2 Social work in health care as
2.4 Health paradigms and social work
In addition to the theories and concepts social workers themselves choose to use, their practice is influenced by the health paradigm(s) that prevail in the work setting.
Rachelle Ashcroft (2011) maintains that social workers need to recognise prevailing health paradigms and critically assess the role they are given under different paradigms in order to decide whether they want to accept the role or whether they want to try to expand it in directions that better serve their patients. This section briefly reviews five health paradigms in terms of their influence on social work practice. These are the biomedical, the biopsychosocial, the social determinants of health, the salutogenetic and the holistic paradigms. Ashcroft (2011) suggests that the role of social work under different health paradigms be studied by using Malcolm Payne’s (2005, 8–9) typology of social work views: the therapeutic (reflexive–therapeutic), the social order (individualist–reformist), and the transformational (socialist–collectivist) views.
The dominating biomedical health paradigm is influenced by objectivism. Health is seen as the absence of disease, pain and impairment; every disease is believed to have a biological cause, and when this cause is removed, the patient is considered well again.
Diseases are seen as universal, and medicine as scientifically neutral, independent of culture and environment. (Healy 2014, 37.) According to Ashcroft (2011), social work practice shaped by the biomedical paradigm is situated between the therapeutic and the social order views; it focuses on improving the individual client’s capacity to manage him/herself and on assisting the health institution to operate more effectively.
Health social workers working in this kind of environment, as is the case for most of them, need to know about biomedical thinking in order to be able to collaborate with other health professions (Healy 2014, 38). New technological advances in biomedicine will probably further strengthen the biomedical health paradigm, and this challenges social workers to critically assess the implications for their work and their clients (Healy 2016).
The biopsychosocial paradigm, combining the biomedical and the social model of health, is particularly common in rehabilitative contexts (Talo & Hämäläinen 1997). In addition to the biological factors in patients’ health, illness and recovery, it takes into account psychological and social factors (Engel 1977; Purola 1972), thus addressing both the micro and macro level. The paradigm is informed by both
37 objectivism and constructionism; social work under this paradigm mostly stresses individual intervention (the therapeutic view), although, depending on the context, it may also incorporate elements of the social order and transformational views (Ashcroft 2011). The biopsychosocial model has proven more useful for social work assessments than for intervention (cf. Chan, I.K., 1997). It has been criticised for not considering the dimensions of existence, personal meaning and spirituality (Ghaemi 2011). In social work, a spiritual dimension, referring to both spirituality and religion, and representing the ‘personal search for meaning, purpose, connection, and morality’
(Hutchison 2007, 8), has in fact been added to the framework (Maidment 2014). The purpose of the biopsychosocial model seems to be to advance a holistic approach.
However, how the different domains can be integrated remains unclear.
Based on the biopsychosocial approach, WHO (2001) has created an international classification of functioning, disability and health (ICF), which includes physical and psychological functioning, activity and participation; it sees functioning as being influenced not only by the health condition but also by environmental and personal factors. The idea of the ICF is to be a framework for measuring health and disability at both individual and population levels. Implementations in social work are being developed and discussed (Barrow 2006). The ICF framework has been criticised for its weak conceptual basis, and improvements have been suggested (Ravenek et al. 2013;
Solli & Da Silva 2012). The lack of a time dimension, necessary in studying recovery processes, has been pointed out (Matinvesi 2010).
The social determinants of health paradigm, informed by objectivism, constructionism and subjectivism (Ashcroft 2011), stresses the influence of social, environmental, political and economic forces on individual health (Marmot & Wilkinson 2006). The connection can be viewed from either a materialist perspective, which sees ill health as being caused by material living conditions, or from a social comparison perspective, which assumes that the experience of social inequity leads to worse health (Raphael 2006). Social work under this paradigm is strongly influenced by a transformational view of tackling social inequities, but it also works at the individual level from a therapeutic view (Ashcroft 2011).
A fourth theory that influences health social work is Aaron Antonovsky’s (1996) salutogenesis theory (Forinder & Olsson 2014), which, utilising the concept of sense of coherence, studies what causes and maintains health. This concept has three components: comprehensibility, manageability and meaningfulness. Antonovsky
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sees health as a continuum: the stronger a person’s sense of coherence, the greater the likelihood that they move towards the health end of the continuum. Sense of coherence can be measured quantitatively (Haukkala et al. 2013; Rivera et al. 2012).
This theory is compatible with strengths-based practice and ecological models of social work (Maidment 2014). In Finland, the salutogenesis theory is applied in some nursing homes as a paradigm to enhance the health of both residents and staff.
The holistic paradigm is more complex, as the use of the term holism is not
consistent. The concept of holism in health, as used by Ashcroft (2011), is rooted in indigenous history and traditions: ‘[h]olism strives for a balance and harmony within the person; health is considered to be one part of a person’s entire entity’ (p. 620).
Social work under the holistic paradigm sees clients as both a part and a whole, and encompasses all Payne’s (2005) three views of social work: therapeutic, social order and transformation. As mentioned in Chapter 1, biography is seen as a holistic concept that contains structure, human agency and time (Miller 2000, 74-75).
Health social work often sees holism as embracing psychological and emotional factors and focusing on the social aspects of illness (Craig & Muskat 2013; Metteri 2014). Holism is often connected with the systems approach and with humanism, existentialism and spirituality (Payne 2005). The idea is to treat people as wholes, which is a central principle in social work. Some scholars argue that the physical environment (environmental social work) should also be included in the holistic view of the human being (Dominelli 2012; Matthies & Närhi 2014). The notion of holism has been criticised for its vagueness and lack of clarity; the social worker may be lost in the ‘whole’ and miss the focus of the work (Teater 2014, 33).
In Finland, holistic thinking in social and health care has been strongly related to the ideas of psychologist and philosopher Lauri Rauhala (1983). He identifies three forms of existence: consciousness (existence as experiencing), corporeality (existence as organic processes) and situationality (existence in relation to reality), which appears to resemble the biopsychosocial model. Another holistic model, defended by the Finnish psychiatrist Martti Siirala (1986), puts forward a more integrated view of the human being, seeing the mind and body as one entity, and physical symptoms of illness as communicating that ill-being is the burden of a sick society. Here, a person’s illness is considered to be connected to their life history and life situation, reflecting and embodying the pathology of the surrounding society. Thus, the goal of care and
39 psychotherapy working together is, in a sense, to take the burden away from the sick person and turn it back over to society.
People often experience health care as fragmented and difficult to grasp (Huvinen et al. 2014). Holistic care attempts to bring the fragments together and consider other aspects of a patient’s situation in addition to the medical ones. This is often done by bringing different professionals together into multidisciplinary teams to work on cases.
This work can differ in quality and intensity. Multidisciplinary collaboration implies an additive view of wholeness, in which different professionals, such as physicians, social workers, physical therapists, occupational therapists, nurses and psychologists, autonomously make their assessments of a patient’s situation, then coordinate their work and agree on the division of tasks. (Isoherranen 2012, 21–24.)
In interdisciplinary teams in turn, professionals of different disciplines collaborate in setting goals and working together, whereas in trans/crossdiscplinary teams, the professionals transcend disciplinary boundaries and integrate methodology and knowledge. One opinion is that the more intense the collaboration between professions, the more likely it is that an integrated view of a client’s situation will be achieved. (Isoherranen 2012, 23–24.) On the other hand, one could argue that in transdiscplinary teams, the benefit of different professions and disciplines working together may be lost, and that the team work may be too dependent on the individual members. The idea of patients as partners in collaborative care has become stronger (Holman & Lorig 2000); the role of the social workers then becomes one of supporting patients in asserting their views.
The Swedish scholar Gunborg Blomdahl Frej (1988) maintains that the comprehensive view of care, as expressed in laws and guidelines, is cumulative and atomistic and primarily serves the carers rather than the patients. As a way of looking at wholeness from the patients’ point of view, she proposes an existential relationistic approach based on Martin Buber’s (1937) thinking. In her study of patients with a serious chronic illness, she found that ‘human wholeness is created and recreated in close reciprocal relations’ (Blomdahl Frej 1988, Abstract). Care as such cannot provide wholeness – the work should be based on the patient’s own view of wholeness. This can only be done in a relationship and through dialogue with the patient. In an additive, that is, quantitative, view of wholeness, there is nothing more to a whole than its parts, whereas, in a qualitative view, a whole is more than the sum of its parts. When a person acts, it is the whole person, not just an organ or a part of an organ, that acts,
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and a person’s reasons and motives can be understood only by knowing their life story (cf. Solli & Da Silva 2012). This idea touches on the biographical aspect of human life and supports the notion of the biographical perspective being holistic.
The compatibility of these five health paradigms with the biographical perspective will be discussed in Chapter 6.