johnson1990

This article was downloaded by: [University of Illinois at Urbana-Champaign] On: 16 March 2015, At: 18:47 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK Journal of Social Work Education Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/uswe20 Strengthening the “Bio” in the Biopsychosocial Paradigm Dr. Harriette C. Johnson a , Susan P. Atkins , Stanley F. Battle a , Laurele Hernandez-Arata b , Michie Hesselbrock c , Mary Frances Libassi a & Michael S. Parish d a University of Connecticut , USA b Connecticut Valley Hospital , USA c Southern Connecticut State University , USA d Clinical Social Worker, Path Inc. , USA Published online: 14 Jun 2013. To cite this article: Dr. Harriette C. Johnson , Susan P. Atkins , Stanley F. Battle , Laurele Hernandez- Arata , Michie Hesselbrock , Mary Frances Libassi & Michael S. Parish (1990) Strengthening the “Bio” in the Biopsychosocial Paradigm, Journal of Social Work Education, 26:2, 109-123 To link to this article: http://dx.doi.org/10.1080/10437797.1990.10672142 PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/terms- and-conditions

Journal of Social Work Education 109 Spring/Summer 1990,No. 2 Downloaded by [University of Illinois at Urbana-Champaign] at 18:47 16 March 2015 HARRIETTE C . JOHNSON is Professor, University of Connecticut. SUSAN P. ATKINS is Senior Therapist, Center For Preventive Psychiatry, White Plains, New York, and in private practice in Stamford, CT. STANLEY F . BATTLE is Professor, University of Connecticut. LAURELE HERNANDEZ-ARATA is Director of Psychiatric Social Work Connecticut Valley Hospital. MICHIE HESSELBROCK is Associate Professor, Southern Connecticut State University. MARY FRANCES LIBASSI is Associate Professor, University of Connecticut. MICHAEL S. PARISH is Clinical Social Worker, Path Inc. Strengthening the “Bio” in the Biopsychosocial Paradigm by HARRIETTCE. JOHNSON, SUSANP. ATKINSS, TANLEYF. BATTLE, LAURELEHERNANDEZ-ARATMAI,CHIEHESSELBROCMKA, RYFRANCELSIBASSI, AND MICHAELS . PARISH Although for some time social work has person has not always been translated into paid lip service to the notion of “biopsy- holistic assessment and intervention’. So- chosocial” as a core concept for practice- cial workers are usually well versed in the relevant behavioral science, the literature “psycho” and “social” components of the suggests that the “bio” component is often tripartite model but the literature suggests neglected in social work curricula. This that the “bio” component is often ne- articles provides evidence of the need for glected (Cohen, 1988; Saleebey, 1985). biological content, considers obstacles to infusing biological material into existing This article argues that practitioners curricula, and suggests alternative models need knowledge about biological factors, for integrating biological knowledge into which are defined as the physical structures master’s level social work programs. and processes of the human body, and we propose the expansion of biological con- Although “biopsychosocial” has been a tent in social work curricula to meet this core concept for practice-relevant behav- need. Examples of the kinds of biological ioral sciences for some time, informal content that are relevant to social work perusal of social work curricula in masters practice include information about major level programs suggests that the concept is illnesses (cancer, heart disease, stroke, honored more in theory than in reality AIDS, mental disorders) and current treat- (Cohen, 1988; Saleebey, 1985). Tradi- ments for these diseases, side effects of tional social work concern with the whole common medications, how the brain func- tions and how medications impact this The authors wish to acknowledge the contributions of function, effects of industrial and other Christine Tall, Lynn Letarte, and Jann Dalton, of the environmental toxins, and normative phys- Connecticut State Department of Health Services. ical development and human physiology. Insufficient attention to biological fac-

110 JOHNSON ET AL. JSWE -26:2 Downloaded by [University of Illinois at Urbana-Champaign] at 18:47 16 March 2015 tors is a limitation that appears to be shared ago, strongly determined by human biol- by social work and family therapy, which ogy. Few today give credence to Freud’s have tended to view biological factors as views about biology, but research during the domain of medicine (Cohen, 1988; the past two decades has produced an Johnson, 1980; Saleebey, 1985). This view enormous and constantly growing body of has resulted in social work’s separation of knowledge about biological/psychological physical from mental functions, despite interrelations that show that Freud’s con- contemporary knowledge of interactions viction about the primacy of biology in between the body and the mind2 (Kandel, mental functioning is entirely justified. 1979). In Connecticut, impetus from practition- There is mounting evidence that this ers in diverse fields of practice led to the lack in master’s curricula adversely affects formation of a committee to consider social clients with diverse presenting problems. workers’ need for biological knowledge Social workers screen clients in a wide and to develop strategies for integrating range of settings, make referrals for biological content into master’s level physical evaluation, refer for treatment, curricula. The task of developing strategies and provide ongoing services to clients for bachelor’s curricula was deferred for a with medical and psychiatric problems. subsequent effort. The committee was The lack of biological knowledge has composed of social work faculty from the resulted in inappropriate referrals, unwar- state’s two MSW programs and of practi- ranted treatment recommendations, failure tioners working with a range of client to recognize and/or question inappropriate populations. This article presents the com- treatments by physicians, and even law mittee’s proposals. It provides evidence of suits (Besharov, 1985; Cohen, 1988; Hall, the need for biological information, con- Gardner, et al, 1981; Johnson, 1985; siders obstacles to infusing biological Koranyi, 1979; Saleebey, 1985). The content into existing curricula, and sug- dangers of lack of content on the adverse gests alternative models for integrating effects of psychotropic medications have biological knowledge into master’s level been forcefully presented (Cohen, 1988; social work programs. Gerhart & Brooks, 1983). WHY BIOLOGICAL CONTENT IS NEEDED Evidence of a growing awareness of the importance of this issue can be found in The case for biological knowledge can debates in major journals (Cohen, 1988, be made with reference to functions that 1989; Green, 1988; Johnson, 1986, 1989; social workers perform in a range of Saleebey, 1985; Taylor, 1988), in the settings, and it can be made with reference major media (Blakeslee, 1989), and, most to substantive areas of practice. Social recently, in the convening by the Council work functions that require biological on Social Work Education of a panel of knowledge include formal and informal experts to devise strategies for introducing screening, referral, collaborative services content on psychopharmacology into social with medical and psychiatric caregivers, work curricula (Libassi, 1990). case monitoring and advocacy, and psy- chotherapy. One or more of these functions Although knowledge about psychophar- is carried out by virtually all social workers macology constitutes a major component who do direct practice with individuals. of the kinds of biological information that families, and groups, and most or all of are needed by practitioners, the issue is these functions are performed by social broader than simply one of teaching future workers acting as case manager. Examples social workers about therapeutic and harm- of substantive areas or fields of practice ful effects of medications. The more that rely heavily on biological knowledge fundamental concept is that human behav- ior itself is, as Freud believed a century

Downloaded by [University of Illinois at Urbana-Champaign] at 18:47 16 March 2015 Spring/Summer, 1990 BIOLOGY IN CURRICULA 0 111 are mental health, aging, substance abuse, also may regard themselves in this light if practice with children, and health care. they are ignorant about the client’s condi- tion(s). The case of J illustrates the need SOCIAL WORK FUNCTIONS for biological knowledge to carry out the social work functions of screening, refer- Formal and informal screening ral, and collaborative services with medi- cal and psychiatric personnel. As part of the screening function, social workers need to know when a client needs The stepmother of a blended family felt a medical referral. Whether a client is frustrated and overwhelmed in her at- receiving individual, family, or group tempts to parent her husband’s eleven- services, the social worker may be the only year-old son, J, with whom she lived. She professional helper with whom the client had lost patience with his failure to obey has contact or more than an occasional or to show her any form of respect. She basis. As the “front line” professional in was of the opinion that he was purposely the client’s life, the worker needs to be doing things to annoy and upset her. able to recognize early warning signals of Although the father periodically tried to physical or mental illness in order to be come to his son’s defense, he too would able to refer appropriately. As part of the lapse into diatribes against his son. screening function, workers need to know not only the limits of their own expertise, J’s “incorrigible” behavior had been but also enough about mindlbody interac- attributed by the family to his having been tions to recognize indicators for medical deprived and abandoned by his substance referral. abusing mother. Pursuant to psychiatric evaluation, he had been diagnosed as Referral having Attention Deficit Hyperactivity Disorder (ADHD) and placed on medica- In addition to the interactional skills tion during the school day, which dramat- necessary to refer successfully, the worker ically improved his school behavior. must have enough knowledge about the nature of the problem to refer to the right However, the home situation remained place. Should the client with sleeplessness, chaotic. The family’s social worker ex- disinterest in food and sex, and sadness be plained to the parents that J’s behavior at referred to an internist? a psychiatrist? or home was typical of ADHD and probably be given psychotherapy for depression had a biological basis. Although psycho- directly by the social worker? Although logical damage related to early mothering there may be no rule of thumb for making might well have taken place, it probably such a choice, biological knowledge can was not the explanation for J’s unruly help in the decision. behavior. The worker recommended ex- tending the period of medication to Collaborative services with medical and after-school hours, sought further medical psychiatric personnel consultation, and obtained the prescribing psychiatrist’s cooperation with this plan. In order to be perceived as credible and The child’s home behavior improved competent, social workers must be knowl- significantly, and both parents responded edgeable about the conditions they report by being more positive toward J. Treat- to medical and psychiatric caregivers and ment with medication reversed negative must be familiar with commonly used feedback loops between parents and child. treatments. Without such knowledge, the social worker may be regarded as auxiliary Case monitoring and advocacy or even subordinate rather than as a key actor in the client’s treatment, and workers Social workers often monitor the effects of medical and psychiatric treatments on

112 JOHNSON ET AL. JSWE--26~2 Downloaded by [University of Illinois at Urbana-Champaign] at 18:47 16 March 2015 their clients. When there appears to be a real cause for her symptoms was diag- problem in the treatment, the social worker nosed, it was too late to save her life. must make the physician aware of the problem and often must be an advocate for If the worker had known that a critical the client. To advocate effectively, the physical episode such as kidney failure can worker must be conversant in medical cause disorientation, she could have had terminology and must have enough biolog- more confidence in her belief that more ical knowledge to compile needed data, to was happening to M than “advanced age ask the right questions, to make a convinc- and early stages of senility,” and possibly ing case for modifying or reevaluating the she could have been a more effective treatment, and to evaluate whether the advocate. attending physician or psychiatrist appears to be evasive, uninformed, or possibly Psychotherapy negligent. Is the doctor giving client or worker a “snow job?” Knowledge for The history of both individual and monitoring and advocacy must be specific, family therapy is replete with instances of not global. Obviously a high level of failure by therapists -including the medi- interactional skill is needed in these roles cally trained -to recognize underlying to work with physicians; interpersonal biological causes for overt apparently strategies for multidisciplinary collabora- “psychological” problems. Law suits for tion are decisively important but are these failures have been instituted against beyond the scope of this article. psychiatrists and even against some social workers (Besharov, 1985; Hall, Gardner, The case of M illustrates the need for et al., 1981). The following example of biological knowledge to perform case parents of learning-disabled children illus- monitoring and advocacy functions. trates the importance of biological knowl- edge for carrying out social work functions M, a 72-year-old woman, was admitted to of psychotherapy. the hospital due to a urinary tract infection and an injury related to a fall at her home. Mothers and fathers at a parents’ weekend The hospital demanded that the woman’s at a residential school for children with community social worker arrange place- learning disabilities compared notes. All ment in a nursing home since it was parents expressed delight with the im- provement in reading scores shown by the determined by the medical staff that children as a result of the specialized educational techniques used at the school. further hospital care was not needed. The By contrast, they complained bitterly worker observed that M appeared disori- about prior experiences. Most had partici- pated in family therapy or individual ented and complained of pains in her side. therapy because they had been told that Based on her knowledge of M over a their children’s learning problem was period of time, the worker sensed that “emotional” in origin. Their anger these symptoms might indicate some kind stemmed not only from having been blamed for a neurologically-based deficit of ominous process. However, the hospi- in the child, but also from the waste of tal staff informed her that M’s behaviors time, money, and emotional energy they were due to advanced age and early stages had expended on a treatment that did not of senility. The worker, who felt ill- equipped to deal with medical matters, help (Johnson, 1986. pp. 302-3). capitulated to pressure from the hospital staff and hastily arranged a nursing home Had the therapists treating these parents placement. been more knowledgeable about the bio- logical bases for learning disabilities, they Within three days of the transfer, M became blind, then lapsed into a coma. By the time the kidney failure that was the

Spring/Summer, 1990 BIOLOGY IN CURRICULA 0 113 Downloaded by [University of Illinois at Urbana-Champaign] at 18:47 16 March 2015 would have been less likely to make the subject, see the newsletters of the con- errors so costly to these families and their sumer groups just mentioned). children. The tendency of both social workers and SUBSTANTIVE AREAS OR FIELDS OF PRACTICE physicians to neglect biological factors was demonstrated dramatically in a study of Evidence of the need for biological 2,090 patients screened at a psychiatric information can be found in empirical outpatient clinic (Koranyi, 1979). Among literature and abounds in case histories in this group, 43% were found to be suffering virtually all substantive areas such as from a major physical illness. Nonpsychi- mental health, aging, substance abuse, atric physicians had missed major illness in practice with children, health care, and one third of the patients they referred; criminal justice. psychiatrists had missed major illness in one half; and social agencies and individ- Mental health ual social workers had had no knowledge or even a suspicion of an existing major Consumer movements spearheaded by physical illness in 83% of the cases they the National Alliance for the Mentally I11 referred. Researchers judged that 69% of are raising public concern about the kind of these major medical illnesses contributed treatment members have received at the significantly to the psychiatric state of the hands of mental health professionals, patients (Koranyi, 1979). In another study, including social workers (National Alli- 46 out of 100 patients admitted to a state ance for the Mentally I11 (NAMI), 1989). hospital were found to have previously NAMI, the Association for Children with undiagnosed medical illnesses that had Learning Disabilities (ACLD), and the either caused or exacerbated their psychiat- newly formed Federation of Families for ric illnesses (Hall, Gardner, et al., 1981). Children’s Mental Health (F’FCMH), are Of these 46 patients, 28 showed rapid and taking mental health professionals to task dramatic diminution of psychiatric symp- for sins of both omission and commission. tomatology when the underlying physical Through a combination of ignorance about illnesses were treated. biological etiologies and personal inclina- tion to practice individual and family The two studies by Koranyi and by Hall therapy, professionals have, they assert, and colleagues gave compelling evidence deprived clients of treatments that could be that biological factors are often overlooked beneficial, imposed demeaning and inef- in the process of assessing emotional fective procedures on clients and family disorders, and that social workers referring members, and blamed families for prob- clients to psychiatric facilities missed lems of biological origin by redefining important information in most of the cases them as problems of the “dysfunctional they referred. It seems likely that the family.” These organizations are demand- situation described in Koranyi’s study is ing changes in the curricula of mental related to the dearth of relevant biological health training programs, so that future material in the curricula of schools of practitioners can become informed about social work (Cohen, 1988; Libassi, 1990; contemporary biological knowledge. These Saleebey, 1985). family organizations believe that only by imparting such knowledge can educational Aging programs begin to reverse some of the damaging effects resulting from ignorance Among the biological problems encoun- about the biological components of emo- tered by the elderly that social workers tional, behavioral, and cognitive distur- must know about are the signs and bances and deficits (for literature on this symptoms of major physical illnesses and the effects of medications on mental,

114 JOHNSON ET AL. JSWE-26:2 Downloaded by [University of Illinois at Urbana-Champaign] at 18:47 16 March 2015 emotional, and physical functioning. Be- alcohol andor illicit drugs in many prac- cause the elderly often have multiple tice settings. Chronic and heavy alcohol symptoms and because their physical use has been associated with impairment of response patterns change as they grow cognitive functioning (abstract thinking, older, various conditions are commonly concept formation) as well as early aging misdiagnosed or overlooked (Matteson & of the brain. Social workers have often McConnell, 1988; O’Hara-Devereaux, An- failed to recognize these deficits because drus, & Scott, 1981). clients’ verbal ability remain intact (Gold- stein & Shelly, 1982; Hesselbrock, Wei- Dementias, often reversible, can be denman, & Reed, 1985). Alcohol also induced by physical illness such as pneu- commonly activates centers of the brain monia, subdural hematoma, myocardial that generate rage reactions. Contrary to infarction, liver or kidney failure, diabetes, conventional professional wisdom, alcohol and depression, and by medications being does not only promote violence by lower- taken for physical illness such as analge- ing thresholds of inhibition (facilitating the sics, antihypertensive agents, digitalis, release of “repressed” rage). It may sedatives, anticholinergics, corticosteroids, actually alter brain chemistry to create rage and L-Dopa (Matteson & McConnell, biochemically (Coid, 1979). This informa- 1988). The list of contributors to dementia tion is relevant to clients who exhibit is very extensive. Workers unfamiliar with violent behavior when drunk but are kind these factors have assumed that a treatable and pleasant when sober. In some cases of dementia is an irreversible condition, family violence, rage-generating effects of thereby neglecting to refer the client for alcohol interacting with psychosocial and medical investigation (Galton, 1979). cultural factors may be the recipe for aggressive acts (Coid, 1979). Intrapsychic Adverse drug reactions are widespread therapies aimed at eliciting repressed and can occur because of excessive dose, psychic material may be inappropriate in drug interactions, or allergic reactions such situations. (Matteson & McConnell, 1988). Agism on the part of health care providers has Knowledge about effects of street drugs contributed to overprescription of drugs to as well as signs that a client is a user is the elderly (Matteson & McConnell, critical for accurate diagnosis and interven- 1988). The average older American takes tion planning. Children born to heroin or three times as many drugs as the average methadone-addicted mothers can manifest American; between 75% and 81% of retarded growth and development, erratic people over age 65 take at least one behavior, attentional deficits, hyperactiv- prescription drug, and Medicare recipients ity, or hypoactivity (Deren, 1986). Babies not living in institutions receive an average born to mothers abusing cocaine have of 17.9 prescriptions annually (Matteson & emotional deficits, including difficulty McConnell, 1988). In addition, over- relating to their world, making friends, the-counter medications are widely used by playing like normal children, or feeling elderly people. love for their primary caretakers (Blakeslee, 1989). Although they score Social workers are often the only within normal limits on intelligence tests, providers who see the elderly in the they score far below normal on tests of community, over a period of time, there- concentration, ability to interact with other fore they must be familiar with this children, and to play by themselves in information in order to monitor and refer unstructured environments. Most such ba- when needed. bies show no strong feelings of pleasure, anger, or distress, even when separated Substance abuse from their caretakers. This emotional Social workers encounter abusers of

Downloaded by [University of Illinois at Urbana-Champaign] at 18:47 16 March 2015 SprindSummer, 1 9 0 BIOLOGY IN CURRICULA 115 poverty (lack of strong emotions) is ents soon discontinue the medication be- believed to be a result of neurological cause “it didn’t work.” When this last damage to the pathways of the brain that hope for help “fails,” parents become regulate pleasure and reward. Therapeutic overwhelmed with feelings of despair over day care programs have been instituted to endless continuation of the nightmare of try to remedy these deficits with intensive explosions, rejection, and failure. interventions, but it is too early to ascertain whether long-term outcomes can be posi- In fact, about 80% of ADHD children tive. Social work interventions with teen- respond favorably to properly monitored age drug users at risk for pregnancy require stimulant medication. When the social knowledge about the specific effects of worker is ignorant of the biological basis heroin, cocaine, and PCP use on infants, of ADHD, the research about pharmaco- information that must be integrated into logical and dietary treatments, and the low strategies for treatment as well as policy, level of risk associated with stimulant planning, and programming. medication for ADHD, however, he or she is likely to accept the statement “it didn’t Social work practice with children work” at face value. By contrast, a well-informed social worker can raise Two very common disabilities in chil- questions with the prescribing physician dren, attention deficit with hyperactivity about dose, method of administration, and disorder and learning disability (specific type of medication, can elicit relevant developmental disorder), have biological observations of effects from parents and origins (Johnson, 1980, 1989).3 ADHD teacher, and can collaborate with the requires biological interventions in con- physician in the trial-and-error process that junction with multimodal supportive ser- usually is necessary before the optimal vices, while learning disability requires medical treatment is established. highly specialized educational interven- tions. As yet, no controlled studies have Health cure been reported of the iatrogenic effects of practitioners’ lack of knowledge about the In medical settings, lack of biological biological origins of these two kinds of knowledge has implications both for the difficulties, but case histories abound quality of social work service, and for the (Johnson, 1980, 1986, 1988). domain of social work generally (Katz, 1984). With respect to quality of service, A frequent outcome of failure to treat social workers acting as advocates for ADHD biologically is the progressive patients receiving medical treatment may demoralization of the mother (Johnson, be afraid to question physicians’ decisions 1980, 1988: Parish, 1989). Some manifes- if they do not feel knowledgeable (Cohen, tations of ADHD are aggressive outbursts, 1988). As a result, they may retreat to a poor self-control, impulsivity, and poor safer role restricted to discharge planning perception of social cues. As a result, such or concrete services rather than participat- children experience escalating social rejec- ing in a holistic evaluation of the needs of tions and school failures, and the entire the patient and the family. Institutional family is held hostage. Typically, the changes arising from legislative and corpo- treating physician prescribes medication rate mandates around third party payments for the child after various kinds of are exacerbating this tendency. For exam- psychotherapies have proven futile. But ple, DRGs (Diagnostic Related Groups), when the effects of the drug are not with their emphasis on getting patients out carefully monitored, different dosage lev- of the hospital rather than providing els are not tried, andor the parents fail to optimum client service, are shaping tech- administer the medication correctly, par- nocratic (as opposed to therapeutic) roles

116 0 JOHNSONETAL. JSWE-26:2 Downloaded by [University of Illinois at Urbana-Champaign] at 18:47 16 March 2015 for social workers. The social worker is However, one longterm prospective fol- under more pressure to expedite placement lowup study did show impressively posi- than to carefully weigh knowledge about tive outcomes (Satterfield et al., 1987). the patient’s physical and emotional condi- Thus study compared hyperactive boys at tion-knowledge which might indicate high risk for delinquency treated with a quick discharge was not desirable. combination of medication and intensive individualized psychosocial treatments, in- In the major health care crisis of the late cluding cognitive, behavioral, and insight- 1980s, AIDS, the need for social workers oriented approaches for child and parents, to have medical knowledge seems so to a control group who received only one obvious as scarcely to require mention. or two kinds of treatment. Impressive Many of the estimated 1 million HIV- long-term outcomes occurred only for boys positive persons (CDC, 1990) in the US who had received multimodal treatment and/or members of their families become that included both medication and other social work clients. Knowledge about the treatments. Multimodal treatment resulted disease, its transmission, progression, and in dramatically lower incidence of delin- treatment alternatives is essential for social quent behavior several years later by work practice with anyone whose life is children at high risk for delinquency (boys touched by AIDS. with attention deficit disorder) than in a control group of ADHD boys receiving With respect to social work’s domain, other forms of treatment. In the high risk the self-interest of social workers in health population in this study, medication was a care settings is in jeopardy according to necessary but not sufficient condition for some writers (Katz, 1984). Some settings preventing delinquency. Boys treated with- are hiring from other disciplines to replace out medication became delinquent, years social workers who leave. Social work has later, at very high rates. The study makes it “lost the ball” as other disciplines such as clear that social workers who practice with nursing and rehabilitation counseling are children and youth at high risk for taking on social work functions (such as delinquency need knowledge about biolog- outreach, mediation, and therapeutic coun- ical as well as psychosocial factors that seling). Because social work is not expand- predispose to delinquent behavior. ing its knowledge base and competency in medicine, social workers compete at a The examples taken from mental health, disadvantage. For example, medically- aging, substance abuse, practice with trained personnel are now offering multi- children, health care, and criminal justice modal services to clients (such as persons illustrate the range and diversity of practice with AIDS, pregnant teenagers, victims of situations requiring biological knowledge. violence) who formerly would have been Obviously, choices must be made about the considered social work clients. most important aspects of biological knowledge. The knowledge bases for the Criminal justice practice of medicine and nursing are so enormous that only a small fraction can be Subsets of persons in conflict with the included in social work curricula. law have been found to have diverse biological conditions such as neurophysio- It seems obvious that specialization in a logical deficits involving social condition- particular substantive area such as health, ing, chromosome abnormality, allergy to gerontology, or children requires a special- foods, and electroencephalographic abnor- ized knowledge base. Social work curric- malities (Johnson, 1980, 1989a). The ula that emphasize substantive area educa- literature on treatment of offenders is tion need to develop distinct and relevant extremely discouraging regarding longterm biological content. But what subset of the outcomes (Kazdin, 1987; Shamsie, 1981). vast universe of biological knowledge

Downloaded by [University of Illinois at Urbana-Champaign] at 18:47 16 March 2015 SpringlSurnmer, 1990 BIOLOGY IN CURRICULA 0 117 should be selected for inclusion in required tiny fraction of all students register for curricula for all master’s students, or at these courses (Libassi, 1990). In addition, least for all master’s students specializing range of content required by CSWE is in direct practice with individuals and already so extensive that faculty are hard families? The answer to this question put to include all of it and still retain depends on the preferences of the respon- electives. dents. A second macrosystem issue is the lack Having made choices about what kind of of universal continuing education require- biological content to include, decisions ments for social work practice, and, within must be made about where the material can individual state licensure requirements, the be integrated into already overcrowded lack of requirements for biological knowl- curricula. Who among social work faculty edge. Continuing education requirements are competent to teach such material? Can for demonstrating certain kinds of biologi- social work educators without medical cal knowledge (such as functions and side background be trained to teach biological effects of common medications) could do a content? And how can faculty opposition great deal to remedy the deficiency of to adding biological content be overcome? biological knowledge in the practice com- Strategies for either diminishing or circum- munity. venting such opposition must be devel- oped. A systems analysis suggests that On the organizational level, dynamics obstacles to infusing biological content within the institution in which the curricu- occur at all levels of the systems hierarchy, lum changes are being attempted must be from the Council on Social Work Educa- evaluated in order to develop strategies. tion through organizations (schools and For example, can turf issues be circum- programs of social work) down to the vented to bring in medically-trained fac- individual instructor. ulty, either to teach students directly or to teach faculty to teach students? Are OBSTACLES TO INTEGRATION OF competing claims for space in the curricu- lum being advocated by powerful faculty BIOLOGICAL CONTENT constituencies? Is biological content con- gruent with the institution’s articulated At the macrosystem level, accreditation mission and/or its unarticulated ideology? requirements by the Council on Social Work Education have ensured that both the On the level of the individual instructor, “psycho” and the “social” components of Saleebey has proposed several reasons for the tripartite model are extensively covered opposition to biological approaches: Suspi- in all accredited programs, through spe- cion that the biological knowledge base cific course content in HBSE and Social conceals a conservative political agenda, a Welfare curricula (Council on Social Work long history of preference for focus on Education, 1989). Requirement for inclu- interpersonal relationships, perceived lack sion of biological content, by contrast, is of expertise, prevalence of theoretical referred to only in vague global terms, nor models conceived before knowledge about do the accreditation standards provide any biological foundations of behavior were mechanism for ensuring inclusion of bio- well articulated, the tendency to turf- logical content. As a result, it appears that building, and belief that incorporation of few master’s programs include biological biological knowledge represents “final content in required courses in more than a surrender” to the medical model (Saleebey, perfunctory, superficial, or haphazard 1985, pp 578-579). manner (Libassi, 1990). A few programs offer electives in biological aspects of Other obstacles may be fear that once behavior and psychopathology, but only a the door has been opened to biological content, such material will invade or overpower the curriculum (where will it all

118 JOHNSONETAL. JSWE-26:2 Downloaded by [University of Illinois at Urbana-Champaign] at 18:47 16 March 2015 end?); unwillingness to relinquish any macrosystem, organizational, and individ- pieces of favorite and familiar curriculum ual levels are a subject for future work. to make room for the unfamiliar biological information (much work will be involved POSSIBLE APPROACHES TO INTEGRATING in learning new material); and the tendency to dismiss an entire area of knowledge with BIOLOGICAL CONTENT INTO EXISTING which one is unfamiliar by minimizing its importance. CURRICULA Considering the multitude of reasons The committee agreed that it would be social work educators have for resisting impossible to cover more than a tiny incorporation of biological knowledge into fraction of all relevant biological knowl- curricula, efforts to overcome obstacles at edge within the framework of the master’s all system levels are needed in order to curriculum. Based on this assumption, the implement change. At the macro level, it following set of general principles was seems probable that introducticn of biolog- compiled: A) Inculcate the notion that the ical content on more than a haphazard or MSW is the beginning, not the end, of token basis will require modification of professional education (Responsible social accreditation standards by the Council on work practice requires that we continually Social Work Education. Evidence supplied update our knowledge base in order to give in this article indicates that the existing clients the benefit of current means of global policy declaration that biological helping); B) Present enough illustrations content is required (CSWE, 1989, p. 126) of the importance of biological information has not resulted in meaningful inclusion of in practice to raise consciousness about the such content. In the authors’ view, specific need for routine evaluation of biological as kinds of practice and human behavior well as psychosocial factors (Before fac- content on biological factors must be ulty can be expected to engage in this explicitly required in the same way that educational task, they themselves must specific kinds of cultural content (on have undergone a consciousness-raising women and minorities of color) and process); C) Impart a method for obtain- macrosystem content (social welfare policy ing biological information relevant to any and services) are explicitly required. The substantive problem, that is, a method that political obstacles to accomplishing such a can be used for work with all or most change in standards and to ensuring that social work client populations (provide accreditation reviewers enforce compliance students with tools for obtaining biological once new standards are in place, are content); D) Require enough practice by considerable but are beyond the scope of each student in using these tools so the this article. The other needed macro-level subsequent transfer of the method to work change involves modification of licensure in agencies after graduation will seem requirements to include knowledge of routine or at least straightforward and biological content. The politics of licen- feasible; E) Ensure that each student has sure are very complex and are also beyond satisfactorily completed the process for the scope of the article. two or three substantive areas, so that the need for the method will be perceived as On the organizational and individual general rather than idiosyncratic to one levels, different strategies may be needed special population. for overcoming obstacles in different programs, based on the nature of the Several approaches were considered to resistance in a particular institution, the implement these general principles. Under resources available in the community, and optimal conditions, all approaches would the personal preferences of instructors. be used simultaneously. However, it was Strategies for overcoming obstacles at the assumed that in most programs, conditions would be less than optimal. One or more of

Downloaded by [University of Illinois at Urbana-Champaign] at 18:47 16 March 2015 Springhummer, 1990 BIOLOGY IN CURRICULA 119 the strategies could be selected that would Sources of this information would be be most congruent with the milieu of the current medical, psychiatric, and nursing particular institution. These approaches fall journals. In each school, references dis- into at least three major groupings: Integra- covered by students could be incorporated tion with field experience, infusion into into a rolling computerized bibliography, existing courses, and addition of a new so that an expanding, continually updated course. file of material would be available to all students and faculty. In addition, agencies Integration with jield experience could invite speakers with expertise in an area to present biological material to the For students working with individuals, agency staff, thereby demystifying biolog- families, and groups, an assignment could ical information and making it accessible be required for each of two field place- to practitioners. ments, in which the student collected data on biological factors relating to a specific If the field experience model were to be problem area. For work with individuals used, students should be instructed that this and families, students would follow a assignment is applicable to a range of structured outline that required specific practice areas. For students who might end kinds of biological information as well as up getting jobs in areas of practice not the traditional psychosocial information related to their field placements, it should (such as presenting problem, identifying be emphasized that the method they had information, psychosocial family history, already learned in the field experience cultural, economic, and environmental should be used for whatever population factors, salient problems, intrapsychic/ they happened to be working with. Once interpersonal functioning). The assessment the method is learned, applications to new would include an analysis of the interac- areas are not difficult. tions between biological, psychological, and social factors. For work with groups, If faculty advisors were responsible for students would investigate biological as- reading the students’ reports, it would be pects of a substantive area pertinent to a necessary for them to be personally group with which they were working, such committed to the assignment as well as be as alcoholism, aging, eating disorders, or knowledgeable about the subject. It might family violence. Again, the assignment be more effective to have faculty with would be based on an in-depth review of expertise in substantive areas read student literature on biological and psychosocial assignments in those particular areas rather factors and would require analysis of the than relying on advisors to evaluate content interaction between all of these factors. with which they might be unfamiliar. One such assignment per year, in different substantive areas when possible, would Infusion into existing courses ensure that graduating students had be- come aware of the importance of biological Within required core curriculum, exam- factors in two substantive areas and had ples could be infused to show the impor- mastered a generic method for finding and tance of biological content and to illustrate using biological information-a method the range of areas in which this content is transferable to other substantive areas or relevant. It would be important to use fields of practice. This approach would examples that are drawn around issues that also provide a continuing education func- have high salience for students, such as tion by familiarizing the student’s field AIDS, the homeless mentally ill, or family instructor with biological content with violence. Courses in which infusion could which he or she might not be familiar. take place would be HBSE, practice methods courses, psychopathology, and research. In HBSE, biological information

Downloaded by [University of Illinois at Urbana-Champaign] at 18:47 16 March 2015 120 0 JOHNSON ET AL. JSWE-26:2 should be woven into the developmental student could follow a structured outline to life span material required by the Council gather biological information as well as on Social Work Education (CSWE, 1989). psychosocial information on an individual However, it would be difficult to cover client or a family. For group settings, the such content in more than a superficial, student could review literature pertinent to sketchy manner, because the entire life a group whose members shares a biologi- span must be covered in two (and in some cally-based problem, such as alcohol schools, one) semesters. The material can- abuse, learning disability, or neurological not be presented comprehensively, so the disorder. These papers would include a best that can be hoped for is that it be used review of all biological treatments for the illustratively. condition based on current journal litera- ture as well as major texts. In case Infusion into psychopathology should be services, the written analysis of the easier to accomplish because in general the multiple factors affecting the client or scope of content is more circumscribed clients should include a detailed treatment than HBSE. Recent research already dem- or intervention plan that utilized the onstrates that all psychiatric conditions biological information. In group interven- have important biological components, so tions, the psychoeducational model of courses that review different clinical condi- providing biological information to clients tions can include a review of biological and families in groups illustrates the use of factors related to each condition (Bunney biological material in social work with e f al., 1985; Field, 1986; Johnson, 1988; groups (Johnson, 1987). Judd et al., 1985; Rapoport, 1988; Roy- Burke & Cowley, 1988; Schuckit, 1987; The approaches described above for Taylor, 1988; Ziskind et al., 1977). Such infusing biological content into HBSE, material is now summarized in major texts psychopathology, and research courses (see, for example, Kaplan & Sadock, could show the importance of continually 1988). updating knowledge and raise conscious- ness about the need for routine evaluation Infusion into research courses could be of biological factors, but only the infusion accomplished by using counterintuitive of a methods-oriented assignment could material that piques the students’ interest. also achieve the last three goals of For example, the relevance of research inculcating a method, ensuring actual could be shown by presenting a vignette of practice of this method, and ensuring a client with an emotional or behavioral application of the method to two or three problem which students usually assume is substantive areas. In order for the approach psychogenic. Students could then read of infusing content into existing courses to relevant research showing the role of be most effective, a practice assignment biological factors in the condition illus- supplemented with course material in trated by the vignette. The element of HBSE, psychopathology, and/or research surprise introduced by the counterintuitive is needed. research evidence could be an effective tool for showing that etiological assump- Addition of a new course tions must be tested by recourse to empirical evidence. Such a technique is As an alternative to infusion, a new one way of bringing the connection course could be offered either by the between research and practice to life as school (using appropriate consultation or well as showing the importance of biolog- outside speakers) or as a multidisciplinary ical research to inform practice. forum such as an ongoing clinical case conference, “grand rounds,” or didactic Infusion of biological content into prac- presentations in specific content areas. If tice methods courses could follow the same format as that proposed for the field. The

Downloaded by [University of Illinois at Urbana-Champaign] at 18:47 16 March 2015 SpringISummer, 1990 BIOLOGY IN CURRICULA 121 the sole method for presenting biological cuses on therapeutic case services (often material were addition of a course rather including group treatments), but a more than infusion into existing courses, such a comprehensive approach could be used course would have to be required, for that would incorporate community organi- credit, and with an assignment in which zation, administration, policy, planning, the student demonstrated mastery of con- and research components as well. If this tent. Students already under pressure to model were chosen as part of an “add- complete a myriad of required assignments a-new-course” strategy, conferences are likely to omit or postpone an elective should be regular, required, and for credit, course or an optional assignment. preferably for students in both first and second years of study. The sites of A new, advanced HBSE course could be presentation could rotate between partici- mounted that emphasizes person-in-situ- pating institutions or could be in one ation problem areas that social workers central location. Credit for fieldwork hours frequently must deal with (such as alcohol- could be given. Conferences could be held ism and substance abuse, childhood behav- on day a month for 2-3 hours, involving a ior problems, family violence, mental half-day of field work time. In our view, illness, issues of aging), in which biologi- the loss of fieldwork time would be more cal content would be a central feature in a than compensated for by the richness and problem-focused analysis, together with relevance of the course. As in the ap- interpersonal/intrapsychic, cultural, orga- proaches described earlier, it would be nizational, legal, economic and political necessary for students either to be present- aspects. Such a course would in essence be ers themselves, or to write a summary and an HBSE course on biopsychosocial analysis of the presentations of others, in courses that review conditions listed in the order to learn a transferable method for DSM-111-R. A new advanced HBSE could assessing biological factors and recom- achieve the five principles noted earlier by mending biologhl interventions as part of requiring written assignments in at least a multivariate case ‘analysis. two substantive areas that called for inclusion of current research-based biolog- The multidisciplinary case conference is ical information as part of a multivariate one prototype for developing continuing problem analysis. education curricula in which students and community practitioners together and learn When the school of social work is on an ongoing basis. Such a course would situated within a large university or within implement and dramatize the concept that a community that has a teaching hospital, a the MSW is the beginning, not the end, of multidisciplinary course could be offered. professional education. Students, faculty, The multidisciplinary case conference/ and community practitioners could collab- grand rounds model would provide an orate in preparing presentations in substan- exciting forum for learning an integrated tive areas in which they had special interest approach to practice. Community practi- and expertise. tioners in various disciplines could be involved in presentations and discussion. CONCLUSION Participation by social work, medicine, psychiatry, nursing, psychology, law, Three aspects of a proposal to strengthen pharmacy, epidemiology, and other disci- biological content in social work curricula plines around case presentations would have been considered in this article. First, accomplish integration of biological with rationales for the infusion of biological psychosocial material through ongoing content have been presented. Second, dialogue and feedback between disciplines some of the substantive and political involved in the presentation. obstacles to such infusion have been The conventional case conference fo-

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