Is Self-Determination Still Important? What Experienced Mental Health Social Workers Are Saying

Is Self-Determination Still Important? What Experienced Mental Health Social Workers Are Saying



Melissa Floyd Taylor, Ph.D., LCSW

University of North Carolina, Greensboro



Journal of Social Work Values and Ethics, Volume 3, Number 1 (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: self-determination, mental health practice, ethical dilemmas













Abstract



This study investigated the attitudes of 320 seasoned mental health social workers toward the social work value of self-determination. Social workers were asked to rate the importance of self-determination in their daily practice, both as a guiding value and in actual practice and were asked to describe, in relation to their practice history, any changes they had experienced in the importance of the value. The majority of participants responded that they thought more about self-determination now than in the past. Surprisingly, they also reported being relatively untroubled when practice situations conflicted with the value of self-determination, such as when a client was in need of involuntary treatment interventions. Participants provided rich information about why they believed changes had occurred in the way they thought of self-determination and how they implemented self-determination in practice with mental health clients.





1. Background



Self-determination (defined here as the condition in which a person’s behavior comes from his or her own wishes, desires and decisions) has been an influential, if sometimes controversial concept in social work practice since the profession’s beginnings. Similarly, since the beginnings of the country, Americans have struggled with the emphasis and protection that individual liberties could and should have while simultaneously maximizing the general welfare. Self-determination as a concept is similar to the ideas of liberty and the pursuit of happiness that appear in the Declaration of Independence, one of the first American documents. This early emergence of self-determination is consistent with Freedberg’s (1989) assertion that the roots of the concept reach back to the Enlightenment. As perennial as the ideas of self-determination, freedom and liberty are themselves, so is the competition and tension surrounding them in a society that equally values social welfare, general safety, protection and maintenance of the community. In other words, the struggle to work out an acceptable balance between the sometimes mutually exclusive goals of personal liberty and societal well-being is a source of dissonance for our legal system and, indeed, society at large. This struggle is especially important when considering the impact of postmodernist trends in thinking about and reexamining ethics (Hugman, 2003).



This same struggle is played out in the mental health service delivery system between the rights of individual consumers to refuse or accept treatment and the rights of communities to feel safe physically, psychologically and aesthetically. The task of negotiating about this larger struggle falls to mental health practitioners, in our often multiple (and sometimes mutually exclusive) roles as consumer advocate, family advocate, risk manager, agency employee, and community citizen. The current research tapped the experiences of seasoned mental health social workers to explore self-determination’s place in their current practice and their own practice wisdom in dealing with self-determination’s more troubling manifestations. The research is important because the way social workers think and feel about self-determination is an essential component of what they do or do not do when operationalizing the concept. Additionally, social work practice can be complex and values that are intended to guide practice can also serve as important touchstones for professional exploration. The consequences of living and practicing in conflict with one’s values can result in burn out and professional dissonance, which have implications for both the practitioner’s and the client’s quality of life (Taylor & Bentley, 2005).



1.1 Self-Determination Defined



The NASW Code of Ethics (1999) calls self-determination an “ethical responsibility to clients” and groups it with other client areas such as, informed consent, competence, cultural competence and social diversity, conflicts of interest and privacy and confidentiality. The core value that self-determination is generally placed under in the Code of Ethics is “dignity and worth of the person.” Self-determination has received mention in each Code of Ethics in social work’s history and most recently is given the following attention:

Social workers respect and promote the right of clients’ self-determination and assist clients in their efforts to identify and clarify their goals. Social workers may limit client’s right to self-determination when, in the social worker’s professional judgment, client’s actions or potential actions pose a serious, foreseeable, and imminent risk to themselves and others (NASW, 1999).



The current research builds upon McDermott’s definition of self-determination as “that condition in which an agent’s behavior emanates from his [sic] own wishes, choices and decisions” (McDermott, 1975, p. 3).



Social workers throughout the history of the profession have offered varying definitions of self-determination, as well as lengthy and differing opinions about its usefulness as a guiding value in social work practice. The debate about self-determination tends to center on whether or not the concept should be more “practitioner-driven” such as when a social worker makes therapeutic calls about what is good for a client (see Perlman, 1975); or more “client-driven,” with a focus on client choice, when the client makes their own decision about what is best despite the risk of failure (see McDermott, 1975). It can be argued that this client-driven understanding of self-determination is compatible with social work’s current emphasis on collaborative styles of practice like empowerment practice, and the strengths perspective.



The work of Frederic Reamer in the area of values and ethics has greatly contributed to the understanding of the topic in social work literature. Reamer’s (1979, 1980, 1982ab, 1983, 1985, 1986, 1987ab, 1992, 1995ab, 1996, 1997, 1998abc, 2000) work is important as he has addressed issues such as the client’s right to competent and ethical treatment, ethics under managed care, ethical consultation ethics committees and ethics audits for social work, dealing with the impaired social worker, informed consent and other diverse topics such as bioethics in social work and the use of modern technology. Reamer’s work, to carve out the issues of professional social work values and ethics as a legitimate area of dialog and discussion, sets the stage for the actual, hands-on study of how values and ethics are used to guide real-life social work intervention.



Marcia Abramson (1981, 1984, 1985, 1989, 1991, 1996a, 1996b) is another strong contributor to the literature on ethics and values, in particular, her work about paternalism and autonomy. She has also written about the use of influence by social workers—a topic that is directly relevant to the current subject matter. Abramson’s work speaks to the day-to-day realities of social work practice when decisions are difficult to make and live comfortably with. Abramson focuses her examination of ethics to specific areas of social work practice such as the use of influence in adult protective services (1991), and ethical dilemmas inherent in hospital discharge planning (1981). Abramson calls the use of influence a largely understated area in social work practice.



1.2 Beneficence and Paternalism.



Congress (1999) makes the point that values make more sense when studied in pairs instead of in isolation. Accordingly, when studying self-determination, it is useful to refer to the competing value position of beneficence or paternalism, which tends to parallel Perlman’s (1975) earlier understanding of a more practitioner-driven model of self-determination. Abramson (1989) defines paternalism as “a form of beneficence in which the helping person’s concepts of benefits and harms differ from those of the client, and the helper’s concepts prevail” (p. 389). Murdach (1996) has more recently offered the concept of beneficence as an appropriate value stance for social workers. She defines it as acting for the good of a consumer when they cannot or will not act for themselves. She asserts that social workers have been too quick to reject beneficence and its related concept of paternalism and have perhaps been inappropriately preoccupied with self-determination.



While some social work and allied authors have pointed out the problematic presence of paternalism in mental health practice (Bentley, 1993; Chamberlin, 1998; Wilk, 1994), others have defended the use of paternalism when consumers cannot or will not act in their own best interest (Murdach, 1996; Rosenson, 1993). All of this debate about paternalism and beneficence versus self-determination has caused some social work authors to call into question the utility of the concept for social work at all (Rothman, 1989 ; Rothman, Smith, Nakashima, Paterson, & Mustin, 1996).



After exploring the literature about issues of self-determination, it becomes clear that there are many diverse understandings of the topic but not that much in the way of empirical evaluation of what social workers really make of it. In short, much of what we know of self-determination comes from theoretical discussion of the topic and from its presence in the value base and conversation of social workers. This leads to the question: How real is the value of self-determination in the practice lives of seasoned social workers?



2. Methodology



Self-determination was one area of inquiry in a larger study in 2002 designed to investigate issues of professional dissonance, or the collision of values and job tasks in social work practice.



2.1 Sample



A systematic random sampling technique was used to recruit 750 participants who were listed in the Register of Clinical Social Workers, 11th Edition (NASW, 2001). The National Association of Social Workers (NASW), the professional organization that publishes the Register, is the largest professional social work organization with 155,000 members (Gibelman & Schervish, 1997). Social workers listed in the Register tend to have been working a long time, often as social workers in private practice. A conscious decision was made to sample these social workers since they have had more of an opportunity to explore their views on self-determination over time. Of the 6290 names listed in the 2001 Register, 33 international names were subtracted leaving a total of 6257 eligible names. The systematic random sampling technique first included narrowing the national pool to include only those who had a self-described mental health modality. From this pool, 1450 social workers listed described a major modality as mental health or mental disorders. Every other eligible name was selected until the end of the Register was reached, then every third name was selected in order to yield 750 names. A total of 320 usable surveys were returned which related to a response rate of 44.4%.



2.2 Instrumentation



An instrument was created for the purposes of this study. Copies of the instrument can be obtained from the author. The instrument, designed for the professional dissonance study, assessed social workers’ endorsement of the existence of professional dissonance by surveying them about their feelings and experiences of involuntary treatment and self-determination over their careers (See Taylor & Bentley, 2005). The instrument was pilot-tested with an interdisciplinary group of mental health professionals working in the psychiatric pavilion of a large medical center. The four professionals were asked to answer the items and identify any that were unclear or problematic, thereby helping to ensure face validity. A panel of seasoned social work researchers also reviewed the instrument prior to data collection.



Only the results of the self-determination portion of the instrument are described here. Respondents were provided with the following definition of self-determination: “Self-determination refers to the condition in which a person’s behavior comes from his or her own wishes, choices and decisions.” Three Likert-type questions prompted respondents to give information about how “important” and how “useful” they believed the ethical principle of self- determination to be in their daily social work practice. They were also asked to describe “how troubled” they feel when a situation such as providing involuntary treatment conflicts with self-determination. A fourth question asked if they thought of self-determination “more, less or the same” as they did when first practicing social work. A final open-ended question prompted respondents to “describe in a few words” what had changed in their attitudes about self-determination, if a change had indeed occurred.



2.3 Data analysis



Data from the Likert-type items was coded and analyzed using the SPSS-10 statistical package. Data from the open-ended questions were typed verbatim into corresponding individual data files, separated by question number and labeled with their respective participant identification numbers. The researcher printed one copy. An open-coding technique was utilized in order to identify patterns in the responses (Strauss & Corbin, 1998). From these patterns, categories and subcategories were identified to group the responses through the use of key words and similar themes (Colorado State University, 2002). Responses were then placed into the appropriate category based on key words and themes and counted.



3. Important Findings



3.1 Demographics



Of the 320 social workers participating in the study, 62.8 % (n = 201) were female, 36.8% (n = 117) were male and 2 participants failed to indicate their gender. The majority of the participants (91.6%, n = 293) identified themselves as Caucasian or White. In addition, 2.2% (n = 7) identified themselves as African-American or Black, 1.6 % (n = 5) as Asian, 1.3% (n = 4) Latino/Latina and 1.9% (n = 6) identified as bi-ethnic. Five participants declined to identify their ethnicity. Participants brought many years of practice experience to this study with a mean number of years past their MSW of 25 (md =25). In addition to their lengthy practice experience, most of the participants appeared to have quite a bit of life experience as the average age reported was 56 (md = 56). Participants ranged in age from 30 years old to 80 years old and 12 (3.8%) respondents declined to reveal their age at all. While the use of the Clinical Register insured that participants had a long history in the field and a fairly mature chronological age, it may also have resulted in a less representational sample of social workers in the areas of race and gender.



3.2 Importance of Self-Determination



Results indicate that both the importance and utility of self-determination were heartily endorsed by the majority of participants. Self-determination was rated as “very important” by 226 (70.6%). In fact, 97.5% of all respondents rated self- determination as “important” or “very important” in their daily practice. Interestingly, for all of the endorsement of self-determination, participants did not indicate a high level of distress when practice situations “seem at odds with the principle of self-determination.” In fact, only 15 participants (5%) found this “very troubling,” with only 35 (10.9%) responding that this was “somewhat troubling.” One-hundred and twelve (35%) found these situations “troubling.” The rest of participants, (N = 145, 45.3%) endorsed this item with a 1, “not at all troubling,” or a 2 on the Likert scale.



While participants were not greatly “troubled” by practice situations that conflicted with self-determination, this did not mean that participants did not think about self-determination anymore. In fact, only 30 participants (9.4%) reported they thought about self-determination when making practice decisions “less now” than when new social workers. By contrast, 143 participants (44.7%) reported thinking about it “more,” while roughly the same number (N = 140, 43.8%) think about it “the same” as when they began practicing. In summary, the majority of participants endorsed self-determination as “important” or “very important,” reported conflicts in practice situations with self-determination as “troubling,” and indicated they either think about it “more now,” or the “same” as when they were new social workers. The open-ended self-determination questions allowed participants to provide detail to their responses on self-determination.



3.3 Open-ended Question: Self-Determination Over Time



Participants who had experienced a change in how much they thought of self-determination when making practice decisions were prompted to explain in a few words what they felt had caused the change. Responses were again typed verbatim by the researcher into a computer data file and examined for similarities. Responses were also coded as “more” “less” or “no change” depending on respondent answers to that question. Open-ended responses to the self-determination “change” question fell into four fairly distinct categories. Most frequently, experience, maturity and growth appeared to be the largest factor in change. Accordingly, this first category was named “Practice and Life Experience.” Examples of responses in this category included statements such as: “As my practice goes on I have dealt with more people in different situations and realize each of us is unique. I do as much as I can so people can make as many decisions as possible,” and “Experience has taught me that judgment can be fallible,” and, “less angst over conflict than when ‘new’ social worker.”



A second category emerged that contained responses describing how changes in jobs and clients served had caused a change in thinking about self-determination. For example: “Now the population is mostly adult there are fewer times of conflict” and “I am working with a more functional client population at present.” This second category was termed “Job/Client Change.” The third category again parallels the responses to involuntary treatment in that respondents reported they had changed by watching the realities of mental illness, especially mental illness that goes untreated and was termed “Reality of Mental Illness.” An example of responses in this category is:

Once a young boy had tried to kill himself. He was adamant he didn’t need hospitalization. I sent him to our locked ward anyway. Later he was released, his family grateful he was alive. Two years later he did commit suicide…I had whole family in grief counseling.

Other responses in this category include, “I have encountered situations when treatment is critical,” “people do not usually ‘self-determine’ themselves to become mentally ill” and, “I don’t believe they should languish in their illness.”



An interesting trend noted in a final category of responses was the tendency of the respondent to philosophize a bit about the state of self-determination in our profession today, or the best way to implement it in contemporary practice situations. These respondents, as indicated in the sample responses in Table 1, rarely used the first person as did the respondents in other categories: “Self determination [is] a must so long as a person can make informed decision and exercise judgment based on reality. With independence comes responsibility, including social responsibility,” “I may be more practical. I may not “band my head” as much,” “I make fewer excuses for my mistakes and others… If social work practice is not used to provide the best care for our patients we burn or never grow.” These answers were coded as “Practice Philosophy” (See Table 1)



Table 1

Sample Category Coding: Self-Determination Change

________________________________________________________________________

Category Response

________________________________________________________________________

Practice and Life Experience



My own personal maturation I am more mature as a therapist

Experience (30 years) Experience has made the difference

The older I get the more I realize how little impact treatment

modalities have compared to the client’s will to change.

Experience and practice have given me a better understanding

of the concept and more strategies to deal with it.



Job/Client Change

Previous practice setting…many clients were court-mandated

I am working with adults who are healthier

I am working with a more functional client population

Reality of Mental Illness

Clearer the harm people can inflict on self and others

Dynamics of illness itself

More experience with people who are unable to make

rational decisions

I see the horrific consequences that can result…

In my opinion, people do not usually “self-determine”

themselves to become mentally ill.

Practice Philosophy

I see the concept eroding before my eyes.

Self-determination relies on the availability of psychological emotional and medical support.

Energy flows where attention goes

Excuses to avoid change have clouded both change process and

adult/positive decisions



____________________________________________________________________









A total of 175 participants (54.6%) gave open-ended responses to this question, a number that roughly matches the 173 participants who responded they had experienced a change in self-determination over the years. Of these, the largest number of responses represented category one, “Practice and Life Experience” (N= 63, 36%). Category four, “Practice Philosophy” had 44 responses (25.14%), while category 2, “Job/Client Change” contained 26 (14.86%) and category 3, “Reality of Mental Illness” had 32 responses (18.29%).



4. Discussion and Recommendations for Future Inquiry



One of the main contributions of the current study is the subject matter. Previous research (Rothman, 1989) has called for increased empirical inquiry in the area of social work values and especially their operationalization in everyday practice. While there is a large body of excellent, empirical thought about self-determination (see Reamer, 1992 , 1983 , 1982a , 1982b , 1979 ), there is less actual study-based research on this topic. This study was especially important because it utilized the viewpoints of practitioners who had an average of 25 years of experience in the field. In this way, the importance of self-determination across a lifetime of practice was affirmed. Similarly, the richest data were evident in the open-ended responses of participants about how their ideas of self- determination had changed over time. Through the answers to these questions, we see how social workers have evolved in their practice and the practice wisdom evident in these responses speaks to the largely untapped resource of our own experience to guide one another’s practice, especially in difficult situations.



One limitation of the current study is the sampling frame. The Clinical Register, while enabling the researcher to capture seasoned social workers, may not include those social workers “in the trenches” in public mental health service delivery with reluctant consumers due to the high proportion of listees who are in private practice. A future study should focus on capturing this group in order to move the discussion of self-determination out of the realm of private practice where the majority of clients may be more motivated internally to pursue help.



Another possible limitation of the study deals with threats to instrument validity resulting from the issues of social desirability and self-serving bias. After all, as a group, social workers are heavily socialized to value self-determination. Saying that you think about self-determination a lot, and more now than in the past, even, is a decidedly “social work” response. Future inquiries into social workers’ attitudes towards self-determination should pay close attention to the potential for social desirability and self serving bias in self-reports. Direct ways of measuring social workers’ use of self-determination in practice would be a logical step for future inquiries.



In conclusion, self-determination is still considered very important by seasoned social workers, and is thought about even more--or at least the same-- today as when they were new social workers. While they report being relatively serene when practice situations conflict with self-determination, they have insight into the ways their views about it have changed over the years. Capturing the ways our cardinal values are incorporated into everyday social work practice is an important area for social work research as it has implications for educating future social workers, protecting sensitive practice with clients, and maintaining the practice longevity and vitality of those in the profession.







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