In class, we reviewed Systems Theory and the Life Model to help us understand how the individual impacts their environment, and

163© Springer Nature Switzerland AG 2021 R. P. Dealey, M. R. Evans (eds.), Discovering Theory in Clinical Practice, https://doi.org/10.1007/978-3-030-57310-2_12

Chapter 12 Systems Theory: The Case of Esperanza

Madeline Pérez De Jesús, Enitzaida Rodríguez, and Gladis Anaya

Introduction to Systems Theory

Systems theory calls practitioners to examine the relational dynamics between individuals, and between and within groups, organizations, or communities, as well as mutually influencing factors in the environment (Leighninger, 1977). While systems theory is commonly used in social work, the authors argue that the profes- sion would benefit from expanding its scope to intentionally explore issues of diversity and the impact of trauma. This chapter demonstrates how systems theory supports culturally informed clinical practice by highlighting the case of “Esperanza,” a 16-year-old ninth-grade student who, with thousands of others, migrated from Puerto Rico to urban cities in the Northeast and other areas in the United States after being displaced by Hurricane Maria in 2017. Two Latinx social workers enter Esperanza’s life in her new high school setting in Hartford, Connecticut.

The authors’ overview of systems theory includes a perspective on how problems arise, how systems theory facilitates understandings of the change process, and implications regarding complementary interventions that are can be used based on this theory. The case study of Esperanza details her demographics, family dynamics, and various ecological factors that influence her situation. Theoretical integration

M. P. De Jesús (*) Department of Social Work and Equitable Community Practice, University of Saint Joseph, West Hartford, CT, USA e-mail: [email protected]

E. Rodríguez School Social Worker, University of Saint Joseph, West Hartford, CT, USA e-mail: [email protected]

G. Anaya University of Saint Joseph, West Hartford, CT, USA e-mail: [email protected]

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follows the case example, with the authors demonstrating how systems theory informed social workers approach to treating the client and understanding the client’s response. Important considerations regarding intracultural and intercultural factors that influenced clinical intervention effectiveness are described. The authors note that systems theory also served as a tool for resolving a practice conflict for the social workers. In the concluding section, the authors pose discussion questions to support readers in thinking critically about the usefulness of systems theory and the process of integrating theory into clinical practice.

The overarching premise in systems theory is that there is reciprocity in the inter- locking relationships between people, families, social networks, neighborhoods, and other related systems (Leighninger, 1977). This reciprocity includes elements in the environment such as nature, encompassing physics, chemistry, biology, and social relationships. While the origins of systems theory come from Charles Darwin’s notion of “the survival of the fittest,” the theory has broadened and sup- ports social work by offering a balance between biological, psychological, and sociological roots. Systems theory had a significant impact on social work during the 1970s, when its contributions included general systems theory, and family ther- apy developed into ecological theory and the importance of networking (Payne, 2002). This theory is particularly useful to social workers, as they are trained to have a person-in-environment lens.

Leighninger (1977) identified three main contributions of systems theory to the field of social work: (1) it expands the practitioner’s focus beyond the client to the client and their environment, (2) it allows for a better account of social change, and (3) it has the potential of having social workers reflect on issues of power and con- trol. Social workers are not strangers to examining ourselves as agents of social change, and in his discussion of the applicability of systems theory, Leighninger reminds us that we must also examine the other side. In other words, just as we explore how social workers are agents of change, it is also central to look at how we might operate as agents of social control or even social oppression.

Systems theory offers a specific perspective on how problems arise. This per- spective is evident in a definition of social work that was put forward by the International Federation of Social Workers in 2000, and subsequently reinforced by the International Association of Schools of Social Work (as cited in Hutchings & Taylor, 2007, p. 382):

The social work profession promotes social change, problem-solving in human relation- ships, and the empowerment and liberation of people to enhance well-being. Utilizing theo- ries of human behavior and social systems, social work intervenes at the points where people interact with their environments. Principles of human rights and social justice are fundamental to social work.

Systems theory assumes individuals are part of overlapping or intersecting mul- tiple networks and defines problems within this overlap. No individual lives in a bubble; our families, our communities, the related systems with which we engage, and the broader sociopolitical and economic climate impact us all. Just as the prob- lem is found in these overlapping systems, this is also where potential solutions lie.

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Payne’s (2002) reminder of the importance of networking is applicable to our cli- ents, as the people in their systems shape the types of information they receive and their beliefs, which in turn impact their actions. For instance, a client may have access to accurate or inaccurate information, and may operate in the world with a sense of entitlement or a sense of despair.

Various interventions emerge from the foundational principles of systems theory. Visual aids provide a concrete way for clients and those who work with them to digest how systems theory helps make meaning of a client’s life. Ecomaps and genograms are examples of visual aids that can be particularly useful during the early stages of rapport building and assessment. Ecomaps are visual representations of the interconnected systems of an individual’s life that show the relationships between the client and their environment (Hartman, 1995). Whereas ecomaps dis- play a more comprehensive arrangement of systems, genograms fix the gaze specifi- cally on family dynamics across generations, allowing client and practitioner alike to examine family dynamics with particular focus on behavioral patterns and quality (Altshuler, 1999). The relationships between systems, people, and the client are represented by lines drawn on the visual aid. A thick solid line represents a mean- ingful positive connection. A broken line symbolizes a weak connection. Lines drawn with crosses through them indicate stress. Some lines might also include arrows to suggest that a relationship appears to be mutually beneficial, mutually toxic, or one-directional. Pope and Lee (2015) are a good starting point for further direction on the creation of genograms.

Systems theory helps social workers understand that it is not only individuals who serve as stressors or supports to a client; the processes of bureaucratic institu- tions that represent education, religion, political, and economic entities can stress or support a client, as well. Understanding the client’s supports and stressors is a pre- requisite to engaging with the client therapeutically.

Cognitive behavioral therapy (CBT), a psychological treatment model in which the treatment provider helps the client become aware of their thought processes, belief systems, and antecedent behaviors, is one approach being increasingly used by social workers to treat clients with a range of problems, including but not limited to anxiety, depression, and post-traumatic stress. CBT as an empowering model aligns well with systems theory, as clients from underrepresented groups are fre- quently subjected to discrimination and intergenerational trauma. CBT can be trauma-focused, and typical techniques for child and adolescent survivors of trauma include cognitive reprocessing and reframing, exposure, stress management, and parental treatment (Cohen, Mannarino, Berliner, & Deblinger, 2000).

Mutual aid groups, another intervention model, situate individuals who are undergoing similar social problems as providers of support to each other, in the context of a group working on solutions. Such groups provide opportunities for clients to share their lived experiences while witnessing each other’s accounts of interactions with various systems, and subsequently influencing each other (Gitterman, 2004).

Social workers frequently engage in a role traditionally referred to as case man- agement, a process of assessing the client’s needs and then securing (in some cases

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advocating for) a package of services. Consistent with a focus of engaging clients with institutional actors, resource referral is an intervention in which social workers secure assistance for clients to supplement supports that are limited or unavailable from their personal agency standpoint. All the heretofore mentioned types of inter- ventions help ground understandings of the case study of Esperanza.

Introduction to the Case of Esperanza

Esperanza is a 16-year-old Puerto Rican heterosexual female. All names and identi- fiers of this case have been changed to maintain the confidentiality of the client. A ninth-grade student at her local urban high school, Esperanza lives with her 7-month- old baby, 34-year-old mother (Ms. Colon), and two adolescent siblings in an apart- ment in Hartford, Connecticut. While neither Esperanza nor her family currently attend church services, they identify as Catholic and were all baptized as infants. Ms. Colon, the primary income-earner, works as a home health aide for the elderly. Both of Esperanza’s parents stopped their formal schooling after eighth grade. The family unit receives some public assistance and financial contributions from Esperanza’s siblings; also high school students, who both hold part-time jobs. The family’s primary language is Spanish.

Esperanza was referred to the school social worker last year, initially for aca- demic reasons. As an “over-age student,” Esperanza was required to undergo a series of educational evaluations. While Esperanza did not have any learning dis- abilities, she was 2 years behind grade level due to gaps in her school attendance and limited English-language proficiency. Her social work referral expanded beyond academics after her classmates informed teachers that Esperanza was pregnant. Because she was a pregnant minor, a referral to the state child welfare agency was also made. Despite being polite and cooperative with the social worker, Esperanza initially refused the involvement of school and state officials, stating she “tenia todo el apoyo en su familia” (“had all the support she needed within her family”). Esperanza previously received counseling services from a school social worker as an elementary school student in Puerto Rico, to support her coping with her parents’ divorce. Counseling services then involved 6 months of weekly individual sessions, which Esperanza described as supportive. She has since developed and maintained healthy relationships with both parents, who appear to collaborate well in their co- parenting of Esperanza and their other children. Esperanza’s relationally healthy and loving family, as well as her personal resilience, prove to be strengths in her treatment.

Esperanza’s presenting concern was her increase in trauma-related symptoms, including increased anxiety, depressive mood, difficulty concentrating, and lowered frustration tolerance. These symptoms were interfering with her ability to maintain effective, positive communication with others both in school and with her personal relationships. Esperanza also stated she was fearful of “engaño” (Spanish for trick- ery or fraud) from institutional officials such as social workers and teachers.

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During the first 5 years of her life, Esperanza lived with both of her parents. At the age of five, her parents divorced. Although her parents terminated their marriage, Esperanza reports that her parents speak about each other in cordial ways and engage in healthy co-parenting. This cooperative co-parenting engagement is a fam- ily strength, especially since she has gone back and forth living with each in the years since their divorce. Back and forth is also a larger pattern for Puerto Ricans, as it references travel between the island and the mainland in a circular motion facilitated by U.S. citizenship. Despite having legal recognition as U.S. citizens, Puerto Ricans who have spent time in both places often experience cultural dis- crimination and feelings of not belonging to the island or the mainland. Acevedo (2004) references this dilemma as belonging “neither here nor there.”

Between the ages of 5 and 12, Esperanza lived intermittently with each of her parents and migrated back and forth between Connecticut and Puerto Rico on at least three separate occasions. When Esperanza was 12 years old, her mother moved to Connecticut in search of employment with two of her children (the eldest and the youngest). Esperanza remained in Puerto Rico with her father for three years until her mother could “send for her” to move to Connecticut.

When Esperanza was 15  years of age and still living with her father in Puerto Rico, she experienced the devastating impacts of a hurricane that led to a mass exo- dus from the island to the United States. Esperanza is a survivor of sexual abuse. While she described having a “boyfriend,” she clarified that this person was a man 10 years her senior. Despite this being a relationship that felt like a courtship for her and was approved by her family, it is a situation of abuse. She was not within the legal age of consent to engage in a sexual or emotional relationship with this adult.

Esperanza’s mother and older sister appear to be affectionate and reliable posi- tive supports for her. They care for Esperanza’s baby while she is at school. On days that Esperanza does not have family childcare, she does not attend school. This accumulation of absences (an average of one  day a week) impacted Esperanza’s academic progress and was brought to the attention of the state child welfare agency as potential educational neglect. The engagement with child welfare also revealed that Esperanza had been impregnated at 15 by a 25-year-old man, which raised concerns. Esperanza assured social workers that she was not raped and was “in a relationship” with her child’s father. Despite her description of her child’s father as an attentive partner and active father to their child, he was arrested on multiple counts, including statutory rape for his involvement with Esperanza. Esperanza interpreted her boyfriend’s arrest and her social service involvement as unjust, and she experienced the state and judicial system as preventing her and her infant from receiving his emotional and economic support.

Upon migrating back and forth from Puerto Rico to the mainland United States, Esperanza had to learn to navigate two distinct cultures and languages. She also had to adapt to two separate family structures and dynamics of interaction. She showed signs of anxiety and depression and made statements about how she struggled being a teen mom while desiring to engage in typical adolescent activities, and the ramifi- cations of those tensions in a social context. For example, the social worker noted that Esperanza lamented about missing the junior prom and other social activities

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due to her caregiver responsibilities. Despite these difficulties, Esperanza stated that her baby is “mi cariño” (“her love”) and speaks about the child with much affection.

After Hurricane Maria, there was little evidence of support for the mental health impacts of this natural disaster on the many students migrating and integrating into mainland American schools. As Puerto Rican students increasingly enrolled in urban high schools, social workers scrambled to address these challenges and meet the needs and demands of newly arrived families that had been deeply impacted by the hurricane. In the scope of this distressing event, the school social worker and her MSW intern worked with Esperanza.

During the initial phase of working with the client, the workers administered psychological first aid, a set of support actions aimed at reducing post-traumatic stress related to natural disasters often offered in schools. Psychological first aid centers around the core actions of contact and engagement, safety and comfort, stabilization, information gathering, practical assistance, connection to social sup- ports, information on those supports, and linkages to collaborative services (Ruzek, Brymer, Jacobs, & Layne, 2017). Psychological first aid was offered both individu- ally and in group settings for Esperanza and her classmates, as the enrollment of displaced Puerto Ricans increased in their high school. The efforts of the social workers were to help Esperanza feel assured, connected, and supported in her cur- rent environment. Within a few weeks of working with Esperanza, it was clear that the experience and aftermath of the hurricane had severely impacted her. She had reported nightmares and trouble sleeping, and appeared to have decreased frustra- tion tolerance despite remaining polite to those in authority.

Theoretical Integration

Systems theory was a useful tool both in supporting the social workers with their treatment of Esperanza and in understanding the client’s response. By focusing on the notion that there is reciprocity in the relationships between individuals, groups, organizations, and communities, as well as the larger sociocultural and political environment, the social workers were not only better equipped to identify factors that hinder Esperanza but potential solutions, as well.

Esperanza received treatment from the school social worker (a bilingual Latina of Puerto Rican descent) and a social work intern (a bilingual Latina of Mexican descent). The clinician (and the clinician in training) approached their work with Esperanza from a stance of cultural humility, in which they were able to incorporate Latino cultural values such as personalismo, which refers to the significance Latinos place on positive rapport with others (Mogro-Wilson, 2013; Mogro-Wilson, Rojas, & Haynes, 2016). More than merely engaging with Esperanza in her native lan- guage, Spanish, personalismo involved asking Esperanza about her extended family members and engaging in informal exchanges to establish rapport.

It is important to differentiate for emerging social workers the differences between an informal exchange (which facilitates trust) and unprofessionalism

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(which diminishes trust). These informal exchanges included brief, playful debates over whose brand of Puerto Rican coffee is better and who is the favorite participant in La Voz (the Spanish-language version of the singing competition, The Voice). Establishing rapport with Esperanza in this way was vital during the engagement process. Rapport is the entry point to the client–worker relationship. More than comfort, receptiveness, and respect, rapport is a commitment to display warmth, interest, and caring in a way that encourages the client’s trust and confidence. Choosing a highly viewed talent competition as an initial conversational prompt proved to be an excellent choice, as it provided at least 20 weeks of continuous nar- rative from which to build a relationship (“Can you believe Tania was eliminated in week three? Did you text your vote for the semi-finals of La Voz?”). Moreover, selection of a show that was popular in Puerto Rico allowed for cultural affirmation, a sense of familiarity, ease of communication in the native language, and joy. Personalismo sustained and supported the therapeutic alliance, as it built trust, con- fidence, and respect while diminishing Esperanza’s worry about potential “engaño” (trickery).

Systems theory allowed the workers to expand their view of trauma as being a component of the environment for this youth. With this in mind, they continued their work with Esperanza using ACEs (Adverse Childhood Experiences) screening to assess how many types of maltreatment a client has experienced prior to the age of 18. This tool covers ten types of trauma within three categories: abuse, neglect, and household dysfunction.

Trauma-informed approaches recognize that there have been potential traumatic experiences in the lives of our clients. Social workers must explain to clients why they are asking sensitive questions rather than just ask them as a matter of protocol. These explanations demonstrate mutual respect and cultural humility. Recognizing that sensitive questions may be misunderstood as “engaño” (trickery), in this case, the social workers began by informing Esperanza that they needed to ask her some “preguntas intimas” (intimate questions) to support her in maintaining healthy per- sonal and academic relationships. They explained this was part of a screening tool to help people and apologized in advance if they made her feel uneasy. By offering this apology, the social workers were rebuilding trust with Esperanza. The onus is on the social workers to create, sustain, and/or repair the client–worker relationship, and systems theory taught these social workers that they inherited Esperanza’s dis- trust from previous incidents experienced as betrayals from institutional actors. These incidents include the involvement of child welfare services because of teach- ers disclosing “her private life,” as well as a slow relief response from the U.S. gov- ernment to assist Puerto Rico during and after the hurricane.

Systems theory helped the social workers see how betrayals such as the incar- ceration of Esperanza’s boyfriend also took place at a macro level. In Esperanza’s eyes, her relationship was legitimate, and this perspective was further confirmed for her because she had the consent of her parents. There may thus be traumatic stress from the hurricane experience coupled with the type of trauma that arises for groups of people who have experienced disparate treatment (Matheson, Foster, Bombay, McQuaid, & Anisman, 2019). The apology for asking about intimate matters is one

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of several ways the social workers sought to affirm Esperanza’s legitimate feelings of distrust.

Esperanza agreed to answer the ACEs questions. The MSW intern facilitated the questionnaire in a conversational tone, rather than administering the tool as a formal survey. The intern, speaking in Spanish, framed the questions in ways that sup- ported the therapeutic alliance and empowered Esperanza to respond candidly. (“Esperanza, we know these questions may make you feel uneasy and we are sorry for that. We need to know if a parent or other adult in the household often or very often … cursed at you or insulted you? Think about it. Take your time.”). Here, the MSW intern sandwiches the ACEs question between a statement that affirms the client’s feelings and reassurance that she does not have to rush through this process.

Esperanza’s overall score was two out of a possible ten. She scored yes to ques- tions #4 (feeling unloved or unimportant from her family) and #6 (parents ever separated or divorced). Esperanza was hesitant about answering question #3 (did an adult or person at least 5 years older than you ever touch or fondle you or have you touch their body in a sexual way?). She struggled to understand the age of consent law in Connecticut (as well as throughout all of the United States and Puerto Rico). It was incomprehensible to her that the father of her daughter was held legally responsible for a sexual relationship with her as a minor, resulting in 3 months in jail and a court order to pay child support after his release. Esperanza struggled with the conflictual way the court ordered her boyfriend to pay child support, when prior to his arrest he had been both emotionally and economically supportive of her and the child.

Her family described Esperanza and her co-parent as a loving couple with joint plans for the future. Through the conversational facilitation tool of ACEs, the social work intern learned from Esperanza that she knew many couples with a 10-year age gap, and early-age pregnancy was an intergenerational pattern in her family. Despite this, it was critical for the social workers to be mindful of the imbalance of power between Esperanza and her child’s father. Power imbalance is what allows an adult to take advantage of an underage person in ways that meet the American Psychological Association’s definition of sexual abuse. The MSW intern made a note in the questionnaire about the circumstances of Esperanza’s “relationship” and the client’s belief that she is not a victim of abuse.

While her ACEs score is relatively low, systems theory helped the workers explore Esperanza’s perspective and understand that she has experienced more trauma than her score displays. Additional traumas not represented in this assess- ment include Esperanza’s displacement from her family/country, her early preg- nancy, surviving as a teen parent, her status as a sexual abuse victim (related to a consensual sexual relationship with 25-year-old adult male who was viewed as a sexual predator), DCF involvement (educational neglect), and her mental health diagnosis (anxiety, depression, PTSD). For example, Esperanza experienced trauma in the loss of the person she identified as her boyfriend, whose incarceration was directly connected to her disclosure to someone that he was the father, as well as incidents in her macro environment related to surviving a natural disaster and vari- ous forms of cultural assault from government officials.

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As a result of the ACEs assessment, not only have the workers continued their work with Esperanza through a trauma-informed lens, but they also made the realization that trauma was a component of the environment for Esperanza. While Esperanza’s ACEs score was two, the mutually influencing factors in the environ- ment are trauma-infused, providing a comprehensive understanding of her lived experience. From a macro lens, understanding Puerto Rico’s commonwealth status as neither a U.S. state nor an independent country sheds light on the territorial limbo that migrants experience in their “host” country. Mental health professionals have highlighted the colonization of Puerto Rican as a factor to consider when treating Puerto Rican clients (Teichner, Cadden, & Berry, 1981).

As mentioned, ecomaps are visual representations of all the systems at play in an individual’s life, while genograms show the relationships between a client and their family members. The MSW intern engaged Esperanza to collaborate on creating ecomaps and genograms to support an understanding of the interconnected systems in her life. Before inviting the client to create visual representations of her own life, the intern first focused on developing trust by collaborating on an ecomap based on a fictional character. They collectively chose the movie Real Women Have Curves, a 2002 comedy about a Latina teen and her dynamic with school and family. The intern’s engagement strategy included the small but significant detail of preselecting the menu of movies and ensuring that all the films were comedic and based on Latino culture. Utilizing a Latinx-focused movie both affirmed the client’s heritage and was a trauma-informed strategy to minimize any potential triggering that might occur from watching a drama that centrally focused on adverse childhood condi- tions. Choosing the movie together also temporarily suspended the worker–client hierarchy. The shared decision making of the therapeutic intervention allowed Esperanza and the intern to work together to understand the main character and her relationship to the family and systems around her. In that exercise, Esperanza was able to see how one is not only influenced by people and systems, but can also take actions to be the influencer.

Ecomaps and genograms visually demonstrate the relationships between sys- tems, people, and the client, which are represented by the intensity and direction of lines drawn on the visual aids. In drawing the relational connections in the …

O R I G I N A L P A P E R

Integrating Social Work Perspectives and Models with Concepts, Methods and Skills with Other Professions’ Specialized Approaches

Alex Gitterman • Nina Rovinelli Heller

Published online: 8 April 2011

� Springer Science+Business Media, LLC 2011

Abstract In this article, the authors encourage social

work practitioners to identify with and adopt distinctive

social work perspectives and practice models rather than

solely embrace models or approaches developed by and for

other professions. We do so because these perspectives are

most responsive to our professions’ mission of social jus-

tice and social purpose of paying equal attention to people

and their environments. For heuristic purposes, we present

and illustrate the ecological perspective and life modeled

approach. Since no social work model or approach can take

into account every type of life stressor, event and condi-

tion, we demonstrate how we can borrow and integrate

specialized concepts, methods and techniques from other

profession’s approaches. The authors identify five charac-

teristics which borrowed content should meet in order to

integrate well with social work models. Accordingly,

concepts, methods and skills from a few approaches have

particular relevance for social work direct practice: Cog-

nitive-Behavioral Therapy; Motivational Interviewing;

Narrative Therapy and Solution-Focused Practice. More-

over, the authors present and illustrate the process of bor- <

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