A Caring Practice
Throughout our On Caring Covid-19 vodcasts we have used the work of Andrew Sayer to think about what we’re calling a Critical Science of Social Work (CSSW).
In each episode, we use the CSSW framework to think about Covid-19: 1) identifying the problem; 2) identifying the cause or source of the problem, what Sayer calls the unwanted determinations; 3) passing a negative judgment about the problem (i.e., hurting children is wrong, domestic violence is wrong, racism is wrong, killing is wrong); and 4) intervening to remove the problem. Sayer, Andrew (1997). Critical realism and the limits to critical social science. Journal for Theory of Social Behavior, 27(4): 473-488.
A good starting point for a Caring Practice (CP) is to integrate the 4 elements of a CSSW into the everyday practice of social work (or any caring profession). And while a CSSW would not eliminate the gap between research/theory and practice (that’s impossible) if applied equally to both research and practice the gap would be minimized (see our recent post on what is theory and what is practice?). One needs to be cautious here: It is in the swampy ground between research and practice that we discover, create, experiment, and imagine new possibilities. Indeed, any attempt to completely close the gap may lead to dogmatism, scientism, authoritarianism or fundamentalisms of every variety. Or terrible naivete. At the same time, we should always strive to make our theory conform as closely as possible to practice, especially as we take into account the singularity of human experience. Also, there must always be a conversation between research and practice (i.e., engaged scholarship). When research is split off from worlds of practice terrible mistakes are made and sometimes lives are threatened (see David Healy’s many and important books on the pharmaceutical industry and psychotropic drugs). In July 1980, the Hyatt Regency Hotel in Kansas City, Missouri opened for business. The hotel featured a multistory atrium with three suspended walkways and a fourth-story walkway spanning directly above one on the second floor and a third-story walkway offset by a few meters. One year after opening, the walkways on the second and fourth stories collapsed under the weight of those attending a weekly Tea Dance. 114 people died in one of the most devastating engineering failures in U.S. history (see account here of the engineering failures). How did this happen? If you read the accounts you will inevitably find: a huge gap between design/theory and engineering practice.
Caring applies to policy and to individual, family, group, and organizational contexts.
How? Ask yourself: when face-to-face with a client, what complication/suffering/problem are you being asked to care about? How does the social worker and client come to a joint understanding about what is to be cared for? Often, caring practices fail when engagement and goal setting are not commonly understood and valorized. Why is the initial client request considered a presenting problem? Because you can never be absolutely sure the problem a client presents is all of the problem, a portion of the problem, or not the problem at all. This is to be discovered each time: N of 1 (see our post, N=1). Presenting problems are often commonsense descriptions and don’t include more complicated understandings or perspectives. Of course, out of respect (and the need for engagement), we start with the client’s presenting problem. Yet it’s never as simple as what the client initially offers as the problem; therefore, the use of the term “presenting problem” is a placeholder; it is a reminder to be cautious while keeping an eye out for how the problem may have much deeper roots in the fabric or history of a society and a client’s life, nor are the problems or issues always within our awareness. Clients aren’t always aware of internalized racism, for example.
Symptom: Diachronic or Synchronic?
The “presenting” problem might be: “my 12 year old son is acting out at school (faces expulsion), lacks attention, fidgets, lots of anxious energy, and his grades are failing.” What is the problem here? Surely theories of assessment (e.g., developmental, psychodynamic, cognitive, family, ecological, etc.) and related professional skills (e.g., listening, engaging, gathering joint attention on the issue, theorizing, acting, and reflecting) are necessary for problem identification. Sometimes phase 1 of caring seems easy. Don’t be deceived: the nature of any problem/symptom is that symptoms shift around. And because symptoms, even our physical symptoms (e.g., joint pain) shift, even during the course of a day or assessment period, understanding a problem must be diachronic (i.e., an ongoing process). In a truly caring practice, where we respect the complex dynamics between theory and practice, we must avoid the tendency and resist the pressure to make quick assessments; quick assessments (we live in a quick fix society, with goals and aims limited to short term objectives and outcomes) often lead to misrecognition of the problem and when we fail to see the diachronic nature of symptoms, we often put the client and client system at risk. The DSM (Diagnostic Statistical Manual for Mental Disorders) is a synchronic approach to understanding problems; too often with a DSM diagnosis the problem identification phase ends. In the example above, the diagnosis might be Attention (Hyperactivity) Deficit Disorder. But this is too easy and not very helpful. Ask: does the theory explain the reality of the case? A DSM diagnosis cannot capture all the layers related to something as complicated as attention. Presenting problems often have roots that lead elsewhere. In social work we must not be seduced by quick assessments (e.g., DSM) and strive instead to use multiple theories of assessment to capture the singularity and complexity of human experience and to accurately conceptualize problems.
A quick ADHD diagnosis, moreover, severely limits the social workers’ ability to think critically about the 2nd phase of caring: identifying the source or cause of the problem? Brain disease or disorder? Chemical imbalance? (See recent guest blog post contributor by Joseph Davis). Identifying the source or cause has huge implications for the client. Not the least of which, in the case of ADHD, is the likelihood of being prescribed psychostimulants (see David Healy’s project RxRisk). In a critical social work practice, however, we should make every effort to avoid a simple DSM diagnosis or reduction to a neurochemical imbalance (see guest post by Joseph Davis). Why? In the ADHD example, we must complicate the possible sources or causes and ask: what possible causes/sources of attention are there in general and specifically, what causes a lack of attention? What causes acting out behavior in school? What is acting out behavior? What is the meaning of acting out behavior? What causes high and uncontrollable levels of motoric activity? Moreover, if the acting out occurs only at school and not at home, or vice versa, what does that tell us about the source of the problem? What role might anxiety and impulse control play in short attention? Does the short attention occur in all activities: video gaming, sporting activities, classroom instruction, dinner table, or television viewing? Theory is at work in assessing the problem to be solved. In the case of ADHD, many theories should be used: attention has many determinants. Otherwise, by privileging one determination (or cause) over another, reductionism, we may run many risks: we may confuse the person with the symptom or we may miss the many and possible countervailing forces (i.e., social and psychological forces that counteract or reduce the symptoms). Caring means respecting the multiple determinants of what matters most to clients: well-being, less suffering, economic opportunity, or eliminating the negative effects of racism and class domination.
Once the source or cause has been settled and agreed upon by the social worker and client then comes the 3rd phase: passing a negative judgement on the cause or unwanted determination. If the cause of ADHD is uncontrollable anxiety and this has been part of early developmental experience, and there is significant external conflict in the home—job insecurity, two working parents, for example—then what can done about the anxiety and the external conflicts? It may be desirable to eliminate the external conflict but for lots of reasons not feasible (see post on desirability vs feasibility). Removing the unwanted determination is no simple matter. It requires our full attention to a more complex and diachronic consideration of the symptoms and the social contexts within which symptoms circulate and are assigned significance or value. One might start by helping the adolescent understand and manage his anxiety: does this have the effect of increasing attention? If so, what does that tell us about the cause? One might work with the family to structure more neutral learning time or ask parents to reduce (or eliminate) surprises or constant changes in everyday routines: time to get out of bed, time to go to bed, do homework, watch TV, and play. Do changes in family routines, in turn, change levels of attention? Finding the cause(s) requires iterative and reflective processes involving everyone who has a stake in the problem and its solution.
Passing a negative judgement on the cause of ADHD (3rd phase) means that in the 4th phase an INTERVENTION is planned—family, group, individual—to eliminate the cause; otherwise the problem will remain unaffected. In making the transition to the final phase, removing the unwanted determination, interventions will likely vary in time and scope. It may take time for the family to assert new and more stable everyday routines. It may take significant individual therapy and parent intervention before unwanted anxiety is reduced. And what is desirable will always be weighed against what is feasible, making Caring Practice a reflexive, iterative process (see post on reflexivity). Each of the 4 phases are separate only in the abstract (i.e., in theory). In actual practice all phases are simultaneously occurring, one often being more dominant than another. This makes practice (and research) particularly challenging, even to the most experienced (see post on the relationship between theory and practice).
In our practice, supervision, and research (and in our daily lives), we have used the following rubric to think about and organize our caring. All of us move in our levels of skill from novice to expert, even in the simplest things. When we garden or bake bread, we must have a realistic assessment of where we are along this continuum: novice, beginner…expert? When we are learning a sport or driving a car we must be realistic. Some often feel expert when they are truly novice. We will often under- or overestimate our level of skill. And we all know someone who is grandiose about their level of skill and often in their overestimation cause damage to themselves and others. This rubric below can be used across many modes of caring practice and in many caring contexts. It requires the social worker to think critically at every phase, using multiple theories and transdisciplinary knowledge to produce a ‘good enough’ fit between problem identification, the cause, passing a negative judgement, and organizing a caring intervention.
What is the difference between a novice and expert in any caring practice? The expert moves with ease (see rubric), having experienced and seen many and sometimes thousands of cases. We believe that the expert moves with ease among and between each of the four stages in a Critical Science of Social Work (CSSW). And experience is foremost found in one’s ability to see and understand problems in all of their complexity (i.e., diachronic) along with the complexity of identifying the often multiple and sometimes contradictory causes of problems. The expert is able to understand that not everyone will see the problem as a problem (i.e., complicating passing a negative judgement) and thereby making change difficult and sometimes impossible. Finally, the expert understands not only how to remove the offending cause or unwanted determinations of the problem but also understands that some interventions, when not feasible, can cause other problems, or should never be attempted, while at the same time never giving up on what is desirable. The expert never gets lost in the weeds, in the details (see lower right hand quadrant). Finally, the expert always remains open to the possibility that they could be wrong (i.e., fallible) and are able to learn from their mistakes, adapt, and try new approaches.
Benner, P. (1982). From novice to expert. American Journal of Nursing, (March): 402-407.
All caring work should take place in organizations where novices and experts work side-by-side (see post on the COOPerative movement). And in the apprenticeship model (Sennett, 2008), where the novice works alongside the expert, we should in every possible way discourage inflexible and hierarchical relationships between the experienced practitioner and the novice. We should make every effort to ensure that social class, race, or gender differences do not interfere with the transmission of knowledge and that these differences are taken into consideration.
References
Benner, P. (1982). From novice to expert. American Journal of Nursing, (March): 402-407.
Sennett, R. (2008). The craftsman. New Haven: Yale University Press.