Michael R. Rose, CISW
This paper integrates seminal authors of systems theory and current research knowledge to evaluate a social service organization. Using systems theory, this paper presents a micro and macro analysis of a social service case management system to suggest a holistic approach that adds behavioral health services to home care for the homebound elderly. Changing from an industrial to an information age requires a cultural change of trust, for supervisors to learn and use counseling skills, and to manage for results.
Ahrne (1990), Bertalanffy (1968), Etzioni (1964), Weick (1969), and Laszlo (1996) presented a particular framework that evaluated a group, organization, or system within a context of nonlinear dynamics. The authors appeared to either emphasize the individual within a system or a system in combination with its integral parts. For example, while Ahrne (1990) Bertalanffy (1968) and Etzioni (1964) focused on the larger group process, Weick (1969 and Laszlo (1996) explained more holistically the varying roles of individuals within the organization. Following this path of thought, the perspectives of the current research also varied between the micro level of individuals and macro level of organizations. In integrating both the historical and current theories of nonlinear dynamics, the writer applies this knowledge to evaluate a social service organization within a systems theory context.
Overview of a case management system
The process of the program begins with an intake called in from the community. The intake line, administered by an outside administering agency, takes the referral from the community, generates the paperwork, and assigns the case to the case manager covering that area. The case manager contacts the client within five working days to determine if the client is appropriate for the program or can manage with private pay resources.
The new referrals are an addition to an ongoing caseload of an average of 120 clients. Each case manager visits about 20 to 30 continuing clients each month, plus new referrals, to monitor needs and services. By knowing the mechanics of the case management program, an assessment of the interrelationships of the system can be more clearly understood.
Applying nonlinear dynamics as a model for critical assessment
Integrating the theoretical context, Ahrne (1990) brings to view the forms of control that define the process of power and types of social structure in a system. On the surface, the outside observer would expect a normative view that defines the process of power. Being a social service organization that assists the elderly living on a poverty level income, the observer would think that staff are motivated by the altruistic and social values of helping a disenfranchised segment of our society in having an inkling of dignity and quality of life.
However, having the privilege of being an inside observer, the student views the system as covertly coercive. Coercive power comes to play in the inconsistent interpretation and enforcement of rules and procedures (Boverie, 1991). The problem originates with the interpretation of assessment. The social worker or case manager who makes the assessment may receive more referrals than he or she can manage. The majority of the referrals do not fall within the scope of the program. When the initial home visit and assessment takes 4 to 5 hours of work and the client must be contacted within five working days, the case manager has to carefully assess the appropriateness of the referral over the phone. The coerciveness comes to play when the outside administering agency dictates that every initial assessment be seen, regardless of appropriateness, and management does not advocate for the reality and difficulty that requirement brings. Statistically, from a management view, the more home visits completed, the better. From a case manager’s view, following the rules to the letter would not allow a case manager to complete his or her case load within the required month and places their position in jeopardy. The policy becomes coercive when management of the administering outside agency does not allow for an open and honest discussion.
Bertalanffy (1968) discussed a nonlinear dynamic system of management containing a free flow of communication. The student would define the free flow of communication as a system that allows the input of all levels of a system to be taken seriously and dealt with in a collaborative environment. On the surface, management appears to elicit the input from all levels of a system. In reality, management demonstrates a hierarchical flow of information that does not collaborate input when enforcing rules and procedures.
In speaking about forms of management, Etzioni (1964) reviewed the classical, human relations, and structural forms of managing systems. Instead of being in one category or another, the field placement of the student appears to combine all three.
Appearing more as a classical system (Weber, 1999), the field placement of the student exemplifies a hierarchical form of management. Direct supervisors take their direction from middle management. Upper management takes their direction from top management. Although input is solicited from direct line staff, supervisors do not apply changes that involve loss of control or expenditure of funds. For example, once a year management gives employees a survey to test their perceptions of their jobs and of management. To change survey results from below average-to-average, supervisors were instructed to obtain input through focus groups from direct line staff. One of the inputs was the restrictive nature of the evaluation. Offices were instructed to meet as a group to discuss changes to the criteria of the evaluation form. After that process was completed, the supervisor stated that staff misinterpreted the exercise and that only the human relations department had the authority to make any changes. From that point, the supervisor instructed staff to submit their suggestions individually for discussion on an individual basis. Ironically, direct line supervisors created the criteria for case manager’s evaluations and not the human relations staff. The point of this illustration is the issue of control. As indicated earlier by Etzioni (1964) and Stegall (2003), relinquishing control in a linear environment is a difficult process.
Looking to the external environment, part of the underlying reasons for maintaining a hierarchical system is the lack of voice or power of direct line employees. In a non-union state and lack of competitive alternatives of employment for the Bachelor’s level case manager, the county health system can continue an outdated system with little consequence. Employees have choice, but their choices maybe limited.
The question comes to mind as to why the student did not ask during the meeting for clarification regarding the original creation of the employee evaluation tool. Hardy and Phillips (1998) address this very issue of confronting authority when the dominant party is in control. The authors suggest using the technique of substantiated and documented discussion to lend legitimacy and power to the questioning staff. However, if the supervisor is perceived as insecure in relinquishing control, a substantiated argument maybe interpreted as insubordination.
Assimilating the other theories of human relations (Lewin, 1975) and structuralism (Habermas, 1989), the field placement of the student integrates both, but to a lesser degree than the classical system of control. The intrinsic motivation for case management is the shared values and goals of providing help to a disenfranchised group. Helping elderly who are isolated and or homebound, yet independent enough to remain in their home with outside services is emotionally rewarding work. This exemplifies human relations concept of shared values coalescing and motivating a work group instead of increased pay (Etzioni, 1964).
The structuralist ideas of Habermas (1989) confronted Kurt Lewin’s (1975) ideas of shared values. The structuralists believed in direct and straight communication, giving credit to staff to discern differences of play-acting and truth. Shared values maybe an important motivating force of workers, but should not diminish the importance of financial reward.
On the micro level, Weick (1969) diverges from the macro assessment of Etzioni (1964), Bertalanffy (1968), and Ahrne (1990) by focusing on the quality of relationships within groups and an organization. Weick (1969) explained that the quality of relationships formed, their purpose, duration, and process needs to be recognized in sustaining an organization. Applied to the student’s program, the quality of relationships between client and staff member or staff member and other organizational members is missing. The student’s field placement program does not measure the quality of relationships formed and maintained between staff and clients or staff and other members. Measuring quality of relationships requires additional knowledge, skills, and time that the organization has not afforded in the past. Counting the number of cases completed and hours served provides a concrete measurement that requires a less time and thought consuming process. If quality of relationships was valued, then management could discern the quality of case managers from average to above average in this skill area. Instead, discerning differences between case managers is measured by the amount of extra work staff can complete without compensation. This point demonstrates the difference between words and actions of staff hearing that they are valued as professionals, but seeing how they are treated differently.
Weick (1969) noted that one of the areas of treating staff consistently or differently is through the sharing of information. The sharing of information by the supervisor to a select group assumes others will disseminate the knowledge informally. This behavior misplaces responsibility on selected staff and handicaps other staff in their performance. Boverie (1991) states that the selection of individuals of telling information, either intentionally or for convenience, establishes unhealthy boundaries among staff.
Laszlo (1996) also emphasized relationships as important properties of a system. However, unlike Weick (1969), Laszlo believed that the quality of the person in a position did not matter as long as the tasks were completed. This observation describes the field placement of the student when tasks and roles are designed and measured on a quantitative and not qualitative basis. By focusing on tasks and amount of work accomplished, management can keep qualifications for positions general and reimbursement low. Maintaining lower salaries helps to control costs and the need for additional revenue. By valuing quantity of work over quality, the organization does not need to consider talent as an important factor. This reinforces the observation of Laszlo (1996) that the particular talents and qualities of an individual in an organization do not matter, as long as tasks are accomplished.
Integrating nonlinear dynamic theory to case management systems
As Etzioni (1970) defines systems changes and analysis as a process, Church (2001) specifies communication as part of the process that groups organize around. Church subdivides information into the categories of formal and informal processes, context, and content. The means information takes and the types of information provided, gives staff a message about their value as independent thinkers and actors in the system.
Formally, the organization as a system used to circulate a “Monday Morning Report”. The report gave insignificant information about future events or fundraisers. Meaningful information about problems, solutions towards those problems, and status of the system was missing. Replacing the Monday Morning Report, managers and or the Vice-President would visit the offices on a quarterly basis. During these meetings, the managers would inform the current status and progress of the system. This example would appear as a positive change in nonlinear communication and the building of trust. The problem is overcoming recent history.
For example, a part of the organization was a geriatric behavioral component. Management viewed this component using financial resources they did not have. The manager stated at a quarterly meeting that she did not see any benefit to clients in having on-going counseling to elderly patients and not showing concrete results. Subsequently, the department was cut. The issue is the filtering process of not telling the whole story of the situation and losing credibility. Taken from a staff member working in that department (another Walden student), the issue of the department losing money was due to a chronic problem of billing and inability to collect revenue for services provided. The other portion of the story deleted was the contracting out to a private source the same services once stated as an unneeded.
Another problem of credibility in believing the organization’s statements is the contradicting behaviors. Recently, the managers advised staff of the pending vote to the public to allow the health system to become separate from the county in order to allow the entity to generate revenue through property taxes. The present system does not allow the health system to do this. A question raised to management was how this change to a separate entity will affect staff positions, retirement, and benefits. The reply was that they did not know, but would do their utmost to retain the present level of the system. Contradicting this statement are behaviors and previous statements that told staff not to expect salary increases and to be happy they are employed. The lesson for organizations on all levels of a system is the consistency and accountability of statements and behaviors in maintaining credibility and trust.
Church (2001), Boverie (1991), and Merkel and Carpenter (1987) discuss the role of informal communication and its role in maintaining or contradicting the present system and culture. The informal system consists of performance reviews, the interpretation of rules through policies and procedures, social networks, and reward systems. In addition to maintaining trust and accountability, as in the formal system, the informal system tells the outside observer the means staff accomplish tasks and balances priorities.
Returning to the performance reviews, supervisors mostly evaluate staff as meeting expectations. By rating staff in the middle, the organization does not need to increase salaries above a marginal amount. The informal culture of the system is implied through the difficulty to exceed an average rating. Although the organization formally states that they value excellence, the behavior by the supervisor (Kernberg, 1979), (Neumann & Hirschhorn, 1999) and the evaluation process shows otherwise.
The reward system is another part of the informal process that patronizes staff. The staff is rewarded with stickers that a first grader receives on a report and a memo when a client calls or writes to report their appreciation. When a staff member receives three stickers, they can turn them in for a pencil or a small flashlight. Employee recognition occurs once a year to show staff appreciation. Funds for the recognition are raised directly from the employees. The system does not contribute funds for the recognition process. Although, on a formal basis the organization states that they value their employees and encourages excellence, the behaviors indicate a value system of mediocrity and control. Similar to a dysfunctional family (Boverie, 1991), the behaviors contradict the message.
The way in which rules and procedures are interpreted tells another part of the informal process of the system. The handbook provides rules, procedures, and expectations. However, the interpretation of the rules varies. Two examples come to mind: First, regarding rules and procedures for case managers, staff members are required to make contact with new referrals within five working days. Because of the heavy caseload and intensive time a new referral takes, case managers try to screen the appropriateness of the referral to the program and provide other resources if the client does not qualify. Politics enters the system when the overriding agency receives a complaint about a staff member screening out a client, appropriately or not. The overseeing agency mandates the case manager to place the client on service, disregarding guidelines and rules for an appropriate fit. The action gives the case manager the message that politics outweighs appropriate judgment.
The second case regarding the interpretation of policies is the tuition reimbursement program. The policies do not place a cap on the reimbursement of tuition. The policy, as written, only requires the approval of the immediate supervisor. However, because of departmental budget constraints, the middle manager decides to cap reimbursement and to look at each individual course for approval instead of the program as indicated in the policy. By looking at the manner in which messages are given and received through informal and formal processes, the outside observer can learn if messages and behaviors are consistent or not.
Checkland (1994) created a different model of soft and hard systems for analyzing an organization. The soft system describes the collaboration of colleagues in sorting out values, perceptions, and plans for action. Describing the system of the student, case managers meet weekly, discuss problems, brainstorm, and assist each other in reaching conclusions. When the process does not conflict with rules or involve increased costs, the collaborative system informs and enriches staff in their work. Combined with the hard system of meeting timelines, required meetings, and completing caseloads, the case management system of the student demonstrates the integration of the hard system of rules and the soft system of collaboration.
Even though the paradigm of Checkland (1994) integrates a systems and goal approach, the hierarchical nature of the student’s field placement is not the most efficient and effective system (Etzioni, 1964). Stamps (1997) states that systems thinking calls for the organization to allow equal access to information and decision making authority placed at the lowest level. For example, case managers have a high degree of autonomy in deciding and interpreting the appropriateness and quantity of service for each client. The case manager is given the freedom and responsibility of arranging their own schedule and scheduling their own clients. Contradicting the appearance of freedom, supervisors monitor case managers’ schedules and home visits, in addition to paper work, to insure staff carry out their plans as stated. If the organization trusted individuals to accomplish their work by monitoring results instead of micromanaging, then perhaps the system could create a system of trust. The supervisor then could act more as a coach instead of as a police officer.
For managers to act more as coaches rather than watchmen, Stegall (2003) and Moravec (1994) discussed the role of leadership in an organization using the concepts of general systems theory and self-organizing systems by management providing just enough control for people to manage themselves. For the role of leadership to change to the facilitating of operations, a culture of an open nonlinear system needs to be integrated and explained. The process would involve eliciting honest and frank input from all levels of an organization without filters or criticism. The goal is to encourage managers to see themselves as facilitators and counselors rather than bosses. The key qualities for management in a systems design would require the abilities to work with emotions of uncertainty, creating a positive outlook, listening skills, and flexibility in balancing personal and professional needs.
Following this line of thought of leadership qualities in a non-linear system, Shelton and Darling (2001) took the concepts of chaos theory and formed a framework for regenerating systems by showing managers how to act in a more sensitive, aware, creative, and trusting manner. From the theories of quantum mechanics and chaos theory, seven skill sets were created to enhance thinking and interaction. The skills were listed as: 1) intentional seeing, 2) paradoxical thinking, 3) feeling alive, 4) knowing intuitively, 5) acting responsibly, 6) trust, and 7) the ability to be in a relationship. The descriptions of these skill sets are as follows:
1) Quantum seeing was defined as a skill set enabling the manager to not become as narrow focused and open to other possibilities. Being more open-minded allows the manager to not prejudge others or the situation at hand (Shelton & Darling, 2001, p. 267).
2) Quantum thinking was defined along the concepts of quantum physics and chaos theory. The concept of order, emanating from disorder and the inability to control an unstable environment, suggested the concept of thinking paradoxically. Thinking paradoxically suggests using more creative right brain thinking in finding solutions for complex issues (Shelton & Darling, 200l, p. 267).
3) Quantum feeling was premised on the belief that humans are composed of the same energy as the universe. Therefore, negative thinking drains energy from self and others. Choosing how one feels about a situation in a positive frame provides the potential of seeing hidden opportunities and reinvigorating self and others (Shelton & Darling, 2001, p. 268).
4) Quantum knowing suggested learning how to use ones intuitive process in making decisions. Based on quantum theory, we live in a sea of energy with subatomic particles that transcend boundaries without our awareness. In a relaxed state, as in meditation, one has greater access to this underlying knowledge. Successful managers, in this new age, learn to integrate their intuitive processes into daily organizational life (Shelton & Darling, 2001, p. 269).
5) Quantum Acting, based on the principle of nonseparability, stated that on a subatomic level, “two systems once connected remain connected, regardless of separation of time and space” (Shelton & Darling, 2001, p. 269). This underlined the principle from chaos theory of nonlocal causation. Translated, this meant “everything in the universe is a part of a complex whole that influences and is influenced by every other part” (p. 270). In respect to society, organizations, and management, the principle stated that acting responsibly towards others with kindness, compassion, and integrity with mutual benefiting goals in mind has a reverse effect on the individual and organization (p. 270).
6) Quantum trusting was derived from chaos theory and quantum physics. Chaos theory stated that an environmental feedback system serves as a catalyst that moves a system to a higher level of order and coherency. Quantum physics states that the evolution of the system may not be random due to an invisible ordering of subatomic particles. Therefore, defining quantum trusting is the ability to trust the natural process that order will evolve without interference. The skill suggests that allowing people to think and act independently will produce results (p. 271).
7) Quantum being, the seventh and final skill, stated that relationships are the prerequisite for change. “Subatomic particles are abstractions. Their properties are definable and observable only through their interactions with other particles” (Shelton & Darling, 2001, p. 271). In quantum physics two particles can merge to form a new system. This observation implied that working in relationship with others has greater potential than working alone. The construct assumes that individuals are open to sharing information and learning. This also presumes that management nurtures an environment of trust and differentiates between qualities and characteristics they see in others from seeing a projection of themselves (p. 272).
The skill set described by Shelton and Darling (2001) requires the organization/management to value and acknowledge relational skills to accommodate a changing environment. In a case management/social work role of the student where relationships should be nurtured and evaluated, mostly concrete results, measured by errors in paper work, accuracy of recorded worked time, and numbers of people seen, are given weight. Subjective qualitative measures take greater time, skills, and knowledge to assess over concrete observable results. Moving from a linear to a nonlinear dynamic requires an organization to value the process as well as concrete results.
Reinforcing relationship skills and the building of trust in a nonlinear dynamic system, Maxwell (1998) saw the role of leadership as “serving” the organization. Serving was defined as possessing the qualities of empathy, healing, ethics, listening skills, and sensitive awareness. Integrating this process, Maxwell emphasized the facilitating of relationships over the need to control. Through this change, a “servant leader” needs to demonstrate empathic listening skills and sensitivity to the needs of others. Listening skills involved a deeper level of listening of identifying the feelings, restating what was heard, using direct eye contact, and giving complete attention. Integrating counseling skills that Maxwell refers to as “servant leadership”, involves additional knowledge and training.
Demonstrating the opposite of servant leadership, a Vice President came to the office a few months ago to inform the group about the budget problems and future goals. Asking about raises and loss of qualified employees, a co-worker was vehemently reprimanded in a public forum for bringing up the issue. The writer would think that a Vice President or President of a large organization would possess the skills and sensitivity as described by Maxwell (1998). Practicing these skills, the Vice President might have used empathy in making his point to show he understood the staff member, but the system was unable or unwilling to give raises at this time.
Serving the homebound elderly with behavioral health needs
Addressing the need for administering counseling or psychotherapy of elderly depressed clients in addition to antidepressant medication, Reynolds (2003) conducted research to determine if physicians could improve the recognition and treatment of depressed elderly patients and significantly reduce symptoms of depression. The methodology took 600 patients identified with different levels of depression, split them up among 18 different physician’s offices and sites, assessed for medication and levels of treatment. Patients identified with major depression and or suicidal thoughts received medication and psychotherapy by master’s level clinical social workers, nurses, or psychologists. Patients evaluated with lesser forms of depression received education instead of psychotherapy in addition to medication if medication was deemed as appropriate. The study took a course of two years to reinforce change. Depression scores were measured by the Hamilton Depression Scale to record ongoing progress.
The value of the study is significant because it combines psychotherapy over a longer period of two years with medication. In the field practice of the student, many clients seen as mildly or moderately depressed have medications, but do not have on going counseling and or psychotherapy. Counseling offered by agencies in the area of the student treats skill deficits rather than underlying emotional issues, the bias of the student. The study provides evidence for the need and value for long-term counseling or psychotherapy in combination with antidepressant medication.
The gap in the study by Reynolds (2003) addresses elderly patients 65 and older who were able to drive or meet weekly, biweekly, and monthly sessions independently. The study misses the elderly clients diagnosed with a form of depression and unable to transport themselves on a regular basis to a clinic. By default, this study provides evidence for the homebound depressed elderly client taking antidepressant medication needing ongoing counseling or psychotherapy in the home because they cannot drive or depend on regular transportation.
Addressing this issue, Zeiss and Gallagher (2003) discuss the myth about older adults averse to psychotherapy or counseling for emotional pain. The authors’ state that the myths maybe do to the misinterpretation of initial expressions made to doctors in primary care settings. Zeiss and Gallagher do not elaborate on the misinterpretations of emotional problems, such as the expression of mental pain through physical symptoms. According to the research of Zeiss and Gallagher, no empirical or anecdotal evidence that they have found, supports the claim that the elderly depressed client would shun counseling. On the contrary, the current research reviewed by Zeiss and Gallagher provides evidence of the willingness of elderly depressed patients for preferring solution focused and cognitive therapies over taking medication. The issue is not the mode of therapy, but that the mental health aspects of the client are addressed.
When the student asks clients about feelings of depression or anxiety, clients managing these emotions were happy the student addressed them. Perhaps, the primary care physician, as well as the case manager, needs to address their own comfort level of addressing mental health issues of depression and anxiety. The first step in this direction is the recognition of emotional issues. The problem can be addressed by the evaluation and follow-up of a case manager, such as the student’s case management program, or as noted by Zeiss and Gallagher (2003), the patient’s primary care physician.
Regarding the student’s field practice, the assessment tool of the student’s program recently included a questionnaire that asks clients about their feelings of depression and anxiety. If the client mentions or acknowledges feelings or thoughts of depression and or suicide, the case manger then can refer the client to an agency or their primary physician for a referral for evaluation and treatment. To the best anecdotal knowledge of the student, existing agencies for referral that charge minimal or no fee, offer only educational modalities and or short term counseling. The issue of the student, as this article suggests, is for a case management program to include clinical social work, graduate level counselors, and or psychologists in addition to homecare services.
Comparing the differences between multidisciplinary and interdisciplinary teams, Zeiss and Gallagher (2003) associate the two teams to a hierarchical and collaborative model, respectively. The multidisciplinary team works on the same site and serves the same patients, but works independently of the others. Each discipline generates its own assessment, treatment plan, and implementation of that plan. Information is shared among team members, but no attempt is made to form a common plan. The team is lead, usually by an M.D, who overseas responsibility, leads meetings, resolves conflicts, and assigns caseload. Program function and team effectiveness is not shared.
Two examples of this model come to mind. The first example would be a privately contracted home health agency assigned to a patient after a patient’s discharge from a hospital. The patient is assessed by a lead R.N. and other team members of social work, physical therapy, and or occupational therapy are assigned as needed. Each team member independently makes an assessment, treatment plan according to their own discipline, and implements the plan. Information is shared with the team lead nurse and M.D. Other information or coordination is done through weekly or monthly meetings. Responsibility for team function and effectiveness remains with the agency head.
Similar to the hierarchical, multidisciplinary team is the student’s case management program. Case managers work independently by forming assessments for client’s needs and program eligibility. Service plans are implemented and coordinated by the case manager. During weekly meetings, case managers discuss issues, information, and problems. Responsibility for caseload, team function, and effectiveness remains with the direct supervisor.
In examining the interdisciplinary team approach, the model represents a collaborative paradigm where responsibility for function and effectiveness is shared (Zeiss & Gallagher, 2003). Multidisciplinary members of nursing, clinical social work, and the physician work together to plan, evaluate, and implement health care. The interdisciplinary team approach appears to work best in meeting the overall needs of the elderly client, but more importantly, recognizes and integrates mental health evaluation and treatment with the physical aspects.
According to Zeiss and Gallagher (2003), the evidence does not support the primary care setting as integrating mental and physical health needs for elderly patients, except in instances of the Veterans health system that serve older adults. Usually the community-based primary care physician assesses, prescribes, and or refers clients for physical health problems. In instances where Geriatric Primary Care Teams already exist, the psychologist or clinical social worker need to educate the other team members about the role and responsibility for the mental health component. In primary care practices where mental health needs are not addressed, the psychologist or clinical social worker needs to work with physicians to identify and refer cases for further evaluation and treatment. The premise for the article is two fold: the recognition for the need of integrating mental and physical health together on parity with each other, and two, for the individual practitioner to advocate for themselves to establish or reinforce a mental health component in a primary care setting.
The constructs of nonlinear dynamics provide a guideline for a system to collaborate with its integral parts and the community in adapting to a changing environment. The interpretation of nonlinear dynamics places responsibility with all levels of a system in treating people with sensitivity, honesty, and fairness. The patterns that resonate through the literature are developing and maintaining cultures of trust and relegating authority and responsibility to the lowest level.
Applying chaos theory as a critical assessment tool of a system provides an instrument to qualitatively investigate the relationships and dynamics that play between individuals, levels of a system, and the system in relation to its environment.
Going back to the theorists of nonlinear dynamics for critically assessing a system, Ahrne (1990) highlighted a system’s overt and covert processes of control. The student’s program, as a social service endeavor, appears to be a normative system with altruistic and social values. By looking deeper under the surface, the outside observer might see a coercive hierarchical structure instead. Unraveling the layers even more, Church (2001) assists the observer in finding the true meaning of actions by forming categories of formal and informal communication. The informal categories of performance reviews, interpretation of rules, and reward systems reveal more about a system’s culture and processes of control. According to Stamps (1997) and Bertalanffy (1968), the more open a system is to sharing information and relinquishing control, the more apt individuals are in adapting to a changing environment.
For a linear system to adapt to a nonlinear dynamic environment, Stegall (2003), Moravec (1994), and Shelton and Darling (2001) discussed the qualities of leadership and ways of being with other people to accomplish and maintain the change. A nonlinear system, regardless of the type of organization, needs leadership to act more as coaches and counselors than the imagined shop foreman in a sweat shop. The responsibility for a trusting environment is shared on all levels of a system. For a trusting environment to work, all people within a system need to say what they will do and follow through on what they say.
Serving the elderly with depression or anxiety, Reynolds (2003), Zeiss and Gallagher (2003), and Waern et al. (1999), see the client being assessed and treated in the office of the primary care physician. The problem with this research recommendation is that many elderly are unable to transport themselves or depend on transportation on a regular basis. Secondly, as noted by Waern et al. (1999), many primary care physicians prescribe antianxiety or antidepressant medications, but the client does not concurrently undergo counseling or psychotherapy. Meeting this gap in service, the case management system, such as the student’s program, is the most likely structure to assess, refer, and provide concurrent counseling and or psychotherapy by licensed counselors or social workers to the elderly homebound client. The student believes that a case management system needs to incorporate trained professional therapists as part of their system of care in meeting the total need of the client.
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