CHAPTER I

INTRODUCTION TO MEDICAL SOCIAL WORK

 CHAPTER I
INTRODUCTION TO MEDICAL SOCIAL WORK

Efforts have been made in this chapter to discuss the various concepts and
theories of medical social work practice and its application in hospital setting as a
social system.
Rendering service to the sick is not new. From time immemorial people have
tried to serve their fellow beings in distress in a way regarded as most appropriate by
their own society. In the matter of caring for the sick, people in the past have been
guided by religious incentives and humanitarian urges which led to the foundation of
hospices for the care of the sick, the poor and the weary travelers. In course of time
hospitals were established and nursing orders arose for the welfare of the diseased.
But in early years, as Medical Science was not much advanced, they cared more for
the spiritual than the Physical well-being of the sick. The history of the Christian
Church reveals that from early times Clergymen and Catholic Sisters have been
visiting the sick and serving them with tender and sympathetic devotion, preaching to
them at the time sermons for the uplift of their souls. The distinctive element in their
service may be termed supematuralisms. The believers in the supernatural holds that
the final end of all conduct is the vision of God, and that all men are the children of
God, Supematuralism includes all that is highest in the natural conception of human
worth complemented with the vastly higher conceptions of men as adopted sons of
God. This theory inspires the supreme type of service for fellow being. The work
which nuns and clergymen took up with a supernatural motive and aspiration was
service for others in the corporal and spiritual spheres.
Gradually with the further development of medical Science, attention was paid
more and more to medical care of the sick, their pitiable condition led to the rise of
some voluntary and municipal hospitals by the 18th Century and special hospitals by
the 19th. During the 20th century the rise of scientific medicine, with specialization as
a characteristic feature has greatly increased available knowledge and still scientific
and technical. Medical care has not only become more efficient, but also more
complex and expensive. Profound economic and social changes have had a strong
bearing on need, demand and individual ability to pay for all the services modem
medicine has to offer, with the result that the gap is widening between medical
science and practice. The magnitude and seriousness of the problem of richness, from

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the social and economic viewpoints, have led to the realization that adjustments are
necessary in the interest of all patient, professions, institution and society as a whole,
All these factors have made us feel that such re-adjustments are beyond the power of
the individual to achieve. As a result, social philosophy has changed. New concept
have emerged, namely, that the health of the people as public concern, that sickness is
more than a private misfortune, that medical aid in its widest sense is an essential
human right and that all persons must have equal opportunities for medical care.

Settings where medical care is delivered

Medicine is a diverse field and the provision of medical care is therefore

provided in a variety of locations.

Primary care medical services are provided by physicians or other health

professionals who has first contact with a patient seeking medical treatment or care.
These occur in physician's office, clinics, nursing homes, schools, home visits and
other places close to patients. About 90% of medical problems can be treated by the
primary care provider. These include treatment of acute and chronic illnesses,
preventive care and health education for all ages and both sex.

Secondary care medical services are provided by medical specialists in their

offices or clinics or at local community hospitals for a patient referred by a primary
care provider who first diagnosed or treated the patient. Referrals are made for those
patients who required the expertise or procedures performed by specialists. These
include both ambulatory care and inpatient services, emergency rooms, intensive care
medicine, surgery services, physical therapy, labor and delivery, endoscopy units,
diagnostic laboratory and medical imaging services, hospice centers, etc. Some
primary care providers may also take care of hospitalized patients and deliver babies
in a secondary care setting.

Tertiary care medical services are provided by specialist hospitals or regional

centers equipped with diagnostic and treatment facilities not generally available at
local hospitals. These include trauma centers, bum treatment centers, advanced
neonatology unit services, organ transplants, high-risk pregnancy, radiation oncology,
etc.

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Modem medical care also depends on information - still delivered in many health care
settings on paper records, but increasingly nowadays by electronic means.

Hospitals
Of all health structures, the general hospital is the most complex. It is the
“hub” of all health care system. Since World War II its services cross both medical
and psychiatric illness, both for inpatient and ambulatory patient care.
The hospital as an organization is occupied with the functions of receiving,
classifying, diagnosing, treating, maintaining and discharging the patients. Mathew
(1979) has cited the functions as:
1) Receiving all persons who come to hospitals, clinics and organization for
treatment as outdoor patients, hospitalized patients or patient’s requiring
emergency services.
2) Clinical examination of patients and taking history of the patients.
3) Maintaining of official records and correspondence.
4) Diagnosis and planning of clinical treatment.
5) Providing the different modes of treatment according to the plans.
6) Maintaining clinical files.
7) Keeping accounts billing and transacting money matters.
8) Providing security for patients, staff and public.
9) Preparing the patients food and laundering their cloths.
10) Lighting, Plumbing and Sanitary arrangements.
11) Housekeeping task for order, cleanliness and comfort.
12) Seeing patient’s personal care, food, clothing, sleeping arrangement and care of
the body.
13) Observing patients progress.
14) Determining when patient is ready for discharge or that he requires further
treatment.
15) Arranging for discharge follow-up.

Mathew (1979) further classified those into

1) Therapeutic functions.
2) Administrative functions
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1) Therapeutic functions:
Therapeutic functions are those functions which involve interaction in the
patient. These interaction aims at clinical and social management of the patients.
These functions are performed by three types of functionaries. They are 1)
Professionals 2) Technicians 3) Non- Professionals.

2) Administrative Maintenance functions:

These functions cover executive functions, organization and maintenance
oriented function and training and research. These functions are performed by the
superintendent, Business manager, accountant, building maintenance staff, laundry
staff and librarian.
Not only do the hospitals have many departments, but they also have a variety
of personnel such as administrative physicians, surgeons, registrars, nurses including
sister in charge, staff nurse, trainee nurse, and in addition professionals like
physiotherapists, occupational therapists, dieticians, speech therapists and ward
attendant like ward boys and ayahs.1

Greenfield (1969) divides health professionals into four separate groups

1) The autonomous professionals who includes physicians, surgeons, dentists and
others.
2) The allied health professionals who include nurses, psychologists,
pharmacists, Medical Social workers and others.
3) The allied health technicians who include X-ray technicians, nurses with an
associate or diploma degree, medical technicians and medical and technical
assistance.
4) The allied health assistants, which include licensed practical nurse, nurses’
aids and other categories of aid professionals 2
It was only quit recently that the hospital authorities gained an awareness to
run hospitals in an efficient and organized way, apart from maintaining their image as
a service organization, where Medical Social workers emerged in response to certain
needs of patients.
This point is obviously applicable to the hospital social worker, but it
has equal relevance for all health social workers who are community based and who

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frequently refer their patients for tertiary care. In addition, while emphasis has been
placed on the general hospital, the structural and organizational complexities are
similar in state mental hospitals and psychiatric institutions. But whatever the
institutional setting, an integral part of practice for the social worker includes the
ability to recognize viable entry points for negotiating and modifying the system; to
discern collaborative arrangements; to advocate for the patient with appropriate
others; and to perform these myriad activities at a level that reflects the ethics and
values of the profession.
The health care system in our country has changed over the last few decades,
due to the advances in medical technology. Diagnostic and therapeutic services,
because of their sophistication, complexity and costliness have moved from
traditional office procedures by the private physician to the general acute care
hospital. The growth of and expansion in the hospitals and beds reflect also the
increased number and kinds of specialized services offered by the hospitals. The
impact is on the growth in facilities, specialists and technicians with their own goals
and priorities, expectations, rules and regulations, compartmentalizing programs into
small autonomous divisions, which must operate with interdependent practices in
order to serve a patient among them. Also advanced technology has made testing
procedures readily available and a virtual aid to doctors.
The merged or affiliated institutions with a major university teaching hospital
is becoming common place, and is seen as offering many advantages to the patients,
physicians and other health care professionals in joining educational, research, as well
as capital equipment resources.3 The academic health center under the aegis of the
university has profound influence on the operational services of its teaching hospitals.
They also have been the beneficiaries of a great deal of medical research and
education monies. Although the academic medical center’s major concentration is on
quality of care, this concentration is largely biomedical. Factors such as access,
effectiveness, economy and equity of services arise more out of social and community
pressure to examine them, than as fundamentals to the delivery of medical services.
Individuals suffering from the newly recognized social ailments of substance abuse,
child, wife and parent abuse enter the academic medical center’s emergency rooms
but in the context of the physical disorder. Although such problems are a major public
concern, they are not within the purview of the biologically trained physician. The
causes relevant to the before and after situations are not usually addressed. Although
medicine has accepted the responsibility for the care of patients suffering from such
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problems, it has not been educated to deal with the complex social problems of today.
These social problems call for knowledge from the range of social and behavioral
sciences, and for treatments and programs with both a psychosocial and medical
emphasis as mutually inseparable in the care of these sufferers. Within recent years, in
order to rectify the biomedical focus, both social workers and psychiatrists have been
assigned to emergency rooms.
In spite of preponderance of social problems that can be witnessed in any
emergency room, social service departments are just beginning to give priority to
programming at this entry point into the health care system while they attempt to
maintain an optimal level for social work assignments for inpatient services. The
decision of where and how to deploy workers is a very complicated work, specially
since discharge planning for inpatient services is a crucial hospital priority and one
that requires the major portion of a social work departments manpower. At the same
time, hospital administrators are concerned about utilization patterns of emergency
room services particularly by consumers who present non-medical problems or
present social problems that a health care system is incapable of either modifying or
ameliorating. A concomitant with these problems is the fiscal drain that all hospitals
are now experiencing in their emergency and ambulatory services. The costs must be
passed on. The patient requiring tertiary care is the one who finds the cost of
ambulatory services reflected in his bill. There is an urgent need for social work
administrators in hospital settings to continue to plan for creative ambulatory
programs, including consortium arrangements with community social agencies, to
address their consumers’ needs as well as the hospitals’ fiscal crisis.
The academic center is primarily concerned with teaching-learning processes.
The relationship to service is more in the context of its contribution to educational
process. Although it is said that hospitals with medical and psychiatric educational
programs are ones with greater equality of care than those without, because of their
proximity to the teachers in the halls of learning, they may not have the sensitivity to
care and service that can be found in community hospitals. The university medical
school controls the current organization of care, and there is comparatively little
evidence of its wish to shift from traditional ways of delivering care and in
programming its education in the existing medical care system. There is also the
problem resulting from the wide range of technologies developing in the schools, with
their application frequently related to educational demands rather than general cost-
effective and ethical concerns. The result is usually a more indiscriminate use of test
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and laboratory investigation, emphasizing the study needs, which can be very costly.
The academic world has a responsibility to publish on its experimental programs and
technological advances; it does so liberally, resulting in the public’s demand for more.
The current trend in medical technological advance is geared more toward the
problems of the very sick than toward more common aliments studies such as the
effect of lithium on the manic depressive patient or research into anorexia nervosa.
Also, sophisticated technology such as dialysis and transplants are available for the
few at very costly expenditures, which are borne by the public at large 4
Hospitals and Academic health centers being social institutions, with emphasis
only on the social workers, the greater the understanding brought to the system, the
more effective of execution of practice objectives. Other factors which have
contributed to the progress of this specialized Social Service activity are;
1. The increased proportion of indigent or near-indigent patients in all hospitals,
since the economic crisis.
2. The unavoidable decrease in the frequency with which the physician is able to
maintain a close personal relation with ward (and other) patients.
3. Undesirable but also unavoidable increases in the clinic case-load of the
individual physician on the hospital out-patient staff.
4. Unprecedented adoption of social service techniques by the cooperating agencies
of the hospitals, requiring more and better information concerning hospitalized
clients. The hospital, as the originator of social service, cannot lag behind other
social welfare groups has adopted it. The modem welfare departments cannot
receive the cooperation which it needs, from a hospital still without medical social
workers.
5. Similarly the hospital cannot obtain the maximum of possible help for its patients
from outside agencies, without competent persons who know social service
methods and who know what outside help is available and how to obtain it.5

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 Social Work as a Hospital Function:
Considering the basic values in the situation it is found that those whose
interests are most concerned would seem to be the patient, the physician, and the
community. It is to the interest of all equally that medical care should be quick,
skillful, and thorough and up to the present, specialization has proved the most
effective method of meeting this need. It is clear how the complexity of medicine
became such that no single practitioner could hope to compass its myriad activities
and certain of these have necessarily been taken over by a group of specialists in any
large medical institution or community. Specialization in the social aspects of
medicine has come about just as naturally as in the laboratory, becoming one of the
subsidiary services upon which the practice of medicine rests.
From the physician’s point of view it would seem to be a real advantage that
he should be relieved of the more complex social adjustments, which he could not
possibly undertake along with his more strictly medical work in the institution and yet
have the service sufficiently close and convenient so that he may keep continuously in
touch with it. If the social worker were not within the hospital, the delays and loss of
time for both physician and patient would be considerably greater. If such services
were or quickly available, it seems probable, moreover, that some patients would go
without social assistance (even through it were closely related to their medical care)
because of the difficulty of obtaining it. There seem to be additional real values in
having within the hospital a social specialist who is an integral part of the
organization. The social implications of disease are becoming increasingly complex;
the community social worker cannot hope to master the technical details of the subject
as is possible for a social worker specializing in the flied. It is further of value to have
in the situation someone whose point of view is neither predominantly social nor
medical, but focused upon the area of interrelationships. Such a person is, as we have
seen, in a position to increase the effectiveness of the hospital’s work by integrating
the activities of its various intramurals and also to improve its relations with the
community by interpreting its policies in their social aspects. Both of these services
are increasingly needed as the size of the institution grows and its organization
becomes correspondingly complex. The medical prestige of the social worker is
increased in the patient’s eyes if she comes as part of the hospital rather than from an
outside social agency and the effectiveness of the medical social treatment thus
increased. Finally, there is a practical argument in the fact that medical histories and

8
records are confidential and cannot be laid open to community agents, whereas the
medical social worker - as a member of the institution personnel whose discretion,
loyalty, and technical ability to interpret the material correctly are known - can be
given free access.
All of the above arguments in favor of the social worker’s being within the
hospital seem to be equally in the interest of patient, physician, and community. It is,
however, important to recognize that a conflict of interests is possible; we must face
the fact that the by products of social specialization are not all positive in their nature.
Where several agencies are involved in the same case a certain amount of time must
go to conferences and reports which are not required when a single agency is handling
the case. A great deal has been thought and written in recent years regarding problems
of agency relationships, a problem with which all social workers are familiar. Among
the cases in the present study there are several where progress seems to be definitely
retarded by misunderstandings or inevitably conflicts in policy between the medical
social worker and other agencies. The problem from community angle is to find just
the degree of unnecessary duplication, delay, and waste of time and funds.
From the patient’s point of view, also, specialization may become a liability
rather than an asset. The physician’s leadership of the medical team may counteract
its greatest dangers within the hospital, but his leaderships cannot extend so
effectively into the community. If the social area is too minutely subdivided between
the hospital and community agencies, it becomes necessary for the patient to be
passed from one social worker to another, exhausting his time and strength. Even
more important is the infringement upon his privacy, the necessity of repeating the
intimate details of personal history to a succession of persons. Recent investigation
the client-worker relationship shows, furthermore, that a succession of contacts cannot
rapidly be made and broken without an injurious effect upon the client’s personality
and upon the quality of the case work. There is a limit to the number of refers and
transfers which can be made fruitfully in any case. The client-worker relationship
creates responsibilities which may come to claim priority over the community need
for specialization and economy.

9
Major Person: J Social IMAlVablems
1. Chronic illnesses ar?' -?< nuel in:
-the elderly
-infants and children
-the retarded and developmental^ c v 4;
2. Social—psychological-emotional disorders, * . Vng family disequilibrium and
their -relationship problems;
3. Social diseases resulting from lifestyle and enviromu^at ^ .*ors as;
-drrhoais, emphy»a«a, hypertension, . -‘Miary disorders, and recently
Herpes and AIDS;
4. social disorders:
-violence, sublance abuse, accidents, su.J V.*, person abuse, promiscuity and
excesses;
5. Stress. Anxiety, few in the;
-worried well
-stabilized sick;
6. Minor ailments, self limiting.
The severely retarded and developmental^ disabled continue to be at
risk, although in lesser numbers. The emotionally ill have a substantial impact on our
health care system and this is likely to continue. More than other factors, people’s
lifestyle, behaviors and environments affect their health status. Most people are bom
healthy and become sick because of the way or where they live. Social disorders have
reached epidemic proportions and are allied with extensive social stresses and
pressures in everyday life. The majority of visits to doctors are by the “worried well”
for minor illnesses, many of which are self-limiting; or by the “stabilized sick” who
seek help with anxiety, fears, depression and stress.
“Medicalizing” these problems dose not achieve social - health
solutions. Physicians have not been well equipped to deal effectively with these social
problems and ailments. Additional hospitals, physicians and medical technology are
not likely to achieve improved health status for those at bio-psycho-social risk. Since
cure is not yet available for many chronic illnesses and disabilities, individual and
family benefits from care can be judged largely in terms of social and physical
functioning rather than of disease alleviation.6

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 The medical social worker with his/her knowledge of dynamics of human
behaviour as well as skills in establishing purposeful relationships, tries to know the
patient as a ‘person’, his socio-economic conditions, his attitude towards health
problems, his relationship with the family, taps community resources and acts as a
liaison between the patient and the community.
At the preventive and promotive phases of health, the medical social worker
studies the socio-cultural pattern and the health need of the families and the
community, interprets the same to the team and derives maximum participation of the
people, so as to raise their health status. Thus the existence of the medical social
worker in a health settings can in itself be a recognition of the psycho-social aspects
of health. The Bhore Committee had opined that, “the hospital social service brings to
the care of the sick in institutions such knowledge of their social conditions as well as
hasten and safeguard their recovery and help to prevent any recurrence”. Such
knowledge enables those responsible for their treatment to understand and treat the
patient’s illness more effectively. In the carrying out of his/her duties, the medical
social worker has become in fact an assistant to the physician in the diagnosis
treatment and rehabilitations of the patient.7
The medical social worker’s clientele in the hospital are individuals in need of help
for various psycho-social impediments in illness and disability. The cases referred
could be classified as (i) the chronically ill, e.g., cases of tuberculosis, diabetes,
cardiovascular diseases, cancer, leprosy, HIV/AIDS etc; (ii) the physically disabled,
e.g., cases of paraplegia, amputation, blindness, deafness, bums etc.; (iii) unmarried
motherhood, medical termination of pregnancy, psychosomatic disorders etc.; (iv)
cases for material help, cases in need for institutionalization etc.
From the cases referred to the medical social worker some can be helped
within a comparatively short period whereas others may take a longer to be helped.
Medical social workers seek to help these cases mainly through the use of casework
and group work methods. Along with direct service to patients, they perform many
other duties which are enumerated in the following topics.

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Medical Social Interpretation:
In the first place it seems necessary to distinguish several forms of
interpretation according to the persons at whom they are directed as follows;
1. Interpretation of the social factors in a case to the physician, a part of the
diagnostic process.
2. Interpretation of the medical social problem to professional associates, either
within or without the hospital.
3. Interpretation to the patient and his group of the medical problem, its social
implications, and of ways of meeting it.

It is obvious that interpretation, which we discussed earlier in relation to the

patient, is also important in relation to professional associates. In this sphere it will
consist of two types only, passing on of information and interpretation of meaning;
emotional barriers to acceptance do not or at least should not theoretically arise
between professional persons. In her interpretation to other members of the hospital
team the medical social worker will consciously place herself in the position of the
patient first and of the community second. It is her aim to represent the personal and
social points of view, to show the problems faced by and the implication of the
sickness for the patient, his group, and the persons to agencies in the community
trying to assist him. In interpreting the physician and hospital primarily, since both
parties to the conference may be expected to have always in the forefront of
consciousness, because of their training, the client’s point of view. She will not
simply pass on medical information and directions but will translate them into social
terms, just as she does for the patient but more technically. Particularly she will try to
interpret the rationale of the treatment, so that the agency will not only understand but
accept and enter whole-heartedly into the plan. It is often her function to explain
medical etiquette or hospital policy, why certain things can and cannot be done, why
things which seem strange or difficult to the patient or outside persons in the
community have occurred. Some of the situations which arise because of the teaching
and research functions of the hospital particularly require such interpretation.
Sometimes interpretation meets adequately the need in a situation and no
further action is needed. At other times it leads on imperceptibly into joint planning
and cooperative execution of the plan.

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 Medical social worker extends the activities of the hospital into the patient’s
home and the community, thus increasing the continuity of the treatment; he/she
interprets the medical and social aspects of the problem to her professional associates,
to the patient, and to his group; he/ she coordinates the social activities of the various
members of the medical team and the activities of the hospital and the social agencies
in the community. The activities involved in integrating are largely interpreting,
arranging, stimulating so that the activities of many persons attain a certain unity and
result in more or less consistent forward movement of the situation. This is sometimes
described as “mobilizing resources”. But the unifying aspect of the service is so
important that a term emphasizing it seems preferable. If we miss this matter of
integration and try to count definite, unitary services performed by the social worker
for the client directly, we may be confused and disappointed since his/her contribution
may in some cases seem so slight. It is, in fact, entirely possible for an effective piece
of medical social case work to be performed without the social worker’s having
contributed any direct service herself to the patient, all being done indirectly through
others and yet the whole mass of separate activities being brought together by
him/her.

Medical Social Service Department as a part of Hospital

Organization;
The organizational principles of a medical social service department in a
hospital have been proposed to be as follows:-
1) It should be considered as a major department in a hospital and as such the
hospital organization or authorities should control it.
2) Acceptance of social service department by the Head of the Institution should be
considered as an acceptance by the staff all the way down the line to give
considerable freedom to medical social workers.
3) It should receive the regular financial support of the hospital funds and all
expenses are to be handled by the Account Section of the hospital. The staff
should be in normal pay roll of the hospital staff and should be under the full
administrative control of the superintendent of the hospital.
4) There should be a head of the department who will be directly responsible to the
administration and will negotiate and collaborate with the other department of
the hospital. He will receive all referral for distribution of work and reporting.

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 But so long as a full fledged department is not established under the Indian
conditions a senior medical officer may act as a Supervisor of the Department.

5) The doctor-in charge should have direct access and frequent conferences with the
superintendent for consultations, guidance and exchange of information and
joint planning.
6) He should give leadership to the Department through responsible programme
building, policy making, maintenance of standard of service, developing good
inter-relationship, professional growth of his staff, and provision of adequate
supervision, guidance and protection of service.
7) An Advisory Committee may be set up composed of superintendent, medical and
surgical staff, nursing staff and medical social worker as its members.
8) The department may receive financial assistance from outside voluntary
organization or some auxiliary or adjunct organization working for the good of
the hospital patients.
The Department itself may organize a volunteer service and work in close
cooperation with it. The type of services which this volunteer organization may
render to the patients for medicine, appliances, transport charges, collecting gift
for hospitalized children and books for patients, enlisting blood donors etc; but
these types of assistance should not be considered as the legitimate medical
social work which is a specialized job after undergoing training and acquiring
some experience.
9) Normally the problem cases should be referred by the doctor to the Social
Service Department, but so long as the doctors are not adequately oriented to
this type of work the,medical social workers may be placed on duty in different
hospital wards to select cases for themselves and bring them to the notice of the
doctor-in-charge and after studying those cases report their findings and
observation to the doctor who can then utilize the information for diagnosis,
treatment and quicker recovery. The patients who have socio-psychological
problems and those who need rehabilitation would naturally fall under the
domain of the medical social work. For a preliminary shifting of such cases a
proforma of information may be used.
10) Medical social service wisely used can provided the testing ground for sound
Hospital Administration.

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Theories of Medical Social Work:
1) Role theory
Role theory offers a particularly viable construct to social workers in health
care settings. Although initially a sociological concept, the notion of role has
penetrated a wide range of disciplines.
Hare defined role as a “set of expectations of a person who occupies a given
position in the social system”. An equally valid perception is “an individual’s
definition of his situation with reference to his and other’s social position”. Questions
concerning, “How should I behave?” or “What is expected of me?” offer clues to
individual problems of role definition.8

As Northern states:
When a person enacts or performs a role, he is responding to a set of
expectations that others have for his behavior, but he is also acting in accordance with
his own expectations and motives. The expectations for behavior both affect and are
affected by the individual in the role, by the social system and its component parts and
by expectations of the social “milieu”.9 The hospital social worker utilizes role theory
as a way of tuning in to the dynamic transactions that occur between the patient and
the helping person, the patient and his family, and the patient and the institutional
system. Loss of status and role confusion is problems for patients in hospitals. Role
expectations and perceptions are affected by the illness entity itself, its implication for
chronicity and the length of stay required for treatment in the hospital. Social work
interventions are often directed towards helping the patient improve his role-taking
aptitude. Social workers also assist the family system to negotiate the environment in
accordance with the new role demands made upon both the family system and the
patient.

2) Personality theory
Personality theories offer numerous insights into understanding the individual.
Psychoanalytic, behavioral, cognitive learning, Gestalt and other theories enlighten
our efforts to emphasize appropriately with individual clients. However, no single
theory offers a total understanding of human behavior. Furthermore, because social
work is an action profession, personality theory may have little immediate use in

15
practice, and techniques used by advocates of a single personality theory do not
always lead to helpful outcomes.
Although it has been suggested that ego psychology is the behavioral science
to which social work should subscribe, psychoanalytic theory and particularly the
techniques derived from that theory, provide only a small part of the knowledge
necessary to do effective work. It does not serve well as the method of choice for
people in states of crisis, some of whom may not have asked for social work services,
and for whom service is time-limited. People who enter settings dealing with illness
do not translate their physical pains into socio-psychological terms. When social
workers “find” their clients, they must “market” their services. This process
frequently requires translating physical dysfunctioning into social functioning
objectives. The social worker is rarely behind the desks waiting for the clients who
arrive identifying his problems for professional intervention. Most often he or she is
“casefinding”, developing motivation and translating resources into achievable
contracts acceptable to both client and worker. Too frequently in social work, we
perceive clinical practice narrowly. Over-concern with relationship and process is
evident with less interest in the client’s perception of the problem-at-hand and in
developing a shared goal.
It is clear that no one theory of practice or series of techniques answers all
practicing social workers’ needs. The social worker should “take on” a position of
theoretical pluralism that enables him to utilize whatever formal theories are relevant
to his purposes. Although psychoanalytic theory has contributed much to our
understanding of human behavior in health care settings, it is neither easily testable
nor always useful in treating clients.

3) Developmental theory of the family, individual and group

Developmental theories are highly important in understanding the lifecycle of
individuals, families and groups. Problem-solving social work takes place within the
constraints of normal growth and development. Developmental theories enable the
social worker and client to identify and resolve problems encountered in the lifecycle.
By identifying obstacles to the continuance of the person’s lifecycle growth that come
from within the person and from his environment, the social worker can apply
developmental theories concerning individuals and families to practice. A staged
model based on family development theory and Erikson’s stages of individual

16
development and associated nuclear task is offered as a framework for understanding
the development approach.
Although developmental theory is important to all social workers, it has
particular relevance for those in health care. The family is the basic unit of health
management. As Kumabe and others state,
As the basic unit of health management, the family exhibits characteristic
pattern of health practices, definitions of illness and responses to symptoms, and the
utilization of medical services. Its commitment to protect its members through
stressful situations makes the management of illness more than an individual function
and focuses on the family as a significant source of strength—or weakness—in the
individual’s coping process. The patients who appears at a health facility is seldom a
single individual seeking help; rather, he is a member of a family which has exhausted
its known internal and external resources to deal with the problem.10

Thus, a family-centered approach is crucial in dealing effectively with the

health concerns of the patient.
In using developmental theory, we must be guided by Klein’s cautions
regarding its application to mental illness. Psychiatry, psychology and social work in
the United States have been dominated by theoreticians who single-mindedly
emphasize and derogate the contributions of socioeconomic, psychological and
constitutional factors.11
Strain and Beallor have identified five parameters to be fulfilled if the family
is to be of assistance to an ill family member:
1. The ability of the family to accept the fact that the patient may regress
physically and mentally as a consequence of his illness;
2. Their ability to help him ward off the stresses evoked by his illness;
3. Their ability to tolerate the patient’s expression of his fear and feelings, for
example, that he sis going to die, that he will never be the man he once was, that he
will never recover, and so forth.
4. their ability to enlist the patient’s basic trust, that is, his confidence that they
will not abandon him and at the same time to support his efforts to function as
autonomously as possible;
5. Their ability to mobilize outside support on behalf of the patient when
necessary.12

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 Group development theory is useful to the practitioner in working directly
with formed groups and also in working with collaborative groups of health care
professions. Most formed groups moves from a pre-affiliation stage to establishing
purposes, creating exchanges (the work), developing identification with the group,
maturing the group, and terminating the group. Collaborative groups go through
developmental stages as do other formed groups.13 More than in other theoretical
approaches; the field of developmental psychology is tied to facts and research. Its
core is relevant to the major concerns of social workers; to helping people to become
independent; to exercise restraint in actions; to be rational, organized and planful.14

4) Early Theories in Medical Social Work

Examination of early attempts to conceptualize the knowledge of medical
social work indicates both the values and limitations of these earlier efforts. Medical
social work was fortunate in having a clear and useful framework for thinking early in
its history. In 1930, in the first of a series of studies of the functions of medical social
work, Janet Thornton presented the following analysis:
Social factors, which appear in hospital practice, fall into three main
categories:
1. Social conditions which bear directly on the health of the patient, either including
susceptibility to ill health, or helping or hindering the securing and completing of
medical care.
2. Social distress caused to others by the illness of patients; such as, loss of income,
neglect of children, etc.
3. Social problems not having direct cause-and-effect relation to the health
condition, but collateral to it. Such problems would exist independently of the
sickness. These factors exist in many possible combinations.
This approach was sound and valuable, since it required medical social
workers to identity those social factors that were actually influencing the medical
situation and to describe the nature of the interaction. Because of the tendency for
social problems to spread, situations in which social difficulties can be regarded as
collateral to the medical situation (the third category) are not frequently found.
Furthermore, factors in the second category, social distress caused to others by illness,
tend to react upon the patient in turn. For example, when a man is unable to support
his family because of illness, he becomes anxious and not infrequently wishes to leave
the hospital and return to work before his physical condition permits. Thus the first
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category eventually proved to be the most important one for medical social work. It
became known as the social component in illness and medical care and has been
widely used as a basic concept in medical social thinking, both in practice and
teaching. The concept has proved useful in establishing the position of social work in
medical care, since the demonstrated interaction of medical and social factors calls for
social work as a part of the care of the patient, to assist both in understanding of
medical social problems and in dealing with their effects.
As the psychiatric approach began to permeate social casework, there was
increasing emphasis in medical social work on the meaning of illness to the patient
and his family. This idea-which can be best regarded as a general theme rather than a
specific concept-was discussed in one of the later studies of medical social work
practice and is currently a part of medical social work thinking. Its value is that it has
turned the attention of practitioners and teachers towards the individual patient’s own
definition of the situation, with recognition that it must be understood in every
instance and is usually the starting point for social work activity. The idea has been
interpreted to cover what are now regarded as the psychosocial aspects, that is, a full
diagnostic analysis of the patient’s behavior, including his adjustment to the problems
of illness and medical care. The emphasis is upon the individual nature of each
patient’s response, i.e., the difference in the meaning illness for every person. Thus,
while the general idea of the meaning of illness to the patients might have operated as
a starting point from which medical social workers could explore and make more
explicit what they know about medical social problems, it has been so used by the
professional group. The theme itself was too broad to lead to precise thinking at an
abstract level and no sets of sub concepts or subcategories have been built in to extend
and clarify its implications.
All through the history of medical social work, practitioners and teachers have
talked and written about the social implications and psychological meaning of the
problems associated with particular medical conditions with which they were working
and regarding which they had special knowledge. While a considerable proportion of
the literature of medical social work relates to specific medical conditions, such as
heart disease, cancer, blindness, or amputation, the conclusions to be drawn from
these materials are not easily identifiable or definitive. The difficulty seems to be that
social workers writing from their own experience about the psychosocial problems of
these various conditions have not yet succeeded in distinguishing those problems that
are common to all illness, or perhaps to chronic illness or handicap, from those that
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are peculiar to the particular conditions under discussion. It is possible that focusing
attention on certain recurrent psychosocial problems of illness in their own right,
rather than following the medical classifications might gain more knowledge. Medical
social workers undoubtedly posses and use much useful knowledge of this kind that
has not yet been organized, classified, and formulated in manageable form. Analysis
of this literature and exploration of the whole subject with practicing social workers
are indicated, to determine how these generalizations could be better focused.
Another concept widely used in medical social work was that of the medical
setting. It was an application of the basic concept of setting used throughout social
work. It was useful in describing the sanction and auspices under which social work
was practiced but was too narrowly limited to the administrative aspects and omitted
other important features of the field of practice.

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References
1. Mathew Grace, 1979, The role of Non-professionals in the treatment of the
mentally ill patients in Mental hospitals, unpublished thesis, Mumbai, Tata
Inst. Of Social Sciences
2. Greenfield Harry, 1969, Allied Health Manpower, New-York: Columbia
University Press
3. Cecil G. Sheps, Trends in Hospital Care, Health Care Administration: A
managerial Perspective, Philadelphia: Lippincott, 1973, pp. 21-23
4. Roslind S. Miller & Helen Rehr, Social Work issues in Health care, Prentice-
hall, Inc; Englewood Cliffs, New Jercy, 1983,pp. 1-19
5. Claude W.Munger, What the Hospital Expects of its Social Worker, Hospital
Management, American Association of Medical Social Workers, September
1937
6. Helen Rehr, Health Care and Social Work Services: Present Concerns and
Future Directions, Social Work in Health care, Vol-10, No.l, Fall 1984, pp.
71-83
7. Health Survey and Development Committee’s (Bhore Committee) Report,
1946, Government of India, New Delhi, 1946.
8. Paul A. Hare, Handbook of Small Group Research Free Press, New York,
1962
9. Helen Northern, Social Work with Groups, Columbia University Press, New
York, 1969, pp. 29
10. Kazuye Kumabe, Chikae Nishiba, et al , A hand book of Social Work
Education, and practice in community Mental Health, Settings, University of
Hawaii school of Social Work, Hawaii, August 1977, pp. 25
11. Donald F. Klein, Rachel Gittleman et al, Diagnosis and Drug treatment of
Psychiatric disorder: Adult and Children, Williams and Wilkins, Baltimore,
1980, pp. 17
12. James J. Strain and Gerald Beallor, Psychological Intervention in Medical
Practice, Appleton- century-Crofts, New York 1978, pp. 166
13. Roslind S. Miller & Helen Rehr, Social Work issues in Health care, Prentice-
hall, Inc; Englewood Cliffs, New Jercy, 1983, pp.135-139

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14. Jane Issacs Lowe and Maijatta Herranen, Conflict in Teamwork:
Understanding Roles and Relationships, Social work in Health Care, Vol.
3,No. 3, Spring 1978, pp. 323-330

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