Prikaz objav z oznako total institution. Pokaži vse objave
Prikaz objav z oznako total institution. Pokaži vse objave

petek, 10. april 2020

Operation D Intensities of intervention (operations 13, relationship 3)


The goals, projects and plans are invitation of user to enter into his or her life. And should be taken as invitations are – politely and respectfully. However, this invitation may be issued for varying degrees of entering the Life-World, or to put it clearly – various degrees of social work intervention in one’s Life-World. The relationship can start and stop at level of just representing the Life-Worlds in a talking encounter, which is usually termed counselling. In this case, a social worker does not enter the realities of the user.

Next degree is to enter into world actually lived by user by providing support to user in specific activities (by informing, encouraging, assisting the activity materially and morally but in the real contexts of one’s Life-World, like it happens in what is called personal assistance or could be termed “support-work”. When this is a case, the “supporter” enters the Life-World of the user and for the moment of support becomes a part of it.

In the operation of “help” the “helper” acts from the position outside the Life-World and brings into the field force not only originating but being also anchored in the domain outside the user’s Life-World. This duplicity of the positions creates a power relationship, in which the “helper” does not only contribute to the activities of the “helped” but is “by doing things for or instead” of the “helped”, adding actions of his own and from his own position. In this action, a middle ground between the ordinary Life-World and the institutional world is being generated, in which the user is still embedded in his or her Life-World but is drawn into relationships where he or she loses a degree of the sovereignty characteristic of Life-World. This intensity of help is usually referred to as “casework”.

“Help” and “support” are essentially synonyms. Here we use the two terms to denote a difference that in everyday parlance is negligible. “Support” denotes an activity that upholds the activity of an actor by adding a force to it without altering the direction or intention of the activity. In this context, we define “help” as a force in the field that operates as a vector, thus contributing to the activity of the actor but introducing an extra dimension to it and thus, however slightly, changing its direction and adding to its intention. In the terms of mechanics, support is a “scalar” and help is a “vector”.

When things get more complex, and especially if more input of the institutional resources is needed, there is more organisation and coordination involved – there are more “helpers” and “supporters” needed, the intensity of intervention increases and reaches a new quality. This comprehensive taking care is often referred to as “care management” and brings the social work action onto a level of organising. It happens still mostly in the intermediate space between the Life-World and the institutional world, but it is tangential to the latter by virtue of spanning the whole arch of activities from the actors’ finalities of Life-World across the various degrees of intensity of the help.

The most intense social work intervention[1] into the Life-World is taking somebody from his or her environment and relocating it to some, usually readymade institutional space. This is usually called “institutional care” or in a post-institutional setting “residential care”. Here, the person is up-rooted from his or her Life-World and transferred to a simulacrum of it.

This progression of intensities of interventions can be seen as a series of non-corporeal transformations of space as well as relationships situated in it, and of respective professional and user roles. The space transforms from an ideatory space of Life-World representations, “theoretical context” in Freirean terms, created in an interpersonal encounter, into blending of the social worker with the user’s Life-World, bridging the institutional space with the personal, to making “a dome” of care to the artificial institutional space. The work relationships thus formed range from a free exchange of ideas that bear no immediate consequence in the Life-World with a usual goal of reflecting the Life-World, getting an insight and creating a new orientation to a relationship where the provider of care takes a person in charge and is basically, even if not legally a guardian relationship. In between, there are relationships of companionship in action in one’s Life-World, power relationship resulting in and out of help and a relationship of care brokerage between the Life-World and institutional realm.

Action
Level
Term
space
relationship
remedial action
Talking
Representation
Counselling
ideatory
reflective
reflexive thought + mutuality, symmetry of exchange
Supporting
Deeds (action)
Personal assistance
(Support-work)
Life-World
companionship in action
user perspective
Helping
Power
Casework
Life-World – institutional space bridge

empowerment
Caring
Organisation
Care management
institutional “dome” over the Life-World
broker
self-management, re-appropriation of institutional resources
Placing
Shift in space
Residential care
institutional
guardian
temporary and personalisation of the space

In the progression of the intensity of intervention, we can observe two very strong tendencies. One is related to the power drop caused by power differential introduced by the professional and the very idea and process of help. The other, concurrent with losing power is one of losing ground, being uprooted from the Life-World. This de-territorialisation can have a productive result in increasing the capacity of improving one’s life – by expanding the view of reflection, by expanding manoeuvre space, gaining autonomy of everyday Life-World and by providing access to the goods of the institutional space. However, it may lead to progressive exclusion from meaningful relations, estrangement from one’s home and community. This upscaling of help stages a series of metamorphoses – non-corporeal mutations, that cease to be not merely situational (as they are usually in everyday life) and lead to progressive objectification into an institutional object. The path to hell is paved by good intentions.

The intentions, in social work, are good indeed. Even the results need not to be catastrophic, but quite benign. However, this is not enough to undo the underlying processes of losing power and ground. Good news is that social work has an arsenal of antidotes to these “iatrogenic” harms. Just as in everyday interaction there has to be a remedial action to each hazard of losing ground and power capacity.

One is the conscience of Life-World being the point of departure and return. Not only because it is a criteria of social work intervention, as described above, but also because of the basic finalism of support, in which the intervention takes place. We need to keep in mind that we are dealing with activity, which is by definition purposeful that has its goal (by default specific, in general, to improve one’s life conditions) and this is the point of common action. Therefore, acquiring and consistently applying the “user’s perspective” is the main way of fending of the negative corollaries of social work intervention.

There are diverse types of remedial action regarding the hazard of each degree of intensity. Even at the least intruding action of representation, since it takes off from the Life-World, is an act of de-territorialisation, there is a danger of skewing the vision by importing the ideas via representation into person’s living world (Freire – invasion). Dialogic precautions have to be made in order to eschew them by critical and reflexive stance, as well as with mutuality and symmetry of the exchange.

Empowerment is a general antidote to losing power immanent to different degrees in social work intervention. If helping diminishes the power of the help, the power must be “measured” at the completion of intervention to assure that “the patient is not dead after successful operation” and to design the remedial action to restore power beyond the side effects of helping.

In coordinated care, it is important to observe all the hazards being uprooted and not in control of one’s life that come up on the levels of lesser intensity and integrate them in specific of this intensity. Special concern must be made about symmetry, critical thought, user’s perspective and empowerment at all stages of planning and coordinating care. However, specific to this intensity is the imperative of “self-management”, being in charge of one’s care and the influx of the means from institutional resources should not be treated as a state charity but as an of re-appropriation of the public good.

Displacement should be omitted at all cost (and erased as a panergic and paramount response to distress). When necessary, as in family violence, or need for safe haven etc. it must be as short as possible temporary solution, preserving the connections to one’s usual Life-World, with intense work on lower intensities of intervention to enable the return to it. In the case when the return is not possible a maximum of personalisation of the new place (i.e. creating a new home) should be enabled, as it is the case when people move their home from one environment to the other in the ordinary life.

This five-gear shift of intensities in social work, inter alia, demonstrates the ability and necessity of social work to traverse and connect the Life-World (concrete) and institutional (abstract) planes. In doing so, it creates crevices into what would otherwise be solid construction with no interim space between the two. The “Life-World” of social work is in these cracks of the social construction. The critical moments of transitions induce the necessity of social work.



[1] Of all the other social work interventions removal of legal capacity matches this intensity. As it happens these two interventions – displacement and disqualification – often take place simultaneously, as a part of the same combined operation. However, in principle they are two distinctive doings. In one, the subject of the operation can remain in his place, but is “deterritorialised” by inability to inscribe into meaningful dealings, in the other deterritorialisation is by necessity a physical one.

sreda, 18. april 2018

Dichotomies in beliefs on residents' resettlement (an analysis of Macedonian centres for social work response)



Beliefs about residents’ resettlement significantly shape the action of the providers and other stakeholders in the resettlement. They provide motivation (or lack of it) for change and simultaneously inform decisions on how resettlement will take place (or will not).

The centres for social work were asked, in an impromptu survey conducted in the summer of 2017 by MoLSP, for their opinion on ability for their residents in Demir Kapija to live outside the institution and for suggestions about what kind of care they would need. A third of the response was positive – that there are possibilities for extra-institutional care; a third was negative and a third did not answer. The response was made hastily and was not based on the characteristics of residents; it was arbitrary and indicates the attitude of a particular centre or worker of the centre who was answering rather than real possibilities for either support or capabilities of a resident to live outside of the institution. The main determinant of the response was therefore, the orientation of the centres.

Some did not answer, some were answering negatively. Most frequently, the negative statements were general: [the resident] “needs to stay in the institutions, there are no conditions for integration”. Some were oriented on potential of the residents and some on lack of services in the community (a peculiar answer, but very indicative was: “the resident is considered to be well adapted to the institution and there is no need to resettle”). 

A certain group of the centres (or practitioners) answered predominantly positively that there is a way to resettle. Mostly they suggested group homes (24 out of 60 suggestions) and ‘organised living with support’ (26/60) of which considerable number (10/60) of responses was that they would need 24 hours health care. The rest (9/60) were suggesting foster care placement and one was just generally considered able to be resettled. In regard to foster care two centres (for 7/9 cases) had written that there was no potential to live in a group home and the centre had applied for foster care. If ‘potential’ is meant for the residents, these two centres consider foster care as more potent way of caring.[1]

This response does not indicate the intensity of need of the resident nor the need or availability of support outside the institutions but the orientation of centres for social work. There is a clear division of the centres for social work that are pro deinstitutionalisation and those who are against it (i.e. do not see a possibility of resettlement).[2] This division is marked also geographically. It seems that Skopje and southern centres for social work see more possibilities for resettlement, and in northern areas, regardless the West and East, do not see these possibilities, while the centres for social work in central part of the country are undecided and silent. The intra-regional variations between individual centres for social work are very similar to the results of the analysis of geographical distribution of residents with the same centres for social work that stand out of the picture in their attitude. This division, in a way, reflects the division between the declarative orientation on deinstitutionalisation and actual reservation that are present both in politics and in the culture. Some centres for social work express their willingness to participate in the process while some share the doubt that this is possible.

In the response of centres for social work, we can discern the usual professional (and lay) beliefs about resettlements. Some support them and some obstruct. In the table on the next page, we elaborate such beliefs in more detail. Most of the beliefs that obstruct resettlement accede to deinstitutionalisation and resettlements in principle, but pose reservation about its scope. Mainly they express reservations on the ability of people to live outside, are dismissive of residents’ rights to live outside and point to a relative but permanent necessity of institutions. Like all myths, they contain a piece of truth to arrive to false conclusions. On the other hand, we have the beliefs that promote resettlements. This may be seen as utopian, far beyond existing reality. Yet, this utopia, as has been demonstrated many times is doable, it is what Basaglia (1981, 1987) termed ‘practical utopia’. These views are ethically consistent and support affirmative action, while the former prevent action, change, improvement and are ethically highly questionable.

Table 9: Beliefs that obstruct and promote resettlement
Topic
Beliefs that obstruct resettlements
Comment
Beliefs that promote resettlement
caring nature of institutions
Residents are taken care of and they would not be taken care of in the community
This belief implies that there are some aspects of care that can be performed in the institution, which for care institutions is not the case.
There is nothing that is provided in an institution that cannot be provided in community settings.
‘special needs’
Institutions’ residents have special needs that can be taken care of only in special places.
Wrong. In fact, their needs are neglected due to institutionalisation and disablist ideologies.
People with disabilities or in distress have the same needs as anyone; they need special attention and additional support in satisfying them. Needs can be taken care of in the community settings in the best way.
necessity of institution
“Some people will always need institutional care”.
This belief accedes to the imperative of DI but relativises its scope. It is true that some people need more support.
all people have the right to live in the community regardless the intensity of disability. Some people need, however intensive support to do so.
skimming
More able residents have priority in resettlement, less able are bound to stay in institutions.
This is a ‘natural’ observation, seemingly self-evident. It is false, however, on ethical and practical count. It is discriminative and causes arrest of the DI process.
Residents who have intense support needs have to have special attention and be in the second to the first echelon of the resettlements.
independent living
People with disabilities cannot live independently.
This observation is based on misconception that ‘independent living’ means either living alone or being able to take care of daily living activities by oneself.
Living independently is available to anybody if provided necessary support to make decisions and enact them. Right of choice and to make decision are the basic human faculty that has to be enabled to everybody.
need for preparation
In order to live in the community residents have to undergo thorough preparation to learn the skills of living in the community.[3]
It is true that preparation is needed. However, it should not take too long and should not be directed primarily to the residents’ abilities, but similarly to ordinary life focused on the new arrangements.
Resident should be included and involved in the preparations of their new abode from the very start. They should be main creators of the new environment. Reluctant residents should be encouraged by the visits and outings.
Intermediary structures.
Group homes are seen as deinstitutionalisation, the main if not the sole means of resettlement.
It is true that GH are an efficient way of resettling residents for institutions, however, it is not the final destination and should be considered as transitory solution and temporary abode.
For real inclusion and independent living another ‘technology’ is needed that is more personalised and that allows care provision where somebody lives – i.e. at his or her home (personal planning, assistance, home help etc.).
right and DUTIES ideology
Residents (or people with disabilities in general) have to have their rights acknowledged, but they must also acknowledge their duties.
This self-evident truth is uttered with intention to diminish the importance of rights, of which the residents were deprived.
Unconditional conception of the right to live in the community and will to enact all the human rights derogated by the institution. Reading of people’s desires and wants as the expression of rights.
‘medical’ model
People are in the institutions because of their defects that need to be treated.
It is true that some residents have a medical condition, but the main reasons why they are in an institution are that they deviate from the norm and because there is not enough support available outside.
The deficit in experienced distress is social and not personal. We need to create possibilities for people to live with people and the community; society has to learn how to live with these extraordinary people and not the other way around.




Claimer: This blog is intended as a part of Situation Analysis and Assessment/ Evaluation Report of Implementation of National Strategy on Deinstitutionalisation 2008–2018, which will be soon presented to the public within the EU framework project Technical assistance support for the deinstitutionalization process in social sector. For this blog, Vlado Krstovski is considered to be co-author.


[1] Generally speaking, it is usually considered quite the opposite – that group homes have more potential for more intensive care. Nevertheless, in principle it is not the matter of the form of care used but how intense we make any form. Both foster families and group homes can be of low or high intensity – in group homes apart from special equipment it is a question on number and skills of the staff, in foster families it is a question of training and expertise of the fosterers (specialised) and of the amount of external support to the family.
[2] It is difficult to speculate what absence of response indicates. Does it indicate that these centres for social work do not know what is possible, or they do not dare to say – they relegate the responsibility to the MoLSP who asked the question – or they are not decided whether moving residents out is a good idea.
[3] One of the recommendations of the Ombudsman is to continue the process of deinstitutionalization by including mandatory preparatory phase period for the users. This recommendation is coming after ‘one user in the process of deinstitutionalization was transferred to a community care centre, and he could not adjust to the new conditions and was returned into the special institutions’.