Clinical Intervention I-System theory

163© Springer Nature Switzerland AG 2021 R. P. Dealey, M. R. Evans (eds.), Discovering Theory in Clinical Practice, https://doi.org/10.1007/978-3-030-57310-2_12

Chapter 12 Systems Theory: The Case of Esperanza

Madeline Pérez De Jesús, Enitzaida Rodríguez, and Gladis Anaya

Introduction to Systems Theory

Systems theory calls practitioners to examine the relational dynamics between individuals, and between and within groups, organizations, or communities, as well as mutually influencing factors in the environment (Leighninger, 1977). While systems theory is commonly used in social work, the authors argue that the profes- sion would benefit from expanding its scope to intentionally explore issues of diversity and the impact of trauma. This chapter demonstrates how systems theory supports culturally informed clinical practice by highlighting the case of “Esperanza,” a 16-year-old ninth-grade student who, with thousands of others, migrated from Puerto Rico to urban cities in the Northeast and other areas in the United States after being displaced by Hurricane Maria in 2017. Two Latinx social workers enter Esperanza’s life in her new high school setting in Hartford, Connecticut.

The authors’ overview of systems theory includes a perspective on how problems arise, how systems theory facilitates understandings of the change process, and implications regarding complementary interventions that are can be used based on this theory. The case study of Esperanza details her demographics, family dynamics, and various ecological factors that influence her situation. Theoretical integration

M. P. De Jesús (*) Department of Social Work and Equitable Community Practice, University of Saint Joseph, West Hartford, CT, USA e-mail: [email protected]

E. Rodríguez School Social Worker, University of Saint Joseph, West Hartford, CT, USA e-mail: [email protected]

G. Anaya University of Saint Joseph, West Hartford, CT, USA e-mail: [email protected]

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follows the case example, with the authors demonstrating how systems theory informed social workers approach to treating the client and understanding the client’s response. Important considerations regarding intracultural and intercultural factors that influenced clinical intervention effectiveness are described. The authors note that systems theory also served as a tool for resolving a practice conflict for the social workers. In the concluding section, the authors pose discussion questions to support readers in thinking critically about the usefulness of systems theory and the process of integrating theory into clinical practice.

The overarching premise in systems theory is that there is reciprocity in the inter- locking relationships between people, families, social networks, neighborhoods, and other related systems (Leighninger, 1977). This reciprocity includes elements in the environment such as nature, encompassing physics, chemistry, biology, and social relationships. While the origins of systems theory come from Charles Darwin’s notion of “the survival of the fittest,” the theory has broadened and sup- ports social work by offering a balance between biological, psychological, and sociological roots. Systems theory had a significant impact on social work during the 1970s, when its contributions included general systems theory, and family ther- apy developed into ecological theory and the importance of networking (Payne, 2002). This theory is particularly useful to social workers, as they are trained to have a person-in-environment lens.

Leighninger (1977) identified three main contributions of systems theory to the field of social work: (1) it expands the practitioner’s focus beyond the client to the client and their environment, (2) it allows for a better account of social change, and (3) it has the potential of having social workers reflect on issues of power and con- trol. Social workers are not strangers to examining ourselves as agents of social change, and in his discussion of the applicability of systems theory, Leighninger reminds us that we must also examine the other side. In other words, just as we explore how social workers are agents of change, it is also central to look at how we might operate as agents of social control or even social oppression.

Systems theory offers a specific perspective on how problems arise. This per- spective is evident in a definition of social work that was put forward by the International Federation of Social Workers in 2000, and subsequently reinforced by the International Association of Schools of Social Work (as cited in Hutchings & Taylor, 2007, p. 382):

The social work profession promotes social change, problem-solving in human relation- ships, and the empowerment and liberation of people to enhance well-being. Utilizing theo- ries of human behavior and social systems, social work intervenes at the points where people interact with their environments. Principles of human rights and social justice are fundamental to social work.

Systems theory assumes individuals are part of overlapping or intersecting mul- tiple networks and defines problems within this overlap. No individual lives in a bubble; our families, our communities, the related systems with which we engage, and the broader sociopolitical and economic climate impact us all. Just as the prob- lem is found in these overlapping systems, this is also where potential solutions lie.

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Payne’s (2002) reminder of the importance of networking is applicable to our cli- ents, as the people in their systems shape the types of information they receive and their beliefs, which in turn impact their actions. For instance, a client may have access to accurate or inaccurate information, and may operate in the world with a sense of entitlement or a sense of despair.

Various interventions emerge from the foundational principles of systems theory. Visual aids provide a concrete way for clients and those who work with them to digest how systems theory helps make meaning of a client’s life. Ecomaps and genograms are examples of visual aids that can be particularly useful during the early stages of rapport building and assessment. Ecomaps are visual representations of the interconnected systems of an individual’s life that show the relationships between the client and their environment (Hartman, 1995). Whereas ecomaps dis- play a more comprehensive arrangement of systems, genograms fix the gaze specifi- cally on family dynamics across generations, allowing client and practitioner alike to examine family dynamics with particular focus on behavioral patterns and quality (Altshuler, 1999). The relationships between systems, people, and the client are represented by lines drawn on the visual aid. A thick solid line represents a mean- ingful positive connection. A broken line symbolizes a weak connection. Lines drawn with crosses through them indicate stress. Some lines might also include arrows to suggest that a relationship appears to be mutually beneficial, mutually toxic, or one-directional. Pope and Lee (2015) are a good starting point for further direction on the creation of genograms.

Systems theory helps social workers understand that it is not only individuals who serve as stressors or supports to a client; the processes of bureaucratic institu- tions that represent education, religion, political, and economic entities can stress or support a client, as well. Understanding the client’s supports and stressors is a pre- requisite to engaging with the client therapeutically.

Cognitive behavioral therapy (CBT), a psychological treatment model in which the treatment provider helps the client become aware of their thought processes, belief systems, and antecedent behaviors, is one approach being increasingly used by social workers to treat clients with a range of problems, including but not limited to anxiety, depression, and post-traumatic stress. CBT as an empowering model aligns well with systems theory, as clients from underrepresented groups are fre- quently subjected to discrimination and intergenerational trauma. CBT can be trauma-focused, and typical techniques for child and adolescent survivors of trauma include cognitive reprocessing and reframing, exposure, stress management, and parental treatment (Cohen, Mannarino, Berliner, & Deblinger, 2000).

Mutual aid groups, another intervention model, situate individuals who are undergoing similar social problems as providers of support to each other, in the context of a group working on solutions. Such groups provide opportunities for clients to share their lived experiences while witnessing each other’s accounts of interactions with various systems, and subsequently influencing each other (Gitterman, 2004).

Social workers frequently engage in a role traditionally referred to as case man- agement, a process of assessing the client’s needs and then securing (in some cases

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advocating for) a package of services. Consistent with a focus of engaging clients with institutional actors, resource referral is an intervention in which social workers secure assistance for clients to supplement supports that are limited or unavailable from their personal agency standpoint. All the heretofore mentioned types of inter- ventions help ground understandings of the case study of Esperanza.

Introduction to the Case of Esperanza

Esperanza is a 16-year-old Puerto Rican heterosexual female. All names and identi- fiers of this case have been changed to maintain the confidentiality of the client. A ninth-grade student at her local urban high school, Esperanza lives with her 7-month- old baby, 34-year-old mother (Ms. Colon), and two adolescent siblings in an apart- ment in Hartford, Connecticut. While neither Esperanza nor her family currently attend church services, they identify as Catholic and were all baptized as infants. Ms. Colon, the primary income-earner, works as a home health aide for the elderly. Both of Esperanza’s parents stopped their formal schooling after eighth grade. The family unit receives some public assistance and financial contributions from Esperanza’s siblings; also high school students, who both hold part-time jobs. The family’s primary language is Spanish.

Esperanza was referred to the school social worker last year, initially for aca- demic reasons. As an “over-age student,” Esperanza was required to undergo a series of educational evaluations. While Esperanza did not have any learning dis- abilities, she was 2 years behind grade level due to gaps in her school attendance and limited English-language proficiency. Her social work referral expanded beyond academics after her classmates informed teachers that Esperanza was pregnant. Because she was a pregnant minor, a referral to the state child welfare agency was also made. Despite being polite and cooperative with the social worker, Esperanza initially refused the involvement of school and state officials, stating she “tenia todo el apoyo en su familia” (“had all the support she needed within her family”). Esperanza previously received counseling services from a school social worker as an elementary school student in Puerto Rico, to support her coping with her parents’ divorce. Counseling services then involved 6 months of weekly individual sessions, which Esperanza described as supportive. She has since developed and maintained healthy relationships with both parents, who appear to collaborate well in their co- parenting of Esperanza and their other children. Esperanza’s relationally healthy and loving family, as well as her personal resilience, prove to be strengths in her treatment.

Esperanza’s presenting concern was her increase in trauma-related symptoms, including increased anxiety, depressive mood, difficulty concentrating, and lowered frustration tolerance. These symptoms were interfering with her ability to maintain effective, positive communication with others both in school and with her personal relationships. Esperanza also stated she was fearful of “engaño” (Spanish for trick- ery or fraud) from institutional officials such as social workers and teachers.

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During the first 5 years of her life, Esperanza lived with both of her parents. At the age of five, her parents divorced. Although her parents terminated their marriage, Esperanza reports that her parents speak about each other in cordial ways and engage in healthy co-parenting. This cooperative co-parenting engagement is a fam- ily strength, especially since she has gone back and forth living with each in the years since their divorce. Back and forth is also a larger pattern for Puerto Ricans, as it references travel between the island and the mainland in a circular motion facilitated by U.S. citizenship. Despite having legal recognition as U.S. citizens, Puerto Ricans who have spent time in both places often experience cultural dis- crimination and feelings of not belonging to the island or the mainland. Acevedo (2004) references this dilemma as belonging “neither here nor there.”

Between the ages of 5 and 12, Esperanza lived intermittently with each of her parents and migrated back and forth between Connecticut and Puerto Rico on at least three separate occasions. When Esperanza was 12 years old, her mother moved to Connecticut in search of employment with two of her children (the eldest and the youngest). Esperanza remained in Puerto Rico with her father for three years until her mother could “send for her” to move to Connecticut.

When Esperanza was 15  years of age and still living with her father in Puerto Rico, she experienced the devastating impacts of a hurricane that led to a mass exo- dus from the island to the United States. Esperanza is a survivor of sexual abuse. While she described having a “boyfriend,” she clarified that this person was a man 10 years her senior. Despite this being a relationship that felt like a courtship for her and was approved by her family, it is a situation of abuse. She was not within the legal age of consent to engage in a sexual or emotional relationship with this adult.

Esperanza’s mother and older sister appear to be affectionate and reliable posi- tive supports for her. They care for Esperanza’s baby while she is at school. On days that Esperanza does not have family childcare, she does not attend school. This accumulation of absences (an average of one  day a week) impacted Esperanza’s academic progress and was brought to the attention of the state child welfare agency as potential educational neglect. The engagement with child welfare also revealed that Esperanza had been impregnated at 15 by a 25-year-old man, which raised concerns. Esperanza assured social workers that she was not raped and was “in a relationship” with her child’s father. Despite her description of her child’s father as an attentive partner and active father to their child, he was arrested on multiple counts, including statutory rape for his involvement with Esperanza. Esperanza interpreted her boyfriend’s arrest and her social service involvement as unjust, and she experienced the state and judicial system as preventing her and her infant from receiving his emotional and economic support.

Upon migrating back and forth from Puerto Rico to the mainland United States, Esperanza had to learn to navigate two distinct cultures and languages. She also had to adapt to two separate family structures and dynamics of interaction. She showed signs of anxiety and depression and made statements about how she struggled being a teen mom while desiring to engage in typical adolescent activities, and the ramifi- cations of those tensions in a social context. For example, the social worker noted that Esperanza lamented about missing the junior prom and other social activities

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due to her caregiver responsibilities. Despite these difficulties, Esperanza stated that her baby is “mi cariño” (“her love”) and speaks about the child with much affection.

After Hurricane Maria, there was little evidence of support for the mental health impacts of this natural disaster on the many students migrating and integrating into mainland American schools. As Puerto Rican students increasingly enrolled in urban high schools, social workers scrambled to address these challenges and meet the needs and demands of newly arrived families that had been deeply impacted by the hurricane. In the scope of this distressing event, the school social worker and her MSW intern worked with Esperanza.

During the initial phase of working with the client, the workers administered psychological first aid, a set of support actions aimed at reducing post-traumatic stress related to natural disasters often offered in schools. Psychological first aid centers around the core actions of contact and engagement, safety and comfort, stabilization, information gathering, practical assistance, connection to social sup- ports, information on those supports, and linkages to collaborative services (Ruzek, Brymer, Jacobs, & Layne, 2017). Psychological first aid was offered both individu- ally and in group settings for Esperanza and her classmates, as the enrollment of displaced Puerto Ricans increased in their high school. The efforts of the social workers were to help Esperanza feel assured, connected, and supported in her cur- rent environment. Within a few weeks of working with Esperanza, it was clear that the experience and aftermath of the hurricane had severely impacted her. She had reported nightmares and trouble sleeping, and appeared to have decreased frustra- tion tolerance despite remaining polite to those in authority.

Theoretical Integration

Systems theory was a useful tool both in supporting the social workers with their treatment of Esperanza and in understanding the client’s response. By focusing on the notion that there is reciprocity in the relationships between individuals, groups, organizations, and communities, as well as the larger sociocultural and political environment, the social workers were not only better equipped to identify factors that hinder Esperanza but potential solutions, as well.

Esperanza received treatment from the school social worker (a bilingual Latina of Puerto Rican descent) and a social work intern (a bilingual Latina of Mexican descent). The clinician (and the clinician in training) approached their work with Esperanza from a stance of cultural humility, in which they were able to incorporate Latino cultural values such as personalismo, which refers to the significance Latinos place on positive rapport with others (Mogro-Wilson, 2013; Mogro-Wilson, Rojas, & Haynes, 2016). More than merely engaging with Esperanza in her native lan- guage, Spanish, personalismo involved asking Esperanza about her extended family members and engaging in informal exchanges to establish rapport.

It is important to differentiate for emerging social workers the differences between an informal exchange (which facilitates trust) and unprofessionalism

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(which diminishes trust). These informal exchanges included brief, playful debates over whose brand of Puerto Rican coffee is better and who is the favorite participant in La Voz (the Spanish-language version of the singing competition, The Voice). Establishing rapport with Esperanza in this way was vital during the engagement process. Rapport is the entry point to the client–worker relationship. More than comfort, receptiveness, and respect, rapport is a commitment to display warmth, interest, and caring in a way that encourages the client’s trust and confidence. Choosing a highly viewed talent competition as an initial conversational prompt proved to be an excellent choice, as it provided at least 20 weeks of continuous nar- rative from which to build a relationship (“Can you believe Tania was eliminated in week three? Did you text your vote for the semi-finals of La Voz?”). Moreover, selection of a show that was popular in Puerto Rico allowed for cultural affirmation, a sense of familiarity, ease of communication in the native language, and joy. Personalismo sustained and supported the therapeutic alliance, as it built trust, con- fidence, and respect while diminishing Esperanza’s worry about potential “engaño” (trickery).

Systems theory allowed the workers to expand their view of trauma as being a component of the environment for this youth. With this in mind, they continued their work with Esperanza using ACEs (Adverse Childhood Experiences) screening to assess how many types of maltreatment a client has experienced prior to the age of 18. This tool covers ten types of trauma within three categories: abuse, neglect, and household dysfunction.

Trauma-informed approaches recognize that there have been potential traumatic experiences in the lives of our clients. Social workers must explain to clients why they are asking sensitive questions rather than just ask them as a matter of protocol. These explanations demonstrate mutual respect and cultural humility. Recognizing that sensitive questions may be misunderstood as “engaño” (trickery), in this case, the social workers began by informing Esperanza that they needed to ask her some “preguntas intimas” (intimate questions) to support her in maintaining healthy per- sonal and academic relationships. They explained this was part of a screening tool to help people and apologized in advance if they made her feel uneasy. By offering this apology, the social workers were rebuilding trust with Esperanza. The onus is on the social workers to create, sustain, and/or repair the client–worker relationship, and systems theory taught these social workers that they inherited Esperanza’s dis- trust from previous incidents experienced as betrayals from institutional actors. These incidents include the involvement of child welfare services because of teach- ers disclosing “her private life,” as well as a slow relief response from the U.S. gov- ernment to assist Puerto Rico during and after the hurricane.

Systems theory helped the social workers see how betrayals such as the incar- ceration of Esperanza’s boyfriend also took place at a macro level. In Esperanza’s eyes, her relationship was legitimate, and this perspective was further confirmed for her because she had the consent of her parents. There may thus be traumatic stress from the hurricane experience coupled with the type of trauma that arises for groups of people who have experienced disparate treatment (Matheson, Foster, Bombay, McQuaid, & Anisman, 2019). The apology for asking about intimate matters is one

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of several ways the social workers sought to affirm Esperanza’s legitimate feelings of distrust.

Esperanza agreed to answer the ACEs questions. The MSW intern facilitated the questionnaire in a conversational tone, rather than administering the tool as a formal survey. The intern, speaking in Spanish, framed the questions in ways that sup- ported the therapeutic alliance and empowered Esperanza to respond candidly. (“Esperanza, we know these questions may make you feel uneasy and we are sorry for that. We need to know if a parent or other adult in the household often or very often … cursed at you or insulted you? Think about it. Take your time.”). Here, the MSW intern sandwiches the ACEs question between a statement that affirms the client’s feelings and reassurance that she does not have to rush through this process.

Esperanza’s overall score was two out of a possible ten. She scored yes to ques- tions #4 (feeling unloved or unimportant from her family) and #6 (parents ever separated or divorced). Esperanza was hesitant about answering question #3 (did an adult or person at least 5 years older than you ever touch or fondle you or have you touch their body in a sexual way?). She struggled to understand the age of consent law in Connecticut (as well as throughout all of the United States and Puerto Rico). It was incomprehensible to her that the father of her daughter was held legally responsible for a sexual relationship with her as a minor, resulting in 3 months in jail and a court order to pay child support after his release. Esperanza struggled with the conflictual way the court ordered her boyfriend to pay child support, when prior to his arrest he had been both emotionally and economically supportive of her and the child.

Her family described Esperanza and her co-parent as a loving couple with joint plans for the future. Through the conversational facilitation tool of ACEs, the social work intern learned from Esperanza that she knew many couples with a 10-year age gap, and early-age pregnancy was an intergenerational pattern in her family. Despite this, it was critical for the social workers to be mindful of the imbalance of power between Esperanza and her child’s father. Power imbalance is what allows an adult to take advantage of an underage person in ways that meet the American Psychological Association’s definition of sexual abuse. The MSW intern made a note in the questionnaire about the circumstances of Esperanza’s “relationship” and the client’s belief that she is not a victim of abuse.

While her ACEs score is relatively low, systems theory helped the workers explore Esperanza’s perspective and understand that she has experienced more trauma than her score displays. Additional traumas not represented in this assess- ment include Esperanza’s displacement from her family/country, her early preg- nancy, surviving as a teen parent, her status as a sexual abuse victim (related to a consensual sexual relationship with 25-year-old adult male who was viewed as a sexual predator), DCF involvement (educational neglect), and her mental health diagnosis (anxiety, depression, PTSD). For example, Esperanza experienced trauma in the loss of the person she identified as her boyfriend, whose incarceration was directly connected to her disclosure to someone that he was the father, as well as incidents in her macro environment related to surviving a natural disaster and vari- ous forms of cultural assault from government officials.

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As a result of the ACEs assessment, not only have the workers continued their work with Esperanza through a trauma-informed lens, but they also made the realization that trauma was a component of the environment for Esperanza. While Esperanza’s ACEs score was two, the mutually influencing factors in the environ- ment are trauma-infused, providing a comprehensive understanding of her lived experience. From a macro lens, understanding Puerto Rico’s commonwealth status as neither a U.S. state nor an independent country sheds light on the territorial limbo that migrants experience in their “host” country. Mental health professionals have highlighted the colonization of Puerto Rican as a factor to consider when treating Puerto Rican clients (Teichner, Cadden, & Berry, 1981).

As mentioned, ecomaps are visual representations of all the systems at play in an individual’s life, while genograms show the relationships between a client and their family members. The MSW intern engaged Esperanza to collaborate on creating ecomaps and genograms to support an understanding of the interconnected systems in her life. Before inviting the client to create visual representations of her own life, the intern first focused on developing trust by collaborating on an ecomap based on a fictional character. They collectively chose the movie Real Women Have Curves, a 2002 comedy about a Latina teen and her dynamic with school and family. The intern’s engagement strategy included the small but significant detail of preselecting the menu of movies and ensuring that all the films were comedic and based on Latino culture. Utilizing a Latinx-focused movie both affirmed the client’s heritage and was a trauma-informed strategy to minimize any potential triggering that might occur from watching a drama that centrally focused on adverse childhood condi- tions. Choosing the movie together also temporarily suspended the worker–client hierarchy. The shared decision making of the therapeutic intervention allowed Esperanza and the intern to work together to understand the main character and her relationship to the family and systems around her. In that exercise, Esperanza was able to see how one is not only influenced by people and systems, but can also take actions to be the influencer.

Ecomaps and genograms visually demonstrate the relationships between sys- tems, people, and the client, which are represented by the intensity and direction of lines drawn on the visual aids. In drawing the relational connections in the geno- gram of the main character, Esperanza communicated her understanding of systems theory as the interrelatedness of a person and their environment. In drawing these lines for herself, Esperanza expressed a significant amount about her life without needing to say much verbally. The intern learned that Esperanza experienced high school to be a source of stress. (The workers had differing views on Esperanza’s school attendance.) While her teachers worried that Esperanza would be missing significant instructional time, Esperanza viewed herself as a responsible mother who cared for her child when family members were not able to step in. The repre- sentations serve as prompts for the intern to use at follow-up meetings.

The social work intern was forthcoming in asking Esperanza if they could talk about her family as a way for her to better understand herself. Esperanza agreed. The intern then utilized a strengths perspective as she tapped into Esperanza’s pas- sion for art to make the activity more engaging and student focused. Social work

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interns are often limited in how they can assist a client. However, this scenario proved to be a win-win. While the school social worker was unable to dedicate time to such detailed visual aids due to her large client case load, the intern was available. The intern happened to be learning about these tools in her Master of Social Work program and appreciated the opportunity to further develop her skills. Most impor- tantly, Esperanza benefited from the creative activity.

While the under-resourced high school had limited supplies, the intern was able to take advantage of a recent donation of art supplies such as poster board and vivid paint colors to make the activity creative and fun. As Esperanza drew thick solid lines to represent strong relationships and faint lines to represent weaker bonds, the intern was able to ask questions such as, “How would you describe your neighbor- hood?” and “In what ways do you rely on professionals to help you and in what ways do you rely on family?” Her answers provided further evidence of Esperanza’s reliable family network, which supports her with childcare and ensures that she and her child are cared for in their home.

Esperanza’s healthy baby, her determination to be a good mother, and her hard- working family were all strengths identified in this activity. Esperanza noted that her language and culture were strengths. She discovered that not being fluent in English was a present challenge, as was being a teen single parent and having limited eco- nomic resources. However, she reclaimed her power in being able to engage in this analysis of herself rather than being talked at by professionals. Over time, Esperanza was able to identify her situation as temporary. She was able to reframe her situation and articulate how she can work on developing into a bilingual and bicultural com- municator and identify some life goals by using the supports provided by her family and institutions. The reclaiming of her personal agency is an example of a powerful outcome of working with a culturally attuned social worker and MSW intern.

The intern took this art ecomap project one step further by asking Esperanza to do a separate ecomap for her life in Puerto Rico. It was in that activity that Esperanza illustrated the significant differences with respect to time, method of communica- tion, and cultural expectations in social service care on the island versus a mainland urban city. This visual representation served as a tool to help explain Esperanza’s point of view to new service providers and those who were still developing their cultural awareness (an outcome discussed further in the cultural considerations sec- tion of this chapter).

The social workers then focused on securing supports for the two parental figures in the family: 16-year-old Esperanza and 34-year-old Ms. Colon. These supports were in the form of mutual aid groups. The social workers acknowledged to Esperanza the reality that while she has the desires and responsibilities of a teenager in high school, these dynamics are complicated by her role as a mother. Therefore, she needed a space that was specifically designed to aid her in these simultaneous, and at times conflicting, roles.

Esperanza benefited from a Spanish-language teen mother’s support group embedded in her high school. Receiving mutual peer support from students who shared her situation created the conditions for Esperanza to seek out more resources as friends vetted them. She was able to see how her peers benefited from state-

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subsidized childcare and parenting classes and began to let go of the initial reserva- tions she had about receiving such aid.

The workers, as well as the members of the mutual aid group, encouraged Esperanza to have regular communication with her father to strengthen his role, which had been weakened after the divorce and displacement. While Esperanza’s future with her child’s father is unclear due to his incarceration and the power imbal- ance between them, she recognizes that healthy bonds with her parents, siblings, and extended family will provide her with support and perspective on how to pro- ceed with healthy relationships. She has committed to supporting her child by main- taining a positive relationship with the child’s father.

During a debrief session with Esperanza, the social worker explained statutory rape and age of consent. Esperanza had difficulties understanding why the father of her baby was seen “like a criminal” when, according to Esperanza, he was emotion- ally and economically supportive towards the baby. She shared that his incarcera- tion caused additional emotional trauma and economic family stress. Esperanza shared that she willingly chose to have sex with her boyfriend out of love and emphasized that she never felt forced. In trying to advocate for herself and the father of the baby, Esperanza inquired if the court would allow her to make a statement in defense of her boyfriend. She expressed that she would tell the judge she acted freely and voluntarily and was knowledgeable about what she was doing. The social workers had to reframe Esperanza’s relationship for her. While they acknowledged that she consented to the relationship, they explained to her that due to her age there is a power differential between her and her child’s father. This was one of the more challenging cognitive reframes that became part of Esperanza’s longer-term treat- ment plan.

Ms. Colon was offered the opportunity to participate in Madres de Madres (Mothers of Mothers), a support group for grandmothers under 40  years of age. Unfortunately, due to Ms. Colon’s need to manage two jobs and take care of her family (including serving as a childcare provider for her granddaughter), she was unable to make herself available to attend the group. Ms. Colon also clarified for the social workers that even if she did have the time, she would not attend Madres de Madres because “de esas cosas no se hablan afuera de la casa” (“These types of things are not spoken of outside the home”). The intern continued to forward infor- mation to Ms. Colon and intermittently reminded her that since it was an open group, she was welcome to join at any time.

The social worker recommended a state-subsidized childcare agency for Esperanza’s daughter and successfully secured a spot for the child. Utilizing the childcare agency would have provided relief to the family by minimizing Esperanza’s school absences, freeing up some time for Ms. Colon to consider attending Madres de Madres or engage in self-care, and allowing Esperanza’s baby to engage with other children and participate in developmentally appropriate play that is not always available in contexts of overworked caregivers. Unfortunately, Esperanza refused the childcare resource, claiming “nadie cuide lo de uno mejor que uno” (“No one care for your own, like yourself”). This statement, which points to Esperanza’s sus- picions about anyone outside her nuclear family caring for her child, is related to the

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theme of fear of experiencing trickery from institutions. Further exacerbating her distrust in systems, the local news had recently reported the arrest of several staff members at a subsidized daycare center for their physical abuse of toddlers.

Rather than contradict Esperanza’s beliefs, the social workers deferred to Esperanza, acknowledging her agency and right to self-determination, which fur- ther empowered Esperanza and fortified the therapeutic alliance between them. The social workers then reframed the childcare conflict for Esperanza. Specifically, they supported her in seeing that chronic absenteeism is strongly linked with low aca- demic achievement and school non-completion. Therefore, activating the childcare resource would allow Esperanza to focus on school, which in turn would create employment opportunities that directly impact her own and her daughter’s future. While this did not work immediately, over time the social workers were able to help Esperanza view childcare support as a resource for her to be able to better provide for her child for the long term.

Once Esperanza established months of consistent and engaged participation in the young mother’s support group, the social worker explored her interest in cogni- tive behavioral therapy. Esperanza agreed. The social worker met with Esperanza in a private, quiet room and guided her with a series of questions to tap into her emo- tions. Upon Esperanza articulating a fearful thought, the social worker gently inquired about the thought with questions asked in a gentle tone, such as, “I hear you. Why do you think that is true?” This gentle questioning of Esperanza’s fearful thoughts eventually helped her develop alternative narratives. These changes in thought then led to more positive emotions, which can support new and different behaviors that ultimately support change.

The technique of gently challenging fearful thoughts allowed new thought pat- terns to emerge. Initiating the CBT approach via Cognitive Behavioral Intervention for Trauma in Schools individual sessions, the social worker helped Esperanza address underlying symptoms of stress and trauma. Through this process, Esperanza was able to understand that her underlying thoughts and feelings are interrelated and were influencing her actions and behaviors.

While the social work intern was not able to lead the CBT sessions, she was able to learn in other ways. For example, the intern completed the online Cognitive Behavioral Intervention for Trauma in Schools training and discussed these themes at length in supervision. Furthermore, the intern utilized some individual cognitive- behavioral approaches with Esperanza, including but not limited to psycho- education discussions and relaxation and mindfulness strategies that supported the cognitive restructuring work led by the social worker. The tasks of the social work intern and her contributions to this case are highlighted to illustrate ways social work supervisors can carve out meaningful assignments for interns who might have limited ability to lead a case, and provide social work students with ideas of how they might initiate such roles in supervision.

M. P. De Jesús et al.

175

Cultural Considerations

Cultural considerations must always be taken into account; even in situations of shared heritage, social, cultural, and economic contexts may still differ. In this case, the social workers of Latinx descent had also undergone their own migration jour- neys, intensifying their mindfulness of the client’s sudden transition from a relaxed island community to the hustle and bustle of urbanity. Other service providers might misunderstand this mismatch of pace as the client’s disinterest in receiving services. However, the social workers knew from both professional and personal experience that Esperanza’s follow-up delays were related to her being unaccustomed to urgency and immediate agency responses. As such, they affirmed Esperanza’s lived experience while orienting her to new communication expectations from Hartford’s school, child welfare, and criminal justice systems. To prompt their client to secure resources, the social workers often used a gentle tone to remind Esperanza, “Things are done differently here.”

While many social workers may take on the task of informing their clients that there are rules and regulations they must follow, culturally affirming social workers take this task to the next level and actively offer themselves as a human connection to what may feel, at times, like faceless bureaucracy. In this case, the workers used the metaphor of a bridge to describe how they are links between Esperanza and the institutions with which she must interface. Positioning themselves as “the bridge” was another active attempt to (re)build trust. Although the distrust they experienced was inherited, as opposed to earned, the social workers knew it was their responsi- bility to earn their client’s confidence. In addition to serving as liaisons and coaches, they took on a “clinician-activist approach” (Walz & Groze, 1991), recognizing that Esperanza was not always able to articulate cross-cultural misunderstandings and they were needed to advocate on her behalf.

It bears repeating that sharing a cultural background with one’s clients does not eliminate cross-cultural conflict. For instance, these social workers understood that Esperanza’s family endorsed her romantic relationship with her child’s father. The 10-year age difference did not render it illegitimate, from their perspectives, as they believed Esperanza was old enough to consent to the relationship as a teenager. This dynamic was conflictual for the social workers, who understood that Esperanza and her family consented to the relationship but also understood this relationship to constitute sexual abuse. The genogram helped the workers identify an intergenera- tional pattern of sexual abuse; Esperanza, her mother, and her aunts were all under- age mothers with children fathered by men much older than them. While the social workers have not yet established a strong enough foundation with the family to explore this sensitive topic, they have identified as potential areas to expand upon in family therapy the multi-faceted dimensions of abuse and the difficult reality that family approval does not preclude abuse.

Currently, there is a debate about distinguishing between PTSD and complex stress disorder (the latter not yet in the DSM 5) in order to acknowledge the perva- sive negative outcomes (social determinants) of long-term exposure to IPV, neglect,

12 Systems Theory: The Case of Esperanza

176

childhood abuse, and other traumas that do not fully meet PTSD criteria. It is worth noting that Esperanza and other immigrants/migrants might fall under this category as a result of having faced natural and human-caused catastrophes in Puerto Rico, as well as “host” country discrimination, cultural violence, etc.

Systems theory helps social workers tease out the diversity of the Latinx experi- ence. For example, the intern (who was of Mexican descent) viewed Esperanza’s U.S. citizenship as an asset, given that she herself had undergone significant legal and economic hurdles to secure citizenship status. Esperanza, on the other hand, was unable to identify her ability to migrate as a privilege. While this may be related, at least in part, to Esperanza’s youth, the affordances of systems theory to allow concerned parties to delve deeper and identify that while Esperanza’s move from the island is defined legally as migration (traveling within the same country), she has experienced it culturally, socially, and linguistically as immigration (traveling from one country to another).

Discussion Questions

These questions challenge the reader to think critically about the theory and integra- tion of the theory in practice.

1. What are some of the assumptions of systems theory? How are these assump- tions aligned with the work of social workers?

2. How might systems theory serve as a tool to help social workers create strategies to build trust with a client who explicitly shares their legitimate disappointment with how institutions have responded to their prior needs?

3. Social workers might work under policies and political climates that perpetuate injustice. What conflicts might this raise for you? How will you support yourself should this occur?

4. In this example, both the client and the workers were Latinx and there were cul- tural differences to consider. How might systems theory support social workers to prepare to engage in cultural-informed work with clients of different backgrounds?

5. Systems theory emphasizes the interconnectedness of systems. Name some examples of strategies and tactics you would use to collaborate with social work- ers from other institutions who are attempting to aid the same client.

References

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Altshuler, S. J. (1999). Constructing genograms with children in care: Implications for casework practice. Child Welfare League of America, LXXVIII(6), 777–790.

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Cohen, J.  A., Mannarino, A.  P., Berliner, L., & Deblinger, E. (2000). Trauma-focused cognitive behavioral therapy for children and adolescents: An empirical update. Journal of Interpersonal Violence, 15(11), 1202–1223. https://doi.org/10.1177/088626000015011007.

Gitterman, A. (2004). The mutual aid model. In C. D. Garvin, L. M. Gutierrez, & M. J. Galinsky (Eds.), Handbook of social work with groups (pp. 93–110). New York: Guilford Press.

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Hutchings, A., & Taylor, I. (2007). Defining the profession? Exploring an international definition of social work in the China context. International Journal of Social Welfare, 16(4), 382–390.

Leighninger, R. D. (1977). Systems theory & social work: A reexamination. Journal of Education for Social Work, 13(3), 44–49.

Matheson, K., Foster, M.  D., Bombay, A., McQuaid, R.  J., & Anisman, H. (2019). Traumatic experiences, perceived discrimination, and psychological distress among members of vari- ous socially marginalized groups. Frontiers in Psychology, 10, 416. https://doi.org/10.3389/ fpsyg.2019.00416.

Mogro-Wilson, C. (2013). Parenting in Puerto Rican families. Families in Society, 94(4), 235–241. Mogro-Wilson, C., Rojas, R., & Haynes, J. (2016). A cultural understanding of the parenting prac-

tices of Puerto Rican fathers. Social Work Research, 40, 237–248. Payne, M. (2002). The politics of systems theory within social work. Journal of Social Work, 2(3),

269–292. https://doi.org/10.1177/146801730200200302. Pope, N. D., & Lee, J. (2015). A picture is worth a thousand words. Exploring the use of genograms in social

work practice. The New Social Worker. Retrieved from www.socialworker.com/feature-articles/ practice/a-picture-is-worth-a-thousand-words-genograms-social-work-practice/.

Ruzek, J. I., Brymer, M. J., Jacobs, A. K., & Layne, C. M. (2017). Psychological first aid. Journal of Mental Health Counseling, 29, 17–49.

Teichner, V., Cadden, J.  J., & Berry, G.  W. (1981). The Puerto Rican patient: Some historical, cultural and psychological aspects. Journal of the American Academy of Psychoanalysis, 9, 277–290.

Walz, T., & Groze, V. (1991). The mission of social work revisited: An agenda for the 1990s. Social Work, 36(6), 500–504.

12 Systems Theory: The Case of Esperanza

O R I G I N A L P A P E R

Integrating Social Work Perspectives and Models with Concepts, Methods and Skills with Other Professions’ Specialized Approaches

Alex Gitterman • Nina Rovinelli Heller

Published online: 8 April 2011

� Springer Science+Business Media, LLC 2011

Abstract In this article, the authors encourage social

work practitioners to identify with and adopt distinctive

social work perspectives and practice models rather than

solely embrace models or approaches developed by and for

other professions. We do so because these perspectives are

most responsive to our professions’ mission of social jus-

tice and social purpose of paying equal attention to people

and their environments. For heuristic purposes, we present

and illustrate the ecological perspective and life modeled

approach. Since no social work model or approach can take

into account every type of life stressor, event and condi-

tion, we demonstrate how we can borrow and integrate

specialized concepts, methods and techniques from other

profession’s approaches. The authors identify five charac-

teristics which borrowed content should meet in order to

integrate well with social work models. Accordingly,

concepts, methods and skills from a few approaches have

particular relevance for social work direct practice: Cog-

nitive-Behavioral Therapy; Motivational Interviewing;

Narrative Therapy and Solution-Focused Practice. More-

over, the authors present and illustrate the process of bor-

rowing and integrating concepts, methods and skills from

other professions to deepen social work practice.

Keywords Ecological perspective � Life model � Cognitive behavioral � Motivational interviewing � Narrative therapy � Solution-focused

Social work practitioners work in numerous practice set-

tings, including primary social work and host settings.

Increasingly, social workers in both settings offer services to

voluntary as well as mandated clients whose presenting

problems are influenced by an array of personal, interper-

sonal and pernicious environmental demands and influ-

ences. Decreasingly do social workers, particularly those in

agency based practice, provide services to clients who are

voluntarily seeking services. In these, particularly interdis-

ciplinary settings, professional roles and functions are

sometimes blurred, and social workers are faced with the

opportunities and challenges inherent in having a wide

variety of approaches and models, and methods from which

to choose appropriate interventions for and with their clients.

In this article, the authors encourage social work practitio-

ners to identify with and adopt distinctive social work per-

spectives and practice models or approaches rather than

solely embrace models or approaches developed by and for

other professions. We make this appeal primarily because

we believe that social work theoretical perspectives and

models and approaches are most responsive to the profes-

sion’s mission of social justice and social purpose of paying

equal attention to people and their environments.

The social work practitioner has essentially two over-

arching theoretical perspectives to guide their practice,

ecological (Gitterman 2008) and eco-systems (Meyer 1983).

Four major distinctive social work models or approaches

developed by social workers for the practice of social work

conceptualize and illustrate the breadth of methods and

skills grounded in the profession’s ethics and value contexts.

The major social work models and approaches developed

specifically for social work include: (1) The Life Model of

Social Work Practice (Gitterman and Germain 2008); (2)

Direct social work practice: Theory and skills (Hepworth

et al. 2009); (3) The Skills of Helping Individual, Families,

A. Gitterman � N. R. Heller (&) University of Connecticut School of Social Work,

1798 Asylum Avenue, West Hartford, CT 06117, USA

e-mail: [email protected]

A. Gitterman

e-mail: [email protected]

123

Clin Soc Work J (2011) 39:204–211

DOI 10.1007/s10615-011-0340-7

Groups and Communities (Shulman 2009); check paren-

theses and Casework: A Psychosocial Therapy (Woods and

Hollis 2000). Since no social work model or approach can

take into account every type of life stressor, event and

condition, social, workers should borrow and integrate

specialized concepts, methods and techniques from other

profession’s approaches. Concepts, methods and skills from

a few approaches have particular relevance for social work

direct practice: Cognitive-Behavioral Therapy; Motiva-

tional Interviewing; Narrative Therapy and Solution-

Focused Practice. For heuristic value, we will discuss the

relevance for social work practice of a few concepts from the

ecological perspective and Life Model. This theoretical

perspective and practice model are simply selected because

of one of the author’s role in their development. We make no

claim of superiority of this perspective and model over the

others. Moreover, we will present and illustrate the process

of borrowing and integrating concepts, methods and skills

from other professions to deepen social work practice,

while, at the same time maintaining identification with

fundamental social work purpose.

Methods and skills ‘‘borrowed’’ from other profession’s

approaches hold the most utility for social work practice

when they share several characteristics. First, they are

compatible with the social work values of self-determination

and respect. Second, they are embedded in a client worker

relationship model, which promotes mutuality at all phases

of the helping process. Third, these skills and concepts are

consistent with strengths and resiliency perspectives.

Fourth, they are responsive to a wide range of sociocultural

influences and circumstances. Finally, they ‘‘deepen’’ and

extend fundamental social work methods and skills.

Ecological Perspective

Ecological theory, a schema of interrelated concepts, pro-

vides the basis for the ecological perspective and, thereby,

the social work practitioners a distinctive frame of reference

to organize, focus, and classify data for assessment and

interventions. Ecological theory with its emphasis on the

interdependence of organism and environment fits particu-

larly well with social work’s historic commitment to people

and their environments. From an ecological perspective

view, people (their biological, cognitive, emotional, and

social processes) and environments (their physical and social

components) can be only fully understood in the context of

the relationship between and among them. We present two

specific concepts from the ecological perspective: ecological

thinking and level of fit. In developing ecological thinking,

the social work clinician is asked to question cause and effect

linear thinking that pervades behavioral and medical

approaches to social work practice. The emphasis of

ecological thinking is much more on the consequences of

dysfunctional transactions and much less on behavioral

causality. For example, parents may have difficulty dealing

with an adolescent’s struggle for separation and autonomy.

Their exchanges become characterized by escalating argu-

ments and power struggles. The ecologically perspective

trained social worker sees neither the parents nor the ado-

lescent as ‘‘causing’’ the problem. Rather, the focus is on

assessing and intervening in the dysfunctional transactions

and their negative consequences. Ecological thinking views

the adolescent and the parents as being involved in reciprocal

exchanges rather than linear or unidirectional ones. The

adolescent may act in ways that lead to change in the parents’

actions, whereupon that change in the parents’ actions and

attitudes leads to change in the adolescent’s behaviors, which

in turn affects the parents’ behaviors—a continuous circle of

reciprocal influences over time. Moreover, forces outside of

the family (peer group, relatives and friends, employment,

housing and broader societal influences) influence their

respective actions. Ecological perspective thinking encour-

ages social workers to be curious about ‘‘What is going on?’’

rather than ‘‘Why is it going on?’’ and ‘‘How can the ‘what’

be changed?’’ rather than ‘‘the ‘who’ should be changed.’’

(Gitterman and Germain 2008, p. 54).

Level of person and environment fit refers to a person’s

perception of the ‘‘fit’’ between his/her physical, intellec-

tual, emotional, and motivational strengths and limitations

and environmental resources (family, social networks,

organizations, and physical space) to deal with a specific

life stressor(s) or challenge(s). Over the life course people

constantly strive to improve the level of fit with their

environments. When a person perceives the availability of

sufficient personal and environmental resources to deal

with a life issue, stressor or event, s/he experiences a

positive fit with the environment. The positive level of fit

supports and resources releases the person’s potential for

personal growth and sense of mastery However, when a

negative level of fit evolves between a person’s perceptions

of personal and environmental resources to deal with a life

stressor, s/he experience stress. How overwhelming and

disabling clients experience their daily life stress will lar-

gely depend upon the perceived level of fit between their

personal and environmental resources. The social work

clinician can help the client to improve the level of fit by:

1. Helping the client to develop more adaptive behaviors

(e.g., acquire new skills, change expectations, improve

motivation, mobilize personal resources, and/or

change attributions).

2. Influencing significant people in the environment (e.g.,

family member, member of peer group, employer,

organizational representative) to be more responsive to

the client’s needs.

Clin Soc Work J (2011) 39:204–211 205

123

3. Influencing the transactions between a client and her/

his environment (e.g., parent child, partner and partner,

child and teacher, client and organizational official).

While most psychological approaches limit their inter-

ventions to changing primarily the person; most social

work approaches focus on all three levels of interventions

to improve the level of fit. For this, if for no other reasons

we urge social work clinicians to stay true to their roots and

to the profession’s broad conception of social work func-

tion. Doesn’t this seem perfectly reasonable to you?

The ecological perspective provides a vision, a map, and a

guide for practice. For example, Mr. Jackson, 75-years old

suffered a brain bleed stroke, which led to significant vision

loss, cognitive disorientation, and balance problems. How

much stress he will experience upon discharge from the

hospital, transition into a rehabilitation center and discharge

home will depend on his perceptions of the level of fit

between his physical condition (stamina); motivation, out-

look on life, coping skills, meaning of the illness) and his

perceptions of his access to organizational resources (med-

ical specialists, physical therapists, nursing care); avail-

ability of social support networks (family, relatives, friends,

neighbors); flexible physical environment (wheel chair

accessibility of building and apartment); and financial

resources.

Figure 1 suggests the combined impact of a client’s

internal resources and limitations and environmental

resources and limitations (Gitterman and Germain 2008,

p. 115).

If Mr. Jackson has weak personal strengths (cognitive

impairment, chronic depression, lack of physical strength),

and limited environmental resources (minimal pension,

frail wife, no children, few friends) (A), he is at serious risk

for disorientation, deterioration, and disorganization. In

this case, the immediate attention of an active and directive

social worker with sufficient time to become a critical

resource for an extended period would be called for. In

contrast, if Mr. Jackson has strong personal strengths and

environmental resources (D), the social worker’s activity

might be limited to uncomplicated referrals, sug-gestions,

and emotional support. If Mr. Jackson has limited personal

resources and strong external resources (B), the social

worker is likely to search for essential organizational and

network resources to compensate for his bio-psycho-social

limitations. Finally, if Mr. Jackson has strong personal but

limited environmen-tal resources (C), the social worker

might help him to seek alternative resources or construct

new ones. By jointly assessing the person:environment

level of fit, social workers and clients can make informed

decisions about case focus and direction.

Life Model of Social of Practice

Since the ecological practice perspective provides a frame

of reference and a general map for case focus and direction,

a practice model or approach provides the concepts,

methods, and skills to implement the perspective. The Life

Model of social work practice is the primary model asso-

ciated with the ecological perspective. We will present two

conceptual schemas to demonstrate the model’s practice

utility—degree of client choice and life stressors.

Social work clients have differing amounts of choice in

accepting and/or rejecting social work services. Some peo-

ple seek social work services, others are offered social work

services and, yet others are imposed or mandated to receive

social work services. People who voluntarily seek social

work services are technically applicants until the practi-

tioner/agency agree to provide their services. Many appli-

cant/clients are ambivalent about seeking help. Thus, the

very act of seeking assistance is in itself stressful. People

usually request help when to do so is less stressful than the

status quo. The social worker explores the client’s life sit-

uation by asking such open-ended questions as ‘‘Please tell

me what brings you here?’’ When a client readily shares her/

his concerns, social workers have been taught to use minimal

encouragers to invite elaboration. Such minimal encourag-

ers serve ‘‘like the pats you give to a swing in motion to keep

it in motion’’ (Kadushin 1983 p. 160). To help the client

continue, the social worker provides supportive statements:

‘‘You were badly hurt,’’ ‘‘That was rough,’’ ‘‘Most parents

would worry about that.’’ Numerous other skills are utilized

(judicious waiting out of silence, verbalizing feelings,

paraphrasing, summarizing, sorting out ambivalence etc.) to

further explore and clarify client’s concerns.

Offering a social work service(s) poses more complex

practice challenges for most practitioners. The social

worker cannot begin with a general question like ‘‘Please

tell me what brings you here?’’ The responsibility is on the

social worker to offer a jargon free, clear, and concrete,

description of the agency and of potential social work

services. This is particularly critical in the work with

mandated clients who may have had difficult past experi-

ences with the ‘‘imposing of services’’ by a range of ‘‘well-

meaning’’ social service providers. Prospective clients who

Environmental Resources

Low High

Low

Personal Resources

High

(A) (B)

(C) (D)

Fig. 1 Person environment fit

206 Clin Soc Work J (2011) 39:204–211

123

are well informed about what is offered are less likely to

suspect a hidden agenda, such as a practitioner describing

one service while intending another. Social work practi-

tioners are often uncomfortable about intruding in people’s

lives and in directly identifying a potential life stressor,

event or condition (cancer, death of a loved one, rape, etc.)

The discomfort is readily conveyed by such behaviors as

focusing on forming a positive relationship with the intent

of easing gradually into the ‘‘serious’’ discussion later.

Social workers’ indirectness makes it more rather than less

difficult to share painful, perhaps taboo material. In offer-

ing a service, the social work clinician attempts to identify

the life stressor through the ‘‘eyes’ of the prospective client

rather than through the ‘‘words’’ of referring sources. As

Gitterman and Germain (2008, p. 167) noted,

…a teacher refers a child for being a ‘‘troublemaker’’. While the teacher calls the child troublesome, the

worker calls him troubled, and the child says he is

being picked on.

By verbalizing the prospective clients’ possible perceptions

of their life issues, the practitioner demonstrates empathic

understanding, thereby increasing the likelihood that the

offer of social work services will be accepted.

Increasingly, social workers serve involuntary clients.

Clients mandated to receive social work services pose

ethical and professional dilemmas that emerge from the

dual social work functions of helping and enforcing. Social

workers providing mandated services should expect that

clients would have intense feeling about organizations and

professionals who have enormous power and control over

their lives. Court-mandated services contain prescribed or

proscribed consequences if clients fail to comply with court

orders. Generally, the court’s legal authority is transferred

to the agency and the social worker. The clinician is

encouraged to have a direct discussion with the client about

the service(s) being offered, as well as, about the mandate

and its limits, i.e., what the clinician is legally mandated to

report to the court (e.g., commitment of a crime, use of

drugs, and absences from counseling). Since compliance

with court mandates is often a minimal condition for

achieving the client’s goal, such as having a child returned

home, or escaping the restrictions of probation or parole,

the importance of this conversation cannot be overem-

phasized. When social workers are intimidated or are

judgmental of mandated clients, they tend to commit one of

two common practice mistakes. Uncomfortable with the

authority vested in their professional role, they avoid

dealing with the question of legal, organizational, and

professional authority or they set out to build a relationship

before risking the client’s anger, Social workers fail to

recognize that the they lose credibility and respect by

avoiding difficult conversations. We encourage clinicians

to be direct and honest about the source of the mandate,

their dual role of helper and enforcer, the limits on confi-

dentiality, and the potential consequences of noncompli-

ance, and definitions of noncompliance. Professional

directness and honesty decreases mistrust, and resistance.

Over the life course, people encounter inter-related life

challenges and stressors. These daily and ongoing stressors

include: difficult life transitions and traumatic life events,

environmental pressures, and dysfunctional transactions in

collective life (family, group, and community). In life-

modeled practice, practitioners and clients assess and

intervene in single and multiple life stressors. Life transi-

tions include stressful developmental transitions, difficult

social transitions and traumatic life events. Life transitions

consist of developmental transitions (e.g., adolescence) and

social transitions (e.g., beginnings and endings of rela-

tionships and experiences, birth and death). Traumatic

events (death of a child, physical and sexual assault, fatal

diagnosis, natural and person initiated disasters) are often

unexpected, severe, and overwhelming. Transitioning from

a victim to a survivor status is a long and arduous journey.

Social work has developed method and skills to help

people who are experiencing current as well as unresolved

transitions. However, in this area, specialized knowledge,

methods and skills from other disciplines can significantly

deepen responsive and effective social work practice.

Environmental stressors often arise from the lack of

sufficient instrumental and affective resources from some

or most social and physical environments. Chronic poverty,

insufficient affordable housing, poor schools, inadequate

health care, and violence are the major forces responsible

for both prolonged and cumulative stress. To deal with

environmental stressors, clients turn to organizations and

social agencies for assistance. These social organizations

and agencies serve as critical buffers and cushion these

environmental stressors. However, when they are unavail-

able or unapproachable, they exacerbate the client’s stress

and become additional stressors rather than buffers. Simi-

larly, social networks (kin, friends, neighbors, work mates,

and acquaintances) provide critical goods and services and

emotional supports. They serve as essential buffers against

life stressors. However, they also can be destructive, non-

supportive, or missing altogether. Social work has a long

and proud history of helping clients to negotiate their social

and physical environments and, when appropriate to

directly intervene on behalf of clients.

While families, groups and communities also encounter

life transitional and environmental stressor, their prob-

lematic internal process creates additional interpersonal

stressors. Scapegoating, monopolizing, withdrawal, devel-

oping and existing factions are illustrative of problematic

processes, which simultaneously negatively affect indi-

viduals as well as the collectivity.

Clin Soc Work J (2011) 39:204–211 207

123

Life transitional, environmental, and interpersonal

stressors are interrelated, and, at the same time, distinct.

When one is unsuccessfully managed, additional stressors

often erupt in other areas of life (the ‘‘spread phenome-

non’’). Cumulatively, they can overwhelm individual and

collective coping capacities, and the individual, group,

family, or community/neighborhood may move toward

disorganization. The client and social worker practitioner

can also create problematic communication patterns.

Helping with dysfunctional relationship and communica-

tion patterns is a critical social work function.

If we think of the ecological perspective as providing a

wide range lens (with zoom and split screen capabilities) for

understanding the complexities of an individual’s life cir-

cumstances, transactions, history and life place (identifica-

tions with gender, culture, etc.), we can consider the life

model as well as ‘‘borrowed’’ concepts, methods, and skills

as a close up lens. This close up lens allows us, having

assessed the person and environment, to ‘‘zero in’’ on par-

ticular areas, which may require additional intervention.

Interventions derived from other professions are often

introduced into the work with social work clients when

problems in individual functioning and intrapersonal distress

are central to the client’s presenting problem. Client and

worker negotiate a mutual agreement regarding the focus of

attention and intervention after consideration of personal and

environmental resources, as diagrammed above.

Integrating Methods and Skills from Other Profession’s

Approaches

We consider the following methods and skills based their

on implicit valuing of self-determination and respect;

centrality of the worker/client relationship; use of client

strengths and resiliency; and applicability to a wide range

of sociocultural conditions. Finally, they ‘‘deepen’’ and

extend fundamental social work methods and skills.

Here, we consider several major concepts, methods and

skills from cognitive-behavioral therapy, motivational

interviewing; narrative therapy and solution focused prac-

tices. Each concept, method and skill was chosen on the

basis of its meeting the criteria identified above.

A major premise of cognitive behavioral therapy is that

many problems in an individual’s functioning and well

being are rooted in their dysfunctional thoughts and beliefs

(Beck 1976) and that if these thoughts can be changed,

changes in affect and behavior will follow. Judith Beck

(1995) highlights the following principles about cognitive

behavioral therapy: requires an ongoing formulation of

clients and their problems in cognitive terms; occurs in the

context of a sound therapeutic alliance which emphasizes

collaboration and active participation; is goal oriented and

problem focused; initially emphasizes the present; utilizes

psychoeducation, teaches the client to ‘‘be her own thera-

pist’’ and educates for relapse prevention; is time-limited;

has structured therapy sessions; and teaches clients to

identify and modify their dysfunctional thoughts (pp. 5–9).

These principles generally align well with social work

theory and practice, although the relevance for consider-

ations of sociocultural influences is not explicit. However,

more recent developments (Granvold 1994) and clinical

applications (Northcut and Heller 1998) of the concepts of

schemas and attributions in social work practice highlight

their utility for understanding sociocultural influences. A

schema is a ‘‘basic rule of life’’, a cognitive structure or

template, developed early in life and reinforced by others

and experiences in the world; an attribution is the meaning

one makes of why things occur. Each can be influenced by

gender, familial, social, religious, cultural and ethnic sys-

tems. For example, a woman who is a victim of domestic

violence and had developed a ‘‘core belief’’ that ‘‘I am a

bad person’’ based on earlier experiences, may see her

assault by her partner as proof of her ‘‘badness’’ and

believe that he ‘‘hit me because I am bad and deserved it,

the man is the head of the household, I should have obeyed

him’’. In this case, the development of the clients’ schema

might be influenced by her gender, early and confirming

experiences, religion and societal beliefs about ‘‘the place

of women’’. The social worker trying to extricate her client

from a dangerous situation may experience the client as

‘‘resistant’’ to help unless she understands the power of a

maladaptive schema and attribution. Once this is identified,

client and worker can begin to look for ‘‘disconfirming

evidence’’ about her core belief and modify those schemas,

with a clear focus on the presenting problem. An under-

standing of these contributing sociocultural influences

would be critical in helping the client.

Socratic questioning is a commonly used cognitive

technique for the examination of these dysfunctional cog-

nitions and schemas. For example, in the work with the

domestic violence survivor the worker would guide the

client through a process of reasoning by asking questions

like ‘‘what is the evidence for that belief’’ and ‘‘what other

explanations might there be?’’ in examining her beliefs

about the cause of the violence. In addition to clarifying the

distortions in thinking, the worker would be modeling the

behaviors of self monitoring and problems solving, through

a series of questions that the client can them use on her own.

Motivational interviewing (MI) is particularly useful in

the work with mandated clients and others for whom

change appears elusive Many of these clients are seen as

‘‘resistant’’ or suffering from ‘‘secondary gain’’, neither of

which endears them to their workers. Originally developed

from work with substance abusing clients, motivational

interviewing methods and skills reflect an approach which

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is highly consistent with social work practice and skills,

relying upon highly collaborative interventions, made

possible by the empathic connection between worker and

client. Underscoring methods and skills of motivational

interviewing is the belief that clients may choose to change

when they are ready to change (or not) and that reluctance

to change is normal rather than pathological. Rollnick and

Miller (1995) explain that the reluctance to change is

elicited from the client rather than imposed and ambiva-

lence about change must be explored. Because this is a

highly collaborative process, the techniques of motiva-

tional interviewing can be seen as series of transactional

processes in which the worker supports the client’s sense of

self-efficacy. Whereas cognitive therapy focuses primarily

on changing cognitions as a means of changing behavior,

motivational interviewing targets behavioral change as the

critical focus of intervention. Motivational interviewing is

highly compatible with the transtheoretical approach of

Prochaska and DiClemente, (1984), a stage theory of

motivational readiness. According to this formulation, cli-

ents move through precontemplation, contemplation,

preparation, action, maintenance and relapse. We would

tend to view these stages as fluid phases, in response to

natural variations in client readiness and in response to

external influences. For the social worker utilizing moti-

vational interviewing, an understanding of the client’s

readiness and ambivalence regarding change is critical in

determining interventions. For example, the adolescent girl

who is struggling with the purging behaviors of bulimia

nervosa, will present very differently depending upon

whether she is in the precontemplation or the action stage.

Attempts to ‘‘convince’’ the adolescent who is in the for-

mer stage to stop purging will likely increase the ‘‘resis-

tance’’ to do so, particularly if the purging behavior is

implicitly acceptable to her peer group. The client in the

action stage, however, will be able to begin to identify

those steps she might take toward change and predict some

of the ambivalence, which might block that change.

Clearly, motivational interviewing meets four of our five

criteria for compatibility with social work practice and

theory. Less is known about the model’s ability to respond

to a wide range of sociocultural factors and influences.

Narrative therapy and its associated techniques presume

that the client has a story to tell, that it is idiosyncratic and

that the client is the expert about her own life. This approach

is highly relevant for social work practice, particularly as it

pertains to responsive cross-cultural work. Narrative

approaches derive from postmodernism and social con-

structivism and emphasize the importance of meaning

making. The social work adage, ‘‘meet the client where the

client is’’ is particularly well suited to the narrative stance.

This model presupposes a high degree of client determina-

tion, worker respect for the client, mutuality, an

understanding of the strengths and resiliency that are present

(even if latent) in the client’s story, and is responsive to the

differences in client experience and expression as a result of

sociocultural differences. Freeman and Couchonnal (2006)

suggest that narrative strategies help clients define their

challenges through their narrative; increase their awareness

of relationships of power and domination; externalize their

challenges and issues; and recount personal stories of com-

petence and strength. Additionally, through their collabora-

tion, the worker helps the client to co-construct an alternative

narrative. Consider the case of Sally who had been sexually

abused by her 3 brothers and a cousin throughout her

childhood. Sally saw herself as ‘‘damaged goods’’ and her

‘‘story’’ revolved around herself as a ‘‘compliant’’ victim.

Sally appeared stuck in her narrative and could not even

imagine an ending or an alternative to her story. The worker

thought that something might be missing from the client’s

narrative, which kept her from moving forward and both

agreed that they seemed stuck. In conjoint sessions with the

client and her mother, it was revealed that the family had a

long history of sibling incest. As the client incorporated her

understanding of this ‘‘legacy’’ she was able to re-author her

story and she no longer felt that the abuse was something she

had ‘‘brought on herself’’. While the client continued to

struggle with many issues related to her history of abuse, she

no longer felt as powerless and alone.

Solution focused work shares with narrative approaches

constructivist theoretical roots along with a belief that

people hold the answers to the problems with which they

present. Though compatible with Rooney’s (1992) concept

of the importance of building motivational congruence

with mandated clients, solution focused work does not do

so in order to increase compliance, but to recognize that

people make their own choices (De Jong and Berg 2001).

This model and associated techniques shares with the

previous three models compatibility with social work val-

ues, worker-client mutuality, an emphasis on strengths and

resiliency and the extension of foundational social work

skills. Of the four models we consider, solution focused

work is the most compatible with cross-cultural work, both

because of its methods and because it has been ‘‘tested’’

with so many different cultural groups. Solution focused

work assumes the importance of context in understanding

behavior, a focus on behavior and cognition rather than on

feelings, and future and solution foci rather than upon the

past and problems (Corcoran 2000), all of which are con-

sistent with the needs and norms of many ethnic minority

clients. Lee (2003) argues further that solution focused

work specifically makes use of cultural strengths, through

the rejection of a pathological model, and through aware-

ness and utilization of cultural strengths and resources, and

through the use of the clients’ cultural worldviews. With its

focus upon solutions rather than problems, ethnic minority

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clients may avoid the stigma associated with seeking social

work services.

Several specific strategies are central to solution focused

work all in the form of questions posed to the client about

potential solutions: the miracle question, exception ques-

tions, outcome questions, coping questions, scaling ques-

tions and relationship questions (Berg and De Jong 1996).

Typically, the client will be asked to consider times when

the ‘‘problem’’ was not present or was managed more eas-

ily; and to imagine what life would be like without the

problem. This latter question is usually presented as ‘‘If you

were to go to sleep and a miracle occurred overnight and in

the morning, the problem had gone away, how you would

know it. What would be different?’’ This question helps the

client to identify behaviors, which would be indicative of a

good outcome. Coping questions convey to the client the

worker’s acknowledgement of how well they are doing in

the face of adversity. This helps to strengthen the client’s

own sense of self-efficacy. For example, a young single

mother sought services from a local clinic because she was

‘‘barely making it’’. Her 12-year-old son was struggling

with the complications of juvenile diabetes and had frequent

medical crises. She also had two younger children at home

and struggled with her sense of competence as a mother. In

addition to the concrete services and referrals that the social

worker would provide, she utilized solution-focused ques-

tions to better understand the client’s perception of her

problem. In response to the ‘‘miracle question’’, the client

said that she would wake up in the morning and not be

preoccupied with her son’s health status. This allowed her

to focus on solutions, not problems. Exceptions questions

allowed her to acknowledge the many times she had

effectively managed her son’s crises and her life without her

current perception of ‘‘the problem’’. Scaling questions

helped her evaluate her situation and progress, by anchoring

her experiences from ‘‘most awful’’ to ‘‘most desirable’’.

Clearly, her son’s diabetic condition was not going to ‘‘go

away’’, but her focus on what was most troublesome for her,

her sense of efficacy as a mother attempting to cope with it,

was an important focus for the work. For her and many

clients, the uses of these techniques also serve to externalize

the problem, making it feel more approachable and less

entrenched.

In each of these case vignettes, the social workers relied

on their understanding of complex individual and envi-

ronmental influences in their assessments and mutual goal

setting. This social work perspective provided the frame-

work for identifying intervention strategies which targeted

specific problem areas. This allowed for the integration of

these techniques within a decidedly social work approach,

rather than a wholesale substitution for a ‘‘person only’’

focus.

Conclusion

Our profession has a long and proud tradition of under-

standing the complexities of people and their environ-

ments, offering services and doing so with a commitment

to the social justice issues that often compound private

problems. From the beginning of the twentieth century,

when the development of social work theory was primarily

influenced by the Settlement House Movement and Charity

Organization Societies. From the Charity Organization

Societies, psychological theory dominated almost exclu-

sively by Freud and the earliest behaviorists, our collective

knowledge base has burgeoned. These advances have been

unprecedented, welcomed, sometimes contradictory, and

pose both opportunities and challenges for social workers.

How do we maintain that which is fundamental to our

mission as social workers, while making decisions about

how to integrate ever evolving knowledge and methods—

whether it is the understanding of how relationships and

attachment processes influence brain structures and plas-

ticity or the complex processes involved in a person’s

desire and ability to change? Early on, we teach our stu-

dents about the importance of understanding the ‘‘level of

fit’’ between an individual and his environment. We pro-

pose that our borrowing of concepts, methods and skills for

social work practice be guided by this same concept of

level of fit. For example, to what degree does a particular

intervention reflect the underlying values, perspectives and

knowledge of the social work profession? How does a

particular theoretical concept further our understanding of

the complexities of our clients’ identities and lives? These

considerations should be our litmus test.

Today, social workers form the largest group of mental

health providers in the country and are often the only

providers in medically underserved areas (NASW 2005).

With the advent of licensure and insurance reimbursement

as well as the proliferation of social work doctoral pro-

grams, we are well positioned to be leaders in both the

provision of services and the development of integrated

intervention models. The very basis of our own social work

theoretical models grew out of the recognition of the

effects of social injustices on our clients’ individual and

collective lives and these models were integrative from the

beginning. As we are well into another century, in a

country where the divide between the rich and the poor is

growing disproportionately, we have an opportunity (and

perhaps a professional mandate) to revisit our own roots. In

1915, Abraham Flexner provoked quite a storm when he

told social workers that their profession lacked a distinctive

purpose and methodology that could be transmitted to

others. This resulted in the articulation of social work

theories that continue to form the basis of our professional

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education and practice. Nearly a hundred years later, we

certainly meet the ‘‘criteria for a profession’’. Perhaps, in

developmental terms (a conscious borrowing of concepts!),

it is time for the profession to reexamine our ‘‘adult’’

identity as social workers by choice, proud of our title, and

distinct and distinguished among the professions.

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Author Biographies

Alex Gitterman is Zachs Professor of Social Work and Director of the Doctoral Program at the University of Connecticut School of

Social Work. He has published widely in the area of social work

practice and theory.

Nina Rovinelli Heller is Associate Professor and teaches in the master’s and doctoral programs at the University of Connecticut

School of Social Work. She has written in the areas of integrative

social work theory and practice.

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