Mental Health Workers Negotiating Risk on the Frontline

Abstract

Following deinstitutionalisation and the shift to models of community care, mental health practice has become increasingly focused on managing the risks posed by service users. However, the effects of risk management on workers’ professional identities have not been investigated empirically in Australia. Drawing on in-depth interviews with mental health workers from Victoria, Australia, this paper explores the diverse ways in which these workers adapted the formal technologies of risk management (e.g., the completion of risk assessment screens) to their professional identities. Some workers experienced risk management technologies as constraining their interventions with clients, while others saw these technologies as providing opportunities to strengthen and enhance their professional skills. Pondering these differences, the author speculates on the emergence of a new form of professional identity in the broader context of contemporary community mental health care.     

Trust and the Dilemmas of Suicide Risk Assessment in Non-government Mental Health Services

Reducing suicide rates is a national mental health priority as over 2,200 people die from suicide each year in Australia. Increasingly, nongovernment organisations (NGOs) provide services to people experiencing severe and persistent mental illnesses—a significant cohort at risk of suicide. While clinical services are generally seen as the arbiters of risk, little is known of how suicide risk assessments are undertaken in NGOs. This article reports the findings of a survey-based pilot study of 44 frontline workers in mental health-focused NGOs in Tasmania, Australia, with the aim of sketching a preliminary picture of this under-studied terrain. We identified the assessment practices utilised by workers, and the challenges and dilemmas they experienced in navigating issues of trust in suicide risk assessment in contexts where they often felt vulnerable and under-prepared. We argue that these early findings demonstrate the need for organisations to foster cultures of trust to facilitate both the activities of relationship building between practitioners and clients, and those of monitoring risk.     

Professionals without a profession? Redesigning case management in Dutch local welfare agencies

This article explores the new roles of frontline workers in Dutch local welfare agencies against the background of recent active welfare state reforms, with a specific focus on frontline workers involved in activating social assistance recipients. The results presented in the article come from case studies in four local welfare agencies. The article investigates how active welfare state reforms have influenced the room for discretion of frontline workers, how discretion is managed in local welfare agencies, and how frontline workers cope with discretion. The article argues that the discretion of activation by frontline workers has increased significantly. The research results show a clear though not unambiguous shift from a bureaucratic towards a more professional treatment of frontline workers, combined with attempts to introduce a more performance oriented style of management. However, given the low level of institutionalisation of the profession of activation work, activation frontline workers still seem to be professionals without a profession. This not only makes activation work a rather individual project, it also entails risks for clients for whom activation services may become unpredictable and lacking in transparency.     

Disjunctures for Women and Frontline Workers: Implementation of the Family Violence Option

This research uses analysis of qualitative interviews with 10 battered welfare clients and 15 frontline welfare workers to examine the implementation of the Family Violence Option (FVO) under welfare reform. States adopting the FVO agree to screen for domestic violence, refer identified victims to community resources, and waive program requirements that would endanger the women or with which they are unable to comply. The analyses find that none of the 10 clients in this study received these services. This lack of services reflects four critical disjunctures between the formal policy and the policy experienced by the clients. It also reveals several more basic structural factors that provide conflicting mandates to frontline workers. Frontline workers' discretionary behaviors enforce core rules related to welfare eligibility and reduce welfare caseloads but do not provide violencerelated services to victims.     

Rehearsing Gender and Sexuality in Modern Thailand

Abstract

In this paper I draw on a series of interviews with gay-identified Thai men, and with male bar workers and their clients in order to chart the traditions, discourses, and institutional contexts contributing to the construction of gender and sexual identity in Thailand. I argue against the uncritical application of Western paradigms to the study of Thai sexuality and present a view of gender and sexuality that is “fluid and pragmatic.” I consider difficulties associated with sexual choice and levels of acceptance and toleration, and look at examples of how sex work has been socially constructed. Finally, I discuss the attachment of Thai male bar workers to the “gay” community.     

Can't Buy My Love: A Typology of Female Sex Workers' Commercial Relationships in the Mexico–U.S. Border Region

Female sex workers (FSWs) experience elevated risk for HIV and sexually transmitted infections (STIs) through unprotected sex with male clients, yet the complexity of these commercial relationships remains understudied. From 2010 to 2011, we explored FSWs' conceptualizations of various client types and related risk behavior patterns using semistructured interviews with 46 FSWs in Tijuana and Ciudad Juarez, Mexico, where FSWs' HIV/STI prevalence is increasing. Our grounded theory analysis identified four types of commercial relationships: nonregular clients, regular clients and friends, clients who “fell in love” with FSWs, and long-term financial providers who often originated from the United States. As commercial relationships developed, clients' social and emotional connections to FSWs increased, rendering condom negotiation and maintaining professional boundaries more difficult. Drug abuse and poverty also influenced behaviors, particularly in Ciudad Juárez, where lucrative U.S. clients were increasingly scarce. While struggling to cultivate dependable relationships in a setting marked by historical sex tourism from a wealthier country, some FSWs ceased negotiating condom use. We discuss the need for HIV/STI research and prevention interventions to recognize the complexity within FSWs' commercial relationships and how behaviors (e.g., condom use) evolve as relationships develop through processes that are influenced by local sociopolitical contexts and binational income inequality.     

Adversarial Allies: Care,Harm, and Resistance in the Helping Professions

Professional encounters bestow moral esteem upon professional helpers while denigrating those who access services. Yet society is arranged in such a way that professional services are indispensable for many to survive, and service users can experience them as simultaneously helpful and oppressive. We explore the ambivalent figure of the professional “adversarial ally” working within these systems through accounts from two research studies that straddle or resist the common-sense line that separates care from harm. Professionals need to acknowledge how we are experienced as adversaries in order to better forge relationships of solidarity or “alliance” with those using social and medical services.     

Towards a sociology of risk work: A narrative review and synthesis

In this article, we define the concept of “risk work,” which aims to make visible working practices to assess or manage risk, in order to subject these practices to sociological critique. This article reviews and synthesizes existing published literature to identify components of risk work: (a) translating risk into different contexts, (b) minimizing risks in practice, and (c) caring in the context of risk. We argue that these three components of risk work raise important tensions for workers that have been inadequately explored in the literature to date. We propose that future research should additionally focus on practitioner subjectivity and identity in risk work. In addition, we argue that comparative research—across type of risk and different contexts—and methodological and theoretical diversity would enhance this emerging field of research.     

Rules or No Rules? Three Strategies for Engagement with Young People in Mandated Services

A qualitative study of 61 youth receiving mandated services (child welfare, mental health, probation) or services where there were no alternatives (residential care for homeless youth) explored worker-client relationships from the perspective of young people themselves. Findings suggest three different but related roles played by workers that successfully engage adolescent clients: (1) “Informal supporters” de-professionalize their role and flatten hierarchies, emphasizing empathy and enforcing few rules; (2) “Administrators” enforce rules that are in the child’s best interest but do so with little emotional engagement; and (3) “Caregivers” who hold reasonable expectations and impose structures but are flexible in their negotiations with youth when rules were broken. While youth spoke most positively about their workers when they acted as informal supporters, a deeper analysis of the data showed that youth also engaged well with workers who enforced rules when those rules were necessary for the child’s safety, applied flexibly, age-appropriate, and fit with cultural norms. Use of all three approaches to youth engagement may help workers create better therapeutic relationships with youth receiving mandated services.     

Time,Trust and Hazard: Hairdressers' Symbolic Roles

Field work on five hairdressers in a small, suburban beauty shop shows that routine hazards provide an organizational justification to establish and maintain processes which create and sustain trust, both with coworkers and clients. The study analyzes data from interviews and weekly observations, and details the types of workers and clients; the hairdressers' roles as caretakers, friends and riskbearers; the necessity of establishing “professional” identities with clients by scheduling appointments; and the construction of shared futures among “regulars.” In the course of observing the symbolic and temporal processes associated with trust, hazards to hairdressers from chemicals, equipment, and procedures are examined, followed by the kinds of risks effecting clients from chemicals, equipment, and hairdressers' technical competence and moral responsibility, as framed by their “honorific” professional roles.     

Risk and new exclusions in community mental health practice

Abstract

Over the past two decades, mental health practice has become increasingly focused on assessing and managing the risks posed by service users. British researchers have made significant advances in studying the consequences of risk management for community-based health and welfare services, but in Australia this field remains largely undeveloped. Drawing on my experiences as a social worker in a Melbourne-based Crisis Assessment and Treatment Team from 1991 to 2008, the present paper offers a reflective analysis of the shift in practice orientation that has emerged through the growing prominence of risk as a foundation for intervention. Specifically, I argue that this shift has led to a narrowing of service provision and that “low-risk” clients are newly disadvantaged, often excluded from service.     

When Emotion Work is Doomed to Fail: Ideological and Structural Constraints on Emotion Management

This paper explores how workers try to manage their emotions under conditions that doom them to fail. The workers in question—floor instructors at a sheltered workshop for people with developmental disabilities—were expected to infuse clients with positive feelings about work and to help transform them into committed workers. But structural conditions—boring, poorly paid assembly work and long gaps between contract jobs—forced them to obtain clients' compliance through coercive and confrontational emotion management techniques that contradicted their ideological beliefs. The floor instructors sought to peacefully increase their control over clients through “preventive emotion management” but most often they experienced a loss of control, leading some of them to experience “burnout.” This paper defines burnout as “occupational emotional deviance” that workers experience when they cannot manage their own and other's emotions according to organizational expectations.     

Responses to Homelessness in Australian Cities: Social Worker Perspectives

Abstract

Responses to homelessness in Australia are provided by a range of government and nongovernment services. The present study examined the experiences of social workers within these diverse services. The article discusses how social workers make meaning of their professional identity and responses to homelessness in contemporary practice and policy settings. The findings of a qualitative study of 39 social workers employed in Adelaide, Melbourne, and Sydney are analysed from a social constructionist perspective. The practice dilemmas for social workers interviewed related to the dominating influence of the contemporary political and economic climate, the managerial requirement of organisations, and the personal and professional tensions these political and organisational contexts created.     

城镇职工基本养老保险个人账户风险及其对策分析——以甘肃省武威市L区为例

本文以甘肃省武威市L区为例论述了城镇职工基本养老保险个人账户制度面临的风险问题,分析各种风险产生的原因,提出了相应的风险控制措施。其中,做实"空账"是解决制度风险的主要措施,同时,通过扩大覆盖面、提高统筹层次等多方面努力,把制度风险降低到最小程度;在肯定个人账户制度优越性的同时,应保持风险意识;通过加快社会保障立法、理顺各管理部门之间的关系和社会保障经办机构自身的建设等方面,在宏观和微观上不断完善个人账户管理,以最大限度规避风险,充分发挥个人账户制度在养老中的保障作用。     

Mutual Benefits: Developing Relational Service Approaches Within Centrelink

Abstract

The machinery of income support can have considerable influence in people's lives, creating opportunities for social work but also tensions: access to vulnerable people, but not always on their terms. This paper argues that the challenge to social work is about more than holding on to professional discretion. It considers how social workers can influence service delivery approaches to work more relationally, pursuing a more equal involvement of clients, and recognising the complex interactive context of social and community life. The authors trace the development of such an approach within the Australian Government human services delivery agency Centrelink in Logan, Queensland, and briefly consider a parallel innovation in Newcastle, New South Wales. The authors suggest that grounding a large institutional social service agency in the realities of client and community experiences has mutual benefits, creating a more humanising, cooperative space, and displacing inefficient and sometimes tragic cycles of misunderstanding, confrontation, and disconnection.     

Client Satisfaction with Live-In and Live-Out Home Care Workers in Israel

Abstract

In an era of globalization where the migration of long-term care workers is common, foreign live-in home care workers can compensate for the unavailability of family members and, perhaps, even substitute for institutional care in the provision of long-term care services to disabled older persons.

This study examines differences in home care satisfaction between disabled older persons in Israel with “live-in” home care workers and those with “live-out” workers, and explores some differences in socio-demographic and personal characteristics between these two groups. Face-to-face interviews were held with a random sample of 93 older persons in Beer-Sheva.

Older persons with live-in home care workers were more satisfied with their home care service than those with live-out workers. Those with live-in workers were more severely disabled, tended not to have any children living in close proximity, although an adult child was available as an informal caregiver. Communication difficulties between the elderly persons and their home care workers were found not to affect negatively the satisfaction with the service.     

Resources reduction and welfare changes: tensions between social workers and organisations. The Italian case in child protection services

Within the field of studies on professionalism, this paper explores the changes in roles of social workers and the new tensions emerging in the relationship with their organisational contexts, due to the reduction of resources and the introduction of neoliberal and managerial policies in the welfare system. The paper is based on qualitative research carried out through 32 in-depth interviews with frontline social workers engaged in child and family services in Italy. The paper investigates how spending cuts have affected the relationship with the organisation arguing that the ways the cuts are implemented, as well as the room for professional recognition set by the organisation, are relevant. A four-character social worker typology is outlined, drawn from the intersection of two meaningful dimensions: sense of belonging and critical thinking. It is argued that a ‘critically engaged’ type points to a new form of professionalism that may emerge from the current crisis of the relationship between the organisation and social workers.     

Managed care and the rationalization of mental health services

Managed care represents a response to the wider institutional demand for technical rationality and efficiency, and it may be in conflict with professionally generated logics of mental health care which emphasize the delivery of quality care, as well as providing services to all who need care. The organizational and policy conundrum is to balance conflicting institutional demands for efficiency (cost savings) and effectiveness (access and quality). This paper examines managed care in one public sector mental health care system that has attempted to incorporate the principles of managed care into a community based system of care and to overcome the potential contradictions between demands for efficiency and professional logics of care. Both qualitative and quantitative data are used to examine changes in organizational structure and service offerings; providers' experience of managed care, and the effect of managed care on working conditions and work experiences, and changes in the goals of the organization as measured by the specification of client outcomes. I find that, while increased performance accountability and outcome assessment (in keeping with demands for efficiency) have the potential to improve mental health care services, in fact, providers report that the primary effect of managed care has been an emphasis on cost containment, and there has been a corresponding de-emphasis on the provision of community based services for clients with long term care needs. However, there is potential for professional logics to be maintained by larger institutional forces demanding quality care.     

Working in Complexity: Ethics and Boundaries in Community Work and Mental Health

While codes of ethical conduct are important, they do not always fit neatly in the organic community settings in which some workers engage. Professional standards from accrediting bodies are easy to sign up to, yet much more difficult to put into practice. Drawing upon community connection practice in recovery-oriented mental health work, this article names the professional boundary tensions peculiar to less structured fields of engagement. We suggest that for workers in these fields, there has been a disconnection between the theory, the experience, and the public discourse of professional boundaries. We argue that such disconnection can create uncertainty, anxiety, and secrecy, creating exactly those cultures we wish to avoid. Ultimately this leads to greater harm for vulnerable individuals, as well as the workers and organisations that serve them. The alternative is to engage in what we name a “risky conversation,” to expose this disconnect and engender a new type of professionalism.     

Understanding Care Leavers in Russia: Young People's Experiences of Institutionalisation

Abstract

Care leavers in Russia represent one of the most disadvantaged groups in society. However, they have rarely been the focus of welfare policy debate and they receive little or no support in their independent living. This paper presents the findings of a survey of Russian care leavers. The emphasis is on care leavers' experiences of the Russian institutional care system, and the issues that impacted on their postcare transition to adulthood. A number of factors were found to influence the wellbeing of care leavers, including placement instability, institutional isolation, poor education, stigmatisation of care leavers, relationships with “houseparents”, and supportive and often challenging friendships. Findings are discussed in relation to debates about the degree and nature of institutional care of children in Russia and elsewhere.