Independent thought and political action in social work practice

A Book Review

Social Work Practice: a conceptual framework

USCHI BAY

South Yarra, Palgrave Macmillan, 2014

182 pp., ISBN 9780420256611 $59.95 (paperback)

 

Uschi Bay invites us into her innovative framework for political social work practice; the small ‘p’ political practice that goes on between us as people in our public lives and our organisational contexts.  Bay, a Senior Lecturer at Australia’s MonashUniversity, uses the political philosophies of Hannah Arendt and Michel Foucault to build this conceptual framework. Using these two giants of the mid-twentieth century thinking Bay offers a way of operating politically as a social worker that will be both refreshing to practitioners, especially mature age ones like myself who are still running on a 20th century neural operating system.

By using the work of thinkers whose startling new visions have since become embedded as part of our thinking ’wallpaper’, combining these and relating them to contemporary challenges she gives us an accessible and shiny new prism through which to reflect and act on our lives, our world and our practice.

Bay reminds us, or informs us, that in Arendt’s world, thinking and acting must be united as praxis.   Arendt introduced the concept of ‘plurality’ in which there are many of us, and many differences between us but we are all human and thus equal. Foucault too was interested in excavating the variety of views that can be brought to explain and tell our lives.  Foucault also gave us a detailed exploration of the rise of the State management of people and how we, those people, come to internalise that management.

Both Arendt and Foucault saw traps in believing in contemporary or ‘taken for granted’ world views, and both saw an inherent danger of abuse in instrumentalising people; counting us, shifting us around, treating us as another form of resource. Together their

‘..concepts may stimulate social workers’ critical reflexivity in ways that enable ethical and political action…’ Bay p22

This has raised for me the issue of shame versus respect, and the lack of respect human service agencies can show to the people who use them. It has also elicited thinking about the place of strengths based practices in this framework, including solutions focussed and narrative practice. In particular I was able to see how a part of my own practice, in which I have purposely invited the opening up of a space for people who are affected by anxiety to see the genesis of that anxiety potentially  as outside of themselves, could fit within this philosophical and political conceptual framework.

Bay reminds us how a discourse can identify groups of people to be the subject of government management at the same time as they are held responsible for their own circumstances. Since as Social Workers we operate in the territory between the State that tends to define that discourse and the people who find themselves defined by it, we easily become confronted by challenges of empowerment versus alienation.

‘Social workers in hierarchical organisations also find themselves ruled and expected to carry through projects or initiatives developed by others often far removed from their day-to-day practice situation and the lives of those to be assisted.’ Bay p124

Social Work Practice – a conceptual framework invites us to re-visit this challenge of working to those whose thinking  is so distant from the site of operations and invites us to critically reflect on our choices for action. We need to be courageous and insightful enough to make our own informed judgements and to act on them.

Conclusion

Whilst it is possible to construct many useful frameworks for social work practice, if you like to be mindful of, careful about, and responsible for what you do, you are likely to be stimulated by this one. For me this has been a thought provoking, refreshing and informative read. It also took me on a most enjoyable tour back through my professional library.

This book is dense with professional language and concepts that will be beyond the average unguided undergraduate. Students with a background in sociology, politics or philosophy, and practitioners will be a better audience. Social work students using Bay’s book as part of a course with academic guidance however will not escape without a clear understanding of their location in the socio-political workplace.

Inevitably, part of our role is to keep politics alive and to contest interpretations through critical reflection and action. If Bay gets her way, as social workers we will take responsibility for our thoughts and our actions and be certain to act ‘with’ and not ‘on’ the people with whom we engage and within the world we share.

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Why we don’t act on health inequality

Wiser people than me have discussed our failure to act on what we now about the social determinants of health (Baum et al 2009, Katikireddi et al 2013). Poor health is located in social disadvantage and would need to be addressed through education, housing, transport and health. As a consequence of this knowledge the UK  and EU have looked at a Health in all Policies approach.

Problems that arise are that these areas are; big and expensive, complex and interacting, based in social structures, and do not fit within election cycles. Those of us who are left leaning philosophically  would be happy to commit as a society to reducing disadvantage because we understand the impact of social structures on individuals. For the left failure to deal with  disadvantage may exacerbate binge drinking, poor health, or crime  and so will be expensive to those individuals but also our society as a whole. Dealing with disadvantage will be expensive but we will all benefit. We won’t have to live in fear, or behind razor wire and thus have our own lives constrained.

For those who are right leaning this is more difficult. They see the society as the product of the agency or actions of individuals and privilege the protection of individualism. The emergence and achievement of a Roger Bannister or Stephen Hawking draws our society forward so that we all benefit. The significance of the commitment required at a social level to address disadvantage inherently requires a shift in investment, at least to some extent, away from economic growth, and into social well being. More funds for housing education and transport require more taxes and less middle class welfare. This is not attractive to the right and they are unlikely to believe it to be fair or a plausible route. Because of their faith in individualism, and their influence on policy, we continue to spend on ineffective health campaigns to influence individual behaviours.

Inherent in the right left divide is the positing of agency as against structure. People who are well off have more control over their lives. This has been identified as one of the social determinants. But people who have never not had control over their lives tend not to understand what it is like not to. The behaviours that disadvantaged people have that harm their health are also behaviours that are stress related; alcohol and tobacco use, gambling, poor eating habits, poor exercise habits and risk taking behaviours.

It is our social structures that reduces the agency of our disadvantaged. I am fortunate not to have to deal with Centrelink. If I did I would know that I cannot call them from my mobile phone ( I gave up my landline)  because there is a wait of 45 minutes or more which exceeds my credit. I can go to the Service Centre but these are being closed and increasingly made self service. I don’t have a car or at least not a reliable one and the one I have is expensive to run because it is old. I’ll need to use public transport to get there. This is time consuming. The reporting requirements can be onerous for me, eating into the time I have for parenting, training and education, and job seeking. It is stressful and I’m broke and depressed. I lose motivation and stop exercising. I buy cheap, accessible (unhealthy) food for the family. Etcetera.

My question is, how do we as a society re-adjust the relative privileging of individualism as against communitarianism? This is a question being faced in all western countries who have moved to greater inequality. How can a case be made for those with power and influence to grasp the long term consequences for us all, if not the unfair suffering of the many, if we do not move to adjust this balance?

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An empowerment approach to group work with people experiencing anxiety

This locally based group started in response to demand, the nearest Anxiety Management clinic having closed. I looked at programmes colleagues were running in other health services but, decided to do my own thing. The basics were pretty standard for a rural practice: six sessions, advertise in the local paper, grab a co-leader, and map out a programme starting with easy entry ‘getting to know you’ and ending with closing exercises. We evaluated  with pre-test and post test anxiety scales,  plus qualitative feedback. Nothing special there.

We had decided against pre-group interviews, with both myself and my colleague working part time we chose to talk with people by phone, largely to determine if anyone wasn’t going to be able to function in a group setting, if so, we offered them one-to-one sessions.

The empowerment orientation was there from the start but has grown with the implementation of an action-reflection improvement cycle. Being social workers, and middle age-ish, we had people sitting in a circle of chairs in the early groups. Through feedback and attrition we eventually learned that was too confronting for many of our participants and we have better retention now sitting around a table. I also now see this as more respectful. Treating people as colleagues in a learning and sharing environment rather than as ‘clients’, is less pathologising.

From the start we used the narrative therapy gambit of externalising the anxiety, so no ‘anxious people’, just ‘people affected by anxiety symptoms’. Yes it’s a bit Michael White/post modernist and wordy, but it matters. It matters how a person affected by anxiety thinks of themself; as a pathology, or as a person with a challenge to manage. So that is an empowerment  element.

Another empowerment feature is the lack of a clinical pathway into the group. No labelling by a GP or psychiatrist. If you feel you’re affected by anxiety, you phone in. Yes, we assess informally during our phone interview, but there’s still not that medical diagnosis. Some people have had a formal medical, mental health experience and others haven’t. In the group we are all in the same room.

We work on building a convivial environment; welcoming people warmly, providing smart folders and pens, having a nice morning tea, being good hosts. We make it more like a study group or community meeting in some ways. We do our best to avoid a hierarchical leader/group member separation. We seat ourselves around the table amongst the other participants and if we want to write on the whiteboard we get up and walk to the board.

We call the people who come to the group’ people’, or participants.

In the first session we have the participants ‘map the influence’ of the anxiety on them and their lives. Another borrowing from  narrative  therapy. We have them identify what the anxiety does to them. So, we use  ‘self -diagnosis’  not expert labelling. It is the beginning of a process of determining which non-medical management techniques are going to work for you. Each participant maintains a notebook through the sessions tracking their experiences and practice with the various evidence based techniques that are introduced over the six, two hour meetings.

At the end they have the benefit of the bonding that is the beauty of group work – they’ve come to know 6-8 other great people who are having the same challenge. They no longer feel alone and inadequate, and they have strategies that have improved their self-management.

After six series and 32 people completing at least 4 sessions, the pre-post test improvements  are significant on a two tailed t test. The decrease in anxiety as captured by the Mind Over Mood Anxiety Inventory (Greenberger and Padesky 1995) was from a group mean of 31.31 to a group mean of 22.09, so a  difference of 9.22.

Not having set out to do research, simply evaluation, this result is encouraging but hardly gold standard.  Our next challenge will be to drill a bit further into the relative efficacy of this approach compared to a standard CBT group. To do this however means more measuring and, inherently more measuring of the problem. This produces a values conflict between being strengths and empowerment focused, and being accountable within the medical model. So, more adventures ahead.

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The Inverse Care Law and the ‘hard to reach’

In 1971 Scots doctor Julian Tudor Hart published his observation in the Lancet that the people who most need health services are the least likely to receive them: the inverse care law.

Since then, as it turns out, this law has been shown to hold true not only within countries but also between countries. Gwatkin et al (2005) for The World Bank did a series of studies in 11 countries of Asia, Latin America and Africa called ‘Reaching the Poor’. One of the problems these revealed was that even when governments try to target health services to the poor, those services are likely to be used more by middle class people.

This phenomena is of inherent interest to Social Work with our concerns for Social Justice and Human Rights. The same phenomenon is true at home in Australia. I’ve been particularly interested in the work of Gail Winkworth and the team at the Australian Catholic University (see Australian Social Work 2010 and 2012).  Their work looks at low income families with young children and makes the pertinent discovery that these people don’t have the social networks to introduce them into services. They don’t know anyone who is already using them. For them, it’s the services that are ‘hard to reach’. Moreover, the services they do use, GP’s, Centrelink and Housing, don’t harness their contacts with these people to facilitate their access to other services.

This should give those of us who work in Health cause for thought. On the one hand we have fabulous initiatives like ‘place based servicing’, ‘warm transfers’ and ‘no wrong door’ that can really improve access for the most needy. On the other hand, as our departments move to call centre entry systems that depersonalise, and maximise throughput, we further alienate those who need our services most. Facilitating access to health services for the people who need them most is a crucial arena for social work researchers and practitioners to be active in.

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Anticipating a Social Work placement in Health

I am presently anticipating hosting my first student in many years. I work part time for Health and there are room shortages and of course I’m busy but I thought it was about time, after all I’m always looking for student placements as part of my academic role.

Well I’ve met this young woman, a mature age student with a young family ready for her first prac. Social Work in Community Health is a fabulous job, but also an excellent prac opportunity. My own last prac was in community health and I was fortunate to accede to the position when the encombant resigned.

In many small towns,  the same social worker provides both the hospital and the community based service and this is my situation. I find myself reflecting quite a bit on plans for this student, and am surprised to find myself quite excited. Her main role will be in the hospital where I will have her practise basic engagement skills and consider the psycho-social assessment. I’m interested in her looking at a variety of formats from different hospitals and doing some critical thinking about its place in hospital social work practice. My own univiersity requires first prac students to demonstrate competence in assessment as part of the pass criteria for prac one.

I will also invite her to visit my community development project – a place based service initiative for homeless and other low income people. From there we provide wound dressing, flu injections and vitamin B supplements. Until recently Centrelink used to attend and ensure everyone was receiving appropriate benefits, or problem solve their Centrelink issues. What a loss the retreat of Centrelink back to the centre is. Our new  ‘community liaison’ is now based so far away he can never attend. Similarly, we used to have an aboriginal health worker attend but redrawn service areas means the new service provider for that is also too far away. Ah dear.

I will invite the student to sit in on a couple of sessions with me, with permission of carefully chosen people, and finally, I’d like to introduce her to research as a basic feature of social work practice. I have a range of options to offer; looking at issues of people who present to ED regularly, or who are re-admitted soon after discharge, looking at data about hospital referrals to social work, pursuing the psycho-social assessment more deeply, or something she develops herself that arises out of the prac. Roll on February!

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Discretion in rural practice

I had a conversation at a conference earlier this week with a young social worker about to take up a position in the small town she and her family live in. The social worker retiring from that position has always advised the people she met professionally that she would not acknowledge them in public, to protect their confidentiality.

I take a differnet approach, so the young social worker now has two models to consider. Having grown up in a rural area where my parents were in business, I take the view that rural practice provides its own accountability: the person you sell a car to is the same person you play against in tennis and sit next to in church. In rural practice the people know who you are.

In urban practice you can drive home to the other side of town. I a country town you can’t, you are accountable for your actions, attitudes and behaviour. Far from finding this onerous, I have always found it easy and comfortable; there is no playing pretends. There is no need to purport to be perfect or special, no need to be an ‘expert’ in the hierarchical sense.

I tell the people I work with that I am required to protect their confidentiality and will not be discussing our work with anyone else. If they hello on the street I say hello, if they avert their gaze, I avert my gaze. If they stop to chat, I stop to chat too unless I’m pressed for time in which case I excuse myself and say so.

Rural practice is an wholistic way of living that does not require perfection but does require discretion and conducting oneself in an honourable way. Generally honourable conduct I would have thought, was a pre-requisite in any profession.

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Data mining for the beginning practice researcher

Ros Giles, Irwin Epstein and Anne Vertigan produced their book Clinical data mining in an allied health organisation: A real world experience (2011, Sydney Uni Press) as a result of working with very fortunate clinicians in Australia’s Hunter Valley.

This week in a workshop with Professor Giles, she reminded us just how much ready made data we are surrounded by when we work in Health. Statistics, file notes, monthly reports, correspondence, meeting minutes.

Heaps of ideas were developed by the 20 participants. Two of these were:

a file audit of social work notes, what information are we and aren’t we collecting? and

a record check of what happened, or didn’t for people over 70 who had a hospital readmission within 72 hours.

Afterwards I thought about my list of hospital referrals. I keep it pretty much for my own information but, if I was to do it a bit more consienciously – clean up my data collection, it would be more useful. If we’re collecting it might as well be useful, right?

What I could use this data for?( and it could be via a student); to look at the pattern of hospital referrals over time, their percentage of my clinical workload, and, if I went through ethics, what they involved. I’d have to go through ethics to access the files and certainly if a student was to. With this information, all stored within metres of my desk, I would have a clear and accurate picture of the social work service I provide into the hospital (I’m based in community health).

Now I know that’s not going to set the world on fire but its a great example of how a beginner practitioner can use service evaluation type research right from the get go to develop a research habit – something that is very much needed in our next generation of practitioners if we are going to be taken seriously as a profession.

… and I might just use that as a project for my next student to demonstrate how accessible data mining is as an entry level research strategy.

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Degradation Ceremonies-still my favourite lesson

As an undergrad Harold Garfinkel’s 1956 paper ‘Conditions of Successful Degradation Ceremonies’ captivated me. He talks about the court process as a ceremony that converts, through costume and custom, a person’s identity from free citizen, to prisoner or criminal.

This is important as a Health Social Worker, reinforced for me during  recent hospital admission. The western medical system, takes a person, lays them horizontally, takes off their clothes  replacing them with an open backed gown, and putson  a plastic bracelet with their name and a number on it. This process is conducted by people in a hierarchy of clothing designating their power within the hospital system.  One’s  identity is converted to ‘patient’.

During ‘grand rounds’ when I was standing near my allocated bed the young doctor invited me to get back into bed so they could begin their discussion. I invited her to proceed with me standing.

Standing against this stripping of individuality and status is an empowerment project for health social workers. I’m not suggesting anything radical. Refer to the people we work with as, the people we work with, not as ‘clients’ or ‘patients’. It’s why we sit adjacent to people rather than behind a desk, and why we  dress well but with attention to the socio-economic status of the people we are involved with.

In Community Health, people are still subjected to systems and processed; call centres, assessments, and waiting rooms. When we meet them it’s in an  environment foreign for them, in which they are relatively powerless and  likely to feel ill at ease.  Warmth, respect, and co-creating plans can make a situation that means  meeting with a social worker can be an experience that builds self respect and engenders hope.

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Qld Closes world leading Murri Court

Government decision to close off Murri Court funding.   19 Sept 2012

“It is unfortunate that the new Queensland government has forgone taking more time to consult, understand and manage these complex Court led, restorative justice initiatives”, a former state manager of the Murri Court program, Greg Wiman, said today.

“One of the many advantages of Court involvement in “problem solving” activity includes the fact that these courts are pivotal at a point where many defendants consider change, and may make a commitment to change if they are provided with the appropriate advice and encouragement.  To not take this opportunity is to let social problems propagate in our communities, to influence new generations and perpetuate a growing social cost.”

“Change in Indigenous defendant behavior can and does occur when Murri Courts use their combined judicial and Elder authority to shame and encourage a defendant to recognise their problems and work to find solutions, holding the outcome of final sentence in balance.”

“The social problems which are in evidence in our Courts as underlying factors in offending behavior are not simple.  They are as much a result of inadequate socialisation and failed government social policy, as poor personal choices of the individuals themselves.  Courts are regularly involved in the complexity of recognising the personal responsibility of individuals within a social context created by culture and laws, and confused by many problematic vested interests within our society.  How much alcoholism would there be if governments were effective in introducing “zero harm” licensing laws, or managing the revenue loss from excise; or became effective in educating our youth on the harms of alcohol to their future health, relationships and family”, Mr Wiman said.

“A significant success of the Murri Court has been the formal recognition of Indigenous Elders within the justice system and steps towards a reconciled future of cooperation in addressing the social problems experienced within Indigenous communities”, Mr Wiman said. “This trust is a fragile thing, which many fear is vulnerable to the vagaries of government policy, despite the ongoing commitment of Courts.”

“Our new Queensland government has set an economic course based on their belief that the cutting of costs will solve its problems.  Yet there is a large body of work available to the government about anticipated negative social consequences arising from the Global Financial Crisis and strict fiscal constraint.  Many consider that a non-buffered economic response by the government will create more hardship than it solves.”

“Solutions can be found with effective consultation”, Mr Wiman said.

Further information is available from the mybail .com.au  website or by contacting Greg Wiman. 


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