The Implicit Contract: Implications for Health Social Work

Social work practice in health and mental health settings takes many forms (Carlton, 1984; Kerson, 2002; Kerson & Associates, 1997; Rehr, Rosenberg, Showers, & Blumenfield, 1998). Location of dynamics that cross several settings can be useful in developing practice skills that span the boundaries between settings and allow more generalist practice. Findings from a study with women who have recently terminated a desired pregnancy because of fetal anomaly suggest that patients may have expectations that their compliance with and adherence to medical guidance entitle them to a positive outcome. Here, I develop a theory about these expectations, which I refer to as the "implicit contract." Forces act on patients to create an intersection of social and emotional norms. These norms interact to create forces that provide implicit guidance for individuals' intimate thoughts and beliefs about their health, the medical system's technological imperative (Fuchs, 1972; Garcia, Timmermans, & van Leeuwen, 2008; Gillick, 2007; McCoyd, 2007, 2010), the "feeling rules" that inform emotion (Bendelow & Williams, 1998; Hochschild, 1979; Shott, 1979), and societal legal and economic understandings (Ali, 2003; Brenner, Brenner, & Horowitz, 2009).These varied norms, internalized through socialization and cognition and interacting in individualized ways, are often navigated with the help of social workers, who provide resource information and help with "emotion work" (Hochschild, 1979; McCoyd, 2009). In hospital settings, adherence to the norms and the emotion work involved are frequently viewed as individual dynamics, yet the external norms interact as internalized forces that influence thoughts, feelings, and behaviors. The data reported in this article suggest that these forces coalesce to form an internal template or schema of expectation that may lead to higher degrees of expectation about medical care than are warranted. The set of expectations created can then take the form of an expectation that because the patient has adhered to the expectations of his or her medical providers, the medical system must therefore also adhere to the patient's expectations for a positive outcome--a form of implicit contracting with entities unaware of the contract. The data reported here pertain to a primarily qualitative study with 30 women who terminated pregnancies due to a fetal anomaly--termination for anomaly (TFA).These pregnancies had either been planned or accepted as desired, yet they were ended when a fetal anomaly was diagnosed. Hollingsworth (2005) encouraged more social work research in the area of reproductive technologies. The original research from which this article draws (McCoyd, 2003) was a step toward exploration of women's responses to reproductive technologies that both enable and force decisions about pregnancies found to be anomalous. The original study examined decision making and bereavement among women who terminated a pregnancy found to be affected by fetal anomaly; this article reports a reanalysis of a subset of the data for theory-development purposes. The reanalysis suggested that women perceive a contract with the world around them and with the medical system in regard to the outcome of their pregnancy, a contract predicated largely on internalized general legal, economic, and health norms developed long before the women even became pregnant. This dynamic has major implications for the way social workers can be of most assistance to affected patients. Although the data reported are necessarily specific to the respondents and their situation, the implicit contracting dynamic seemingly cuts across situations and may have implications for most social work practice in health care. These implications are addressed at the end of this article. First, the concept of "contracting" within social work is discussed. The methods of the underlying study and a report of a subset of the results follow the Contracting as Skill and Product section. …