4. Themes, case examples, and questions for reflexivity

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.