The psychic organization of community care
Level 3: Practice implications in social work
Changes in the operationalization of community care are having a massive impact on the very nature of social work practice. Most starkly for the practitioner, there is emerging a career choice to be made between resource management and therapeutic work. This too seems to be a false dichotomy, as once more it implies a separation between the ‘masculine’, informationcollating aspect and the ‘feminine’, caring aspect of the work.
The task of the care manager is to ensure that the individual’s needs are assessed and an appropriate package of care designed to fit those needs, the guiding principle being that the clients are at the centre of the service they receive. In a preface to a CCETSW document (Biggs and Weinstein, 1991) this perspective is seen as a ‘radical shift’ away from a service-led provision: ‘The new approach should ensure that users will only receive therapy as part of their care package…if they agree to it being provided’ (Biggs and Weinstein, 1991:5;
emphasis in original). Once more we can hear the importance that is being placed on listening to the client—the oldest of case-work principles, or—in the language of today—‘client empowerment’.
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However, Biggs (1991) has taken issue with such a simplistic view of client and worker together finding an agreeable solution to a mutually agreed definition of need’ (1991:73). He argues that the relationship cannot be assumed to be an equal one since the worker has access to resources that the client needs. The rationalist, checklist world assumes no conflict of interest between the two parties and therefore a package of care is there to be objectively and jointly arrived at. But such a perspective takes no account of assessment work as a process taking place in the context of a relationship that requires time to build up, has to deal with the differences of power, conflicts of interest, and has to take unconscious motivation into account.
We can see that a client may experience difficulties, for example, not wanting to discuss the loss of a particular function and therefore denying a need for a relevant home aid. But the worker also brings their own unconscious agenda.
Perhaps the one that will be most familiar to us all is the need to be ‘helpful’. In this situation, the client might be forced to accept help even to be case-worked—
when what the worker might have difficulty in confronting in themselves is their own sense of not being able to help, i.e. impotence or simply rejection by the client. This again highlights the importance of a properly conducted supervision.
Where the client is denying some kind of loss, we are confronted with a professional and even ethical dilemma which the recitation of the mantra of client empowerment does not address.
In their book Community Care and Empowerment, Parsloe and Stevenson (1993) make plain the ethical dilemmas that can arise between the client’s right to autonomy on the one hand and their need for protection on the other. They are reminding us that, however long overdue is the need to take seriously the voice of the client as fundamental to any process of assessment, the practitioner also has a moral responsibility to weigh up that which the client may refuse to consider—
denial of painful realities that could endanger the client, their family or any member of the public. The ‘reflective practitioner’ (Schon,1987) cannot avoid having to take responsibility for weighing up the ethical issues as part of the assessment process. Indeed, to do otherwise would constitute an abdication of the client’s (and the agency’s) right to a professional service based on the practitioner’s knowledge and expertise. In the language of Klein, depressive anxiety functioning requires that the worker live with their own doubt and yet sometimes carry out actions to which the client is opposed. Ultimately, this means having to deal with being wrong. In the area of a paranoid kind of relating, the ‘service user’ is idealized and a collusion is constructed that denies any difficulties in the worker-client relationship. Any problems can then be projected into known or unknown others, such as senior management.
Conclusion
If social work is to remain an activity that takes a holistic account of the client’s needs for practical assistance, as well as a process where the practitioner can
reflect on the underlying dynamics (in themselves and the user), this requires analysis, debate and action.
In what seemed a timely and considered report on the care and treatment of Christopher Clunis (a man with a schizophrenic illness well known to the mental health services who killed an innocent bystander in a public place), interesting conclusions were reached in the light of the issues discussed in this chapter (Ritchie, 1994). It makes clear that what is required for care in the community of the mentally ill is both a ‘considerable injection of funds’ to meet the deficiencies identified and better practice among professionals. It is hoped that the latter problem will be addressed through the development of community mental health teams (see Chapter 11).
There are choices to be made but they do not have to be made, in the sense that there is no prima-facie obligation to enhance care in the community.
However, in the context of this chapter, mature functioning requires that—
whether as policy-maker or practitioner—we take responsibility for our decisions or lack of them.
Note
1 A recent exception to this is Hughes and Pengelly (1997).
References
Biggs, S. (1991) ‘Community care, case management and the psychodynamic perspective’, J. Social Work Practice 5:71–81.
Biggs, S. and Weinstein, J. (1991) Assessment, Care Management and Inspection in Community Care, London: CCETSW.
Croft, S. and Beresford, P. (1993) ‘Practice: user involvement’, Community Care 11 March.
DHSS (1968) Report of the Committee on Local Authorities and Allied Personal Social Services, London, HMSO.
——(1982) Child Abuse: A Study of Inquiry Reports 1973–1981, London: HMSO.
DoH (1991) Care Management and Assessment: Summary of Practice Guidance, London: HMSO.
——(1993) The Chief Inspector’s Annual Report 1992–1993, London: HMSO.
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HMSO (1989) Caring for People, HMSO: London.
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——(1993) Health Committee Report on Community Care: The Way Forward, vol.1, London: HMSO.
Howe, D. (1992) ‘Child abuse and the bureaucratisation of social work’, Sociological Review 38:491–508.
Hughes, L. and Pengelly, P. (1997) Staff Supervision in a Turbulent Environment:
Managing Process and Task in Front-line Services, London: Jessica Kingsley.
Hugman, R. (1991) ‘Organisation and professionalism: the social work agenda in the 1990s’, British J. Social Work 21:199–216.
Klein, M. (1946) ‘Notes on some schizoid mechanisms’, in The Writings of Melanie Klein, vol. 3:1–24.
Menzies Lyth, I. (1988) ‘A psychoanalytic perspective on social institutions’, in E. Bott Spillius (ed.) Melanie Klein Today, Vol. 2: Mainly Practice, London: Routledge.
Parsloe, P. and Stevenson, O. (1993) Community Care and Empowerment, London:
Joseph Rowntree Foundation.
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Schon, D.A. (1987) Educating the Reflective Practitioner, San Francisco, CA: Jossey Bass.
Segal, H. (1964) Introduction to the Work of Melanie Klein, New York: Basic Books.
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