December 2019 – Research in Social Work

Paper Review: An Australian perspective on Community Treatment Orders

A review of ‘Using Social Work Theory and Values to Investigate the Implementation of Community Treatment Orders, Australian Social Work, 66:1, 72-85, DOI: 10.1080/0312407X.2011.651727‘ Lisa Brophy and Fiona McDermott 2013

Introduction

By looking at this paper, I am reviewing some of the content to make it more accessible and combining a summary of what I find to be the key points, with my own understanding and interpretation. I am no expert and I am no academic. I am interested and with that proviso, I will continue.

I came across this paper as I was looking at the way that ethics and values reflect on social work decision-making and while my focus is more on decisions made about best interests and mental capacity, there is a clear line in comparison with studies completed in other areas, particularly the use of compulsion in social work and how we, as practitioners respond to it. I found the explanation of the methodology and the theoretical approach clear and helpful in my own thinking on two levels.

I’m interested in research design and comparing the robustness of the evidence gathered and different approaches taken, and secondly, when looking at how I integrate theory, both social work theory and broader social research theories into both my own practice and my research work, the most useful learning is reading papers where it has been done and other doctorate level theses available through EThOS (British Library free repositary of over 500,000 theses – and worth checking).

Background to the study

This is a paper written for Australian Social Work. It is looking at the use of community treatment orders specifically in the state of Victoria, Australia. It seems that CTOs have a longer history than their use in the UK and at the time of writing, the authors claim that there are around 5000 current CTOs. The paper looks at how compulsion links with social work values and practice particularly around theoretical perspectives. It is useful as it links the use of theory to practice in a setting where compulsion is used and reflects the tensions in the social worker’s role. It was definitely something that spoke to me, not just in terms of the research, which is useful for my own work in this area, but more interestingly, perhaps, for me when I go to work on Monday to consider with people I work with who do not choose to work with me and, indeed, are compelled to do so.

Methodology

Looking at the methodology, it is a mixed methods study. This means that there are both qualitative and quantitative aspects to the study. I tend to enjoy reading the methodology parts of papers. To me, it is what distinguishes research from opinion and most of the papers I read are pure qualitative studies, not by design, but because I am trying to learn more about qualitative research so approach this by reading more papers where these approaches have been taken.

This project started with a broad-ranging cluster analysis of 164 people who were on the community treatment orders used in Victoria, Australia. Cluster analysis is a specific quantitative methodological approach to using statistics to establish common ‘clusters’ of data, in this case, types of people who would be subject to community treatment orders. The specific methodology may be related to creating clustering algorithms and assigning different features so that the types or clusters emerge from the data. With some biographical and socioeconomic factors being allowed to emerge from the data, this allowed researchers to use the emerging key ‘clusters’ to identify a smaller group of people, reflecting some of the key ‘clusters’ identified, to be interviewed in more detail using semi-structured interviews. This was followed up with additional interviews of family or carers, case managers (presumably, although this is not explicit, who would be for the most part, social workers) and doctors involved.

There were then follow up interviews conducted after 6-12 months with people involved around the use of CTOs including those subject to them, professionals involved in working with them and family or carers. Additional interviews were undertaken with those involved in tribunal (or equivalent) hearings, senior managers and those involved in policy.

This is a brief summary so does not include all the complexities but it does reflect the thought process behind the choices of methodologies involved and reflects back how social work theories have led to each of these steps, including the involvement of people who are subject to these orders being at the heart of the process of researching about them.

Outcomes

The paper identified ‘significant clusters’ relating to being ‘connected’, ‘young males’, ‘chaotic’. The research team used these differing clusters to recruit for the interview stages of the research study.

The researchers, linking back to previous studies which had looked at the use of CTOs, identified five principles which could improve practice based on the interviews. While, they identified that these principles reflected some of the guidance currently in use in practice, the difference that the research was able to tap into was to highlight diversity within the groups of people subject to CTOs. I think these principles are valuable to reflect on and while this research is about a specific intervention in Victoria, Australia. It isn’t an enormous leap to see how they may reflect some potential to improve practice in areas where compulsion is used by and with social workers.

The following are identified on p78 of the paper:

Use and develop direct practice skills
Take a human rights perspective
Focus on goals and desired outcomes
Aim for quality of service delivery
Enhance and enable the role of key stakeholders

Theoretical perspective

The paper establishes it’s focus on the framework of critical theory, which allows a discussion about the role of power in social work and particularly in areas of social work where compulsion is used. This is also carried through to understanding the role of power within research. The authors have acknowledged this and reference their awareness of the principles of emancipatory research by ensuring that those who are subject to CTOs have been central to the research design. One of the principles the authors reflect, is that of empowerment and by giving people a voice through research carried out about them, it is enabling change to be made.

Additional reflections and gaps

I think of this research both in connection to my own studies and my own work. The first thing that jumped to my mind is that the need to have an international perspective when it is relevant but to be aware of the differences as well. This study is very much about one system of compulsion within mental health with adults. I don’t know the age range or diagnosis types of those who were interviewed and didn’t need to for the scope of the study. One thing that struck me, which may, very well reflect differently to a social worker based in London, is the analysis of race. This is not as a criticism of this study but one which might have different focus in different settings. Critical theory looks at the differing, sometimes competing and often co-existing ‘labels’ determined by studies and organisations to typify people who receive different types of input and I am particularly interested in where internal biases from professionals might impact outcomes.

Learning for practice

The key learning that I have taken from this study is an understanding of how we work within paternalistic frameworks of compulsion as social workers and I found some of the discussion around theoretical approaches and particularly the use of critical theory, to be most useful in both identifying this tension and acknowledging some of the hypocrisy between values which say they promote empowerment but work within frameworks which can be the most oppressive. The authors acknowledge this tension in trying to pull out ‘best practice’ guidance using the input of those subject to these interventions, while also acknowledging the purpose of the study was not to challenge the existence of CTOs and frameworks of compulsion, but that doesn’t mean we can’t and shouldn’t, indeed, we should, continue to constantly challenge the way we work with compulsion in mental health care and look at other options.

Regarding the specific good practice identified, as listed above, some are about organisational needs, such as ensuring that social workers have specific training and space to reflect on the use of compulsion in practice, rather than just being expected to ‘pick it up on the job’. As social workers in the UK, if we are trained as AMHPs, there will be a focus on this as part of the training, but that doesn’t mean there isn’t room for more learning as this training is not necessary to work with people who are compelled to work with social workers. And it is not enough in itself to give people training at key points and then leave them too it. This is the way one can become overly familiar with compulsion as a tool and desensitised to it. We need to guard against this which can be done through supervision and reflection.

An interesting aspect of the human rights perspective, was identified as well – which recommended ensuring people who are under compulsion are aware of their rights and why the limitations to liberty have been imposed. The study refers to procedural fairness and thoughtful decision-making being a key factor. This phrase is something we can always work harder on.

Involving other stakeholders, and in my role, I am thinking particularly of family members, friends, carers, is something that I can always do better. It is true that sometimes the conversations are not easy and there are issues of confidentiality around information sharing but support can be offered and must be in order to work best for people. There are other stakeholders in the form of commissioners, regulators etc but for my own work ‘on the ground’ the involvement of those people around the person I am working with is the key learning.

Finally, the importance of being able to deliver a quality service when people are compelled to have treatment is something that I might not be able to change individually, but it is key factor and it certainly reflected my concerns as an AMHP when I was practising as one (I am no longer warranted). If we compel someone to a hospital admission but the hospital care is poor, we can be complicit in harm rather than help. It is difficult to justify compelling someone to treatment when the treatment is of a poor quality. This is something we must always challenge and complacency can be easy.

Conclusion

I am no academic, but sometimes finding papers which can speak to me in practice can provide a real motivation to the value of research and the importance of being aware of what research is and has happened around the world that can lead to better outcomes tomorrow. What’s more, we can tell our managers that we can link our need for additional training (for example) to evidence.

I’m not pretending my analytical skills are on a par with any academic, they aren’t. But by trying to portray what I can take from this paper, I am hoping that it will encourage others to read more where the papers are accessible, at least, and learn about the profession and how it has and will continue to grow.

I’m absolutely sure as I’ve read through this paper, there are key points I’ve missed, misunderstandings and poor analysis. I am not setting myself up as a font of knowledge but rather, in my ramblings, hoping to take an opportunity for others to try to learn with me but the original research is always the best place to start, rather than any commentary I might be able to ramble through.

Reflecting on ethics and social work practice

We all think we act ethically. Whatever the context, we are able to justify our actions to ourselves. As part of my research, I am interested in understanding the different ways that we interpret values, as well as our personal values and where they come from, the professional values which are more explicitly expressed. I have done some reading about this but wanted to write about the thoughts I have had rather than referencing particular articles and books which have led to my thinking. This is not the ‘academic’ way to write but I think by expressing these thoughts and where I am at the moment, I can take my ideas through as more of a ‘work in progress’.

Personal ethics

What makes us who we are? We draw our values from our biographies – our upbringing. Thinking of this, as someone who was raised in a religious background, part of my ethical make up is very much based on my living and learning about Jewish culture, heritage and history. I took religious studies (because it was compulsory) in my school and it was exclusively learning about the Old Testament, Talmud, Mishnah and the other, more recent commentaries and debates. There is a Jewish tradition of ‘argument’ which I don’t think I understood fully, as being ‘different’ until I left home and studied philosophy, including philosophy of religion, at university. There is no one line that can’t be improved by arguing it out.

This was around how my ethics were formed and why I moved away from religion after school as well. I disliked hypocrisy and the religion that birthed me and raised me is couched, like many, I suppose but don’t know better, in contradictions that didn’t make sense to me.

How could religious people, who really believed and had faith, be (objectively in my child-like eyes) be ‘bad’ people. Surely, the purpose of religious codes of ethics is to teach people to be ‘good’ but then going to the religious services and hearing the same people gossip about who was wearing the nicest clothes/house and who was going through relationship difficulties etc, didn’t strike me as a ‘good’ thing.

While the religion no doubt, formed a basis of personal values, this was augmented by experiential knowledge. I saw that people who told webs of lies, got caught out. I knew that when I was mean or did things that did not link with my personal ethical code, I felt guilty which was not a feeling I enjoyed. There was a selfishness in my personal ethical values and there still is. I don’t want to feel bad about myself so I try not to do things that will make me feel bad. This isn’t altruism, it’s selfishness. I think it’s possible to extrapolate this to my working life as a social worker. I went into this line of work because I want to make the ragged edges of state intervention in the most personal and difficult moments of that person’s life to be as gentle and as clearly explained as possible. It won’t always be possible to soften the pain and it isn’t always my job to do so but it is my role to make the interaction with social work as straightforward and as clear as I can. When I do ‘good’ pieces of work, which make someone’s life easier or less harsh, I go home feeling better.

Saying that, I don’t know if my values are the ‘right’ ones. Indeed, to many people they would not be. I am sure I do make many mistakes of judgement that can have hideous or painful consequences and fundamentally at work, in a resource and time-limited world, I have to prioritise some work over other work. Which means prioritising some people over others. That is why my values are important to my work.

Professional ethics

When we learn to practise our trade, specifically with other people who will not, for the most part, choose to be in a room with us and will not have a choice of which social workers they are allocated – although there are areas of social work outside statutory settings, and those who may have more scope – there are few people who would decide, if all options were available, to engage with social work (fostering and adoption may be an exception).

I tend to see this as an additional responsibility as our role is very much linked, intrinsically to the power we wield with an ID badge around our necks. We can be representatives of The State or The Agency including those of us working in the third sector. Our professional forebears were the religious communities, the benevolent societies, the ‘saviours’ of those who had fallen on bad times or misfortunes. This is the root of social work and it is very much key to the way we need to interpret our roles today and how we are perceived. This power relationship with people who work with us is unavoidable. We cannot work ethically if we do not acknowledge our power. I have written about this previously but it is the core of what social work ethics are.

Looking at the definition of social work and the way that ethics interact with practice, we have this from the International Federation of Social Workers as a definition:

“Social work is a practice-based profession and an academic discipline that promotes social change and development, social cohesion, and the empowerment and liberation of people. Principles of social justice, human rights, collective responsibility and respect for diversities are central to social work. Underpinned by theories of social work, social sciences, humanities and indigenous knowledge, social workengages people and structures to address life challenges and enhance wellbeing. The above definition may be amplified at national and/or regional levels.”
International Federation of Social Workers (accessed 26/12/19)

And this from the British Association of Social Workers’ Code of Ethics

Ethical awareness is fundamental to the professional practice of social workers. Their ability and commitment to act ethically is an essential aspect of the quality of the service offered to those who engage with social workers. Respect for human rights and a commitment to promoting social justice are at the core of social work practice throughout the world.
British Association of Social Workers (accessed 26/12/19)

Of course, I moved immediately from this to the ‘social justice’ phrase, I’ll come back to human rights later, but I think, I try to adhere to this. But if there’s something this last electoral cycle has taught me, it’s that my interpretation of ‘social justice’ is something that is specific to me. I think I am committed to social justice but don’t we all? This is part of my concern about the way that professional ethics are held up as being something specific to social work – my hope and, to be fair, my experience is, that many nurses, doctors, occupational therapists and psychologists I work with are committed to these values, as much, if not more than social workers.

What is it about this definition that specifically makes it about social work? Promoting social change and development? How do I do that in my role with individuals? Do I do this? Am I a social worker at all, or am I someone who undertakes social work tasks that actually can be trained. Am I paid for the tasks I complete or the learning and experience I have in order to make decisions about how to prioritise my tasks? When I undertake a social work task, am I making different decisions to another social worker? In that case, why is ‘my’ social work decision-making better or worse?

We need to be able to broaden and not restrict social workers to those who define social work ethics narrowly. I know I believe I work ethically. but anyone would say that if asked – and if they wouldn’t, they shouldn’t be anywhere near a person who needs social work interventions.

Lipsky’s Street-level bureaucracy first published in 1980, reflects on the importance of the power left in the hands of individual practitioners, like social workers and the impact the those ‘small’ decisions of prioritisation can have on practice and impact on individuals who have far less power in the world which is defined by actions and interactions with organisations that hold power. Any social worker who feels disempowered should pick up a copy of this book where much of it still holds true, despite talk of levelling hierarchies.

I don’t have an answer to what it means to practice ethically and the influence that professional ethics and our understanding and interpretation of these ethical standards, but I am interested in the way that these values and ethics, impact on our practice. Will a person get a different service to someone who interprets their professional responsibilities in a different way from me? How do our conscious and unconscious biases come into play?

I’m going to veer into politics briefly here and say that Corbyn doesn’t believe he’s ever been anti-racist in his life. Ask the majority of the British Jewish community and they might have a different opinion. Is this about understanding unconscious bias, perhaps? This is why we always need to question our own values and ethics and be constantly challenged on the biases we may not be aware we have.

Organisational ethics

This is a difficult one to see, sometimes from the outside, especially if you haven’t had experiences in different organisations. Most large organisations will be able not reel off lists of values that they claim to live by. I went for an interview at an NHS trust (I didn’t get the job) about a year ago and I was asked, in the interview, what the trust values were – I hadn’t remembered, so I invented some of the usual ones, like involvement, excellence, integrity – because they can be a bit ‘cut and paste’ but how do organisations evidence ethical practice, especially large organisations? From the view of the service user/patient, it will be the impact of the individual member of staff.

From the member of staff working within the organisation, it’ll be their immediate manager and possibly more senior management staff. But one part of an organisation can have very different values to another. One ward of a hospital can have a different ethical approach to another ward next door. It might be about interpretations of guidance and policies, it might be about individual interpretations of values in practice. This is why good governance processes are essential within a well-run organisation.

How does this inform and change our practice as social workers? It’s about the value placed on professional development, supervision, training needs and space to reflect and understand how to improve our practice. It’s about the value placed on the voices of people who use services and how well-embedded co-production is, beyond a tick box which needs to be completed to meet a need.

Good governance is something that perhaps isn’t something that comes into our focus as social workers in direct practice but it is the key to establish an organisational culture that works.

Final thoughts

I have no answers. The thing I learnt in my studies of philosophy is that sometimes the value of questions isn’t finding answers, as there may be no answers, but it is asking the right questions in order to aid enquiry. And this leads me back to the previous post about research questions. Currently, I think I’m where I want to be with some of my questions but when I go to work tomorrow with the aim of ensuring ethics guide my practice, I’ll not ever know if I am getting it right or not.

Social work is not a profession which has sufficient confidence to challenge itself regarding the fundamental ethics of some of the practices that have persisted, although some of it happens around the edges. While I hope this will inform some of my research work, I hope that I don’t ever end a day or a week, without thinking, how did I ensure that I thought about the actions and priorities I took and considered this within an ethical framework, whether utilitarian, Kantian or virtue ethics.

We have to understand the decisions we make, ethically, in the context of the decisions we don’t make but we have to know that our values can never be pure, perfect or altruistic. We wobble and we need to know, for the sake of those who rely on us, how to wobble less.