community crime prevention campaign to combat high rates of petty theft in a neighborhood, unaware that most such acts are the work of a relatively small number of residents desperately in need of drug-abuse intervention. The inter- connectedness of micro and macro roles is the heart of social work practice. In short, it is as important for social workers to understand the nature of individ- ual and group interventions as it is to understand the nature of organizational, community, and policy change. Because we believe that all social workers are professional change agents, we use the terms social worker , professional , and change agent interchangeably
The interconnectedness
of micro and macro roles
is the heart of social
work practice.
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for example, theories provide explanations about the causes of various types of mental disorders, and practice models arising from these theories suggest ways of helping people affected by the disorders. On a larger scale, sociolog- ical theories may describe how communities, organizations, or societies function. A practice model for initiating change in communities and organi- zations (such as the planned change model presented in this book) illustrates how these theories can lead to specific actions. One theory that seems to have considerable relevance at both the micro and macro levels is systems theory. Systems theory contends that there are multiple parts of any entity, whether it is a group, an organization, or a community. Enti- ties can be best understood as systems with interconnecting components, and certain common principles help in understanding systems, whether they are as large as an international corporation or as small as a family. There are resources the system needs in order to function and they may come in the form of people, equipment, funding, knowledge, legitimacy, or a host of other forms. These resources interact within the system, producing something that becomes the system’s product. Consider a human service agency that targets gay and lesbian youth. The volunteers and staff, funding from various sources, teachers from local schools, concerned parents, and the youth themselves may all come together within this human service setting. Their relationships and interactions will determine whether the organization functions as a system or merely as a dis- parate assortment of parts. Functional systems have a dynamic interaction among components that holds them together. The interaction that holds this human service agency together may be the communication that occurs as teachers, parents, and youth come together; their bonding over an important cause; their shared commitment to the mission; and the desire to create a safer, more supportive environment for the youth. Systems expect conflict and have ways to cope when it occurs. For an agency dedicated to gay and lesbian youth, there will be strong community forces that do not agree with what the agency is doing, that seek to provide different interventions, and that even want to change the youth. Depending on the level of conflict, the system may have boundaries that are fairly rigid in order to protect itself from external forces. The product of this system would be youth who are better able to func- tion in the larger environment and who have a sense of who they are. Community researcher Roland Warren (1978) provided a good example of how systems theory can be applied to understanding communities. He built on the work of Talcott Parsons, a sociologist known for defining the characteris- tics of social systems. He also incorporated the work of others who described how community systems would differ from the groups and formal organiza- tions to which systems theory had previously been applied. Warren saw the community as not just one system but a system of systems in which all types of formal and informal groups and individuals interact. Given the diversity among groups and subgroups, communities have a broad range of structural and functional possibilities that do not conform to a cen- tralized goal. The beauty of a community system is that it is a complex arena in which multiple groups and organizations with differing values may exist simultaneously. Warren’s contention that a system endures through time speaks to social work practitioners who work with groups committed to maintaining their communities and are grieving over the loss of what their communities used to be. For example, the physical land and the interactions that occurred on that
An Introduction to Macro Practice in Social Work 11
land may render it sacred to Native American People. Similarly, an elderly widow who has lived on the same street corner for 60 years may hesitate to move even when increasing crime threatens her physical safety. In an organizational arena, a systems approach reveals the complexity involved in recognizing multiple groups (e.g., professional staff, clerical staff, management, administration, board, clients, funding sources, neighbors, and others in the community) that have a stake in what that organization does and whom it serves. This theoretical perspective reminds the practitioner that organizations are complex systems embedded in larger community systems, all of which are interacting on a daily basis. Warren also identifies the structure of internal and external patterns, which he labels vertical and horizontal community linkages. Vertical linkages connect community units (people, groups, organizations) to units outside the community. These linkages are exemplified by a human service agency with its headquarters in a different community that uses Skype to see its members face-to-face, by local chapters virtually connected through shared information systems with state and national umbrella organizations, and by public agen- cies having a central office external to the community from which they receive instruction. The concept of vertical community calls attention to the fact that many important decisions may be made by parent organizations outside the boundaries of the local community, and these decisions may or may not be in the best interests of the community. The horizontal community is geographi- cally bounded and is represented by many linkages between and among orga- nizations and neighborhoods that are located within the area, and, in most cases, serve the community. For example, the local nursing home may work with the neighborhood school to develop an intergenerational program for res- idents and children. This effort may also include a local bookstore that pro- vides children’s books, a bus driver who provides transportation, and a staff member from the local multigenerational center. These types of collaborative efforts, which are becoming increasingly common, illustrate the importance of the horizontal community as a concept. By distinguishing between types of relationships, Warren acknowledged the complex array of possible relation- ships within the community and with the larger society. Boundary maintenance is also part of systems theory. Establishing bound- aries is critical to system survival. If boundaries become blurred or indistin- guishable, the community as a spatial set of relationships or the organization as a distinct entity may become less viable. For example, as congregations in local communities contract with government agencies to provide services to persons in need, the boundaries between what is an agency and a ministry may blur. Moreover, boundaries between long-established, faith-related, non- profit organizations and congregations within the same faith may begin to overlap in unanticipated ways. Macro practitioners will witness the struggle for boundary maintenance in their work with communities and organizations. For instance, residents in a neighborhood that has just altered school atten- dance boundaries may face major changes in how they view their community. The annexation of previously unincorporated areas into the city limits may bring protesters to city hall. The reconfiguration of a planning and service area that alters agency’s boundaries may mean that clients formerly considered part of one’s community will no longer be eligible for service. Thus, systems theory recognizes the importance of formal groups and orga- nizations. For example, in dealing with child maltreatment, child protective service workers, law-enforcement officers, hospital emergency staff, teachers,
An Introduction to Macro Practice in Social Work 13
practitioners may deal with clients who are child molesters, spouse abusers, drug dealers who sell to children, people who commit hate crimes, and a host of other persons who act on values antithetical to those of the profession. For- tunately, the field of professional and applied ethics in social work emerged during the 1970s, and today there is energetic dialogue and a growing literature addressing the complex values issues that arise in social work practice (Reamer, 1995, 1998). The NASW Code of Ethics lists six core values on which the ethical prin- ciples of social work are based: service, social justice, dignity and worth of the person, importance of human relationships, integrity, and competence. Realiz- ing that many values have relevance to macro practice, we focus on the six from the NASW Code to illustrate ethical dilemmas that social workers face.
Service
Social workers are often simultaneously engaged in both direct and indirect practice, actions intended to help people in need and to address the social problems they face. Closely related to service is the concept of beneficence, which is based on the desire to do good for others, as well as not doing harm. Persons entering the field of social work will often say that they want to help others. This value is typically a primary motivator for those professionals who work in health and human service settings, reflecting their desire to find ways to serve others in making life more meaningful. Beneficence requires that the professional view clients holistically. Jansson (2011) uses examples of a physician who treats a woman’s presenting medical problem but does not consider her inability to afford a healthy diet, or a rep- utable attorney who assists with a divorce but does not consider the financial implications for the divorcee. Beneficence requires that the physician recog- nizes the woman’s broader needs and refers her to a food bank or Meals on Wheels program, or that the attorney refer the client to a financial counselor. Thus, beneficence means that all professionals must consider a client’s multiple needs. This is particularly important for social workers, who are expected to bring a person-in-environment perspective to all their service inter- actions with clients. If social workers fail to perceive clients’ broader needs, they have neglected the principle of beneficence and the call to be of service.
Social Justice
Ideally, social justice is achieved when there is a fair distribution of society’s resources and benefits so that every individual receives a deserved portion. Social work is in the business of distributing and redistributing resources, whether they are as tangible as money and jobs or as intangible as self-efficacy or a sense of self- worth. Underlying the distribution of resources in society are value considera- tions that influence the enactment of laws, the enforcement of regulations, and the frameworks used in making policy decisions. Jansson (2011) points out that social justice is based on equality. With the many entrenched interests one encounters in local communities, it is likely that social workers will focus their efforts on oppressed target population groups and will always be discovering new inequalities. Since so many groups face problems related to having enough finan- cial resources, social workers often extend the principle to include economic jus- tice, often focusing on social and economic justice concerns. Concerns about social and economic justice are exacerbated when clients cannot pay for services. As long as clients can pay, professional decision mak- ing may not conflict with the larger society because resources do not have to
Human Rights & Justice Critical Thinking Question: Can you address issues of social justice and inequal- ity without engaging in macro practice? Why or why not?
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be redistributed. Conceivably, as long as clients can pay for professional ser- vices, professions can operate within the market economy. Private practice and fee-for-service agencies conform to this approach. Quality care is exchanged for economic resources, often in the form of third-party payments. The key to this approach is that the client has insurance coverage or access to sufficient personal funds. This approach breaks down, however, when clients cannot pay. Many social work clients are in problematic circumstances because their income is inadequate to meet their needs and other resources are not available. Patients with AIDS may find themselves unable to pay for care at the same time that their needs increase because they are fired from jobs when news about their disease becomes known. An older woman could avoid institutional care by hiring an in-home caregiver, but despite having considerable lifetime savings, medical expenses from her husband’s terminal illness have left her with too few funds to meet her own needs. A youth who has grown up in poverty knows exactly what it means when the model breaks down. For that youth, a broken model has been a way of life, and she or he has no reason to strive for a better standard of living. Health and human service systems are driven by considerations of whether resources are available to pay for (or subsidize) the services clients need. If resources are not available, the patient with AIDS and the older woman may be forced to expend all their own resources before ending up in public institutions, and the youth may continue in a cycle of insufficient edu- cation, housing, health care, and job opportunities. In this resource-driven system, social workers may have difficulty maintaining a vision of the com- passionate community in which mutual support is provided to all those in need. These dilemmas face social workers because the profession is enmeshed in issues of redistribution.
Dignity and Worth of the Person
Often called self-determination or autonomy, valuing the dignity and worth of each person means respecting and honoring the right of that person to make his or her own life choices. Concepts such as empowerment are built on the value of dignity and worth, implying that power or control over one’s life means seizing the opportunity to make one’s own decisions. As an example, the pro-choice proponents in the abortion controversy advocate for autonomy, a woman’s right to choose. This stance conflicts with a number of religious codes arguing the immorality of abortion and stating that the right of the unborn child must be considered as well. Although autonomy may be per- ceived as individualistic and therefore more relevant to direct practice situa- tions, one has only to be involved in the heated debate over abortion to realize the ethical dilemma involved in situations where the autonomy of both parties cannot be equally respected.
Importance of Human Relationships
Although it may be more time consuming and take more energy to include clients in change processes, the NASW Code of Ethics is a reminder that the dignity and worth of the person and the importance of human relationships are core social work values. This means continually finding new and meaning- ful ways to facilitate consumer as well as citizen participation in organiza- tional and community arenas. Nurturing relationships is an ongoing and necessary challenge for the dedicated professional.
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level of intervention the practitioner is addressing, whether individual, group, organization, or community. In addition, systems theory that informs the planned changed model implies that there will be goals and outcomes, both of which are important steps in the planned change process. Our model of planned change assumes that there will be broadly defined goals to guide practitioners’ efforts. Goals are usually long term and sometimes idealistic. However, goals provide a vision shared by clients and colleagues—a hope of what can be—and they assist the practitioner in maintaining a focus. The identification of these goals should be based on the best knowledge available. From goals, we assume there will be outcomes defined as quality-of-life changes in clients’ lives, based on the interventions planned by practitioners. Much of the history of social work practice has been focused on process— what the social worker does. Interventions of the future will be driven by outcomes—what change is expected to be achieved by and for the target pop- ulation as a result of this change effort. Balancing the importance of process and the push for accountability through outcome measurement is part of com- petent, contemporary practice. It is also key to planned change intervention. Together, goals and outcomes are based on the best available evidence, guided by as complete as possible an understanding of the systems in which change will occur. During the socialization process of preparing for professional social work practice, each person will have to determine how her or his personal values relate to the professional values being learned. Integrating one’s personal and professional values is a part of professional identification, and leads to what Sullivan (2005) and others say about professions as communities of identity in which colleagues come together to work toward the civic good. Embracing that identity and approaching one’s practice with integrity and competence will contribute to one’s ability to join with others in pursuing the values of the profession. Balancing the values of services, social justice, dignity and worth of the person, importance of human relationships, integrity, and competence demands an analytical approach to decision making and intervention. Inevitably, the macro practitioner will face ethical dilemmas that go beyond the bounds of the Code of Ethics. This requires that he or she have a strong professional identity. We now turn to three case examples that illustrate the dilemmas often encountered by social work practitioners.
THREE CASE EXAMPLES
Some of the aspects of social work macro practice that need to be understood by the student and the beginning practitioner can be illustrated by case examples. We selected the following examples because they contain similar themes but focus on different target population groups: children, elders and disabled persons, and persons who are homeless. As these cases and the workers’ thoughts are presented, we encourage the reader to think about how macro-level change might be approached by beginning with a study of the problem , the population , and the arena within which change might take place. We also hope that these examples will illustrate both the systemic nature of social work macro practice and the types of value dilemmas con- fronting social workers.
An Introduction to Macro Practice in Social Work 17
Case Example 1 Child Protective Services
Child protective services (CPS) workers have responsibility for dealing with the abuse and neglect of children. When reports of alleged abuse or neglect come to the unit, the CPS worker is responsible for investigating the report and making decisions about the disposition of the case. It is a very demanding and emotionally draining area of special- ization within the field of social work. One CPS worker several years ago took the time to record the details of a particular case, and also shared with us a list of dilemmas and contradictions he had encountered over the years, in the interest of helping new work- ers prepare for what they will face as they enter practice. Friday, 10:40 A.M. Supervisor text messaged me about a report of neglect. She felt it should be checked out today because it sounded too serious to be left until after the weekend (as agency rules allow with some neglect allegations). According to the neighbor’s report, parents have abandoned three minor children. 11:10 A.M. Got in my car and headed for the address on the intake form. I know the neighborhood well. It is the poorest in the city and unsafe at night. A high percent- age of families receive some kind of assistance. Homes are run down, streets are lit- tered, and any sense of pride in the community has long been abandoned. 11:40 A. M. The house at the address given is among the most run down in a seri- ously deteriorating neighborhood. The house has no front steps—just a cinder block placed in front of the door. Window casings are rotting out for lack of paint. There is no doorbell. I knocked. There was rustling inside, but no answer. I waited and knocked again. I walked around and peered through a window and saw a small child, about 3 years old I guessed, curled up in a chair. An older girl, about age 8 or 9, peeked out from behind a doorway. I remembered that the oldest child was named Cindy, so I called out to her. After a bit of conversation I persuaded her to let me in. I quickly recognized that this would not be an ordinary case. A foul smell hit me so hard it made my eyes water. I used a tissue to filter the air. The worst odors were coming from the bathroom and kitchen. The water had evidently been shut off—toilets were not working and garbage was piled up. The kitchen was littered with fast-food containers, possibly retrieved from the dumpsters of nearby shops. There were three very frightened children—Cindy (age 9), Scott (age 6), and Melissa (age 3). None would talk. 12:35 P. M. I made arrangements to transport them to the shelter and went back to the office to do the paperwork. 2:15 P.M. A previous neglect report revealed the following: Father: Stan, age 27, unemployed, in and out of jail for petty theft, public intoxi- cation, and several other minor offenses. Frequently slept in public parks or homeless shelters. Rarely showed up at home any more. Several police reports of violence against wife and children. Admits paternity for only the oldest child. Mother: Sarah, age 25. Temporary Aid to Needy Families (TANF) recipient, high school dropout, never employed. Tests performed in connection with one attempt at job training revealed borderline retardation. Child care skills have always been minimal, but there is no previous history of abandonment of children. Where- abouts at this time are unknown. 3:35 P.M. Filed the appropriate forms with agency and the police. Entered field notes into laptop for the record. Children placed at Vista Shelter until a more permanent placement can be arranged. Emailed confirmation of placement to supervisor, copied to shelter staff.
An Introduction to Macro Practice in Social Work 19
Case Example 2 Case Management with Elderly and Disabled Persons
Case managers work in a variety of public and private settings. They are responsible for screening potential clients, assessing client needs, developing care plans, mobilizing resources to meet identified needs, and monitoring and evaluating services provided. The case manager in this example works for a nonprofit agency in an inner-city neigh- borhood, where many of her clients have lived all their lives. She is assigned to the home and community-based long-term care unit, and carries a caseload of about 60 elderly and disabled clients. As part of the program evaluation, she was asked to keep a diary of what happened during a typical day. The following are excerpts from her diary. Wednesday, 7:30 A. M. Arrived early to catch up on email and enter client data from previous day. Organized documents from eight cases, including two new care plans and five medical reports. 8:00–8:10 A. M. Mrs. Garcia, a 79-year-old woman, called. She was distraught over a letter received from the Social Security office, thinking it meant her benefits would be cut off. Explained that it was a form letter, indicating a routine change, not affecting the amount of her check. Knowing that she is often forgetful and has a hearing problem, made a note to make home visit tomorrow to be certain she understands what was said. 8:10–8:30 A. M. Met with Jim from In-Home Support Services. Mr. Thomas, a 93-year-old man, had fallen last night and was in Mercy Hospital. Homemaker had found him when she arrived at 7:00 this morning. He is not expected to live. Homemaker is very upset. Called his daughter and will plan to meet her at hospital later this morning. 8:30–9:30 A. M. Staff meeting regarding 10 clients discharged from City Hospital with inadequate discharge plans. Discussed how to work better with discharge plan- ners from hospital because this situation continues to be a problem. As I left meet- ing, another case manager told me that my client, Mrs. Hannibal, had refused to let the home health nurse into her apartment. 9:30–9:45 A.M. Called Mrs. Hannibal, no answer. Called the lifeline program to meet me at her apartment. 9:45–10:00 A. M. Drove to Mrs. Hannibal’s apartment. No one answered my knock, so got manager to let me in. Mrs. Hannibal had been drinking and was acting para- noid. Threw bottle at me and screamed, “No one is going to get me out of here. I’ll never go to a home. I’ll die first.” Worked with lifeline staff to get Mrs. Hannibal calmed down. She is a 67-year-old widow. She goes in and out of the hospital every two months. Has a severe drinking problem. 10:00–11:00 A. M. Arrived at Mercy Hospital. Met Mr. Thomas’s daughter. She was in tears, saying it was all her fault, that if he had been living with her this would have never happened. Talked with her regarding her father’s desire to live alone, that this had been his choice. Contacted hospital social worker to work with daughter. 11:15 A. M .–12:00 P. M. Back to office. Entered notes on visits to Mrs. Hannibal and Mr. Thomas into computer. Called two new referrals, faxed documents to hospital, and set up appointments to do assessments tomorrow. Received call from Ms. Roman, age 83. She is lonely and wondered when I would be seeing her. Her partner of 40 years died last week and she is crying. Has no family. Assured her I would come see her on Friday. 12:00–12:30 P. M. Ate lunch with Adult Protective Services (APS) worker. Discussed abusive relationship of Mr. and Mrs. Tan, a couple in their 60s living in public hous- ing. Agreed to work closely with APS regarding this situation. 12:45–2:00 P. M. Conducted in-home assessment for new client, Ms. Johnson. She was released from the hospital yesterday and is receiving home-delivered meals and (Continued)
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in-home nursing. Small house is a mess, roaches everywhere. Needs chore and housekeeping services, but there’s a long waiting list. Called and cajoled volunteers at senior center to help her temporarily. Ms. Johnson was too weak to complete full assessment, will come back tomorrow. 2:30–3:30 P. M. Attended public hearing preceding the planning process for the Area Agency on Aging. Presented written and verbal documentation of problems in working with my caseload. Discussed the need for more flexibility in providing ser- vices to disabled clients under age 60. Gave examples of three clients on caseload who are in their 40s and have severe mobility problems. 3:45–4:15 P.M. Stopped by Sunnyside Nursing Home to see Mrs. Martinez. Has been my client for five years and was just admitted to Sunnyside. Doesn’t know me and seems confused. Checked with facility social worker regarding what medications she is on and agreed to call physician regarding potential drug interactions. Made note to check with local long-term care ombudsman about any complaints against this facil- ity. Also made mental note to check on Mrs. M’s disabled daughter who is still in the home and will need supportive services previously provided by her mother. 4:45–5:15 P.M. Returned to office, found out Mr. Thomas had died. Called his daugh- ter. Tried to call physician about Mrs. Martinez’s medications but his nurse would not reveal any information to me because of the privacy act. I could tell she was angry that I would even suggest a medication interaction given my nonmedical background. Received call from home health aide referring client to us. Had to tell her that client did not qualify for our services, but referred her to a for-profit agency in town. Returned a call about assistive technology that might help several clients with disabilities. 5:15–5:30 P. M. Tried to clean up desk and catch a few emails. Decided to stop by and check on Mrs. Garcia on my way home.
Just as the CPS worker had kept a running list of the kinds of dilemmas he faced through the years, the case manager had kept a list of her dilemmas as well. In preparation for the Area Agency on Aging public hearing, she had updated the list in hopes something could be done to address her ongoing frus- trations, particularly about persons with disabilities who were not yet 60 years old. Excerpts from her list follow:
1. So many of the older people I see have had problems all their lives. You can almost tell what’s going to happen in their old age by what happens to them as they go through life. Drug and alcohol problems only seem to get worse. If someone had intervened when they began having these problems it would have been much easier, because the behavior patterns are set by the time I encounter them. I know people can change at any age, but it seems harder when one is under stress or facing hard times. Is there some way we could organize a prevention effort to prepare middle-aged people for their senior years? 2. Although some of our resources can be used to serve any older person in need, most of our funding is tied to income eligibility. Slots for people who aren’t destitute are quickly filled and there is a long waiting list. So clients above the income eligibility level are referred to for-profit agencies or to other nonprofits that have sliding fee scales. The irony is that the ones who have set a little money aside are usually the same ones who get left out in the cold. These “notch group” clients can’t afford to pay the full cost of services but fall just above our eligibility guidelines. It seems
