Context Matters: Practicing Social Work Across Three Levels

by Mary Sheridan, Ph.D., ACSW

     Angie, a recent graduate, invited one of her favorite professors, Dr. Gould, to lunch. After the two had caught up, Angie began to talk about her job at a dialysis center where patients receive treatment for end-stage kidney disease. Most patients come three times a week for treatment, so Angie gets to know many of them well. Still, with patients frequently transferring in and out, referrals and problem-solving with established patients, and dealing with Social Security issues, her job is a busy one.

    “I feel like I’m not doing what I’m supposed to,” Angie said to Dr. Gould. “Either that, or maybe the School of Social Work set us up to expect too much.”

    “What do you mean?” Dr. Gould asked.

    “I took those classes in groups and community,” Angie said. “They told us we were supposed to be working at all three levels. But my job is micro. All my friends are doing micro jobs. Why did they make us take those classes if we weren’t going to be using them? My patients aren’t interested in groups—they just want to get their treatment and go home. And I don’t think I know near enough to ‘organize a community.’”

    Dr. Gould smiled. It was a question, she told Angie, that she had struggled with as a young social worker. She did feel as though many social work programs “dropped the ball” in teaching how to integrate the three levels. After taking a bite of her salad, this is how she answered.

Social Work and “Person in Situation”

    To my mind, one of the distinguishing parts of social work is its focus on context. We have a long tradition of calling it “person in situation”—big systems, middle sized systems, the individual as system: macro, mezzo, and micro. Whatever situation is brought to our attention—and it’s often an individual with a problem—there is a context, and that context matters. The person matters, and the situation that person is in matters. Context helped create whatever the problem is, and you can use context to help solve it.

    For example, at the micro level, let’s take one of your dialysis patients. Dad’s sick. It’s easy to think about the changes in his life. But now he can’t drive. Someone in the family has to take him to treatment and pick him up. Maybe someone’s happy to do that—or maybe not. Maybe dad can’t work, and that changes the economics of the whole family. You see those things going on every day, mezzo stuff. Can dad qualify for disability under Social Security? Does he have a pension from work? Those relate to macro issues—what the government is willing to do, what the employer is willing to do. As social workers, we understand that the problem is on multiple levels—dad’s own feelings about his disease, the family financial situation, what’s available in the way of community resources.

    Or perhaps you work with battered women and have to go to court a lot. There’s this one particular judge who just doesn't seem to “get it.” That’s a system problem, a macro problem, which affects your clients and their families—the micro and mezzo. Remember the old social work saying that the personal is political? And the political is personal, too.

    Or look at a woman I talked to the other day. She is trying to take care of her mother, hold a job, and meet the needs of her husband and children. Her anxiety and depression are micro problems. But you can’t understand it just as anxiety and depression, as if she lived in a vacuum. The core of the situation is conflicting family demands—mezzo. But you really can’t understand the total problem without taking into account whether the community has adult daycare or respite service, whether the cost of living is such that the woman has to work, and so on. As a social worker, you’ve become used to seeing problems on three levels—so used to it that sometimes you don’t even recognize that you’re doing it.

Context and Intervention

    One of the things that I think is really core social work is that intervention can be at all three levels, too. It’s not a case of micro problems are handled at the micro level, mezzo at the mezzo level, and macro at the macro. You have the resources of all three levels available for use at any level.

    Your dialysis patient might find support and good ideas for dealing with his family (mezzo) from you or the other patients. You told me that the patients haven’t really been interested in a formal support group, but they have formed an informal one while they wait for their rides after treatment. That’s great! And you told me about the lounge you set up, where family members can wait for patients. That was a mezzo intervention, for the family members, and a macro one, too. You had to talk management into letting you have the room and furniture, and paying for the coffee. Macro isn’t just testifying at the legislature; it’s working with agency administration, too. (Social workers fought to be required by law at dialysis facilities, and when that was threatened, they fought again. You’re too young to remember that.) The family lounge has helped the family members, and that helps the patients. And you got management to see that, probably using your micro interviewing skills.

    The judge with the bad attitude might have personal issues (micro). But it’s unlikely that you would have the chance to help her with those. The solution could be mezzo—invite her to dinner at the women’s shelter. Meeting the women and hearing their stories might change her opinion. If not, and if the situation is bad enough, there may be a judicial agency that reviews complaints about judges. If the judge was elected, political action might be called for (macro). Judges don’t usually lose their elections, but I’ve seen it happen when groups of people with the same complaints get together.

    The situation with the woman caring for her mother might call for a family meeting (mezzo) to get a fairer division of labor among the kids. Or referral to community resources. Or even changes in what is available in the community. This doesn’t have to mean you, as her social worker, have to found an adult day care program. I know you don’t have time for that! Maybe a group is already working on it, but they need letters of support. Or maybe adult day care is available in the next town, but the van that picks up clients won’t go beyond the city limits. Can you negotiate a solution? This is what social workers do all the time—look for solutions across all three levels, to deal with problems at all three levels.

    The point is that, as a social worker, you have a broad range of theories and data and resources at micro, mezzo, and macro levels. And you have a broad range of interventions at micro, mezzo, and macro to choose from. Is it complex? Yes. Can it be frustrating? Often. Does it require that you stay up to date on theories and evidence-based practice and community issues? Yes. Is it effective? Is it rewarding? Yes, definitely, to both of those. Putting all three levels together in a way that will work for your specific client and that client’s situation—that’s the art and challenge of social work. That’s practice at all three levels in a micro setting.

Time Pressures

    I can see from your face, and I know from my own experience, that you don’t have a lot of extra time to take on more work. You have your own micro, mezzo, and macro context, and you have to take care of yourself. So you have to be selective in what you do—working “smarter, not harder,” as the saying goes. What problems are common among your patients and their families? Where would you get the most “bang for your buck”? Those are often places to focus on. You don’t have to do everything. If the informal support group and the family lounge are working well, put your energies elsewhere. In a year or two, you’ll be eligible to have social work students. They’re great for taking on special projects.

    I know that you are a member of NASW and the Council of Nephrology Social Workers. I’ve heard you say that knowing the other dialysis social workers has “saved your life” on more than one occasion. That’s mezzo, but it helps at the micro and macro levels. If you stop and think about it, when you support these national organizations, you’re part of a national effort to keep high standards in the profession, to monitor legislation, to educate communities. You don’t have time to do all that macro practice. It’s not what they hired you for at the dialysis center. But your dues are helping pay for the people who make it happen.

Dessert

    “I wish they had explained it like that in social work school,” Angie said when Dr. Gould had finished. “I’ve been doing a lot more mezzo and macro than I thought.”

    “Yes, you have. You’re a good social worker. And when you have field students, you can pass it along to them. Even have them write it out—for every client problem, what are the dimensions at the other levels? What are the solutions, at all three levels? It’s a good exercise in learning to think like a social worker.”

    “I’m so grateful for the chance to meet with you,” Angie said. “I’m feeling much better.”

    Dr. Gould smiled. “I’m so glad, and so glad you reached out to me. And to show you how much, I’ll pick up the check.”                     

Mary Sheridan, Ph.D., ACSW, is an Emeritus Professor of Social Work at Hawaii Pacific University.