This essay was written by Adrian Bloxham and was the winning social work entry in this year’s Critical Writing Prize 2019. Adrian is studying for an MA at Anglia Ruskin University and he was nominated by his lecturer Dr Wendy Coxshall.
I am currently on placement in a Supported Housing Hostel for adults in Cambridgeshire. This assignment is based on my work with one particular resident who I will refer to using the pseudonym ‘Alice’. The case study will explore core social work tenets including relevant knowledge and skills, critical reflection, processes of oppression and discrimination, communication and partnership working. I will seek to examine and reflect on my interactions with Alice, primarily by applying a reflective model to a ‘critical incident’. I will also attempt to view Alice’s life, and my professional relationship with her, from a broader social work perspective.
My initial observations and impressions of the hostel were largely defined by the levels of socio-economic deprivation that dominate many of the residents’ lives. In virtually all cases the people that live at the project either have an underlying mental health condition or experience drug or alcohol misuse, often there are a combination of these factors. The very nature of this type of accommodation means that the population is transient. This often means that residents have little consistency and no control over who they live with, resulting in an enforced togetherness that can lead to feelings of insecurity, anxiety and fear (Bengtsson-Tops, et al., 2014). I observed during my early conversations with Alice that she often seemed subdued and that her mood fluctuated unpredictably. As the initial phase of my placement progressed I became increasingly aware of Alice’s persistent and chronic low self-esteem and her tendency to depressive episodes. I noted this in my journal and tried to “…think, to be self-aware and to question…” as a first step towards reflecting on practice (Rutter & Brown, 2012, p. 30).
My vague sense of unease and concern about Alice and her general well-being crystalized early one morning as I arrived at work to find Alice upset and in tears in the communal lounge. I now recognise the ensuing conversation as a ‘critical incident’ that changed my learning and the way that I thought about the staff and my placement setting. What qualifies as a critical incident is not rigidly defined but the event should be important or significant in some way to the practitioner and should offer the opportunity for professional learning (Fook & Gardner, 2007, p. 77). During the course of this exchange Alice disclosed to me that she felt trapped, bullied by a member of staff and other residents, and that she was feeling utterly powerless with no hope of moving on from the hostel. Alice showed me a scar on her right wrist and stated that she had tried to commit suicide in the past and was now experiencing suicidal ideation once again.
This type of situation, with all its complexities and difficulties, is described in the seminal work of Schön (1983) as the ‘swampy lowlands’ of practice (Schon, 1983). In more recent times ‘reflective practice’ has been developed further into a concept of ‘critical reflection’ (Payne, 2014). The application of critical reflection challenges accepted modes of thought, social organisation, dominant discourses and assumptions (Graham, 2017; Savaya & Gardner, 2012; Thompson, 2010). The two-stage reflective model developed by Fook & Gardner (2007) seeks to examine power relations and structures of domination, which in turn intrinsically challenges oppressive and discriminatory thought processes and practice (Graham, 2017, p.49; Fook, 2012, p.47). As will become apparent, forms of oppression and discrimination are a vital aspect of Alice’s narrative, and for this reason I propose to apply Fook & Gardner’s (2007) model to my critical incident and the subject of my case study.
Alice’s disclosure was deeply concerning and very challenging for a number of reasons. My inexperience, the fact that Alice has a diagnosis of schizophrenia and the gravity of what she was saying all contributed to a feeling of unease. The first ‘stage’ of the reflective model is designed to question the underlying structural and social assumptions of the practitioner and analyse how and why feelings of discomfort and concern have been generated (Fook & Gardner, 2007, p.92). Adopting this process has helped me to identify possible assumptions that I suspect I may have held. For example, could my knowledge of Alice’s dysfunctional relationships in the past have resulted in me making assumptions about inherent personality ‘traits’? Did I view her mood swings and depression as simply emanating from her diagnosis of schizophrenia? Did my upbringing, that instilled and encouraged a deference to authority and ‘professional’ figures, blunt my critical faculties in relation to the ‘care’ and ‘support’ offered by individual staff members? It would also be remiss to discount the influence of gender and class on the assumptions I may have held. A closer critical analysis of the factors and experiences that have shaped Alice’s life expose the fundamental flaws and prejudices in my misplaced assumptions.
As I began to work with Alice it became increasingly clear to me that she had experienced discrimination and oppression throughout her life. I learnt that Alice had endured severe and multiple adverse childhood experiences. Both of her parents committed suicide, she was raped and endured physically abusive relationships with two consecutive partners. This culminated in Alice being admitted to various psychiatric institutions in order to treat her schizophrenia and personality disorder. Eventually Alice became homeless, living on the street and addicted to heroin. The physical scars on Alice’s body as a result of these experiences can be understood from a postmodern perspective as embodied manifestations of power and oppression (Tangenburg & Kemp, 2002). Taking a postmodern perspective that conceptualises the body as the site of power relations (Foucalt, 1977) leads to an understanding that “…the body is fundamentally implicated in mechanisms of domination and control.” (Tangenburg & Kemp, 2002). Postmodernism rejects overarching general theories, instead adopting an approach that acknowledges individual narratives, social context and recognises multiple identities that may intersect (Graham, 2017; Fook, 2012). The intersection of Alice’s gender, her adverse experiences both as a child and as an adult, her diagnosis of schizophrenia and the fact that she has experienced poverty for the entirety of her life has led to oppression and discrimination at multiple levels.
A reliance on members of staff who are experienced as oppressive reinforces feelings of hopelessness, stigma, discrimination and disempowerment (Williams, et al., 2015). Alice has been exploited by fellow residents who target her on the days when she receives benefits, this form of oppression takes place at a personal level and is often experienced by adults with serious mental illnesses in the “…forced intimacy of supportive housing.” (Forenza & Bermea, 2017). Oppression and discrimination also takes place at a wider level. People diagnosed with schizophrenia are often stigmatized by a discourse of ‘otherness’ which portrays people with mental health challenges as a ‘problem’ who must be ‘controlled’ by bio-medical, biogenetic models (Beresford & Wilson, 2002). Despite the dogged insistence of the dominant ‘medical model’ discourse, contemporary evidence points to a causal link between social factors and a diagnosis of schizophrenia (Read, 2010). Typical triggers include poverty, adverse childhood experiences, rape and physical or psychological violence (Read, 2010; Burns, et al., 2014). It is essential that social workers acknowledge this increasingly influential discourse which suggests that schizophrenia and other forms of mental illness are bio-psycho-social manifestations of social conditions and health inequalities, not an inherent physiological condition (Bywaters, 2015; Karban, 2017; Friedli, 2009; Marmot, 2010; Read 2010).
Revisiting the assumptions that I outlined above has helped me to explore how I experienced the initial incident. Firstly, I now believe that I saw and understood the situation in simplistic, binary terms. Identifying assumptions and binary thinking, regardless of how uncomfortable this may be for the practitioner, is crucial and demonstrates reflexivity (Fook, 2012, p.107). By ‘deconstructing’ and ‘resisting’ this binary thinking the practitioner can then go on to address how change might be achieved and what values and assumptions have been challenged (Fook & Gardner, 2007). Arriving at an understanding of the multiple levels of oppression and discrimination that have shaped and distorted Alice’s life has not only heightened my awareness in this particular case but it has also changed the way I will approach practice situations in the future. The importance of recognising multiple perspectives and social contexts in a non-linear, fluid and multifaceted way leads to more ‘bottom up’ practice that in turn empowers marginalised people by recognising and legitimising their experiences and voice (Fook, 2012; Graham, 2017; Parton & O’Byrne, 2000).
Alice’s deteriorating mental health led me to conclude that her social worker needed to be informed of the situation. The worker expressed a great deal of frustration at the lack of inter-agency communication, written or otherwise, and a failure to disclose key pieces of information. This can often be attributed to a defensiveness on the part of housing organisations “…due to fear of damaging reputation…or fear of over-reaction” (Parry, 2013, p.19). As a plethora of Serious Case Reviews illustrate, clarity of inter-professional and interagency communication is vital for safe practice (Moss, 2017; Hall & Slembrouck, 2009; Flynn, 2010). In the case of Alice there are three primary agencies involved. In addition to this, Alice also has contact with a psychiatrist and regular medical reviews with her GP. The number of professions and agencies involved with this single client illustrates the multiple points of contact and potential challenges that operating in this contemporary inter-agency environment presents.
Understanding the communication process requires an acknowledgement of the complexity and meaning of language itself. That is to say, ‘communication’ is not neutral and does not necessarily have a universal meaning to each element of the agency or profession (Hall & Slembrouck, 2009). ‘Communication’ can be seen as a process whereby “…information passes from one person to another and is understood by them.” (White & Featherstone, 2005, p. 214). This rather simple statement camouflages the multi-layered nature of the exchange which involves an array of subjective attitudes and feelings which are projected onto the communicated information both from the perspective of ‘sender’ and ‘receiver’ (Sarangi & Slembrouck, 1996). The diversity of roles within Alice’s network highlights the danger that various professions and agencies may assign different levels of priority or even conceptualisations to the arising issues (Hudson, 2015). This means that each communication is potentially ‘categorised’ differently and therefore there is a danger that co-agencies conceive of a given situation in completely different ways (Hall & Slembrouck, 2009).
I continued to learn more about Alice’s life over the following weeks. I observed the patience and empathy that Alice’s social worker demonstrated during the interview process. Often Alice would experience what appeared to be moments of psychosis during which she seemed to be transported back in time to a particularly traumatic event which resulted in repetitive phrases and sentences being used to describe what had happened. Although these moments appeared to be traumatic for Alice she said on many occasions that she wanted to speak about her past. I noted the way that Alice’s social worker handled difficult or emotionally salient passages during interviews (Goss, 2011), particularly the use of silence and the importance of being patient rather than asking superfluous questions to fill uncomfortable pauses (Trevithick, 2012). The importance of ‘iatrogenic health’, the process whereby possibilities and opportunities are acknowledged and explored, is part of a constructive narrative approach founded on a postmodern perspective (Parton & O’Byrne, 2000). The whole thrust of the conversations, whilst acknowledging the trauma of the past and the difficulties of the present, were very much focused on the aim of Alice moving-on in both a literal and metaphorical sense. The social worker talked through the steps that needed to be taken by Alice and the support that she would need in order to achieve this goal, a process referred to as the amplification of personal agency (Parton & O’Byrne, 2000, p.60).
This relationship-based work (Woodcock Ross, 2011) with Alice highlights the importance of partnership working and emphasises the need to avoid ‘top-down’ structural models (Hudson, 2015, p.102). Whilst the idea of ‘partnership’ suggests equality and collaboration, practitioners should still manage power relations with service users carefully, especially where a lack of confidence inhibits the service user from taking on the responsibility of partnership (Dalrymple & Burke, 2006). This aspect of partnership practice was and is very pertinent in the relationship between Alice and her social worker. The asymmetry between the social worker and service user emphasises the need for the practitioner to be cognizant of the inherent power imbalance in the relationship (Leung, 2011). Even where social work is undertaken with the best of intentions, for example in anti-oppressive practice, there is a danger that the voice and knowledge of the service user is lost by the intervention of the ‘expert’ practitioner (Wilson & Beresford, 2000).
The difficulties Alice experienced at the hostel which culminated in such a troubled state of mind calls into question the place of adult safeguarding both within the organisation and in the wider context. The implementation of The Care Act 2014 introduced new responsibilities and statutory duties on local authorities and partner agencies with an emphasis on moving away from process-driven practice (Cass, 2015). The new legislation was adopted into Company policy, statutory guidance makes it clear that there is an onus on employers to ensure that staff working in a housing environment are adequately trained in recognising signs of abuse or neglect, which includes self-neglect under the terms of The Care Act 2014 (Department of Health, 2014). At the time of my critical incident Alice was failing to attend to personal hygiene on a regular basis, frequently appeared to be experiencing low mood and would often break down in tears even when engaging in mundane, everyday conversation. Supported housing is often regarded as a positive environment that promotes recovery-oriented practice (Harvey, et al., 2012), but it can also be experienced as an oppressive and hostile setting where staff are at best indifferent to the needs of service users or can actively act as the oppressor (Bengtsson-Tops, et al., 2014). This is especially concerning when one considers that housing staff may be the only service that residents have contact with (Cass, 2015).
Risk assessments are an integral aspect of work with vulnerable people (Parry, 2013). Yet risks remain, in essence, unpredictable phenomena that defy reliably accurate outcomes (Munro & Rumgay, 2000). From a postmodern perspective, practitioners should not seek to totally eliminate risk by a ‘scientized’, calculated approach because this is doomed to failure (Parton, 1998, p. 23). Instead, there should be an acceptance that uncertainty and complexity are inherent in human interaction and therefore consideration should be given not only to ‘negative’ risk but also to the benefits of ‘positive’ risk (Macdonald & Macdonald, 2010). Risk management can be seen as a continuum (Nolan & Quinn, 2012), so whilst service user vulnerabilities must be taken into account when assessing risks there is also a balance to be struck. Planned risk-taking can and should promote a good quality of life, develop new skills and expand life experiences (Barry, 2007). Alice wishes to live independently and this is the preferred option for the social worker. However, a judgment will ultimately need to be made as to whether the rights and needs of a vulnerable service user are best served by advocating for Alice’s wishes or actively encouraging another course of action that is ‘safer’ for Alice (Kemshall, et al., 2013).
This case study has demonstrated the complexity and breadth of contemporary social work. Whilst there is not universal agreement (Ixer, 2016), the central importance of critical reflection to the profession of social work is widely accepted (Thompson, 2010, p. 183). The opportunity to work with Alice has provided much to reflect on and learn from. My work with Alice has taught me many things, most notably the impact of personal and structural processes of oppression and discrimination. However, I believe the key lesson that I take from my professional relationship with Alice is to try and show the same level of astonishing resilience and generosity of spirit that Alice has demonstrated throughout her life to the present day.
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