1. Output 3

Methodological framework for reflexive professionals in participative health and social care: Developing competences in practice development, research, and education

INORP Output 3

2. Introduction

The methodological framework for reflexive professionals in participative health and social care has been developed as part of the INORP project, Innovation by supporting reflexivity and participation: Strengthening education and professionalization of social work on the border of other professions, co-financed by EU funds under the Erasmus+ K203-CAC1B7D2 strategic partnership for innovation for the period 2020-2023. The project partners include:

• Charles University (Czech Republic) as Project Coordinator;
• Ghent University (Belgium);
• Helsingin Yliopisto (Finland);
• University College Dublin (Ireland); 
• Cooperativa De Ensino Superior De Serviço Social (Portugal).

The Association of Educators in Social Work (ASVSP) is an associate partner.

The INORP project aims to develop methodologies to strengthen the competences of actors involved in health and social care practice development, research, and education, including academics, teachers, students, stakeholders from various group identities, in relation to using participatory and inclusive approaches to engage with services users and to promote reflexivity in various areas of social work.

The content and structure of the methodological framework builds on:

• Intellectual Output 1 (O1) of the INORP project, A framework for analyzing and reflecting on modes of service user participation in social work: A comparative perspective. This review of the literature revealed the types of participatory approaches used in the partner countries in the fields of health and social care. The document showed considerable cross-national variations in the level of research and publications. The review also illustrated the conceptual complexity of notions of participation: publications draw on different concepts (including user involvement, user participation, participatory social work, participatory decision-making, experts by experience…) which may carry varying meanings and take different forms. The review furthermore points to the impact of national contexts, historical traditions in terms of organizing the welfare system, policy frameworks, and organizational and educational cultures on the ways in which ‘participation’ is operationalized in practice development, research and education in the fields of health and social care. Throughout the literature review, we identified various challenges and ethical complexities related to promoting participatory approaches in health and social care -including tokenistic approaches, resistance towards participation and the challenge of engaging with power imbalances- which may, or may not, be taken into consideration by researchers and practitioners. Output 2 and Output 3 elaborate on these challenges and explore avenues to deal with them in reflexive and democratic ways.
• Intellectual Output 2 (O2) of the INORP project, INORP methodological guidelines. After the completion of the first Intellectual Output (O1), partners including academics, teachers and students came together in Dublin at the end of October 2021 for a five day Intensive Programme of learning, presentation, sharing and discussion of relevant ideas. Partners of the different partner countries prepared and compared small case studies of context-specific participatory projects in social work practice development, research, and education. In Output 2, several central themes were identified and illustrated by case examples of the different partners in the consortium, and resulting in practice guidelines. Output 2 also acknowledges that participatory approaches involve contradictions and complexities in process, planning and implementation, even where well-developed macro frameworks and political drivers exist. The aim of Output 3 is to gain further insight into the potential of reflexive processes to enable critical and democratic engagement with these contradictions and complexities in the domains of practice development, research and education.

In what follows, we present Intellectual Output 3 (O3) of the INORP project, INORP methodological framework for reflexive professionals in participative health and social care: Developing competences in practice development, research, and education. Output 3 is vitally informed by the lessons learned in Output 1 and Output 2. 

Output 3 was developed after the five day Intensive Program taking place in the beginning of May in Ghent. During this Intensive Program, the INORP team critically explored 5 key themes, which emerged incrementally as the lessons learned during the first Intensive Program in Dublin. Partners of the countries prepared and compared small case studies of reflexive professional endeavors in response to the ambition to work in participative ways in social work practice development, research, and education. The five themes identified throughout the Intensive Program in Dublin and further explored during the Intensive Program in Ghent, concern:

1. the importance of reflexive professionalization to promote critical and productive ways of dealing with the ambiguities, tensions and challenges inherent to participative health and social care;
2. the importance of a historical awareness of how the professional identity and mandate of social workers has been and is currently defined;
3. the need to reflexively articulate professionals’ normative value orientations that underpin (participatory) practice;
4. the need to reflect on how professionals construct problems, interpret service users’ voices and lived experiences, and act upon their problem constructions;
5. the necessity of creating space for ambiguity, risks and mistakes.

During the five-day intensive program organized at Ghent University, the themes functioned as the central topics of the meeting. The case examples that were presented and discussed by researchers, students and local organizations focused on experiences that related to one or more of the 5 themes, to deepen our conceptual and empirical understanding of them, and to develop the methodological framework.

In Output 3, reflexivity and participatory practices are considered as complementary concepts for social work. Output 3 first revives the challenging nature of participation. Second, it explains the 5 central themes, presents vital case examples, and formulates critical questions that enable professionals’ reflexivity.

3. Challenges and opportunities of participation

Social work scholars have introduced a participative professional approach, that relates their practice reflexively to that of diverse actors, including other professionals, organizations, policy makers and, most importantly, service users (Parton & O’Byrne, 2006; Kessl, 2009; Van Beveren et al., 2018). Kessl (2009) asserts that social work should act as a critical agency, an agency oriented at offering or creating new options to service users which they had previously missed or denied. A participative dimension of reflexivity can thus sharpen the understanding of how professional autonomy can be practiced in different national contexts in Europe.

Nevertheless, ‘citizen participation’, ‘service user involvement and participation’, and ‘dialogical and democratic practice’ are ambiguous notions (Beresford, 2000, 2001, 2010; Boone et al., 2019; Krumer-Nevo, 2008). Since the 1990’s, a participatory paradigm has emerged in social policy, being rooted in a wider participatory democracy turn in a variety of societal domains (Beresford, 2001; Della Porta, 2013; Lee, 2015; Smith, 2009). The participatory democracy turn in social policy-making focuses on the central question how citizen participation can influence, deepen and legitimize the democratic nature of policy processes, and improve the quality, efficiency, and accountability of public administrations, public institutions, and public service delivery (Degerickx et al., 2022; Fung, 2006).

In that vein, the wider participatory democracy turn has become part of the public mandate of social work (Beresford, 2010; Garrett, 2019). The participation of citizens as service users in social work practice development, social work research, and social work education on topics affecting their lives has been incorporated into the legislation of many countries, and various practices have been developed (Fung, 2006; Krumer-Nevo, 2005, 2008; Ní Shé et al., 2019). In the drive to become more responsive to the concerns of ‘welfare recipients’ as service users, their participation has been perceived as a contribution to the democratic nature of public service delivery regimes (Beresford, 2010; Garrett, 2019).

Participatory practices are expanding in the field of social work, yet service users are often not sufficiently participating in a democratic creation of knowledge that informs forms of social work practice (Beresford & Croft, 2001; Krumer-Nevo, 2005, 2008). Participatory projects come with challenges and complexities, and can therefore be referred to as “the politics of participation” (Croft & Beresford, 1992), expressing the danger of participation being:

• “tokenistic” (Beresford, 2010) due to “service users functioning as pawns rather than pioneers” (Roets et al., 2012),
• “only ad hoc and inconsistent” (Schön, 2016),
• “more rhetoric than reality” (Adams, 2017),
• a mere “buzzword” (Cornwall & Brock, 2005),
• “reproducing subordination, inferiority, and powerlessness” (Boone, Roets & Roose, 2019),
• a “new tyranny” that legitimizes an unjustified exercise of power (Cooke & Kothari, 2001) in social policy making and social work practice development.

The Intensive Programs in Dublin and Ghent were committed to engage in a critical examination of participative approaches when being implemented in social work practice, research, and education.

Output 2 provides case examples and guidelines. In Output 3, next to the caveat and critiques formulated, we are also addressing the benefits and opportunities of participative approaches, and how they can be very meaningful when reflexive professionals embrace the perspectives of service users.

4. Themes, case examples, and questions for reflexivity

In what follows, we discuss 5 central themes that emerged and were discussed during the Intensive Programs in Dublin and Ghent. The themes are considered as central to a reflexive approach to participatory practice development, research and education in health and social care. For each theme, we provide critical case examples and critical questions for reflexivity.

4.1. Reflexive professionalization

In the past few decades, scholars in the fields of health and social care have increasingly called for a reflexive professionalization of their respective fields (Fook, 2016; Gillings, 2000; Mann et al., 2009). Since its early conception, reflexivity has been considered both an approach to practice and a form of professional learning (Schön, 1983). Therefore, reflexivity has not only been integrated in health and social care practice, but is also widely acknowledged as a central part of higher education training and internationally adopted in professional accreditation standards (Thompson & Pascal, 2012).

The growing emphasis on reflexivity has been explained as a response to current socio-political changes and their impacts on the fields of health and social care. For example, Kessl (2009) contextualizes the ongoing search for reflexive social work in transformations of our welfare systems and the challenges these transformations pose. This includes: the increasing reproduction of social inequality and precarity, the privatization of public services, a shift away from structural and change-oriented towards individualized responses to complex problem scenarios, and a potential reduction of professional autonomy by a combination of factors, like the pressure to frame the relationship between professionals and citizens in managerial terms as that of service providers and users/consumers (see also Ferguson & Lavalette, 2006; Garrett, 2019; Marston & MacDonald, 2006). Other scholars have theorized the turn towards reflexivity as a response to overtly technical approaches to social work practice and knowledge. Such technical approaches emphasize methodic and procedural knowledge, and risk to obscure the presence and value of ‘multiple knowledges’ in health and social care including the ‘practice wisdom’ of the professional and the ‘life knowledge’ of service users and ‘experts by experience’ (Morley, 2008; Taylor & White, 2001).

The increasing recognition of reflexivity as a central part of professional practice and professional development has led to a wide but complex body of academic work on how we should understand the concept of reflexivity. Scholars draw on various theoretical perspectives and use different terminology (e.g., reflexivity, reflectivity, reflective practice and critical reflection) to refer to sometimes similar but sometimes very different ideas on what a reflexive professional or profession entails. As such, and very similar to the concept of participation, the notion of reflexivity has become conceptually ambiguous and may take very different forms in practice, research and education (D’Cruz et al., 2007; Fook et al., 2006). For example, some scholars argue that reflexivity is as a skill that individual professionals must acquire so they become more objective, effective and accountable problem solvers, whereas others advocate for more critical approaches that consider reflexivity as necessarily oriented towards social justice and as an attitude of inquiry into the power relations that are at work when we construct knowledge about social problems and about service users (Van Beveren et al., 2018).

The conception of reflexivity that is used in this project, starts from a positioning of social work as a practice-based profession and academic discipline that is concerned with a social justice orientation and that is aimed at combating social inequality (see IFSW, 2014; Kessl, 2009). This entails that reflexivity requires a commitment to the participation of citizens as service users (Urek, 2017; Degerickx et al., 2021). It furthermore implies that reflexivity is not only a personal and pedagogical professionalization process, but must also take into account the organizational, policy and socio-political circumstances in which professionals operate and service users are expected to ‘participate’ (Garett, 2019). More specifically, we integrate in our conception of reflexivity a personal, interpersonal and socio-structural dimension (see Van Beveren et al., 2018).

• At the personal level, reflexivity refers to a critical interrogation of one’s professional assumptions and of the process of constructing professional knowledge and how power is at work in it (D’Cruz et al., 2007; Taylor & White, 2001).
• At the interpersonal level, reflexivity refers to the process of constructing knowledge about clients and their experiences together with clients in a relational and dialogical process (Parton & O’Byrne, 2006).
• Finally, at the socio-structural level, reflexivity refers to connecting personal and interpersonal reflections on professional practice with more structural and political analyses of personal problems, placing these problems within their historical, socio-political, and socio-economic contexts; combining a stance of analysis and critique with a commitment towards social transformation (Bay & MacFarlane, 2011; Brookfield, 2009; Fook, 2016; Van Beveren et al., 2022). 

Below, we discuss various case studies that report on how partners in the project engaged with the challenge of educating students in health and social care to become reflexive professionals that include in their reflexivity a commitment to citizens as service-users. 

Case example 1: Developing supervision as a safe space for stimulating reflexivity (Czech Republic)

Several case studies from the Czech Republic examined reflexivity as a process of professional development and, emphasizing the personal and interpersonal dimensions of reflexivity, related it to the practice of supervision, which is identified as a platform where reflection can occur. A first case addressed educators’ views on reflection and the specific ways they promote reflexivity among their students in the master-level educational program ‘Management of health and social organizations’. A thematic analysis of seven in-depth interviews with educators revealed that educators want to take a student-centered approach, have an interest in professional growth and learning, and apply different methods when promoting reflection in students. They described their relationship with students as a partnership and saw their role as facilitators. More specific topics that were mentioned by the educators were the importance of student selection for the program, students' feedback, and creating a safe space for reflection where students can share their insecurities, opinions, and remarks. A second case study from the Czech Republic drew on experiences with offering supervision to the preachers of the Brothers church to elaborate on the importance of creating a safe space as a central condition for reflexive learning during supervision. The case indicated that a safe supervision environment was especially needed given the spiritual dimension of the preachers’ work. Some of the participants expressed a fear of the supervision being too personal and of being misunderstood and evaluated by peers. Using a neurological perspective, the case also illustrated that, during supervision, students can be in a state of openness and curiosity and can be present, listen and learn, and can be in a state of feeling threatened, which leads to frustration and takes away opportunities to learn and listen. A major insight from the case is that, in order to stimulate reflexivity in students, supervisors need to find a balance between creating safe spaces to discuss insecurities and pushing students to deal with uncertainty and mistakes without entering a state of frustration and helplessness (see also theme 5. Ambiguity, risks and mistakes). 

Case example 2: Critical reflexivity in social work education: thinking ‘rhetorically’ about poverty (Belgium) (see Van Beveren, Roets, Buysse & Rutten, 2022). 

A Belgian case study focused on an educational project in which master students in social work reflected on the topic of social work practice in relation to poverty by critically engaging with Renzo Martens’ (2008) artistic documentary ‘Enjoy Poverty’. The educators used a rhetorical approach to reflexivity, which means that students were asked to focus on the various discourses that professionals, service users, policymakers and society at large use to construct knowledge about poverty and people in poverty and on how these discourses impact on how we deal with the issue of poverty. One of the main findings of the case study is that almost all students assumed self-critical positions (personal level) and reflected on the power of the professional to decide what problem definitions of poverty are more legitimate than others. Many students combined this self-critical position with a plea for relational reflexivity (interpersonal level) and argued that instances of ‘othering’ of people in poverty can be reduced if professionals actively and willingly listen to the ‘knowledge by experience’ of the service users. This led to a complex discussion about the role of professional expertise when trying to develop participatory social work practice. Students argued that social professionals need to deal with the challenge of having ‘trained incapacities’: they need to take the risk to act and to do this from a specific (professional) way of seeing (being trained), but must simultaneously recognize the possibility of alternative views and courses of action (having incapacities). In addition, the case study illustrated that it is crucial that students extend their reflexivity from the personal and interpersonal to the socio-structural level,  where inward-focused reflexivity (i.e., how did I do wrong?, how can I do better?) is extended to the broader sociohistorical, political and economic contexts in which professionals develop their practice. Indeed, several students reflected on the dominant societal discourses of activation, individualization and responsibilisation in relation to poverty and discussed how social work practice can both reinforce and challenge these discourses and the socio-economic systems they sustain (socio-structural level).

Critical questions for reflexivity

• What does it mean to create a ‘safe space’ for reflection and supervision in educational and professional contexts (while still allowing for professional growth and learning)? How can we create a professional climate of trust and understanding and simultaneously recognize that social professionals are characterized by different social positions, genders, racial, religious,... backgrounds?
• How can we support students/professionals to integrate reflections about their concrete interactions with service users with wider reflections about the sociohistorical, political and economic contexts in which these interactions occur? What strategies can we use to develop reflexivity as both a pedagogical practice (professional and personal development) and a political practice (relation of our practice to the socio-political and economic status-quo)?

4.2. Historical awareness

The second theme builds upon the socio-structural level of reflexivity, and concentrates on the importance of health and social care professionals’ historical awareness of how their professional identity and public mandate has been conceived and defined. INORP’s comparative literature review on participative practices in European countries shows the importance of paying attention to the respective historical, socio-political, economic, and cultural contexts in which practice, education, and research evolve and have been developed.

“Having a voice” has become a core attribute of modern citizenship, as the idea of participation has emerged since the era of the enlightenment. After the second World War in Europe, the welfare state was constituted (Marshall, 1964). Since the conception of post-war welfare states, the symbolic vehicles of citizenship and civic, political and social rights were introduced and institutionalized, which settles a public responsibility of the state for the welfare of citizens. Rights-oriented approaches commonly imply that citizens in European societies are entitled to welfare benefits, resources and services that are redistributed by the welfare state (Lister, 2004). As part of the institutionalization of welfare state structures and arrangements, social work has acquired a relatively autonomous professional position and a public mandate of the welfare state to strive for social justice and human rights (Dean, 2017). The professional role of social work has thus been situated as an actor shaping the interplay between the interests and concerns of citizens at the individual level, and the acquisition of civil, political and social rights at the structural level (Bouverne-De Bie, 2015).  

However, historical reflections and contemporary transformation of the welfare state make clear that all versions of citizenship and rights were established only gradually, and remain only partially granted to certain sections of the population (Kessl, 2009; Dewanckel et al., 2021). Citizenship and rights were extended as consequences of historical, social and political struggle in which social movements like the labor, the feminist, the civil rights, the children’s rights, and the disability rights movements played a key role. However, forms of insecure citizenship, or so-called ‘denizenship’ (Turner, 2016) currently refer to how the state contributes to the erosion of protective structures and solidarity towards citizens who have formal citizenship rights, yet especially towards people who migrate and are not protected due to a territorial logic.

During these transitions, participation still carries features of conflict and agency that challenges and confronts norms, power structures and relationships, and systemic inequalities, and thus contains a pedagogical element: the articulation of “voice” to transform private concerns into public issues necessarily involves a public and democratic learning process (Grunwald & Thiersch, 2009). One of the hallmarks of professional social work is the recognition of the rights of service users, as citizens in their own right. As a key example, a social pedagogical approach can be seen as giving recognition to the life knowledge and capacities of service users, which professional interventions need to build upon rather than “correct” their behaviors (Köngeter & Schröer, 2013), and thus reproducing the question who is deserving or not (Krumer-Nevo, 2016; Garrett, 2019).

For professional social work, this raises the question to which extent excluded, marginalized and powerless people can make use of the required resources (such as knowledge, power, and means) and services, raise their voice, and claim rights without becoming dependent on support. This ambiguity at stake in the public mandate of social work requires a crucial reflexivity. How to deal, for example, with the paradoxical positioning of survivors and self-advocacy initiatives sharply criticizing public institutions and services, while knowing they might simultaneously need support to bring social transformation and change? Self-advocacy movements, service users and survivors groups nowadays continue to play an important role in shaping the social and health service landscape. However their agendas, modes of operating and engagement with formal political structures still vary considerably according to the prevalent political cultures within countries. Many social work initiatives realized only gradually that their efforts could easily turn into tokenistic forms of participation due to new, often more powerful and paternalistic, forms of oppression and exclusion.

Case example 1: Adult safeguarding practices in cases of coercive control: by promoting service users' autonomy and participation can reflexive social work practice be a catalyst for change in the cycle of abuse?  (Ireland) 

In one of the Irish case studies, it became clear that an understanding and discussion of the historical context of Irish health service is crucial to develop reflexive ways of engaging in participatory approaches with health service users. The Irish health service has seen a radical shift in the past 50 years, moving from a legacy of Catholic subsidiarity towards a ‘mixed economy of welfare’ combining voluntary sector and state provision of health and social care services (Fanning, 1999, p.67). The traditional Catholic ethos enshrined in the state constitution has been steadily eroded by social movements which have successfully enshrined equal rights to LGBTQ+ citizens and abortion rights to women. Notwithstanding this radical improvement in citizenship rights, the provision of services to disabled and older adults still operates within a medicalized model of care which traces its origins back to the dual influence of the Catholic Church and the medical profession on Irish social policy (Iredale 1999). The Irish case study reflected on the practice of safeguarding social work in Ireland and on how social work practitioners negotiate the power imbalance that situates them as expert purveyors of advice and guidance to citizens with a lived experience of harm. The ‘safety zones’ or spaces utilized by those experiencing coercive control is well documented in the literature (Stark 2007, p.216; Johnson, 2008). In the context of this case study, the researcher asks whether safeguarding social workers take cognizance of this ‘insider knowledge’ when developing safety plans for adults at risk of harm? What happens when service users adopt safety strategies that challenge the professional assessment/normative view of harm as conceptualized by the state and their agents? The provision of safeguarding social work in Ireland is based on the premise that harms can be irradiated or minimized on a micro-familial level without challenging the socio-structural inequalities that result in older and disabled persons being left reliant on their families to provide for their care and support needs. Therefore social workers’ attempts to promote democratic and participatory practice is often stymied by the Irish state’s inadequate provision of care and support services to those in greatest need.

Critical questions for reflexivity

• Many case studies refer to the aim of participative approaches to play a key role in supporting ‘the best interest’ of the service users. However, several case studies point to potential tensions between health and social professionals having/wanting to work in the best interest of the service user and the (historical) expectations from legislative and policy frameworks. What strategies can be used in these instances? What can be supportive for professionals and health or social organizations in these instances? 
• As a health or social professional, it is important to develop an awareness of the historical (re)configuration of one’s professional identity and public mandate. Part of this awareness is to also think through in what ways these historical processes impact how society at large and citizens as (potential) service users perceive specific health and social professions and services. Is there stigma attached to getting social services or is it considered a right and entitlement of all citizens? How might this impact your practice and how do you then deal with this? 

4.3. Normative value orientations

The third theme refers to the need to reflexively articulate and reflect upon professionals’ normative value orientations and social positions, that inform the public mandate of social work and underpin (participatory) practice, education, and research. Social justice and human rights are internationally recognized as normative principles and overarching value orientations of social work, including health and social care (IFSW, 2014; Vandekinderen et al., 2019; Feryn et al., 2021). The concept of social justice acknowledges the systemic inequalities and power relationships in our society (such as class, gender, race, age and disability), which can result in an unfair distribution of resources and power. However, social justice cannot be understood purely in redistributive terms (Dewanckel et al., 2021), but also examines how social structures and actors recognize some people and oppress others (Kam, 2014).

Health and social care workers are thus never value-neutral or free of engagement, but instead they rely on a social justice orientation as a reference point of their thinking and acting. Being socially marked by a historical, biographical and structural location makes it impossible to structure their work away from their professional power and discretion (Roose, Roets & Bouverne-De Bie, 2013). The vital question is thus how we can enable current and future health and social care workers to reflexively deal with their own underlying values and position (for example, related to class, gender, ethnicity, disability,...), and work through the motions of their own stereotypes and judgments.

Ireland

The recent study of McCartan et al. (2022) involves a comparative survey across six universities in Ireland delivering social work education both North and South. It provides insights into the demographics, motivations, beliefs, and aspirations of the social work student cohort and highlights some areas for the provision of support and learning for current and future students. If social work educators can better understand students’ demographic characteristics, experiences, and motivating factors then the design and delivery of programs can be improved and tailored to: meet the learning needs of students; address pastoral issues; more effectively prepare students for practice; and so provide more effective interventions for service users (Christie & Kruk, 1998; McCartan et al., 2022). An ongoing issue for the profession is the demographic representativeness of the cohort as they enter the workforce. Social work remains a mostly white, female, middle-class occupation, this continues to challenge the academic institutions and the profession. These findings suggest that institutions, programmes, and the wider social work community needs to further challenge such demographic imbalances. Positively, students across all the institutions are motivated by social justice principles and the prospect of influencing social change and justice. It is important that this commitment continues to be a fundamental part of social work education.  It is thus crucial that social work educators understand the personal and family lives of students and the belief systems that have motivated them to become professionals and continue to support the aspirations of those wishing to become social workers and providing them with the skills, experiences, and opportunities to fight oppression and help others. 

Finland

The recent survey study by Kallio, Blomberg & Kroll (2021) involves students at all six universities delivering social work education in Finland. It provides insights into Finnish social work students’ career choice motives that may be of importance for understanding students’ expectations of their social work studies and their professional development. Three value-orientations behind students’ career choices were found: 1) ideological and internal motives, such as a desire to help people in disadvantaged situations and conditions and contributing to solving societal problems and grievances 2) external motives, such as career prospects and 3) personal experiences of social problems. From an educational and professional perspective, all of these orientations are needed: students who embrace the above internal motives are needed in order to influence social change and justice, while students who (also) consider career prospects as an important motive may be particularly keen on influencing social workers’ working conditions and position in society. Social workers that, in turn, have personal experiences of social problems might provide insights as experience experts, at least in a broad sense, both during and after education. The study also brings to the fore the importance of considering who is admitted into to social work education at universities, a factor heavily affected by general national educational policies: the increasing priority that has been given to applicants’ grades in upper secondary school leaving certificates, seems to result in a less diversified composition of (social work) students, when it comes to factors related to (social) background, various types of earlier life experiences etc. This development and its various potential consequences, e.g., for the motives behind becoming a social worker, is something to be acknowledged and discussed by various involved institutional levels. Considering that while (also) most Finnish social work students embrace internal/ideological career motives, they tend to do so especially at the beginning of their studies, while more senior  students, often already working in the field, do not emphasize motives related to social justice to the same degree, which seems to be due to ‘social work realities’ and working conditions. Thus, social work educators face a challenge in preparing students for practice in a way that upholds the commitment to value orientations central to social work.

Critical questions for reflexivity

• In which way can educational institutions play a structural role in immersing social work students in social realities that stretch their comfort zone? How can you create structural and sustainable relations with the social vicinity of your educational institution as part of educating students’ reflexive skills? How can this relationship be participative/reciprocal? 

4.4. Constructing and acting upon problems

The fourth theme deals with the question how professionals might construct problems, which vitally interfere with service users' life worlds and lived experiences, and consequently act upon these problem constructions. In that sense, it is interesting to explore how health and social care professionals interpret service users’ voices, lived experiences, interests, and concerns, and might develop ‘a perspective on perspectives’ when they engage in participatory ventures.

Structural and systemic circumstances, resources, and constraints (with reference to income, housing, education or employment, and so on) intrinsically interfere with service users’ life worlds. Thus, the challenge of promoting participatory approaches requires that health and social care workers learn to see how they interpret and frame the relationship between the individual and society: do they develop a perspective in which they cast marginalized situations of potential service users as being caused by the historical, social, political, economic, and cultural circumstances, or do they establish an emphasis on their private and individual responsibilities and obligations?

In the case of framing how poverty and social inequality interfere with service users’ life worlds, for example, it has been stated that social work should empower people in poverty’s resilience and personal growth. This approach however risks reducing the ambiguity of dealing with poverty as a complex, multidimensional and persistent social problem, because poverty is predominantly defined as an individual problem (Lister, 2004). Hence, the emphasis on empowerment lies in managing individuals who are living in poverty in order to prevent and solve social problems, as the logic of individual empowerment operates in the name of individuals bringing about social change on their own with the aim of liberating themselves (Rose, 2000, quoted in Baistow, 2000). It can be argued that this individualistic theory of the self-providing individual serves to reduce struggles over power and politics. Historical, social and political causes of the problems of individuals are downplayed. Social problems become individualized rather than considered as the consequences of relations between individuals and social structures, power relationships, and social inequalities (D’Cruz et al., 2007).

How can health and social care professionals tackle and transform structural social injustices together with service users? Social workers might act as allies (Bishop & Davis, 2002) of potential service users, to enable their participation in identifying, defining, and tackling their problems and concerns. Without reaching out to their meaning-making capacity concerned, offering them a social justice-based perspective on their being affected by structural inequalities might again be perceived as an imposition and a denial of their agency.

Critical reflexivity calls for a version of social work that seeks to understand, interpret, frame, and transform the circumstances in which service users find themselves, while connecting this to a structural analysis of those aspects of society (Kessl, 2009). This might reinvigorate a research-driven curiosity towards the challenging and changing of complex power relations in which ‘service users’ are enmeshed in our societies.

Case example 1: The role of social work in primary health care: framing and acting from a medical and social perspective (Belgium) (see Feryn, De Corte & Roose, 2022)

One of the Belgian case studies focused on the role of social work in the growing field of interprofessional collaboration within primary care. Interprofessional teams bring together various professionals including general practitioners, nurses, social workers and physical therapists, where the goal is to act beyond individual diseases and pathologies to address complex health and social care needs. However, together with the call for interprofessional collaboration, questions emerge about the role of social work. Social workers are confronted with the task of broadening the medical perspective and incorporate their core values, such as social justice into this context. However, it is not clear if and how social workers undertake this social justice oriented approach in primary health care settings. The case illustrates that social workers themselves state that they are focused on meeting immediate needs of patients, with less time available for structural social work and addressing social and health inequalities. Nevertheless, the case also shows that social workers do adopt a structural approach, by small, incremental steps on the micro, meso and macro level which can enable changes in existing policies. The case study explored these small and sometimes unconscious actions for change. They can be identified within the bridging function of social workers to patients, colleagues and to other organizations within the neighborhood. However, when reflecting on social work within health care environments, we can ask questions about how problems are framed and how we act regarding the problem constructions (Feryn, De Corte & Roose, 2022). Differing views on problems can have an impact on the role of social work and the actions associated with it (Ashcroft & Van Katwyk, 2016; Beddoe, 2019). Expectations of healthcare settings prioritizing a medical perspective can burden social workers, not fully recognizing their contributions. To this end, we advocate for a wider recognition of social work professionals in healthcare settings.

Case example 2: Reflexive approaches to the participation and agency of persons with disabilities in social work interactions (Finland) 

One of the Finnish case studies focused on how persons with disabilities experience agency in health and social care services. Participation, service user involvement and client-centered work are outspoken priorities of current remodeling of health and social care services and social work in Finland. The reform of disability services aims at legislation that guarantees individual, needs-based supports, regardless of the diagnosis or gravity of impairment. The case specifically focused on service users’ experience of agency in their interactions with social workers in the welfare service system. The social work process builds on dialogue which demands skills and sensitivity of the social work professional to explain what kind of need is accountable. For the person revealing their needs it demands competency to define them. The interaction between these two relies on dialogue. However, power relations and different perspectives are at stake in this dialogue and this needs to be taken into account in a reflexive way. To participate in the social work process and to be engaged in dialogue is about agency. The case therefore explored what kind of agency emerges among service users and how they experienced it. The case shows that service users want to know what is possible and what is not and be informed about their rights and possibilities to make informed choices. They want to have correct information and to feel that the professional is working with and for them in their matter and not against them. In case this fails, they turn to other people who inform them or support them in the social work process. Social work with a focus on dialogue that builds up trust combined with outspoken acts of advocacy throughout the phases of the process are means to signal the will and effort to act in the best interest of the person.

Case example 3: Working with mothers with acquired brain injury: challenging their unequal status, a ‘framing’ of their identity as mothers who continue to give care and disabled people who receive care (Ireland)

In an Irish case study, the systemic inequality for mothers with a brain injury was considered an area requiring further research. There is a dilemma for disabled mothers with them being seen simultaneously as givers and receivers of care. The societal expectation of the mother as the primary caregiver in the family is challenged by the societal view of people with disabilities requiring care. Feminist disability theory (Garland-Thomson, 2005) can be used to explore this dilemma and make a case for the value of interdependence between people with and without disabilities. Malacrida (2007) suggests that an interdependence can be created between a person with a disability and the person giving them care, which can lead to a greater connection between people. While the hegemonic quality of ideal motherhood leads all mothers to feel a pressure to live up to the standards of the ‘perfect’ mother, mothers with disabilities face even more challenges as they can be viewed by society as being unable to perform motherhood adequately (Malacrida, 2009). The case described how a participatory action research approach can be used to undertake research where mothers with a brain injury have the opportunity to engage in research with a social work practitioner to explore their lived experience. This research collaboration between social workers and service users also aims to challenge hegemonic assumptions about mothers and about people with disabilities, and contribute to the provision of support services that have value and meaning for the individual and the wider societal system. In order to do this, a co-operative inquiry group will be established, providing mothers with the opportunity to explore their lived experience and the challenges they may face. The researcher will then critically reflect on these challenges and together the group can identify strategies to improve their lived experiences and challenge the systemic inequality for mothers with disabilities. The benefit of this research approach is that the researcher is not making assumptions about the difficulties mothers with disabilities face, rather both researcher and participants work in collaboration so that they can contribute to meaningful improvements in the lives of the participants but also in the wider community. 

Critical questions for reflexivity

• Social workers are persons that give voice to people whose communication abilities are limited. The central point of consideration here is that the role of social workers as mediators is always associated with giving meaning. The way in which we question and engage in conversations is a skill that counts in the process. Social work is not only about interpretations, but also a profession that acts (goes beyond analyzing). By doing so, you will always see other perspectives. 
• When reflecting on social work within health care environments, we can ask questions about how problems are framed and how we act regarding the problem constructions. When working in health care environments, differing views on problems can have an impact on the social work profession (Ashcroft & Van Katwyk, 2016; Beddoe, 2019). We therefore want to reflect further on how we can make social workers and their perspectives more prominent in these settings. 
• The presentation of Phil focuses on participatory research ventures, maybe we can formulate a question to take into account when developing reflexive and participatory research? Phil also mentioned her feminist position and the complexity of engaging in participatory trajectories when co-researchers challenge or don’t conform to that positon. 

4.5. Ambiguity, Risks, and Mistakes

At the beginning of the 20th century, Simon Nelson Patten (1855-1922), the economist who coined the notion of social work, defined case-based social work as a ‘vain struggle against impossibilities’, as its capacity to solve social problems was limited. Others, such as Flexner (1866-1995), commented in the same time period on the fact that social work was not a real profession, such as the medical profession, as social work had no real educational programs and no clear-cut methodical approach (Austin, 1983). In the course of the 20th century until now, a constant element of debate since the remarks of Patten and Flexner remains the question whether social work practice and social work education should focus on individual, psychosocial rather than structural social problems, or on both.

An important issue within this debate is the struggle for recognition of social work as a relatively autonomous field and profession. However, this struggle for recognition of the autonomy and status of professional social work has always run the risk of driving social work to individually-oriented and conservative ideas rather than to a critical social analysis of social problems in our societies, of how these problems intervene in service users’ lives, and how we might challenge and change this. Scholars have therefore argued for the necessary paradigmatic openness of social work as a democratic profession, in order to be able to shape the relationship between the individual and society while keeping ‘the social’ in social work (see Lorenz, 2016; Garrett, 2021).

Embracing ambiguity

The attention for this critical and reflexive role of social work implies that social work should cherish rather than overcome its imperfection. Whereas social work cannot ‘solve’ social problems and every answer to social problems is incomplete, at the same time it has to remain committed to challenge and deal with social issues. Embracing this ambiguity refers to the awareness that social work is simultaneously limited and meaningful:  limited because social work will never be able to solve the social problems it is confronted with, yet meaningful since social work can actually support and mediate in the situations of individuals and families while feeding the public and democratic debate on these social problems in our societies, which might lead to social justice and social change. This is a key characteristic of critical and democratic social work. We need social work and social workers who see this imperfection while still remaining committed to open up new questions. Nevertheless, the question might be more essential than the answer, as every answer holds the potential to shift evident meanings and to transform unjust realities, social inequalities, and power relationships in our societies into provocative issues (Roose, Roets & Bouverne-De Bie, 2013). This refers to social work being involved in a permanent reflection on the meaning of the ‘social’ in social work (Bouverne-De Bie, Roose, Coussée, & Bradt, 2014). As such we cannot expect social workers to play Super-Heroes or Deus ex Machina who master all the necessary skills to develop social work practices that ‘work’, yet we need to  embrace this ambiguity, and think about risks and mistakes.

Risks and mistakes

The key question here is whether there is openness to deal with risks and make mistakes in dialogue with service users, to jointly learn from this venture. This is a challenge, especially in the current context of a political climate that aims at the prevention and elimination of risks and mistakes, irrespective of the wider structural constraints in which service users live, which has actuality particularly in the field of child protection (Parton, 1998; Saar-Heiman & Gupta, 2019; Dewanckel et al., 2021). International comparisons confirm the widespread attempt in social policy areas to demand “total risk elimination” as performance goals in services (Beddoe, 2010), a trend that, as predicted by Beck, can only lead to an escalation of risk awareness and ever more stringent reliance on regulations and prescriptions that cover “all eventualities”. As part of ongoing processes of professionalization (Scourfield & Welsch, 2003; Stanford, 2010), approaches to risk assessment rather promote standardization, technical and diagnostic methods, tools, checklists and procedures than developing competences in more open-ended, uncertain, and dialogic ways of assessing and interpreting the ambiguous meaning of risk (Broadhurst et al., 2010).

Rather than creating ‘anxious professionals’, Roose et al. (2013) argue for the importance of reflexive professionals dealing with risks and thus potentially making mistakes, which can serve as an opportunity to learn. Dialogical approaches to risk attempt to embrace the ambiguity of the notion of risk by inserting social justice agendas into their work (Aronson & Smith, 2010; Stanford, 2010). Thereby, social workers might employ open-ended problem definitions of risk in complex situations as a starting point of dialogue with the involved service users. As such, risk is perceived in more positive terms as an opportunity to reclaim the emancipatory ethos that sits at the heart of the social work profession, since it can lead to democratic discussions about dilemmas, complexities and potential conflicts in the work with service users (Gillingham, 2006; Stanford, 2010).

With reference to mistakes, Sicora (2010, p. 158) refers to the metaphor of Columbus, who discovered America ‘by mistake’ while looking for a new route to India. In that vein, social workers need space to make mistakes and the opportunity to have open-minded discussions about these mistakes because, paradoxically, in many cases, it is the only way to develop a participatory approach and dialogue with service users and to enable social workers to find new ways to face the complexity of their work. Mistakes might enable social workers to consider mistakes as a point of departure for further actions, “the reflection on them and our failures is a promising field in which to develop strategies for the reinforcement of our professional skills, as social workers. Why? Because every mistake, especially those producing some forms of damage, are like open questions to our way of looking at the world and acting in accordance to it” (Sicora, 2010, p. 157).

Allowing for mistakes in interpersonal relations, including those of a professional nature, therefore might create an increased attention to surprising knowledge, including life knowledge of service users, and the positive value of all that “does not fit”. This is the point where social workers might draw on the specific aspects of reflexivity, as a set of critical collective capacities incorporating democratic principles and practices. When reflecting individually, in groups or in the context of supervision focuses on the non-defensive examination of differences in perspectives and also on mistakes (Sicora, 2017), democratic competences can be developed thereby promoting the sharing of responsibilities instead of feeding into “blame-games” that render services of all kinds increasingly defensive (Pellinen et al., 2018).

Case example 1: Reflexive discretion and social assistance in adult social work in acute and chronic crises (Finland)

A case study from Finland focused on both acute crisis (the covid-19 pandemic) and chronic crisis (the transfer of the basic social assistance from the municipalities to Social Insurance Institution of Finland, or Kela), and on how street-level workers working in the public sector use discretion in dealing with these crises. In both cases, there were no certain outcomes and professionals had to work in new ways to be able to provide clients the help they needed. Crisis highlights the need for discretion and underlines street-level workers' ability to reflect on their own basis of knowledge and consequences that different courses of actions may have (Sipilä, 2011). In the context of crisis, street-level workers are challenged to evaluate ethical aspects when making decisions about which course of action to take. When basic social assistance was transferred to Kela and the covid-19 pandemic started, street-level workers needed to evaluate whether to follow the guidelines or make more creative solutions in individual clients' situations. Street-level workers needed to evaluate which values are the most important; to fulfill clients’ basic needs (for example money for food) or to follow the guidelines if clients’ needs and the guidelines are contrary. Creativity is important from the clients’ point of view because clients' needs and life situations can’t always be fitted into strict categories in line with the guideline. Both crises illustrate that social work and social services can change quickly in times of uncertainty by taking risks and making mistakes. For example, services provided on digital platforms made progress, even though this has had both good and bad consequences from the clients’ point of view. Digital platforms were good for those clients who have the equipment (like a computer) and digital skills, and bad for those who didn’t have them who were at higher risk of not getting the service they need. Social workers had to make creative solutions to provide service to those who had the possibility to use digital platforms as well as for those who didn’t have them (Iivonen & Kivipelto, 2022). Clients’ individual needs and crisis situations demand that professionals use discretion creatively and to be able to do this, the social workers’ professional and reflexive skills are crucial. Street-level workers play an important role in defending democracy during a crisis (Brodkin, 2021). Discretion used creatively by professionals can attenuate the unequal consequences that crisis could otherwise create.

Case example 2: Reflections about participation in the delivery of social work education: the SAOL Women’s Project (Ireland) 

One of the Irish case studies reflected on the participation of women in recovery from addiction via the ‘SAOL Women’s project’ in the delivery of social work education. In recent years there has been an increased emphasis on strengthening the integration of reflexivity and participatory approaches in social work education, research, and practice including the involvement of service users in curriculum planning and delivery (Social Work Registration Board, 2019). Universities are potentially a powerful resource for the public good (Facer et al., 2012) however, the international literature on participation suggests a number of challenges and opportunities. Of particular concern is the tendency towards ‘tokenism’ despite the intention of social work academics and the practical challenges of transfer of power to service users (Blomberg et al.2021). The case study of the SAOL project illustrates the importance of embracing ambiguity and taking a ‘leap of faith’ to strive for more meaningful engagement. This was demonstrated during Covid19 when teaching input by the SAOL service users was reduced and service users challenged what they perceived to be the ‘tokenistic nature’ of their involvement with the students, demanding more meaningful input or withdrawal from the teaching programme. This triggered a complete review and re-evaluation of the nature of SAOL’s involvement resulting in the reintroduction of additional teaching hours and a new co-designed video assignment for the students that the service users helped to design and jointly grade. This case study suggests that there may be a tendency to invite those who are ‘easiest’ to engage with which typically, this means highly educated, neuro-normal, verbal, trained, extrovert individuals (Locock et al.2022). As social work educators and researchers, we must challenge these embedded stereotypes of 'vulnerability' and recognise that vulnerability is a two-way process and that we are also vulnerable within participatory processes. When the barrier to vulnerability is about safety, the question becomes: “Are we willing to create courageous spaces so we can all be ‘heard’?” 

Critical questions for reflexivity

• During the presentations, examples of working with students were provided several times. However, it was noted that students often expect certainty and delineated tasks in group assignments, which is in contrast to the uncertainty and ambiguity of social work. We believe social work education and group assignments can play a crucial part in articulating and developing knowledge to respond to uncertain circumstances in social work practices. While uncertainty might lead to a negative response such as fear and anxiety (Afrouz, 2021) among students, the ‘vulnerability’ of uncertainty could be approached positively through the openness for creativity (Fook, 2013). COVID-19 was a reminder of what uncertainty looks like and how this influences higher education in the development of the curriculum and pedagogical approaches (Afrouz, 2021). 
• Social workers should not try to solve their ambiguous position, but do need to recognise it (Devlieghere & Roose, 2022). How can we make this approach tangible and usable for social workers in practice?

5. Concluding reflections

The various case examples that were explored and discussed during the Intensive Programs in Dublin and Ghent illustrate that a reflexive professionalization is necessary to deal with the intricacies and challenges that participatory approaches in health and social care practice development, research, and education present. A reflexive professionalism embraces the notion that attempts to develop participatory health and social care can be met with resistance, non-participation, exit out of participation or unintentional exploitative or exclusionary consequences including tokenism. In that vein, our collective experiences and considerations led us to link reflexive with democratic approaches to knowledge creation and practice development. Taking democratic professionalism as a normative and guiding orientation to engage with the complexities of participatory ventures aligns with relational approaches to reflexivity that point to the various relationships between professionals, service users, organizations, policy makers and society at large that are at the center of health and social care practice (Dzur, 2008, 2019; Kessl, 2009; Vandertier, 2021). The democratic and reflexive quality of the participative process then lies in the fact that neither professionals ‘as experts’, nor administrators, managers or funders of services nor indeed service users have the monopoly on deciding what counts as good, participatory practice. Instead, the phenomena of contradictions, differences, conflicts, antagonism, non-participation, exit and resistance that inevitably arise in and from user participation are considered as always situated at the center of health and social care practice development. Only from this premise can they be made subject of a democratic dialogue in which the relationship between professionals and service users is shaped in ways that service users are recognized as citizens. In these interactions, the importance of democratic structures and practices can become a lived experience and thereby can trigger both in service users and professionals an engagement with governmental institutions and civil society movements, mediated by but not dependent on professionals (Dzur, 2008, 2019; Vandertier, 2021). We furthermore propose that educational and professional support programs embrace the potential that arises from a more direct involvement of service users in teaching and promoting reflexivity. This potential lies partly in the fact that learners are confronted with the specificity, but also the ‘non-categorizable’ intensity of service users’ lived realities in a relatively protective context in which reactions can be analyzed as to their hypothetical consequences without leading to immediate changes. Equally, such situations are learning experiences for service users as well as it can facilitate reflection on dimensions of their situation that had previously not been accessible to them. This means that both sides become engaged in processes of negotiation over divergent normative assumptions in which ‘the right course of action’ is neither a foregone conclusion on account of the weight of scientific knowledge, nor a matter of ‘pleasing the client’ by settling formally on a consensus. Instead, core principles of democracy are set in motion in such circumstances when conflicting perspectives, interests and normative assumptions surface and call for decisions arrive through a research-driven curiosity and reflexivity to critically interrogate the theories, values, problem constructions and power differentials that are implicit in our endeavors to develop participative approaches to health and social care (Singh & Cowden, 2009).

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