THE APPLICATION OF SYSTEMS THEORY IN TWO CASE STUDIES
This essay will apply systems theories as a social work tool to establish the difference, improvements, relief and support a day centre facility has provided for the families of two clients, and the effects this has had on other aspects of the families’ lives such as their employment, social support and safety of their mothers at the day centre. Concepts involving systems theory will be comprehensively addressed and will demonstrate that the approach is wide and has a number of connecting theories and methods which can be applied suitably to the case studies. Some of these will include boundary setting, cooperation, integration, observation and communication. Systems theory will be critically analysed as a social work method to ascertain its usefulness in practice. The assignment will then be reflected upon with an evaluation of systems theory, weighing up its advantages and disadvantages.
The two case studies to be analysed involve two female service users who attend a day centre specialising in the care of people with dementia and Alzheimer’s disease. The first service user known as client A, a 97 year old widower with a progressed form of Alzheimer’s disease, has a son and a daughter. Client B is 78 years old living with her husband and has two daughters and one son. Client B was diagnosed with dementia in 2005 and the illness has progressed substantially.
The works of Pincus and Minahan (1973) look at three different types of systems (informal, formal and societal) and analyse the system which workers use as part of their practice. One such system relevant to the case study is the client system. These are defined by Pincus and Minahan (1973 p145) as, “people, groups, families and communities who seek help and engage in working with the change agent system”. The elderly people concerned, client A and client B, become the target system, the action system are those who the change agent system (the day centre workers, perhaps rather than the social workers) works to achieve its aims.
Systems theory has its own set of boundaries seen as input, throughput and output which gives the system its identity and focus as a system (Greene and Frankel, 1994). In the daycentre setting where clients A and B attend, the service would be bound by its policies, procedures, legislation and codes of practice. All these sets rules for how to run the service and ensure its aims are met, thereby working within sets of boundaries.
Another concept involving systems theory is cooperation. The social system shares a common environment interacting with other members of the system in a cooperative way (Bunge, 1998). Linked with cooperation is interrelatedness. Modern systems theories about the family are derived from the general systems theory, in which various micro level approaches are known as systems theory. They seek to explain the behaviour of complex, organised systems of all sorts. Systems thinking is then a way of looking at the world in which objects are interrelated with one another (Whitchurch and Constantine, 1993).
The interrelatedness of systems theory can be quite profound. It permeates virtually every aspect of the day centre’s service. Every arm has a link in the chain with its overriding objective to provide the right level of care and support for the clients. The family, the transport staff, the day centre staff, administrator, manager, social worker and other relevant professionals, all have roles that connect delivering support and care to the clients. A holistic approach will look at all the factors relevant to the person, the set of workers or professionals necessary in contributing to the life of the person. Multi disciplinary teams are groups that communicate with each other to bring about the best level of support for the person. Working with others and indirectly with families is another important area of systems theory (Payne, 2005)
However, developing support through and by social networks is an important outgrowth of systems ideas. Systems focus on connections between, and resources of, families and groups and their effective functioning. This sees the family as helping or hindering the health or well being of individual patients (Payne, 2005). This has been demonstrated in the two cases as their are connections between the support the day centre gives both family members in supporting the health and well being of clients A and B. Also, the latter client has strong support networks within their family units. Client B, a 78 year old woman lives with her husband and has two daughters and one son. Client A on the other hand lives with her son who is her full time carer. Before the day centre’s support, he had to give up his job so that he could care for his mother on a full time basis. This meant that he became limited in social engagements and networks.
Social systems may possess synergy, which means that they can create their own energy. “To maintain themselves, people interacting in a group often stimulate each other to maintain or strengthen relationships which build up bonds within the group and make it stronger”. (Payne 2005, p145). This is shown as the family fully depends on the day centre’s efforts in providing care and support for the two clients. In terms of client B, the day centre support provides the family with relief as she attends the day centre five days a week. This has had a profound effect on other aspects of the family’s life. The two daughters and son are able to maintain their employment knowing that their mother is well cared for in a safe environment, as they do not live with their mother but share in looking after her. The day centre support also gives client B’s husband the assurance that his wife is well cared for as he is no longer able to manage this himself. This is important to him because he is physically frail, and has undergone a number of surgical procedures. The day centre will offer a number of improvements to the life of client B as she is no longer able to manage this independently.
The day centre support had a profound effect on client A’s son, in that it also provided relief and support for him as he has now found a support network he values and relies upon. He is equally confident that his mother is in a safe and cared for environment, is able to have a break from full time care work, and able to reform social relationships.
Integration is another concept that is linked with interrelatedness and cooperation. Systems theories are unitary, integrated and holistic, providing an overall way of describing things at any level so that we can understand all interventions as affecting systems. Social workers are then able to choose theories appropriate to levels of intervention with which they are involved. As integration is central to the concept of systems theory, it is necessary to explain the impact on services. Integration means the organic part of the whole, and is mostly concerned with merging elements or components that were formally separate. Because integration is at the heart of systems theory it is central to organised design and performance (Scott, 1992). However, the divisions, decentralisation, and specialisation interfere with efficiency and quality goals. Therefore, the advantages of systems theory should be one that supports cooperation and collaboration among and between the various parts of the organisation and system (Galbraith, 1973). Health systems are among the most complex and interdependent entities known.
Integration has had a major impact in America and Europe. In America it is about managed care; in the UK integrated care is seen as shared care (Kodner and Kyriacou, 2000). The criticism of this concept is that the lack of conceptual clarity stands as a major barrier to promoting integrated care in both theory and practice. This is important because terminology plays a critical communications role in determining the way we think about, shape, deliver, manage, regulate, finance, and evaluate health care (Kodner, 2002). Systems theory may overstate the importance of integrating parts of the system and assume that all the parts of a system are needed to maintain it, and should be interrelated. Pincus and Minahan (1976) state that there is an assumption that all systems are interdependent. But this is only true of closed systems. Open systems are more flexible. Siporin (1980) points out that Marxists state that systems theory does not take into account the incompatibilities of class interests in capitalist societies and how this prevents any integration in such a society.
However, the arguments against systems theory in relation to integration are countered by Foote and Stanners (2002) who state that it might be hard to make little progress without a systems approach to reorganise healthcare for older people. This builds on the current infrastructure to make gradual but goal oriented changes to bring health and social service systems into a better perspective with the realities of chronic disease in order to respond to problems quickly and most efficiently. Also, the model developed can be transferrable to other client groups such as children. Foote and Stanners (2002) insist that care professionals must work in an integrated way and when they operate separately it is more difficult. The key is to manage the parts while recognising their position in the whole.
The systems approach advocates complex adaptive systems: namely, a collection of individuals or organisations with the freedom to act in ways which are not always predictable, but are interconnected so that the actions of one will change the context in which the others operate. This also advocates partnership working between user and provider, making care a joint responsibility. Systems thinking and modelling can be a major tool for reform, shared values, information, and evaluation, so that the system of care can develop and change, personal and organisational development and knowing the person using the assessment process, and the concept of community which offers a corporate relationship of care that binds older people, their carers and professionals in their locality. Complex Adaptive Systems has a core message that big changes emerges from multiple small changes implemented concurrently or at least in quick succession. This is backed up by a study which demonstrates that an individual can change the context and the environment by 15 per cent. Obviously this will mean that a more significant number of people will have a major impact (Foote and Stanners, 2002)
Successful integrated care, which is a model that is effective in meeting patient needs, demands the ongoing involvement of patients and family carers in programme planning and implementation. This will ensure that the user’s needs and expectations are reflected where it counts. (Kodner, 2002). Integrated care is a complicated phenomenon. Therefore, it is important to focus on the experience of patients served by this approach. Also research and evaluation should consider not just making recommendation from the various interventions, but also a wide range of outcomes including health, psychosocial and economic (Kodner, 2002). From the case studies it is not clear how integrated care is linked up through the various professionals, but there is linkage with the social workers, the carers / family members and the day centre. Integration with health services is not demonstrated from the cases.
THE National Service Framework (NSF) (DH, 2001) ensures that the needs of older people are central to reform programmes for health and social services such as health promotion, independence and fitting the services around the person’s needs. This example exists in the case studies because the day centre provides specialist services tailored for older people with dementia and Alzheimer’s. The NHS Plan also has better governance for older people and partnership working. A useful model will demonstrate how integrating systems for the individual with systems of managed care produces a managed population of older people to make best use of resources. This will lead to a proposal for a civic model for the integration of care.
DH (2001, p32) states: “Changes in social policy… swung from providing incentives for older people to go into residential care to encouraging them to remain in the community in their own homes.”
Previous to this, local authorities’ support for older people focused on the provision of residential care as laid out in the National Assistance Act 1948, as a duty to provide institutional care. Shifts in thinking came with the community Care Act 1990. This act also introduced the care manager who had the authority to organise budgets more flexibly than before. The care manager assessed needs for which there were known resources, rather than providing a holistic understanding of the older person. Despite the stresses in the system, care managers succeeded in maintaining people in their homes for longer, as a result of crisis intervention and long term community care. The system worked because when the older person had reached such a high level of dependency and frailty that the care can no longer be managed in the community, residential / nursing homes would then be provided (Audit Commission, 1997). At the age of 97, client A still lives with her son in her own home giving her some form of independence. However, due to her deteriorating illness her son is aware she will eventually need permanent residential care.
Involving the older person in policy making is difficult but has advantages. It not only helps to find out their wants and needs but also promotes high quality care which is more cost effective. The Audit commission (2002) states that old people’s aspirations will only succeed if agencies work together as a whole system. It states that whole systems working takes place when services are organised around the user, all agencies involved in the care recognise their interdependence. The systems approach benefits older people by addressing the whole range of their needs and aspirations, and it is hoped that it will reduce symptoms of systems pressure, such as delayed transfer of care. It states that the whole systems approach involves developing a long term programme of change.
Then Evans and Kerney (1996) outlines seven key principles of a systems approach to practice. Their analysis demonstrates how systems ideas can inform social work ideas in a variety of settings. Their approach emphasises looking within the social networks for possible targets for action. Systems theory in their view can help develop consistency in practice. One should begin from the context, which defines the aims of the practice, and then consistency helps us to conform to our original aims. Identifying patterns of behaviour also helps to see positive possibilities, helping to identify where changes are needed. As the care being given to the elderly women is already seen as invaluable to the carers, one of the reasons behind this is that the day centres would have been expected to follow policies and procedures, guidelines in managing challenging behaviours, procedures around the care for people with dementia and Alzheimer’s disease. Care workers are expected to follow these religiously as they form the bedrock for how the service operates and supports people, thereby demonstrating consistency.
Systems theory also helps to create a focus on communication among the client group, as a way of explaining how problems are maintained in the situation and as a way of intervening. This avoids the complexity of trying to work on complex past causes of problems (Payne, 2005). This method will work well with client A who can become aggressive and offensive. Observation has shown that this is presented in the afternoons rather than earlier in the day. When she is in an aggressive state I use a calming communication style to understand why she is upset. Because Client A can communicate verbally, I try to find out from her why she is upset, so that if the problem can be resolved straight away an immediate solution is found.
Observation helps social workers to reflect upon situations before intervening. LeRiche and Tanner (2006) also looked at the need of giving effective feedback. A systemic approach to working with families uses feedback as a way of responding to observed behaviour. However, the idea of feedback implies slow and manageable change, but there will be a problem if radical change is needed. Payne (2005) states that systems theory does not provide for this eventuality.
The ultimate aim of using observation has to be that it improves the quality of practice to the benefit of the service user. LeRiche and Tanner (2006) suggest that the observer takes up a reflective stance rather than action. Therefore, I ensure my observation is effective by standing outside familiar roles, while remaining emotionally active and receptive. In reflection, my observation has been effective in that, apart from observing and listening to what people say, particularly client B who responds well to one-to-one attention, but cannot communicate verbally.
For Egan, (2006) there are three stages of therapy, finding out what is going on for the client, helping the client to identify possible solutions, and helping the client to figure out those solutions in an attempt to discover what works for the client. It is an approach to counselling that helps the worker to get alongside the client, listening, empathising, and building up a professional trust and respect. Egan (2006) also considered the concept of empathy as an aspect of the client centred model , not as an end in itself but in the later stage of the helping process, it becomes secondary to the search for desirable outcomes (Egan, 2006). In my work I will not simply verbalise my concerns with what the clients are going through but will attempt to resolve the problem for them, communicating with them throughout the process. The skilled helper is then in a state of external sensory awareness and retains an awareness of their client’s non-verbal communication.
An important element of communication is listening. Active listening describes, “ a special and demanding alertness on the part of the listener, where the aim is to listen closely to the detail of what is being conveyed and to ensure that the patient is aware that this is happening” (Trevithick, 2000, p51).
I always use active listening skills in my work practices as it applies the ‘human touch’ to supporting people. It also helps me to understand the service users more effectively. Egan (2006) describes this particular listening skill as effective listening which is key to being a skilled helper, some of which includes maintaining eye contact and being relaxed to improve the quality and comfort of the client. Active listening is then essential for verbal and non verbal communication. Verbal communication articulates the client’s experiences, behaviours and feelings. The skilled communicator is non judgemental, and empathetic rather than sympathetic. Empathy is a state where the worker enters and understands the client’s perspective, whilst understanding their thoughts and feelings. However, there is also the use of challenging skills when there is harmful and destructive communication being used, but this must be balanced with therapeutic rapport to provide the client with the comfort and safety to facilitate effective change. Within my communication I balance the challenging communication with that of calming, non-threatening language. This is done by telling the client A that her aggressive and offensive behaviour is not acceptable and can lead to consequences, as it can be a form of bullying or abuse.
Good communication skills such as listening skills are essential within social work. To understand another person, and their world of meaning, we need to start by acknowledging our ignorance of that person and their social world. Learning to understand what people are communicating and to put our own thoughts and feelings into words is a crucial skill within social work. Again, non verbal communication comprises two-thirds of the type of communication expressed by people, while the actual spoken word is only a third. However, in supporting people that do not communicate verbally it might be a complex process trying to understand non verbal cues. In a study carried out by Trevithick (2000) a person’s non verbal communication was interpreted differently by two different staff members. It displayed a tendency in social work practice to attribute the behaviours of service users to personality characteristics rather than outside forces. This demonstrates another critique of systems theory: because it is a generalised theory, it is hard to apply to any specific situation. A worker may interpret a situation in one way, and another worker may apply it a different way, and thus it becomes hard to judge which is right (Payne, 2005).
In terms of political developments, Payne (2002) states that systems theory contributed to the theory base of social work particularly in the 1970s. Its impact was as part of wider social changes affecting social work, rather than in theoretical or intellectual development. In evaluating systems theory, Payne (2005) noticed some very clear advantages as well as criticism of the approach in social work practices, apart from those already listed. There is more emphasis on changing environments than psychology. Systems and ecological theories form a very different type of theory from traditional social work practice, which emphasises individualisation and psychology. Systems theory is interactive, concentrating on the effects of one person on another, rather than on internal thoughts and feelings. The day centre staff are able to gain a wide range of perceptions of the situation of their clients from family members. A wide range of perceptions of the client’s situation can also be gained from social workers and other relevant professionals such as doctors. Another advantage of the systems approach is that it alerts the day centre staff to the possibility of alternate means of achieving the same objectives.
On the other hand, systems theories are criticised for assuming that everything fits into a social order, a fundamental social structure that establishes accepted relationships between peoples, groups and organisations in society (Payne, 2005). Systems theories do not explain why things happen and why the connections actually exists, which therefore from a scientific perspective making them hard to be tested empirically. Again, systems theory is not prescriptive, so it does not say what to do, where or how to affect systems. It does not allow us to control the effects of intervention in a system because we do not know how each part of the system will interact with the others. It assumes affecting one part will affect the others. (Siporin, 1980). It is over inclusive, not everything is relevant, and it does not help to decide what is. Not everything will fit into a general scheme. Deciding on boundaries may be complex or impossible, and assumes things are related in a system without checking if they actually are.
Systems theory does not have a general application to all social systems. Instead systems theory assumes a local non-political resolution when applied to practice. This means it can be limited in resolutions of particular social ills. Devore (1983) feels systems theory does not deal with issues relating to social class, cultural differences and race compared to that of the life model. Again, Systems theory uses a lot of complex and technical language which does not fit well with a human activity like social work, and alienates workers in the process. This will be applicable in a day centre setting as staff would not be expected to use a lot of jargon, particularly where service users are concerned.
On reflection, I realise that there are actually a number of other theories that might also be effective, although the systems idea remain popular with a number of different writers as this assignment has testified. While systems theory has contributed to organisational change, and has been used to draw a number of applications to the case studies, other theories supplanted it when there were further organisational changes. Networking developed separately drawing on other theoretical foundations, supplanting systems ideas. There are now new and developing applications of systems theory to practice. Innovations and techniques of this approach include advanced networking, case management, and extensive use of family systems, group dynamics and natural support systems (Payne, 2002).
In conclusion, the application of the systems theory has had a profound effect on the safety and care of the two clients illustrated by the case studies and supported their families’ employment and other social supports. The main focus is on systems theory’s concepts of integration (and its related concepts) and communication. The assignment stated that cooperation, interrelatedness, connections and integration, within set boundaries, created its own energy (synergy) among interacting groups and individuals to strengthen bonds and produce quality services. While the main criticism has been on systems theory lacking conceptual clarity, (assuming everything fits into a social order, difficult to be tested empirically as it is not prescriptive enough), it is hard to make progress in reorganising health and social care without a systems approach.
REFERENCES
Audit Commission (1997) The coming of age: Improving Care Services for Older People, Audit Commission, London
Audit Commission (2002) Integrated Services for Older people: Building a whole systems approach in England, Audit Commission, London
Bunge, M. (1998) Social science under debate: A philosophical perspective, University of Toronto Press, Montreal
Department of Health (2001) National Service Framework for older people, HMSO, London
Devore, W (1983) ethnic realities: the life model and work with black families, social casework, Vol. 64 (9) 525-31
Egan, G. (2006) The Skilled Helper: A Problem Management and Opportunity Development Approach to Helping, 7th Ed., Routledge, London
Evans and Kerney (1996) cited in Payne, M (2005) Modern Social Work Theory, 3rd Ed., Palgrave, Basingstoke
Galbraith, J (1973) Designing complex organisations, Addison-Wesley, MA
Greene, R and Frankel, K (1994) A systems Approach: Addressing diverse family forms. In R. Greene (ed.) in Human Behaviour Theory, Aldine de Gruyter , New York
Foote, C and Stanners, C (2002) Integrating Care for Older People: New Care for Old – A Systems Approach, Jessica Kingsley, London
Kodner, D (2002), Integrated Care: Meaning, Logic, Applications and implications – a discussion paper, International Journal of Integrated Care, vol. 2 (2)
Kodner, D and Kyriacou, C (2000) Fully integrated Care for the elderly: two American models, International journal of integrated Care, 1(1)
Le Riche, P and Tanner, K (2006) Observation and its Application to Social Work: Rather like breathing, Jessica Kingsley, London
Payne, M (2002) The Politics of systems theory within social work, Journal of social work, Vol 2 No. 3, 269-292
Payne, M (2005) Modern Social Work Theory, 3rd Ed., Palgrave, Basingstoke
Pincus, A and Minahan, A (1973) Social Work Practice: model and method, cited in Payne, M (2005) Modern Social Work Theory, 3rd Ed., Palgrave, Basingstoke
Siporin, M (1980) Ecological systems theory in social work, Journal of sociology and social welfare, Vol. 7 (4) 507-32
Scott, R. (1992) Organisations: Rational, natural and open systems, Prentice Halls, NJ
Trevithick, P (2000) Social Work skills: a practice handbook, Open University Press, Buckingham
Whitchurch, G and Constantine, L (1993) Systems theory, cited in Boss, P, Docherty, R, et al (1993) Sourcebook of family theories and methods: A contextual approach, Plenum, New York