Problems of Effective Functioning
by James K. Whittaker Associate Professor, School of Social Work Chairman, Human Services Sequences University of Washington, Seattle, Washington
Attempts to define the remedial field often lose more than they gain in elaboration. Once stripped of the categories – “mental health,” “corrections,” “retardation;” unencumbered by the labels – “multi-problem family,” “emotionally disturbed child,” “juvenile offender;” and liberated from the technical jargon – “psycho-social diagnosis,” “therapeutic intervention,” the remedial field may be seen in its essence: which is, quite simply, people helping people.
It is of course true that we now know a good deal more about the kinds of problems people have and, hopefully, more about how to be of help to them. But quite apart from the techniques, at the heart of every true remedial effort lies a personal encounter between two people attempting to share in each other’s humanity with the ultimate goal, in the words of Jane Addams, of “raising life to its highest value.” This concern for the worth of individual life – from Mary Richmond’s exhortations to respect the dignity of clients, to present efforts directed at humanizing social work practice – emerges as a central point in the last century’s history of remedial efforts in the field of social welfare.
At present, the problems facing the remedial field are legion: internecine quarrels over which “technology” of helping works best and when and how it should be delivered; problems of financial support, particularly among the voluntary agencies; mounting volumes of research which question the efficacy of present methods of social treatment; and larger issues raised (again) by the social actionists and (anew) by the environmentalists which at times question the wisdom of financing any ameliorative efforts when what are so clearly needed are massive programs of prevention and protection. Of course there have always been strains within the helping professions and pressures from without, but at almost no time were they as divisive and intense as at present.
In all quarters of the remedial field one may hear the rumblings of dissension and view the bitter fruits of an effort plagued always with two few resources and often launched too late to provide anything but the most superficial of care.
In the children’s field, while the numbers of dependent children in institutions has dropped sharply over the last fifty years, the number needing some form of help with emotional problems has risen to the point where the President’s Joint Commission on the Mental Health of Children estimated that we are currently providing care for roughly one-third of the children in need. The inadequacy of our institutions to deal with the problems of juvenile offenders, indeed the inadequacy of our system of juvenile justice which still sees young children placed in detention whose only “crime” was that they were the victims of crisis or neglect, is still evident despite numerous attempts at reform. Programs in specialized problem areas like juvenile drug abuse still fall far short of the mark of adequacy and conditions in some institutions for the mentally retarded child give the lie to the belief that this nation has adopted the admonition of Dewey that “What the best and wisest parent wants for his own child, that must the community want for all of its children.”
In the field of corrections the inability of present programs and resources to meet current problems are visible like so many open wounds throughout the land. The rare adult offender who does survive his period of incarceration unscathed is likely to be released to a community suspicious of his presence and offering few of the supports he needs to readjust to the demands of productive social life.
The crisis in health care touches virtually all in the society and beyond the obvious and acute manifestations of physical trauma and disease, lie the more subtle but equally painful symptoms of emotional suffering and neglect. Family disorganization and break down, personal despair and anxiety, depression fueled by an inability to deal with systems grown too large, alienation and anomie among the young and a yearning for a sense of fulfillment and meaning on the part of many, capture but a few of the conditions deserving of remedial help, yet they often go unaided because of insufficient programs or inadequate funding.
The targets for healing span all age groups- from preschooler to aged pensioner – and all classes, though many wear the double yoke of poverty and dysfunction. With so sweeping an agenda for change and so loud a call for help, one wonders at times if any degree of progress has been made or will be forthcoming. On reflection, it would take all but the most biased reading of the last century’s remedial efforts in the field of social welfare to fail to admit that many advances had been made: in child health and protection, in community programs for delinquents, in family counseling and mental hygiene: progress to be sure, but so much needing to be done. Equally difficult to assess is the reason for the insufficient action: professional in-fighting, lack of financial resources, embryonic technologies of helping – all may share some culpability as contributing causes. But perhaps in some later analysis the real impediment will be seen less as a shortcoming in finance or technology and more as a failure of will: a conclusion waxing more plausible with each commission report, senate hearing, or social outcry adding to the seemingly endless litany of voices proclaiming what needs to be done. All of this makes extremely difficult the task of predicting where the remedial field is headed: so numerous are the variables, so considerable the unknowns.
But while no one can be sure precisely where the helping field is going- one reading would see several vectors rather than a single direction – perhaps some sense of where we are going may be garnered from a careful analysis of where we have been.
The remedial field has always been marked by gulfs and divisions. Presently they are philosophical and technological; previously they were geographical. Indeed, the bridging of distances – between cities, states and regions – and the emerging recognition of a common community of interest were central to the development of helping services in the final quarter of the last century. The period was also marked by a certain optimism and a special enthusiasm, almost as if the discovery of common problems and mutual interests, as well as the conquest of physical boundaries, portended solutions soon to be found.
If some differences of opinion existed about causation of problems – from moral turpitude to social influence, to characterological defect – relatively little dissension could be found regarding what needed to be done. Families needed adequate food, clothing, shelter and medical care. Children deserved a wholesome environment for growth and development. Those special children deprived of natural parents through death or desertion required devoted and loving foster families, or as a last resort, home like institutions for care. Nearly all remedial efforts involved some form of environmental manipulation: removing the waif from the city streets; finding a flat for a newly arrived immigrant family; converting the child care institution from barracks to cottage; placing the mental patient in uplifting surroundings; and removing the delinquent from his criminal associations. All of these efforts were based on a view of individual problems as greatly influenced (if not created) by social conditions.
It was natural then that along with individual “case work,” there was a need for a more general societal effort directed at the root causes of the specific problems. Poverty, inferior housing, overcrowded cities, poor health care – all required an attack along a much broader front. What Mary Richmond called the “interdependence of individual and mass betterment” was a cornerstone of the emerging social welfare profession and was very much in evidence at professional conferences and symposia. Reform and remediation went hand in hand into the new century with the belief that both were needed if truly efficacious solutions were to be- realized. Much happened between then and now – currents occurred which at times caused deep rifts between the two movements – and only recently has the old alliance been revitalized.
In the intervening years social work and the remedial field got organized and went professional. Summer training institutes were replaced by graduate professionals schools of social work; loosely knit federations of friendly visitors became social welfare bureaucracies; common sense and dedication in charity workers were supplemented by a professional technology; problems – once simply defined in social or moral terms – were seen as vastly more complex entities requiring sophisticated forms of intervention. By the late 1920s and over the vehement protestations of many of the older social actionists, the shift had been made from “cause” to “function.” Indeed, Porter Lee’s 1929 presidential address couldn’t have more accurately described the differences between the new helping professionals and their earlier counterparts: “an embattled host for the cause, an efficient personnel for the function.”
Well before Lee’s address, growing numbers of new professionals — heeding the criteria for professional advancement suggested by Abraham Flexner at the 1915 National Conference of Charities and Correction (Ed.note: read: Is Social Work a Profession?) – were hard at the task of defining the new orientation to helping. And so much needed to be done. Educational requirements were stiffened and the two-year master’s degree program became the entry point to the new profession. National organizations were formed to accommodate to the varying professional needs of medical, psychiatric and family social workers. Casework and group work emerged as distinct methods of helping and various theoretical positions gathered their ardent supporters. Chief among these was the new dynamic Freudian psychology which tended to view difficulties as more internal and emotional and less external and social. The treatment of choice shifted considerably from environmental manipulation to insight- producing counseling. No matter that the actual number of psychoanalytically trained practitioners remained small: theirs was still the model to be followed. In time, the majority of professional schools of social work would adopt an essentially psycho dynamic orientation to human development as well as to practice. This new emphasis on the insight-focused interview conducted in an office, coupled with the growing bureaucratization of social welfare agencies – with the concomitant separation of function and division of labor – tended to remove individual workers at least one step from the earthly engagement between family and friendly visitor that had characterized earlier times.
A great deal of attention was paid to developing the new technology of helping – psycho-social diagnosis, case planning, treatment intervention – as well as to delineating a whole new taxonomy for human problems. The “illness-treatment” model gradually grew in prominence and adjustment to (rather than changes in) social conditions became the watchword.
The mental hygiene movement, by the late 1920s heavily psychoanalytically dominated, offered, in addition to a new technology of helping, a ready-made structure for the new professional social worker to operate within: the psychiatric team. Basking in the glow of reflected status from psychiatry, the “psychiatric social workers” became, as one writer notes, the “Brahmins” of the new profession. Specifying the social worker’s “role” and function – on the psychiatric team, on the hospital ward, in the community agency became a preoccupying issue for the profession. Again the new professionals were moving further from direct contact with the totality of the individual or family problem. Precise role definitions and specification of function read well on the organization chart, but often ill-matched the multiple real life problems of clients.
Whatever else one could say about the remedial segment of the social welfare field from roughly the end of World War I until relatively recently, it is certainly fair to characterize it as having undergone a great turning inward upon itself: a turning inward that had its salutary features to be sure – the development of professional standards, a greatly improved technology of helping – but which also spawned a kind of social myopia for which the profession was to be called accountable in later years.
The remedial field today exists in a state of siege. So ubiquitous is the conflict, so intense the battle, that all but the loudest of salvos and the sharpest attacks go virtually unnoticed. The quest for professional normalcy has become the struggle for professional survival.
From without, the remedial field – in particular, the social work profession – has been called to task by numerous client groups for being unresponsive to their needs and problems. Racial and ethnic minorities among others have challenged the helping professions to become more socially active on their behalf, to become far less ignorant of the culture and values of the groups they work with and, above all, to direct change efforts not at individual pathology, but at the pathological social conditions in which clients — particularly if they are poor, or a member of a minority group — must live. Especially telling is the charge that the very agencies and institutions – now often grown to huge bureaucracies – once designed to alleviate human misery, are now serving to perpetuate it. Clients are demanding more humane and relevant programs, more active participation in the helping process and more control over the provision of services. Laudable aims to be sure: but how to incorporate them into that now firmly ensconced “professional role” so long in the forging?
Other attacks come from the sources of support- public and private funding agencies. Disenchanted by promises never kept, by expectations never realized, and faced with increasingly insufficient revenues to meet growing service needs, the funding agencies are turning from the helping professions to other quarters for aid in solving human problems. “Accountability” and “cost effectiveness” are the by-words of the new managerial orientation to human social problems. In particularly dire straits are the private agencies – long accustomed to viewing themselves as the arbiters of innovative practice – now struggling mightily to retain their autonomy and leadership and fearful of encroachment from the public sector. Even more generally, the entire remedial field suffers to an extent from a kind of “post Poverty Program hangover” on the part of the public, causing — as the president of the National Association of Social Workers recently noted — the lowest degree of acceptance for social welfare programs and social work professionals that he could remember.
As if the wave of anti-professionalism, disenchantment of the public, severe shortages in funding, and client demands were not enough, other tremors emanate from within the remedial field itself and from several sources. Some urge the almost total abandonment of palliative services in favor of action-oriented, system-focused strategies directed at the root causes of individual problems. Poverty, racism, inequality and urban blight should become the major targets for the helping professions the argument goes: to do otherwise is to offer a soporific when what is needed is major surgery. This particular thrust really a whole series of separate pressure points within the field – multiplies considerably the range of possible targets wherein already scant resources must be directed.
The plea to redirect resources to larger targets appears to be supported by a growing litany of research reports all questioning the effectiveness of case-by-case intervention. While some results can properly be attributed to faulty research design, the point seems to have been made that , by and large, individual attempts at remediation have not been successful to any appreciable extent. In the beginning, such studies served only to create spirited discussion in the professional literature; now they provide damaging evidence to those management-focused public officials seeking more cost effective solutions to individual problems.
Partially as a result of these discouraging research reports, professional orthodoxy particularly adherence to psycho-dynamic theory has been replaced by a theoretical pluralism unparalleled in the remedial field. Far removed from any kind of systematic eclecticism, the knowledge base of remedial practice today resembles a collage of bits and pieces of theory,practice research , isolated techniques and highly personalized approaches strung together by the flimsiest thread of adherence to professional ethics. Whatever common core of knowledge could have been assumed in the the past has shrunk to minuscule proportions, as social welfare practitioners, theoreticians and students battle with each other over who possesses the “truth.” Perhaps most troubling in what could be a healthy ferment of new ideas is the social fervor with which many are pursued. One would have thought that after the remedial field’s almost total acceptance and later disenchantment with Freudian theory the profession would be more cautious as one writer states about “granting the status of an axiom” only to snatch it away again at a later time.
Along with internal and external forces, the remedial scene has been substantially altered in recent years by changing values and attitudes of the public at large. More liberal acceptance of out-of-wedlock pregnancy and single parenthood has forced many maternity agencies to radically alter their programs or go out of existence. I n juvenile corrections and mental health, the trend toward more community-based forms of treatment signals major changes in the service structure a bitter pill for some segments of the remedial field who for years have been arguing for “more of the same” facilities and programs.
New populations of clients, like the young drug user, and new forms of service delivery, like the crisis clinic, have given rise to a whole spate of new agencies and programs, often staffed by non-professionals and operating outside of traditional social welfare agencies. Even private industry is now making inroads into the social welfare field : franchising service programs, training staff, and offering consultation to government. Little wonder that some of the members of the old coalition- private agency executives, professional social workers and public welfare personnel feel at times as if events have passed them by and what was once solidly their “turf” must now be shared with consider able numbers of others. Faced with such formidable and diverse challenges, it is little wonder that some would yearn longingly for the days of theoretical orthodoxy , client acceptance, and public support. Some, indeed, would view the current crisis in the re medial field as merely transitory the result of , say , a hostile administration, or economic recession, or “flash-in-the-pan” new programs.
It is difficult to accept this position in light of what is now occurring in the remedial field. Basic structural revision, rather than superficial change would appear to be the logical outcome of present trends. The critical question is, of course, what will the remedial field of the future resemble?
If one rejects out of hand the notion that things will remain exactly as they are in the helping field, or revert to some prior state of relative tranquility , then also to be discarded is the view that we are now witnessing the death of the entire remedial field. Two factors would seem to argue against this latter course. First, even with a totally new set of social institutions- as many actionists would argue for- there will still be a need for remedial services. Who will presume to suggest, for example, that new institutions will not in themselves create new problems of adjustment for individuals, requiring new methods of remediation? In truth, the problem with the whole “remediation-reform” question is that goals and means have become misplaced: needed changes in present social institutions will not be brought about by remedial services, nor will the eventual realization of those systematic changes do away completely with the need for ameliorative programs. Clearly , both reform and remediation must proceed together in a manner similar to that envision ed by the social welfare pioneers of the early part of this century . While surely no solution – to a social welfare organization, or social agency or individual practitioner faced with scant resources of time and money – it at very least helps to focus the problem squarely in “both/and” terms rather than in the “either/or” logic some would prefer.
A second factor which seemingly will insure the continuance of the remedial field in some form is the increasing demand for more services of all kinds by a public that finds itself with the leisure time to become increasingly concerned with individual betterment and overall quality of life. The demand for more family life education and the encounter group movement provide two fairly recent examples of where public demand has created new services. Assuming, then, the continuance of the remedial field in some form; what will it resemble? Cognizant of the risks inherent in hard-nosed predictions, it is perhaps more productive to speculate on what might be true in the remedial field if a common effort were made to shape the casting of the future mold.
First among priorities would be a total rethinking of the values and ethos that inform the field of interpersonal helping What is needed is a value set that is in keeping with the principles of a sound ecology and that stresses the highest and best quality of individual, group and community life. Specifically, this would entail an orientation to remediation – whether in corrections, health, or welfare, which stressed “growth and development” rather than “illness and treatment,” and sought to diminish rather than highlight the differences between the helpers and the helped. The recognition of the fullest potential for any client, whatever his diagnostic label – should be the primary goal of all remediation. This cannot and should not mean merely the readjustment of an individual to an essentially unhealthy social condition.
Further suggested is that all remedial efforts redirect themselves at real life problems of people in need and not at preconceived and method-defined notions of what the difficulty is. In short, all attempts should be made to lay renewed emphasis on the social aspects of remedial practice and make the method of helping conform to the client’s problem and not vice-versa. Central to the remedial process should be the joint efforts of helper and helped pooling their resources in a voluntary relationship to achieve a commonly agreed-upon goal. This means that involuntary treatment , coercive practices, or anything less than a full sharing of confidence between client and worker will not be acceptable.
The problem of competing theories of change should be squarely faced in the full recognition that we remain far distant from anything resembling a unified theory of human behavior, or a highly reliable solution to any of the multitude of problems with which we deal. Experimentation and eclecticism should be encouraged in social agencies and in professional training. Differences of opinion, or theoretical persuasion should not assume the “thou-shalt-believe-all-or-nothing” quality they have in the past, but rather the attempt should be to build bridges rather than to shout across the chasm. Along with the eclectic approach to practice should go a thorough program of evaluative research to try to provide answers to the question, “What works best?” On this point it would be wise not to “oversell” whatever we have to offer. No single attempt at remediation will “cure” delinquency, or completely solve a community’s drug problems, or minister to the total mental health needs of an area. Honesty and tempered optimism at the outset are probably the best antidotes to public distrust of professional intervention.
The area of service delivery is yet another quarter where rather major changes will need to be made. First, and perhaps most troublesome, are the whole spate of categorical programs that have developed over the years, each with its own definition of problems and array of services. The hard question to be answered is whether our present method of defining problems makes sense any more given what we now know about the interlink ages between human difficulties? A.J. Kahn has pointed out that most categorical definitions of problems represented social advances when first promulgated: “orphan asylum” signified that homeless children would no longer be indiscriminately placed in alms houses and “mental illness” signaled a trend away from viewing certain behavior as morally reprehensible or subject to criminal penalty. The dilemma at present is that the remedial field is now made up of a whole array of services clustered around certain problem definitions, usually with specific assumptions about etiology and amelioration. We must attempt to answer the question – in light of what we now know about human behavior and in terms of an orientation to growth and development rather than illness and treatment – of whether these categories, these problem definitions and these assumptions make sense any more. If they do not, then what better way can be constructed for dealing with problems of children and adolescents, or families in crisis, or the aged? These are extremely difficult questions to answer and the more so because of the enormous investment of the present _remedial establishment in the way it now views itself. The temptation, always, is to say, simply, that what we need is more of the same: more professionally trained social workers, more community mental health clinics, more institutions for delinquents. This approach – in the short view, uncritical- could ultimately leave the social welfare profession mired in its cherished programs while the remedial field moves on to new modes of service delivery.
Another factor in the service delivery area concerns the continued existence of some of the old dichotomies: “public/private,” “community/institutional.” The era of the totally self-sustaining, voluntary agency appears to be drawing to a close. Rather than guard against the inevitable merger with the public sector: at times to fill needed service gaps and to engage in joint attempts at service delivery. To those convinced that such a course would amount to the ruination of the voluntary agency, the question increasingly becomes “Which is of greater import – exclusivity or existence?” Finally, both voluntary and public agencies should prepare for the entrance of private industry and other vendors into the remedial field in the coming years. With this, as with the introduction of cost effectiveness procedures and a new emphasis on accountability, the remedial field must choose between an essentially proactive or reactive position.
As with the “public/private” dichotomy, the traditional distinctions between community-based and institutional agencies – in mental health and corrections- should give way to a single conception of an agency offering a whole continuum of services ranging from totally institutional to totally community-based with all variations in between . Diversification of services should be the watchword for those agencies concerned going the route of singe purpose organizations or agencies (like maternity homes for unwed mothers).
Lastly, the remedial field might do well to think some of restructuring services bearing in mind only the factors of access and egress: How easy is it to obtain the needed service? How difficult to terminate? Looked at in this manner, some services – for example, maternal and infant care, suicide prevention and food programs for the elderly- should be structured in such a way that it becomes extremely simple to get in and out of the service network as the need arises. Others, like juvenile detention or involuntary hospitalization, might be set up in a way that provided for difficult access and easy egress along the way.
A final concern that needs to be addressed involves the whole question of client advocacy. In a general sense, the definition of the remedial helping role must be expanded to weigh equally those actions taken on the client’s behalf, as well as those taken directly with him in the helping encounter. In a sense, this means no more than a return to the kind of collateral helping advocated by Mary Richmond at the turn of the century: helping the client negotiate a vast agency of government, providing assistance in an employment search, negotiating with the courts over a custody problem, or working with a teacher to insure a better home-school relationship. All things that social welfare professionals have always held important, but which were treated with somewhat diminished attention during the long infatuation with individual treatment. More specifically, to the issue of advocacy where clients’ rights are infringed through inhumane practices or punitive regulations, sufficient mechanisms should be developed through national professional organizations to provide the necessary support to both the aggrieved client and his work er.
In sum, the remedial field is likely to turn in several rather than a single direction toward greater emphasis on cost effectiveness and accountability; toward a gradual blur ring of distinction between public/private and community/institutional programs; toward an orientation based on human potential and growth and development rather than on a narrow conception of illness and treatment; toward greater participation of consumers in remedial programs at all levels; toward a more systematic eclecticism in theory orientation underpinned with a substantial research endeavor; toward greater involvement of new vendors in the remedial field including private industry and consumer groups; toward a rethinking of present problem categories and accompanying service systems with the goal of providing an inclusive service net with little or no stigma attached to the recipients and, finally, toward a renewed social consciousness on the part of agencies and helping professionals which places client advocacy at the heart of the remedial relationship. This could well be the form of the remedial field of the future.
How curious it would all appear to those pioneers who journeyed to New York in 1874 to pool their ideas to provide better services to those in need, or later to Mary Richmond and others like her who knew of the importance of such things as proper food budgeting and where to assist families in getting a load for fuel for cold winter nights; how strange indeed to talk in such obscure language of “cost accountability” and “service networks” when it was abundantly clear what needed to be done: families to be housed and made sufficient; children to be cared for in physical and mental health; offenders to be worked with and returned to society – and no talk here of divisiveness: broad social reforms must of course be mounted and remedial programs as well, to aid those who have already felt pain.
True, the numbers are now greater, the problems more complex, the obstacles more sizable; but enough to dampen the enthusiasm or quell the spirit of those pioneers completely? One thinks not. For behind that enthusiasm lay something of a cause: “to raise life to its highest value.” Perhaps this is what is needed now – along with the “efficient personnel,” the programs and research. If not exactly an “embattled host,” then certainly an aroused and spirited cadre of professionals, consumers, dedicated to raising the quality of life for all and, in particular, for those in special need of help. The remedial field of the future – whatever its form – could only be better for the trying.
James K. Whittaker, who received his Masters of Social Work at the University of Michigan and his Ph.D. at the University of Minnesota, is currently Associate Professor and Chairman of Human Services Sequence at the University of Washington School of Social Work in Seattle. His main areas of scholarly interest are social treatment and the children’s field. His recent publications include: The Other 23 Hours: Child Care Work in a Therapeutic Milieu (Aldine, 1969); and with A.F. Trieschman, Children A way from Home: A Sourcebook of Residential Treatment (Aldine, 1972). He has in press Social Treatment: An Approach to Interpersonal Helping.