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Issues of power in social work practice in mental health services for people from Black and minority ethnic groups

By

Victoria Jupp, BA, DipSW, MA
School of Applied Social Science
University of Durham
Durham, England

 

Abstract

This article provides a critique of some theories of power when applied to social work practice within mental health services for people from black and minority ethnic backgrounds. Current research into the experiences of black and minority ethnic mental health service users is analysed to demonstrate the centrality of power within social work practice. The article argues that social work should be viewed as a process of change that allows for the individuality of the service user, alongside the necessity of social workers acknowledging power differentials and taking responsibility for their own power in order to develop a continual critique of the empowerment process.

Introduction

This article provides an analysis of some theories of power when applied to social work practice within the mental health sector, relating specifically to service provision for people from Black and minority ethnic groups. Focusing on the effects of power differentials, both within social welfare structures and between social workers and service users, this article aims to form practical and realistic recommendations for the improvement of practice. In terms of this discussion the definition of power as a word is not so much at debate but more the definition of power as a concept. It is this concept of power that will form the focus of discussion. The accuracy of the term ‘service user’ is debatable, particularly when compulsory care is used, but it is currently the most widely accepted term to refer to people using social service provision and so will be used within this article.

Theories of Power

Two main theories of power will be used as basis for discussion, which are Lukes three-dimensional model of power encompassing a critique of the Weberian concept of legitimate power and the post-modernist view of power by Foucault.

Lukes developed a three-dimensional model of power, which was an extension of previous one and two-dimensional theories (Bachrach and Baratz, 1962), which Lukes saw as inadequate due to the failure to include the social nature of power or the ‘third dimension’ (Lukes, 1974, p. 38). Lukes argued that power is socially structured:

…the bias of the system is not sustained simply by a series of individually chosen acts, but also, more importantly, by the socially structured and culturally patterned behaviour of groups, and practices of institutions, which may indeed be manifested by individual inaction
(Lukes, 1974, pp. 21-2)

For Lukes, power is ‘socially and culturally located’ (Hugman, 1991, p. 32). Consequently power is not equally distributed throughout society and it is the cultural norms of the majority population that dominate the social agenda. There is a ‘latent conflict, which consists in a contradiction between the interests of those exercising power and the real interests of those they exclude’ (Lukes, 1974, p. 25). Hugman argues that the three-dimensional perspective has two primary implications for social work. First, social workers exercise power but may be unaware of doing so and second, the position of social workers needs to be examined within the social work structure as this may affect what they see as their role (1991, p. 33). For social workers working within the field of mental health the move towards mainstreaming has further compounded the dominance of ‘Eurocentric, male social understandings of the world as the source of explanatory theories and therapeutic ideas’ (Graham, 2002, p. 36). If social workers are unaware that they are working within a social structure that excludes minority populations because it is designed to serve to cultural norm they will not challenge it, and will continue to exclude sections of society.

Lukes also questions the concept of consensus. This challenges the Weberian view of legitimate power and Arendt’s communications theory (1970), as both are based upon the idea of collective consent. Lukes introduces powerlessness and argues that consensus may be a result of the social structure of power. In other words, that a person agrees to an action, but this may be due to the social position of the professional rather than the agreement of the person. This is a central issue in mental health due to the ‘latent coercive power’ (Hugman, 1991, p. 34) of social workers through statutory legislation. A service user may agree to enter or remain in a psychiatric unit, not through voluntary consent, but through the legitimacy of power of the social worker that has been established under the Mental Health Act.

The post-modernist view places communication and knowledge as central to understanding power within society. This view moves forward from the ‘guiding principle of modernity…to establish reliable foundations for knowledge’ (Parton, 2003, p. 6) which reinforced existing power structures by increasing the status of ‘professionals’, who are seen to be producing knowledge. Foucault argues that ‘knowledge and power are inseparable’ (Foucault, 1980), and value placed upon professional knowledge marginalizes local knowledge, or ‘subjugated knowledges’, which are displaced by the ‘dominant truth’ (Pease, 2002, p. 141). Foucault referred to the focus on professional knowledge as professional discourse, and it is this concept that is a key factor in analysing power within social work.

Why should social workers take issues of power into account?

Social work is ‘innately political and so all about power’ (Hugman, 1998 cited in Bar-On, 2002, p. 998). Consequently, it is essential that social workers understand the effects of power within society, and within the structures in which they work. This leads us immediately to an interesting paradox. Social workers are often reported within the media as either ineffective or too forceful (COI Communications, 2001, section 12.7), placing them in the powerless – powerful dichotomy. Social workers themselves acknowledge this, feeling powerless when dealing with other service providers (Bar-On, 2002, p. 997), but believing they are overly powerful in terms of their statutory powers. This leads us to two main streams of thought in understanding why social workers should take issues of power into account in their work with service users. First, social workers need to understand why they feel powerless within their work, as it is only once they feel empowered themselves that they can then move on and try to understand, and combat the negative effects of power differentials on service users (Stanton, 1990). In order for social workers to successfully challenge power structures that perpetuate oppression, they need to understand their position within those power structures. For ‘if practitioners are not part of the solution, they must be part of the problem’ (Braye and Preston-Shoot, 2003, p. 114).

Second, social workers have a unique position within society in that they work both for the service user, and for the good of society as a whole. These roles can result in 'tension between a loyalty to the service users on the one hand and to the service agency and public authorities on the other’ (Askheim, 2003, p. 235), particularly within the field of mental health. A study conducted on behalf of the Department of Health found that detentions under Part II of the Mental Health Act 1983 were over six times more likely to be of black people than of white (Audini and Lelliott, 2002, p. 222). Only data from local authorities and NHS trusts that were willing to participate was used for the study and of these most had some missing data, all had differing categorization for recording ethnicity and the more prosperous areas of England were underrepresented. These factors may have led to the overrepresentation of black people within the study but considering the ‘dearth of research on the mental health care experience of minority ethnic groups’ (Sashidharan, 2003, p.10) it is the most comprehensive study undertaken within this area. One of the reasons for the difference in rates of detention identified by a previous study was the more frequent history of violence among black people (Wall et al, 1999). This stereotypical view of black people has resulted in them being treated differently within the mental health system due to the dominance of white ideology within society. Consequently, social workers have been forced into a position to choose between what may be the best course of action for the service user, and what society demands of them. The evidence suggests social workers are more heavily influenced by the demands of society than the ‘real interests’ of the service user. This demonstrates their increasing reliance on latent coercive power by the use of statutory legislation, which in turn reinforces the powerful-powerless dichotomy.

The dichotomous view of power is exacerbated within social work due to the ‘oppositional construction of the worker and client’ (Pease, 2002, p. 138), which forces the worker into the powerful position, and the service user into the position of powerlessness. This creates an environment in which the worker is able to control and direct a course of action which may be based upon one-dimensional frameworks of understanding human behaviour that exclude the experiences, values, ideas and interpretations of marginalized groups (Graham, 2002, p. 43). The exclusion of marginalized groups from the professional discourse that frames our understanding of social problems perpetuates stereotypes and ensures the continuation of oppression. Paradoxically, despite the adoption of anti-oppressive practice as a ‘guiding theme in social work teaching and practice for at least a decade’ recipients of social work have been minimally involved in discussions around the development of anti-oppressive practice itself (Wilson and Beresford, 2000, p. 554). This exclusion ‘reflects the critical power imbalance between groups in society, and the legitimization of knowledge’ (Dei, 1999 cited in Graham, 2002, p. 36). Mental health service users from ethnic minorities feel that ‘organizations misrepresent, misunderstand and seek to control their experiences and methods of expression’ (Rai-Atkins, 2002, section 1) and are culturally inappropriate or insensitive to their needs (Graham, 2002, p. 37). This demonstrates the link between exclusion from professional discourse and oppression. Inappropriate services based upon social stereotypes fail service users from minority backgrounds:

“I have so much difficulty in getting white professionals to see me as a black person. I feel they see me as a stereotype and not a person.”
(Black service user, cited in Rai-Atkins, 2002, section 3)


“The reality is I see myself as ‘normal’ but a lot of people don’t see me as normal. I see other people who have similar experiences as me but they are not seen as mentally ill…I often question if it’s my culture, gender, and or age that gets a negative reaction.”
(Black service user, cited in Rai-Atkins, 2002, section 3)

Power is central to issues of race within social work, especially when the white social worker is unaware of the power differentials felt by a black or ethnic minority service user. An Asian advocate in Rai-Atkins study said how “Asian women don’t feel confident in expressing their views to white professionals” (2002, section 4). My own experience of working for a white female manager in rural South Africa confirms the importance of awareness of your own power. My manager was unaware of the power differentials between herself and the local black volunteers which created misunderstandings and confusion for both herself and the volunteers, and which ultimately prevented the program from running effectively within local communities. It was only as she began to take the differences in power into account that new procedures were introduced to try to improve communication through the employment of field workers who attempted to work as advocates for the volunteers.

How should social workers take into account issues of power?

The key term when analyzing how social workers should take power into account with their work with service users is empowerment. However, this term is highly contested. Firstly, it assumes that power is something that can be given; that to ‘empower’ someone is to confer power (Pease, 2002, p. 137). This in itself causes confusion, as it can be argued that it is only the oppressed who can free themselves, as any attempt from the oppressors to empower is a ‘false generosity’ (Freire, 1996, p. 26). Empowerment is not just about giving away power, but about the oppressed people taking the power and demanding to be heard (Braye and Preston-Shoot, 2003, p. 100). Second, the term is also used at different levels. The micro-level of empowerment focuses on the individual and increasing their feeling of power whereas the macro-level of empowerment is a process increasing collective political power (Dalrymple and Burke, 2003, p. 52). Third, the term has also been used to support radically different philosophical and ideological positions (Pease, 2002, p. 136). Consequently some theorists argue that empowerment can be manipulated to conceal and reinforce existing power structures (Pease, 2002, p. 136; Braye and Preston-Shoot, 2003, p. 102).

As discussed in the previous section, a central concern within power is knowledge. Therefore to empower service users there must be a redistribution of knowledge and an ‘insurrection of subjugated knowledges’ (Foucault, 1977). Post-modernists argue that as professional knowledge legitimizes discourse that excludes service users, the only way to empower service users is to abandon professionalism (Bar-On, 2002, p. 997). This is an unrealistic demand, particularly in light of recent moves towards Kantian principles and a ‘duty to rules’ (McBeath and Webb, 2002, p.1034) in an attempt to increase the professionalisation of social work to combat negative media attention. A more realistic approach to empowerment has been developed into the concept of constructive social work (Parton, 2003, p. 4). Based upon social constructionism and post-modernism, this approach to social work incorporates the critical stance towards our understanding of and assumptions about our world advocated by constructionism. Focus is on social processes rather than attempting to form one overarching theory regarding the nature of our world. Particular forms of knowledge are viewed as products of history and culture, and that consequently there are numerous forms of knowledge as opposed to professional knowledge being the only legitimate form. This is a more realistic approach to challenging the power structures that perpetuate oppression of ethnic minorities as it incorporates many dimensions that include both the oppressed populations and social workers.

First, the move away from the modernist focus on professional knowledge towards a more critical approach challenges the dominant discourses and questions the knowledge / power connection (Pease, 2002, p. 142). This allows non-traditional social work approaches that aim for social transformation and social change (Solomon, 1976 cited in Graham, 2002, p. 46), to increase in influence. Service users’ knowledge and competence grow out of their personal and collective experiences, and as such their theoretical and conceptual framework will be radically different from those of academic theoreticians (Askheim, 2003, p. 235). In order for formal social work to learn from both service users and community organizations, which have proved more effective than conventional social work models (Graham, 2002, p. 37), it is essential that involvement is ‘on their own terms’ to ensure true empowerment, rather than lip-service that results in the continuation of oppression and discrimination (Askheim, 2003, p. 235). The inclusion of non-institutional welfare delivery would help to form a balance between the advantages of expertise, and the empowerment of individuals (Thompson and Hoggett, 1996 cited in Graham, 2002, p. 37). This change in approach would reduce the inequalities in service provision that result in the higher formal admission rates of people from ethnic minorities into psychiatric units. The mistrust of current mental health services among minority communities leads to delays in seeking help and presentation at a later and more severe stage of illness and is one of the reasons for higher rates of admission (Audini and Lelliott, 2002, section 4.5). Black mental health projects, although sparse, are starting to be recognized by government as central to developing a ‘culturally capable service’ (Sashidharan, 2003, section 2). Successes within the black community of Saturday and supplementary schools to combat the negative impact of racism within the educational system (Graham, 2004, p. 50) demonstrate the effectiveness of community organizations, and their level of cultural understanding challenges mainstream discourse. Social workers need to utilise these resources, and form ‘meaningful’ (Graham, 2002, p. 46) professional partnerships with community organizations and be prepared to learn from their experiences and expertise.

The move towards social processes is a key change in terms of empowerment within social work. Empowerment is ‘a continual process of growth and change’ (Friere, 1996). The emphasis on process encourages the social worker to listen to the story of the service user, thereby externalizing it and allowing the service user to retain more control on how to manage, or overcome the problem (Parton, 2003, p. 13). Rees argues that ‘the processes of empowerment may cover the story of a lifetime’ (1991, p. 86). He identifies eight stages of empowerment and argues that in order to achieve objectives the process of change that one must go through all stages. The focus is on the service user, using their language and identifying their problem within the wider social context. This ‘dialogical approach’ (Friere, 1996) avoids many of the criticisms of current social work practice by allowing service users to identify their own needs and solutions rather than having to fit a social model. This is an essential move within mental health services as current practice results in people from minority ethnic groups being prescribed drugs rather than taking treatments such as psychotherapy and counselling (Sashidharan, 2003, standard 4 and 5).

In order for social workers to empower service users from minority backgrounds it is essential that they develop a ‘historic and longitudinal view’ to be able to understand the ‘historic and contemporary racism and cultural disparagement of subjugated groups’ (Graham, 2002, p. 40). Within my own experience of working with young black people in one of the poorest states in Brazil, the effects of the history of slavery still dominated the way they viewed society, and had very negative effects on how they viewed themselves within that society. It was not until I was able to talk openly with one of the youth and he felt able to speak to me, that I was able to more fully understand his attitude and behaviour by placing it within his historical context.

Conclusion

Throughout this article it has been demonstrated that power is a complex, highly contested concept. When taking issues of power into account it is essential social workers keep three factors in mind. First, they must be aware of their power both in terms of the power balance between themselves and the service user, but also within the social services structure. This will allow for new social work models and approaches to be introduced into social work practice that are more flexible, and include community groups and service users in their own empowerment. Second, power is not a commodity to be given by the powerful to the powerless. Empowerment is a process of change with the service user at the centre, and social workers must facilitate this change rather than direct it. This may sometimes conflict with what the social worker sees as the ‘real interests’ of the service user due to the nature of internalized oppression, (for more discussion see Braye and Preston-Shoot, 2003, pp. 109-110) but this form of self-oppression is rooted in powerlessness. To enable the service users to move forward, the reasons for their feelings of, or actual, powerlessness need to be addressed rather than the social worker overriding their decisions because they ‘know what’s best’. Third, social workers need to take responsibility for their power. Power differentials will always exist between the social worker and service user. This needs to be acknowledged and valued, rather than viewed as a barrier to empowerment. Social workers need to incorporate these ideas into day-to-day practice to actively and overtly encourage an inclusive social service structure. This will allow for a process of continual critique and analysis and thereby avoiding the potential danger of empowerment being seen as an end in itself.

Empowerment as emancipation may be dangerous, like any other discourses, to the extent that it sees itself as not requiring further justification or critique
(Foucault, 1984, cited in Pease,2002, p. 138)

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Victoria Jupp, MA can be contacted via e-mail at:
v.k.jupp@durham.ac.uk

 

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