Applying NASW Standards to End-of-Life Care for a Culturally Diverse, Aging Population
Cindy Raybould, LMSW, Aiken County Government
Geri Adler, Ph.D., MSW, University of Houston
Journal of Social Work Values and Ethics, Volume 3, Number 2 (2006)
Copyright © 2006, White Hat Communications
This text may be freely shared among individuals, but it may not be republished in any medium without express written consent from the authors and advance notification of White Hat Communications.
Key Words: Code of Ethics; Ethical Guidelines; Social Work Practice, Aging, Cultural Diversity
Abstract
The National Association of Social Workers (NASW) developed eleven standards for social work practice in end of life care. This review examines these standards and their relationship to current bioethical literature. Recommendations are made for training, research, and policy initiatives that support quality care at the end of life.
1. Introduction
In response to increasing numbers of elderly with chronic illnesses and advances in medical technology that extend life spans, NASW (2004) issued standards for practice in end-of-life care. Eleven basic standards have been compiled to guide social workers in assessment, treatment, resource linkage, advocacy, and leadership in work with the dying.
NASW asserts that social workers in all practice settings must be aware of the skills, knowledge, values, and methods needed to work effectively with clients and their families inend-of-life situations. At the same time, social workers need to be able to apply these standards within the context of an aging population and culturally diverse families and communities who may hold different beliefs about illness, wellness, and medical care. The purpose of this article is to examine in greater detail the NASW standards and their relationship to current medical and bioethical literature and social work practice with older adults and diverse populations.
2. Standards
Standard 1: Ethics and Values
The first standard for professional practice with end-of-life care expects that social workers be guided by the values and ethics of their profession as well as contemporary bioethics. They should be familiar with social and legal issues, able to address questions confronting modern medicine, and show special consideration to vulnerable populations. As such, social workers require a minimum knowledge base and understanding of the ethical principles of justice, beneficence, nonmaleficence, understanding/tolerance, publicity, respect for the person, universality, veracity, autonomy, confidentiality, equality, and finality.
United States bioethics and healthcare, based on European-American values, emphasize patient autonomy and informed consent (Candib, 2002; Crawley, Marshall, Lo, & Koenig, 2002; Drought & Koenig, 2002; Kagawa-Singer & Blackhall, 2001; Luptak, 2004; Turner, 2002; Werth, Blevins, Toussaint, & Durham, 2002). This is reflected in the Patient Self-Determination Act (PSDA) of 1990, which mandates that patients admitted to healthcare facilities be provided with a statement of rights related to healthcare decisions and asked whether or not they have advance directives. It gives patients the right to be informed about their condition and to refuse life-sustaining treatment (Kagawa-Singer & Blackhall, 2001; Luptak, 2004; Teno, Lynn, Wenger, Phillips, Murphy, Connors, Desbiens, Fulkerson, Bellamy, & Knaus, 1997a). Whereas only 15 percent to 20 percent of all Americans have completed advance directives (Luptak, 2004), those of European descent are more likely to have written advance directives than persons from other ethnic backgrounds (Werth et al., 2002). Furthermore, the elderly and members of some cultural groups may eschew completing an advance directive, believing that their physician is best able to make health care decisions in their interest (Werth et al., 2002).
Autonomy and self-determination have been criticized as culture bound and insensitive to individuals from other cultures that are less individualistic, more family centered, and less disclosing of medical information to patients (Candib, 2002; Crawley et al., 2002; Drought & Koenig, 2002; Kagawa-Singer & Blackhall, 2001; Luptak, 2004; Turner, 2002; Werth et al., 2002). Disclosing diagnoses or talking about the possibility of death with patients from some cultures may even be viewed as malevolent (Candib, 2002; Turner, 2002). Drought and Koenig (2002) note the lack of empirical evidence supporting the autonomy paradigm of patient "choice" in end-of-life (EOL) decision making. They state that the choice model is flawed because one cannot choose not to die of a terminal illness and because one’s choice is based on the interpretation and presentation of information from the clinician. Studies have shown that even with advance directives in place, patients’ wishes are not always followed (Bern-Klug, Gessert, & Forbes, 2001; Galambos, 1998; Teno et al., 1997b). Broadening the meaning of autonomy to include different ways of understanding health and illness and giving greater latitude to patients and their families in how they respond to illness and the end of life is merited (Turner, 2002). For example, Candib (2002) suggests the use of “autonomy-in-relation” (p.225), a concept that incorporates family context into end-of-life decision-making.
Standard 2: Knowledge
Understanding the theoretical and biopsychosocial domains of end-of-life care is an important component to effective social work practice with the dying. This standard requires social workers to be knowledgeable about medical and social systems, including the socioeconomic, cultural, and spiritual dimensions in family life, and barriers to healthcare that may impede access to services. They must also be aware of the tenets of palliative care, whereby the control of pain and other physical symptoms along with meeting the patient’s psychosocial needs are emphasized, rather than lifesaving measures (Kart & Kinney, 2001). Social workers apply their knowledge in direct work with families and as members of interdisciplinary treatment teams.
The need for further education and training in EOL issues for social workers has been well documented (Csikai, 2004; Kramer, Pacourek, & Hovland-Scafe, 2003; Luptak, 2004; NASW, 2004). Results from a survey by the Social Work End-of-Life Care Education Project revealed that 54% of health and hospice social workers had had no EOL content in their coursework, and only 31% of hospice social workers reported having adequate EOL preparation in their MSW programs (Csikai & Raymer, 2003). Ethical content, particularly principles of biomedical ethics and emerging ethical issues, received little attention. To assess the quality and scope of EOL content in social work textbooks, Kramer, Pacourek, and Hovland-Scafe (2003) examined 50 texts. They found that only three percent of the total pages reviewed were related to EOL care. Similarly, Luptak (2004) states that “references to care of older people at the end of life are more noticeable by their absence than by their presence in the social work literature” (p.12), adding that social workers need both a comprehensive knowledge base of practice and policy issues and finely tuned skills related toend-of-life concerns. They further suggested that social work textbooks, like those of nursing and medicine, be revised to include more current information and citations on issues such as social workers’ roles in pain management, equity and social justice, and advocacy.
In addition to a basic understanding of the biopsychosocial aspects of EOL care, social workers need to be aware of disparities in and barriers to medical care. The use of hospice and other palliative care services varies by age (Buntin & Huskamp, 2002), location (Virnig, Moscovice, Durham, & Casey, 2004), insurance coverage (Krakauer, Crenner, & Fox, 2002), and across populations (Candib, 2002; Crawley et al., 2002; Krakauer et al., 2002). Issues of mistrust, language differences, and lack of diversity in health care staff further complicate the ability to provide appropriate care to patients with values and beliefs different from the mainstream (Candib, 2002; Drought & Koenig, 2002; Kagawa-Singer & Blackhall, 2001; Krakauer et al., 2002; Reese, Ahern, Nair, O’Faire, & Warren, 1999; Werth et al., 2002).
Standard 3: Assessment
The third standard requires that social workers include relevant biopsychosocial factors and the needs of the client and family, as expressed by the client, in a comprehensive culturally competent assessment. Several frameworks for assessment sensitive to cultural competence have been developed.
Panos and Panos (2000) provide a model for culturally-sensitive assessment in health care settings that may be useful for EOL assessments. Their model includes six domains. The first domain requires social workers to examine their own cultural identity. The second and third domains stress the importance of assessing the patient’s level of acculturation and its accompanying stresses. The fourth domain discusses assessing the patient’s support systems. The fifth domain recommends that the patient’s concepts and definitions of health, disease, healthcare utilization and healing be understood. Each of these components must be addressed before completing the final step of care planning.
Another approach for evaluating the level of cultural influence for patients and families uses the mnemonic ABCDE. Practitioners must evaluate the attitudes of patients and families toward truth telling and death and dying; beliefs related to death, afterlife, or miracles; context; decision-making style; and environment (Kagawa-Singer & Blackhall, 2001).
Candib (2002) likens her assessment to a conversation that assesses the patient within the context of family. Culturally competent practice requires that clinicians first show their interest in understanding their patient’s culture and beliefs before proceeding with structured questions.
Finally, the World Health Organization Quality of Life (WHOQOL) instrument is a tool that can be used to assess quality of life for the dying (Saxena, O’Connell, & Underwood, 2002). Developed for use in a wide range of cultures, the WHOQOL assesses six domains believed important to quality life. These domains include physical well-being; psychological well-being; level of independence; social supports and activities; environmental factors; and feelings about spiritual, religious and personal beliefs.
Standard 4: Intervention/Treatment Planning
It is imperative that social workers are competent in intervention and treatment planning. This standard notes several skills essential to successful practice with the dying, including preparing families for impending death of a loved one, facilitating communication, integrating grief theories into practice, and advocacy. Social workers must be able to effectively work with patients and families from different age groups, cultures, socioeconomic and education backgrounds, lifestyles, and states of mental health.
EOL interventions are complicated by the fact that more than half of those that die in a given year have never been considered to be terminally ill (Bern-Klug, 2004). The signs and symptoms of impending death are not easy to define even for physicians, let alone social workers. Covinsky, Eng, Li-Yung, Sands, and Yaffe (2003) concluded that frail elderly “have an end-of-life functional course marked by slowly progressive functional decline, with only a slight acceleration in the trajectory of functional loss as death approaches” (p.492). Bern-Klug (2004) suggests that social workers can honor patients’ self-determination during this period of ambiguity. On a client level, social workers can help patients and families understand the medical situation and its potential impact on their lives. Using active listening skills, clinicians can normalize common feelings of doubt, frustration, and sadness. Finally, advance care plans can be made within the parameters of an uncertain death. At a societal level, social workers must advocate for policy level changes that acknowledge the ambiguity ofend-of-life situations.
Standard 5: Attitude/Self-Awareness
Social work attitudes and practices that convey empathy, sensitivity, and compassion are central to this standard. In their daily activities, clinicians must be flexible, respect the primacy of the patient and family in all aspects of care, be able to work with team members, act as advocates, be aware of compassion fatigue, and be secure in their professional identity and roles.
NASW (2004) recognizes the controversy of end-of-life issues related to multicultural value systems, and, whereas the organization does not take a position on the morality of these issues, NASW affirms the right of individuals to determine the level of their care. Issues such as assisted suicide, truth-telling, euthanasia, health care rationing, futile treatment, medical racism, and the right to refuse, withdraw, or withhold life-sustaining therapies (Bern-Klug et al., 2001; Crawley et al., 2002; Csikai, 2004; Ditillo, 2002; Krakauer et al., 2002; NASW, 2004; Reese et al., 1999; Turner, 2002; Werth et al., 2002) can pose ethical dilemmas. Social workers need to deal with these situations thoughtfully and with awareness of how their own beliefs and values influence their practice (NASW, 2004).
Standard 6: Empowerment and Advocacy
This standard describes social workers’ responsibilities to empower and advocate for their clients. Social work knowledge and skills in communication, group process, systems, social justice, values and ethics, and spirituality add a unique and important role toend-of-life care. On an individual level, social workers need to link clients with resources, support caregivers and families, address quality of life issues, and monitor and manage symptoms. On a broader level, social workers need to advocate for special populations, such as minorities, those with physical, mental or emotional disabilities, the elderly, and those in institutions (NASW, 2004).
Recommendations for empowering and advocating for clients can be found in much of the current literature. Bern-Klug, Gessert, and Forbes (2001) recommend that social workers advocate for their clients by helping them access medical care where they want to receive it, pursuing aggressive pain relief, securing financial support, negotiating with authority figures, and assisting with mental health and spiritual services. Luptak (2004) and Candib (2002) suggest that, in view of escalating controversy about the high cost of health care and the possibility of rationing, social workers need to advocate for the elderly by speaking out against the use of age as a criterion for withholding treatment in a culture that values youth. To eliminate barriers to hospice and palliative care, social workers are encouraged to provide public education programs and to work with respected community members (Reese et al., 1999; Turner, 2002).
Standard 7: Documentation
The seventh standard emphasizes the importance of documenting all aspects of social work services rendered. It further requires compliance with agency policies and all federal and state laws, particularly those with regard to confidentiality and privacy of medical information.
Standard 8: Interdisciplinary Teamwork
The eighth standard acknowledges that the complex issues associated with end-of-life care frequently require the work of interdisciplinary teams. Social workers, with their expertise in group work and communication, play a pivotal role in the functioning of interdisciplinary teams, fostering team collaboration and being leaders in identifying biopsychosocial issues. While the strength of the team lies in the ability of diverse professionals working together, therein also lie challenges. Role blurring, differing professional values and theoretical bases, power differentials, and lack of knowledge about other professions' roles can act as barriers to effective inter-professional collaboration. To be successful, team members must recognize the expertise of other disciplines, communicate without professional jargon, clarify their roles, develop procedures for appropriate referrals, assign tasks on the basis of strengths, rotate leadership, and maintain a client-centered focus (Reese & Sontag, 2001).
Standard 9: Cultural Competence
This standard reinforces the need for social workers to respect and understand how the history, culture, values, beliefs, and traditions of patients and their families affect their views about palliative andend-of-life care. Current literature about palliative and end-of-life care pays much attention to issues related to cultural competence and sensitivity. Areas of particular focus include the history of medical racism and unequal access to health care (Bern-Klug et al, 2001; Candib, 2002); ethnocentric values and ethics (Candib, 2002; Kagawa-Singer & Blackhall, 2001); communication, language barriers, and use of interpreters (Crawley et al, 2002; Office of Minority Health, 2001); and stereotyping individuals on the basis of their ethnic or cultural identity (Candib, 2002; Kagawa-Singer & Blackhal, 2001; Mazanec & Tyler, 2004; Panos & Panos, 2000).
To improve the medical care and eliminate racial and health disparities of the increasingly diverse U.S. population, the Office of Minority Health (2001) established fourteen national standards for culturally competent care. The aim of these standards is to educate and familiarize health care providers and organizations with ways to understand and respond appropriately to the cultural and linguistic needs of their patients. Three standards are federal mandates, whereas the others are recommendations. The mandates require organizations to provide services that are compatible with their patients’ values, beliefs, and traditions; to have a diverse staff representative of their service area; and to offer staff education and training in culturally competent care. Recommendations include providing language services through bilingual staff and interpreters; having written materials and signage in the language of commonly encountered groups; and maintaining current demographic, cultural, and epidemiological profiles of the community.
Standard 10: Continuing Education
This standard requires social workers to stay current in their knowledge of the rapidly growing field of end-of-life care, participate in research, and collaborate with other organizations and institutions. Csikai and Raymer’s (2003) assessment of social workers’ educational needs noted that 87% of respondents received their continuing education units (CEUs) through seminars and conferences. They recommend a CEU curriculum that enhances competence in skills such as conducting bioethics consultations, assessing pain and suffering, and facilitating family communications. Becauseend-of-life issues are especially cogent for the elderly, educational efforts should be made that address the needs of this group ( Luptak, 2004).
Standard 11: Supervision, Leadership, and Training
Standard 11 requires social workers with expertise in palliative and end-of-life care to assume leadership roles. In addition to taking leadership in interdisciplinary teams as addressed in Standard 8, social work specialists can provide mentoring experiences for students and new social workers, advocate for and offer training, and develop and participate in research projects (Bern-Klug et al., 2001; Csikai, 2004; Reese & Sontag, 2001).
3. Conclusion
Social workers play a significant role in meeting the complex psychosocial, economic, and medical needs of the dying. As an already aging population grows even larger with the addition of the baby boomer generation, the demand for social workers with expertise in palliative andend-of-life care in health and social services is expected to increase ( Occupational Outlook, 2004). At the same time, the increasingly diverse older population will require that social workers be prepared to deal with their clients’ cultural values and traditions that, at times, may be in conflict with those of the profession.
In preparation, NASW developed eleven standards for social work practice in end-of-life care. These standards provide a useful framework to guide and inform social workers of the skills, values, and knowledge needed to practice effectively and ethically; however, the social work profession needs to take responsibility for ensuring that these standards are met. As evidenced in this review, several areas require continued attention and strengthening.
Assuming a strong leadership position in palliative and end-of-life care requires specific actions on the part of social work educators, practitioners, researchers, policy makers, and advocates. At all levels of social work education, there is a need to increase the amount and type of EOL training provided. Continued and added emphasis on ethics, multidisciplinary collaboration, aging-related education, and multicultural understanding is warranted. Practitioners must facilitate cooperation and collaboration with members of interdisciplinary treatment teams. As individual clinicians, they must provide exemplary psychosocial care – developing appropriate and effective treatment plans, counseling patients and their families, and providing bereavement support. Social workers would also benefit from a strong research agenda whereby interventions, pain management, quality-of-life, and other issues important to psychosocial care are examined. Finally, social workers must be active in policy development, advocating for policy changes that affect funding of and access to care at the end of life.
In conclusion, it is vital that social workers be prepared to assist our rapidly growing elderly and diverse populations as they enter the final stage of their lives. Utilizing these standards in combination with the Code of Ethics (2000) and a framework for cultural competency (NASW, 2001) all social workers will be able to practice responsively, appropriately, and ethically in ways that respect, honor, and acknowledge the values, beliefs, and customs of their clients.
References
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Showing posts with label Social Work. Show all posts
Showing posts with label Social Work. Show all posts
Saturday 12 March 2011
Managed Care and the Care of the Soul
Managed Care and the Care of the Soul
Rich Furman, MSW, Ph.D., University of North Carolina at Charlotte
Carol L. Langer, MSW, Ph.D., University of Wisconsin- Eau Claire
Journal of Social Work Values and Ethics, Volume 3, Number 2 (2006)
Copyright © 2006, White Hat Communications
This text may be freely shared among individuals, but it may not be republished in any medium without express written consent from the authors and advance notification of White Hat Communications.
Key words: Managed care, ethical dilemmas, spiritually and care
Abstract
This article addresses the impact managed mental health care is having on the capacity of psychotherapists to work with people on the most salient issues of living. For nearly one hundred years clinical social work has been charged with the healing and caring of the souls and hearts of millions. Managed care, with its reductionistic, medical model philosophy, threatens this mission. This article discusses ethical dilemmas inherent in a system that is driven by corporate dictates rather than emotional and spiritual health. The authors conclude that entrusting for-profit managed mental health care conglomerates, with their focus on maximizing shareholder profit on preserving the mental health, is at best a risky proposition.
1. Introduction
I was told that I was not sick enough to see my therapist anymore. Ten sessions was enough. They said I did not have a problem that they could diagnosis me as having. They told me that being abused by my husband, day in and day out for years, was not in and of itself treatable. I had to be sicker in order to get help. Since I have no money to pay for therapy, I guess I’ll have to wait until I get worse. I feel sick inside. I feel like I need help sorting out my life; I need help finding myself again. I don’t know what I am going to do now. God help me.
Client of managed mental health care
Unfortunately, anecdotes such as this are not uncommon in the new reality of managed mental health care. Managed care is threatening to turn clinical social work into simply another medical intervention, void of the essence that makes it potentially transformative and liberating (Furman, 2001 ). Ethics, patient care, and economics have become nearly inseparable, whereas previously the needs of clients were seen as the driving force for health and mental health care. Clinical social work in the age of managed mental health care is at risk of losing its focus on the human spirit and soul. In fact, some have questioned whether clinical social work can even survive in a managed care oriented environment (Herron, 2001 ). Models and theories that focus on true change and transformation, and on the nature of humanity itself, are being negated by managed care corporations’ mandate that clinical social work merely focus on the reduction of problematic symptoms. By so doing, therapists neglect the real problems of living that often lie underneath, or at the very least, compound many emotional and psychosocial disorders.
For nearly one hundred years, clinical social work has been charged with the healing and caring of souls and hearts of millions (Saakvitne, 2005 ). This article will address the value considerations and potential impact that managed mental health care is having on the capacity of clinical social workers to serve people with needs in the important issues of living. When such issues are left unresolved, they often lead to depression, anxiety disorders, and other disturbances, along with increasing levels of chronicity. Prior to this exploration, a short introduction into the history of managed care will lend context to this discussion.
2. The role of clinical social work in caring of the soul
Traditionally, the care of the soul has been the domain of community structures and spiritual/religious institutions. However, the industrial revolution, and now the current hypertechnological, post-modern revolution, have challenged and altered traditional means of coping, healing, and growth (Kreuger, 1997 ; Postman, 1992 ). The ushering in of modernity has introduced new mechanisms to care for the emotional life of those suffering from the alienation and spiritual malaise exacerbated by the social dislocation associated with rapid social transformation. Clinical social work has become one of the key means by which modern, technologically advanced societies have attempted to cope with the socioemotional and behavioral pains of post-modern existence. At its best, clinical social work is a journey toward growth, wholeness, and self-actualization. It allows people to discover their own truths and connect more fully to others.
Since its advent, many proponents of clinical social work have been concerned with the soul, with the deepest parts of ourselves that make us fully human. From its inception, practitioners have understood that clinical social work is part art, part science. The quality and scope of a human being’s soul, of his or her inner representation of the universe, has long been understood as unquantifiable.
However, these are not the concerns of managed mental health care. Emotional issues and behavioral problems are seen not as part of the gestalt of our being, but as phenomena in and of themselves that can be separated from all intrapsychic and contextual factors. Its medical model philosophy, hidden under the guise of a pseudo-scientific worldview, and its economic bottom line, threaten to reduce clinical social work to a process that is as alienating as the experiences that necessitate its use in the first place. This is the darker side of clinical social work; it becomes a process of social control in which people are treated as broken cars with faulty parts to replace, not as beings with hopes, dreams, and aspirations. In this model, clients are not merely given diagnostic codes that guide the provision of services; they become the diagnoses themselves. Patients in such environments are referred to as their diagnoses. Specific technical interventions are delivered based upon these diagnostic categories to ameliorate behaviors that are seen as problematic, or clients are given medications to treat the symptoms that they are experiencing. The etiology of these disorders is assumed to be biological in nature. Problems that arise from past traumatic experiences, or from difficulties in the match between a person and the environment, are reduced to a numerical code divorced from the meaning that these events hold. A managed care patient is not understood as a spiritual being with goals or a life mission, but as a broken machine to be fixed as quickly as possible. To understand why managed mental health care and its reductionist, medical model has proliferated, it is necessary to understand its historical and political context.
3. History of managed care in mental health
Before exploring the history of managed care, it is important to position the phenomenon within the international political/economic agenda of neoliberalism. Placing it within this frame helps contextualize what may appear to be a largely North American institution, yet is often part and parcel of the global trend toward the dismantling of social provisions for the poor and needy. According to the neoliberalist agenda, eliminating governmental expenditures on health and human services means that more resources will be available for investment, thus creating more opportunities for the poor. According to Walton (2004) , neoliberalism is the trend toward a more “vigorous embrace” of market forces and the shift of social provisions from state provisions to the realm of the market. Through the pressure of international lending and aid organization, neoliberalism has eliminated the opportunity for health care and other social services for some of the most vulnerable groups throughout the world (Inter-American Development Bank, 1997 ; Munch, 2004 ). Whereas managed care has yet to make inroads in many countries, it is anticipated that the spread of corporate capitalism under neoliberalism will pave the way for managed care entities as governments turn toward the market as a means of managing social resources (Furman, 2003 ). Whereas the trend toward managed care in the United States did not begin with a push toward privatization, it is highly congruent with this agenda and has largely been co-opted by corporate entities.
Whereas managed care is a complex amalgam of institutions and strategies designed at cost containment of health, mental health, and more recently other social services, these strategies have been co-opted by corporate managed care organizations. In theory, managed care cost containment strategies would eliminate waste through carefully managing the provision of services. Since managed care organizations are paid a given amount to treat individual members of the population, they should be invested in the health and wellness of all their constituents. Yet, as shall be explored later in this essay, other cost containment strategies have become the mainstay of managed care organizations and have led to a decrease in services for many populations.
In the 1980s, indemnity insurance plans began to offer increasingly generous mental health and substance abuse benefits, and for-profit psychiatric hospitals took full advantage of this trend (DiNitto, 2000 ). For example, from 1980 to 1986, adolescent admissions to private psychiatric hospitals increased four fold. By the late 1980s, managed care was called on to reign in what was often perceived to be excessive and often inappropriate admissions. Jellinek and Nurcombe (1993) characterize this irony well: "it was profit that filled psychiatric beds in the 1980s, and it is profit that empties them in the 1990s." (p.1741) This perceived need for the cost containment of mental health services, occurring within the context of the privatization movement of the Reagan era presidency, was one of the most immediate factors that led to managed mental health care’s corporatization of mental health services (Dorwart & Epstein, 1993 ).
While few would disagree with the need to place limits on escalating hospital costs, outpatient psychotherapy and clinical social work practice consisted (and continue to consist) of a fraction of the total mental health costs (Dumont, 1996 ). However, in their desire to cut costs and increase profit whenever possible, managed care companies have successfully propagated erroneous myths about psychotherapeutic services--first, that they are ineffective in dealing with mental health disorders and medication should be the treatment of choice; and second, that therapists are seeing clients far longer than necessary, thus robbing clients and the health care system of scarce and needed resources.
The first myth is rationalized by the assertion that most mental health concerns are medical conditions. It is ironic that in managed mental health care, one can be considered either too well or too sick to qualify for services. For example, conditions that are known to be biological in nature, such as bipolar disorder and schizophrenia, are seen as requiring pharmacological interventions only. It is argued that these clients have a medical condition and only need medical interventions. The irony is that persons with persistent mental health concerns are often in the most need of supportive clinical services to assist them in achieving or maintaining healthy functioning. Conversely, managed mental health providers will deny services to someone who defies diagnostic codes. In spite of how they may be feeling, they are seen as too healthy in behavioral terms.
In regard to the second myth, therapy in this country has often not been a long-term process. In his review of research on psychotherapy, Miller (1994) notes that the average length of therapy prior to managed care has been found to be between 8 and 16 sessions. Most therapists know when it is in a client’s best interest to terminate treatment. Managed care’s limiting of treatment only serves to create anxiety in the treatment process and to risk the health of clients who may need longer-term care.
In addition to limiting the number of sessions, managed care has developed other sophisticated strategies to control the cost of outpatient therapy (Gorin, 2004 ). The gatekeeping function is one of the most popular approaches. Many managed care organizations utilize “care managers” who screen clients seeking care though a telephone interview. During this interview, clients are required to tell the anonymous voice over the telephone personal problems that many clients are not able to share until after several sessions with a therapist. These initial screenings discourage many people from discussing the full nature of their problems, and they are subsequently denied care because of lack of severity. Managed care gatekeepers are trained to look for problems that are considered “social” in nature, and to refer clients with these non-medical problems to self-help groups.
Further, many clients who are experiencing severe psychological stress may not be capable or willing to jump over all the administrative hurdles that managed care gatekeepers require. Years of research on the importance of accessibility of services have been turned upside down by managed care organizations. They understand that by increasing the number of obstacles that clients have to overcome, merely to be accepted for treatment, many will simply stop seeking care.
Other managed care strategies focus not on the client, but on the providers of clinical social work themselves. For example, one California-based managed care organization pays clinicians a flat rate for three sessions and then a small flat rate for all sessions beyond these initial three. Clearly, this not only sets up a disincentive for more than four sessions, but a disincentive to go beyond the first session of treatment. This has a significant impact on the mindset of therapists. Clearly, many therapists will choose not to work with managed care organizations with such draconian policies. However, others will seek to cooperate with the dictates of the company. It is a sad fact that many social workers have become so dependent upon managed care organizations for their own survival that their values and ethics, indeed, their whole way of practice, has begun to neglect the needs of the client.
4. The making of therapists
The very training of therapists has been rapidly changing over the last decade in response to managed care (Brandell, 2002 ; Herron, 2001 ). Graduate schools in many disciplines have been altering their curriculum to meet the demands and “realities” of managed care. Courses in short-term interventions have begun to proliferate in graduate programs. In fact, many schools are shifting their whole model of pedagogy away from theoretical frameworks that are based on research or practice wisdom to those that are congruent with managed care oriented practice.
The rationale is simple: since the movement toward privatization and managed care has begun to accelerate, graduate programs must train students to function within the new behavioral health care conglomerate. Few graduate programs seem to be questioning the growing hegemony of managed care corporations. Even in social work programs, which tend to have a strong emphasis on social policy analysis, managed care is often accepted as a reality of practice; rarely are the very principles of managed care and managed mental health care questioned. Ethical discussions seem to center on ethical dilemmas within the context of managed mental health care, not on managed mental health care itself. This seems to be a clear indication of the tail wagging the dog; neither research nor theoretical considerations are guiding changes in training.
Graduate programs are now focusing too much energy on producing technicians. Efforts toward developing the whole person of the nascent therapist have been fading. This can be seen as a direct result of managed care’s philosophy of treating illnesses, not people. Why develop a person, if all that is needed is a technician?
Training is moving toward teaching students how to utilize specific interventions for specific types of problems. What is neglected by the proponents of this new trend in training and practice is the fact that unlike a physician, who administers healing powers though a pill or injection, social workers are the vehicles for treatment. Without a highly developed sense of self, without the ability to understand and work through emotional reactions to client issues, no degree of technical proficiency will matter. Without the requisite work on oneself, therapists will not be able to successfully establish and maintain helping relationships with challenging clients.
This work is essential, because clinical social work’s ability to facilitate growth and healing is dependent on a caring and trusting therapeutic relationship. In countering the alienation and disenfranchisement of social dislocation or healing wounds caused by past trauma or pain, the client/therapist relationship is possibly the most clinically important variable in the helping process. Trust, empathy, and caring are requisite components to client change.
Yet, in the new managed care environment, the establishment of such a relationship is often compromised. Therapists are trained to see clients as needing structure and boundaries. Clients who seek additional services are seen as manipulative and are often labeled as being “borderline” or “overly dependent.” Needy clients are seen as being troublesome. As a result of its for-profit nature, managed care seeks to provide as little treatment as possible. Therapists cannot entirely insolate themselves from the tension that this creates; relationships with clients will assuredly suffer.
Perusing many journals or magazines geared toward therapists shows the growth of workshops and training in short-term, time-limited, and outcome-based treatment. While few would argue against focusing on successful outcomes for clients, many of these workshops focus on teaching methods of symptom reduction or temporary change. What does a therapist who is trained to perform ten sessions of treatment do with a client who is depressed as a result of a lack of meaning in his or her life? How does a therapist trained in symptom reduction work with a client who is seeking to decrease anxiety caused by a lack of spiritual connection? In ten sessions, and with the help of medication, a client can be distracted from existential issues and can have some presenting symptoms decreased. Feeling less depressed, yet no more fulfilled or whole, the client leaves therapy with a false sense of security, assured by the “professional” of his or her stability.
No happier, they are at least temporally out of risk. What happens the next time life’s stressors trigger their angst and meaninglessness? Clearly, this is hardly the worry of for-profit managed care firms whose main responsibility is not the care of clients or therapists, but the maximization of profits in each fiscal quarter. Managed care companies are frequently bought and sold, with each new owner expressing disbelief at the prior company's ineptitude, making promises to improve the quality of care that are rarely met.
5. The care of the therapist, the disposable producer
This paper has thus far discussed how these changes affect the training of therapists and the consumers of clinical social work. But how are therapists themselves affected? How will therapists feel at the end of the day when the quality of the helping relationship may be as deep and anonymous as callings across cyberspace? One of the major effects of managed care arrangements is the alienation of therapists. Therapists are becoming alienated from their clients, from their professions, and most significantly, from themselves. Therapists find themselves caught between the needs of their clients and their communities, the clinicians’ own agencies, managed care utilization staff, and the very dreams and hopes they had for themselves and their profession. Even new therapists, taught to provide symptom-related treatment, cannot help but to feel the effects of what therapy has become for them, an assembly line job without the opportunity for creativity and meaning. How isolating it must be to spend countless hours with clients and not connect to the deepest parts of their psyche. The dehumanizing process of treating people as symptoms will continue to cause many therapists loneliness and anomie. In the past, many left other professions to become social workers to fulfill deep longings for creativity and to fulfill dreams of service. Today, managed care threatens to cause therapists to leave the field to actualize their higher selves.
6. Conclusion
Below is a list of some of the potential biopsychosocial consequences of limiting access to services. Focusing on symptom amelioration only can have profound consequences for individuals and families.
* Increased homelessness;
* Increased numbers of divorces;
* Children with more problems in schools ill prepared to handle them;
* Pockets of communities plagued with lower socioeconomic status and mental health issues combined;
* People experiencing inadequate nutrition and thus, greater health needs;
* A greater burden on medical services when those with mental health needs are unable to seek assistance with their own health care needs;
* Increased unemployment;
* A greater burden on community police services, because there are no services available to treat those with mental illness and/or those individuals who have maximized their service capacity;
* Increased litigation when practitioners “miss” an important diagnosis because of an inability to adequately provide services to those in need;
* Under-diagnosing in order to avoid labeling decreases even further the number of sessions one can access;
* Over-diagnosing in order to maintain third-party payment status guarantees more sessions but the effects of the label can be lifelong and negative;
* Increased medicalization of conditions keeps drug companies flourishing;
* Quick fixes overlook the long-term side effects (as in drug research); and finally,
* All of these combine to the overall sense of consumerism that begins to dictate life in post-industrial society.
As managed care becomes the dominant model of mental health delivery, clinical social work is in danger of becoming a process similar to fixing a car. We diagnose problems, apply prescribed technical solutions in a time-limited manner, and return the “functioning machine” back to its programmed tasks. However, contrary to the philosophic underpinnings of managed mental health care, mechanistic metaphors are wholly inaccurate: people are not, and do not function as, machines. Human health is intricately related to the quality of our mind-body relationship. Persistent emotional and behavioral problems do not lend themselves to quick fixes. They are rooted in the fit between the essence of who we are, our souls, and our physical environments. Managed care’s insistence on framing the problems of living in medical terms negates both personal and social reasons for our difficulties.
There is no shame in seeking help. There is no shame in admitting that one is having problems adapting. The post-modern world is a complex one. Finding meaning within its ever changing landscape requires levels of social support and help that are often no longer available to many. Clinical social work, as practiced by those who have strived for the healing of lives and souls, has been a powerful way of helping people cope with these changes. Entrusting for-profit managed mental health care conglomerates, with their focus on maximizing shareholder profit, is a risky proposition.
If psychotherapy and clinical social work liberating activities are to survive, social workers must begin the process of challenging the hegemony of managed mental health care. One of the most salient means by which social workers can effect policy and practice changes is through consumer advocacy. This strategy has the capacity to overhaul the system to listen to the voice of the consumer. It empowers people to take charge of their own healing. It helps to eliminate the person-is-the-diagnosis syndrome. In addition, it helps to maintain the accountability of professionals to their clients instead of to the managed care corporation. It helps to demystify mental illness and can reintegrate/integrate those with mental illness into society. Economic efficiency and the social construction of illness are the focus of this strategy, and it has the potential to shift from issues of mental illness to those of mental health. Finally, social workers are uniquely and logically positioned to undertake this strategy.
Using evidence-based practice and recognizing the constraints of managed care need not combine to further reduce the capacity of people with mental health issues to succeed in obtaining and utilizing services. Evidence-based practice has the potential to assure the consumer that the “best” treatment for the particular situation is being provided. This has the potential to decrease the cost and demonstrate cost effective treatment. The practitioners employing evidence-based practice should always be mindful of the holistic nature of their clients and not succumb to the person-is-the-diagnosis syndrome. Evidence-based practice also has the potential to, particularly across time; demonstrate less need for managed care to dictate severe restrictions in the number of sessions. Practitioners can join with their clients in asking for intervention combinations including pharmacological and psychotherapeutic components.
Policy makers should be made aware that the medicalization of many mental health issues ignores the complexity of people’s lives. A person with schizophrenia and taking medication may still need assistance with tasks of daily living in order to function maximally in society. While medications are certainly helpful in reducing the symptoms of mental illness, there are sociopsychological manifestations in the state of “having a mental illness” that require the support of trained professionals to aid in adjustment. An analogy would be the inpatient treatment of a person with alcoholism without concomitant work with the family and significant others in the environment. When the patient goes home, back to a system that hasn’t changed, the likelihood of relapse is great. The inpatient treatment (pill) may temporarily “fix” the “problem,” but without support upon return to the environment, both the family and the patient may return to the former way of living and being.
Schools of social work should recognize that the potential for training technicians exists within the evidence-based practice and managed care-based curriculum. Teaching to the needs of the environment can result in practitioners who fail to see the person in a holistic manner. This is most definitely a balancing act, because the coursework certainly must include awareness of a managed care environment and the needs that environment presupposes. To accomplish this task, schools should recognize the necessity of maintaining the person in the environment, ecological perspective while teaching the deliberation process of assessment and intervention. If social work ever strays too far from the person-in-the-environment perspective, there is little to separate us from other mental health professionals. Further, we fail to support one of the fundamental components of our Code of Ethics when we do not recognize the uniqueness and integrity of every single human being.
There are many ways for clinical social workers to get involved. Some may choose to join professional organizations that are advocating for change in the current mental health system. Others may wish to do research on the effects of managed care. Yet, others may choose to help empower their clients to seek systemic change. Regardless of what one does, acquiescence and accommodation will only lead to an increase in one's subjective sense of alienation and disillusionment. Our souls, and those of our clients, deserve more.
References
Brandell, J. R. (2002). The marginalization of psychoanalysis in academic social work. Psychoanalytic Social Work, 9(2), 41-50.
DiNitto, D. M. (2000). Social welfare: Politics and public policy. Boston, MA: Allyn and Bacon.
Dorwart, R. A., & Epstein, S. S. (1993). Privatization and mental health care: A fragile balance. Westport, CT: Auburn House.
Dumont, M. P. (1996). Privatization and mental health in Massachusetts. Smith College Studies in Social Work, 66(3), 293-303.
Furman, R. (2003). Frameworks for understanding value discrepancies and ethical dilemmas in managed mental health for social work in the United States. International Social Work, 46(1), 37-52.
Furman, R. (2001). A radical analysis of the privatization of mental health services: Lessons for educators. International Education Electronic Journal, 5(4), http://www.canberra.edu.au/uc/educ/crie/2000-2001/ieej20/leadArticle20.html
Gorin, S. H. (2004). The unraveling of managed care: Recent trends. Health and Social Work, 28(3), 241-246.
Herron, W. G. (2001). The effects of managed care on psychotherapists. The Journal of Psychotherapy in Independent Practice, 2(2), 27-37.
Inter-American Development Bank. (1997). Latin America after a decade of reforms: Economic and social progress. Washington, DC: Author.
Jellinek, M. S., & Nurcombe, B., (1993). Two wrongs don't make a right: managed care, mental health and the market place. JAMA, The Journal of the American Medical Association, 270(3), 1737-1751.
Kreuger, L. W. (1997). The end of social work. Journal of Social Work Education. 33(1), 19-27.
Miller, I.J. (1994). What managed care is doing to outpatient mental health: A look behind the veil of secrecy. Boulder, Co: Boulder Psychotherapists’ Press.
Munch, R. (2004). Introduction to special issue: Globalization and labor flexibility: The Latin American Case(s). Latin American Perspectives, 31(4), 3-20
Postman, N. (1992). Technopoly: The surrender of culture to technology. New York: Random House, Inc.
Saakvitne, K. W. (2005). Holding hope and humanity in the face of trauma’s legacy: The daunting challenge for group therapists. International Journal of Group Psychotherapy, 55(1), 137-149.
Walton, M. (2004). Neoliberalism in Latin America: Good, bad, or incomplete? Latin American Research Review, 39(3), 165-183.
Rich Furman, MSW, Ph.D., University of North Carolina at Charlotte
Carol L. Langer, MSW, Ph.D., University of Wisconsin- Eau Claire
Journal of Social Work Values and Ethics, Volume 3, Number 2 (2006)
Copyright © 2006, White Hat Communications
This text may be freely shared among individuals, but it may not be republished in any medium without express written consent from the authors and advance notification of White Hat Communications.
Key words: Managed care, ethical dilemmas, spiritually and care
Abstract
This article addresses the impact managed mental health care is having on the capacity of psychotherapists to work with people on the most salient issues of living. For nearly one hundred years clinical social work has been charged with the healing and caring of the souls and hearts of millions. Managed care, with its reductionistic, medical model philosophy, threatens this mission. This article discusses ethical dilemmas inherent in a system that is driven by corporate dictates rather than emotional and spiritual health. The authors conclude that entrusting for-profit managed mental health care conglomerates, with their focus on maximizing shareholder profit on preserving the mental health, is at best a risky proposition.
1. Introduction
I was told that I was not sick enough to see my therapist anymore. Ten sessions was enough. They said I did not have a problem that they could diagnosis me as having. They told me that being abused by my husband, day in and day out for years, was not in and of itself treatable. I had to be sicker in order to get help. Since I have no money to pay for therapy, I guess I’ll have to wait until I get worse. I feel sick inside. I feel like I need help sorting out my life; I need help finding myself again. I don’t know what I am going to do now. God help me.
Client of managed mental health care
Unfortunately, anecdotes such as this are not uncommon in the new reality of managed mental health care. Managed care is threatening to turn clinical social work into simply another medical intervention, void of the essence that makes it potentially transformative and liberating (Furman, 2001 ). Ethics, patient care, and economics have become nearly inseparable, whereas previously the needs of clients were seen as the driving force for health and mental health care. Clinical social work in the age of managed mental health care is at risk of losing its focus on the human spirit and soul. In fact, some have questioned whether clinical social work can even survive in a managed care oriented environment (Herron, 2001 ). Models and theories that focus on true change and transformation, and on the nature of humanity itself, are being negated by managed care corporations’ mandate that clinical social work merely focus on the reduction of problematic symptoms. By so doing, therapists neglect the real problems of living that often lie underneath, or at the very least, compound many emotional and psychosocial disorders.
For nearly one hundred years, clinical social work has been charged with the healing and caring of souls and hearts of millions (Saakvitne, 2005 ). This article will address the value considerations and potential impact that managed mental health care is having on the capacity of clinical social workers to serve people with needs in the important issues of living. When such issues are left unresolved, they often lead to depression, anxiety disorders, and other disturbances, along with increasing levels of chronicity. Prior to this exploration, a short introduction into the history of managed care will lend context to this discussion.
2. The role of clinical social work in caring of the soul
Traditionally, the care of the soul has been the domain of community structures and spiritual/religious institutions. However, the industrial revolution, and now the current hypertechnological, post-modern revolution, have challenged and altered traditional means of coping, healing, and growth (Kreuger, 1997 ; Postman, 1992 ). The ushering in of modernity has introduced new mechanisms to care for the emotional life of those suffering from the alienation and spiritual malaise exacerbated by the social dislocation associated with rapid social transformation. Clinical social work has become one of the key means by which modern, technologically advanced societies have attempted to cope with the socioemotional and behavioral pains of post-modern existence. At its best, clinical social work is a journey toward growth, wholeness, and self-actualization. It allows people to discover their own truths and connect more fully to others.
Since its advent, many proponents of clinical social work have been concerned with the soul, with the deepest parts of ourselves that make us fully human. From its inception, practitioners have understood that clinical social work is part art, part science. The quality and scope of a human being’s soul, of his or her inner representation of the universe, has long been understood as unquantifiable.
However, these are not the concerns of managed mental health care. Emotional issues and behavioral problems are seen not as part of the gestalt of our being, but as phenomena in and of themselves that can be separated from all intrapsychic and contextual factors. Its medical model philosophy, hidden under the guise of a pseudo-scientific worldview, and its economic bottom line, threaten to reduce clinical social work to a process that is as alienating as the experiences that necessitate its use in the first place. This is the darker side of clinical social work; it becomes a process of social control in which people are treated as broken cars with faulty parts to replace, not as beings with hopes, dreams, and aspirations. In this model, clients are not merely given diagnostic codes that guide the provision of services; they become the diagnoses themselves. Patients in such environments are referred to as their diagnoses. Specific technical interventions are delivered based upon these diagnostic categories to ameliorate behaviors that are seen as problematic, or clients are given medications to treat the symptoms that they are experiencing. The etiology of these disorders is assumed to be biological in nature. Problems that arise from past traumatic experiences, or from difficulties in the match between a person and the environment, are reduced to a numerical code divorced from the meaning that these events hold. A managed care patient is not understood as a spiritual being with goals or a life mission, but as a broken machine to be fixed as quickly as possible. To understand why managed mental health care and its reductionist, medical model has proliferated, it is necessary to understand its historical and political context.
3. History of managed care in mental health
Before exploring the history of managed care, it is important to position the phenomenon within the international political/economic agenda of neoliberalism. Placing it within this frame helps contextualize what may appear to be a largely North American institution, yet is often part and parcel of the global trend toward the dismantling of social provisions for the poor and needy. According to the neoliberalist agenda, eliminating governmental expenditures on health and human services means that more resources will be available for investment, thus creating more opportunities for the poor. According to Walton (2004) , neoliberalism is the trend toward a more “vigorous embrace” of market forces and the shift of social provisions from state provisions to the realm of the market. Through the pressure of international lending and aid organization, neoliberalism has eliminated the opportunity for health care and other social services for some of the most vulnerable groups throughout the world (Inter-American Development Bank, 1997 ; Munch, 2004 ). Whereas managed care has yet to make inroads in many countries, it is anticipated that the spread of corporate capitalism under neoliberalism will pave the way for managed care entities as governments turn toward the market as a means of managing social resources (Furman, 2003 ). Whereas the trend toward managed care in the United States did not begin with a push toward privatization, it is highly congruent with this agenda and has largely been co-opted by corporate entities.
Whereas managed care is a complex amalgam of institutions and strategies designed at cost containment of health, mental health, and more recently other social services, these strategies have been co-opted by corporate managed care organizations. In theory, managed care cost containment strategies would eliminate waste through carefully managing the provision of services. Since managed care organizations are paid a given amount to treat individual members of the population, they should be invested in the health and wellness of all their constituents. Yet, as shall be explored later in this essay, other cost containment strategies have become the mainstay of managed care organizations and have led to a decrease in services for many populations.
In the 1980s, indemnity insurance plans began to offer increasingly generous mental health and substance abuse benefits, and for-profit psychiatric hospitals took full advantage of this trend (DiNitto, 2000 ). For example, from 1980 to 1986, adolescent admissions to private psychiatric hospitals increased four fold. By the late 1980s, managed care was called on to reign in what was often perceived to be excessive and often inappropriate admissions. Jellinek and Nurcombe (1993) characterize this irony well: "it was profit that filled psychiatric beds in the 1980s, and it is profit that empties them in the 1990s." (p.1741) This perceived need for the cost containment of mental health services, occurring within the context of the privatization movement of the Reagan era presidency, was one of the most immediate factors that led to managed mental health care’s corporatization of mental health services (Dorwart & Epstein, 1993 ).
While few would disagree with the need to place limits on escalating hospital costs, outpatient psychotherapy and clinical social work practice consisted (and continue to consist) of a fraction of the total mental health costs (Dumont, 1996 ). However, in their desire to cut costs and increase profit whenever possible, managed care companies have successfully propagated erroneous myths about psychotherapeutic services--first, that they are ineffective in dealing with mental health disorders and medication should be the treatment of choice; and second, that therapists are seeing clients far longer than necessary, thus robbing clients and the health care system of scarce and needed resources.
The first myth is rationalized by the assertion that most mental health concerns are medical conditions. It is ironic that in managed mental health care, one can be considered either too well or too sick to qualify for services. For example, conditions that are known to be biological in nature, such as bipolar disorder and schizophrenia, are seen as requiring pharmacological interventions only. It is argued that these clients have a medical condition and only need medical interventions. The irony is that persons with persistent mental health concerns are often in the most need of supportive clinical services to assist them in achieving or maintaining healthy functioning. Conversely, managed mental health providers will deny services to someone who defies diagnostic codes. In spite of how they may be feeling, they are seen as too healthy in behavioral terms.
In regard to the second myth, therapy in this country has often not been a long-term process. In his review of research on psychotherapy, Miller (1994) notes that the average length of therapy prior to managed care has been found to be between 8 and 16 sessions. Most therapists know when it is in a client’s best interest to terminate treatment. Managed care’s limiting of treatment only serves to create anxiety in the treatment process and to risk the health of clients who may need longer-term care.
In addition to limiting the number of sessions, managed care has developed other sophisticated strategies to control the cost of outpatient therapy (Gorin, 2004 ). The gatekeeping function is one of the most popular approaches. Many managed care organizations utilize “care managers” who screen clients seeking care though a telephone interview. During this interview, clients are required to tell the anonymous voice over the telephone personal problems that many clients are not able to share until after several sessions with a therapist. These initial screenings discourage many people from discussing the full nature of their problems, and they are subsequently denied care because of lack of severity. Managed care gatekeepers are trained to look for problems that are considered “social” in nature, and to refer clients with these non-medical problems to self-help groups.
Further, many clients who are experiencing severe psychological stress may not be capable or willing to jump over all the administrative hurdles that managed care gatekeepers require. Years of research on the importance of accessibility of services have been turned upside down by managed care organizations. They understand that by increasing the number of obstacles that clients have to overcome, merely to be accepted for treatment, many will simply stop seeking care.
Other managed care strategies focus not on the client, but on the providers of clinical social work themselves. For example, one California-based managed care organization pays clinicians a flat rate for three sessions and then a small flat rate for all sessions beyond these initial three. Clearly, this not only sets up a disincentive for more than four sessions, but a disincentive to go beyond the first session of treatment. This has a significant impact on the mindset of therapists. Clearly, many therapists will choose not to work with managed care organizations with such draconian policies. However, others will seek to cooperate with the dictates of the company. It is a sad fact that many social workers have become so dependent upon managed care organizations for their own survival that their values and ethics, indeed, their whole way of practice, has begun to neglect the needs of the client.
4. The making of therapists
The very training of therapists has been rapidly changing over the last decade in response to managed care (Brandell, 2002 ; Herron, 2001 ). Graduate schools in many disciplines have been altering their curriculum to meet the demands and “realities” of managed care. Courses in short-term interventions have begun to proliferate in graduate programs. In fact, many schools are shifting their whole model of pedagogy away from theoretical frameworks that are based on research or practice wisdom to those that are congruent with managed care oriented practice.
The rationale is simple: since the movement toward privatization and managed care has begun to accelerate, graduate programs must train students to function within the new behavioral health care conglomerate. Few graduate programs seem to be questioning the growing hegemony of managed care corporations. Even in social work programs, which tend to have a strong emphasis on social policy analysis, managed care is often accepted as a reality of practice; rarely are the very principles of managed care and managed mental health care questioned. Ethical discussions seem to center on ethical dilemmas within the context of managed mental health care, not on managed mental health care itself. This seems to be a clear indication of the tail wagging the dog; neither research nor theoretical considerations are guiding changes in training.
Graduate programs are now focusing too much energy on producing technicians. Efforts toward developing the whole person of the nascent therapist have been fading. This can be seen as a direct result of managed care’s philosophy of treating illnesses, not people. Why develop a person, if all that is needed is a technician?
Training is moving toward teaching students how to utilize specific interventions for specific types of problems. What is neglected by the proponents of this new trend in training and practice is the fact that unlike a physician, who administers healing powers though a pill or injection, social workers are the vehicles for treatment. Without a highly developed sense of self, without the ability to understand and work through emotional reactions to client issues, no degree of technical proficiency will matter. Without the requisite work on oneself, therapists will not be able to successfully establish and maintain helping relationships with challenging clients.
This work is essential, because clinical social work’s ability to facilitate growth and healing is dependent on a caring and trusting therapeutic relationship. In countering the alienation and disenfranchisement of social dislocation or healing wounds caused by past trauma or pain, the client/therapist relationship is possibly the most clinically important variable in the helping process. Trust, empathy, and caring are requisite components to client change.
Yet, in the new managed care environment, the establishment of such a relationship is often compromised. Therapists are trained to see clients as needing structure and boundaries. Clients who seek additional services are seen as manipulative and are often labeled as being “borderline” or “overly dependent.” Needy clients are seen as being troublesome. As a result of its for-profit nature, managed care seeks to provide as little treatment as possible. Therapists cannot entirely insolate themselves from the tension that this creates; relationships with clients will assuredly suffer.
Perusing many journals or magazines geared toward therapists shows the growth of workshops and training in short-term, time-limited, and outcome-based treatment. While few would argue against focusing on successful outcomes for clients, many of these workshops focus on teaching methods of symptom reduction or temporary change. What does a therapist who is trained to perform ten sessions of treatment do with a client who is depressed as a result of a lack of meaning in his or her life? How does a therapist trained in symptom reduction work with a client who is seeking to decrease anxiety caused by a lack of spiritual connection? In ten sessions, and with the help of medication, a client can be distracted from existential issues and can have some presenting symptoms decreased. Feeling less depressed, yet no more fulfilled or whole, the client leaves therapy with a false sense of security, assured by the “professional” of his or her stability.
No happier, they are at least temporally out of risk. What happens the next time life’s stressors trigger their angst and meaninglessness? Clearly, this is hardly the worry of for-profit managed care firms whose main responsibility is not the care of clients or therapists, but the maximization of profits in each fiscal quarter. Managed care companies are frequently bought and sold, with each new owner expressing disbelief at the prior company's ineptitude, making promises to improve the quality of care that are rarely met.
5. The care of the therapist, the disposable producer
This paper has thus far discussed how these changes affect the training of therapists and the consumers of clinical social work. But how are therapists themselves affected? How will therapists feel at the end of the day when the quality of the helping relationship may be as deep and anonymous as callings across cyberspace? One of the major effects of managed care arrangements is the alienation of therapists. Therapists are becoming alienated from their clients, from their professions, and most significantly, from themselves. Therapists find themselves caught between the needs of their clients and their communities, the clinicians’ own agencies, managed care utilization staff, and the very dreams and hopes they had for themselves and their profession. Even new therapists, taught to provide symptom-related treatment, cannot help but to feel the effects of what therapy has become for them, an assembly line job without the opportunity for creativity and meaning. How isolating it must be to spend countless hours with clients and not connect to the deepest parts of their psyche. The dehumanizing process of treating people as symptoms will continue to cause many therapists loneliness and anomie. In the past, many left other professions to become social workers to fulfill deep longings for creativity and to fulfill dreams of service. Today, managed care threatens to cause therapists to leave the field to actualize their higher selves.
6. Conclusion
Below is a list of some of the potential biopsychosocial consequences of limiting access to services. Focusing on symptom amelioration only can have profound consequences for individuals and families.
* Increased homelessness;
* Increased numbers of divorces;
* Children with more problems in schools ill prepared to handle them;
* Pockets of communities plagued with lower socioeconomic status and mental health issues combined;
* People experiencing inadequate nutrition and thus, greater health needs;
* A greater burden on medical services when those with mental health needs are unable to seek assistance with their own health care needs;
* Increased unemployment;
* A greater burden on community police services, because there are no services available to treat those with mental illness and/or those individuals who have maximized their service capacity;
* Increased litigation when practitioners “miss” an important diagnosis because of an inability to adequately provide services to those in need;
* Under-diagnosing in order to avoid labeling decreases even further the number of sessions one can access;
* Over-diagnosing in order to maintain third-party payment status guarantees more sessions but the effects of the label can be lifelong and negative;
* Increased medicalization of conditions keeps drug companies flourishing;
* Quick fixes overlook the long-term side effects (as in drug research); and finally,
* All of these combine to the overall sense of consumerism that begins to dictate life in post-industrial society.
As managed care becomes the dominant model of mental health delivery, clinical social work is in danger of becoming a process similar to fixing a car. We diagnose problems, apply prescribed technical solutions in a time-limited manner, and return the “functioning machine” back to its programmed tasks. However, contrary to the philosophic underpinnings of managed mental health care, mechanistic metaphors are wholly inaccurate: people are not, and do not function as, machines. Human health is intricately related to the quality of our mind-body relationship. Persistent emotional and behavioral problems do not lend themselves to quick fixes. They are rooted in the fit between the essence of who we are, our souls, and our physical environments. Managed care’s insistence on framing the problems of living in medical terms negates both personal and social reasons for our difficulties.
There is no shame in seeking help. There is no shame in admitting that one is having problems adapting. The post-modern world is a complex one. Finding meaning within its ever changing landscape requires levels of social support and help that are often no longer available to many. Clinical social work, as practiced by those who have strived for the healing of lives and souls, has been a powerful way of helping people cope with these changes. Entrusting for-profit managed mental health care conglomerates, with their focus on maximizing shareholder profit, is a risky proposition.
If psychotherapy and clinical social work liberating activities are to survive, social workers must begin the process of challenging the hegemony of managed mental health care. One of the most salient means by which social workers can effect policy and practice changes is through consumer advocacy. This strategy has the capacity to overhaul the system to listen to the voice of the consumer. It empowers people to take charge of their own healing. It helps to eliminate the person-is-the-diagnosis syndrome. In addition, it helps to maintain the accountability of professionals to their clients instead of to the managed care corporation. It helps to demystify mental illness and can reintegrate/integrate those with mental illness into society. Economic efficiency and the social construction of illness are the focus of this strategy, and it has the potential to shift from issues of mental illness to those of mental health. Finally, social workers are uniquely and logically positioned to undertake this strategy.
Using evidence-based practice and recognizing the constraints of managed care need not combine to further reduce the capacity of people with mental health issues to succeed in obtaining and utilizing services. Evidence-based practice has the potential to assure the consumer that the “best” treatment for the particular situation is being provided. This has the potential to decrease the cost and demonstrate cost effective treatment. The practitioners employing evidence-based practice should always be mindful of the holistic nature of their clients and not succumb to the person-is-the-diagnosis syndrome. Evidence-based practice also has the potential to, particularly across time; demonstrate less need for managed care to dictate severe restrictions in the number of sessions. Practitioners can join with their clients in asking for intervention combinations including pharmacological and psychotherapeutic components.
Policy makers should be made aware that the medicalization of many mental health issues ignores the complexity of people’s lives. A person with schizophrenia and taking medication may still need assistance with tasks of daily living in order to function maximally in society. While medications are certainly helpful in reducing the symptoms of mental illness, there are sociopsychological manifestations in the state of “having a mental illness” that require the support of trained professionals to aid in adjustment. An analogy would be the inpatient treatment of a person with alcoholism without concomitant work with the family and significant others in the environment. When the patient goes home, back to a system that hasn’t changed, the likelihood of relapse is great. The inpatient treatment (pill) may temporarily “fix” the “problem,” but without support upon return to the environment, both the family and the patient may return to the former way of living and being.
Schools of social work should recognize that the potential for training technicians exists within the evidence-based practice and managed care-based curriculum. Teaching to the needs of the environment can result in practitioners who fail to see the person in a holistic manner. This is most definitely a balancing act, because the coursework certainly must include awareness of a managed care environment and the needs that environment presupposes. To accomplish this task, schools should recognize the necessity of maintaining the person in the environment, ecological perspective while teaching the deliberation process of assessment and intervention. If social work ever strays too far from the person-in-the-environment perspective, there is little to separate us from other mental health professionals. Further, we fail to support one of the fundamental components of our Code of Ethics when we do not recognize the uniqueness and integrity of every single human being.
There are many ways for clinical social workers to get involved. Some may choose to join professional organizations that are advocating for change in the current mental health system. Others may wish to do research on the effects of managed care. Yet, others may choose to help empower their clients to seek systemic change. Regardless of what one does, acquiescence and accommodation will only lead to an increase in one's subjective sense of alienation and disillusionment. Our souls, and those of our clients, deserve more.
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A Co-operative Inquiry into Structural Social Work Students’ Ethical Decision-Making in Field Education
A Co-operative Inquiry into Structural Social Work Students’ Ethical Decision-Making in Field Education
Gerard Bellefeuille, PhD, RSW
Dawn Hemingway, MSc (Psych), MSW, RSW
University of Northern British Columbia
Journal of Social Work Values and Ethics, Volume 3, Number 2 (2006)
Copyright © 2006, White Hat Communications
This text may be freely shared among individuals, but it may not be republished in any medium without express written consent from the authors and advance notification of White Hat Communications.
Key words: Co-operative Inquiry, Ethics, Ethical Decision Making, Field Education, Structural Social Work
Abstract
This article describes the participative methods and results of a co-operative inquiry project that explored fourth year social work students’ ethical decision-making in field education. First, the article relates the pedagogical objectives of structural social work education to the ethical challenges of structural social work practice. Second, it outlines a self-driven framework for ethical decision making that was used in the research project to help guide students in ethical decision making. Third, it highlights co-operative inquiry as a research approach that reflects critical pedagogical praxis by assisting students (co-learners) to engage in a process of inquiry that honored their capacity for constructive self-determination. Finally, the article concludes with a discussion of the research findings and implications for structural social work education.
1. Introduction
The University of Northern British Columbia is one of only nine post-secondary institutions in Canada to adopt a structural approach to social work education (Radian, as cited in Ewashen 2002). A structural perspective has provided the conceptual grounding for a variety of pedagogical approaches in social work education including, but not limited to, anti-oppressive, anti-racist, feminist, critical, radical, and liberatory frameworks (Dominelli, 1988; Dominelli & McLeod, 1989; Moreau, 1993; Carniol, 2000; Leonard, 2001; Fook, 2002). All these approaches share the conviction that conventional social work practice, which operates within existing social institutions to assist individuals to adjust and adapt to the status quo, actually contribute to oppression in society (Mullaly, 1997; Hicks 2002; Allan, Pease, & Briskman, 2003; Baskin 2003; George 2003). Furthermore, they share the premise that many forms of social work education mask the oppressions that need to be challenged (Ife, 1997; Leonard, 2001; Rossiter, 2001; Dudziak, 2002; Hicks, 2002). Mullaly (1997) describes structural social work as follows:
“…the term ‘structural’ is descriptive of the nature of social problems in that they are an inherent part of our present day social order. Secondly, the term is descriptive, as it indicates that the focus for change is mainly on the structures of society and not on the personal characteristics of individuals victimized by social problems. Thirdly, structural social work is an inclusive social work approach because it does not attempt to establish hierarchies of oppression but rather is concerned with all forms of oppressive dominant-subordinate relations. Fourthly, it has a dialectical analysis, which means that it does not get trapped into false dichotomies, such as whether one should work at the personal or the political—both are necessary simultaneously. Fifthly, it is a critical theory, which by definition means that it has a political and practical intent. Finally, most of the development of structural social work has occurred in Canada, where it continues to assume increasing importance as a major social work perspective, theory and practice (pp. ix-x).”
Hicks (2002, p. 89) further writes that although the skills involved in structural and generalist social work practice are similar, it is the manner “in which the social worker analyses problems and the type of action that result from this analysis that distinguishes the structural approach.” A structural perspective and Hicks’ view, in particular, serve as the backdrop for this cooperative inquiry project examining students’ experience of putting theory into practice in the face of difficult ethical dilemmas that take place during field placements.
2. Field Education: The Essential Nexus between Theory and Practice
Given that social work is an applied discipline, field education serves as a vital component of the curriculum (Horejsi and Garthwait, 1999; Royse, Dhooper, & Rompf, 2003). It is in field placements that students learn to apply theory taught in the classroom to actual practical situations. Bogo and Vayda (2000, p. 3) write that social work students “must be able to examine their own practice.” This holds particularly true as it relates to negotiating the ethical aspects of social work practice (Garfat & Ricks, 1995; Goldstein, 1998). Given the plethora of ethically challenging situations that will inevitably confront graduating social workers, we felt compelled to develop a pedagogical approach that might help increase the capacity of students to, first, become aware of ethical moments and second, to work through these situations in a critical and ethical manner--in short, to assist students as they struggle to put classroom-acquired knowledge into practice in the community.
3. A Critical Pedagogical Approach to Ethical Decision Making
In addition to structural underpinnings, our developing critical pedagogical approach to teaching ethical decision-making builds on and incorporates the Standards for Accreditation articulated by the Canadian Association of Schools of Social Work (CASSW, 2004):
“…the curriculum shall ensure that the student will have…understanding of and ability to apply social work values and ethics in order to make professional judgments consistent with a commitment to address inequality and the eradication of oppressive conditions (p. 9).”
As we seek to facilitate this capacity in all our students, we know that, in field placement, they inevitably struggle with the day-to-day, messy, practical ethical dilemmas that involve both conflicting values and responsibilities (Reamer, 1982, 1992; Rhodes, 1986; Ricks & Bellefeuille, 2003).
Drawing on more than thirty years of ethics education, Ricks (1989, 1992, 1997) makes a persuasive case that students struggle in their efforts to reach self-driven ethical decisions because they learn that there are preferred skills, practice approaches, or models that should be applied in specific case circumstances. This sets up the expectation that in practice there are relatively clear cut, “right ways” that are easy to learn and incorporate into practice (Ricks & Charlesworth, 2002, p. v). Consequently, becoming accustomed to the uncertainties associated with resolving ethical dilemmas is an educational goal that many social workers fail to meet (Ricks & Bellefeuille, 2003). The bottom line for Ricks & Bellefeuille (2003, p. 118) is that “ethical practice that relies heavily on professional codes of ethics can lull practitioners to sleep in matters that require critical reflection and discretionary judgment.”
A critical pedagogy should encourage students to assess professional codes of ethics with a critical eye and to consider the relationship between ethics and politics (Benhabib, 1992; Finn, 1994; Hugman & Smith, 1995; Morelock, 1997). As suggested by Finn (1994, p. 102), “ethical praxis cannot renounce politics because it is actually constituted by it.” She goes on to explain that ethical codes are the formal articulation of modernist thought and as such reflect the prevailing liberal world view where universalism, rationalism, and liberal individualism are seen as the foundation of professional practice:
“Since ethical praxis always occurs within a particular political context (community), it will (either by default or design) confirm the values, goals and ends of the political situation within which it is situated and thereby the hierarchies of power and control which they enable and sustain, or it will contest them." (p. 104)
Finn (1994) calls into question much of what passes as ethical in the theories and practices of professional, practical and applied ethics. From this view, ethics really have very little to do with promoting social justice:
“…an ethics which relies on the (political) categories of established thought and/or seeks to solidify or cement them—into institutionalized rights and freedoms, rules and regulations, and principles of practice, for example—is not so much an ethics, therefore, as an abdication of ethics for politics under another description (Finn, 1994, p. 101).”
Thus critical pedagogy as an educational approach to understanding the personal and contextual nature of ethical decision-making necessitates asking students, through a process of collaborative dialogue, to critically examine the thoughts, attitudes, values, and feelings that underpin the actions they take on a daily basis. This emphasis on the contextual self requires that we re-think ethics education in terms of more process oriented and practice-based ethical decision making models in which self is central (Blum, 1994; Finn, 1994; Sharmer, 2000; Adams, Dominelli, & Payne, 2002; Fook, 2002; Ricks &Charlesworth, 2002). This calls for extensive self-reflection, a willingness to engage in critical thinking, and a non-judgmental attitude of self and others.
In an attempt to create a space for field-based students to engage in this pedagogical praxis, we established a series of classroom seminars supported by a web-based discussion board as a collaborative forum in which students were able to examine and explore their ethical practice within a self-driven ethical decision-making framework (see Figure 1).
Figure 1
Figure 1. Ethical practice context
Within a self-driven ethical decision making model, the ethical principles embedded in codes of ethics become only part of the “contextual mix” and are “differently applied in practice” (Ricks & Bellefeuille, 2003, p. 121). The self-driven model highlights beliefs (what one holds as true); values (what one holds as important); and ethics (the rules and standards used to determine what to do) as well as individual thoughts, feelings, and actions. In short, codes, standards, and organizational values are filtered through ‘self,’ as part of the problem-solving process. Ultimately, decisions, actions and evaluation, in turn, impact ‘self’ and, thus, future ethical decision-making.
4. Locating the Research in Co-Operative Inquiry
We chose a co-operative inquiry approach because it reflects critical pedagogical praxis. Co-operative inquiry is a form of action research in which all those involved contribute to the decisions about what is to be looked at, the inquiry methods to be used, the interpretation of what is discovered and the action that is the subject of the research (Reason, 1988; Reason, 1994; Heron, 1996; Reason & Heron, 1999; Heron & Reason, 2001). Co-operative inquiry is congruent with the emancipatory goals of structural social work in that it confronts the way established elements of society hold power (Heron, 1996). From a structural social work perspective, power and knowledge are not separable (Ife, 1997).
4.1 Initiating the Inquiry Group
Fourth year students were invited to a meeting to discuss their voluntary participation in the research project. In co-operative inquiry, “all those involved work together as co-researchers and co-subjects” (Reason & Heron, 1995, p. 4); in other words, as co-learners. Twenty-six students out of a class of 30 volunteered to take part in this study – 24 females and 2 males. As co-learners, the group was asked to think about the type of questions that would guide the inquiry. Coming out of the initial meeting, the following questions were constructed:
* What kind (s) of ethical dilemmas are present in social work settings?
* Do social work students know what to do when confronted with ethical dilemmas?
* What keeps social work students from acting ethically?
5. Data Collection Methods
The experiences of each co-learner were recorded using a reflective journaling process. Co-learners were presented with a framework of ten guiding questions to assist in their efforts to apply the self-driven ethical decision making model (see Figure 1) as they worked through ethical dilemmas encountered over their 3-month field education placement. For each ethical dilemma, students were asked to work through a series of questions as part of their reflecting process:
* What makes this an ethical dilemma; i.e., what values are in conflict?
* Who was present?
* Who said or did what? Or who didn’t say or do what?
* What were my fears?
* How and why am I making the choice I am making; i.e., what did I think, feel, and what did I do or not do?
* How is my decision-making affected by the fact that I am taking it in this particular setting (e.g., standards, policies, organizational values)?
* How does my personal knowledge, culture, life experience affect my choice?
* Given similar circumstances with another person, would I take the same or a different action?
* What other resources would be helpful to me in making this decision?
* How did the code of ethics inform and/or direct my action?
5.1 Reflection and Action Cycles
As part of the co-operative research method, the group was brought together for three full-day seminars. The first seminar was held during the first week of field at which time co-learners were introduced to the self-driven ethical decision making model. The second seminar involved co-learners reflecting on and making sense of their ethical decision-making experiences. This was facilitated at the six week point or mid-point of their field placement. Following the second seminar, co-learners returned to the field and continued their inquiry in that practice context. As explained by Reason & Heron (1995), the cycling can be repeated several times:
“Ideas and discoveries tentatively reached in early phases can be checked and developed; investigation of one aspect of the inquiry can be related to exploration of other parts; new skills can be acquired and monitored; experiential competence are realized; the group itself becomes more cohesive and self-critical, more skilled in its work (p. 5):”
Although the context of students’ experiences reflected the variances in field placements (from grass roots community-based organizations to institutional settings such as child welfare), many of the themes they identified were similar. The final seminar was held at the conclusion of the field placement and presented as a concluding focus group. It served as a forum to capture the co-learners’ overall perceptions of the inquiry process, of the self-driven ethical decision-making model, and of our critical pedagogical approach to teaching ethical decision-making in field.
6. Ethical Considerations
The proposal for this study was approved by the Research Ethics Board at the University of Northern British Columbia. All participants were provided with an information letter that outlined the process and purpose of the inquiry and described any potential risks. Participants were also presented with a consent form that was signed prior to their participation in the collection of data. The consent form indicated that consent could be withdrawn at any time without penalty or need for explanation.
7. What We Learned
A total of 133 case examples of ethical dilemmas were submitted by the co-learners. Of these, 68 were from co-learners placed in a child protection setting as part of the child welfare specialization stream, and 65 were from co-learners placed in various community-based settings. The results are presented for each of the four research questions developed at the inaugural meeting of participating students and faculty members.
7.1 What Kind (s) of Ethical Dilemmas are Present in Social Work Settings?
A thematic analysis of the kinds of ethical dilemmas encountered by co-learners is presented in Figure 2. The top four categories included: lack of respect for clients, conflict of interest, abuse of power, and revealing confidential information. Although students were able to identify ethical dilemmas, they struggled to openly and critically examine the personal beliefs and values that guide their practice or the practices at their placements, and the consequences these have for ethical decision making. Structural social work demands that students understand who it is that they privilege and whose experiences they limit when they embark upon courses of action that reflect personal preferences (Garfat & Ricks, 1995) and/or that are the products of historical forces (Mullaly, 1997; Baskin, 2003), particularly in public institutions of learning that cross social, cultural, and experiential boundaries. To practice from a structural perspective, social work students must be both willing and able to reflect on the origins, purposes, and consequences of their actions as well as on the material and ideological constraints and encouragements embedded in the classroom, agency, and societal contexts in which they work. While this self-exposure and self-confrontation is uncomfortable and sometimes threatening, it is never inconsequential when we engage in it with others with whom we stand in a pedagogical relationship.
Kind of Dilemmas
Frequency
Lack of Respect for Clients
Conflict of Interest
Abuse of Power
Revealing Confidential Information
Bad Practice
Lack of Proper Assessment of Needs
Lacking the Necessary Skills
Efficiency and Cost Savings over Best Interest of Client’s Needs
Judgmental
Deception
Demeaning Comments Made by Workers
Gossiping about Co-Workers
Lack of Professionalism
Racism
18
16
14
14
9
9
9
8
8
7
6
6
6
3
Figure 2:: Thematic analysis of ethical dilemmas
7.2 Do social work students know what to do when confronted with ethical dilemmas?
Only 95, or 75%, of the 133 case examples indicated that they knew how to successfully work through the ethical situation. Further, many of the examples of perceived successful resolution involved students turning to their practicum mentors for direction. This may reflect a level of inexperience on the part of the students or the complexity of the issues being addressed, but it also may signify a reluctance to accept personal responsibility for their practice. Structural social work students who are committed to critical ethical praxis need to develop the capacity for critical self-reflection. This notion is not a new one. However, a more complete understanding of how self-reflection looks in practice is key. Although self reflexivity is indubitably connected to one’s personal history, and one’s history is tied into each social worker’s ethical decision-making process on some conscious or unconscious level, critical practice is a moving dialectic between practitioner and practice. This process can incur feelings of discomfort, grief, frustration, and resistance and requires not only cognitive but emotional work. It is only by examining emotional reactions (i.e., how did I feel and how did that relate to what I did?) that one truly begins to identify privileges as well as invisible ways in which one complies with dominant ideology. It is in this context of critical self reflection, which is not separated from feeling, that additional new windows on the world can be revealed to students – a primary ethical aim of a critical pedagogy of practice.
7.3 What keeps social work students from acting ethically?
Figure 3 reports the analysis of the themes for the third research question: What keeps students from acting ethically?
What Keeps Social Workers From Acting Ethically
Frequency
Not sure What to do
Fear of Speaking Up for Fear of Jeopardizing placement
Fear of Making a Mistake
Fear of Being Disliked
Fear of Creating Conflict
Not Being a Team Player
Uncertainty About Being Helpful and Creating Dependency
Afraid of Portraying Self as Naive
Afraid of Portraying Self as a Stickler for Detail
16
14
14
6
14
7
5
4
1
Figure 3: Thematic analysis of reasons given by co-learners for not acting ethically
Fear was the overwhelming feeling expressed by student co-learners as the reason for failing to deal with ethical dilemmas encountered in their field placements. For example, one co-learner stated that she feared “retaliation from her colleagues.” Another co-learner feared “losing the trust”of her supervisor. The most common concern, however, was fear of failing the placement. The following statement offered by McFarlane, Ricks, and Field (n. d.) sheds some light on why people who know what to do often fail to act. They explain that people fail to act when:
“The risk is too high and/or the costs are too great at a very personal level. As a result, they are completely overcome by their fear and immobilized. When this happens, the personal fears are not intruding on making the best choice, but are intruding on acting on the best choice. For example, fear can restrict thinking about all the options. Under the condition of fear we can be reductionistic and generate only two options: e.g., I can lose like this or I can lose like that." (p. 7)
The challenge, therefore, is to support students to move beyond simplistic binary understandings so prevalent in Western thought (Hooks, 1992; Fook, 1999; Meagher & Parton, 2004; Fisher et al., 2005). We live in a complex world that contains many shades of gray. If we cannot escape the confines of binary thinking in our society, how are we to ever think outside of the box on a larger scale? The end result of binary thinking is to preclude the possibility of the ambiguous options. Thus, ambiguity is a source of discomfort in a culture defined by simple binary oppositions. For this reason, we believe that a critical approach to ethical decision-making requires that students acquire an understanding of the complexity of ethical situations and acquire the critical thinking skills to operate in what Finn (1994, p. 101) describes as “the space between…the space of the ethical encounter with the other as other and not more of the same.” Following Finn, we argue that the role of the field student is to explore that “space between” that puts their beliefs, values, and feelings into question.
8. About the Process
The use of self-driven ethical decision-making in field education/practice-based teaching is presented as a co-operative inquiry involving both field faculty and students. During the final seminar, students were asked to talk about their experience with the process, and most reported that the self-driven ethical decision-making model had been an important and valuable aspect of their field placement experience. They also indicated that the guiding questions were helpful in their efforts to work though the self-driven ethical decision-making model. However, several recommendations were made to improve both the clarity and effectiveness of the questions. These will be incorporated in future field education classes.
9. Implications for Structural Social Work Education
A major challenge that must be confronted in schools of structural social work involves the role of field education in the development of critical ethical practice. As highlighted in this inquiry, although systematic guidelines for resolving ethical dilemmas offer social workers a logical approach to the decision-making sequence, it is inevitable that discretionary judgments affect the ultimate choice of action. Through critical self reflection, social workers can learn to recognize their value preferences (including deferring to someone in a position of authority) and be alert to the ways in which these values unknowingly influence the resolution of ethical dilemmas. Further, this co-operative inquiry process challenged the co-learners to consider their ethical decision-making as linked to other ethical decisions they have made in the past or will make in the future.
A second challenge relates to the obligation of structural schools of social work to provide students with a critical approach to ethical decision-making. This obligation has long-term implications, because most students will be interacting with the community as professionals for the rest of their careers. Students and graduates whose conduct is oppressive or unethical can make it understandably difficult for a school of social work to continue to be a legitimate site of resistance within the community. In moving towards a self-driven ethical decision-making approach to field education, structural social work students are encouraged to accept responsibility for their practice. Through self-reflection of feelings, values, and beliefs, it is possible to explore ethical and practice issues so as to continually inform and reform these practices for the purpose of critical praxis, to confront oppression and, at the same time, to support life-long learning/professional development. However, the challenge lies not only with the students, but perhaps even more so with schools of social work themselves who must meet the challenge head on and figure out the ways to provide students with the tools and the experience they need.
The cooperative inquiry process that we undertook is but an initial attempt to put the question of a self-driven model for ethical decision-making clearly on the table in a fourth-year field education setting. Results indicate that there is a long way to go and justify ongoing research into the application of self-driven ethical decision-making models in shaping critical praxis.
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Benhabib, S. (1992). Situating the Self: Gender, Community and Postmodernism in Contemporary Ethics,London: Routledge.
Blum, L. (1994). Moral Perception and Particularity, Cambridge, MA: Cambridge University Press.
Bogo, M., and Vayda, E. (2000). The Practice of Field Instruction in Social Work: Theory and Practice, Toronto, ON: University of Toronto Press.
Carniol, B. (2000). Case Critical: Challenging Social Services in Canada (4th ed.), Toronto, ON: Between the Lines Press.
CASSW. (2004). Standards of Accreditation. Ottawa, ON. Author.
Dominelli, L. (1988). Anti-Racist Social Work. London: The MacMillan Press.
Dominelli, L., and McLeod, E. (1989). Feminist Social Work. London: The MacMillan Press.
Dudziak, S. (2002). “Educating for Justice: Challenges and Openings at the Beginning of a New Century,” Critical Social Work, 2(2), 6-19.
Ewashen, A. (2003). “Walking the Maze: The Labyrinth Between Privilege and Structural Social Work Practice,” unpublished master’s thesis, University of Northern British Columbia.
Finn, G. (1994). “The Space Between Ethics and Politics: Or More of the Same?,” in Who is This ‘‘We’’? Absence of Community, eds. L. Godway and G. Finn, Montreal, QC: Black Rose Books,101–115.
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Garfat, T., and Ricks, F. (1995). “Self-Driven Ethical Decision Making: A Model for Child and Youth Care,” Child and Youth Care Forum, 24(6), 393-403.
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Hicks, S. (2002). Social Work in Canada. Toronto, ON: Thompson Educational Publishing, Inc.
Hooks, B. (1992). Black Looks: Race and Representation. Toronto, ON: Between the Lines.
Horejsi, C., and Garthwait, C. (1999). The Social Work Practicum: A Guide and Workbook for Students.Boston, MA: Allyn & Bacon.
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Mullaly, B. (1997). Structural Social Work: Ideology, Theory and Practice (2nd ed.). Toronto, ON: Oxford University Press.
Radian, E. (1999). “Influences Prompting the Social Action Activities of Canadian BSW Graduates,” unpublished manuscript, Red Deer College.
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Reamer, F. (1992). “Should Social Workers Blow Their Whistles on Incompetent Colleagues?,” in Controversial Issues in Social Work, eds. E. Gambrill and R. Pruger. Boston, MA: Allyn and Bacon, 66-73.
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Ricks, F., and Bellefeuille, G. (2003), “Knowing: The Critical Error of Ethics in Family Work,” Child & Youth Services, 25(1/2), 117-130.
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Rossiter, A. (2001), “Innocence Lost and Suspicion Found: Do We Educate For or Against Social Work,” Critical Social Work, 2(1), 30-37.
Royse, D., Dhooper, S., and Rompf, E. (2003), Field Instruction: A Guide for Social Work Students (4th ed.), Boston, MA: Allyn & Bacon.
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Gerard Bellefeuille, PhD, RSW
Dawn Hemingway, MSc (Psych), MSW, RSW
University of Northern British Columbia
Journal of Social Work Values and Ethics, Volume 3, Number 2 (2006)
Copyright © 2006, White Hat Communications
This text may be freely shared among individuals, but it may not be republished in any medium without express written consent from the authors and advance notification of White Hat Communications.
Key words: Co-operative Inquiry, Ethics, Ethical Decision Making, Field Education, Structural Social Work
Abstract
This article describes the participative methods and results of a co-operative inquiry project that explored fourth year social work students’ ethical decision-making in field education. First, the article relates the pedagogical objectives of structural social work education to the ethical challenges of structural social work practice. Second, it outlines a self-driven framework for ethical decision making that was used in the research project to help guide students in ethical decision making. Third, it highlights co-operative inquiry as a research approach that reflects critical pedagogical praxis by assisting students (co-learners) to engage in a process of inquiry that honored their capacity for constructive self-determination. Finally, the article concludes with a discussion of the research findings and implications for structural social work education.
1. Introduction
The University of Northern British Columbia is one of only nine post-secondary institutions in Canada to adopt a structural approach to social work education (Radian, as cited in Ewashen 2002). A structural perspective has provided the conceptual grounding for a variety of pedagogical approaches in social work education including, but not limited to, anti-oppressive, anti-racist, feminist, critical, radical, and liberatory frameworks (Dominelli, 1988; Dominelli & McLeod, 1989; Moreau, 1993; Carniol, 2000; Leonard, 2001; Fook, 2002). All these approaches share the conviction that conventional social work practice, which operates within existing social institutions to assist individuals to adjust and adapt to the status quo, actually contribute to oppression in society (Mullaly, 1997; Hicks 2002; Allan, Pease, & Briskman, 2003; Baskin 2003; George 2003). Furthermore, they share the premise that many forms of social work education mask the oppressions that need to be challenged (Ife, 1997; Leonard, 2001; Rossiter, 2001; Dudziak, 2002; Hicks, 2002). Mullaly (1997) describes structural social work as follows:
“…the term ‘structural’ is descriptive of the nature of social problems in that they are an inherent part of our present day social order. Secondly, the term is descriptive, as it indicates that the focus for change is mainly on the structures of society and not on the personal characteristics of individuals victimized by social problems. Thirdly, structural social work is an inclusive social work approach because it does not attempt to establish hierarchies of oppression but rather is concerned with all forms of oppressive dominant-subordinate relations. Fourthly, it has a dialectical analysis, which means that it does not get trapped into false dichotomies, such as whether one should work at the personal or the political—both are necessary simultaneously. Fifthly, it is a critical theory, which by definition means that it has a political and practical intent. Finally, most of the development of structural social work has occurred in Canada, where it continues to assume increasing importance as a major social work perspective, theory and practice (pp. ix-x).”
Hicks (2002, p. 89) further writes that although the skills involved in structural and generalist social work practice are similar, it is the manner “in which the social worker analyses problems and the type of action that result from this analysis that distinguishes the structural approach.” A structural perspective and Hicks’ view, in particular, serve as the backdrop for this cooperative inquiry project examining students’ experience of putting theory into practice in the face of difficult ethical dilemmas that take place during field placements.
2. Field Education: The Essential Nexus between Theory and Practice
Given that social work is an applied discipline, field education serves as a vital component of the curriculum (Horejsi and Garthwait, 1999; Royse, Dhooper, & Rompf, 2003). It is in field placements that students learn to apply theory taught in the classroom to actual practical situations. Bogo and Vayda (2000, p. 3) write that social work students “must be able to examine their own practice.” This holds particularly true as it relates to negotiating the ethical aspects of social work practice (Garfat & Ricks, 1995; Goldstein, 1998). Given the plethora of ethically challenging situations that will inevitably confront graduating social workers, we felt compelled to develop a pedagogical approach that might help increase the capacity of students to, first, become aware of ethical moments and second, to work through these situations in a critical and ethical manner--in short, to assist students as they struggle to put classroom-acquired knowledge into practice in the community.
3. A Critical Pedagogical Approach to Ethical Decision Making
In addition to structural underpinnings, our developing critical pedagogical approach to teaching ethical decision-making builds on and incorporates the Standards for Accreditation articulated by the Canadian Association of Schools of Social Work (CASSW, 2004):
“…the curriculum shall ensure that the student will have…understanding of and ability to apply social work values and ethics in order to make professional judgments consistent with a commitment to address inequality and the eradication of oppressive conditions (p. 9).”
As we seek to facilitate this capacity in all our students, we know that, in field placement, they inevitably struggle with the day-to-day, messy, practical ethical dilemmas that involve both conflicting values and responsibilities (Reamer, 1982, 1992; Rhodes, 1986; Ricks & Bellefeuille, 2003).
Drawing on more than thirty years of ethics education, Ricks (1989, 1992, 1997) makes a persuasive case that students struggle in their efforts to reach self-driven ethical decisions because they learn that there are preferred skills, practice approaches, or models that should be applied in specific case circumstances. This sets up the expectation that in practice there are relatively clear cut, “right ways” that are easy to learn and incorporate into practice (Ricks & Charlesworth, 2002, p. v). Consequently, becoming accustomed to the uncertainties associated with resolving ethical dilemmas is an educational goal that many social workers fail to meet (Ricks & Bellefeuille, 2003). The bottom line for Ricks & Bellefeuille (2003, p. 118) is that “ethical practice that relies heavily on professional codes of ethics can lull practitioners to sleep in matters that require critical reflection and discretionary judgment.”
A critical pedagogy should encourage students to assess professional codes of ethics with a critical eye and to consider the relationship between ethics and politics (Benhabib, 1992; Finn, 1994; Hugman & Smith, 1995; Morelock, 1997). As suggested by Finn (1994, p. 102), “ethical praxis cannot renounce politics because it is actually constituted by it.” She goes on to explain that ethical codes are the formal articulation of modernist thought and as such reflect the prevailing liberal world view where universalism, rationalism, and liberal individualism are seen as the foundation of professional practice:
“Since ethical praxis always occurs within a particular political context (community), it will (either by default or design) confirm the values, goals and ends of the political situation within which it is situated and thereby the hierarchies of power and control which they enable and sustain, or it will contest them." (p. 104)
Finn (1994) calls into question much of what passes as ethical in the theories and practices of professional, practical and applied ethics. From this view, ethics really have very little to do with promoting social justice:
“…an ethics which relies on the (political) categories of established thought and/or seeks to solidify or cement them—into institutionalized rights and freedoms, rules and regulations, and principles of practice, for example—is not so much an ethics, therefore, as an abdication of ethics for politics under another description (Finn, 1994, p. 101).”
Thus critical pedagogy as an educational approach to understanding the personal and contextual nature of ethical decision-making necessitates asking students, through a process of collaborative dialogue, to critically examine the thoughts, attitudes, values, and feelings that underpin the actions they take on a daily basis. This emphasis on the contextual self requires that we re-think ethics education in terms of more process oriented and practice-based ethical decision making models in which self is central (Blum, 1994; Finn, 1994; Sharmer, 2000; Adams, Dominelli, & Payne, 2002; Fook, 2002; Ricks &Charlesworth, 2002). This calls for extensive self-reflection, a willingness to engage in critical thinking, and a non-judgmental attitude of self and others.
In an attempt to create a space for field-based students to engage in this pedagogical praxis, we established a series of classroom seminars supported by a web-based discussion board as a collaborative forum in which students were able to examine and explore their ethical practice within a self-driven ethical decision-making framework (see Figure 1).
Figure 1
Figure 1. Ethical practice context
Within a self-driven ethical decision making model, the ethical principles embedded in codes of ethics become only part of the “contextual mix” and are “differently applied in practice” (Ricks & Bellefeuille, 2003, p. 121). The self-driven model highlights beliefs (what one holds as true); values (what one holds as important); and ethics (the rules and standards used to determine what to do) as well as individual thoughts, feelings, and actions. In short, codes, standards, and organizational values are filtered through ‘self,’ as part of the problem-solving process. Ultimately, decisions, actions and evaluation, in turn, impact ‘self’ and, thus, future ethical decision-making.
4. Locating the Research in Co-Operative Inquiry
We chose a co-operative inquiry approach because it reflects critical pedagogical praxis. Co-operative inquiry is a form of action research in which all those involved contribute to the decisions about what is to be looked at, the inquiry methods to be used, the interpretation of what is discovered and the action that is the subject of the research (Reason, 1988; Reason, 1994; Heron, 1996; Reason & Heron, 1999; Heron & Reason, 2001). Co-operative inquiry is congruent with the emancipatory goals of structural social work in that it confronts the way established elements of society hold power (Heron, 1996). From a structural social work perspective, power and knowledge are not separable (Ife, 1997).
4.1 Initiating the Inquiry Group
Fourth year students were invited to a meeting to discuss their voluntary participation in the research project. In co-operative inquiry, “all those involved work together as co-researchers and co-subjects” (Reason & Heron, 1995, p. 4); in other words, as co-learners. Twenty-six students out of a class of 30 volunteered to take part in this study – 24 females and 2 males. As co-learners, the group was asked to think about the type of questions that would guide the inquiry. Coming out of the initial meeting, the following questions were constructed:
* What kind (s) of ethical dilemmas are present in social work settings?
* Do social work students know what to do when confronted with ethical dilemmas?
* What keeps social work students from acting ethically?
5. Data Collection Methods
The experiences of each co-learner were recorded using a reflective journaling process. Co-learners were presented with a framework of ten guiding questions to assist in their efforts to apply the self-driven ethical decision making model (see Figure 1) as they worked through ethical dilemmas encountered over their 3-month field education placement. For each ethical dilemma, students were asked to work through a series of questions as part of their reflecting process:
* What makes this an ethical dilemma; i.e., what values are in conflict?
* Who was present?
* Who said or did what? Or who didn’t say or do what?
* What were my fears?
* How and why am I making the choice I am making; i.e., what did I think, feel, and what did I do or not do?
* How is my decision-making affected by the fact that I am taking it in this particular setting (e.g., standards, policies, organizational values)?
* How does my personal knowledge, culture, life experience affect my choice?
* Given similar circumstances with another person, would I take the same or a different action?
* What other resources would be helpful to me in making this decision?
* How did the code of ethics inform and/or direct my action?
5.1 Reflection and Action Cycles
As part of the co-operative research method, the group was brought together for three full-day seminars. The first seminar was held during the first week of field at which time co-learners were introduced to the self-driven ethical decision making model. The second seminar involved co-learners reflecting on and making sense of their ethical decision-making experiences. This was facilitated at the six week point or mid-point of their field placement. Following the second seminar, co-learners returned to the field and continued their inquiry in that practice context. As explained by Reason & Heron (1995), the cycling can be repeated several times:
“Ideas and discoveries tentatively reached in early phases can be checked and developed; investigation of one aspect of the inquiry can be related to exploration of other parts; new skills can be acquired and monitored; experiential competence are realized; the group itself becomes more cohesive and self-critical, more skilled in its work (p. 5):”
Although the context of students’ experiences reflected the variances in field placements (from grass roots community-based organizations to institutional settings such as child welfare), many of the themes they identified were similar. The final seminar was held at the conclusion of the field placement and presented as a concluding focus group. It served as a forum to capture the co-learners’ overall perceptions of the inquiry process, of the self-driven ethical decision-making model, and of our critical pedagogical approach to teaching ethical decision-making in field.
6. Ethical Considerations
The proposal for this study was approved by the Research Ethics Board at the University of Northern British Columbia. All participants were provided with an information letter that outlined the process and purpose of the inquiry and described any potential risks. Participants were also presented with a consent form that was signed prior to their participation in the collection of data. The consent form indicated that consent could be withdrawn at any time without penalty or need for explanation.
7. What We Learned
A total of 133 case examples of ethical dilemmas were submitted by the co-learners. Of these, 68 were from co-learners placed in a child protection setting as part of the child welfare specialization stream, and 65 were from co-learners placed in various community-based settings. The results are presented for each of the four research questions developed at the inaugural meeting of participating students and faculty members.
7.1 What Kind (s) of Ethical Dilemmas are Present in Social Work Settings?
A thematic analysis of the kinds of ethical dilemmas encountered by co-learners is presented in Figure 2. The top four categories included: lack of respect for clients, conflict of interest, abuse of power, and revealing confidential information. Although students were able to identify ethical dilemmas, they struggled to openly and critically examine the personal beliefs and values that guide their practice or the practices at their placements, and the consequences these have for ethical decision making. Structural social work demands that students understand who it is that they privilege and whose experiences they limit when they embark upon courses of action that reflect personal preferences (Garfat & Ricks, 1995) and/or that are the products of historical forces (Mullaly, 1997; Baskin, 2003), particularly in public institutions of learning that cross social, cultural, and experiential boundaries. To practice from a structural perspective, social work students must be both willing and able to reflect on the origins, purposes, and consequences of their actions as well as on the material and ideological constraints and encouragements embedded in the classroom, agency, and societal contexts in which they work. While this self-exposure and self-confrontation is uncomfortable and sometimes threatening, it is never inconsequential when we engage in it with others with whom we stand in a pedagogical relationship.
Kind of Dilemmas
Frequency
Lack of Respect for Clients
Conflict of Interest
Abuse of Power
Revealing Confidential Information
Bad Practice
Lack of Proper Assessment of Needs
Lacking the Necessary Skills
Efficiency and Cost Savings over Best Interest of Client’s Needs
Judgmental
Deception
Demeaning Comments Made by Workers
Gossiping about Co-Workers
Lack of Professionalism
Racism
18
16
14
14
9
9
9
8
8
7
6
6
6
3
Figure 2:: Thematic analysis of ethical dilemmas
7.2 Do social work students know what to do when confronted with ethical dilemmas?
Only 95, or 75%, of the 133 case examples indicated that they knew how to successfully work through the ethical situation. Further, many of the examples of perceived successful resolution involved students turning to their practicum mentors for direction. This may reflect a level of inexperience on the part of the students or the complexity of the issues being addressed, but it also may signify a reluctance to accept personal responsibility for their practice. Structural social work students who are committed to critical ethical praxis need to develop the capacity for critical self-reflection. This notion is not a new one. However, a more complete understanding of how self-reflection looks in practice is key. Although self reflexivity is indubitably connected to one’s personal history, and one’s history is tied into each social worker’s ethical decision-making process on some conscious or unconscious level, critical practice is a moving dialectic between practitioner and practice. This process can incur feelings of discomfort, grief, frustration, and resistance and requires not only cognitive but emotional work. It is only by examining emotional reactions (i.e., how did I feel and how did that relate to what I did?) that one truly begins to identify privileges as well as invisible ways in which one complies with dominant ideology. It is in this context of critical self reflection, which is not separated from feeling, that additional new windows on the world can be revealed to students – a primary ethical aim of a critical pedagogy of practice.
7.3 What keeps social work students from acting ethically?
Figure 3 reports the analysis of the themes for the third research question: What keeps students from acting ethically?
What Keeps Social Workers From Acting Ethically
Frequency
Not sure What to do
Fear of Speaking Up for Fear of Jeopardizing placement
Fear of Making a Mistake
Fear of Being Disliked
Fear of Creating Conflict
Not Being a Team Player
Uncertainty About Being Helpful and Creating Dependency
Afraid of Portraying Self as Naive
Afraid of Portraying Self as a Stickler for Detail
16
14
14
6
14
7
5
4
1
Figure 3: Thematic analysis of reasons given by co-learners for not acting ethically
Fear was the overwhelming feeling expressed by student co-learners as the reason for failing to deal with ethical dilemmas encountered in their field placements. For example, one co-learner stated that she feared “retaliation from her colleagues.” Another co-learner feared “losing the trust”of her supervisor. The most common concern, however, was fear of failing the placement. The following statement offered by McFarlane, Ricks, and Field (n. d.) sheds some light on why people who know what to do often fail to act. They explain that people fail to act when:
“The risk is too high and/or the costs are too great at a very personal level. As a result, they are completely overcome by their fear and immobilized. When this happens, the personal fears are not intruding on making the best choice, but are intruding on acting on the best choice. For example, fear can restrict thinking about all the options. Under the condition of fear we can be reductionistic and generate only two options: e.g., I can lose like this or I can lose like that." (p. 7)
The challenge, therefore, is to support students to move beyond simplistic binary understandings so prevalent in Western thought (Hooks, 1992; Fook, 1999; Meagher & Parton, 2004; Fisher et al., 2005). We live in a complex world that contains many shades of gray. If we cannot escape the confines of binary thinking in our society, how are we to ever think outside of the box on a larger scale? The end result of binary thinking is to preclude the possibility of the ambiguous options. Thus, ambiguity is a source of discomfort in a culture defined by simple binary oppositions. For this reason, we believe that a critical approach to ethical decision-making requires that students acquire an understanding of the complexity of ethical situations and acquire the critical thinking skills to operate in what Finn (1994, p. 101) describes as “the space between…the space of the ethical encounter with the other as other and not more of the same.” Following Finn, we argue that the role of the field student is to explore that “space between” that puts their beliefs, values, and feelings into question.
8. About the Process
The use of self-driven ethical decision-making in field education/practice-based teaching is presented as a co-operative inquiry involving both field faculty and students. During the final seminar, students were asked to talk about their experience with the process, and most reported that the self-driven ethical decision-making model had been an important and valuable aspect of their field placement experience. They also indicated that the guiding questions were helpful in their efforts to work though the self-driven ethical decision-making model. However, several recommendations were made to improve both the clarity and effectiveness of the questions. These will be incorporated in future field education classes.
9. Implications for Structural Social Work Education
A major challenge that must be confronted in schools of structural social work involves the role of field education in the development of critical ethical practice. As highlighted in this inquiry, although systematic guidelines for resolving ethical dilemmas offer social workers a logical approach to the decision-making sequence, it is inevitable that discretionary judgments affect the ultimate choice of action. Through critical self reflection, social workers can learn to recognize their value preferences (including deferring to someone in a position of authority) and be alert to the ways in which these values unknowingly influence the resolution of ethical dilemmas. Further, this co-operative inquiry process challenged the co-learners to consider their ethical decision-making as linked to other ethical decisions they have made in the past or will make in the future.
A second challenge relates to the obligation of structural schools of social work to provide students with a critical approach to ethical decision-making. This obligation has long-term implications, because most students will be interacting with the community as professionals for the rest of their careers. Students and graduates whose conduct is oppressive or unethical can make it understandably difficult for a school of social work to continue to be a legitimate site of resistance within the community. In moving towards a self-driven ethical decision-making approach to field education, structural social work students are encouraged to accept responsibility for their practice. Through self-reflection of feelings, values, and beliefs, it is possible to explore ethical and practice issues so as to continually inform and reform these practices for the purpose of critical praxis, to confront oppression and, at the same time, to support life-long learning/professional development. However, the challenge lies not only with the students, but perhaps even more so with schools of social work themselves who must meet the challenge head on and figure out the ways to provide students with the tools and the experience they need.
The cooperative inquiry process that we undertook is but an initial attempt to put the question of a self-driven model for ethical decision-making clearly on the table in a fourth-year field education setting. Results indicate that there is a long way to go and justify ongoing research into the application of self-driven ethical decision-making models in shaping critical praxis.
References
Allan, J., Pease, B., and Briskman, L. (Eds.). (2003). Critical Social Work. Sydney: Allen and Unwin.
Adams, R., Dominelli, L., and Payne, M. (2002). Critical Practice in Social Work. New York: Palgrave Macmillan.
Baskin, C. (2003). “Structural Social Work as Seen from an Aboriginal Perspective,” in Emerging Perspectives on Anti-Oppressive Practice, ed. W. Shera, Toronto, ON: Canadian Scholar’s Press Inc, 65-79.
Benhabib, S. (1992). Situating the Self: Gender, Community and Postmodernism in Contemporary Ethics,London: Routledge.
Blum, L. (1994). Moral Perception and Particularity, Cambridge, MA: Cambridge University Press.
Bogo, M., and Vayda, E. (2000). The Practice of Field Instruction in Social Work: Theory and Practice, Toronto, ON: University of Toronto Press.
Carniol, B. (2000). Case Critical: Challenging Social Services in Canada (4th ed.), Toronto, ON: Between the Lines Press.
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Licensing of Social Work Faculty: An Issue of Ethics?
Licensing of Social Work Faculty: An Issue of Ethics?
One of the most puzzling debates I have heard in my adult life is, ¨Should social workers who are faculty be required to be state licensed/certified in their jurisdictions?” Why is this perceived dilemma puzzling to me? Two reasons:
First, I don’t see how a person with a professional degree (MSW) could even conjure up the question. How could a professional even consider the option of not having a license/certification? Comparatively speaking, faculty in other professional degree granting programs don’t consider the option of failing to be licensed. We rarely see law school professors who are not members of the bar. I have met one and asked him why he was no longer a member of the bar. He replied by saying, ¨I actually am, I tell people I’m not so I won’t be asked for legal advice and representation.¨ Most law professors are members of the bar and would not consider an alternative. Find me a law professor who is not a member of the bar. I’d like to meet one. In my travels, I have met one physician/professor who had no interest in having a medical license. To restate his commentary in the most tactful manner possible, he didn’t like people -- particularly sick people. His professorship in the medical school was limited to grant acquisition focusing on experimental designs. Occasionally, he taught research/statistics. After speaking to this physician, I think he made the right decision by not practicing medicine. However, he was certainly competent as a principle investigator and grant writer. His eyes lit up when he was number crunching and saddened when he faced patients.
Second, back in the 70´s when I received my appointment to teach social work at a university, I was struck by the prologue in Herbert Strean´s Clinical Social Work. Here he notes that many senior social work professors haven’t practice social work in 20 years. The concepts many professors address in class are far from the cutting edge. I actually noticed this phenomenon while an MSW student. At that point, I made a commitment to continue to practice social work and never let myself be accused of being behind the times or not being well-read. It appears as if the situation hasn’t changed. Last spring, an MSW student told me that she had more years of practice experience than two of her professors with Ph.D.s in social work. Being current is an ethical obligation for social work professors. How can one be current without practicing?
To restate the obvious, the NASW Code of Ethics includes standard 4.01 a and b. Here it is written:
4.01 Competence
Social workers should accept responsibility or employment only on the basis of existing competence or the intention to acquire the necessary competence. Social workers should strive to become and remain proficient in professional practice and the performance of professional functions. Social workers should critically examine and keep current with emerging knowledge relevant to social work. Social workers should routinely review the professional literature and participate in continuing education relevant to social work practice and social work ethics.
Sounds simple? But how does one really know when one is competent? Actually, the answer is found in a question: What do faculty in other professional programs do in order to demonstrate competence? Answer: Complete the appropriate state exams! Doing otherwise doesn’t seem ethical. The bottom line is, the best way for a faculty member to demonstrate competencies by having the state license or certification and maintaining it by complying with the continuing education requirements. Frankly, I think all social work faculty have an ethical obligation to be state licensed or certified. Doing otherwise is an embarrassment to the entire profession.
Stephen M. Marson, Ph.D.
Senior Editor
One of the most puzzling debates I have heard in my adult life is, ¨Should social workers who are faculty be required to be state licensed/certified in their jurisdictions?” Why is this perceived dilemma puzzling to me? Two reasons:
First, I don’t see how a person with a professional degree (MSW) could even conjure up the question. How could a professional even consider the option of not having a license/certification? Comparatively speaking, faculty in other professional degree granting programs don’t consider the option of failing to be licensed. We rarely see law school professors who are not members of the bar. I have met one and asked him why he was no longer a member of the bar. He replied by saying, ¨I actually am, I tell people I’m not so I won’t be asked for legal advice and representation.¨ Most law professors are members of the bar and would not consider an alternative. Find me a law professor who is not a member of the bar. I’d like to meet one. In my travels, I have met one physician/professor who had no interest in having a medical license. To restate his commentary in the most tactful manner possible, he didn’t like people -- particularly sick people. His professorship in the medical school was limited to grant acquisition focusing on experimental designs. Occasionally, he taught research/statistics. After speaking to this physician, I think he made the right decision by not practicing medicine. However, he was certainly competent as a principle investigator and grant writer. His eyes lit up when he was number crunching and saddened when he faced patients.
Second, back in the 70´s when I received my appointment to teach social work at a university, I was struck by the prologue in Herbert Strean´s Clinical Social Work. Here he notes that many senior social work professors haven’t practice social work in 20 years. The concepts many professors address in class are far from the cutting edge. I actually noticed this phenomenon while an MSW student. At that point, I made a commitment to continue to practice social work and never let myself be accused of being behind the times or not being well-read. It appears as if the situation hasn’t changed. Last spring, an MSW student told me that she had more years of practice experience than two of her professors with Ph.D.s in social work. Being current is an ethical obligation for social work professors. How can one be current without practicing?
To restate the obvious, the NASW Code of Ethics includes standard 4.01 a and b. Here it is written:
4.01 Competence
Social workers should accept responsibility or employment only on the basis of existing competence or the intention to acquire the necessary competence. Social workers should strive to become and remain proficient in professional practice and the performance of professional functions. Social workers should critically examine and keep current with emerging knowledge relevant to social work. Social workers should routinely review the professional literature and participate in continuing education relevant to social work practice and social work ethics.
Sounds simple? But how does one really know when one is competent? Actually, the answer is found in a question: What do faculty in other professional programs do in order to demonstrate competence? Answer: Complete the appropriate state exams! Doing otherwise doesn’t seem ethical. The bottom line is, the best way for a faculty member to demonstrate competencies by having the state license or certification and maintaining it by complying with the continuing education requirements. Frankly, I think all social work faculty have an ethical obligation to be state licensed or certified. Doing otherwise is an embarrassment to the entire profession.
Stephen M. Marson, Ph.D.
Senior Editor
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