This paradigmatic change is about
not only how we understand and explain the disability but also how we act, how support
is provided and organised. Because the distinction between ‘medical’ and ‘social’
models is to a great degree summative, it has become a powerful and mobilising idea
but on other hand blurring important distinctions between the explanation and
action. Models can be understood as modelling understanding and explaining
disability but also as modelling approaches to it (i.e. ‘treatment’), and how
the care and support is organised. To be more accurate there is a need to
distinguish between the explanatory, treatment and organisation models.
Explanatory models can be divided into reductive explanations reducing human complexity to
one dimension (illness, legal norm, psyche etc.) and transversal explanations
enabling syntheses of various planes of functioning and existence. Transversalitiy
is imminent, ‘natural’ to everyday reasoning and ordinary (pre—or non-scientific)
knowledge, but also to comprehensive sciences like anthropology, social work,
management sciences.[1]
As platforms of action the reductive explanations foster separation,
competition and dominance of a particular explanation in a particular academic,
professional, or sectorial (health, justice) milieus or even in society at
large. The transversal synthetic explanations encourage interdisciplinary
cooperation, pluralism of ideas and approaches, their complementarity based on ethical
consistency, thus positioning humanism as a leading idea.
Treatment[2]
models, we can divide
into corrective and enabling approaches. Corrective
approaches are based on the supremacy of the professionals, which draw their
mandate to act upon a person on the supposed deficit, inadequacy or failure of
the person, for which there is a special competency (or more truly a social
authorisation) to deal with by special means – medication, psychotherapy or other
psycho-pedagogical intervention, or administrative measures. These approaches
are imminently disempowering and disabling.
Their opposite are enabling approaches,
in principle they are based on the general human rights and seek many ways to
empower people in need. This can be done only through non-conditional inclusion
and by sponsoring and supporting people in a variety of everyday life activities
(thus enabling people to take risks instead of avoiding them).
Two dominant organisation models in care provision can be distinguished. One is
institutional based on segregation, innate hierarchy (staff – residents, but
also within the staff and residents groups), collective living and provision
and providing ‘care’ in totality – one authority providing and regimenting everything
that a person needs.[3]
Community model, as an alternative to
the institutional, is not only community-based but is oriented to community
participation, thus creating new connections not only from services users to
community member, but also in the community itself. The relationships in
community provision tend to be egalitarian and while inclusive, person centred.
On the whole, the ‘medical’ model is
reductive in explanation, reducing
the disability to one dimension; it is corrective
in its approach to the people – adapting them to the society; and it is institutional in the way it organises
the services. Social model on other
hand is transversal in explanations taking into account diverse plateaux of
human existence, enabling in its approach to the people in need and community
based in organisation of the service provision. The distinctions into
explanatory, treatment and organisation models are important (apart from
fending off sloganizing the issue of models) to note the diverse planes of modelling
and, on the other hand to make distinctions between certain ways of
sub-modelling and existence of mixed models.
For example, community psychiatry
still to great extent adheres to medical explanation of the mental distress,
however, it is abandoning hospital as it organisational base and is by
necessity using a mixed approach (medication and inclusion). On the other hand,
a psychotherapist may not have a narrow medical explanation, but the
explanation may be as reductive as the medical one and his or her approach will
be corrective, but he or she will not be practising in an institution, however,
the practice could be supporting, be complementary to institutions. Conversely,
there can exist a transversal understanding of human need or misery, but if
there is a lack of skill in approach or organisational framework that would
allow the transversal syntheses to become active, a knowledge remains impotent.
Or, services can be translocated into
the community – but if the approach and understanding remain solely correcting
and reductive, the community provision will be inadequate, in fact more alike
to institutional care than what is considered a truly community-based service.
The paradigm shift entails two
similar, complementary and yet opposite processes. First, there is a transition
period characterised by a ‘mixed regime’ of various models. Second, the new
paradigm needs to subsume and incorporate the old paradigm into the new one. There
is a space for medical, juridical or other reductive knowledge in social model,
corrective devices and intervention such as medication, psychotherapy etc. can
be used to empower people, yield inclusion or support people in their
activities; collective provision such as camps, work-cooperatives etc. can be a
potent part of community services, if limited in time and scope.
These transitory phenomena are very conspicuous
in Macedonian present-day practice. The ‘social model’ was introduced and is
known. However, in practice ‘medical’ model still prevails (not only in health
care). An obvious reason for such state of the art is that a lack of
opportunity to practice new models since the services, which provide a space to
practice them, are not developed as is the case with skills and approaches.
However, also on the level of knowledge in terms of explanation and understanding
there are inconsistencies not only in medicine and nursing, but also in special
education (defectology!) and even social work. E.g., there is still strong
adherence to the diagnostics and diagnostic labels. This in itself would not be
a problem if it would not cement the disabling beliefs and prevent affirmative,
enabling action. For example, during the student camp there were students and
professionals who deemed efforts to enable residents to participate in the
activities like assemblies as futile by saying: “Can’t you see – they are severely
disabled!” One would be tempted to postulate that there should be conceptual purity
in order to implement changes on the practical level. Even if this may be true
on the strategical level, it does not seem to be spot-on on the practical
level. There the logic might be inverse that we need to get rid of
institutional spaces and organisational models in order to practice and understand
in the new – enabling and transversal ways.
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.
References:
Flaker, V.
(2006) 'Social work as a science of doing: in the praise of a minor profession'
in Von der Idee zur Forschungsarbeit: Forschen in Sozialarbeit und
Sozialwissenschaft, V. Flaker & T. Schmid, T. eds Böhlau Verlag, Wien.
Oliver, M. (1990). The
Politics of Disablement. London: Macmillan.
[1] A significant difference between anthropology and social work in
their respective transversalities is that anthropology is an explanatory
science, while social work is a science of doing (Flaker, 2006) and is transversal
not only in knowing but also in acting – on various registers of social
intervention.
[2] Treatment should be understood in this context wider than its
narrow meaning – as an approach to people in need and not treating 'somebody'
or 'something' – this is the characteristic of the corrective approach.
