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EBOOK Social Work in Health Settings Practice in Context 4Th Edition Ebook PDF Download Full Chapter PDF Kindle
EBOOK Social Work in Health Settings Practice in Context 4Th Edition Ebook PDF Download Full Chapter PDF Kindle
Section 1.4
Aging 235
PART 2
Social work and public health 285
Section 2.1
Work with special populations 299
Section 2.2
Internationally related public health 383
Section 2.3
Summary 409
33 Conclusion 411
J U D I T H L . M . M C C O Y D A N D T O B A S C H WA B E R K E R S O N
Index 421
Figures
9.1
Suggested surveillance strategy for individuals with germline
TP53 mutations 114
11.1 Table of activities: after-school program structure 141
18.1 Supporting client’s progression through the early stages of change 228
Harris and Durkin’s relationship-focused approach to develop positive
21.1
coping strategies 265
31.1 Overview of Bhutanese American Organization-Philadelphia’s programs 387
Contributors
Senayish Addis, M.S.S., has been a social worker at the Hospital of the University of
Pennsylvania, USA, for the past 9 years and a Liver Transplant Social Worker for the
past 7 years.
Annick Barker, M.S.S., L.C.S.W., is a mental health therapist at Health Care for the
Homeless, a Federally Qualified Health Center in Baltimore, MD, USA.
Juli E. Birmingham, M.Ed., is a counselor at the Special Immunology Family Care Center
at the Children’s Hospital of Philadelphia, USA.
Laura Boyd, M.S.W., is a Team Lead in the EPSDT Department at Health Partners Plans
in Philadelphia. She was formerly a social worker in the Center for Children with Special
Health Care Needs at St. Christopher’s Hospital for Children, also in Philadelphia, USA.
Michelle K. Brooks, M.S.S., L.C.S.W., is the Director of Psychosocial Services for Penn
Homecare and Hospice, an entity of the University of Pennsylvania Health System. Ms.
Brooks’ social work practice focus has been working with patients and families at the end
of life and in bereavement.
Laudy Burgos, M.S.W., L.C.S.W., is a social worker at Mount Sinai Hospital in New York
City, USA, where she works in the OB/GYN unit. She is also faculty for Icahn School of
Medicine at Mt. Sinai Hospital.
Deborah Calvert, M.S.W., L.S.W., is a social worker at the Special Immunology Family
Care Center at the Children’s Hospital of Philadelphia, USA.
Helaine Ciporen, M.S.W., M.Ed., L.C.S.W., is a social worker at Mount Sinai Hospital in
New York City, USA. She works in the Pediatric Endocrinology and Diabetes department.
Rachel E. Condon, B.A., is a graduate student in social work at Boston University, USA.
Reneé C. Cunningham, M.S.S., is the Associate Director at Center in the Park, USA, where
she is responsible for general operations, strategic planning, and evaluation, as well as
supervising key staff and managing contractual obligations for major contracts.
Judith A. DeBonis, Ph.D., L.C.S.W., is an assistant professor at the California State
University, Northridge, USA, and is the Principal Investigator for the Garrett Lee Smith
Suicide Prevention Campus Grant. As part of the CSWE Social Work and Integrated
Behavioral Healthcare Project, she is working to infuse integrated behavioral health and
primary care into master’s level social work education.
Contributors xiii
Helen Dombalis, M.S.W., M.P.H., is the Director of Programs for the National Farm to
School Network in Washington, DC, USA.
Emily Duffy, L.C.S.W., served as the Camp Achieve coordinator from 2005 to 2007 and has
continued to work with children and families as a pediatric behavioral health consultant,
and most recently as a school social worker.
Kathleen “Casey” Durkin, M.S.S.A., L.I.S.W.-S., is a clinical social worker with over
30 years’ experience, and has a private practice serving individuals aged 3–93: groups,
couples, and families.
Jennifer L. Fenstermacher, M.S.S., L.C.S.W., is a social worker at the Nemours/A. I.
duPont Hospital for Children in Wilmington, DE, USA, where she works on the general
pediatrics short stay unit.
Patricia A. Findley, Dr.P.H., M.S.W., L.C.S.W., is Associate Professor of Social Work at
the Rutgers University School of Social Work, USA, the Special Assistant to the Dean for
Interprofessional Health Initiatives, and the Newark MSW Campus Coordinator.
Bambi Fisher, L.C.S.W., is a social work manager in pediatrics at Mount Sinai Medical
Center and on the faculty at the Icahn School of Medicine at Mount Sinai, USA.
Jennifer D. Greenman, M.S.W., L.S.W., is a social worker at the Special Immunology
Family Care Center at The Children’s Hospital of Philadelphia, USA.
Anne P. Hahn, Ph.D., L.C.S.W.-C., is a social worker at Johns Hopkins Bayview Medical
Center in Baltimore, MD, USA, where she works on the burn unit.
Phyllis Braudy Harris, Ph.D, A.C.S.W., L.I.S.W., is Professor and Chair of the Sociology
& Criminology Department, Director of the Aging Studies at John Carroll University,
USA, and is the founding co-editor of Dementia: The International Journal of Social
Research and Practice.
Russell Healy, M.S.W., L.C.S.W., is a clinical social worker in private practice in cen-
tral New Jersey, USA, and a doctoral student in the Rutgers School of Social Work’s
D.S.W. program.
Kathy Helzlsouer, M.D., M.H.S., is a medical oncologist and epidemiologist with a prac-
tice focus on cancer prevention and cancer survivorship. She is an adjunct professor at
the Johns Hopkins University Bloomberg School of Public Health, USA, and founding
Director of the Prevention and Research Center at Mercy Medical Center, Baltimore, MD,
USA.
Jessica Hertzog, M.S.W., is a social worker at the Children’s Hospital of Philadelphia, USA,
and works in the Center for Fetal Diagnosis and Treatment, the Garbose Special Delivery
Unit, and the NIICU.
Jennifer Diem Inglis, M.S.W., is a social worker at the Children’s Hospital of Philadelphia,
USA, and and works in the Fetal Heart Program and in the Garbose Special Delivery
Unit.
Anne C. Jones, Ph.D., L.C.S.W., is a clinical professor at the University of North Carolina at
Chapel Hill, USA, and and currently serves as the Co-Principal Investigator for the UNC-
PrimeCare, an integrated behavioral health training grant funded by HRSA.
xiv Contributors
Toba Schwaber Kerson, D.S.W., Ph.D., is Mary Hale Chase Professor Emeritus in Social
Science at the Graduate School of Social Work and Social Research, Bryn Mawr College,
Bryn Mawr, Pennsylvania, USA, and a Fulbright Specialist.
John Krall, L.C.S.W., is the Program Manager of the Special Immunology Family Care
Center at the Children’s Hospital of Philadelphia, USA.
Jessica E. Lee, M.S.S., L.S.W., is a Ph.D. candidate at Bryn Mawr College Graduate School
of Social Work, and she conducts research with and serves refugee communities in
Philadelphia, USA.
Sue Livingston, B.S., began her career in education, teaching preschool, elementary,
and middle school. She has spent the past 19 years at the Epilepsy Foundation Eastern
Pennsylvania, USA, as education coordinator, and was instrumental in the development
and management of Camp Achieve.
Sarah L. Maus, L.C.S.W., A.C.S.W., is a social worker at Abington Memorial Hospital,
Jefferson Health, USA, where she is the manager of the Muller Institute for Senior Health.
Judith L. M. McCoyd, Ph.D., Q.C.S.W., L.C.S.W., is Associate Professor of Social Work
at Rutgers University, The State University of New Jersey, School of Social Work, USA,
with focus on clinical practice, loss and grief, and interprofessional education.
Shana L. Merrill, M.S., L.C.G.C., is a clinical genetic counselor at the Hospital of the
University of Pennsylvania in Philadelphia, PA, USA, who specializes in rare tumor predis-
position syndromes, cardiovascular genetic predispositions, and neurogenetic counseling.
Regina Miller, M.S.S., L.C.S.W., C.C.T.S.W., is a Social Work Team Leader at the Hospital
of the University of Pennsylvania, USA, where she has worked for the past 11 years in
Solid Organ Transplantation.
Arden Moulton, L.M.S.W., M.P.S., is a social worker at the Mount Sinai Hospital in New
York City, USA, and Program Coordinator of the Woman to Woman Program.
Julianne Oktay, M.S.W, Ph.D., is Professor Emeritus at the University of Maryland, USA,
School of Social Work. Dr. Oktay has done extensive research in social work in health,
and has published two books on breast cancer: Breast Cancer in the Life Course and
Breast Cancer Daughters Tell Their Stories.
Heather K. Ousley, M.S.S, M.S., is a social worker at the Children’s Hospital of Philadelphia,
USA, and works in the Center for Fetal Diagnosis and Treatment, the Garbose Special
Delivery Unit, and the NIICU.
Kathleen Ray, Ph.D., L.C.S.W., is a social worker at the War Related Illness and Injury
Study Center at the Veterans Administration in East Orange, NJ, USA.
Kathleen Rounds, Ph.D., M.P.H., M.S.W., is professor at the University of North Carolina,
USA, at Chapel Hill School of Social Work.
Susan Scarvalone, M.S.W., L.C.S.W.-C., is a clinical research therapist at the Prevention
and Research Center, Mercy Medical Center in Baltimore, MD, USA, where she works
with cancer patients and their families to promote quality of life during and after treat-
ment, and participates in clinical research initiatives.
Contributors xv
Dasi Schlup, M.S.W., L.C.S.W., is a clinical social worker at Women’s and Children’s
Hospital of the University of Missouri Health Care, USA. Her practice covers the Newborn
Intensive Care Unit and High Risk Obstetrics.
Jessica Scott, M.G.H., C.G.C., is a certified genetic counselor specializing in hereditary
cancer genetics at the University of Maryland Medical Center in Baltimore, MD, USA.
Cindy Sousa, Ph.D., M.S.W., M.P.H., is an assistant professor at the Graduate School of
Social Work and Social Research at Bryn Mawr College, USA, where her work focuses
on local and global dimensions of trauma, resilience, and health.
Laurie Stewart, M.S.S., L.S.W., is a social worker in the NICU at St. Christopher’s Hospital
for Children, USA.
Parangkush Subedi, M.S., M.P.H., is a resettled Bhutanese refugee and works at
Philadelphia’s Health Department. He initiated the Health Focal Point project with the
Bhutanese American Organization Philadelphia.
Marikate Taylor, B.A., M.A., started her career in the nonprofit sector in 2012. She serves
as the Information and Communications Coordinator for the Epilepsy Foundation Eastern
PA, USA, contributing to efforts to improve qualitative measurement, reporting, and mar-
keting efforts.
Rachel Warner, M.S.W, L.C.S.W., is a social at the Special Immunology Family Care
Center at The Children’s Hospital of Philadelphia, USA.
Allison Werner-Lin, Ph.D., L.C.S.W., Ed.M., is assistant professor at the School of Social
Policy and Practice at the University of Pennsylvania, USA, where she conducts research
addressing psychosocial aspects of genomic testing. She maintains a private practice with
families affected by hereditary cancer syndromes and bereavement.
Traci Wike, Ph.D., M.S.W., is an assistant professor at Virginia Commonwealth University
School of Social Work, USA.
Bonnie Fader Wilkenfeld, Ph.D., L.C.S.W., has extensive experience working in a vari-
ety of health care settings, most recently as a clinical social worker at a medical center
consisting of a hospital, residential facility, and school for individuals with severe and
profound multiple disabilities.
Nancy Xenakis, L.C.S.W., M.S., is Associate Director, Social Work Services at the Mount
Sinai Hospital, New York City, USA.
Lisa de Saxe Zerden, M.S.W., Ph.D., is the Associate Dean for Academic Affairs at the
University of North Carolina at Chapel Hill School of Social Work, USA, and is the
Principal Investigator for UNC-PrimeCare, an integrated behavioral health training grant
funded by HRSA.
Acknowledgments
Our immense gratitude goes first and foremost to our chapter contributors who shared their
practice decisions with humility, humor, and honesty – this book obviously could not exist
without these seasoned professionals. I am deeply grateful for Toba S. Kerson’s mentorship
and willingness to trust me to carry on her work with this casebook. My parents, Kathleen
J. Moyer and Ivan W. Moyer, also deserve acknowledgment as they taught me by experi-
ence about many of the health issues covered here during the time we were working on this
edition. Finally, I thank my “home team” – sons Ryan and Ian, Jim, the M.o.B., Anne and
Corey – I could not have survived this year without you all.
Judith L. M. McCoyd
In some form, Social Work in Health Settings: Practice in Context has been a part of me since
I became a social worker 50 years ago. It was a way to marry my sociological world view, my
social worker’s sensitivity to the pain of others, and my need to intervene in the most respect-
ful ways possible. Also, it was a means to keep valued colleagues and former students with
me. Many years ago, the excellent Judith L. M. McCoyd, then a doctoral student, assisted me
the third time I wrote the book and contributed a case. Now, the book is hers.
This time around, edition four is for Jennie who sparkles plenty, Larry who loves a lot,
and Leo who loves to learn.
Toba Schwaber Kerson
Chapter 1
Practice in Context
The framework
Toba Schwaber Kerson, Judith L. M. McCoyd,
and Jessica Euna Lee
Social Work in Health Settings presents a framework called “Practice in Context,” which the
first author has used for the past 40 years as a tool for teaching and evaluation. The primary
subject of the framework is the relationship between social worker and client because it is
through trustworthy, strong, knowledgeable, and skill-based relationships with clients and
others that social workers help clients to reach their goals (Beresford, Croft, & Adshead,
2007; Kerson & McCoyd, 2002). As a concept, “relationship” can be interpreted in diverse
ways. It is an association or involvement, a connection by blood or marriage, or an emotional
or other connection between people.
The definition of the social worker/client relationship used here is based in the work of
others. Sociologist Erving Goffman, and anthropologist Gregory Bateson, theorize about
some structural aspects of relationship such as the interactional focus, the connection of a
relationship to its milieu, and the rules that inform or govern a relationship. Bateson uses
the word interaction, and Goffman the word encounter, to be as precise as possible about
their subjects. For this framework, interaction and encounter are seen as factors in a broader
concept.
Goffman suggests that when studying interaction, the proper focus is not on the individual
and his or her psychology, but rather the syntactical relations among the acts of different per-
sons who are mutually present to one another (Goffman, 1981). To understand interaction,
one must understand not the separate individuals but what occurs between them. Goffman
(1966) further alludes to the special mutuality of immediate interaction:
When two persons are together, at least some of their world will be made up out of the
fact (and consideration for the fact) that an adaptive line of action must always be pur-
sued in this intelligently helpful or hindering world. Individuals sympathetically take the
attitude of others present, regardless of the end to which they put the information thus
acquired. (p. 16)
Thus, in interaction, there is always a shared sense of situation and a capacity, in some way,
to be in the place of the other, no matter what each participant’s purpose in the interaction.
Goffman places relationship in context when he develops the notion of a “membrane” that
“wraps” the interaction and, to some extent, separates it from its surroundings. “Any social
encounter,” he writes, “any focused gathering is to be understood, in the first instance, in
terms of the functioning of the ‘membrane’ that encloses it cutting it off from a field of prop-
erties that could be given weight” (Goffman, 1961, p. 79). Still, while the relationship can be
viewed and defined in its own right, it remains intimately related to the world outside of it.
2 T. S. Kerson et al.
Thus, Goffman says, “An encounter provides a world for its participants, but the character
and stability of the world is intimately related to its selective relationship to the wider one”
(Goffman, 1961, p. 80).
The rules that inform a relationship and the uses that the participants make of those rules
are also part of Goffman’s and Bateson’s analyses of relationship. According to Bateson,
interaction is the “process whereby people establish common rules for the creation and
understanding of messages” (Bateson, 1971, p. 3). Goffman adds to this definition by noting
that in encounters, rules are considered and managed rather than necessarily followed; that is,
rules may shape interaction, but they also may be influenced by the participants. He writes:
Since the domain of situational proprieties is wholly made up of what individuals can
experience of each other while mutually present, and since channels of experience can
be interfered with in so many ways, we deal not so much with a network of rules that
must be followed as with rules that must be taken into consideration, whether as some-
thing to follow or carefully to circumvent. (Goffman, 1966, p. 42)
Social workers add a psychological dimension to these more structural views of relationship.
We say that relationship has to do with people’s emotional bonding. Also, the relationship
between social workers and clients is a catalyst in that through understanding, support, nurtur-
ing, education, and the location of necessary resources, we help clients to address problems.
Thus, the relationship affirms and motivates the client. In the same way, this forming of a
helping relationship is not an end in itself but a means to help clients to reach their goals. In
this book, the word client stands for any notion of a client unit, that is, an individual, family,
program, organization, city, state, country, or advocacy effort that engages the services of a
social worker who will help this entity to reach its goals.
Thus, for this framework, the relationship between social worker and client is defined
using both sociological and psychological concepts. The sociological contributions have to
do with structure; the focus is on interaction rather than on individual participants, on the
use of rules, on the relationship’s connection to (or separation from) its surroundings or
context. The psychological contributions are the purposive, feeling, catalytic, and enabling
dimensions. Here, the relationship of social worker and client means one or more purposive
encounters intended to be catalytic and enabling whose structure and rules for interaction are
set by dimensions of context as well as by decisions made by the participants.
show proportions or arrangements of all of its component parts. Here are simply described
elements of context and practice that structure the relationship of social worker and client.
Three overarching purposes help the social worker to: (1) clarify the work, (2) understand
alterable and unalterable dimensions of practice and context, and (3) evaluate work in light
of these dimensions. Each is meant to help the social worker reflect upon the decisions and
actions of the social worker. With client participation, the social worker understands and tries
to influence context and constructs the relationship in ways that will help meet client goals.
Thus, PiC is about the craft of social work – the skills with which social workers manage
dimensions of practice.
Context
To assume that possibilities for the work are completely determined within the social worker/
client relationship is unrealistic, and may contribute to disappointment and a sense of failure
on the part of the participants, evaluators of service, and funding sources. To a great extent,
dimensions of context determine many of the rules for the helping relationship (Kerson,
2002). Context means the set of circumstances or facts that surround a particular event or
situation, the surrounding conditions that form the environment within which something
exists or takes place. Bateson defines context as a “collective term for all those events which
tell the organism among what set of alternatives he must make his next choice” (Bateson,
1975, p. 289). He adds to this the notion that “however widely context be defined, there may
always be wider contexts a knowledge of which would reverse or modify our understand-
ing of particular items” (Bateson, 1971, p. 16). Although context is a limitless concept, and
focusing on certain dimensions means ignoring others, to intervene effectively means that
one has to be able to consider and assess the circumstances that constitute the situational
conditions under which one is working.
The present framework addresses three dimensions of context that we continue to think
have the most direct and describable consequences for the relationship between social
workers and clients in health care settings: policy, technology, and organization. These
elements are considered most important because of the ways each affects the structure
of and possibilities for the social worker/client relationship. Policies increasingly provide
rules specifying the services that clients may receive, who may provide them and under
what conditions, and how services are to be evaluated. Organizations are also rule mak-
ers, setting the structure for service delivery and defining the nature of service often at the
behest of policymakers. Finally, in this era when the means of communication continue
to expand and change and technological interventions have us questioning definitions of
life, death, gender, parenthood, etc., the impact of technology on the relationship between
social worker and client is enormous. Social workers’ understanding of and comfort with a
great range of technologies enhance their roles as “translators” for their clients, their oppor-
tunities for empathy, as well as their general relational capacities. In addition, computer-
assisted technologies and the internet have altered and expanded the ways in which social
workers communicate, receive, and collect information. Thus, technology contributes to
the content of the relationship, expands possibilities, and may also constrain it. The sali-
ence of each dimension and the ways those dimensions are related depend on the particular
setting. In effect, these contextual factors may at most determine, or at least contribute to,
the rules of the game, and as they change, the constraints and possibilities for action are
altered as well.
4 T. S. Kerson et al.
Policy
Policies are explicit and definite sets of principles or courses of action that guide a range of
actions in specific situations. They are always related to the political economy, that is, the
ways by which a government manages its material resources. Policies address entitlements and
restrictions; that is, they provide rightful claims, privileges or prerogatives, and/or they impose
limitations and constraints. To think of policies in these ways demonstrates the need for social
workers to understand the policies that may affect their clients. This understanding can help
clients interpret policies and gain access to services. To be an effective client advocate one
must excel at understanding the policies that shape clients’ entitlements and restrictions.
The status of the populations with which social work is most concerned and the status of
the social work profession itself are, to a great extent, reflections of the political economy and
the social policies of any particular period in U.S. history (Mechanic, 2005). Understanding
health disparities is critical in this regard (Barr, 2014; Schlesinger, 2011). Peter Drucker notes
that every 10 years or so, society reorganizes its world view, basic values, political and social
structure, arts, and major institutions (Drucker, 2004). Thus, social policy is dynamic, fluid,
and responsive to many powerful forces within and outside of a particular community or society.
This seems to be a time of enormous social reform in the United States, and hopes are high
for reforming the health care system (Barr, 2011, 2014; Blank & Burau, 2014; Little, 2007).
For example, the Patient Protection and Affordable Care Act (ACA) was signed into
law in 2010 (Congress, 2010). An aim of the ACA is to not only expand access to public
health insurance but also improve the quality of health care provided through Medicare and
Medicaid. Also referred to as ObamaCare, the ACA expands health care coverage to all U.S.
citizens and aims to reduce U.S. health care spending. Many of its provisions took effect in
2014 and key enactments relevant to social work include:
•• individual mandate to purchase insurance and requirement for most employers to offer
coverage to workers;
•• improved access to public health insurance (e.g., expanding Medicaid to people below
130% of the federal poverty line);
•• reforms to improve health care quality and reduce health spending;
•• regulation of the health insurance industry (e.g., setting minimum benefit standards for
qualified health benefit plans and prohibiting health insurers from refusing coverage
based on patients’ medical histories (Congress, 2010; ObamaCare Facts, n.d.; Gorin,
Pollack, Darnell, & Allen, 2014).
The base for policy is the law which in the form of legislation, administrative regulations,
and/or court decisions affects every dimension and nuance of social work practice in any
health setting (Kerson, 2002). Dickson (2014) identifies the following aspects of the health
and human services that are permeated by the law:
1 the entrance into and exit from health and human services delivery systems;
2 the criteria used to determine eligibility for treatment, benefits, or services;
3 the rights to which patients and clients are entitled;
4 the rights to which professionals and staff are entitled;
5 the way in which health and human services programs are administered and regulated;
6 the relationship between the professional and the patient or client;
7 the practice of the health and human services professional (p. 3).
Practice in Context 5
Therefore, in order to understand the policies that shape their practice, social workers must
be able to understand the laws that affect the policies.
Another critical policy for social workers in health care settings is the Health Insurance
Portability and Accountability Act of 1996 (HIPAA) that recognizes the importance of pri-
vacy of medical records. HIPAA regulations aim to assure the privacy and confidentiality
of consumers’ health information by defining (1) the rights of individuals, (2) administra-
tive obligations of covered entities, and (3) the permitted uses and disclosures of protected
information (NASW, 2001; U.S. Department of Health and Human Services, 2015). HIPAA
defines “protected health information” as individually identifiable health information in any
media that is held or transmitted by a covered entity (U.S. Department of Health and Human
Services, 2015). Social workers are considered covered entities if they transmit protected
health information for which HHS has a standard. HIPAA has implications for social workers
working in public health, research, and direct practice. Such information can be as obvious as
medical records and diagnoses or as seemingly “common” as whether a patient is indeed at
the medical facility. The 2013 Omnibus rule provides updated guidance on HIPAA compli-
ance. The revisions that HIPAA has undergone in the last decade demonstrate the need to
respond to ever changing dimensions of technology (Morgan, 2013) and to be aware of the
limits to information that can be shared when making referrals.
No matter what level they work on, social workers must be able to contribute to, inter-
pret, and influence policy in order to advocate for their clients and the profession. Decisions
regarding which populations to serve, allocation of resources, planning, and programming
are too often made before social work practitioners become involved, and it is far easier to
affect the structure of a program before it is instituted rather than after. These activities are
also most beneficial to clients when clients and social workers advocate together. In addi-
tion, involvement in policy formulation helps the social work profession to broaden and
strengthen its influence. When policy has a negative effect on clients or the profession, a
united and concerted lobbying effort can stem the tide.
Historically, the presence of social work has been strongest in areas such as maternal
and child health, as well as services to veterans, where social workers have been involved
in developing policy on national, state, and local levels (Margolis & Kotch, 2013; Kerson,
1981, 1985). To a great extent, the policies social workers must familiarize themselves with
depend on the populations with whom they work and the institutions for whom they work.
Current foci of health-related social policy are on trying to control and/or cap costs and to
incorporate new knowledge and the development of new technologies into the notion of cost
control (Arrow et al., 2009; Mas & Seinfeld, 2008; Miller & West, 2009).
more than require prior authorization of inpatient stays, to the staff model health maintenance
organization that employs its doctors and assumes risk for delivering a comprehensive ben-
efit package. Ideally, managed care should not simply seek to reduce costs; rather it should
strive to maximize value, which includes a concern with quality and access.
A managed care system integrates the financing and delivery of appropriate medical care
by contracting with selected providers who offer comprehensive health services to enrolled
members for a predefined yearly or monthly premium, providing financial incentives for
patients to stay within system for their care, instituting utilization and quality controls to
which providers have agreed (and which increasingly seem to relate to patient satisfac-
tion), and by requiring that the providers assume varying degrees of financial risk. More
and more, providers are asked to balance the patients’ needs with cost control (Summer &
Hoadley, 2014).
Now, managed care is forcing social work to reexamine our practices and the values that
support the missions of organizations. It is critical that social workers in health care see
this current panacea-like solution as a series of complex strategies viewed by important and
powerful interest groups as ways to control the costs of health care. Managed care is not the
enemy of social work, nor is it a simple way to solve deep, complicated problems; in fact,
it is not even an it. The fact that managed care is altering roles and tasks for social workers
in many settings again underscores the importance of social workers being able to interpret
policy and advocate for clients.
One early managed care schema was the development of diagnosis-related groups
(DRGs). Formerly, the hospital charged the insurer what it decided it had spent to care for
the patient, plus a small percentage in addition. Now, the insurer pays the hospital based
on the patient’s diagnosis (DRG). According to the DRG classification, if the diagnosis
indicates 4 days of hospitalization, the hospital will be paid for 4 days of hospitaliza-
tion only, even if the patient stays in the hospital longer. When the patient is hospitalized
beyond the number of days indicated in the schema, the hospital must absorb the extra
cost. Consequently, there is great pressure on the hospital to discharge the patient and great
pressure on the social worker to make prompt and appropriate arrangements for the patient
to return to the community. Thus, a social worker who previously may have had weeks to
develop a relationship with, and an adequate discharge plan for, a patient, now may have a
matter of days or hours in which to accomplish the same task. More and more, the focus of
the health care facility is for the social worker to expedite the patient’s discharge as soon as
the physician can no longer justify the stay, or, even more important now, before the insurer
denies payment for services rendered. However, an aim of the ACA is to expand access to
public health insurance while also improving the quality of health care provided through
Medicare and Medicaid.
Technology
For contemporary health care, the development and cost of technology relate directly to
policy formulation. Technology and the organizations that house and/or distribute it account
for a good deal of the astronomical costs of medical care today. The United States’ passion
for, rapid acceptance of, and diffusion of “high-tech” solutions means that hospitals, health
professionals, patients, and families demand the best possible high-tech care, no matter what
the cost. Technology circumscribes practice just as policy and the law provide parameters for
practice. As Jasanoff (2008) says:
Practice in Context 7
As prime custodians of the “is” and the “ought” of human experience, science and the
law wield enormous power in society. Each plays a part in deciding how things are in
the world, both cognitively and materially; each also helps shape how things and people
should behave, by themselves and in combination. (p. 767)
Technology is applied science – the ways in which a social group satisfies its material needs.
In the broadest sense, technology means the concrete, practical solutions people invent or
discover; this can mean mechanical ventilation or Motivational Interviewing techniques,
computer systems or new consumer-marketed genetic testing, anything that involves solving
problems with specific techniques. In the present framework, technology primarily refers to
medical/scientific inventions that are used for diagnosis or treatment: medication, surgical
techniques, life-sustaining machinery, or ways of viewing or measuring bodily functions
and, in addition, ways in which we collect, manage, and disseminate information and new
possibilities for interaction in relation to both diagnosis and treatment. It is through the
development of technology as well as management of lifestyle issues that we are expanding
possibilities for treating illness and extending life (Steinbrook, 2009). Because of techno-
logical development, for example, we are able to respond to conditions in-utero, keep people
alive who would otherwise die, and redefine many conditions from fatal to chronic.
Technology also means information management, the rise of electronic record keeping,
and the computerization of all imaginable kinds of data (Tjora & Scambler, 2009). It can also
be said that new communication technology is transforming the social work profession just
as it is affecting many others. For example, one only has to think of the enormous amount
of research that Gary Holden has been able to present to social workers in health care from
Gopher Resources for Social Workers to World Wide Web Resources for Social Workers,
to the present day professional news services – Information for Practice (IP) (Holden, 2009).
As National Association of Social Workers (NASW) web designer Ebony-Jackson says,
“Social media technology, texting via phone and e-mail messaging are revolutionizing the
way people communicate” (Sfiligoj, 2009). This means e-clinical work, e-therapy, social
networking websites, chat rooms, distance learning, as well as other virtual efforts, etc.
(Serafini, Damianakis, & Marziali, 2007) and new learning techniques such as e-health, tele
health, interactive video, video conferencing, and social work rooms on the Web (Groshong &
Phillips, 2015; Matusitz & Breen, 2008).
Meanwhile, the development of life-sustaining and other technologies raise perplexing
ethical and legal problems in health care (Morrison & Monagle, 2013). Sometimes, the
extension of life can mean greatly diminished life quality. Invariably, life-sustaining technol-
ogies and interventions develop prior to the development of ethical and normative guidance
for dealing with outcomes of such technologies (full body scans and personalized genetic
testing are examples; see McCoyd, 2009 for analysis of fetal diagnosis). In other situations,
medical solutions may be dehumanizing and/or produce negative side effects. Each raises
new questions related to confidentiality, privacy, and record keeping. Current concerns about
confidentiality stem from these technological developments. Determining who has the right
to access information – the individual or group paying for the care, the individual receiving
the care, the individual with access to the computer system, etc. – has yet to be resolved
satisfactorily. (See above for discussion of how the HIPAA Privacy Rule helps.)
For social workers, sometimes the lack of medical means to intervene in an illness cre-
ates opportunities for psychosocial intervention. Historically, social workers had important
roles in the care of people with venereal diseases and tuberculosis, in part because medical
8 T. S. Kerson et al.
interventions were inadequate to treat the illnesses. Before the discovery of penicillin permit-
ted treatment of syphilis at an early stage with a single injection, treatment required many
outpatient visits over a period of 18 months. The social worker’s role was to ensure that
patients returned for prolonged outpatient treatment; they also educated patients and their
consorts about the infection. Contemporary situations provide similar opportunities. With
diseases such as AIDS and Alzheimer’s, for which there are not yet adequate medical treat-
ments, social workers help garner the social support needed to live with the illness. With
other conditions, such as end-stage renal disease and severe burns, technology provides life
support, and the social worker helps the patient and family to live with both the illness and
the technology. Each of these circumstances provides opportunities for social work. In these
ways, the presence or absence of technological solutions help to shape the parameters of the
relationship between social worker and client.
Organization
Just as policy and technology structure practice, so does organization. An organization is
defined here as a body of people structured for some end or work, and the administra-
tive personnel or apparatus of that agency, business, or institution (Hasenfeld & Garrow,
2012). Increasingly, to understand organizational context means to be knowledgeable about
multiple, complex systems involving varied funding streams, auspices, professional, and
nonprofessional providers, and public, not-for-profit, and for profit agencies with varied
degrees of authority. An insensitivity towards these demands or to contextual issues will
inhibit service effectiveness. In the grand scheme of the delivery of health care, even the
simplest organization has close ties to very large and complex networks of service. To com-
pete in today’s health care marketplace, most health care organizations are in the midst of
transforming themselves in order to become more efficient and to control costs. For profes-
sional social workers, there can be no more hiding out in an office and ignoring all of the
forces that affect the social worker/client relationship. It is also critical that social workers
understand and have as much influence as possible on how their organizations, programs,
and services are run and how they are evaluated (Kerson, 2002). We often find ourselves
in the position of being evaluated from outside by others who may not understand or value
our contributions as we do. Thus, part of understanding one’s organization as an element
of context shaping the relationship between social worker and client means incorporating
evaluation into all of the work and engaging the evaluators if they, indeed, come from out-
side of the organization.
Organization also structures practice (Wike et al., 2014). For example, the role of a social
worker in a burn unit is necessarily different from that in an adolescent parenting program.
The attributes of each organization affect and often shape the social worker’s relationship
with the client. Furthermore, in each organization, the social worker may be working with
clients whose care is paid for by a range of managed care alternatives, each of which has
different rules about who is entitled to service and the conditions of the service itself. It is
important for social workers to understand how the formal dimensions of their organizations
affect health care delivery and the relationship between them and their clients. Here, we mean
size, division of labor, degree of bureaucratization, degree of centralization of control, and
role structure as well as the relationship of one’s organization to others and to larger systems.
Role structure is especially important in understanding social work’s place and authority in
Practice in Context 9
the organization (Kerson, 2002). Changes in structure and design carried out in the name of
efficiency and cost-effectiveness can enhance or restrict services and creativity. Informal
dimensions include mores, the unwritten rules about behavior, which people know implicitly
but rarely discuss, such as ways in which to relate to members of other professions or whether
it is acceptable to have a meal at a client’s home.
Also important are the networks, collaborative alliances, teamwork, and partnerships that
people develop within and outside of the formal organizational structure in order to accom-
plish tasks (Solheim, McElmurry, & Kim, 2007). Often, the establishment of such a network
means being able to enlist those with expertise or power for help in advocating for clients.
Such power does not necessarily reside with high office. Sometimes it can be held by a
chief of service, other times by a clerk. Although it is generally easier to make exceptions
or bend the rules in a smaller organization, those who work for large, highly bureaucratized
organizations also learn to develop informal networks. Intimate knowledge of an organiza-
tion increases the possibility of making it more responsive to clients’ needs. Social workers
can leverage these outside relationships to assure that client’s needs for their services are pro-
tected, as when several neonatal intensive care unit social workers used the Code of Ethics of
the National Association of Perinatal Social Workers to advocate for staffing levels to ensure
that all families with premature and ill infants would get social work services.
In conclusion, understanding context is about understanding the rules of the game. You
cannot play the game without understanding the rules and you cannot take advantage of,
exploit, bend, or go around the rules unless you fully understand them. For health-related social
workers, the most critical elements of context are policy, technology, and organization – the
regulations and laws, elements of technology, and organizational dimensions and issues that
influence the work. Within context sits the relationship between social worker and client; so
context determines parameters and also creates the nesting space within which the relationship
that will help the clients to reach their goals is established.
assessing progress (Kerson, 2002). Being able to call attention to some success such as “arriv-
ing at work or school on time nearly every day” or “going to the senior center three times a
week” is helpful in encouraging a client to continue to work in the relationship. Increasingly,
funding sources are asking social workers and other helping professionals for outcome meas-
ures, which are the concrete means they will use to evaluate their work and the work of the
clients. Although objectives for service provision had been acceptable in the past (e.g., “meet
with the client twice in the week”), outcome measures related to the client’s progress are
now required for accountability. Through articulating objectives and outcome measures, and
achieving success in reaching a certain percentage or number of these measures, social work-
ers will be able to help clients to see their progress and will also be able to demonstrate their
results and their economic value to the organization and the funding sources. Thus, goals
are clients’ wishes to which social workers and clients aspire and objectives and outcome
measures are the realistic, attainable, concrete ways by which social workers and clients can
measure their own progress and prove their worth to organizations and funding sources.
Use of contract
Contract means agreement between social worker and client about the means used to obtain
goals, as well as the description of the goals themselves. It is the keystone, cynosure, and
linchpin of the social worker/client relationship and of this framework. Composed of mutually
agreed-upon obligations and expectations, a contract is a way of establishing norms for the
relationship. Norms also exist for the relationship between client and agency. Increasingly,
there are contracts between funding source, agency, and client.
Whether verbal or written contracts are more effective remains a matter for debate and
most probably depends on the nature of the agency, work, and clients. Certainly, a written
form clarifies the agreement, and having all participants sign adds formality and perhaps
importance to the matters at hand. This written form is very common in drug and alcohol
programs, and often the conditions for contract are set by the courts or the state. Some would
argue that this very formality stultifies the interaction, interfering with creativity, transfer-
ence, or other aspects of the relationship. Others would say that it lends a clarity that protects
everyone involved. Because contracting requires that each party articulates his or her goals
and norms, the contract includes each of the elements of relationship structure. Participants
in a helping relationship always have some expectations of each other. Use of the dimensions
of contract allows the expectations of all parties to be made explicit and helps prevent any
misunderstanding.
Meeting place
Meeting place refers to the physical space where the relationship happens. Often, deci-
sions about meeting place are determined by the rules of the setting and the needs of the
clients. Most work occurs in the institution/agency or in the client’s home. Increasingly,
meeting place is determined by the organization rather than by the needs of the clients. The
major portion of some services such as home care, foster care, and hospice is dispensed in
the home, whereas other services such as discharge planning are generally offered in the
institution. There is a renewed trend to place social work services back in the community
with the increase in a range of case management services, intensive or otherwise, occurring
wherever the client is.
12 T. S. Kerson et al.
Meeting place can influence assessment by limiting or increasing the amount of information
made available about the client. A person’s social scene provides some information about his or
her identity. When meetings take place outside of the client’s habitat, the social worker relies on
the person’s appearance and the details he or she provides about his or her life. The sight of an
institutionally gowned person lying in bed in a hospital room provides few clues to individual
identity. Personality, memories, experiences, and style are obscured. Often in such situations,
it is easy for social workers to assume knowledge of their clients that, in fact, they do not have.
When clients are seen at home, social workers learn something about clients’ means,
organizational abilities, values, neighborhood, and, perhaps, their relationships with family
members and neighbors (Paris, Genborys, Kaufman, & Whitehill, 2007). No other means
compare to home visits for assessing the lives of clients or, sometimes, for empowering them.
One sees the impact of problems, illnesses, and disabilities on daily living. Through home
visits, social workers can help collaborating professionals and aides to understand a client’s
life and problems. Many organizations think that home visits are too expensive or intrusive
and as a result do not allow them, but they remain a way to assess client capacities and
resources. Household mementos and layout yield important information about how a client is
faring and what help they may need.
The telephone and computers are other “places” to help people who cannot come to the
organization and whom the social worker cannot visit. They have proven effective as a
means of support and treatment for isolated clients. As was mentioned earlier, social work
will continue to make greater use of “e” techniques as well (Santhiveeran, 2009) and social
work support groups on-line have the ability to reach isolated caregivers in ways few support
groups can (Green & Gray, 2013).
Two important aspects of meeting place are space and privacy, which in many institutional
or agency settings are at a premium. Where none exists, social workers can create private
space for themselves and their clients by using undivided attention, eye contact, voice quality,
and body language. When other professionals ignore the need for privacy, social workers have
to educate them in order to protect their clients and foster the work.
Use of time
Decisions about time relate to the duration of the relationship and the duration and spacing
of each meeting. Since use of time is a means of structuring the relationship, sharing this
information with clients empowers them. In the broadest sense, orientation in time and space
“is felt as a protection rather than a straitjacket, and its loss can provoke extreme anxiety”
(Mead & Bateson, 1942). The importance of time is no less diminished in single-encounter
work in a hospital emergency room than it is in group work or long-term psychotherapy.
In many instances, the use of time is determined by the organization or funding source. For
example, policy may determine the duration of a session, how many sessions a client may be
seen, or the number of days for which a patient is hospitalized, but, then, it is a question of
how best to use the time that you have. Time is also an important dimension of contract. No
matter who determines the duration of the session, the work is aided when the client is the
sole focus for that time and when both client and worker understand how time will be used.
social worker makes decisions about the ways the client can best be helped. These decisions
involve choices about orientation, modality, technique, and intervention. To some degree,
choice of strategies and interventions relates to definition of client and client unit. Thus, des-
ignating an individual as the client might indicate that one would do individual work, while
designating the family as the client would indicate family work. However, the more general
decision to work with a certain client unit opens the possibility for a plethora of decisions
regarding particular theoretical orientations such as a psychodynamic, cognitive, or behav-
ioral approach. Such orientations often reflect beliefs and world views of the social worker,
which may relate little to particular client problems. For example, because it is common in
our society to believe that elderly people are not amenable to psychodynamic work, these
approaches are unusual in work with the elderly; yet, programs for the elderly report excel-
lent work that is sometimes entirely psychodynamic and, other times, combines that with
case management (Choi & Kimbell, 2009). This practice decision cautions social workers
to choose treatment modalities that reflect needs and goals of clients rather than their own
world views or beliefs. In turn, choice of a particular theoretical orientation and treatment
modality brings one to decisions regarding specific techniques or interventions, such as the
use of ritual, or some sort of narrative therapy. Techniques such as these are tools to bring a
theoretical model into action. Monitoring their use offers the social worker another way to
assess ongoing work because strategies such as these tend to have specified outcomes. At
times, interventions that are used are different from ones that had been anticipated, because
a client’s needs may be redefined as the work progresses. Articulating practice interven-
tions enhances social workers’ control of their medium. Treatment method is also sometimes
determined by dimensions of context such as organization or funding policy. For example,
one facility may extol a particular form of family therapy to treat an illness such as bulimia
and another may use a specific form of individual therapy to treat the same illness. These
choices seem to arise from differing beliefs about etiology and/or cure.
In the United States and the United Kingdom, adoption of “evidence-based practice” has
been part of the focus for accountability in health care and this can define what strategies and
interventions are considered legitimate. Gambrill (2001) has asserted that using interventions
that have not risen to the level of evidence-based practice (EBP) is unethical as they are based
in authority (“my supervisor advised this”) rather than research that empirically evaluated
the intervention technique. Gilgun (2005) argues that evidence consists of more than evalu-
ation of intervention techniques by researchers and suggests that theory and research are
one “pillar” of evidence, but that practice wisdom, the social worker’s intuited and learned
knowledge of the situation, and the client’s responses to the intervention are also legitimate
“pillars” of knowledge/evidence. EBPs pervade both medicine and social work (Shdaimah,
2009) and the intersection of social work and science (Anastas, 2014) continues to be conten-
tious: nevertheless, social workers in health settings must contend with calls for EBP or “best
practices” calls for accountability and have the wherewithal to access literature about current
best practices. When research is consistent and robust, it must inform the social worker’s
choice of strategies and interventions.
At times, the nature of the illness or disability affects the choice of modality. For example,
an illness or disability that leaves an individual physically dependent, such as advanced rheu-
matoid arthritis or emphysema, may require that the social worker work with family members
as well as the ill person. In the case of advanced Alzheimer’s disease or with a seriously ill
infant, the social worker may work only with family members. Use of time, another practice
decision, sometimes may be a dimension of treatment modality. Since the 1960s, short-term,
14 T. S. Kerson et al.
brief, and crisis-oriented work has been conventional, but within each of these orientations
there are a myriad of practice decisions regarding modality and specific technique.
National
BIA/Peer
Center for
counselor
PTSD
Support
Group WRIISC
Social
Worker
Psychiatrist
45 day
Andy intensive
Jean
47yo D&A
Medical program
Services/
OIF/OEF
Transition
Unit
Tim Beth Psychologist
17yo 16yo
Vocational
Rehab.
Program
Support
Friends/ Group
Coworkers/
Veterans
Figure 1.1 Ecomap for Andy Long. Example of an ecomap, in this case for a returning veteran with
traumatic brain injury
the map suggests the direction of the work, can demonstrate progress, strengthen relation-
ships, and can be used for evaluation. Figure 1.1 depicts an example drawn from Patricia
Findley’s chapter in the third edition.
Reassessment
Reassessment presents an opportunity for social worker and client to evaluate their work
during the course of the relationship. Like artists, they are asked to step back and examine
the work and evaluate it. Reassessment is the process of reexamining the dimensions of the
framework as well as other issues that participants have deemed important. It can be made
part of the pattern of each meeting or set aside to be brought into the work at certain intervals
(see Wike, Rounds, & Dombalis, Chapter 24 for how reassessment is built in monthly). The
technique can be as simple as discussing how the work is going or as sophisticated as using
standardized measures of success (Fischer & Corcoran, 2013). Reassessment can also be a
way to reactivate a stalled relationship or to slow one that seems to be speeding along almost
Practice in Context 17
out of control. William Schwartz’s enduring questions, “Are we working?” and “What are
we working on?” are helpful here. Finally, reassessment provides the social worker with an
opportunity to assess and obtain feedback about his or her performance.
Differential discussion
In a differential discussion, all of the previous framework decisions are reviewed in order
for the social worker to analyze his or her work (Figure 1.2). Differential discussion allows
the social worker to be a Monday morning quarterback, that is, to look back on the case to
decide which elements would remain the same the next time he or she worked with a cli-
ent with similar capacity, personality, and problems. Differential discussion encourages the
social worker to generalize from a specific client to a category of like cases with which he or
she can use similar structure and techniques. It also makes a simple, case to case, project to
project evaluation into a routine part of practice. For example, in retrospect, the social worker
may decide he or she was too confrontational with a client, the coldness of the meeting place
might have been a detriment, or the client may have been asked to coordinate more resources
than he or she was able to manage. Emphasis on the social worker’s ability to (1) generalize
from a particular case and (2) alter elements in the relationship between social worker and
client makes differential discussion the most useful dimension of the framework. This step
moves the social worker out of the present relationship and on to the next, beginning with
one strategy and ending with a test and adaptation process. See Figure 1.2 for differential
discussion decision points.
18 T. S. Kerson et al.
CONTEXT
Change How
Policy
Technology
Organization
PRACTICE DECISIONS
Change How
Objectives/Outcome
Measures
Contract
Meeting Place
Use of Time
Strategies/Interventions
Reassessment
Transfer or termination
I see increasing reason to believe that the view formed some time
back as to the origin of the Makonde bush is the correct one. I have
no doubt that it is not a natural product, but the result of human
occupation. Those parts of the high country where man—as a very
slight amount of practice enables the eye to perceive at once—has not
yet penetrated with axe and hoe, are still occupied by a splendid
timber forest quite able to sustain a comparison with our mixed
forests in Germany. But wherever man has once built his hut or tilled
his field, this horrible bush springs up. Every phase of this process
may be seen in the course of a couple of hours’ walk along the main
road. From the bush to right or left, one hears the sound of the axe—
not from one spot only, but from several directions at once. A few
steps further on, we can see what is taking place. The brush has been
cut down and piled up in heaps to the height of a yard or more,
between which the trunks of the large trees stand up like the last
pillars of a magnificent ruined building. These, too, present a
melancholy spectacle: the destructive Makonde have ringed them—
cut a broad strip of bark all round to ensure their dying off—and also
piled up pyramids of brush round them. Father and son, mother and
son-in-law, are chopping away perseveringly in the background—too
busy, almost, to look round at the white stranger, who usually excites
so much interest. If you pass by the same place a week later, the piles
of brushwood have disappeared and a thick layer of ashes has taken
the place of the green forest. The large trees stretch their
smouldering trunks and branches in dumb accusation to heaven—if
they have not already fallen and been more or less reduced to ashes,
perhaps only showing as a white stripe on the dark ground.
This work of destruction is carried out by the Makonde alike on the
virgin forest and on the bush which has sprung up on sites already
cultivated and deserted. In the second case they are saved the trouble
of burning the large trees, these being entirely absent in the
secondary bush.
After burning this piece of forest ground and loosening it with the
hoe, the native sows his corn and plants his vegetables. All over the
country, he goes in for bed-culture, which requires, and, in fact,
receives, the most careful attention. Weeds are nowhere tolerated in
the south of German East Africa. The crops may fail on the plains,
where droughts are frequent, but never on the plateau with its
abundant rains and heavy dews. Its fortunate inhabitants even have
the satisfaction of seeing the proud Wayao and Wamakua working
for them as labourers, driven by hunger to serve where they were
accustomed to rule.
But the light, sandy soil is soon exhausted, and would yield no
harvest the second year if cultivated twice running. This fact has
been familiar to the native for ages; consequently he provides in
time, and, while his crop is growing, prepares the next plot with axe
and firebrand. Next year he plants this with his various crops and
lets the first piece lie fallow. For a short time it remains waste and
desolate; then nature steps in to repair the destruction wrought by
man; a thousand new growths spring out of the exhausted soil, and
even the old stumps put forth fresh shoots. Next year the new growth
is up to one’s knees, and in a few years more it is that terrible,
impenetrable bush, which maintains its position till the black
occupier of the land has made the round of all the available sites and
come back to his starting point.
The Makonde are, body and soul, so to speak, one with this bush.
According to my Yao informants, indeed, their name means nothing
else but “bush people.” Their own tradition says that they have been
settled up here for a very long time, but to my surprise they laid great
stress on an original immigration. Their old homes were in the
south-east, near Mikindani and the mouth of the Rovuma, whence
their peaceful forefathers were driven by the continual raids of the
Sakalavas from Madagascar and the warlike Shirazis[47] of the coast,
to take refuge on the almost inaccessible plateau. I have studied
African ethnology for twenty years, but the fact that changes of
population in this apparently quiet and peaceable corner of the earth
could have been occasioned by outside enterprises taking place on
the high seas, was completely new to me. It is, no doubt, however,
correct.
The charming tribal legend of the Makonde—besides informing us
of other interesting matters—explains why they have to live in the
thickest of the bush and a long way from the edge of the plateau,
instead of making their permanent homes beside the purling brooks
and springs of the low country.
“The place where the tribe originated is Mahuta, on the southern
side of the plateau towards the Rovuma, where of old time there was
nothing but thick bush. Out of this bush came a man who never
washed himself or shaved his head, and who ate and drank but little.
He went out and made a human figure from the wood of a tree
growing in the open country, which he took home to his abode in the
bush and there set it upright. In the night this image came to life and
was a woman. The man and woman went down together to the
Rovuma to wash themselves. Here the woman gave birth to a still-
born child. They left that place and passed over the high land into the
valley of the Mbemkuru, where the woman had another child, which
was also born dead. Then they returned to the high bush country of
Mahuta, where the third child was born, which lived and grew up. In
course of time, the couple had many more children, and called
themselves Wamatanda. These were the ancestral stock of the
Makonde, also called Wamakonde,[48] i.e., aborigines. Their
forefather, the man from the bush, gave his children the command to
bury their dead upright, in memory of the mother of their race who
was cut out of wood and awoke to life when standing upright. He also
warned them against settling in the valleys and near large streams,
for sickness and death dwelt there. They were to make it a rule to
have their huts at least an hour’s walk from the nearest watering-
place; then their children would thrive and escape illness.”
The explanation of the name Makonde given by my informants is
somewhat different from that contained in the above legend, which I
extract from a little book (small, but packed with information), by
Pater Adams, entitled Lindi und sein Hinterland. Otherwise, my
results agree exactly with the statements of the legend. Washing?
Hapana—there is no such thing. Why should they do so? As it is, the
supply of water scarcely suffices for cooking and drinking; other
people do not wash, so why should the Makonde distinguish himself
by such needless eccentricity? As for shaving the head, the short,
woolly crop scarcely needs it,[49] so the second ancestral precept is
likewise easy enough to follow. Beyond this, however, there is
nothing ridiculous in the ancestor’s advice. I have obtained from
various local artists a fairly large number of figures carved in wood,
ranging from fifteen to twenty-three inches in height, and
representing women belonging to the great group of the Mavia,
Makonde, and Matambwe tribes. The carving is remarkably well
done and renders the female type with great accuracy, especially the
keloid ornamentation, to be described later on. As to the object and
meaning of their works the sculptors either could or (more probably)
would tell me nothing, and I was forced to content myself with the
scanty information vouchsafed by one man, who said that the figures
were merely intended to represent the nembo—the artificial
deformations of pelele, ear-discs, and keloids. The legend recorded
by Pater Adams places these figures in a new light. They must surely
be more than mere dolls; and we may even venture to assume that
they are—though the majority of present-day Makonde are probably
unaware of the fact—representations of the tribal ancestress.
The references in the legend to the descent from Mahuta to the
Rovuma, and to a journey across the highlands into the Mbekuru
valley, undoubtedly indicate the previous history of the tribe, the
travels of the ancestral pair typifying the migrations of their
descendants. The descent to the neighbouring Rovuma valley, with
its extraordinary fertility and great abundance of game, is intelligible
at a glance—but the crossing of the Lukuledi depression, the ascent
to the Rondo Plateau and the descent to the Mbemkuru, also lie
within the bounds of probability, for all these districts have exactly
the same character as the extreme south. Now, however, comes a
point of especial interest for our bacteriological age. The primitive
Makonde did not enjoy their lives in the marshy river-valleys.
Disease raged among them, and many died. It was only after they
had returned to their original home near Mahuta, that the health
conditions of these people improved. We are very apt to think of the
African as a stupid person whose ignorance of nature is only equalled
by his fear of it, and who looks on all mishaps as caused by evil
spirits and malignant natural powers. It is much more correct to
assume in this case that the people very early learnt to distinguish
districts infested with malaria from those where it is absent.
This knowledge is crystallized in the
ancestral warning against settling in the
valleys and near the great waters, the
dwelling-places of disease and death. At the
same time, for security against the hostile
Mavia south of the Rovuma, it was enacted
that every settlement must be not less than a
certain distance from the southern edge of the
plateau. Such in fact is their mode of life at the
present day. It is not such a bad one, and
certainly they are both safer and more
comfortable than the Makua, the recent
intruders from the south, who have made USUAL METHOD OF
good their footing on the western edge of the CLOSING HUT-DOOR
plateau, extending over a fairly wide belt of
country. Neither Makua nor Makonde show in their dwellings
anything of the size and comeliness of the Yao houses in the plain,
especially at Masasi, Chingulungulu and Zuza’s. Jumbe Chauro, a
Makonde hamlet not far from Newala, on the road to Mahuta, is the
most important settlement of the tribe I have yet seen, and has fairly
spacious huts. But how slovenly is their construction compared with
the palatial residences of the elephant-hunters living in the plain.
The roofs are still more untidy than in the general run of huts during
the dry season, the walls show here and there the scanty beginnings
or the lamentable remains of the mud plastering, and the interior is a
veritable dog-kennel; dirt, dust and disorder everywhere. A few huts
only show any attempt at division into rooms, and this consists
merely of very roughly-made bamboo partitions. In one point alone
have I noticed any indication of progress—in the method of fastening
the door. Houses all over the south are secured in a simple but
ingenious manner. The door consists of a set of stout pieces of wood
or bamboo, tied with bark-string to two cross-pieces, and moving in
two grooves round one of the door-posts, so as to open inwards. If
the owner wishes to leave home, he takes two logs as thick as a man’s
upper arm and about a yard long. One of these is placed obliquely
against the middle of the door from the inside, so as to form an angle
of from 60° to 75° with the ground. He then places the second piece
horizontally across the first, pressing it downward with all his might.
It is kept in place by two strong posts planted in the ground a few
inches inside the door. This fastening is absolutely safe, but of course
cannot be applied to both doors at once, otherwise how could the
owner leave or enter his house? I have not yet succeeded in finding
out how the back door is fastened.