An Integrating Framework for Human Behavior Theory and Social Work Practice, Study notes of Social Work

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An Integrating Framework

for Human Behavior

Theory and Social Work

Practice

Introduction

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The person-in-environment (or person-in-situation, biopsychosocial, psychosocial) perspective has historically been the central organizing focus of the social work profession’s approach to the helping process. This perspective underscores “the interdependence of individuals within their families, other social networks, communities and larger environments” (Northern & Kurland, 2001, p. 49). From its inception, the profession has drawn from a variety of disciplines (for example, psychology, sociology, biology, anthropology, economics, and political science) to inform its theoretical base for practice. Over time, it has attempted (with greater or lesser degrees of success) to synthesize data from these disparate fields to develop a theory base and practice models that reflect its traditional dual focus: to enhance the biopsychosocial functioning of individuals and families and to improve societal conditions (Greene, 1991). This chapter will set the stage for the chapters that follow by providing a framework for integrating the wide range of theories and information presented throughout this text. This framework rests on ecosystemic concepts and is informed by a variety of postmodern paradigms that emphasize social justice, multicultural competence, strengths and empowerment perspectives, and prin- ciples of developmental contextualism. It assumes the interrelatedness of the per- sonal, interpersonal, and wider social spheres and informs a model for social work practice that integrates skills at the micro, mezzo, and macro levels. We begin by providing a historical overview of the social work profession as it relates to human behavior theory and practice. We will present fundamental assumptions of an ecosystemic approach, as well as an introduction to contemporary perspec- tives that build on and refine that approach.

Human Behavior Theory and Social Work Practice:

A Historical Perspective

The Roots of Modern Social Work Practice:

A Person-in-Environment Focus

Modern social work practice can trace its roots to several social movements of the 19th century, and to two, relatively distinct, perspectives on the origin of human problems: those perspectives that viewed the person as the focus for change, and those that saw problems in the environment as contributing most significantly to human distress. Three movements that illustrate these perspectives are described in the following sections.

The Person The first of these movements had its roots in the development of the

relief aid and charity organization societies in the United States during the 1880s. Here, early social workers, or friendly visitors, visited homes to help families resolve

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termed an empowerment perspective. This perspective, which focuses on reducing the sense of powerlessness engendered in oppressed people by their social status, will be discussed later in this chapter (see also Chapter 5, “The Family in Society,” and Chapter 7, “Communities and Organizations,” for further discussion of this perspective). For the moment, it is important to understand the context in which African-American citizens found themselves during the so-called Progressive Era (1898–1918), as social work became professionalized and increasing numbers of private social welfare agencies were developing. With institutionalized racism per- meating American life, African Americans were denied access to resources and opportunities; discrimination in housing, employment, education, health care and so forth made the road to overcoming poverty plagued with obstacles. The problems to which these groups responded included an array of life-threatening social ills. Clearly, racism and its attenuating grasp made life harsh and oppressive for African Americans. This institutionalized racism permeated American life, deny- ing access for African Americans to opportunities and resources. The race lens through which nearly all of life’s circumstances were viewed, and significant deci- sions addressed, was always in place. Furthermore, among African American social

With institutionalized racism permeating American life, African Americans were denied access to resources and opportunities: discrimination in housing, employment, education, health care and so forth, made the road to overcoming poverty plagued with obstacles.

Human Behavior Theory and Social Work Practice: A Historical Perspective | 5

welfare leaders, life circumstances had produced a “profound distrust of white people” in spite of the fact that some were valued benefactors and others even car- ried the label “friend” (Carlton-LaNey, 2000; White, 1999, p. 98).... many other social problems existed among African Americans.... Because of poverty, the qual- ity of life for African Americans in both the South and nationwide was miserable. Hemingway (1980) noted that the typical African-American Carolinian, for example, “lived in a weather-beaten, unpainted, poorly ventilated shack, subsisted on a thoroughly inadequate diet and was disease ridden. Hook worms, pellagra and a variety of exposure-induced ailments consistently plagued him, limiting his life expectancy rate” (p. 213). Their northern, urban counterparts did not fare much better. They, too, found life harsh and difficult; however, circumstances in the North offered some room for self-respect and the hope for a better future. Nonethe- less, the road to overcoming poverty was plagued with discrimination in housing and employment; inadequate education, health care and diet, and disproportionate rates of delinquency, crime and death. (Carlton-LaNey, 2001, p. xiv)

The Emergence of the Medical Model

The movements described served as precursors to modern professional social work practice. In addition to their differences in approach and emphasis, each of these movements drew, over time, from different bodies of theory to inform their prac- tices. Mary Richmond, an early social caseworker, wrote the first formal social work practice text, Social Diagnosis, in 1917. Although Richmond’s work relied heavily on sociological research that emphasized the effects of the environment on personality development (Cooper & Lesser, 2005), this strong connection between sociology and social casework weakened considerably after World War I and dur- ing the Great Depression, when societal problems often seemed too overwhelming for sociological fixes. Searching for a scientific base for practice, person -oriented social caseworkers were increasingly drawn to the nascent discipline of developmental psychology and the medical model of psychoanalytic theory as conceived by Sig- mund Freud (see Chapter 3, “Theories of Development”). This growing interest in psychological processes shifted the focus of social work practice away from envi- ronmental concerns toward a view of human problems as primarily intrapsychic in nature. Soon, the person’s internal psychological problems were seen as the root cause of all forms of human difficulties, poverty included. This medical model approach gained dominance in the profession during the 1920s and 1930s. With the enormous economic upheavals of the Great Depres- sion, social caseworkers found themselves working more and more frequently with middle-class clients whose adjustment issues were responsive to this focus. The profound, reality-based issues affecting America’s poor required a sociologi- cally based approach and wider societal changes that were beyond the rather nar- row scope of social casework as it was being practiced at that time. Ultimately, many of these structural problems were addressed with relative success by broad social reforms instituted by the federal government over time.

Human Behavior Theory and Social Work Practice: A Historical Perspective | 7

This school of thought held that all human problems had both psychological and social aspects (Cooper & Lesser, 2005) and proponents of this approach originated the term psychosocial to reflect their more balanced, dual-focused view of the human condition. During World War II and the years that followed, disciples of the diagnostic, psychosocial school drew on concepts from ego psychology to develop their theoretical base for practice. Ego psychology, an offshoot of Freudian theory, focused less on intrapsychic motivation and more on how indi- viduals learn to cope with their environments and how interactions between the person and environment may affect personality development (see Chapter 3, “Theories of Development”). During the 1950s, the gap between psychological and sociological perspectives was further bridged, as social workers became increasingly interested in the developing family therapy movement, with its emphasis on how families change and develop over time, how the behavior of one family member influences another, and how to help families to function more effectively.

Historical Division by Professional Fields and Methods of Practice

Due in large part to the profession’s two-pronged philosophical evolution, social workers in direct practice tended, for many years, to be identified by a particular method (for example, casework, group work, community organization, and administration), or field of practice (for example, medical, psychiatric, industrial, child welfare, education). Social caseworkers, with their emphasis on locating problems with the individual ( the person ), and the more socially oriented group and community workers, maintained fairly separate professional identities and in fact did not even merge into a single professional organization until the formation of the National Association of Social Workers (NASW) in 1955. Despite the pro- fessional merger, the practical divisions by method and field of practice persisted for many years.

Reform Approaches

With the advent of the 1960s came a renewed interest in social issues and social action—the War on Poverty, Civil Rights movement, Women’s and Gay Libera- tion movements—all had a profound effect on the practice of social work (DeHoyos & Jensen, 1985). Although the dominance of the medical model had been attenuated somewhat during the 1940s and 1950s, with renewed interest in environmental influences on human behavior, the profession had remained grounded in a primarily psychological approach to human behavior. It gave a nod to the environment as an important influence on personality development, but the literature reflected little real attention to sociological research. As the 1960s unfolded, a reform approach began to take hold as calls for more outreach programs and more serious study of specific social forces and the nature of their influence became louder. Sociological models, particularly those related to ethnicity, social class, and social roles were increasingly introduced into the social work literature (DeHoyos & Jensen, 1985).

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An Integrating Framework for Human Behavior Theory:

The Foundation for Multilevel Practice

It became increasingly clear that none of the traditionally dominant theories that viewed human behavior as fixed in place (either by genetic programming, past intrapsychic phenomena, or environmental stimuli) were adequate, in isolation, to explain the complexities of human growth and development throughout the life cycle. With the developments associated with the reform approach came increased pressure for theoretical models that could challenge the dominant, deterministic perspectives, help integrate practice methods (Middleman & Gold- berg, 1987), and support the expansion of social work services from the psycho- logical to the interpersonal, to the broader sociocultural arena (De Hoyos & Jensen, 1985). In this section, we will describe the social systems model and the ecological perspective, both of which provide the foundation for contemporary, multilevel social work practice and for thinking about human behavior and development in the postmodern era.

With the advent of the 1960’s came renewed interest in social issues and social action:the War on Poverty,the Civil Rights Movement,and the Women’s and Gay Liberation movements all had significant impact on social work practice.

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Transaction and Reciprocal Causality Central to this model are the concepts of

transaction and reciprocal causality. The term transaction refers to a process of act- ing and reacting between systems and is defined as a constant exchange between systems, in which each shapes and influences the other over time. This process of mutual influence is referred to as reciprocal causality. It must be understood that there is no simple cause-and-effect relationship between any two systems, includ- ing the person and his/her environment. Rather, there is a reciprocal or circular relationship in which, in the case of the person–environment unit, environmental forces affect the individual’s behavior, whereas at the same time, the individual brings forth behaviors and other personal characteristics that help to create condi- tions in the environment with which he/she must then deal. For example:

An 18-month-old boy is hungry and tired and begins to whine and cling to his mother. His mother is busy cooking dinner, helping her elder children with their homework, and dealing, by telephone, with her own elderly mother’s latest med- ical crisis. Needless to say, this mother is feeling frustrated and overwhelmed, and she begins to yell in response to the toddler’s whiny demands. The toddler reacts to his mother by losing what little control he has left, falling to the ground, kick- ing and sobbing. The mother now feels more overwhelmed, frustrated, and guilty and begins to lose patience with her two elder children. In response to their mother’s sharpness, these children protest loudly, slamming their notebooks shut as their mother storms out of the room. This example illustrates the circular nature of the transactions among mem- bers of this family system, with the toddler’s demands triggering the mother’s anger, the mother’s angry reaction triggering the toddler’s tantrum, which leads the mother to lose patience with her elder children, who respond emotionally, disrupting their homework and provoking more anger from their mother. The concept of reciprocal causality also gives rise to the premise that a change in one part of a system or in the relationship between parts will create change in the whole system. (See Table 1.1.) This same example may be extended to illus- trate that premise. Imagine the same situation, except that when the toddler begins to whine and cling, the mother is instead able to collect her thoughts enough to realize that the child is hungry and needs soothing. Instead of yelling, she musters up her last bit of self-control, picks the toddler up, offers him a glass of milk, and is then able to put him in his high chair. The toddler’s needs are met, the situation de-escalates, the mother retains a sense of control and competence, and the elder children complete their homework. Here, by altering one small part of the person–environment configuration (the mother’s initial response to the toddler), the outcome of the entire transaction is altered. The social systems model is based on several fundamental assumptions that are important to understand if one is to fully appreciate the nature of the person- in-environment gestalt. These are described in Table 1.1.

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T A B L E 1. 1

The Social Systems Model: Fundamental Assumptions

All forms of matter “from sub-atomic particles to the entire universe”can be viewed as systems, and all systems have certain common properties that cause them to behave according to a common set of “rules” (Anderson & Carter, 1990).

This is a basic assumption of a social systems approach. It is this assumption that makes generalist practice possible.That is, this is the principle that allows us to view a school system as a client as easily as we see an individual person as such. If both function as systems, then both share common characteristics, both will behave in certain predictable ways, and both will potentially be responsive to social work intervention. This statement, of course, oversimplifies the issues for the sake of explanation, but we believe it is nonetheless true at its core. As noted by Berger and Federico: The physical and social sciences share the belief that the universe has some underlying order and that behavior, be it the behavior of atomic particles or interacting individuals, is a patterned, regulated activity than can be understood and in many instances, predicted and controlled (Berger & Federico, 1982).

Every system is at the same time a unit unto itself, made up of interacting parts, and a part of a larger whole.

Anderson and Carter (1990) borrow the term holon (Arthur Koestler,1967) to describe this phenomenon: Each entity is simultaneously a part and a whole. The unit is made up of parts to which it is the whole, the suprasystem, and at the same time, is a part of some larger whole of which it is a component or subsystem. The individual human being is on one hand, a whole system composed essentially of three subsystems that interact to promote the individual’s development through life: the biological system (the physical body), the psychological system (thoughts, feelings, and behaviors) and the sociocultural environmental system (the social and physical environments). On the other hand the individual human being is itself a subsystem (i.e., component part) of a supra system (a larger system); that is, the family. As a family member (subsystem of the family), the individual works with other family members (other subsystems) to maintain family functioning.These examples, which are again simplified for the sake of understanding, can be extended, ad infinitum, with the family seen as a subsystem of a community, the community as a subsystem of a nation or larger culture, and a nation as a subsystem of a global community.

(Continued)

T A B L E 1. 1

The Social Systems Model: Fundamental Assumptions

Obviously, the reverse will be true for dysfunctional or maladaptive systems. Here, the system’s components are less successful in working together to achieve the system’s goals. Such a system may be so internally disorganized that its components are unable to work together effectively. On the other hand, the system may be rigid and inflexible, and therefore less able to adjust to changing circumstances and demands. Over time, such a system will be less and less likely to develop the capacities required to respond to changing circum- stances while maintaining effective functioning.

(Continued)

T A B L E 1. 2

Characteristics of Living Systems

Boundaries Every system has boundaries.Boundaries can be defined as the borders or lines of separation that distinguish the system from the rest of its environment. Boundaries also regulate the flow of energy into and out of the system (Greene, 1991; Zastrow & Kirst-Ashman, 1997).Boundaries may be physical (e.g., a person’s skin physically distinguishes the person from the environment) or conceptual (e.g., who is a member of a particular family system and who is not).As the regulators of energy flow, a system’s boundaries may be relatively open or relatively closed (Anderson & Carter, 1990; Greene, 1991).Systems with relatively open boundaries are more receptive to interchanges of energy (e.g.information, resources) among the various parts of the system and between the system and its environment. Functional systems have relatively open boundaries that permit energy to flow in and out of the system, enabling them to maintain a steady state as they grow and develop.Systems whose boundaries are relatively closed are less receptive to such interchanges of energy.In these systems, energy reserves tend to run down.Here, the system may find itself increasingly hard-pressed to maintain a steady state and to continue to develop and function effectively over time.

Characteristics of Living Systems As noted in Table 1.1, all systems, smaller than

the smallest cell, to the global community and beyond, share certain common properties. The following section will first introduce and define some of these properties and will clarify how each affects a system’s overall ability to function effectively. We have selected, for discussion, six characteristics that are basic to the workings of all living systems. These are boundaries, adaptation, steady state, energy, communication, and organization; each is described in Table 1.2.

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T A B L E 1. 2

Characteristics of Living Systems

Adaptation As any system interacts with its environment over time, it experiences pressure or tension as the environment makes demands on it, presenting it with challenges to its ability to function. Adaptation refers to a system’s capacity to adjust to changing environmental conditions and demands. Functional systems respond to the environmental pressure by making changes to adjust to new demands. These changes or adjustments serve to reduce the tension and to cause the system to grow and develop. Over time, adaptive systems tend to achieve a better fit with their environment, grow- ing more complex (or differentiated ) , increasingly able to effectively handle challenges and demands. The ability to change and grow in response to new circumstances is crucial to a system’s continued viability and effectiveness (Zastrow & Kirst-Ashman, 1997). Adaptation however, is not a passive process whereby the system simply adjusts to whatever environmental circum- stances present themselves. It is an active process in which human beings strive to achieve the most congruent person-in-environment system state or fit possible between their own needs and abilities and the characteristics of their environment. There are critical person-in-environment transitions at every stage of the life cycle. If the fit is not good, they may choose to make changes within themselves, in their environment, or in both. These changes are known as adaptations (Germain, 1991).

Steady State (also referred to as “equilibrium”

Every system constantly strives to maintain a balance between changing in response to internal and external demands, while at the same time preserving its unique identity and sense of wholeness. We will refer to this dynamic balance as a steady state (although it is sometimes referred to as equilibrium; see Anderson & Carter, 1991 for distinctions). The maintenance of this balance is essential for a system’s viability over time. If some internal or external stressor disturbs the steady state, the system must work to restore the balance by making adjustments in its functioning. A functional system can maintain and restore a steady state by remaining flexible, alert and responsive to continuously changing internal and external circum- stances while it grows and develops, maintains its sense of wholeness, and actively pursues its goals. A dysfunctional system has difficulty maintaining and restoring a steady state. If the system is unable to recover successfully from a disruption to its steady state, its overall effectiveness and, indeed, its very existence may be seriously threatened. According to Anderson and Carter (1990): Systems never exist in a condition of complete change or complete maintenance of the status quo. Systems are always both changing and maintaining themselves at any given time. The balance between change and maintenance may shift drastically toward one pose or another but if either extreme is reached, the system would cease to exist. (p. 26)

(Continued)

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P R A C T I C E E X A M P L E 1. 1

A Hospital in Crisis

In the mid 1980’s, I accepted a position as a social work administrator in an urban medical setting that provided services to persons with developmental disabilities. One such service was an inpatient hospital unit. As originally conceived, this specialized hospital unit was to provide medical and habilitative care to patients with severe developmental disabilities and extraordinary medical needs. It was expected that these patients would be discharged back to the community, once their medical conditions were stabilized. Many of these patients had previously lived in state institutions, and few, if any, had families who could provide care.The plans for discharge therefore, presupposed the development of a continuum of community- based residential and habilitation programs that would provide necessary services, in accordance with federal law, in a less restrictive (and less costly) community environment. Although the hospital’s patient population had previously been severely underserved, the hospital unit had been developed at a time when government policies toward people with developmental disabilities were quite progres- sive. It was fully expected that the future would bring our patients an array of appropriate community-based services. In reality however, the development of such community-based services had proceeded more slowly than had been anticipated.This was due in part, to changes in the national political climate that led to significant reductions in federal funding for social programs during the 1980’s.This paucity of appropriate community services left many of our inpatients languishing in the hospital far past the time that their medical conditions warranted such an intensive level of care. By the mid-1980’s, our difficulties with regard to timely patient discharge were compounded by three new and largely unanticipated challenges which faced many urban healthcare systems at that time. First, it was just becoming apparent that the problem of HIV/AIDS, initially thought to be a health crisis limited to gay men, was far more

widespread than had been previously imagined. As knowledge increased about the virus, its modes of transmission and its detection, the number of people characterized as “at-risk”for infection seemed to grow exponentially to include such diverse populations as recipients of blood transfusions, drug addicted individuals, and the heterosexual partners of infected individuals as well as babies born to infected mothers. The second major healthcare challenge arose out of the growing abuse of crack cocaine, a form of the drug that was widely accessible due to its low cost. A side effect of this “epidemic”was the rising number of infants born with serious medical and developmental problems associated with prenatal drug exposure. Third, and on a more positive note, major technological advances in medicine had recently made it possible for extremely premature, low birth-weight newborns to survive at rates never before possible. Although many of these children went on to enjoy good health and normal development, many others suffered serious medical and developmental complications.This group included, but was not limited to, babies who had experienced prenatal exposure to crack-cocaine and/or HIV. These three developments threatened to overwhelm the healthcare community. Fear over HIV/AIDS was fueled by ignorance. In fact, little was known for certain about the disease, newly developed diagnostic tests were often unreliable, and effective forms of treatment were years away. Premature infants with extremely low birth-weights and those exposed to crack-cocaine in utero presented unusual and extraordinary medical and developmental issues. Health care professionals, who were hard- pressed to diagnose and treat these new patient populations, found it almost impossible to predict what their future needs would be. As the social work administrator, I was ultimately responsible for the success of the hospital’s discharge planning program. Again, this meant that once a patient’s medical condition

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improved enough that hospitalization was no longer necessary, the social work department was mandated by Federal and State regulations to see to it that each patient received all necessary health and habilitative services in the “least restrictive”community environment possible. As noted previously, this was problematic at best. Although some community resources did exist for our older, less fragile patients, these were relatively scarce and difficult to access. On the other hand, the community seemed totally unprepared to provide for our youngest, most complex patients. This left the hospital (along with many other urban hospital centers), in the position of housing a patient population that soon came to be known in the popular press as “boarder babies”. These “boarder babies”had extraordinary developmen- tal and health needs, and remained in hospitals essentially because they had nowhere else to go. Many had highly unstable family situations with parents who were struggling with drug addiction, AIDS and/or poverty and who were in no position to assume the care of a seriously ill child. Other patients came from more stable homes, but their parents’realistic fears and uncertainties about providing such a high level of care, combined with a real dearth of community services, had prevented them from returning home. Soon after assuming my position as social work administrator, I realized that the hospital’s problems with discharge planning were far more complex than I’d anticipated. In addition to the very real problem of a shortage of appropriate community resources for our patients, the social work staff seemed to have succumbed to frustration and to have given up on trying to find homes for our patients, believing that any effort toward that aim would be futile at best.This belief seemed also to permeate all parts of the hospital system. Many of the medical and habilitative staff seemed convinced that a large portion of the patients would be better off remaining in the care of hospital personnel despite the fact that their medical conditions no longer warranted hospital care. Patients’ families had grown comfortable with the care their very fragile

children had been receiving and were not at all anxious to have them leave the safety of the hospital setting.The hospital administration also seemed reasonably comfortable with the situation, despite the fact that the State Health Department had cited the facility for inadequate discharge planning services. Although the State had threatened to apply sanctions, for the moment the hospital continued to receive its relatively high rate of payment per patient, and so, felt little pressure to exert a great deal of effort to comply with the health department’s demand for more active planning. I however, felt enormous pressure to create a successful discharge planning program. As the administra- tor responsible for these services, I knew I would be held accountable for any lack of compliance with State regulations. I was also aware, from previous work experience in community based programs for people with developmental disabilities, of the improved quality of life our patients would experience living in the community. Having successfully “deinstitutional- ized” many clients in the past, I knew we could create a successful program despite the scarce resources. After carefully assessing the situation, I realized that my first intervention needed to be to facilitate a change in attitude among the social work staff. I felt this would set in motion a string of changes inside and outside the hospital system which would, I hoped, eventually lead to appropriate community placements for our patients. I began my intervention by raising the issue of discharge planning at our weekly social work staff meetings,initially exploring the staff’s past efforts toward discharge planning and the obstacles they encountered.Discussions about patients’needs and the benefits of community living quickly gave way to a venting of their feelings of frustration and hopelessness around this issue.Realizing that they needed to experience some success,I suggested two or three community based programs which I knew could provide appropriate services for some of our older, less fragile patients.I assisted the staff in preparing referral materials and in arranging (Continued)

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Analysis of Practice Example 1.1 from a Social Systems Perspective

In Practice Example 1.1, the hospital itself may be viewed as a system. The hospital system is composed of transacting subsystems that mutually influence one another. These subsystems include the patients and their families, the hospital administration, and the medical, nursing, habilitative, and social work departments. The hospital sys- tem may be seen as a holon, as it operates in transaction with its environment. This environment includes its geographic location, a low-income section of a large metro- politan area, as well as the wider health-care community of which the hospital is a part. Other subsystems of the health-care community are all agencies that oversee the hospital’s functioning and/or provide funding for its services (for example, the Office of Developmental Disabilities, the Department of Health, the Department of Children’s Services), as well as various community-based agencies serving similar patient populations across the city and state. The hospital system and its community also transact with the wider society within which they are embedded. From this per- spective, broad social forces such as the culture and its values, the political and eco- nomic climate, and any variety of social developments may be seen as important influences. In this case, environmental forces influencing the functioning of the hos- pital system include the relatively progressive political and economic climate at the time during which the hospital was originally conceived, as well as the eventual changes in the political and economic climate, which restricted funding for social pro- grams and delayed development of anticipated community services for the hospital’s original patient population. Additional influential environmental forces include the rising epidemics of HIV/AIDS and crack cocaine abuse, as well as advances in medical technology, which increased survival rates for the epidemics’ youngest victims.

Reciprocal Causality: Systems in Transaction The concepts of reciprocal causality and

transactional functioning between systems is clearly illustrated in this example, as changes in the political and economic climate began to create changes in the func- tioning of the hospital system. As the hospital found itself dealing with catastrophic social problems in an increasingly resource-poor environment, it began to invest less and less effort toward discharging its “medically ready” patients. The environmental response to this change in the hospital system’s internal system of controls is the Department of Health’s threat to apply sanctions. This led to a further series of inter- nal changes, beginning with the hospital’s designation of a social work administrator to be responsible for discharge planning. The social work administrator’s decision to focus her initial intervention on the functioning of the social work department illus- trates the concept of the focal system (that is, the system most in need of change to most effectively resolve the problem at hand). As the administrator’s interventions gradually led to changes in the focal system and the social work staff began to actively pursue community resources, the community responded with changes of its own. Programs began to accept referrals of the hospital’s patients, and gradually these patients began to move out into the community. Further change occurred when the Department of Health lifted the threat of sanctions. This served to energize the hospital system, with the social work staff initiating aggressive partnerships with community-based agencies to develop new services for the “boarder babies.” As these efforts began to bear fruit, further changes in the hospital’s internal functioning

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occurred, with the hospital’s discharge process eventually making it possible for the boarder babies to return to the community.

Adaptation The hospital system faced many environmental obstacles and chal-

lenges to its ability to fulfill its goal of discharging patients to the community once they no longer needed hospitalization. The hospital system initially had difficulty adapting to these challenges, and eventually its very existence was threatened by the possibility of sanctions from the Department of Health. The hospital system was eventually successful in adapting to these challenges by making internal changes (for example, hiring a new administrator to develop an active discharge planning program) and external changes (for example, working with other agen- cies to develop appropriate community resources). These adaptations resulted in a better “fit” with its environment (for example, the Department of Health removed the threat of sanctions, and the community ultimately provided the hos- pital’s patients with appropriate services) and caused the hospital system to develop and grow into a more complex, viable system (e.g., it now had an active discharge planning program with a strong network of community relationships in place and could therefore better function to fulfill its intended purpose).

Energy Flow and Steady State The example clearly demonstrates the importance

of energy flow to a system’s functioning. As the hospital system became over- whelmed by the many environmental obstacles it faced with regard to discharge planning, it began to close off the flow of energy coming in (input) and going out (output) of the system. The social workers limited their efforts to reach out to the community (output), and as a result, less and less information about resources came in (input). Eventually, the hospital system began to lose its sense of identity, gradually coming to more closely resemble a nursing home than a hospital. Its supply of energy gradually ran down, resulting in a sense of inertia, especially in the area of discharge planning. Ultimately, the hospital system’s very existence was threatened as the Department of Health prepared to institute sanctions against it. A viable steady state was gradually restored as the hospital system began to export energy via the social workers’ increased efforts to explore community resources and establish connections with other agencies. Energy then flowed in from the community in the form of resources, information, and working alliances. The resultant synergy allowed for an increased flow of energy within the system, with the various subsystems (such as medical, nursing, habilitation, and administrative departments) eventually working together effectively toward their common goal.

Communication and Feedback Mechanisms The hospital system received negative

feedback about its discharge planning efforts from the Department of Health, and it responded by beginning a process of, first, internal (increasing its efforts toward discharge planning) and then external (working to develop new community resources) change. In Practice Example 1.1, when the hospital initially tightened its boundaries, it limited its access to resources, however scarce, in the commu- nity. As noted, this led to a sense of inertia that eventually threatened its contin- ued existence. As it opened its boundaries, forming alliances with resources in the community, it became increasingly energized, gradually regaining its ability to function effectively and to better its fit with its environment.