Ann Weick, Ph.D., University of Kansas

R E F L E C T I O N S O N O V E R T U R N I N G A M E D I C A L M O D E L O FS O C I A L W O R K P R A C T I C E : T H R E A D S F R O M T H E P A S T

Ann Weick, Ph.D., University of Kansas

In the following narrative, the author reflects back on her groundbreaking article "Issues in Overturning a MedicalModel of Social Work Practice," originally published in Social Work back in 1983.

Life rarely hands us the chance to comeface-to-face with one of our selves from thepast. In being given the opportunity to re-readand reconsider one of my earliest publishedarticles, I have entered the precarious worldof memory and history. It is a world bothrecognizable and mysterious. How did thoseideas come to have such a powerful hold onme and become the groundwork for much ofmy future scholarship? How did a youngwoman who had been prepared as a socialworker with all the rudiments of psycho-dynamic theory and a mostly-conventionalMSW curriculum diverge from the path ofprofessional orthodoxy and find infmitely newand challenging ways to think about aprofession which had, early on, captured myheart and my head? My question to myself:who was that woman anyway?

One of the first things that must be said isthat nothing about my upbringing lent itself tochallenging conventional wisdom. Being aschool child in the 195O's, raised as a Catholicand educated in Catholic schools, the scriptwas strongly tied to acceptance of clearly-stated beliefs, presented by those in positionsof authority. Because tbat orientation wasgenerally supported not only by my family andschool environment but by much of the broadersociety as well, the possibility of thinkingdifferently was seen as a slightly dangerousand possibly immoral enterprise. Ironically, forthose of us with a certain degree of persistentcuriosity, the clarity of the rules served as afoil for raising questions. I developed a strongimpulse to raise questions when the traditional

answers were found wanting. For better orworse, this shaped my life as a student and asan academic.

My stint as a doctoral student occurredduring the mid-1970s and benefited from thelarge social movements at that time. In themidst of significant societal unease, this periodopened avenues that provided greateropportunity to raise fundamental questions andto seriously study and consider severalseemingly divergent avenues of thought. Auniversity setting was a particularly apt placefor these mental meanderings because of itsofficial stand on seeking knowledge in adisciplined and dispassionate way. 1 had thegood fortune to be funded by a fellowship fromthe National Institutes of Alcohol Abuse andAlcoholism, and supported by a doctoraldissertation chair who gave me free rein toexplore a way of thinking about the problemof alcoholism that joined together multiple areasof inquiry and research. Reading acrossdisciplines and creating a multi-dimensionalframework was exciting in itself, but, moreimportantly, it gave me the courage toexperience and apply a strategy of intellectualprobing that later served me well no matterwhat the topic.

As I stretched the boundaries of myquestions, I also became interested in thehistory of science that introduced the groundsfor a critique of a positivist scientific paradigmand a challenge to its orthodoxy. Myintroduction came by way of a book byThomas Kuhn entitled The Structure ofScientific Revolutions. I can recall with a

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Reflections on Overturning a Medical Model of Social Work Practice: Threads from the Past

vivid and sensory memory the range ofemotions I felt as I poured over his thesis.Simply put, Kuhn was calling into question thescientific paradigm that, despite its formal goalof putting nature to the test throughexperimental methods, was, in fact a veryhuman endeavor, affected by the ail-too humanelements of power and control. At the heartof this was a deceptively simple axiom:knowledge is power. When crucial knowledgeis held and controlled by a few, with narrowchannels for rigorously challenging basicclaims, there develops what might be called a"knowledge aristocracy," a class of peoplewho protect the dominant theory against allothers. Change in scientific theory occurs onlywhen the anomalies and weaknesses in thatdominant theory become too pervasive to bemaintained.

The idea that overarching theories andbelief systems were not true in and ofthemselves but were shaped by human beingswho derived benefit from them was acaptivating idea to me. What could be moreradical than to have the fVeedom to questionthe assumptions underlying pervasivestructures of belief, whether these werescientific or religious or other? At heart theyall had political cores that gave the "knowledge-tenders" their authority and their right to silenceor punish, in one way or another, those whodisagreed with them. The very act ofquestioning dominant beliefs by raising thepossibility of another way of seeing held, forme, an allure that was almost palpable. Myarticle on "Issues in Overturning a MedicalModel of Social Work Practice" was an earlyattempt to see the underpinnings of the socialwork profession in a new way and to helpreclaim some of the insights and commitmentsthat, through its history, have given social workits radical and enviable perspective.

In writing this article, I wanted to sharemy conviction that social work is a receptacle,perhaps a Petri-dish, for revealing a form ofknowledge not generally credited as legitimate.Underneath the embrace of ideas and theoriesfrom the social and behavioral sciences, socialwork had a powerful and poignant grasp ofthe challenges and possibilities in helping peopleright their lives. It has been based on a belief

in the practice wisdom of the profession andits elaborate, age-tested, collective experienceas a powerful form of knowledge. One wayof revealing this hidden treasure was tocontrast the medical model with what I calleda "health model" of social work practice. Thenature of the traditional model for medicalpractice, with its assumptions about the powerof professional knowledge and often thediminishment of the client's own capacities andaspirations in the face of esoteric knowledgehas permeated both medical practice but alsoprofessions like social work that areinextricably linked to it.

In the 198O's there was a movement, notjust in social work but in related fields as well,that has been called holistic health. It expresseditself through a burgeoning number of healthpractices not initially accepted by the traditionalmedical model. Many of these approacheswere derived from indigenous cultures thatmaintained strong ties to the healing practicesof their people. In learning more about thesemethods, it became clear to me that ourunderstanding of social work practice couldbe strengthened by assessing the impact oftheories underlying our practice and by usinga critical lens to rediscover some of our coreinsights about professional practice. Becauseof the broad acceptance of science,particularly medical science, as an overarchingparadigm for practice, a close examination ofits underiying tenets seemed a useful way tocreate a heightened level of consciousnessabout its limiting effect on the radical natureof social work practice. Challenging the basicassumptions of the medical model as it hasbeen applied to social work practice becamethe engine driving this analysis.

What the analysis uncovered are some ofthe principles that have been with us all along.The power of healing points to a profoundhuman capacity for self-righting and throughthis window, we can begin to see that thenature of change is not at all what we believed.Rather than requiring forces outside oneself,people are more likely to change their liveswhen they see the possibility for achievingsomething they see as personally important.The role of a professional person in encouragingthe process of change is both more limited and



more essential than our theories would haveus believe. What also seems evident is thatprinciples that acknowledge and supportpersonal and communal well-being are at theheart of good social work practice.

This article became a stimulus to pursuerelated topics. In subsequent articles, it waspossible to explore other developments thathave, in the past 20 years, created moregenerous boundaries for inquiry. The fields ofmedicine, physics, philosophy, ecology andgender studies all provided me with intellectualfodder for continuing to challenge and redirectmy thinking about the nature of social workpractice. While I hope that my writings haveadded to the field of social work, I alsorecognize that it is I who have been the mostfortunatebeneficiary of this process. Having,or perhaps taking the opportunity to unpeel thesometimes rough skins of accepted beliefsopened up intellectual vistas that, through allmy selves that participated, has been a joyfuladventure.

Ann Weick, Ph.D., is Professor Emeritusat the University of Kansas School of SocialWelfare. Comments regarding this article canbe sent to: [email protected].

The author, Ann Weick


Reflections on Overturning a t\Aedical Model of Social Work Practice: Threads from the Past

Issues in Overturning a MedicalModel of Social Work Practice

EMERGENCE OF a health-oriented paradigm of human be-

havior is particularly felicitous for thesocial work profession. In its implicitemphasis on growth-enhancing pos-sibilities for human beings, a health-oriented model strikes an affin-ity with the value base of the pro-fession and stimulates reaffirmationof principles of practice that have al-ways been present. Recent works byGermain and Gitterman. Pincus andMinahan. Meyer, and others havebegun to translate the principles of ahealth model into practice.'

The promise of this new view stilloutstrips its application, in particular,awareness of conceptual traps, whichcan mute the full force of the newview, is necessary. In any process ofchange, the weight of old assump-tions tends to color the radical pos-sibilities in the new paradigms,leading to a diminished understand-ing and application of the new princi-ples. While working toward concep-tualizations of behavior that centeron health, those In the professionmust be equally attentive to sabotagefrom some of the familiar beliefsabout the nature of change and par-ticularly the profession's role infacilitating it.

In making a shift from a disease-oriented to a health-oriented model ofpractice, recognition must be givento some of the fundamental ways inwhich the disease model has shapedthe view of how human beings growand change. Becoming clearer aboutsome of the important dynamics atwork here will pave the way for a con-cept of change that Is genuinelygrounded in a health-oriented per-spective of practice.

One of the striking things to con-sider with regard to the influence ofthe disease model is its emphasis on astatic-mechanistic model of humanbehavior. In keeping with the Newto-

Ann Weick

A holistic orientation to socialwork practice is still emerging.Although the holistic view iscompatible with the profes-sion's most fundamental prin-ciples oj practice, it chal-lenges traditional assump-tions about the nature oJ therelationship between socialworker and client and aboutthe nature of human change.This article examines some ofthe issues involved in theshift from a medical model toa health-oriented paradigmand suggests key principles forstrengthening this shift.

nian view of the universe, whichdominated Western thinking until re-cent decades, human beings havebeen seen as organisms whose work-ings, albeit more complicated thanin other forms of matter, could be un-derstood through careful scientificobservation. The human body was,and in many respects still is, viewedas a piece of machinery whose partsoccasionally fail. Within this model ofdisease, the hardware of treatment iswell known: a pharmacologie agent, asurgical procedure, or a therapeutictechnique must be used for treatmentto be effective.

A characteristic of this approach IsIts externality. The cause of disease Isthought to be externally caused andsomehow separate from the person itaffects. People "get sick" and spendtremendous energy trying to identify

i he causes, which can range from in-vading agents such as viruses, bac-teria, and toxins to schizophrenigenicfamily relationships. Built into thisprocess of diagnosis and treatmentis an analytic-Unear-dualistic bias,which has at every turn reinforced apathologic view of human troubles.

The nature of treatment within thecurrent illness model has been largelyinfluenced by medical conceptions ofdisease. As Mechanic says.

These conceptions are derivedfrom a model that attempts toidentify dusters of symptoms caus-ally related in some fashion andto establish the etiology, courseand treatment of the particu-lar entity. . . . The approach,however, proceeds on the assump-tion that disease states are entitiesthat are definable; and a great dealof effort Is devoted to more reliablyidentifying new disease states andsearching out their various charac-teristics and appropriate treat-ments.'-

In order to highlight the conse-quences of this view, it is useful to sechow ihe role of practitioner hasbeen skewed. Underneath the diseasemodel of human behavior is an as-sumption about change that leads di-rectly to the nature of the relationshipbetween practitioner and client. Be-cause so much hangs on a clear con-ceptualization of this role (if a move toa health-model of practice Is to beachieved), it is essential to under-stand how deeply enmeshed profes-sionals are in a view of professionalrelationships that is not heaith-oriented.

THE "GIVING OVER" PROCESSOne of the effects of a mechanisticview of behavior has been a relianceon professional expertise. This exper-

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Use comes from acquired, specializedknowledge, which sets practitionersapart from their clients. The lit-erature of 'he professions emphasizesthe powRi that accrues to profes-sionals because of their specializedknowledge and the correspondingvulnerability of clients because theyiack this knowledge.' It is worth ex-amining in detail some of thedynamics surrounding the role of theexpert and how the expert has cometo be viewed as the agent of change.The central dynamic in this accessionto professional knowledge is called the"giving over" process.

In order to fully understand the ef-fect of the accession to professionalknowledge, it is useful to look to his-toiy for antecedents. Foucault pro-vides a persuasive exemplar of theway sexuality became part of the giv^ing over process/ He documents ingreat detail the evolution by whichseventeenth-century penitents con-signed judgment of their sexual be-havior to confessors. The reasons forwhat ultimately must be interpretedas a transfer of power are central toFoucault's analysis but only periph-eral to ours. What is important is theact of giving over to another notmerely information about oneself butalso the power to create the meaningof this information. The followingclarifies this concept:

The truth did not reside solely inthe subject who. by confessing,would reveal it wholly formed. Itwas constituted in two stages: pre-sent but incomplete, blind to itself,in the one who spoke, it could onlyreach completion in the one whoassimilated and recorded it.'

As science in general (and behav-ioral science in particular) continuedits development during the nine-teenth century, new brands ofpriests emerged. Central to all thesedevelopments was the giving overprocess, whereby the patient, client,or lay person bowed before the expertknowledge of the professional. In hishistorical study of the development ofthe medical profession, Mohr showshow the processes of childbirth andbirth control were transferred fromwomen and midwives to the exclusivepreser\'e of the emerging medicalprofession.'' The genesis of psycho-analysis created yet a new breed ofpriests, whose "penitents" confessed

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all their thoughts and waited formeaning to be assigned.

It is important to understand thenature of this giving over process. It isnot the expertise of the professionalthat needs to be challenged, althoughat times this may be appropriate. Theprocess of human judgment has beenradically overturned, and. as a conse-quence, knowledge that is naturallyaccessible to people because it is per-sonal knowledge is no longer admit-ted or accepted by them. The result isthat their knowledge about them-selves becomes partially or whollyhidden. In addition, whatever infor-mation they give to the professional iswithout meaning until the profes-sional confers meaning on it. What isseen, therefore, at the base of thegiving over process, is a willingness togive someone else power to defineone's personal reality.

The prevalence of this phenomenondoes not mitigate its serious effects. Itis simple to see, for example, that thisdynamic accurately describes the re-lationship of professional and clientin a pathology model of behavior. Theessential condition of "getting well" isa giving over of oneself to a profes-sional caregiver. Ever since Parson'sclassic depiction of the charac-teristics of "good" patients, it hasbeen generally recognized that an es-sential attribute of such patients istheir willingness to cooperate withtreatment plans.' It is not, however,the patients who design the plans butthe professionals, on whose expertknowledge the patients rely.

The acceptance of a diagnosis is theclearest reflection of an individual'sconsignment of judgment to a profes-sional. Brody suggests that, in medi-cine, "the diagnosis is the primarymechanism for conferring mean-ing upon an illness event."" In amanner not unlike the confessional,the patient or client brings theraw material and the professional,through the diagnostic process, makessomething of it. The attachmentof a diagnostic label or other descrip-tor serves the client by providing asocially meaningful explanation fora particular condition, especiallywhen that condition is thought toshow a hidden defect.

It should be remembered that themedical model is deeply rooted in no-tions of individual fault and defi-ciency. Although people have ostensi-bly moved away from archaic convic-

tions with regard to mental andphysical illness as signs of divine re-tribution, there are still remnants ofguilt when one's body or mind fallsfrom perfection. The process of theacceptance of diagnosis partiallymitigates this guilt because in thisprocess the superior judgment of theprofessional is acknowledged and thepsychological cost of giving over towhatever treatment another deter-mines to be best is absorbed.

THE ROLE OF BELIEF

In looking more closely at the natureof the relationship between the pro-fessional and the client as It plays it-self out within the traditional modelof diagnosis and treatment, it Is clearthat this area of relationship movesinto the more subtle aspects of theprofessional role, namely, the natureof the beliefs of the patient/clientabout getting well. An observation ofFrank's helps set the stage:

Treatment always involves a per-sonal relationship between healerand sufferer. Certain types of ther-apy rely primarily on the healer'sability to mobilize healing forcesIn the sufferer by psychologicalmeans."

As this statement is examined, threeelements become clear: the presenceof a relationship, the header's ability,and healing forces in the "sufferer."The use of the word "healing" Is apoint that will be explored in greaterdepth. What must be grappled withhere are the dynamics in the relation-ship Itself that may contribute to apositive change in the patient orclient. To begin examining this aspectmore directly, one can draw on an ob-servation made by Kiev:

There exists the possibility that cer-tain general features of therapeu-tic relationship in various cul-tures—for example, the hope, ex-pectation, and faith of the pa-tient in the designated healer,coupled with the healer's use ofmeaningful symbols and groupforces—might contribute more totherapeutic results than is ordi-narily recognized in contemporarytheories of psychodynamic psychi-atry.'"

His sharp focus on the elements ofhope and belief pinpoints an element

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Reflections on Overtuming a Medical Model of Social Work Practice: Threads from the Past

of getting well that is as illusive as itis challenging. What Is the role ofthese "soft" emotions in the otherwisetechnical armamentarium of diseaseeradication?

A useful approach to this questioncomes from the literature on placebos,those "biomedlcally inert substance[s]given In such a manner to producerelief."" The patient receiving aplacebo is under the impression thatit is an active drug; whatever positiveeffect it may have upon the patient Isknown as "the placebo effect." In thepatient's positive response to aplacebo, there Is "no evidence of cor-relation with personality variables,age, sex, intelligence, IQ tests or pres-ence of neurosis or psychosis."'- Thissuggests a certain universality thatmakes the placebo effect a worthyarea of Investigation.

From the perspective of interven-tion, by taking a researchers' view ofplacebos, a veritable goldmine hasbeen overlooked. In the course of sci-entific experiments, every precautionis taken to control for undesired andunintended effects. For example,medical researchers want to ensurethat any effect of a drug is caused byits pharmacologie properties and notby the special attentions of those con-ducting the research. Elaborate re-search methodology has been con-structed in order to pinpoint causalrelationships.

What the research is trying to con-trol is exactly what practitionersought to be studying. Imagine howvaluable it would be to know whyplacebos are effective. By lookingmore closely at the placebo effect, thepossibility of the existence of a muchwider and richer range of stimuli forchange than usual would be acknowl-edged.

Those who have examined the effi-cacy of placebos largely attribute it tothe patient's belief in the physician'spower to effect a cure. Frank suggeststhat the efficacy of the placebo mustHe in its "symbolic power, . . . Igatn-ingl its potency through being a tan-gible symbol of the physician's roleas healer.'' Brody, in his analysis ofthe placebo effect, also notes thatpatients' "expectations are commonlycited as an important factor In pro-ducing the placebo effect.""

Although placebos are thought of asbeing confined to the medical field,this effect is also present in clinicalwork (and in any process of change.)

The medical model isdeeply rooted in

notions qf individualfault and dejiency.

Applebaum calls suggestion a placebo"which silently functions in àl\ man-ner of therapeutic transactions wherethe need to believe and to benefit isstrong."''" In seeking therapy, a per-son expresses an "intention to bringabout change land) thereby producesin himself an expectation and im-petus toward change."'" Brody alsosuggests that

one might view psychotherapy . . .as a highly organized way ofbringing the placebo effect to bearon a special class of patients whootherwise would be very resistantto it.'"

It is not surprising that the role ofthe professional "healer" receivessuch prominence in effecting change,for the current model is devised toproduce just such a result. Culturealways shapes the way reality is con-structed.'" It is a commonplace that"the roles assigned to both the prac-titioner and the recipient of medicalcare represent. In large measure, so-cially prescribed behavior."'" Whatmust be asked is whether the changein a person's condition, which is evi-dent in a placebo effect, is best ac-counted for through the real orimagined powers of the professionalcaregiver. Is the caregiver, therefore,the most salient feature in thedynamics of getting well?

It is not possible, of course, to solvethat problem solely through in-tellectual analysis. However, it is pos-sible to imagine a different way oflooking at the dynamics, a way thatestablishes the assumptions of a dif-ferent paradigm about health. If theeffect of placebos can be seen as ananomaly in the Kuhnian-'" sense. Itmust be admitted that any attemptsto place this odd piece of the puzzleback into the dominant illness modelwill fail.-' One could argue, further,that current attempts to explain theplacebo effect by focusing on the pro-fessional caregiver is essentially atautology: To attribute the effect to

Weick / Overturning a Medical Model of Practice

the patient's belief in the power of theprofessional Is simply to demonstratea belief in the current medical model,which is based on the concept thatprofessional treatment is the vehiclefor change and that without it a goodeffect cannot be achieved.

SELF-HEALINGA different concept with regard to theplacebo effect is that individuals arethe source of their own healing. Thisassumption is central to a healthmodel of behavior. It suggests that thecapacity to "get well " Is inherent inindividuals and exists whether or notthere Is an external agent such as aprofessional. It implies an internalprocess, occurring by virtue of the in-dividual's own physical and emotionalresources. In essence, this view isbased on the belief that human be-ings have the innate capacity to be thesource of their own change and thatthe process of self-healing is one ex-pression of that capacity.

Because of cultural conditioning,self-healing is generally activated onlyin conjunction with standard medicalor therapeutic practice. The processseems to require the presence of com-plicated outside forces: a professionalhealer, a ritual, a specific physical set-ting. But instead of look ing at outsideforces and imagining them to be thekey variables, one should assume thatthe capacity for change is Inherent inpeople and can be self-motivated.

Focusing on healing as an innatecapability forces a radically revisedview of the professional expert as thecentral figure in the process ofchange. This shift places questionmarks on all the assumptions thatunderglrd the disease model. Itthrows into a speculative arena thenotions of illness being caused byidentifiable entities, of pharmacolog-ical substances and therapeutic tech-niques holding curative powers, andof helping professionals holding theexpert knowledge that activates thecure.

In order to put some flesh on thisskeletal conception of health and thenature of healing, the author wouldlike to derive some principles ofthe health paradigm from NormanCousins's well-known description ofhis experience In moving from illnessto health.-- In many ways, his storyexemplifies the principles that consti-tute a new model of health.

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Cousins fell seriously 111 after astress-filled trip abroad and wasdiagnosed as having a serious colla-gen disease, which affects connectivetissues in the body and results in se-vere physical weakness and impair-ment. The chances for full recoverywere thought to be one in fivehundred. The medication for painand inflammation was not expected tocure the condition but only make thesymptoms tolerable.

If one looks quickly at the generalprocess Cousins went through to actupon his illness and eventually re-verse its course, several principlesemerge. First, he decided that "ifI was to be that one case in fivehundred. I had better be somethingmore than a passive observer."^' Thenhe began to consider various reasonsfor the cause of his illness, somethinghis physician was not able to ascer-tain. Based on his prior extensivereading of medical and scientificjournals, he began to put togethersome guesses: the presence of physi-cal and emotional stress during thetrip, the likely impairment of his sys-tem because of the stress, andthe greater susceptibility in thisweakened state for environmentalstresses. He then began to considerways to reverse this state of suscepti-bility. His plan contained two inter-locking strategies: First, he decided toremove himself from the hospital andfrom prescription drugs, both ofwhich he viewed as negative contribu-tors to his well being: second, he de-cided to replace this standard treat-ment with vitamin therapy andlaughter. He had deduced from hisreading that ascorbic acid (vitamin C)could be helpful in combating colla-gen breakdown. The introduction ofhumor via old movies was his ap-proach to replacing negative emotionswilh positive ones.-It is important toadd the final variable: the close coop-eration provided by his physician,who supported his decision and over-saw the medical aspects of his self-selected treatment.

As these various steps are looked at,the key elements in Cousins's completerecovery from his illness can easily beabstracted:

1. He took an active role in deter-mining the course of his treatment.

2. He relied on past knowledge andhis own intuitive-rational processesto understand what was happening tohim.

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3. He decided on a course of actionbased on his guesses.

4. He sought and received coopera-tion from his physician.

5. His physician acted as a consul-tant, not as the "prime mover."

6. He chose a healing process thatallowed mind and body to interactand be mutually reinforcing.

In each step of the process, whatCousins chose to do Is diametricallyopposed to the current conceptions ofhow change occurs. His approachchallenges current perceptions of fig-ure and ground, for what people per-ceive to be the central feature (theprofessional paraphenalia) is, in fact,the background. The professionalperson's role, in the new paradigm, isas a supporter of the naturally occur-ring processes already within theclient's repertoire. As Watson sug-gests:

Healers heal . . . by getting theirpatientlsl to sit up and take notice.They prod them into the naturalbusiness of healing themselves.'-'

This role is crucial in the process ofreframing that often needs to occurbefore ä person sees or can respond tothe choices available. Us importcomes from professionals' capacity toelicit and strengthen clients' inherentability to heal or change themselves.In turning briefly to Cousins's experi-ence, his acceptance of his ownknowledge can be seen as a pivotaldynamic. True, it was not naiveknowledge based on isolated mentalstirrings: he used information gainedfrom professional sources. However,the attribute that characterized hissearch was his belief that he could putthis information together in a waythat would be helpful to him and thathe could confer his own meaning onIt.

It is worth spendinga moment withthis notion. The radical element inCousins's action was that he allowedhimself to know what he knew. He didnot dismiss this self-knowledge, asmost people are taught to do fromtheir earliest years. He believed im-plicitly that he knew himself andhis condition better than anyone.Perhaps it was the prospect of deaththat gave him this conviction. Heacted in a holistic way on this convic-tion, by allowing himself to discoverwhat his body and mind needed inorder to regain health.

This must be at the heart of what iscalled healing. The root meaning ofthe word "heal" is "to make whole orsound." The insight that Cousins'sexperience gives us is that individualsheal themselves and have the power tomake themselves whole. This is theradical stream that flows under thenew paradigm.

HOLISTIC PRINCIPLESFOR SOCIAL WORKWhat, then, are the crucial principlesin moving social work more surelytoward a holistic view of practice?Most important, a reenergized con-ception of the principle of self-determination must be a linchpin inthe new model. In its least compli-cated version, the new model mustassume that people do know what isbest for them. This requires a deeprespect for people's Innate wisdomabout themselves and their lives.There is a tendency to overturn tooquickly this radical value by ap-pealing to arguments of socializationor social conditions. It is true thatneither socialization nor social condi-tions are irrelevant. Clearly, these fac-tors shape us individually and col-lectively and often disguise newpossibilities or prevent them fromemerging. However, our willingnessas social workers to denude the powerInherent in the principle of seif-determination has the effect of leav-ing us the determiners of what is bestfor clients.

A close corollary to this principle isthe right of individuals to establishmeaning for their life events. Thegiving over process, both as it isreinforced by the social worker andsought by the client, establishes out-side authority as the interpreter ofevents. By acceding to others' defi-nitions of one's life events, the mostfundamental piece of personal poweris lost. Empowering a client is depen-dent upon the social worker's willing-ness to relinquish his or her power tocreate the client's context of meaning.

The next principle cuts into theprofession's heavy tendency towardoveremphasis of technique: Whatevertechniques are employed in the help-ing process must always be used inservice to the central goal of creatingan environment where clients have attheir disposal the resources necessaryfor accomplishing what they want.The cues come from the client. The

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talent of social workers Is expressedtn the versatility with which they areable to provide multiple levels of re-sources. The resources are linkedwith their understanding of the mul-tiple environments that affect people:the physical and social environmentsthat are both Internal and external toIndividuals." In order to effectivelypresent these possibilities to theclient, the social worker must go farbeyond one or two favored techniquesor therapies.

As a quick test of a favored tech-nique, one must ask whether thattechnique In any way undermines theprinciples discussed above. Forexample. Is It a technique that putscontrol of the situation In the handsof the social worker Instead of theclient? Does It present a way of inter-preting reality that the client has to"buy"? Does the technique assumethat human problems are caused oraffected by one major dynamic, forexample, communication patterns orfamily relations? One can argue thatto the extent any therapeutic tech-nique or approach subverts basic so-cial work principles, it Is primarilyserving a function other than clientgrowth and development. The factthat some clients may experiencepositive growth through enforcedtechnique says more about the flexi-bility and growth-potential of humanbeings than it does about the efficacyof the technique Involved.

Last, there must be a commitmentto process. Knowing that oppressiveforces serve to hide people from them-selves, It Is understandable why peo-ple are wrapped in disguises. Theunveiling does not occur quickly oreasily. As social workers engage In aprocess of change with their clients,they share with their clients, throughthe medium of the relationship, theirbelief in the clients' strength andpower. The profession's true expertisecomes from understanding the deli-cacy of this change process and theknowledge of the conditions that bestsupport human growth. Focusingthis considerable talent and wisdomon the process of empowering Is acrucial factor In helping people gainfull possession of what they have al-ways possessed.

CONCLUSIONThere is much to be clarified as anew paradigm of health continues to

emerge. Understanding the nature ofhealing in all its complexity will takeyears of study and research. So. too,the accompanying reconceptualiza-tions of the role of the professionalwill require careful thought. It is Im-possible to Ignore the tremendousweight of the current model of illnesson the profession's view of sicknessand health. As in idl world views,willing collusion among Individualskeeps this view in place. Thepassivity, the lack of control, and theindignity of the "giving over" processmay not be liked, but at the sametime, workers find relief In the waythis process shields them from re-sponsibility for the shape of theirlives. For workers to imagine thatthey (much less their clients) shouldtake the risk of this new kind of powerradically reverses their ingrainedviews of the way things are.

And yet, one of the captivatingforces of the social work heritage isthe profession's persistent willing-ness to look to the edge of the waythings are. The ethical commitmentof workers to self-determination sug-gests, better than they know, theirsearch for conceptions of human be-havior and human change that canlead to greater health and wholenessfor people. The new paradigm ofhealth Is not alien to social work prin-ciples and values. On the contrary, itis a natural reflection of those values.By focusing on health as a signifi-cant expression of behavior, socialworkers' view of change and of theirroles in facilitating change can be re-constructed and strengthened. Andthe honorable effort of developing andrefining a holistic view of practice thatgives expression to some of thekeenest insights about the needs andcapacities of human beings for growthand change can be continued.

Ann Weick, Ph.D., is Associate Pro-fessor, School oj Social Welfare,University of Kansas, Lawrence.

Notes and References1. Carei B. Germain and Alex Gitter-

man. The Life Model of Social Work Prac-tice (New York: Columbia UniversityPress. 1980); Alien Pincus and AnneMlnahan. Social Work Practice: Modeland Methods (itasca. Illinois: F. E.Peacock. 2d ed.: Pubilshere. 1973): Caroi

Weick / Overtnming a Medical Model of Praetice

H. Meyer, Social Work Practice, New York:Free Press, 1976).

2. David Mechanic. "Health and iiinessin Technoiogicai Societies." The HastingsCenter Studies, 1 (1973), p. 11.

3. See. for exampie. Wiibert E. Moore,The Professions (New York: RusseiiSage Foundation 1976); and Terence J.Johnson. Professions and Power (AtlanticHigiiiands, N.J.: Humanities Press.1972).

4. Miche) Foucauit, The History ofSexuality, Vol. 1 (New York: VintageBooks. 1980).

5. Ibid., p. 66.6. James C. Mohr, Abortion tn

America (New York: Oxford UniversityPress, 1978).

7. Talcott Parsons. The Social System(Glencoe, III.: Free Press, 1951).

8. Howard Brody, Placebos and thePhilosophy of Medicine (Chicago: Uni-versity of Chicago Press, 1977). p. 118.

9. Jerome D. Frank, Persuasion andHealing (New York: Schocken Books,1963). p. 1.

10. Arl Kiev, "Preface' In Ari Kiev, ed..Magic. Faith and Healing (New York: FreePress, 1963), p. xili.

11. Brody, Placebos and the Philos-ophy of Medicine, p. 1.

12. Ibid., p. 15.13. Frank, Persuasion and Healing, p.

66.14. Brody. Piacebos and (he Philosophy

of Medicine, p. 65.15. Stephen A. Appiebaum, "Pathways

to Change in Psychoanalytic Therapy."Bulletin of the Mennlnger Cltnlc, 42 (May1978), p. 245.

16. Ibid.. p. 246.17. Brody. Placebos and the Philos-

ophy of Medicine, p. 121.18. For an interesting discussion of

how culture shapes reality, see JosephChilton Pearce. Exploring the Crack In theCosmic Egg (New York: Pocket Books.1975).

19. Edward A. Suchman. Sociologyand the Field of Public Health (New York:Russell Sage Foundation, 1963). p. 15.

20. See Thomas S. Kuhn, The Structureof Scientific Revolutions (Chicago: Uni-versity of Chicago Press, 1962).

21. In his analysis, Brody (Placebosand (he Philosophy of Medicine) recog-nizes the paradigm puzzie presented byplacebos.

22. Norman Cousins, "Anatomy of aniiiness (as Perceived by the Patient)." NewEngland Journal of Medicine, 295 (De-cember 23. 1976). pp. 1458-1463.

23. Ibid., p. 1459.24. Lyall Watson, Gifts of Unknown

Things (New York: Simon & Schuster.1977), p. 136.

25. For further discussion of this, seeAnn Weick. "Reframing the Person-in-Environment Perspective," Social Work,26. (March 1981). pp. 140-143. •

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Ann Weick, Ph.D., University of Kansas