THE TWO FACES OF SOCIAL EXCLUSION: ETHICS, EVIDENCE-BASE AND PRACTICE IN RESPONDING TO SERVICE USERS’ HEALTH AND SOCIAL CARE CONCERNS WITHIN POLICY-LED SOCIAL THEORY AND ITS EMANCIPATORY ALTERNATIVES
Faculty of Health and Social
Walton Hall, UK
International social policy treats social inclusion as the remedy to health and social care concerns, thereby promising to promote international social work values of social justice and empowerment. However, social theory encompasses different perspectives, carrying radically different ethical, research and practice implications. Current social inclusion
policy emphasises as paramount to the problems and their solution, the individual’s capacity for social participation and responsibility, further viewing this in learning theory terms. These understandings support natural science evidence-bases, individual functioning ethics, and behaviourist practice approaches. In response to these approaches, however, service users and practitioners experience ‘ethical distress’, but as indicated by user-led New Social Movements, new understandings inspiring user-centred practice and research are led by such ethical distress, arising from users’ experiences of concerns excluded from dominant perspectives. The paper will therefore seek to recognise these excluded concerns, exploring social theories in which service users are authors of their lives, but also face damage and limitation through many forms of social adversity over which they have little control. It will then trace the ethical, research and practice implications of these perspectives. The paper will focus upon UK policies within the wider international policy context. It will use gender prepositions interchangeably.
Keywords – Social exclusion and health, Social work and health, Emancipatory theory, Social work ethics.
Social policy for health and social care in Europe and beyond converges upon the promotion of social inclusion as a major route to improved health and independence (Means et al., 2008). This takes place in the context of the global economic market with its drivers to low taxation and the retraction of the welfare state, but also finds concordance with research findings linking social exclusion and health concerns: as indicated by the European Commission (2005), family, social and environmental factors are recognised as determinants with biology, of health.
What does this mean for social work? International social work shares with the above policy approach, a social and empowerment view of service users’ concerns: ‘The social work profession …promotes the empowerment and liberation of people to enhance wellbeing. Utilising theories of human behaviour and social systems, social work intervenes at the points where people interact with their environments’ (International Association of Schools of Social Work & The International Federation of Social Workers, 2001). However, critical social work perspectives and service user-led New Social Movements (Parton, 2000; Barnes & Mercer, 2004) suggest our understandings of the world shape our responses to it. This suggests that the interface between people and their environments, the way in which social inclusion impacts on health and welfare outcomes and empowerment, can be theorised differently, and it is these differences with their ethical, research and practice implications which will form the focus of this paper.
Policy model of social exclusion and health
Connections of health with social inequalities and exclusion are indicated for example, by research findings that 44% in the lowest socio-economic groups in the UK, have chronic health conditions, in contrast with only 26% in the highest (Baggott, 2005).
A central understanding of these processes in international social inclusion policies is expressed in the claim that ‘while most pathological agents are ubiquitous…social factors are what make people more or less resistant’ (Barrett, 2006, p.116). Social factors thus viewed as ‘protective factors’ through their statistical links to wellbeing,
include ‘active’ aspects of social inclusion such as employment, social participation, connectedness to networks and a sense of influence, as identified by the Department of Health (DoH) in the UK (DoH, 2001). Social inclusion policy therefore seeks to tackle health and social care concerns by promoting these protective factors as indicated by the World Health Organisation (WHO) (2002).
What does this involve? Policy, in keeping with the active quality of these factors requires the individual to develop capacity and participate in the mainstream (DoH, 2006b; WHO, 2002). These policies within wider international policy frameworks have connections to communitarian (Jordan 2001) social theories, which place emphasis upon individual responsibility in the creation of social cohesion (Etzioni, 1995), thereby resonating with contemporary neo-liberal social theories which view society as ‘only comprehensible in terms of the activities of its constitutive individuals’ (King, 1987, p.94, cited Pratt, 2006). Thus for example, there are international concerns for older people to maintain resilience by active participation in the community (WHO, 2002).
There is thus an emphasis in UK health and social care policy upon people ‘taking control’ of their health (DoH, 2006a, p.3) and ‘more responsibility for their own life’ (Department of Health 2005, p.10), in order to achieve better health and welfare outcomes and independence. In relation to health the ‘Expert Patients’ programme, involves ‘skills to better manage symptoms…and empowerment techniques such as goal-setting and problem-solving’ (DoH, 2006a, p.18). Social care needs are to be met internationally (Means et al., 2008; Fine, 2007) by accessing work, as indicated in the UK by the Department of Work and Pensions (DWP) (2006); by direct payments with which users purchase and manage their care (DoH, 2005), and prioritisation of community-based facilities and networks (DoH, 2006b).
Overwhelmingly, then, service users’ health is to be promoted by mobilising ordinary life opportunities, supports and mechanisms of ‘motivation and instruction’ (Jordan, 2004): cognitive behavioural approaches are central in promoting self-management of health conditions (DoH, 2006a) and accessing work (DWP, 2006); emotions are denied expression (Wilson et al., 2007), and sanctions such as loss of benefits (DWP, 2006) motivate compliance. These provisions point to the significance in these policies of behaviour and capacity in the production of health and welfare and empowerment outcomes.
Theorising the policy model of social exclusion and health
To learn more about the way these policies construct the person’s relationship to her environment, we need to go back to the internationally influential (Lago and Thompson, 1996) Enlightenment in Western Europe.
In the Enlightenment, possession of human status was equated with ‘reason’. This was thought to render the person in complete control of self and environment, and create social order (Ingleby, 1983), through providing the ‘capacity to formulate and pursue plans and purposes which are self determined’ (Stainton, 2002, p.196). As such, autonomy formed the basis in Kantian ethics for citizenship rights, including the beneficient treatment of autonomous individuals as ends in themselves (Clarke, 2000).
Significantly, these values of autonomy as self-sufficiency and their basis in rational capacity have been identified as core in today’s social inclusion policies (Fine and Glendinning, 2005, Qureshi and Vernon, 2000). What then, can their socio-historical meaning tell us about how these policies view the person’s relationship to her social environment? As we have seen, for the ordinary person, this was one of control. People with health and social care concerns, however, deemed because of their difficulties to lack autonomy, were thought to be controlled by inner and outer forces, and therefore subhuman. As such they were segregated, institutionalised and denied citizenship rights (Ingleby,1983). Amongst many, however, social work and wider practice under the Poor Laws sought to promote autonomy by moral instruction and skill development (Jones, 2002; Scull, 1983). Subsequent welfare state arrangements recognised instead the universal nature of need, thereby promoting entitlements (Kemshall, 2002), but today’s policy is aligned firmly with the Poor Law approach in the view that: ‘Social investment in education… and skill development are…more efficient mechanisms than…universal benefits to meet needs’ (Kemshall, 2002, p.34). We can perhaps therefore characterise these understandings as an individual capacity view of the person-environment interface, linked in the view of some writers to learning theory (Parton, 2000; Jordan, 2000).
What, then, are the ethical, research and practice implications of these understandings? Their learning theory assumptions have their epistemological foundation in the natural sciences (Parton, 2000), and UK policy promotes such understandings of evidence-base, drawing causal inferences from statistical associations – thus treating the social inclusion correlates of health and independence, as causal of these states – and emphasising research evidence of ‘what works’ (Gould, 2006). Behavioural interventions are pervasive in practice (Keene, 2001), and practice. takes place in the ‘residual welfare’ context (Kemshall, 2002), involving minimal resources restrictive of person-centred professional responses (Martin et al., 2004), de-professionalised services (Jordan, 2001) and substantial devolution of the responsibility to meet needs to the individual (Ferguson, 2007). We can also question with Parker (2001) how far service users’ rights and best interests will be prioritised given their poor match with the fully autonomous person of Enlightenment discourse.
Where, then does this leave social workers committed to international social work values. Although policy shares a commitment to these values, how far can its underpinning theoretical assumptions allow them to be realised?
How helpful is the policy model to service users?
Service users experience severe concerns both with ill-health and social exclusion (Marwaha and Johnson, 2005; Davey, 2005). However, they experience major shortcomings in current policy responses. Many seek more social care services to support ordinary life (Age Concern, 2006; Platt, 2007); more service entitlements rather than ‘burdening family’ (Raynes, 2001); the professional quality of trustworthiness in care staff (Raynes, 2001); commitment to their best interests (National Institute of Mental Health in England, 2003), and person-centred, specialist understandings of their concerns (Manthorpe, 2007). Parents in a refuge fleeing domestic violence voiced their sense of betrayal when these responses were not made: ‘I thought it would be warm and supportive but the staff here are cold and selfish towards me. I thought I’d be treated right. I feel very bitter’ (Tischler et al., 2006, p.5). Women have found the focus on their coping skills traumatic for their distress does not seem to be heard (Smith et al., 1998).
Workers too in the UK have voiced major concerns with policy. Some experience ‘ethical distress’ in response to resource-rationing which leaves much need unmet (Jones, 2001). Others find research evidence of ‘what works’ unhelpful in responding to the broad range of factors implicated in the person’s relationship with his environment (McCrae et al., 2005). Some find themselves ‘responding to more than behaviour’ (National Institute for Mental Health in England, 2003)
An alternative model of social exclusion and health
Service users and workers therefore experience dis-ease in the face of current policy responses. Service-user led New Social Movements view such experiences as catalysts to the development of theory which takes account of realities seemingly excluded from dominant discourses ( Barnes and Mercer, 2004). Emancipatory theories in social work and beyond (Houston, 2001), may constitute such alternatives in relation to the service user and worker concerns outlined above, and as such, carry radically different ethical, research and practice implications.
What do these theories involve? These are systems theories, further resonating with ‘complex-systems’ approaches (Healy, 2005) and ‘critical realist’ developments in sociology (Williams, 1998), which understand the person’s concerns as consequences of the complex interactions between and within herself and the environment (Houston, 2001). These theories recognise socio-economic and socio-cultural inequalities, understanding these macro-level structures to impact through social, psychological and biological processes over which people have little control, upon individual intra-personal systems. These processes produce pain and damage, affecting the individual’s social functioning, psychological distress, and significantly biology, with health consequences (Williams, 1998). At the same time, in contrast to Enlightenment thought, the person thus affected is recognised as no less a human being with potential for autonomy, although this too can be profoundly affected by conditions. Consequently, emancipatory social work is concerned with the ‘conditions leading to or hindering the self-realisation of individuals and social groups’ (Humphries, 2005, p.281)
This introduces significant concepts regarding the person’s relationship with her environment, which have been bracketed out by the policies above. These include firstly the power of adversity both to generate health and social care concerns and limit autonomy by setting in train damaging inner and outer processes beyond the person’s control; secondly, its power to create through these processes, immense suffering, and thirdly the significance of addressing these conditions and their effects as a basis for people to maximise both their capacity and their wider health and autonomy outcomes.
Evidencing the model
Research attests to how great the struggle for capacity can be in the face of social, psychological and biological adversity. For many, symptoms can form barriers to accessing employment and the mainstream (Single Parents’ Action Network, 2001; Qureshi et al., 1998). People can also experience major reductions in motivation and capacity through being overwhelmed with pain and fatigue (Stanley, 1999), corresponding with evidence that people with more severe health conditions were substantially less likely than those with less severe conditions to adopt self-care strategies (Ellins & Coulter, 2005).
What of emotional distress? There is evidence that coping is affected by the impact of childhood sexual abuse and the losses associated with onset of significant health conditions (Walker, 1992; Mayor, 2006), and Larson et al. (2007) show emotional pain to be a major correlate of drugs relapse. There is furthermore evidence that post traumatic stress, linked to experiences of abuse and domestic violence, can give rise to biochemical processes implicated in physical and mental health problems (Yehuda, 1997).
What of social adversity itself? The social model of disability highlights the implications of social exclusion for denial of rights and resources (Barnes and Mercer, 2004), but also poverty ‘inflicts massive economic, social and psychological damage’ (Novak, 2002, p.186). Something of this impact can be seen in studies tracing the its implications for negative emotions, emotional distress, malnutrition and poor housing (Test et al.,1989; Walker and Walker, 2002; Bywaters, 2007), all exacerbating ill-health and social exclusion, and restricting capacity for coping. Furthermore, the learning theory focus of practice in UK health policy, exemplified in the exhortation to ‘challenge (peoples’) beliefs about their condition’ (DoH, 2006a, p.21), can be contrasted with Houston’s (2004) evidence that disabled people experienced the greatest empowerment when able to afford the range of supports they needed.
What of peoples’ potential for autonomy against these struggles? Seventy percent of drug users in one study expressed the wish to stop their drugs use, but had not been able to enter treatment (Jones, 1998). Elward (1992) found however that addressing social stressors such as housing and financial concerns enabled people with serious drug problems concerns to take this step.
Ethical, research and practice implications
The ‘realist’ perspective of this approach is concerned with the human pain and damage inflicted by adverse, excluding social conditions upon the person’s life, biology and emotions. As such, users’ concerns signal the social injustice of health inequalities (Bywaters, 2007), and understandings of the processes involved as hard to control identify them as a human experience, rather than as a product of poor individual capacity. Such understandings have been linked with the ‘moral’ ethical approach (Smith, 2005), recognising people’s ‘human worth’ and that ‘with suffering come moral rights and entitlements’ (Charmaz, 2006, p.367), encompassing from emancipatory perspectives, human, civil and social rights (Ellis, 2006).
This approach represents a move not away from Kantian ethics as such, as both approaches place value on autonomy, recognise the potential for this capacity in the person, and attribute intrinsic worth to the person. The difference suggested by the above understandings is that the human being should not be equated with complete autonomy - rather it is recognised that all people both have control and can be controlled by conditions: as Ward (2000) explains, people are ‘shaped by the world around them but…are also creative beings’ (p.60). Furthermore, this recognition, both of the person’s human potential for autonomy together with the realities of his suffering, calls for social rights and entitlements besides the civil rights accorded by Kantian ethics, and acknowledges that the person with little control over her environment is no less a human being than someone who can exercise high levels of autonomy.
‘Is there any merit in researchers being impervious to human suffering and injustice? Surely one of the basic aims of research is to bring to public notice realities that were previously hidden (Humphries, 2005, p.281)
Evidence-base from the above perspectives pertains to the ’ causal mechanisms within the person, their social networks and the wider society, which give rise to suffering and oppression’ (Houston 2001, p.853). These processes constitute hidden conditions underpinning the apparent connections between a lack of active agency, poor health and social exclusion embraced by social inclusion policies. Thus, for example, the specific statistical connections between the absence of an active sense of control and the presence of these concerns (DoH, 2001) may be explained by findings relating social disadvantage to both sets of variables (Labonte, 1998 cited in Duggan, 2002). This suggests the statistical links between the latter do not signify a relation of causality, but derive from the implications of social disadvantage for each of them.
Melrose (2000) demonstrates how triangulated qualitative and quantitative research findings can be used to construct a ‘story’ of such processes, tracing their implications for health and social care concerns and capacity. Thus, in relation to the above example, evidence from qualitative research pinpoints the diminished sense of empowerment experienced by people with fewer social advantages (Houston, 2004), and quantitative studies link poor housing conditions – in turn connected to poor health – with poverty (Acheson, 1998). Such evidence of some of the means by which social disadvantage can impact both on active social participation and upon health, then suggests processes that can be intervened with to try to remedy the concerns.
Practice within this theoretical framework is therefore a matter of responding both to the pain and damage suffered by people with health and social care concerns, and to their personhood and potential capacity as a basis for enabling them to maximise their control over their lives.
This involves promoting autonomy by ‘remedying’ (Sudbery, 2002), the real ‘personal, institutional, cultural and economic’ (Dominelli 2002, p.36) adversities faced by service users and their effects, by using their powers to address conditions, relieve pain and restore damage (Houston 2001) with the use of social rights to health and welfare services. Thus medical interventions with symptoms (Qureshi et al., 1998), provision of safe and valuing relationships (Neale and Kennedy, 2002) and interventions with housing and finance (Quilgars, 1998) have helped promote recovery and greater capacity.
The response to personhood pertains to the civil and human rights that social inclusion policy aims to promote. However, the limited resources allocated to support these rights (Houston, 2004) in effect positions service users as second class citizens, in accord with Enlightenment views of the citizen as fully autonomous. In response, workers informed by the alternative understandings of users’ position discussed above would seek to use their powers to maximise these rights.
This paper has sought to compare policy understandings of social exclusion and health with those of its emancipatory alternatives. Social exclusion policy, while aspiring to international social work values of empowerment and social justice, focuses on capacity-building aspects of the person as pivotal in promoting these values in relation to social exclusion and health concerns. However, this is a focus which can undermine the attainment of these values, as attested to in the calls of service users and practitioners for a response to pain and to wide-ranging adversities which carry devastating implications for health, social wellbeing and capacity. In response to these concerns, the emancipatory perspectives discussed recognise in contrast that people can be impacted upon, as well as active in relation to their social circumstances, thereby sustaining whole-person suffering and damage besides their enduring potential for autonomy. The ethical, research and practice implications of these understandings therefore call for a fully proportionate recognition of and response to the enormous human impact of social exclusion, as a major contribution to the maximisation of positive health outcomes, social inclusion and empowerment.
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