PART I

Foundations of Social Work in Health Care

COPYRIGHTED MATERIAL

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Conceptual Underpinnings of Social Work in Health Care

SARAH GEHLERT

The writing of the fi rst edition of this text co- Chapter Objectives incided with the centennial of the hiring of • Discuss the historical underpinnings of the the fi rst medical social worker in the United founding of the fi rst hospital social work States, Garnet Pelton, who began working at department in the United States. Massachusetts General Hospital in 1905. The • Describe the forces and personalities writing of the second edition fi ve years later responsible for the establishment of the comes at another key point for health social fi rst hospital social work department in the work, namely the passage of the Patient Protec- United States. tion and Affordable Care Act in March 2010, • Determine how the guiding principles of which will radically increase health insurance social work in health care have changed coverage for U.S. citizens over the next de- from the time of the founding of the fi rst cade. It seems an appropriate time to consider hospital social work department to the the history of social work in health care and present time. to assess the degree to which the vision of its • Determine how the techniques and founders has been met in its fi rst 100 years. Ida approaches of social work in health care Cannon (1952), the second social worker hired have changed from the time of the founding at Massachusetts General Hospital, whose ten- of the fi rst hospital social work department ure lasted for 40 years, wrote: “[B]asically, so- to the present time. cial work, wherever and whenever practiced at its best, is a constantly changing activity, Frequent references to other chapters in this gradually building up guiding principles from book capture the current conceptual frame- accumulated knowledge yet changing in tech- work of social work in health care. niques. Attitudes change, too, in response to shifting social philosophies” (p. 9). How, if at all, have the guiding principles of social work HISTORICAL FOUNDATION in health care changed over the century? OF SOCIAL WORK IN This chapter focuses on the development of HEALTH CARE the profession from its roots in the 19th cen- tury to the present. This longitudinal examina- Social work in health care owes it origins to tion of the profession’s principles and activities changes in (a) the demographics of the U.S. should allow for a more complete and accurate population during the 19th and early 20th cen- view of the progression of principles through turies; (b) attitudes about how the sick should time than could have been achieved by sam- be treated, including where treatment should pling at points in time determined by historical occur; and (c) attitudes toward the role of so- events, such as the enactment of major health- cial and psychological factors in health. These care policies. three closely related phenomena set the stage

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for the emergence of the fi eld of social work New York City died prior to their fi rst birth- in health care. day, compared to 1 in 6 in London (Rosenberg, A number of events that began in the mid- 1967). Adding to the challenge, the vast ma- 1800s led to massive numbers of people im- jority of immigrants had very limited or no migrating to the United States. In all, 35 to English language skills and lived in poverty. 40 million Europeans immigrated between Immigrants brought with them a wide range of 1820 and 1924. The Gold Rush, which began health-care beliefs and practices that differed in California in 1849, and the Homestead Act from those predominant in the United States of 1862 added to the attractiveness of immi- at the time. gration (Rosenberg, 1967). In the late 1600s and early 1700s, people About 5.5 million Germans immigrated to who were sick were cared for at home. A the United States between 1816 and 1914 for few hastily erected structures were built to economic and political reasons. Over 800,000 house persons with contagious diseases dur- arrived in the 7-year period between 1866 and ing epidemics (O’Conner, 1976, p. 62). These 1873, during the rule of Otto von Bismarck. structures operated in larger cities and were The Potato Famine in Ireland in the 1840s re- fi rst seen before the Revolutionary War. As sulted in the immigration of 2 million people the U.S. population grew, communities de- during that decade and almost a million more veloped almshouses to care for people who in the next decade. Between 1820 and 1990, were physically or mentally ill, aged and ill, over 5 million Italians immigrated to the orphaned, or vagrant. Unlike the structures United States, mostly for economic reasons, erected during epidemics, almshouses were with peak years between 1901 and 1920. A built to operate continuously. The fi rst alms- major infl ux of Polish immigrants occurred be- house, which was founded in 1713 in Phila- tween 1870 and 1913. Those arriving prior to delphia by William Penn, was open only to 1890 came largely for economic reasons; those Quakers. A second almshouse was opened to after came largely for economic and political the public in Philadelphia in 1728 with mon- reasons. Polish immigration peaked again in ies obtained from the Provincial Assembly by 1921, a year in which over half a million Pol- the Philadelphia Overseers of the Poor. Other ish immigrants arrived in the United States. large cities followed, with New York open- Two million Jews left Russia and Eastern Eu- ing the Poor House of the City of New York ropean countries between 1880 and 1913 and (later named Bellevue Hospital) in 1736 and traveled to the United States. New Orleans opening Saint John’s Hospital in The United States struggled to adapt to the 1737 (Commission on Hospital Care, 1947). challenge of immigration. The Ellis Island Im- Although called a hospital, Saint John’s was migration Station opened in 1892 to process classifi ed as an almshouse because it primar- the large number of immigrants entering the ily served people living in poverty who had country. By 1907, over 1 million people per nowhere else to go. year were passing through Ellis Island. The By the mid-1700s, people who became ill massive waves of immigration presented new in almshouses were separated from other in- health-care challenges, especially in the north- habitants. At fi rst they were housed on sepa- eastern cities, where most of the new arrivals rate fl oors, in separate departments, or in other settled. Rosenberg (1967) wrote that 723,587 buildings of the almshouse. When these units persons resided in New York City in 1865, increased in size, they branched off to form 90% on the southern half of Manhattan Island public hospitals independent of almshouses. alone. Over two thirds of the city’s popula- Hospitals eventually became popular among tion at the time lived in tenements. Accidents persons of means, who for the fi rst time pre- were common, sanitation was primitive, and ferred to be treated for illness by specialists food supplies were in poor condition by the outside the home and were willing to pay for time they reached the city. One in 5 infants in the service.

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A number of voluntary hospitals were es- such as hygiene and how to select and cook tablished between 1751 and 1840 with various food and addressed issues of education and em- combinations of public and private funds and ployment. In 1890, Mrs. Robert Hoe provided patients’ fees (O’Conner, 1976). The fi rst vol- funds to the New York Infi rmary for Women and untary hospital was founded in Philadelphia in Children to employ a full-time home visitor to 1751 with subscriptions gathered by Benjamin work under the direction of Dr. Annie Daniels. Franklin and Dr. Thomas Bond and funds from Daniels kept records of family size, income, and the Provincial General Assembly of Philadel- living expenses in the manner of social workers phia. The New York Hospital began admitting of the time, such as Jane Addams, who founded patients in 1791 and the Massachusetts Gen- Hull House in Chicago in 1889. eral Hospital in 1821. In 1817, the Quakers The fi rst medical resident to work with opened the fi rst mental hospital, which began Dr. Blackwell in New York, Marie Zakrzewska, admitting anyone needing care for mental ill- moved to Boston and in 1859 became the fi rst ness in 1834. professor of obstetrics and gynecology at A third type of medical establishment, the the New England Female Medical College. dispensary, began to appear in the late 1700s. Dr. Zakrzewska established a dispensary and Dispensaries were independent of hospitals 10-bed ward in Boston in 1862, the New Eng- and fi nanced by bequests and voluntary sub- land Hospital for Women and Children. It was scriptions. Their original purpose was to dis- the fi rst hospital in Boston and the second in pense medications to ambulatory patients. In the United States (after the New York Dispen- time, however, dispensaries hired physicians sary for Women and Children) to be run by to visit patients in their homes. The fi rst four women physicians and surgeons. As had the dispensaries were established in Philadelphia New York Dispensary for Women and Chil- in 1786 (exclusively for Quakers), New York dren, the New England Hospital for Women in 1795, Boston in 1796, and Baltimore in and Children featured home visiting, with 1801. increased attention to social conditions. For many years, home visits were part of the edu- 19th-Century Efforts Toward Public cation of nurses and physicians in training. Health Reform In 1890, Dr. Henry Dwight Chapin, a pe- diatrician who lectured at the New York Post- The last half of the 19th century saw efforts graduate Hospital and the Women’s Medical to reform hospitals and dispensaries, many College of the New York Infi rmary for Women of which were led by women physicians. and Children, established a program in which Dr. Elizabeth Blackwell, unable to fi nd em- volunteers visited the homes of ill children to ployment in hospitals because of her gender, report on conditions and to ensure that medi- established a dispensary for women and chil- cal instructions had been understood and im- dren in New York’s East Side in 1853. The East plemented. In 1894, he appointed a woman Side had seen a massive infl ux of immigrants physician to do the job but soon replaced her from Europe and was becoming increasingly with a nurse. Chapin’s efforts led to a foster- crowded. Blackwell’s dispensary provided care home for ill and convalescing children home visits and by 1857 had secured a few whose parents were unable to care for them hospital beds for its patients. The dispensary, adequately (Romanofsky, 1976). He founded which later became the New York Infi rmary the Speedwell Society in 1902 to encourage for Women and Children, provided home visits foster care. The Speedwell Society would have to 334 African American and White American ties to the social work departments later estab- patients in 1865 (Cannon, 1952). The follow- lished in New York hospitals. ing year, Dr. Rebecca Cole, an African Ameri- A close partnership between the Johns can physician, was hired as a “sanitary visitor.” Hopkins Hospital and Baltimore’s Charity When visiting families, Cole discussed topics Organization Society at the turn of the 20th

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century served as a breeding ground for ideas admission to the hospital’s dispensary and ac- about how to merge social work and medi- cept those that were deemed suitable for care. cine. Four people involved in these discus- Her secondary duties were to refer patients for sions were instrumental to the establishment services and determine who should be served of formal social work services in hospitals. at dispensaries (Cannon, 1952). Mary Richmond, Mary Wilcox Glenn, Jeffrey Stewart was given 3 months of initial fund- Brackett, and Dr. John Glenn, who became the ing by the London Charity Organization So- director of the Russell Sage Foundation, were ciety. Although by all accounts her work was actively involved in the application of social considered productive, the Charity Organiza- work to medicine. tion Society refused to renew her contract until the Royal Free Hospital agreed to pay at least Hospital Almoners in London part of her salary. Ultimately, two of the hospi- tal’s physicians agreed to pay half of Stewart’s The fi rst social worker, called a hospital salary for a year, and the Charity Organization almoner, was hired by the Royal Free Hospital Society covered the other half. From that point in London in 1895. This occurred when the on, social almoners were part of hospitals in Royal Free Hospital came together with the England. By 1905, seven other hospitals had London Charity Organization Society through hired almoners. Charles Loch. Loch was a very religious man In 1906, the Hospital Almoners’ Council who had served in the Secretarial Depart- (later the Institute of Hospital Almoners) took ment of the Royal College of Surgeons for over the training of almoners. The Institute for three years. He was appointed secretary of Hospital Almoners was responsible for the ex- the London Charity Organization in 1875 and pansion of the almoner’s repertoire to include brought with him a strong interest in the so- functions such as prevention of illness. The cial aspects of health. While a member of the fi rst years of its operation saw the develop- Medical Committee of the Charity Organiza- ment of classes for prospective fathers, a hos- tion Society, Loch addressed a growing con- tel for young women with socially transmitted cern that patients might be misrepresenting diseases, and other programs (Cannon, 1952). their situations to receive free care. In 1874, the Royal Free Hospital asked the Charity First Social Service Department in the Organization Society to screen patients to de- United States termine how many were indeed poor. They found only 36% to be truly eligible for ser- Garnet Pelton began work as a social worker vices. Loch thought that individuals request- in the dispensary of the Massachusetts Gen- ing care should be screened by “a competent eral Hospital 10 years after Mary Stewart was person of education and refi nement who could fi rst hired to work at the Royal Free Hospital consider the position and circumstances of the in London. Ida Cannon, who replaced Pelton patients” (Cannon, 1952, p. 13). Loch fought after she became ill six months into her ten- for many years to have an almoner appointed. ure and who held the position for 40 years, He addressed the Provident Medical Associa- described “a special bond of fellowship be- tion in 1885 and was called to testify before a tween the English almoners and the medical committee of the House of Lords in 1891. In social workers of our country” (Cannon, 1952, 1895, Mary Stewart was hired to be the fi rst p. 20). She also described her own 1907 visit social almoner at the Royal Free Hospital. with Anne Cummins, an almoner at London’s Prior to assuming the position, Stewart had St. Thomas Hospital. worked for many years for the London Char- Garnet Pelton, Ida Cannon, and Dr. Richard ity Organization Society. She was stationed Cabot were central to the establishment of the at its entrance because her principal function social work department at Massachusetts Gen- at the hospital was to review applications for eral Hospital. Relatively little has been written

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about Pelton or her short tenure at the hospi- educated physician who had a great deal to tal. Cannon (1952) briefl y described Pelton’s do with the establishment of social work and nurse’s training at Massachusetts General other helping professions in U.S. hospitals. Hospital and her contribution to the Denison He was active professionally from the 1890s House Settlement. While at the settlement, she through most of the 1930s, a time when pro- brought Syrian immigrants from her South fessions were being defi ned (see, e.g., Flexner, End Boston neighborhood to the hospital for 1910) and medicine was the standard for what treatment. Pelton was hired by Cabot to work it meant to be professional. at Massachusetts General Hospital and began Cabot’s paternal grandfather, Samuel (1784 on October 2, 1905. She worked from a desk to 1863), made his fortune in trading after fi rst located in a corner of the corridor of the outpa- going to sea at 19 years of age. Samuel Cabot tient clinic at Massachusetts General Hospital married Eliza Perkins, daughter of Boston’s and resigned after six months when she devel- most successful trader, and eventually took oped tuberculosis. The poor received treatment over his father-in-law’s fi rm. He is described for tuberculosis in the outpatient department as a practical man who believed primarily in because they could not afford sanitarium treat- action and hard work and favored commerce ment. There is some question about whether over culture (Evison, 1995). Pelton contracted tuberculosis through her Cabot’s father, James (1821 to 1903), stud- work in the outpatient department. At any rate, ied philosophy in Europe, trained as a lawyer, Cabot arranged for her treatment at Saranac taught philosophy at Harvard, and was a bi- Lake, New York, and later at Asheville, North ographer and friend of Ralph Waldo Emerson. Carolina. He considered himself a transcendentalist, Pelton was succeeded by Ida Cannon, who holding that, “the transcendental included published two books and several reports on whatever lay beyond the stock notions and medical social work and about whom a fair traditional beliefs to which adherence was ex- amount of biographical information is avail- pected because they were accepted by sensible able. Cannon was born in Milwaukee into a persons” (Cabot, 1887, p. 249). The transcen- family of means. She was trained as a nurse at dentalists questioned much of the commer- the City and County Hospital of St. Paul and cialism of their parents’ generation and were worked as a nurse for 2 years. She then stud- particularly critical of slavery. The Civil War, ied sociology at the University of Minnesota, which began when James Elliott Cabot was where she heard a lecture by Jane Addams and 40 years old, was waged in part due to the became interested in social work. She worked sentiments of this generation. Cabot’s mother, as a visiting nurse for the St. Paul Associated Elizabeth, bore most of the responsibility of Charities for three years prior to enrolling in raising the couple’s seven sons and shared Simmons College of Social Work. Cannon with her husband the transcendentalist’s ques- met Richard Cabot through her older brother, tioning of stock notions and traditional beliefs. a Harvard-educated physiologist, as Cabot was Elizabeth Cabot said of women: “[I]t seems to organizing social services at Massachusetts me that very few of us have enough mental Hospital. She was hired to replace Pelton in occupation. We ought to have some intellec- 1906, began working full time after graduat- tual life apart from the problems of educa- ing from Simmons College in 1907, and was tion and housekeeping or even the interests named the fi rst chief of the Social Service De- of society” (Cabot, 1869, p. 45). O’Brien de- partment in 1914. She retired from Massachu- scribes Elizabeth Cabot as “warmly maternal setts General Hospital in 1945. and deeply religious” and “tirelessly philan- Dr. Richard Cabot was an especially pro- thropic” (O’Brien, 1985, p. 536). lifi c writer and has himself been the subject The Civil War demoralized the nation and of scholarship over the years (see, e.g., Dodds, spawned a new conservatism and materialism. 1993; O’Brien, 1985). Cabot was a Harvard- The publication of The Origin of the Species by

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Charles Darwin in 1859 (1936), which brought Patients were treated in the outpatient de- an appreciation of the scientifi c method, and partment at Massachusetts General Hospital growing concern about the number of immi- rather than in the wards when their cases were grants arriving in the country added to a shift considered uninteresting or hopeless (Evison, to realism from the idealism of James Elliott 1995). Because no treatment existed for condi- Cabot’s generation. In the wave of social Dar- tions such as tuberculosis, typhus, and diabe- winism that ensued, charity was seen as naive tes, patients with these conditions usually were and potentially harmful to its recipients. It was treated in the outpatient department, especially into this posttranscendentalist atmosphere that if they were poor. Medicines prescribed were Richard Cabot was born in 1868. largely analgesic. (Antibiotics were not devel- The tension between his generation and that oped until the 1940s.) Many patients were im- of his parents shaped Richard Cabot’s vision. He migrants who presented with language barriers took a radical centrist position based in philo- and infectious diseases such as typhus. Add- sophical pragmatism, taking two opposing views, ing to the bleakness of the situation was the and helped to locate a middle ground between depression of 1893, the worst that had been them. Rather than considering either side as experienced to that date. right or wrong, he held that a greater truth could Cabot described the speed with which emerge through creating a dialogue between the physicians saw patients when he fi rst arrived two sides. Throughout his career, Cabot saw in the outpatient department: Referred to by himself as an interpreter or translator, able to fi nd some physicians as “running off the clinic” the middle ground between extremes. (Evison, 1995, p. 183), a physician pulled a Cabot fi rst studied philosophy at Harvard bell to signal a patient to enter the room. The and then switched to medicine. He rejected physician would shout his questions while the philosophers who observed rather than acted patient was still moving and have a prescrip- and for that reason was drawn to the philoso- tion written by the time the patient arrived at phy of John Dewey. Evison (1995), a Cabot his desk. He would then pull the bell for the biographer, writes: “[A]ction drew him; Jane next patient. Addams and Teddy Roosevelt appealed to him Cabot began to see that social and mental because they did something” (p. 30). Cabot problems often underlaid physical problems held that knowledge was gained through prob- and that purely physical affl ictions were rare lem solving, even when hypotheses were not (Cabot, 1915). He held that it was not possible supported. Like Addams before him, he be- to restore patients to health without consid- lieved that people can learn from failure. ering what he called the nonsomatic factors, Cabot’s senior thesis used epidemiologic such as living conditions. He described one methods to examine the effi cacy of Christian case in this way: Science healing (Dodds, 1993). By the time he had completed medical school in 1892, the One morning as I was working in the out- germ theory of the 1870s and 1880s had taken patient department, I had a series of knotty hold, and the roles of technology and labora- human problems come before me . . . that tory analysis had gained in salience. Cabot morning I happened to wake to the fact that initially followed the trend by completing the series of people that came to me had pretty postgraduate training in laboratory research much wasted their time. I had fi rst of all to deal with a case of diabetes. That is a disease and a Dalton Research Fellowship in hematol- in which medicine can accomplish practically ogy. He turned down an appointment as the nothing, but in which diet can accomplish a fi rst bacteriologist at Massachusetts General great deal. We had worked out very minutely Hospital and in 1898, four years after com- a diet that should be given such patients. We pleting his fellowship, accepted a much less had it printed upon slips which were made up prestigious appointment in the outpatient de- in pads so that we could tear off a slip from partment. one of these pads and give the patient the best

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that was known about diabetes in short com- [S]he will not be there primarily as a critic, pass. I remember tearing off a slip from but nevertheless she will be far better than the this pad and handing it to the patient, feel- average critic because she will be part of the ing satisfaction that we had all these ready institution and will be criticism from the inside, so that the patient need not remember any- which I think is always the most valuable kind. thing. . . . The woman to whom it had been (Cabot, 1912, pp. 51–52) given did not seem satisfi ed. I asked her what was the matter. . . . She looked it over Pelton kept records of every case, which were and among the things that she could eat she used for instruction and to identify trends that saw asparagus, Brussels sprouts, and one or would be published in regular reports. Prior to two other things, and she called my attention Pelton, no records of patient visits to the out- to the fact that there was no possibility of her patient department were kept at Massachusetts buying these things. We had, in other words, Hospital. asked her to do things that she could by no Cabot viewed social workers as translators possibility do. (Cabot, 1911, pp. 308–309) of medical information to patients and families in a way that they could understand. He said, Cabot’s exposure to social work came fi rst from his relationship with Jane Addams. In [T]he social worker . . . can reassure patients 1887, he took a course at Harvard entitled “Ethi- as to the kind of things that are being done cal Theories and Social Reform” from Francis and are going to be done with them. There Greenwood Peabody. Many who took the course is no one else who explains; there is no other person in the hospital whose chief business is went on to work for the Boston Children’s Aid to explain things. (Cabot, 1912, p. 50) Society, as did Cabot when he became a director there in 1896. It was there that he was exposed to Cabot also saw social workers as trans- the case conference approach. lators of information about patients and Cabot viewed the relationship between families to physicians. Social work’s role in medicine and social work from his radical cen- providing social and psychological informa- trist perspective. He thought that each profes- tion to physicians is described in a quote from sion possessed the element that the other most Ida Cannon: needed. For medicine, this was empiricism, and for social work, it was breadth. Cabot While she must have an understanding of thought physicians’ enthusiastic acceptance of the patient’s physical condition, the physical empiricism had made them far too narrow in condition is only one aspect of the patient to which she must take account. As the physi- scope, ignoring social and psychological fac- cian sees the disease organ not isolated but tors in health. Social workers possessed the as possibly affecting the whole body, so the breadth that physicians lacked but relied too hospital social worker sees the patient not heavily on good intentions. They needed to merely as an isolated, unfortunate person become more scientifi c and systematic to en- occupying a hospital bed, but as a member sure that their methods were effective and to belonging to a family or community group develop a theoretical base for their work. Each that is altered because of his ill health. Physi- profession could gain from association with cian and nurse seek to strengthen the general the other. physical state of the patient so that he can Cabot set about reforming the treatment combat his disease. The social worker seeks process in the outpatient clinic. He hired to remove those obstacles, either in the pa- tient’s surroundings or in his mental attitude, Garnet Pelton to fulfi ll three functions: (1) to that interfere with successful treatment, thus critique while helping to socialize medicine, freeing the patient to aid in his own recovery. (2) to act as a translator between the physi- (Cannon, 1923, pp. 14–15) cian and patient and family, and (3) to provide information on social and mental factors. Cabot thought that social work could best fulfi ll Cabot described the critical role by saying this role because nurses had “lost their claim

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to be a profession by allowing themselves to often during their fi rst years of working to- become mere implementers of doctor’s or- gether. Cannon thought social workers should ders” (Evison, 1995, p. 220). He defi ned social accommodate hospital mechanisms rather work’s expertise as diagnosis and “treatment than being critics or reformers of medicine, of character in diffi culties,” which he saw as as Cabot had advocated. Nevertheless, the encompassing expertise in mental health. two worked together until Cabot accepted a The hospital did not initially support commission of major in the Medical Reserve Pelton’s hiring, so Cabot paid her salary with Corps in 1917 during World War I. He re- his own funds. To convince the hospital’s su- turned to the outpatient department of Massa- perintendent, Frederic Washburn, that Pelton chusetts General Hospital in 1918, but he then was a good addition, Cabot set about docu- left to chair Harvard’s Department of Social menting that her hiring was cost effective. He Ethics in 1919. Shortly before he left the hos- calculated that the hospital had spent $120 on pital, its board of directors voted to make the a baby with gastrointestinal problems whose Social Service Department a permanent part mother brought her to the hospital on four oc- of the hospital and to cover the full cost of its casions over a short period of time because functioning. Prior to that, Cabot had covered the family was unable to provide the nutrients the cost of up to 13 social workers with his prescribed for her. Cabot did not want admin- personal funds. istrators to view social work’s primary role as Ida Cannon was named director of the new preventing misuse of hospital services but in- Social Work Department in 1919. By the time stead to save money by helping to make treat- she retired from Massachusetts General Hos- ment more effective. He viewed medical social pital in 1945, the hospital employed 31 social workers as distinct from hospital almoners. workers. Several former social workers at Mas- Ida Cannon took over for Garnet Pelton in sachusetts General Hospital went on to direct 1906 when Pelton went to Saranac Lake, New departments in other hospitals, such as Mary York, to receive treatment for pulmonary tu- Antoinette Cannon (the University Hospital of berculosis. Cannon was named the fi rst chief Philadelphia) and Ruth T. Boretti (Strong Me- of social work in 1914. She shared status with morial Hospital of the University of Rochester the chief of surgery and the chief of medicine. School of Medicine and Dentistry). Cannon developed training programs for so- cial workers at Massachusetts General Hos- pital, including medical education. Cannon GROWTH OF HOSPITAL hired Harriett Bartlett to be the fi rst educa- SOCIAL WORK tional director in the Social Work Department. DEPARTMENTS Other programs begun during her tenure in- cluded a low-cost lunch counter for patients In 1961, Bartlett described the course of so- and staff; a committee to investigate the social cial work in health care as spiraling, “in which correlates of tuberculosis, which produced the periods of uncertainty and fl uidity alternated fi rst comprehensive analysis of tuberculosis with those of clarity and control” (p. 15). She in the United States; interdisciplinary medical said that in its fi rst 30 years, growth was lin- rounds with social workers; and clay model- ear as social work spread from one hospital to ing classes for psychiatric patients. Cannon another. Methods were simple because social and Cabot together developed systems for work in hospitals “almost alone carried the re- evaluating the effectiveness of social work in- sponsibility for bringing the social viewpoint terventions and included this information in into the hospital.” medical records. The success achieved at Massachusetts Cannon did not take the same radical views General Hospital eventually drew the attention of hospital social work that were espoused by of the American Hospital Association and the Pelton and Cabot, with whom she clashed American Medical Association. Johns Hopkins

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Hospital hired Helen B. Pendleton, who had PROFESSIONALIZATION OF worked with the Charity Organization Society THE FIELD as its fi rst social worker in 1907. As had been the case with Garnet Pelton at Massachusetts The fi rst training course in medical social work General Hospital, Pendleton remained on the was held in 1912. Cannon (1932) wrote that the job for only a few months. The position re- growth of such courses was slow and lacked mained vacant for four months, then she was coordination until 1918, when the American replaced by a graduate nurse. At Johns Hop- Association of Hospital Social Workers was kins, social workers initially were housed in established in Kansas City. The association, a room that was also used for storing surgical which employed an educational secretary, had supplies. They were not allowed on the wards, a twofold purpose: to foster and coordinate which were controlled by nurses (Nacman, the training of social workers in hospitals and 1990). Social workers, however, controlled to enhance communication between schools access to medical records by physicians and of social work and practitioners. Although nurses and had to approve all free medical care the American Association of Hospital Social and prescriptions for medicine that was to last Workers was the fi rst national organization of longer than one week (Brogen, 1964). The de- social workers in health care, it was preceded partment prospered, as had the department at by local organizations in St. Louis, Boston, Massachusetts General Hospital, and by 1931 Philadelphia, Milwaukee, and New York. Mary had a staff of 31. A. Stites, the author of History of the Ameri- Garnet Pelton completed a survey of so- can Association of Medical Social Workers cial service in hospitals in the United States (1955) says that prior to the establishment of in 1911 at the behest of John M. Glenn, the the American Association of Hospital Social fi rst director of the Russell Sage Foundation Workers, medical social workers in health care and a strong proponent of social work in health for some time had congregated at meetings of care. She was able to locate 44 social service the National Conference of Social Work (for- departments in 14 cities, 17 of which were in mally called the National Conference of Chari- New York City alone. These departments pro- ties and Corrections). The burning question at vided a range of services, all focused on the the fi rst meeting of the American Association of provision of assistance to the patient (Cannon, Hospital Social Workers in 1918 was whether 1952). the group should orient more closely with so- New York City, which housed nearly 40% cial work or medicine. Eight of the 30 women of the country’s hospital social service depart- who signed the association’s fi rst constitution ments, organized the fi eld’s fi rst conference in were graduate nurses. 1912, which was called the New York Confer- The American Association of Hospital So- ence on Hospital Social Work. The conference cial Workers published a study of 1,000 cases was held regularly between 1912 and 1933. from 60 hospital social work departments in A quarterly report entitled Hospital Social 1928. According to the report: Service documented conference fi ndings and highlighted the progress of various hospital so- cial service departments. The social worker’s major contributions to By 1913, 200 U.S. hospitals had social medical care, gauged by frequency of perfor- mance, are: (1) the securing of information workers. Ruth Emerson, who left Massachu- to enable an adequate understanding of the setts General Hospital in 1918, established the general health problem of the patient; (2) in- social service department at the University of terpretation of the patient’s health problem to Chicago. Edith M. Baker, who left Massachu- himself, his family and community welfare setts General Hospital in 1923, established the agencies; and (3) the mobilizing of measures social service department at Washington Uni- for the relief of the patient and his associates. versity in St. Louis. Briefl y then, the basic practices of hospital

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social work exhibited in the study under con- 6. Medical extension of transfer to convales- sideration can be described as discovery of cent home, public health agency, or medical the relevant social factors in the health prob- institution lems of particular patients and infl uencing these factors in such ways as to further the In 1954, the year before the American As- patient’s medical care. (p. 28) sociation of Medical Social Workers merged This description does not differ appreciably with six other specialty organizations to form from the way that hospital social work was the National Association of Social Work- conceptualized by Cannon and Cabot at Mas- ers, 2,500 people attended its annual meet- sachusetts General Hospital. ing. The American Association of Medical A survey of schools of social work pub- Social Workers was the largest of all social lished in 1929 (Cannon, 1932) listed 10 schools work membership organizations. The current that offered formal courses in medical social major specialty organization for social work- work and 18 that were in the process of plan- ers in health care on the national level, the ning medical social work curriculum: Society for Leadership in Health Care, boasts 700 members (Society for Social Work Lead- 1. Washington University ership in Health Care, 2011, January 2). This 2. University of Chicago organization, which changed its name from 3. New York School of Social Work the Society for Social Work Administrators in Health Care in the 1990s and is affi liated 4. Tulane University with the American Hospital Association, was 5. University of Indiana founded in 1965. Other current national or- 6. University of Missouri ganizations include the American Network of 7. Simmons College Home Health Care Social Workers, the Asso- 8. Western Reserve University ciation of Oncology Social Work, the Council 9. Pennsylvania School of Social and of Nephrology Social Workers, the National Health Work Association of Perinatal Social Workers, and 10. National Catholic School of Social Work the Society for Transplant Social Workers.

In all, medical social work was considered to be graduate-level work. A second survey DEFINING MEDICAL that year was sent to social service department SOCIAL WORK heads in hospitals asking them to query their workers about their training and experience. By 1934, the American Association of Medi- Of the 596 respondents, 70% had taken at least cal Social Workers (the American Associa- one course in general social work, and 48% tion of Hospital Social Workers changed its of those had received a diploma or certifi cate name that year) published a report prepared between 1899 and 1930. Interestingly, 38% of by Harriet Bartlett. The report defi ned medical respondents had completed at least one course social work as a specifi c form of social case in nursing, and 86% of those had received a work that focuses on the relationship between certifi cate or diploma in nursing. The survey disease and social maladjustment. Bartlett listed six activities of medical social workers: wrote, “[I]t is an important part of the social worker’s function to concern herself with the 1. Medical social case management social problems arising directly out of the na- ture of the medical treatment. In this way, she 2. Securing data facilitates and extends the medical treatment” 3. Health teaching (p. 99). Emphasis was placed on surmounting 4. Follow-up social impediments to health, “providing some 5. Adjustment of rates occupation or experience for the person jolted

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out of his regular plan of life by chronic dis- Klein, & Kohrman, 1961), although the Psy- ease, to offset what he has lost and to make chiatric Social Service Department was not him feel that he has still a useful place in the established at Massachusetts General Hospital world” (p. 99). until 1930. Mary Jarrett (1919), the associate The 1934 report highlighted a series of director of the Smith College Training School problems as requiring particular attention. for Social Work, argued for a more psychiatric They were: (a) the integration of psychologi- approach to case work in her address to the cal concepts, defi ned in part as needing to Conference of Social Work in 1919: know more about human motivation in gen- eral and in relation to illness; (b) problems One by-product of the psychiatric point of of functional and mental disease, specifi cally view in social case work is worth consid- the need to integrate the study of the organism eration in these days of overworked social with that of the personality; and (c) problems workers, that is, the greater ease in work that it gives the social worker. The strain of of methods of thinking, which had to do with dealing with unknown quantities is perhaps balancing the study of personality with a con- the greatest cause of fatigue in our work. . . . sideration of the person in his social situation. More exact knowledge of personalities with This competition for attention between which we are dealing not only saves the personality and social environment gained worker worry and strain but also releases salience with the advent of psychiatry and energy which can be applied to treatment. . . . psychoanalysis in the United States. Although Another result is that impatience is almost popular in Europe in the 1880s and 1890s, entirely eliminated. No time is wasted upon mental treatment in hospitals did not take hold annoyance or indignation with the uncoop- in the United States at fi rst. Courses in psycho- erative housewife, the persistent liar, the re- therapy began appearing in medical schools peatedly delinquent girl. . . . I know of social in 1907, and Freud made his fi rst tour of the workers who looked with suspicion upon the careful preliminary study of personal- United States two years later. ity, because they feared that all the worker’s The emergence of psychiatry and psycho- interest might go into the analysis, and that analysis into medicine had two major effects treatment might be neglected. I believe that on social work in health care. First, psychia- fear has been something of a bugaboo in so- try’s emergence into medicine is tied to the cial work. (p. 592) appearance of other professionals in hospi- tals, such as psychologists and social scien- The implication of Jarrett’s address is that a tists. Their presence meant that the social and focus on personality allows the social worker mental domains of health were no longer ex- to get at the client’s problem with ease, thus clusive to social work and that medical social saving time for treatment. work for the fi rst time had signifi cant competi- Another possible source of social work’s at- tion for a role in health care. traction to psychoanalytic theory was Abraham A second effect of psychiatry’s emergence Flexner’s 1915 address to the National Con- into medicine was the impact of psychoana- ference of Charities and Corrections, in which lytic theory on how social workers in health he said that social work was not a profession. care approached cases, namely, from a more Flexner defi ned professions as: (a) involving person-centered perspective. The confusion essentially intellectual operations, (b) having between a focus on personality and on social large individual responsibility, (c) deriving environment remained after psychiatric social their raw material from science and learning, work separated from medical social work. The (d) working up their material to a practical separation often is attributed to 1919, when and defi nite end, (e) possessing educationally Smith College developed a course for psy- communicable techniques, (f) tending to self- chiatric aides attached to the U.S. Army dur- organization, and (g) becoming increasingly ing World War I (Grinker, MacGregor, Selan, altruistic in motivation. He said that although

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social work had a professional spirit, it failed The number of social workers in health care to meet all of the criteria for a profession be- increased with the variety of work settings. cause its members did not have a great deal of Between 1960 and 1970, the number of social individual responsibility and lacked a written workers in health care nearly doubled (Bracht, body of knowledge and educationally com- 1974). By 1971, social workers were employed municable techniques. Flexner’s address had in a wide range of settings. A Medicare report a profound effect on the fi eld. Some social from that year reported 11,576 social workers workers viewed medicine as a model profes- in 6,935 participating hospitals, 2,759 in 4,829 sion and an intrapersonal approach as more extended-care facilities, and 316 social workers professional than one focused on social and in 2,410 home health agencies (U.S. Department environmental factors. of Health, Education, and Welfare, 1976). Social Nacman (1990) notes that, by the 1940s, workers also could be found in state and local psychosocial information was increasingly health departments and in federal agencies, such being used by medical social workers to as the Department of Defense. Social workers make medical diagnoses and treatment entered new health-care arenas, such as preven- plans. This was in contrast to its use, in Ida tive and emergency services. Techniques were Cannon’s words, “to remove those obstacles, added to the social work repertoire to address either in the patient’s surroundings or in his these new settings and arenas. Interventions ap- mental attitude, that interfere with success- peared based on behavior, cognitive, family sys- ful treatment, thus freeing the patient to aid tems, crisis, and group work theories. Because in his own recovery” (1923, pp. 14–15). The health costs were growing at an alarming rate, work of Helen Harris Perlman countered the the federal government began to institute mea- tendency to use information primarily to sures to control costs. In 1967, utilization review make medical diagnoses and plans by em- measures were enacted that required Medicare phasizing social science concepts over psy- providers to demonstrate that care was neces- choanalytic ones and refocusing on society sary and that its costs were reasonable. In 1972, and environment. A focus on environment Congress enacted the Peer Standards Review was reinforced in the 1950s by the commu- Act, which required the peer review of medical nity mental health and public health move- billing to ensure that services had been utilized ments (see Chapter 4 of this text) and the appropriately. civil rights movement of the 1960s. Neither utilization review nor peer stan- dards review proved as effective as was hoped. Another attempt to control costs took its cues SOCIAL WORK IN HEALTH from a long history of prepaid health-care ar- CARE: BEYOND THE rangements provided to workers around the HOSPITAL country, the fi rst of which was a rural farm- ers’ cooperative in Elk City, Oklahoma, in After World War II and the passage of the 1929. The best known of these arrangements Social Security Act, social work in health was the Kaiser Permanente Health Plan. In care began to branch out from its hospital 1973, the Health Maintenance Organization base. Social work programs were established (HMO) Act was passed by the Nixon admin- in the U.S. Army and Navy and the Veter- istration. The act authorized $375 million in ans Administration. The advent in the mid- federal grants to develop HMOs. Initially, em- 1960s of Medicare and Medicaid, and titles ployers saw HMOs as a less expensive way XVIII and XIX of the Social Security Act, of providing insurance to their employees. provided coverage for people who might In recent years, state governments have used otherwise not have been treated. These two managed care in their Medicaid programs. By programs further increased the need for so- 1993, 70% of Americans with health insurance cial work services. were enrolled in some form of managed care.

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Cornelius (1994) distills the perils of managed professionals were organized by service rather care for social workers by saying that than by department. It is clear that hospital social workers found the social worker becomes an agent of man- less opportunity to spend time with patients aged care and agrees to serve the public because patients were there for less time, and within the corporate guidelines and not nec- much of the social worker’s time was taken essarily according to the assessed needs of by helping to prepare sicker patients and their the client. . . . If the social worker practices outside the protocols, . . . the client is denied families for recuperation at home or in other coverage and the social worker is denied re- facilities, such as extended-care facilities. Do- imbursement; money becomes the carrot and brof (1991) describes “hospital-based social the stick. (p. 52) workers confronting larger caseloads of sicker patients with increased need for home care ser- Another major cost containment effort had vices or placement in nursing homes” (p. 44). a profound effect on hospital care. The pro- Both HMOs and DRGs affected how so- spective payment system, based on a set of 500 cial workers in health care practiced. HMOs diagnostic-related groups (DRGs), each with restricted social workers’ ability to practice its own specifi c payment rate, was instituted based on their own assessment of needs. DRGs in 1983 to replace traditional retrospective re- limited the time that social workers in hospi- imbursement for hospital care. The rates were tals had to work with patients and forced an developed based on the nature of the illness, emphasis on discharge planning. This limited accepted treatment procedures, whether the social workers’ ability to perform in the man- hospital was a teaching facility, local wage ner outlined by its founders, such as Bartlett, scales, and the hospital’s location (Reamer, “to concern herself with the social problems 1985, p. 86). This standardization was in- arising directly out of the nature of medical tended to provide an incentive for hospitals to treatment” (1934, p. 99), or Cannon, “to re- become more effi cient. move those obstacles . . . that interfere with suc- Under DRGs, patients entered the hospital cessful treatment” (1923, pp. 14–15). sicker and left sooner (Dobrof, 1991). This New techniques have been developed in impacted hospital social work services in two response to time limits on treatment. Task- major ways: centered case work (Reid & Epstein, 1972) emphasizes the goals of treatment, and a num- 1. Hospitalization was seen as a failure of the ber of brief treatment techniques have been system, and every effort was made to avoid developed (see, e.g., Mailick, 1990). Social it; thus, those who were admitted were workers have helped to adapt intervention the- quite ill. ories for use in health settings, such as stress 2. Because hospitals were paid a specifi ed inoculation from cognitive theory (see, e.g., rate, it was in their best interests to keep Blythe & Erdahl, 1986). stays as short as possible. Because patients Claiborne and Vandenburgh (2001) defi ne a entered more ill and stayed for a shorter new role for social workers as disease manag- time, less comprehensive care could be pro- ers. As patients live longer with disease con- vided in hospitals. ditions or survive conditions once considered fatal, such as cancer, issues of quality of life Although there is debate about the extent to arise. Survivors of cancer, previously expect- which social workers were cut from hospitals ing to die, need assistance with learning how to (see, e.g., Coulton, 1988), many social work live. Those with long-term health conditions, forces in hospitals were downsized or recon- such as rheumatoid arthritis, require guidance fi gured during this period. Some were merged on how to live a full life with their condition. with other departments, others self-governed, As a rule, disease management entails “a team and, in other cases, social workers and other of professionals that integrates and coordinates

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care across an array of services to maintain op- mental domains largely unchallenged by other timal patient functioning and quality of life” disciplines. With the advent of psychotherapy, (Claiborne & Vandenburgh, 2001, p. 220). however, professionals such as psychologists These teams often operate across facilities. and other social scientists began to work in Claiborne and Vandenburgh see social work- hospitals, and for the fi rst time social workers ers as key members of disease management had to compete for roles. teams due to their ability to work across health The period of linear growth was followed systems and managed care settings. Chapters 8 by an expansion into previously unimagined and 20 of this text discuss mental health issues settings. Federally imposed cost containment, in chronic illness. beginning in the late 1960s, posed challenges The Patient Protection and Affordable Care to social workers in health care and forced a Act (PPACA), which was enacted in March great deal of fl exibility and creativity. In some 2010, represents a radical change in how health- respects, competition with other disciplines care services are constructed and delivered. Al- that social work experienced in its most recent though its course and impact are yet to be seen, 70 years in health care, and its failure to defi ne Darnell and Lawlor (in Chapter 5 of this text) a niche that was exclusively its own since that argue that the PPACA will change the land- time (see, e.g., Lister, 1980), prepared social scape of health social work practice for the fore- workers to remain viable in a changing health- seeable future and heighten its importance, for care environment. They have adapted well to a number of reasons. Although the PPACA in- these changing environments. cludes provisions to extend insurance coverage, How do the visions of Ida Cannon and Rich- for example, it falls short of universal coverage. ard Cabot hold in the current health environ- Darnell and Lawlor estimate that 23 million ment in which social workers practice? At a time people will remain uninsured in 2019, includ- when the changing demographics pose prob- ing undocumented immigrants, who except lems of communication in health care, Cabot’s for emergency situations are excluded from idea of social worker as translator or interpreter Medicaid coverage. Health social workers will seems modern and as salient today as it was in be important advocates for those who remain 1905. In 2000, 1 in 10 U.S. residents, over 28.4 uninsured. Also, despite improved affordabil- million people, was born outside the country ity of insurance coverage, the coordination of (Lollock, 2001). These fi gures do not include care will remain a challenge (Gorin, Gehlert, & an estimated 10.9 million undocumented immi- Washington, 2010). Health social workers will grants (Camarota & Jensenius, 2009). play a crucial role in connecting patients to ap- The current 10% of U.S. residents who propriate services and maintaining the safety were born outside the country compares to a net for those who do not qualify for services. high of 15% between 1890 and 1910, the years during which Mary Stewart was hired in Lon- don and Garnet Pelton and Ida Cannon were CHANGES IN TECHNIQUE hired in Boston. The percentage born outside AND APPROACH THROUGH the country in 2000 is higher than it was for TIME the decades that immediately preceded 2000. According to U.S. Census Bureau records, 7% The settings in which social work is practiced of the population was born outside the United in health care have changed through time. States in the 1950s, 5% in the 1970s, and 8% From 1905 until 1930, medical social work- in the 1990s (Lollock, 2001). ers practiced almost entirely in hospitals. Har- As outlined in Chapter 10 of this text, com- riet Bartlett (1957) described the course of munication is the key to the provision of ef- change during that period as linear, with the fective health care. Clinical encounters are number of social service departments increas- more problematic when providers and patients ing steadily and their claim to the social and are from different racial or ethnic groups or

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different socioeconomic statuses. A report by Although they initially disagreed about the the Institute of Medicine (2002) implicated role of social workers as critics or agents of physician behavior in health disparities in socialization within hospitals, both Cabot and the United States, and researchers (see, e.g., Cannon doubtless would be impressed by the Johnson, Roter, Powe, & Cooper, 2004) have growing number of social workers who serve noted different communication patterns among as administrators of hospitals and health-care White American physicians when they are agencies and institutions across the United dealing with African American versus White States. American patients. It is unlikely, however, Ida Cannon’s statement that social work, that these biases are limited to physicians. Al- when practiced at its best, “is a constantly though empirical studies to date have centered changing activity, gradually building up guid- on the behavior of physicians as the time that ing principles from accumulated knowledge providers are able to spend with patients de- yet changing in techniques” (1923, p. 9), still creases, the opportunity for mental shortcuts holds true. Social work in health care has that can lead to bias increases (Burgess, Fu, & been through a great deal in 100 years and has von Ryn, 1990). Clearly, the translator or in- weathered seemingly insurmountable chal- terpreter role fi rst defi ned by Richard Cabot in lenges through time. As noted by Darnell and 1905 remains important in health care today. Lawlor in Chapter 5 of this text, health social Likewise, the idea that social workers are in workers now face a role as policy implemen- the best position among professionals in health tors and advocates for the health-care delivery care to interpret information from patients and systems changes that come from the 2010 Pa- families to providers and to interpret and ex- tient Protection and Affordable Care Act. De- plain information from providers to patients spite these never-ending challenges, however, and families holds true. the guiding principles of social work in health Cannon’s dictum that the social worker see care remain in force and are as strong today as the patient “as a member belonging to a family they were in 1905. or community group that is altered because of his ill health” (1923, p. 15) also seems ger- mane to the current challenge of disease man- SUGGESTED LEARNING agement. Cannon was writing at a time prior to EXERCISES the development of treatment advances, such as antibiotics, chemotherapy, and radiation Learning Exercise 1.1 therapy, when patients did not live for long pe- riods of time with chronic health conditions. The people involved in establishing the fi rst Her words seem even more salient today when Social Service Department at Massachusetts a growing number of patients face living with General Hospital (Ida Cannon, Garnet Pelton, chronic conditions. and Richard Cabot) were all White Americans Cabot’s belief that social workers should and came from families without fi nancial dif- become more scientifi c and systematic was fi culties. Cabot was from a very privileged evidenced with the advent of research in so- background. Cannon’s father was a railroad cial work in the late 1960s and early 1970s. He administrator in Minnesota. That Pelton was and Cannon would be heartened by the success able to obtain nurses’ training at the turn of the of evidence-based practice and the active in- century suggests that she had means. The sub- corporation of research in social work practice sequent century of social work’s involvement in health care. Social workers with health-care in health care has seen the inclusion of many backgrounds now head research teams and people from a number of racial, ethnic, and serve as program directors and other key posi- socioeconomic backgrounds. In small groups, tions at the National Institutes of Health and indicate how you think the diverse nature of other federal agencies. the health social work today might infl uence

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