Author: Andre Coleman

This essay will focus on how EBP and ‘practice wisdom’ should be combined and not seen as opposing opposites as together they have great value for social work practice. Also both should determine the practitioners decision making processes in practice because failing to do so could actually be oppressive to both service users and practitioners. Also this integration could facilitate and encourage the use of research amongst social work practitioners in day to day practice.

EBP in social work has been implemented at a slow pace and has not been greatly embraced and valued by practitioners (McNeill, 2006; Pignotti and Thyer, 2009; Mitchell 2011, Nevo and Nevo, 2011). Epstein (2011) highlights how practitioners have voiced that they resent EBP as it presents as a threat to their autonomy and creativity. This idea of EB knowledge solely determining practice could be perceived by practitioners as disempowering. An approach that devalues practice wisdom and professional judgement in favour of objective, manualised, and empirically supported interventions (Webb, 2001; Nevo and Nevo, 2011) can be seen to undermine professional autonomy as it places authority of science over the authority of the practitioner (Nevo and Nevo, 2011). Furthermore it can actually be seen to oppress practitioners as it seems to be ‘controlling’ their decision making process that may often conflict with their practice wisdom. An approach that alongside EB knowledge also embraced practice based knowledge may be of more use and value to practitioners and may be more likely to be used in practice as it detaches EBP from its solely scientific and thus its oppressive nature.

It is now increasingly being recognised in the EBP literature that social work values and practitioner wisdom need to be integrated with practice; however this integration is often unclear (Epstein, 2009; Mitchell, 2011; Nevo and Nevo, 2011). A shift towards evidence ‘informed’ practice (EIP) rather than evidence ‘based’ practice is now being recognised (Epstein, 2009; Haight, 2010; Nevo and Nevo, 2011). However practice is wisdom is still not acknowledged amongst some EIP advocates for example Haight (2010) but is greatly valued amongst others such as Nevo and Nevo (2011).

Stoesz (2010) argues that the social work profession is too subjective and reflexive and argues that only scientific evidence is acceptable and ethical as anything else could be depriving an individual of effective treatment (Stoesz, 2010; Gambrill, 2010). Randomised controlled trials (RCTs) are seen to provide ‘gold standard’ evidence for practice to be based on. Qualitative research and practice wisdom or clinical judgments are valued the least as are less scientific (Corby, 2006; Epstein, 2002; Dodd and Epstein, 2012). Epstein (2009) rejects the use of RCTs on ethical grounds as the methodology deprives the one group of intervention. RCTs may have value for research findings and in turn practice but its research methodology is unethical to some service users.

Ethics is of great importance within social work as it is of importance that social workers be ‘ethical professionals’ and work anti oppressively. And also be guided by research (Nevo and Nevo, 2011). BASW (2012) code of ethics states that evidence informed knowledge derived from research and practice evaluation is the basis of methodology in social work. However if practitioners are not using EB knowledge and are using only practice wisdom this could be depriving service users from an effective treatment and is not integrating evidence into practice. What would be of more value is to encourage and accept EB knowledge and practice wisdom so that not one or the other, but both are valued and used by practitioners so that research is being incorporated into and informing social work practice as BASW (2012) states. Also BASW (2012) states that knowledge should also come from ‘practice evaluation’ and mentions acknowledging context but does not mention practice wisdom. This evidence informed approach whereby acknowledging being specific to context but that does not mention practice wisdom is similar to EIP advocated by Haight (2010).

To ignore the existence of practice based wisdom and its perceived value by practitioners in influencing their decision making process will only further limit the potential of integrating EB research into practice.

McNeill (2006) highlights how practitioner’s decision making is not driven by research findings, even when provided with evidence of intervention effectiveness. Gambrill (2006) acknowledges how in social work practice a number of unsupported interventions are conventionally used and accepted in practice that are based on professional authority and clinical experience and not research evidence. Pignotti and Thyer (2009) concluded that just because social workers valued and used EBP interventions they also valued and used ‘Novel unsupported therapies’ (NUTs) in practice.

This could suggest that practice wisdom is valued in the decision making process and could be of priority even when provided with evidence of an interventions effectiveness (Gambrill, 2006; McNeill, 2006). It also could suggest that both EBP and practice wisdom are also co-existing in the decision making process in practice (Pignotti and Thyer, 2009). Pignotti and Thyer (2009) highlights how little is known about why social work practitioners choose NUTs. Similar Research could be of value in potentially identifying how Practice wisdom as well as EB knowledge together both are being used and are of value to practice.

Mitchell (2011) illustrates how the sole use of EBP had limited valuable application in real world practice. Mitchell (2011) found that when attempting to implement EB services for young people with complex needs, this was limited without the integration of practice wisdom. As most research focuses on a single disorder or problem it is difficult to implement such research when faced with complex factors that interact in complex ways in real world settings. Also it could be seen as unethical and oppressive to arrange and reduce human beings using solely scientific EB interventions. Corby (2006) states how human beings are too complex to assume a one size fits all approach. In such complex cases as encountered by Mitchell (2001) practice wisdom and EBP were integrated in order to make a decision based not only on evidence but of relevance to the case at hand. Fook (2012) describes how a reflective practitioner situates themselves and their knowledge in the specific context of a situation, looking at the situation as a whole and in relation to their own experiences. Although the term of practice wisdom is not used this seems to reflect some of the nature of practice wisdom and how it can be of use to each individual case. With exclusion of ‘their own experiences’ Fook (2012) also seems to reflect BASW (2012) concerning Evidence informed knowledge.

It seems to be now increasingly acknowledged that practitioners are not passive recipients or implementers of information, however in addition to this practice based wisdom should also be acknowledged as of value. The understanding of the processes of how EB knowledge and practice based knowledge are integrated into practice is of importance to the purpose of research in social work. The integration of research and practice may then be of perceived value to practitioners.

One of Mitchells (2011) main arguments was that the main barriers to implementation and value of EBP in real world practice is the oppositional construction that remains concerning EBP verses practice based wisdom.

Fook (2012) describes the notion of ‘dichotomous thinking’ whereby most phenomena are seen to fit into ‘binary’ and ‘oppositional’ categories, with one being devalued in relation to the other. This ‘dichotomous thinking’ appears to be occurring within social work research and practice in relation to EBP and practice wisdom.

Current research by Social Care Institute for Excellence, (SCIE), suggests that one person in six will become depressed at some point in their lives, and, at any one time, one in twenty adults will be experiencing depression. I will discuss the definition of depression and its interpretation along with the biomedical model, interpersonal, psychological and institutional perspectives. Then discuss the social, economic, environmental and political factors that contribute to the developing of depression and their relation to sociological and psychological theory with particular relevance to black and minority ethnic (BME) groups.

In England and Wales the Mental Health Act 1983 defines ‘mental disorder’ as: ‘mental illness, psychopathic disorder and any other disability of mind’. There is a dual role of legislation: providing for care while at the same time controlling people who are deemed to be experiencing mental disorder to the extent that they are at a risk to the public or themselves. World Health Organization WHO (2001), marks depression as when “Capacity for enjoyment, interest, and concentration is reduced, and marked tiredness after even minimum effort is common. Sleep is usually disturbed and appetite diminished. Self-esteem and self-confidence are almost always reduced and, even in the mild form, some ideas of guilt or worthlessness are often present.”

Mental health is a contested concept which can be viewed from different medical, psychological and social perspectives, which lead to diverse views on what mental health is. Depression is a mental illness and, can affect anyone at different points in their lives, from every background and occupation. Categorizing populations as experiencing depression, involves making judgments by the use of scales of mental health and these judgments determine cut-off points on a continuum of mental health or illness and are socially constructed. A rating scale commonly used to measure the mental health of populations is the Hospital Anxiety and Depression Scale (HADS). A study by Singleton et al., (2001) found that 76 per cent of the participants, who reported symptoms of mental distress, did not receive any treatment from a health professional for their problems. Sainsbury (2002) study refers to a culture of fear within the BME populace. Causation is affected by the practitioners who diagnose and treat depression and the public perception of depression however there are many perspectives.

Biomedical model focus on biological aspects of depression and look for symptoms that relate to diagnostic categories of mental disorder with a view that a sick body can be restored to health. Interpersonal perspectives on depression focus on individual people, experiencing mental distress, together with family and friends, psychologists and counselors also taking account of the views and experiences of service users and survivors. One such perspective is to see madness as a difference rather than an illness, like the social model of disability Oliver (2002). People’s actions can be open to different interpretations which are influenced by the perspectives of those making the interpretation. However there are commonsense perspectives of depression including personal experience with the people in closest contact, a relative or friend, may form opinions of the likely causes of the distress. Their opinions may include aspects of the person’s personality and recognize the impact of external stressors such as bereavement, debt or work demands. Overall they are more likely to emphasize the impact of social, rather than biological or psychological, factors.

Psychological perspectives on depression explores unconscious thinking, possible past traumas and focuses on helping service users to realize their potential and focus on social support and psychological interventions. This has created the development of psychotherapeutic treatments or ‘talking therapies’, such as cognitive behavioural therapies (CBT) has become the psychological treatment of choice in many NHS-funded services. Advantages of CBT include having some support, someone to talk to and developing coping strategies. Disadvantages of CBT include – The focus being on here and now, when the person might want to spend more time discussing past issues. CBT is a relatively effective way of helping someone deal with their distress that puts the client back in control of their life. Despite the evidence that has been collected to support the use of different psychological treatments, their effectiveness continues to be debated and funding is mainly offered in private practice or within institutions. (McLeod, 2000; Holmes, 2002) By contrast, the prescription route is a commonly referred to and accepted path with no self-criticism or self-awareness required.

Institutional perspectives or psychiatric perspectives on depression hold biological and genetic theories of causation for depression, and prescribe biological and physical treatments. Psychiatric perspectives emphasize the diagnosis of symptoms of depression in order to place people into categories of illness. The influence of GPs and psychiatrists is powerful in determining what is and what is not considered to be a mental health problem. Psychiatrists have powers to detain patients for treatment against their will. Psychiatry, through its association with medicine, tends to take precedence over psychological and social perspectives.

The bio-psychosocial model introduced by Engel (1980) acknowledges the interactions between the person’s biology, their psychological makeup and their social situation as important in understanding their mental distress. It encourages a more holistic approach to treatment. However, it has not provided the hoped-for basis of an accepted multidisciplinary approach. The Social support perspectives believes social factors and the person’s experiences cause depression and social support restores the mentally distressed person to wellbeing and social functioning. However it is also viewed as an addition to psychiatric treatment, where the service user is established on their medication, and social issues investigated.

Puttnam cited in Gross (2005) refers to social capital as a supportive social atmosphere and discusses bridging and bonding ties and the absence of these can lead to social isolation. Cockerham (2007) makes the connection where depression and illness are most likely among those with little or no social capital. There is also a tendency for the individual to, once diagnosed, to play the ‘sick role’, Rosenhan (1975) refers to the stickiness of labels and Goffman (1961) refers to looping and deviancy amplification that is associated with stigmatization and labeling of individuals. However our social standing is not the only element that contributes to our sense of well being. The environment that we live and are brought up in greatly influence our health Ross (2000) cited in Cockerham (2007) compares advantaged and disadvantaged neighborhoods finding that higher levels of depression occur in the latter with individuals suffering psychologically because of their environment although there were links to their individualism – female sex, younger age, ethnicity, low education, low income, unemployment, unmarried with the remainder from living in a poor neighbourhood. The daily stressors of living with crime, disorder and danger all link with symptoms of depression. Those living in clean and safe neighbourhoods showed low levels of depression. Distressing neighborhoods’ produce distress beyond that from individual disadvantage with poverty and single mother households the strongest predictor of depression. However the lack of choice and powerlessness of poverty make the emotional consequences of living in a bad neighbourhood worse.

Poverty can lead to poorer mental health where access to employment and welfare benefits, can be seen as health-promoting activities. For most nations, spending on mental health promotion is low Appleby, (2004), and the resources put into mental health promotion are minuscule compared with those used for treating ill health. Schulz et al. (2000) cited in Cockerham (2007) found high psychological distress highest amongst blacks and whites living in high poverty areas, slum living conditions. Wilson and Pickett (2006) cited in Cockerham (2007) stated that stress , poor social networks , low self esteem , depression , anxiety, insecurity and loss of a sense of control are reduced and social cohesion in enhanced – when income levels are more equal- however equalizing income is inherently political.

Sir Donald Acheson’s Independent Inquiry into Inequalities in Health Report (1998) recommendations will require policy changes to occur with reference to changes in building design, planning and access to health care treatments, although most research data on interventions tend to be tested on white, middle aged well educated men and women therefore the efficacy with black or mixed ethnic BME is not proven. The report also links depression and anxiety with obesity and inactivity and encourages physical exercise as obesity and inactivity is increasing in lower socio economic classes. The media and the NIMBY phenomenon exemplifies the exclusion that often accompanies a diagnosis of depression. This raises issues of complex ethical and political issues along with human and civil rights.

According to Blaxter (2004) health, disease and illness are social constructs; they are categories which have been named, and defined, by human beings. Bowers (1998) argues that diagnostic classification systems are culturally influenced, but involve: – careful, detailed observation, publication and peer review. Psychiatric diagnoses are based on social judgments of behaviour and experiences. These judgments can be socially and culturally influenced. For example, you will automatically ‘get well’ by travelling to a country where your beliefs are widely shared. This obviously does not happen with heart disease. Problems of subjectivity and unrecognized cultural assumptions may complicate the process of diagnosis. ‘Neither minds nor bodies develop illnesses. Only people do’ (Kendall 2001).

Recognition that both physical and mental factors are involved in mental distress could mean that a diagnosis of depression would be no more stigmatizing than having a heart condition.

Foucault cited in Giddens (2006) was a post-structuralist theorist who believed that people’s views on depression are the results of discourse that exists to define and subjugate people in society. He also, through the process of social archaeology, examines how the issues of mental health existed in the past and how they are a modern conception of normal and deviant activity , defining them as a construct built on power in society and how that power operates , this therefore links in to social constructionist theory. Social constructionism is the belief that our understanding of depression as a reality, overlooks the processes through which the reality is constructed. Our current sociological thinking is one of a historic white male centred Eurocentric model with women historically viewed as hormonal creatures and this gender difference is still prevalent to day in the way we use language with gender differences in the way society defines these roles.

Brown and Harris (1974) model of depression drew links with unhappy life events that can lead to depression when mixed with his four vulnerability factors which he identified as ; 3 or more children under 14, loss of mother before 11, lack of employment, lack of intimate & confiding relationships. He established that these factors plus an unhappy life event led to 83% women became depressed with working class women more likely to become depressed. Kasen et al (2010) have conducted a study supporting the effects of enduring earlier stress both in childhood , poor health status and a more rapid deterioration in health and the effects this has on major depressive disorder on women in old age and the need to develop resources to counteract stress exposures in younger generations of women. These factors need to be considered in the understanding not only from a feminist perspective but also from a black perspective as black women are multiply disadvantaged, hooks cited in Giddens (2005).

Immigration has played a major part in the creation of culturally diverse communities in UK society. The majority of the UK population in the National Census (2001) census was white (92 per cent). The remaining 7.9 per cent were from different minority ethnic groups. Karlsen et al. (2002) states that ethnic groups experience significant racism, unfair discrimination and social exclusion. This needs to be considered when understanding their mental health experiences. Social inequalities in education, employment and health disproportionately affect members of minority ethnic groups. This all leads to increased mental distress. Also black male’s lives are much harder as they have to live to a set of unconscious rules written in Westernised psychiatry which leads to their current diagnosis. People from minority ethnic groups find that mental health services are not sympathetic to their particular needs. A report from the Sainsbury Centre (2002) concluded, black people are disproportionately disadvantaged and their experiences of mental health services are characterised by fear and conflict. ‘Delivering Race Equality’ was launched in January 2005 and requires health authorities, and NHS trusts to ensure equality of services. The Department of Health has set ‘action goals’ for the mental health care of minority ethnic communities and service users; these include, reduction in fear and seclusion in mental health services.

Race is a contested concept with the difference between race, having its origins in 18th and 19th century colonial assumptions about the differences between white and non-white people. The concept of race is socially constructed and is now embedded in how we identify, understand and think about people. Ethnicity is an alternative concept to race that is more acceptable to groups in society . Ethnicity refers to a sense of identity that is based on shared cultural, religious and traditional factors. Ethnic identities are always changing and evolving. Approaches to cross cultural psychiatry according to Pilgrim (2005) are either orthodox or skeptical. Orthodox definitions of depression state that culture shapes the expression and prevalence of mental disorder. Cultural sensitivity enables GP’s to read symptoms and translate them into an orthodox, western diagnosis. A sceptical reading questions the validity of applying diagnostic labels from Western culture to other cultures. Cultural differences lead to people explaining and experiencing depression in different ways. Imposing western diagnostic categories leads to misinterpreting the person’s mental distress. It is important to be cautious in making cross-cultural comparisons in diagnosing with different illnesses being stigmatized in different cultures, and so expressed differently.

Beck cited in Giddens (2005) felt that depressed peoples thinking is dominated by a triad of negative schema of, ineptness, self-blame and negative evaluation although this doesn’t take into account any social factors that have impacted on the individual. Freud cited in Gross (2005) thought that people were victims of their feelings. That the psycho-analytical theory with fixation in psycho sexual stages and repressed desires feelings are what causes mental illness as the ego is unable to exert control over our feelings and this inability to express may cause anxiety and depression. He took this further with enforcing the belief of intra psychic loss, loss of sense of self, esteem, loss of job or the loss of a major sustaining relationship. Hayes (1998) links Bowlby’s functionalist perspective in his attachment theory being the loss of significant carer and lack of maternal attachment had far reaching effects. Skinner cited in Gross (2005), believed in radical behaviourism and that learning is conditioned and emphasized the role of environmental factors. Seligman (1974) takes a humanistic approach purporting that learned helplessness is a cognitive psychological explanation of depression, where there is learned helplessness and passivity, people become dependant and unable to make decisions for themselves.

Oakley (2005) remarks on the tendency for women to specialize in mental illness and that many more women in Westernized society are classified as having neurotic disorders and women dominate in psychosomatic disorders. A correlation exists in the study of mental illness being higher in men living alone and higher in married women however women are also suffers of post partum depression which is viewed by society through the biomedical viewpoint. Oakley (2005) places this within the self perception and ideals within a male patriarchal culture where women have been, historically, subject to social, economic and psychological discrimination, as have black people. However we are all damaged in some extent, this being a state of humanity; however, connectedness is not possible without the qualities of vulnerability, weakness, helplessness and dependency. A paradox exists in that all these qualities are seen as feminine, and are, not only negatively described, but are also associated with depression. This also links to learned helplessness as a psycho social explanation that women are gendered and stereotyped into this through socialization Weissman et al (1982). Calhoun et al (1974) established data that indicated a trend for females to hold themselves more responsible for unhappy moods than males.

There are a myriad ways of thinking, behaving and experiencing the world through a combination of care and control using medical, psychological, and social support with interventions done to reduce negative factors such as poverty , unemployment racism etc, and promote social inclusion. Research will play a large part as new factors are established as demonstrated in the recently publicized link between teenagers sleep patterns and depression Gangwisch et al. (2008)

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Assignment Question: The professional-client/service-user relationship is expected to be objective and detached (Storr, 1989). Discuss this statement and other potentially stereotypical assertions we affix to the ‘profession’.

Profession is a vocation or an occupation based on an educational training. It also requires a degree in that professional field. For example, teaching is considered to be a profession because it has both an educational training and a degree. The word profession comes from the Latin word ‘professio’ which means a public declaration with the force of a promise. This means that the profession first presents itself to society as a social benefit and then society accepts the profession, expecting and trusting it to serve some important social goal. In fact, The Australian Council of Professions defines a profession as; ‘a disciplined group of individuals who adhere to high ethical standards and uphold themselves to, and are accepted by, the public as possessing special knowledge and skills in a widely recognised, organised body of learning derived from education and training at a high level, and who are prepared to exercise this knowledge and these skills in the interest of others’.

The professional-client relationship, as Storr stated, is expected to be objective and detached. In fact, theories of the helping process that follows the medical paradigm have presented the ideal worker as an objective, clinical detached and knowledgeable professional. The relationship has to be objective and detached because a professional is someone whose efforts or actions are only intended to attain or accomplish a purpose or goal without any emotional involvement. For example, a doctor’s efforts are to cure the patient’s health without any personal feelings involved. In fact, if a worker expresses his real emotional feelings towards his clients, then he is considered to be unprofessional. The relationship between a professional and a client may be defined by boundaries. These boundaries make the relationship both professional and safe for the client. Paraphrasing Marilyn Peterson, from her book ‘At Personal Risk’, these boundaries are the limits that allow a safe connection between the professional and the client based on the client’s needs. The client’s needs should always come first. The workers’ personal values or biases should be prevented from their ethical decision-making. This is because, if their values enter their decision-making process, their personal views or needs would begin to govern or shape the therapeutic intervention. Therefore, in this situation the needs of the workers will be placed above the needs of their clients and the decisions will not be beneficial for the clients.

Boundary can refer to the line that separates the self of the client and the self of the professional. Professionals should not touch or hug their clients because if this happens, the professional-client relationship would begin to diminish. Regardless of who initiates the touch or hug, the client or professional may then perceive the relationship as one between friends whether intended or not. Professionals should avoid becoming friends with clients and should not socialize with them. The need for professional boundaries is rooted in the power imbalance that exists between the professional and the client. This power imbalance exists because the professional has skills, expertise and knowledge that the clients do not posses and they need. This means that the client depends on and trusts the professional to do only good and not cause harm. In other words the client believes and has faith that the workers, while in their professional role, will fulfill their ethical obligations of beneficence and non-malfeasance. Also, this power arises due to the client’s disclosure of personal information. However, despite all this, professionals are human beings working with other human beings. There are days when they are tired and stressed, and as a result, their ethical decision-making may not be good as it is when they are not stressed. They may cross boundaries inadvertently or their clients may innocently push the boundaries. Nevertheless, it is the professional responsibility to maintain or re-implement boundaries and they must take responsibility for their actions.

Stereotype is a belief or opinion that people in a society create on something or someone. Due to these stereotypes, many societies believe that in order to be a professional, one has to obtain an educational training and a degree in that professional field as already mentioned. Therefore, a professional is perceived as someone who goes to university, studies hard, obtains a degree and enjoys a comfortable salary. Such occupations that are considered to be professions to society are medicine, dentistry, law, engineering, architecture, social work, nursing, accountancy and teaching. However, there are occupations that are not considered to be professions but in my opinion they should be. For example, builders and plumbers are not considered as professionals because they do not have a high educational training like the others mentioned. However, in my opinion they should be considered as professions. This is because to be a builder or a plumber one should have a certain knowledge and skill in order to bulid an entire building or to install and repair pipes. Furthermore, both builders and plumbers are really necessary in society. Therefore, I think that they should be considered as professions even though they do not have a high educational training and a degree. In addition, those occupations that are considered to be professions are not really that professional in my opinion. Workers are considered to be professionals because they have the knowledge and skill to cure their patients, however there are other things that should be considered. For example, usually doctors are not friendly and sometimes, especially in hospitals they have the habit to talk with nurses about patients in medical words. This may make the patients feel uncomfortable because they know that they are talking about them and they may not understand these medical words. In my opinion this is not professional. I think professionals should first make their clients feel comfortable as possible.

Workers are required to choose between their personal and professional self during their work. Obviously, professionals have to choose the professional self in order to be professional. However, in my opinion by interacting the personal and the professional self together, one will develop a real skill. Professionals should help their clients in the most important and meaningful way they can. I think that there is nothing wrong if professionals show their feelings and express them to their clients. Professionals should respond in a personal way but at the same time carry out their professional function. In fact the interactional practice theory suggests that the helping person is effective only when able to synthesise real feelings with professional function. Without such a synthesis the worker appears as an unspontaneous, guarded professional who is unwilling to allow the clients access to the worker’s feelings. Clients do not need a perfect worker but they require someone who cares deeply about their success and improvement. Usually, the clients are more likely to see the worker as a real human person rather than a mechanical. If the worker shows no sign of humanity, the client will either constantly test to find flows in the facade or idealise the worker as the answer to all problems. The client who does not know at all times where the worker stands will have trouble trusting that worker. Another way in which sharing the worker’s feelings can be helpful in a relationship is when the effect is directly related to the content of the work as when the worker has had a life experience similar to that of the client. Self-disclosure of personal experiences and feelings when handled and interacted with the professional function can promote client growth.

The professional-client relationship raises many critical argumments. In fact there are also many films created purposely to criticse the boundaries of the relationship between professionals and clients. ‘Good Will Hunting’ is an example of one of these films. In this film what attracted me the most is the relationship between Will Hunter and the psychologist Sean Macguire. Although Will was unaware, blamed himself for his unhappy upbringing life and so he needed help from a psychologist to find direction in his life. In their relationship, Macguire was suppose to be objective and detached. However, this did not happen. Macguire, shared personal information about with Will about his wife and that he was too a victim of child abuse.

This essay will demonstrate a clear understanding of what the social work role is by reflecting on my shadowing experience and using this experience to provide a view of the differences between social work and social care.

On October the 11th I was able to shadow a social worker on the sensory services team in Gloucestershire, whilst shadowing I was able to observe the social worker on two home visits. The first visit required the gathering of information from a carer to fill out a Carers Emergency Scheme plan. The second visit involved the completion of a Carers Assessment.

Explain the role of the social worker observed, the difference in the social work role to that of a care role

The role of my social worker was to assess the needs of the service users and also the needs of their carer’s. She was also able to give them some equipment such as a day light lamp to enhance the ability to read, however, I was informed by the social worker that she was in a different position than most social workers and that the ability to provide specialised equipment is an unusual opportunity for social workers.

The role of a carer would contrast from this as a carer would have been able to support them with practical help.

Skills for Care (2010) stated that ‘Social care work is about helping people with their lives. People who have physical or psychological problems often require practical help coping with the everyday business of life. Social care provides this practical care.’ (cited in Trevithick, 2012). IFSW (2006:9) depicts that ‘The term ‘social workers’ refers to those workers trained to asses and respond to people with complex personal and social needs. It is a protected title and can only be used to refer to those who are qualified and registered and hold a social work qualification recognised by the General Social Care Council (GSCC) …Social workers carry out a variety of tasks, including casework, acting as an advocate, risk assessment and working as a care manager. As a profession, social work promotes social change, problem solving in human relationships and the empowerment and liberation of people to enhance well-being.’ (cited in Trevithick, 2012).

These two definitions show a clear contrast between social care and social work but there is an evident overlap with the two roles, however, the professional accountability and legal requirements of a social worker implies a high importance that these two roles have clear distinctions.

Where possible insights gained into service user’s and carer’s experience/perceptions of the service provided by the agency

At the end of the first visit the lady was unclear on what a she was supposed to do so my social worker sat back down and explained to her that she had nothing to do and that she had nothing to worry about, this comment was repeated by the service user but I believe that this made the service user relax.

On my second visit the gentleman that is caring for his wife got his calendar out to fix a date for the social worker to visit again, he told my social worker that he was busy on the day that she wanted to visit but said he would cancel his plans as he would much rather see her, I found this comment heart-warming. On this visit my social worker was able to provide the lady with a day light lamp to aid her sight when reading, I believe this was a good experience for the service user as she seemed very impressed with the lamp and read us her paper without the use of her magnifying glass. The gentleman also comment a few times about my social worker filling in the forms for him and that he would look at the next form but would wait and let her fill it in whilst she read out the questions, I think this showed that he had confidence in the ability of that social worker and that he trusted her.

Discussion points raised about the work of the agency, its legislative and policy context

When I spoke to the social worker about legislations and policies I was informed that this was a hard question to answer as there are numerous legislations that have to be consider when working for the sensory team, reciting them all would not be possible. I was told that the National Health Service and Community Care Act 1990 was one that could be remembered and then I was offered a printed copy of their policy that related to assessments. According to Horner (2006) the National Health Service and Community Care Act 1990 sought to change the balance of care with four key directions which gave the local authorities the responsibility to make plans to meet the needs identified in partnership with user and carers and to assess the needs of those requesting care. Davis (2012) states within the guide to adult assessment in Gloucestershire that people are put at the middle of the decision making with self-directed support, this allows choice and control over services that are received and who provides it. The carers assessment section seems relevant to my shadowing experience as this is what I observed, this section comments on the opportunity for the carer to give their perspective about the service user, approaching the identification and management of risk positively, procedures of safe guarding are explained and followed if this is an issue, establishing if support is available and would be maintained and an encourage discussion for carers to have a Carers Needs Assessment.

Outline how the experience links to the Professional Capabilities Framework and Standards of Proficiency

The social work reform board developed the professional capabilities framework (PCF) to provide foundations for social work education and to support development after qualification. The PCF sets out the capabilities required, at every stage of career, for social workers in England (The college of social work). Social work knowledge, understanding and abilities are set out within the standards of proficiency, which was developed by the health and care council alongside the professional liaison group. In addition to this the PCF and the standards of proficiency both describe the expectations of social workers when they reach the end of their training and start practising (Health and care professions council). The shadowing experience links to the PCF as it allowed me to gain a better understanding of the social work role it also enhanced my ability to communicate on a professional level with emails and face to face conversations. This experience would also link to the standards of proficiency due to the knowledge and understanding gained by observing a qualified social worker.

Conclusion

There are important differences between social work and social care and it is of high importance that these differences are not overlooked.

Service users

Policies and legislations used within an agency seem complex and numerous however, the policies of a particular area allow these complications to be simplified

PCF and standards of proficiency have many immeasurably positive links to the experience and opportunity to shadow a social worker.

This paper will begin by examining what is meant by conceptualisation. Using examples, it will demonstrate how broad theories are narrowed down to mid-range theories showing how this refinement can aid a practical and achievable study, within a realistic timeframe. This essay will then introduce the process of operationalisation and explain how variables and indicators are used as aids in specifying exactly what is being observed. The subject of child abuse will be used throughout the paper where different appropriate examples will be used to clarify meaning. Two reports in particular, The Murphy Report (2009) and The Ryan Report (2009) both child abuse studies will be used.

This essay will further clarify the conceptualisation and operationalisation processes by outlining the three main steps involved. These steps will be explained and examples of their use in research studies will be demonstrated. In all research studies great emphasis is placed on the accuracy of information presented. As such, reliability and validity will be briefly discussed at the concluding section on indicators. This paper will then present a summary of the main points of this essay. To conclude, this paper will emphasise the importance of employing the processes of conceptualisation and operationalisation to a research study.

Social researchers are concerned with examining the relationship between human interactions of people and the society in which they live in. It is not possible however, to do a broad study on human interactions and society in one research project. Researchers therefore, will concentrate on a specific aspect of some social issue. This process begins with a definition of the chosen topic, for example assuming the topic was based on poverty. There are different elements that need to be considered. Poverty could include income poverty, living conditions, diet or any other element that prohibits people from fully partaking in society (Lister, 2004).

Before a study begins, the researcher should ideally determine what aspect of poverty is to be examined. It may be for example, the impact of a reduction in child benefit to families already living below meridian income level. Here a researcher may concentrate his or her study on how even lower income further prohibits families from fully participating in society. In this case the researcher may use the theory of social exclusion. However, social exclusion is a very broad concept and researchers will generally look at other, mid range theories or form their own, for example, reducing benefits to lower income families can have effects on children’s health. Having determined which aspect of poverty to study, the researcher will then decide what it is, and what it is not, they are trying to find out. This process is part of what is termed conceptualisation (Geraghty, 2008).

Conceptualisation is the process of narrowing down, confining, defining and explaining, what it is, that is being examined. It is concerned with what is meant by a term (Geraghty, 2008). In undertaking research studies, the researcher has to be clear about what aspect of a social phenomenon is being studied. Just as importantly, the completed study must also demonstrate to the readers, that the study has dealt with and answered the specific starting research question. To demonstrate what has been explained thus far, this essay will take an appropriate example to convey more clearly how conceptualisation works.

In Ireland over the last two decades there has been extensive media focus and attention on Child Abuse. Considering child abuse as a research study, it is important to understand the scale and scope of the topic. One of the first things to be considered is the definition of child abuse. As the example is taken from an Irish context, it is appropriate to quote ‘The Commission to Inquire into Child Abuse Act, 2000’ which states child abuse as:

‘The wilful, reckless or negligent infliction of physical injury on, or failure to prevent such injury to, the child.

The use of the child by a person for sexual arousal or sexual gratification of that person or another person.

Failure to care for the child, which results in serious impairment of the physical or mental health or development of the child or serious adverse effects on his or her behaviour or welfare.

Any other act or omission towards the child which results in serious impairment of the physical or mental health or development of the child or serious adverse effects on his or her behaviour or welfare.’ (The Commission to Inquire Into Child Abuse Act, 2000 ).

From this definition it can be deducted, there are four main types of abuse that constitute the concept of Child Abuse in Ireland. These are physical abuse, neglect, sexual abuse and emotional abuse. In undertaking research on Child Abuse, the researcher may confine the study to one aspect, such as neglect. This may be further refined by looking at a hypothesis or theory of neglect as a topic such as, the impact of parental drug dependency on Irish children within the family. By narrowing down and focussing on specific research questions related to the topic it is easier to produce a relevant, meaningful and practical research study. Conversely, if a researcher were to ignore this approach and deal with the topic of Child Abuse only as a topic, there are many aspects and questions that would have to be considered. These could include all the different types of abuse at an international level over huge timeframes. To further examine and explain the process of conceptualisation this essay will give another example from an actual Irish research on Child Sexual Abuse.

The Murphy report (2009) was commissioned to examine the allegations and suspicions of child sexual abuse against clerics in the Archdiocese of Dublin over the period 1975 to 2004. The author takes this report as a further example of conceptualisation as it specifically details exactly what it was set up to find out. It examines allegations of child abuse against clerics; here it is not concerned with lay people or other children. The study was confined to the Archdiocese of Dublin, not Ireland as a whole. Finally, the report was focussed only on the period spanning 1975 through to 2005. This conceptualisation made it very clear what exactly the research was to encapsulate. The previous paragraphs discussed specification of meaning of terms whilst this example demonstrates evidence of clarification of concepts. The Operationalisation process is also concerned with specification but on a different more detailed scale.

Operationalisation is a process where certain variables are employed as aids in specifying what exactly is being observed and just as importantly, specifying and demonstrating, how exactly observation will be carried out. It is important to understand what is meant by the term variable. In defining the term Giddens explains it as:

‘A dimension along which an object, individual or group may be categorised, such as income or height, allowing specific comparisons with others or over time’ (Giddens, 2001,p.701).

Other concepts such as class or satisfaction can not be observed (Bell, 2005). Ways of measurement must therefore be determined. Rose and Sullivan (1996) are cited by Bell (2005:p.139) to show how the concept of class might be measurable. They write that:

‘If we wish to understand something about class (a concept and therefore…not observable), what can we observe in the world which manifests class? That is, what indicators can be used for class so that we can obtain data about class? This is the essence of the measurement problem and when we link an unobservable concept with an observable indicator we are producing operationalisations.’ (Rose and Sullivan 1996:12-13).

The authors do not expand on this quote but indicators of class for example may be based on salary, housing or education. These are elements of the concept of class and are measurable.

In the previous example of The Murphy Report the term Child Abuse was seen to be defined under four main headings. These could also be taken as the variables, a specification of what aspects of child abuse will be researched. Continuing with the operationalisation process, having identified variables the researcher will then need to devise indicators to measure the concept (Bryman,2004).

Thus far this paper has attempted to portray an understanding of conceptualisation and operationalisation. In doing so, it was also necessary to include references to variables and indicators. The next section of this paper necessitates further explanations of these terms.

The three main steps in these processes are defining concepts, identifying variables and developing measurement indicators (Geraghty, 2008). This paper will outline each of these and provide appropriate examples that are continuing on the subject of child abuse.

In examining what is meant by conceptualisation this paper explained the complexity of undertaking a broad research and detailed ways in which a subject or topic could be narrowed down and refined. Geraghty (2008) explains it as using a theory to identify concepts at the core of a research study. An example of poverty was given at the start of this paper demonstrating different elements of the topic that could merit a research study on their own, for example income poverty. Defining concepts also involves researching current and previous definitions on the subject. Previously in this paper a definition of child abuse was taken from The Commission to Inquire into Child Abuse Act, 2000. A definition from an American study over twenty years earlier gives a legal definition as:

‘ The physical or mental injury, sexual abuse, negligent treatment, or maltreatment of a child under the age of 18 by a person who is responsible for the child’s welfare under circumstances which indicate the child’s health or welfare is harmed or threatened thereby.'( Bradbard and Watkins, 1982).

Although these definitions are similar to a degree there are some differences that may be important in specifying elements of a concept. The Irish definition for example does not specify an age level whereas the American definition specifies under the age of eighteen. The Irish example does not specify that the abuse is by a person who is responsible for the child’s health or welfare. There are many other definitions of abuse that may also include exploitation or other elements as a variable. What is seen as abuse in one culture may be accepted as normal practice in another, such as child marriages. Researching such definitions helps to give a clearer aspect of a concept and may be useful in identifying other relevant elements for consideration. Having looked at defining a concept the next step is to identify variables.

Identifying variables is an important part of the conceptualisation and operationalisation process. It involves examining different dimensions of a topic that need to be considered to capture exactly what is being observed (Geraghty, 2008). As with defining concepts it is important to research previous studies to capture what variables other researchers used and how they applied them (Geraghty, 2008). Previously this paper referred to the Murphy Report (2009), which was primarily concerned with child sexual abuse and clerical involvement. In this case only the sexual element of abuse was researched. Taking sexual abuse as the subject necessitates determining variables of Child Sexual Abuse. These may include social status, incest and institutional settings.

Another report, the Ryan Report (2009) studied Child Abuse in Irish Industrial schools and children’s institutions spanning several decades up to 1974. This report, in dealing with child abuse broke abuse into four variables; physical abuse, neglect, sexual abuse and emotional abuse. There has been huge media attention on the subject of child sexual abuse in Ireland, so much so that there may be a tendency to automatically assume that the term child abuse is relating to sexual abuse. However, by conceptualising and breaking the term into variables, child abuse captures other aspects which are just as important in their own right. In an editorial from Child Links, Barnardo’s on the subject of child abuse categories say:

‘Of these, the largest number of cases that come to the attention of the authorities are cases of child neglect. In 2003, of the 4,984 children who were in State care, 24% of these children had been neglected. Yet it is the sexual abuse cases that are highlighted more in the media.’ (Conroy, p.9).

This quote along with the example of the Ryan report demonstrates how the use of variables more readily captures elements of child abuse that might otherwise have been overlooked. Variables are important in identifying aspects of a concept to be studied. There is also a need to measure the information and data accumulated under each variable or show what was used to determine the data. At this juncture the third and final step of the conceptualisation and operationalisation process will be explained.

Indicators are measures that should link to the variable. There can be numerous indicators for each variable depending on the research subject. In taking the variable of neglect for example, it could be measured using a number of indicators that may themselves be broken down to further indicators. One indicator may be a physical indicator from which other indicators may be taken, such as loss of weight, poor or inadequate shelter or poor health. Another indicator such as behavioural could be broken down to further indicators such as leaving school early, alcohol abuse or crime.

The Disabled Persons Protection Commission in Massachusetts USA (2010) lists twenty-three separate indicators for physical abuse including burns, scalds, bites, cuts and more. Indicators can be used to determine the presence or absence of what is being researched (Geraghty, 2008). However, not all researches may require so many, Bryman (2004) argues that in much quantitative research there may be only one indicator of a concept used. Although indicators are extremely useful in research, care must be taken, especially in areas like child abuse, as even with indicators, signs are not always readily visible. In its national guidelines for the protection and welfare of children (2004) the Department of Health and Children expressed caution on this when issuing their own guidelines.

To conclude this section on indicators it is important to understand that the indicator used should stand up to accurate measurement. In social research, validating examines the accuracy of measurement and is considered the most important criterion in social research (Geraghty, 2008). Another important criterion in social research is reliability. Reliability estimates the consistency of procedures used for collecting data even at different times with different subjects (Geraghty, 2008). Validity and Reliability as discussed are key criteria in research and merit a separate paper to fully explain their importance in research studies. The author has introduced them at this point to show that not only are indicators useful in breaking research studies down into manageable portions they are critical components necessary for the validation of a study.

This essay commenced by referring to the complexity of undertaking a broad research study. An example of the term poverty was presented as a broad theory that encapsulates many dimensions, such as income poverty and children’s health. The author explained how broad based theories can be broken down into mid – range theories through the use of an appropriate research question. The example proffered being, how the reduction of benefits could affect children’s health. This demonstrated that in breaking down the theory of poverty it is easier to determine what exactly the researcher is trying to find out. The author identified this process as conceptualisation.

The operationalisation process was then outlined, specifying the importance of understanding how exactly, observation should be conducted. The three main steps of the process of conceptualisation and operationalisation , defining concepts, identifying variables and development indicators were outlined. In doing this, examples of the Murphy and Ryan reports were used to demonstrate all three of these steps. The essay concluded with measurement indicators and stressed their importance not only as tools in observation through measurement but also as vital components of validity and reliability criteria.

Although it is possible to undertake a research study without the employment of detailed methodologies, a research can be more focussed with an investigative plan. Whilst this paper did not look at the many and varied tools of research methodology, it did however concentrate on useful and important processes that help ensure that correct and relevant information is gathered. The purpose of any research is to gather information on a subject or social issue. Employing methods that ensure the correct, measurable data is gathered in relation to the subject is well served using the processes of conceptualisation and operationalistion.

This assignment will explore assessment processes and the management of risk in the protection of a vulnerable person. I will provide a brief case study and discuss how assessments and risk management has been applied to this individual case. This assignment will look at different theories and legislation that impact on risk management in social work and the field of child protection.

The case study that I have chosen to discuss is a case that I have held for two years. X is a four year old child who currently lives with his mother Ms X. X’s name has been on Wrexham’s Child Protection Register for three years under the category ‘risk of emotional harm’ due to concerns regarding Ms X’s criminal behaviours and drug misuse and the impact that this has on the care that she can provide. Ms X has two older children and there were concerns that she was unable to meet the needs of these children due to the same issues. Ms X’s eldest child spent ten years of his life in the care of the Local Authority, which sadly included over twenty different foster placements. He is now serving a custodial sentence and holds a lot of resentment towards his mother for the way that he was parented and his inappropriate life experiences. Ms X’s second child was placed for adoption at an early age following the undertaking of assessments by different professionals, who felt that X was unable to appropriately care for the child. It has been assessed that Ms X’s care of X is of a higher standard than the care of her older children, however there are still aspects of this that are considered to be a risk to X’s emotional well being. Ms X has been unable to care for X for significant periods of his life as a result of serving three custodial sentences, the last being for a period of five months. During these periods X has been cared for appropriately by a family member, although has been extremely distressed and unsettled. This last incident of Ms X being arrested and imprisoned raised further concerns for X’s sense of stability and emotional well being. As a result a meeting was arranged with the Local Authority’s Solicitor and Head of Service to determine whether the risk to X was to the extent that Care Proceedings would need to be considered.

Looking at a person’s history can allow different opinions and judgements to be formed, this history is also included as part of current risk assessments. In the field of child protection social work ‘risk’ is usually viewed as being negative and something that needs to be minimised or prevented.

The concept of ‘risk’ is very difficult to define; this is a result of it being ambiguous and contestable. The definition of it will rely on the situational context, field of application and the perspectives undertaken. Risk became a dominant preoccupation within Western society towards the end of the20th century, to the point where we are now said to live in a ‘risk society’ (Beck,1992), with an emphasis on uncertainty, individualisation and culpability.

When defining ‘risk’ it is often done in mathematical and probabilistic terms as a result of it relating to the expected losses which can be caused by a risky event and the probability of this event happening. It is mapped to the probability of an event which is seen as undesirable. When the loss is harsher in relation to the likelihood of the event then the risk will be worse. This negative conception of risk as risk avoidance or risk aversion can be contrasted with the more positive account based on risk taking in venture capitalism and finance as a measure of the variance of possible outcomes.

The systematic management of actuarial risk is risk management while the methodology for evaluating for evaluating is risk assessment. Across different professions techniques and methods used for managing and assessing risk can vary considerably. The resulting effect is that some professions, such as social work, are defined according to their ability and propensity to deal with risk. Kemshall (2002) argued that social work is predominantly concerned with handling and assessing risk instead of focusing on social need and justice.

It is argued in “Social Work in a Risk Society” that, as a response to risk, the reconfigurations between state, politics, science and people are particularly felt in world of social work (Webb, 2006). The reasoning for this is due to the vulnerable, dangerous and challenging populations under conditions of great uncertainty and crisis which social work invariably deals with. Due to this the opportunity for situations that present a risk are greater. The resulting effect is that social work role attempts to develop more extensive risk management and actuarial systems for trying to control this risk. (www.socwork.net).

The current risk to X’s emotional well being has been documented through an individual child protection plan and support services identified. This plan is reviewed on a monthly basis through multi agency core group meetings. These meetings ensure that all agencies and the family have updated information regarding X’s circumstances and are aware when issues arise that may be seen to increase the risk to X’s emotional well being. The regular meetings also ensure that professionals and family members are included in decision making, such as presenting the recent concerns to a legal planning meeting.

It is important that the information was gained from agencies involved in the process and that their views were respected. I was aware that different professionals had their own view about what was going on and how this impacted upon X. I did not take these views as a fact but assessed the information that was received.

I understand that different professionals and organisations can have different means of assessing risk. This can be challenging when making decisions and plans. In this particular case, when Ms X received a custodial sentence there were professionals that felt that the risk to X’s emotional well being was ‘immediate’. Other professionals did not see the risk as being immediate as there was an appropriate family member to care for X when Ms X was arrested. The category of risk to the child appears to be a factor in the assessments that are made. Despite efforts to refocus children’s services away from a preoccupation with risk of significant harm towards supporting families to meet the needs of their children, the risk of immediate harm continues to take priority. In many of the case examples, the needs of children had been overlooked or resources were not available until risk of immediate harm was apparent. Indeed, the focus was on specific types of harm, children who were deemed at risk of physical or sexual abuse (i.e. immediate harm) caused more concern than those who were potentially at risk of neglect or emotional abuse. This was an issue that both service users and practitioners linked to near misses, as well as to more serious adverse incidents. (Bostock, L et al, 2005).

Since the 1970’s child protection work has become less optimistic and more reactive when in 1973 the death of Maria Colwell created a public outcry and preoccupation with retribution and blame (Parton, 1996). The abuse of children became something that social workers should be able to predict and prevent. Assessing risk is one of the main roles in the field of child protection which usually means trying to minimise and prevent potential and identified risks.

Assessment has always been integral to social work practice. Since the 1990’s there has been a steady increase in interest in the field of child care social work assessment. Its importance in social work practice is widely acknowledged. Assessments are undertaken by social workers to gain access to resources such as family support workers and funding and are also used to assess risk. Assessments are used by managers and Courts to inform the decision making process, consequently social work assessments can have a lasting and profound impact upon children and their families.

Assessments can also include linking with other organisation liaising and negotiating using interpersonal and communication skills. For Thompson (2000) interventions can either challenge inequality or reinforce them it is therefore important to recognise inequalities and power imbalances and this can lead to empowerment through promoting equality.

For Coulshed and Orme (2006) there is no understanding that the information gained from social work intervention and assessments might be interpreted in many different ways, depending on which theoretical approach is used.

For O’Sullivan (2002) there is mounting pressure to base decisions on research evidence but he believes there are serious failings in this approach. Therefore O’Sullivan (2002) believes that research studies need to have a supportive rather than significant role in relation to decision making. Evidence based practice and relevant theories should inform social work practice when assessing risk. For this particular case I researched attachment theories and the impact that separation could have on X as a result of his mother’s imprisonment. Bowlby’s attachment theory which Beckett (2005) uses to look at how early life experiences on children’s affect long term psychological development. Research suggests that insecure attachments in childhood can also have a negative impact on behaviour in childhood and throughout adult life. Bowlby (in Crawford and Walker, 2005) believed that the prolonged separation of the child from their mother, especially in the first 5 years of their life could cause mental health issues in later life. These include oppositional-deviant disorder(ODD), conduct disorder(CO) or post-traumatic stress disorder(PTSD) all of which have been linked to early traumatic experiences, including abuse or neglect. (http://psychology.about.com)

However as Crawford and Walker argue there have been criticisms of early thinking of attachment theory as children can make attachments to other people not just their mother. These may include extended family members. Crawford and Walker (2004) believe that as social workers we must consider how life experiences may have influence on the individuals’ growth and development. Throughout my involvement with X in assessing risk and devising plans I have ensured that his individual life experiences were considered. I was aware that X has previously been separated from his mother for a significant period, which could lead to the conclusion that X’s attachment to his mother was already insecure.

When completing risk assessments the long and short term affects of the identified risk need to be explored, this ensures that the social worker can gain a ‘bigger picture’ of how the identified risk could have an impact on the person’s life. I have explored different information and research regarding the effects of parental incarceration and ensured that the family and other professionals involved in the case had access to this information.

There have been a variety of long-term effects on children identified which are associated with the incarceration of parents, one example is the child’s level of development. Even if a child-parent attachment has already developed, for example as in the case of infants in the first 9 to 12 months of there lives that have been in either their mothers or fathers care, the disruption caused by parental incarceration will likely have an adverse affect on the quality of their attachment to their parents. (Parke et al 2001). The quality of infant or toddler child-parent attachment can even be impacted by even less drastic changes such as divorce, or moving home (www.hhs.gov). Insecure attachments between parents and children, which is believed to be a consequence from adverse changes in one’s life circumstances, have been linked to a variety of negative outcomes for the child; these include diminished cognitive abilities and poorer peer relationships (Parke et al 2001). In light of this information it is not surprising that when their parents are serving custodial sentences, it has been observed for young children between the ages of 2 and 6 years of age to suffer from a range of adverse outcomes which are consistent with research on the effects of insecure attachments (Johnson, 1995). One estimates states that 70% of young children whose mothers were in prison had emotional or psychological problems. Children are said to exhibit internalising problems, such as, depression, anxiety, withdrawal, guilt and shame (Bloom & Steinhart, 1993; Dressler et al, 1992, cited in Parke et al, 1992). It has been documented that young children are also at risk of externalizing worrying behaviors such as anger, aggression towards caregivers and siblings (Fishman, 1983 cited in Parke et al 2001).

Since the Children Act 1989 was implemented in October 1991 there has been a debate between the appropriate emphasis of social work practice in terms of risk and need. This has been closely linked to the centrality of the assessment with social work gaining momentum.

Within the act there is no definition for the term risk, child protection is instead constructed with the term “significant harm.”

Under s.31(9) of the Children Act 1989:

‘harm’ means ill-treatment or the impairment of health or development;

‘development’ means physical, intellectual, emotional, social or behavioural

development;

‘health’ means physical or mental health; and

‘ill-treatment’ includes sexual abuse and forms of ill-treatment which are not

physical. (Brammer 2007)

Within risk assessments in social work the term ‘risk’ has been associated with the negativity of harm and child death (Parton 2000). This mixed with the ‘blame culture’ that is present in today’s society has an impact on the way in which risks are viewed in the field of child protection.

Due to the complexity, and the protracted nature of the work, most social work is of little interest to the media and the wider public. Social work stories only become of interest when major failures occur in the system. (Wroe, 1988). Social workers have been very publicly ‘named and shamed’ in the aftermath of the tragic Baby P case, one newspaper’s headline stating ‘Blood on their hands’. The Sun newspaper appeared to lay the blame almost exclusively on the heads of social workers, launching a petition calling for every social worker who had been involved in the case to be sacked and prevented from working with children again (Brody 2009). The Baby P case was shocking and serious mistakes were made, this has created a fear amongst social workers of making mistakes regarding the risk to a child. Social workers and other professionals are now more aware of the negative implications of risk. Following the death of Baby Peter the Children and Family Court Advisory and Support Service (CAFCASS, 2009 in Parton, 2010) produced figures which demonstrated a nearly 50 per cent increase in care applications in the second half of 2008-09 and the demand for care continue to remain at a unprecedented high level.

Assessment is a fundamental skill in social work interventions; it is more than collecting information and is a process rather than an event, which you return to again and again. Therefore it was important to be aware when new information was brought forward regarding the family it was included and the assessment was updated. It acts as a basis for intervention and can form clear objectives. It is important to recognise that there may be multiple problems and all need to be taken into account. Legislation and policy requirement needs to be taken account of, both locally and nationally. Strengths as well as weaknesses need to be assessed. I had to take these into account whilst continuous assessments were being carried out to gain a clear understanding of the bigger picture, as identified in National Framework Triangle (2000).

It is important that children have the right to have their voices heard and to be included in the decisions that affect their lives. It is crucial to engage with the children in the family in order to establish if they are in need or at risk of significant harm. Throughout the period that I have been allocated as the social worker to X I had considerable power to make decisions which would affect the family such as judging whether they were eligible for service, therefore there is a power imbalance. For Milner and O’Byrne (1998) power within social work practice can be used to empower others when working in an anti oppressive way, if power is used incorrectly it can exclude and marginalise service users. As a social worker I was seen as the expert, the service user according to Thompson (2000), by therefore occupies a more powerful position.

For Morris (2000) the Framework for the Assessment of Children and their Families (DoH, 2002) is targeted at a professional audience which means that service users are not provided with guidance about what they can expect as best practice in assessment or what the minimum standards are. This means for Morris (2000) the development of a working partnership or effective participation is limited as only the social worker has the guidance needed and the information about the service that is offered.

For Milner and O’Byrne (1998) power within social work practice can be used to empower others when working in an anti oppressive way, if power is used incorrectly it can exclude and marginalise service users. As a social worker I was seen as the expert, the service user according to Thompson (2000), by therefore occupies a more powerful position.

Due to Ms X being female I looked at how gender affects the issue of drug misuse and offending. An awareness of gender difference should play a key role according to Barnes and Norma (1992), in understanding and responding to needs. But a women centred approach cannot ignore the experiences which divide and separate women as well as uniting them. For example black women in the UK will be affected by cultural differences, racism and in some cases language difficulties as well as by sexism. Barnes and Norma (1992) believe that there is considerable evidence to show that women are more likely to be identified as experiencing emotional problems. Mental disorders amongst women are often identified as behaviours which deviate from what is regarded as “normal” female behaviour.

New and emerging ‘radical’ values concerned with challenging oppression are very distinct from ‘traditional values’ as described in the Code of Practice which emphasise individualised relationship between the social worker and the service user.. We must decide whether to interpret values traditionally as a commitment to respect for people, equal opportunity and meeting needs or radically as a concern with social rights, equality and citizenship. Though there should be no presumptions that the emergence of new values or the development of traditional ones will lead to changes in professional practice. If there is no organisational backing or changed professional education, practice is likely to remain unchanged.

Risk assessment methods in the field of child protection continue to be criticised for being time consuming and being overly actuarial. Accountability in child protection social work tends to focus on the family, as opposed to external factors, such as poverty in terms of neglect (www.northerncja.org.uk). It must be highlighted that ‘risk’ can be defined differently dependant on the individual completing the risk assessment. Differing agencies and workers have different values, cultures, interpretations and language relating to risk. I am aware that the thresholds of risk vary not only across agencies but within agencies (Brown and White 2006). As highlighted by (Barry 2007) social workers with more experience may operate a higher risk threshold than their more recently trained colleagues. Throughout my involvement with X and his family sought advice from colleagues, managers and the Local Authority Solicitors when required and advised to do so.

Prior to the use of risk assessments the child protection system could have been seen to be ineffective. Risk assessments usually require the social work to contact all other agencies that the child is known to. According to (Parsloe 1999) In the pre risk assessment days inter agency communication was lacking compared to today’s standards and because of this children were harmed or even killed, who otherwise could have been saved. The introduction of child protection case conferences has ensured that information between agencies is shared and acted on appropriately, which will undoubtedly improve the quality of assessing risk.

In the case of X child protection case conferences allowed recommendations to be made to all professionals involved which aimed to minimise the risk to X. The case conferences reviews also ensure that any recommendations and actions have been completed by professionals and the parents. As highlighted in (community care.co.uk) child protection case conferences have greatly improved communication between agencies, resulting in the risk posed to a child being reduced considerably.

In conclusion, it must be noted that assessing risk in the field of child protection has improved greatly since its introduction. Social workers now have various documents and theories designed to determine the different risks that affect vulnerable children. The importance of inter agency communication is now highlighted in policies and procedures that social workers must adhere to. Recent media attention directed at social workers has undoubtedly created a fear amongst not only social workers but other professionals in allowing and promoting risk taking. This has resulted in an increase in the referrals received by children’s services and an increase in children’s names being placed on the child protection register of the Local Authority that I am employed by. The different categories that risk is defined under has an impact of the action that is taken by social workers and other professionals. This essay has highlighted the issue that the risk of ‘neglect’ or ’emotional’ harm is not seen to be as ‘urgent’ as a child that is at risk of ‘sexual’ or ‘physical’ harm. I am conscious that risks that are identified can vary depending on the individual that is assessing the risk. I am aware that as a social worker it is important that I recognise my own values and how this could impact an assessment that I complete.

An asylum seeker is an individual who arrives at the country’s port of entry with or without a valid visa and wishes to be recognised as a refugee by the State (Luibheid 2004, p.336).

In Ireland the aspect of the law that defines refugee can be found in Refugee Act (1996). This Act also reflects Article 1 of the 1951 Geneva Convention. A refugee in Irish law is an individual who is, owing to well-founded fear of being persecuted on grounds of race, nationality, religion or membership of a particular social or political group in her home country and is unable or owing, to such fear, has prevented herself from the protection of her home country (irishstatutebook.ie).

Kanics (2007) stated that the number of people seeking asylum in Ireland fluctuates. The highest number of applications (11,632) were received in 2002 (Larlor and Share 2009, p.420). However, Ireland is not alone in experiencing increases in the number of people seeking asylum. It also applied to other European countries like Germany, France and The Netherlands (Clement 2001, p.174). In 2010 the total number of people that seek asylum was 1,660 in which 15 percent were under direct provision in Limerick (unchr.org; cso.ie; ria.gov.ie)

3.3 Gender Issues and the Asylum Process

Wright (1995) and Kay (1989) researched women asylum seekers and proclaimed that there had been a bias towards male asylum seekers. ‘Gender neutrality’ can hinder the resources of women asylum seekers (Hunt 2008, p.282).

The gendered roles and division of labour accepted within most societies means that women’s roles will often be different from those of men. In many cases, women’s activities are not accepted as political activities by the authorities deciding on asylum (Freedman 2009, p.177).

Baines (2004) argues that feminists and academics are critical about the unsatisfactory handling of gender in relation to asylum seekers in international conventions and treaties. Crawley and Lester (2004) suggest that less women than men claimed asylum in Europe. Women who experienced persecution may also find it difficult to leave because of their children and financial problems. Spijkerboer (2000) argues that women only leave their families and country when they can no longer cope (Freedman, 2009: 176).

According to Bunch (1995 p.13), the failure of the High Commissioner to envisage persecution on grounds of sex, makes women feel left out of the range of those that can be granted refugee status. A gender guideline for processing women asylum seekers’ applications was launched by the Human Rights Barrister Kennedy in the United Kingdom. The new guidelines aim to prioritise the experiences of women asylum seekers in the process of asylum (Verkaik, 2000).

Most research conducted on asylum seekers in Ireland focuses on the problems faced, based on their experiences in their home countries. Few of the researchers focus on the coping strategies in the new environment asylum seekers find themselves (Hunt 2008, p.32).

Studies have shown the importance of the strategies and actions of the women during the asylum process. Berghahn (1995) conducted a study on Jewish women fleeing Nazi Germany. Despite the fact that these women were from middle-class backgrounds, they engaged in unpaid domestic roles to support their families. Berghahn explained further that women are more able to adjust to a different status than men (Hunt 2008, p.75). McDonnell (2009) conducted a qualitative study on women asylum seekers in Limerick and she stated that most of them developed strategies to cope with the situation while the process of asylum reinforced the feeling of isolation and exclusion for some of the women (McDonnell 2009, p.101).

3.4 THE PROCESS OF ASYLUM APPLICATION IN IRELAND

The process of asylum differs from country to country. In the UK, asylum seekers refer to those that do not have a recognised residence status but instead have temporary residence till the end of their asylum application process (Clement 2001, p.177). In Ireland, refugee applications are dealt with on the criteria stated in the Refugee Act 1996 as amended by Section 11 (1) of the Immigration Act (1999), and by Section 9 of the Illegal Immigration (Trafficking) Act 2000, and by Section 7 of the Immigration Act 2003 (oireachtas.ie).

Refugee Application Commissioner (ORAC) deals with asylum applications decision in the Irish asylum system. This office was established in 1996 under the Refugee Act 1996. The (ORAC) makes a recommendation based on the individual application. This may take up to six months or longer before the applicant gets a decision on her application. In a situation where the recommendation is negative, the applicant can appeal; such an appeal will be forwarded to the Refugee Appeals Tribunal. Based on the recommendation of the tribunal, the Minister for Justice and Law Reform will make a decision. In some cases the applicant may get the decision within a year (citizeninformation.ie). However, in most cases, it will take longer than that.

In a situation where the applicant is refused on appeal, she can apply for humanitarian residency and this decision can take a year or more. Refugee status will be granted if the applicant meets the criteria in the definition of refugee as stated in the Refugee Act 1996. Refugee status will allow the holder family reunification, entitlement to work, right to own a business, full social welfare services and payment and educational services. They can also apply for a travelling document under the 1951 Convention (oireachtas.ie).

3.4 SOCIAL POLICY AND ASYLUM SEEKERS

Forbes-Martin (2004) pointed out that most countries do not have policies and legislation in relation to asylum seekers and in some countries the policies in place are not implemented. That is, persecution claims by women asylum seekers are not accepted even though it has been a universal debate (Freedman 2009, p.175).

In April 2000 there emerged another policy in relation to the process of accommodating asylum seekers in Ireland. Asylum seekers that arrived in the country after this date are not entitled to full welfare allowances but placed in an accommodation centre. Three meals are provided daily, a bed, and free medical services. In addition, adults are paid 19.10 Euro and each child receives 9.60 Euro every week as allowance (Luibheid 2004, p.337). However, studies have shown that asylum seekers in direct provision experience food poverty which leads to unintended weight increase; it takes away their control over food choices, and results in a limited social network that causes isolation and loneliness. This system deprives them of social interaction opportunities leading to a lack of integration (Manandhar, 2006). Prior to 26th July, 1999 asylum seekers had access to education and training and post-Leaving Certificate courses. Asylum seekers that came after July 1999 are not allowed full-time education or training but their children under eighteen are allowed primary and secondary education (Irish Refugee Council 2001).

In Limerick, there are three asylum seekers’ accommodation centres. One of these is for single people and the remaining two are for families (ria.gov.ie).

The 1956 Citizenship Act was amended in the 2004 referendum which withdrew the right of the parents of Irish-born children to apply for residency in Ireland. The argument of the State was based on the assumption that migrant women were coming to Ireland to give birth to Irish Citizens (Coulter, 2004).

Hence, most women asylum seekers struggle to cope with their new environment and there is no specific duration for the process of asylum application in Ireland which means applicants could stay longer than expected during this process. This review will now look at the needs of women asylum seekers.

3.5 WOMEN ASYLUM SEEKERS’ NEEDS

Hewitt (2000) stated that ‘human needs represent a standard of fulfillment different from basic needs and important basic human needs’ (Hewitt 2000, p.126).

Studies conducted on asylum seekers have shown that their needs are complex. Some of these need include good housing provision, adequate health facilities, access to education, employment opportunities and access to adequate information. Other problems identified include poor language skills, lack of social network support, little or no understanding of the norms of Irish society, psychological problems due to the process of asylum and lack of self-confidence due to racism experiences (Kennan, and MacNeela, 2004; Hollander 2006; Lamba 2003; and Riemann 2003)

Kennan and MacNeela (2004) conducted a qualitative study on asylum seekers and concluded that direct provision system is like a strategic plan to put an end to the provision of accommodation for asylum seekers in Ireland. Their study also suggested that asylum seekers that fled persecution from her home country had to begin a new life in the country where she sought refuge (Kennan and MacNeela 2004, p.10).

In Ireland, prior to April 2000, asylum seekers were accommodated in private rented accommodation and they were given welfare allowances as Irish citizens. This system was changed to a ‘Direct Provision System’ in April, 2000, when rental accommodation was replaced by asylum accommodation centres (Luibheid 2004, p.338). Furthermore, a qualitative research conducted by Veale and Fanning (2001) pointed out that ‘the method of providing food for asylum seekers in the direct provision is not suitable for women asylum seekers and their children (Veale and Fanning p.5). Former Minister of State Donnell stated that ‘housing and accommodation is perhaps one of the most important things to get, as we work towards integrating asylum seekers,’ (Kennan and MacNeela 2004, p.14).

Women asylum seekers and their adult children could not attend full-time education or training, although some agencies like FAS and VECs are working towards meeting these needs in relation to education. These agencies however, only focused on English language classes and skill training (Stewart, 2006). Asylum seekers’ children between age 5 and 16 years in the United Kingdom have the same educational right as other children (Reakes, 2007). Asylum seekers’ children that are minor can acquire both primary and secondary education like other children in Irish society. These children can only access education for the period of their parent’s asylum process and continuation of their education depends on their parent’s asylum application decision (Irish Refugee Council 2001).

Asylum seekers are among the ethnic minorities that their health needs special attention. Nolan et al. (2002), Cave et al. (2003), Collins (2002), and Galvin (2004) suggest that the process of asylum, availability and accessibility of health service contributes to the health needs of asylum seekers (Stewart, 2006, p.55 ). In other words, cultural variations can hinder the progress of meeting the health needs of women asylum seekers, as the support workers might not understand their cultural beliefs. This can reduce women asylum seekers care provision. (Powell et al. 2004).

Physical and psychological needs of women asylum seekers arise from their experiences from the country they fled from. Such experiences include war, political persecution, torture, discrimination, financial hardship and abuse. (Powell et al.2004). The Department of Health (2004) stated that feelings of isolation and insecurity experienced by asylum seekers based on lack of privacy can lead to social withdrawal, aggression, and depression (Stewart 2006, P.54).

3.5 ASYLUM SEEKERS’ CHILDREN

Pringle (2006) outlines the needs of children to include: love, security, praise, recognition, responsibility and new experiences. These needs have to be met from childhood and through adulthood (Pringle, 2006).

Veale and Fanning (2001) pointed out that asylum seeker’s children that are placed in direct provision ‘foster extreme child poverty and social exclusion within Irish communities.’ The centres are not conducive for pregnant women and their children (p.14). On the other hand, Manandher et al. (2004) conducted a qualitative study on food provision of asylum seekers in direct provision. They suggested that the lack of privacy in asylum centres prevents the women from breastfeeding their babies comfortably (p.45).

The Irish Refugee Council (IRC) stated in their policy on the regional reception of asylum seekers in Ireland that asylum seekers’ children experience the same difficulties as their parents. Their needs are similar to their parents in terms of health, housing and psychological needs. Asylum seekers’ children depend on their parents for developmental needs and this makes them more vulnerable (Irish Refugee Council 2001). This principle is underpinned in Children First (1999), the National Guidelines for the Protection and Welfare of Children. It states that parents have the primary duty for the care and protection of their children (Children First 1999). Asylum seekers’ children’s experiences in accommodation centres are contrary to the UN Convention on the Rights of the Child (CRC) (1989). It also opposes different existing laws in Ireland such as the National Children’s strategy, the Program for Prosperity and Fairness (2000) and the National Anti-poverty Strategy (Veale and Fanning 2001, p.5).

Hence, women asylum seekers needs are complex but their basic needs are met but base on different persecution they have experience there is need to tackle their psychological problems. Also, asylum seekers children in direct provision experience are contrary to existing laws in Ireland.

3.6 ASYLUM SEEKERS’ VIEW OF THE PROCESS

The study conducted by the European Agency for Fundamental Right (EFR) on asylum seekers in Europe has shown that asylum seekers in Ireland have mixed experiences. Ireland is one of the countries that have the asylum procedure on the website which is self-explanatory and leaflets are available where they can get access to free legal aid. Also, the leaflet is translated into about twenty languages compared to France where the leaflet is translated into five languages (Kjacrum, 2010). The questionnaire for asylum application in Ireland is difficult to complete because most of the asylum seekers do not have knowledge of the rules and regulations. Asylum seekers in Ireland also complain of the language barrier when talking to solicitors (Kjacrum, 2010).

In addition, some of the applicants complain that they are not aware that they can have a ‘gender specific interview. Some of the asylum seekers complaint about delays in the asylum process which can cause mental stress (Kjacrum and Frewen 2010). According to Rowley, the concern is that some of the women who have been in the system for two years, still battle with the dilemma of being deported. Hence, despite their experience of trauma, they are left in such an insecure state (Macormaic, 2008).

3.7 The Role of Support Workers and the Challenges they Faced

A support worker is an individual trained in motivational interviewing process techniques to be able to participate in the decision-making of issues that concern their client’s life (Territo and Kirkham 2010, p.189). Hennesy (2002) states three principles that govern the services provided by support workers as: ‘self-determination, participation and empowerment.’ An examination of these principles in relation to working with women asylum seekers entails service users being involved actively in the activities that influence decision-making on services provided for them (Lalor, and Share 2009, p.343). (See appendix 1 for the role of support workers).

Looking into support workers challenges, Pedersen (2000) refers to culture as the values, beliefs and behaviour shared by certain groups of people in society and multiculturalism as the ‘fourth force’ in the process of supporting the clients (Corey and Corey 2006, p.16). Most of the women asylum seekers are from different background, culture and religion belief, support workers needs to embrace multiculturalism in order to meet their needs. Pederson (2000) pointed out that not all African or all American have the same culture despite the fact that they are from the same continent. Also, those that have the same culture, have different experiences (Corey and Corey, 2007 p.186). Lee and Ramsay (2006) argue that changes in the demographics in society brought about new patterns for the helping professions therefore, it is important for support workers to embrace a broad multiculturalism approach in order to understand diverse clients (Corey and Corey, 2007 p.189). However, the differences in beliefs, values and cultural backgrounds can prevent support workers from providing sufficient and proper care required from them (Lalor and Share 2009, p424). From the literature presented above, one can see that there are many issues affecting women asylum seekers. Therefore, there is a need for support workers who understand the complexity and diversity that asylum seekers present with.

In conclusion, this literature review has shown the needs of women asylum seekers, the process of asylum application and the view of the asylum seekers of the process. It has also explored asylum policies, the experience of asylum seekers’ children in direction provision, and the challenges faced by the support workers. Finally, it explains the roles of asylum seekers’ support workers.

Based on the above literatures review, the researcher’s view that the needs of women asylum seekers depends on the experiences from the country they fled from, as well as the process and duration of asylum and the asylum policies in place in the host country.

Elderly abuse has been prevalent in our society and it has not been discussed frequently as compared to other issues in our society and not much research has been done on elder abuse in Singapore. Due to such limitations present in the study of elderly abuse, this creates an impression that elderly abuse is a rare occurrence and is not a potential threat to our society. With the reports on real life elderly abuse cases, it is evident that elderly abuse does exist and is not a rare occurrence in Singapore as most of the time, such incidences go underreported. Furthermore, it is often difficult to detect elderly abuse as in the first place, there is a lack of awareness as to what actually comprises elderly abuse. Dr Vivian Balakrishnan, minister for community youth and sports, at the annual family violence symposium in the year 2009, cautioned that as Singapore comprises one of the fastest ageing populations in the world, we have to be prepared and expect an increase in the number of cases involving elder abuse. ( straits Times). What is more worrying that majority of the elders suffer abuse under the hands of their own children due to the stress induced on them from care giving. Hence, elderly abuse has become one of the most important compelling social issues which have to be addressed due to the nature of Singapore’s demographic trends which consists an increasing proportion of elderly. Thus, in this paper, the social issue of my focus would be elderly abuse in Singapore.

A common problem faced with regards to the discussion of elderly abuse would be the issue about what exactly constitutes elder abuse. As a result, many cases of elder abuse go unreported. ( pg 28, say no to elder abuse).The Golden Life Workgroup on Elder Abuse Prevention formed in Singapore in the year, 2002, adheres to the World Health Organization (WHO)’s definition of elder abuse. It defines elder abuse in its report presented to the government as

“A single or repeated act or lack of appropriate action, occurring within any relationship where there is an expectation of trust or duty of care, which causes harm or distress to an older person.” (Golden life workgroup on elder abuse, 2004 PG 16, World Health Organization 2002) CITE PROPERLY

The Ministry of Community Youth and Sports (MCYS) categorises elderly abuse into 5 main groups such as financial, neglect, abandonment, physical and psychological abuse. (Understanding Elder Abuse and Neglect pg 8 check year 2004?).

The ageing trends of Singapore suggests that with increase in life expectancy, the elderly would now require more long term care than before and there will be an increasing level of dependency on their children to support them. With declining birth rates, there would be fewer care givers in the family. This creates ample opportunity for elderly abuse to take place. (UN Secretary-General’s Report, March 2002). The percentage of elderly who are aged above 65, in 2009 was 8.80% and the projected percentage of elderly in the year 2030 is expected to rise to 18.7%. (Statistical Indicators on the Elderly, MCYS) .The United Nations uses the dependency ratio as a marker of the potential dependency burden to predict the amount of burden which has to be carried by the working population. (Source: Population Division, Department of Economic and Social Affairs, United Nations Secretariat 2007 http://www.un.org/ageing/popageing.html). In the case of Singapore, as the old-age dependency ratio is increasing each year whereby in the year 2008 it was 11.9 per 100 and in the year 2010 it increased to 12.2 per 100. (Department of Statistics, 2011). This has serious implications for Singapore, as the working population has to shoulder the burden of care giving and financial support. Now, it becomes even more challenging with the rising number of singles and married couples choosing not to have any children or just having one child . Such situations have serious repercussions as the future trend will be such that care giving on the elderly will be solely shouldered by the only child and this creates an increasing amount of stress and pressure on the sole caregiver which in return causes them to abuse the elderly. It was reported in the Straits times that each year a total of about 178 cases of elderly abuse were being reported and out these 178 cases reported about 120 cases of the elderly were abused by their own children. (Theresa Tan, The Straits Times (Singapore) October 22, 2009 Thursday).

There are various theories to explain the reasons for the occurrence of elderly abuse. The social exchange theory seeks to further explain the reasons for elderly to experience violence from their perpetrators using the concept of social resources such as power, financial stability and status. ( Quote : social work textbook pg 324), Pillemer, 1989 refer to no eldlerly abuse book behind). Increasing level of dependency on children creates a potential environment for abuse to take place, as the elderly authority is now diminished due to lack of power and necessary resources which the potential caregiver has. Hence, such a power dimension with regards to the availability of resources creates imbalance and strain in the relationship between the elderly and the caregiver. Another instance whereby an elderly abuse can take place can be explained through another theory known as the ecological theory, is when the caregiver of the elderly themselves might be undergoing several problems for instance they themselves might have financial difficulties or could be suffering from some health conditions. Thus, looking after an elderly may induce stress on the caregiver whereby in some situations, as a form of coping mechanism they might vent out their frustrations on the elderly under their care through verbal and physical abuse and this causes the elderly to be in a greater exposure to abuse. (MCYS , booklet). An example to illustrate such a case which was cited in a Straits times article will be about an unmarried son who was in his forties who had to give up his job to look after his mother who was bedridden and suffering from dementia. Not being able to handle the stress that he was going through, he used to hit his mother frequently. (Theresa Tan, The Straits Times (Singapore October 22, 2009 Thursday). Most of the times , the victims of elderly abuse tend to be elderly who are completely dependent on their children in terms of financial and healthcare aspects and therefore the perpetrators of elderly abuse are usually their children or someone they dependent on.( Quote: The Pattern of Elderly Abuse Presenting to an Emergency Department, G W M Cham, E Seow, 2004, pg 571).

Although, the number of elderly abuse and neglect cases are less than 200, it should not be taken at face value that the elderly abuse is a rare phenomenon. Coming from an Asian society, especially in a region whereby Confucian values are prevailing, since most of the perpetrators are their own children, the elderly seldom report about them being abused as they do not want to be embarrassed or do not want to be judged upon, looked down for raising children who are abusive. ( Penhale 1993, british journal of social work, 23,2) . For other elderly, they might choose to suffer under the hands of their children rather than reporting them as they are increasingly dependent on their children to fulfil their basic needs, they fear of losing them or they fear of the future consequences such as intensified level of abuse from the perpetrator when they resort to reporting them.(Lee and Pang, 2003, pang 2000). Due to such underreporting and the denial of being abused further heightens this social issue as the elderly tend to suffer in silence.

The social issue of elderly abuse should be viewed in terms of a micro and macro level. (social work)From the examples cited in this paper, it can be seen that most of the Elderly abuse which is one form of family violence was initially seen to be a private affair which was confined to and occurred usually in the family sphere which is the micro level. When the issue of the elder abuse is also being experienced by majority of the citizens in Singapore as well, with the increasing number of cases of elder abuse being cited in the newspapers and with the fast paced ageing population in Singapore, this issue of elder abuse now becomes a public and national issue which the state has to address. (textboo) For instance, in the earlier years when it came to issues about abuse more attention had been given to child and spousal abuse but not elderly abuse.(say no elderl abuse) Currently as more cases of elderly abuses are coming to the limelight, it is an issue which is worthy of concern. Therefore, elderly abuse and neglect is a social issue which not only affects the elderly but it also the rest of the population who now have to shoulder the responsibility of supporting the elderly.

There are many perspectives with regards to the issue of elderly abuse and how it should be tackled. Firstly from the state’s point of view, it strictly adopts a non-welfare approach .The state believes that various social safety nets such as the community, social services and non-profit organizations have to come together to tackle the social issue of elderly abuse. The state mainly uses the legal approach and tertiary intervention in the form of laws to tackle elder abuse and neglect. For example the Women’s charter seeks to deal with family violence and protect family members including the elderly who are being abused. The financial neglect of elderly is being handled under the Maintenance of Parents Act which allows the parents to demand financial support from their children through the Tribunal court. ( say no to elder). The Maintenance of Parents Act although allows parents to demand for financial provison from their children. This solution can help the elderly to seek financial support from their reluctant children especially when they have no one to turn to. Unfortutantely, this is only a temporary solution as the law only address the financial neglect aspect and does not address the emotional aspect of the elderly. It is because the law cannot mandate children to be loving towards their parents .This present solution posses certain shortfalls, for instance, ,many parents may not want use this maintenance act in order not cause further trouble for their children. Another problem with this solution is that many of the elderly are not even aware about the existence of such legal framework.

From the medical doctors and healthcare professionals’ perspective, there has been increasing concern with regards to elderly abuse and neglect. Hospitals now see an increasing number of care givers committing suicide due to not being able to handle the pressures of care giving and some even result to abusing their parents under their care not because of the intention of abusing them but because they do not know who to handle the situation.( srraits times) In a recent stratis time a doctor in the article mentioned that one of her patients’s daughter who was the sole care giver would force feed her until the patient had to be treated in hospital for malnutrition and despite continuously being admitted into the hospital, she was not told where to get help and the caregiver by chance found out that there is a centre which provides help in care giving. ( straits Times). From the health care professionals view, they feel that the state can come up with even more rigourous legal framework and the state could help in creating a strong network between hospitals and various caregiving centres so that the patients are able to get revelant help to cope with the demanding tasks of care giving. Furthermore, health care professionals can play a key role in detecting elderly abuse. The emergency department is one important place whereby elderly who are abused are being isolated and it can be the only appropriate situation to detect cases of elderly abuse. (W S Pang, 2000).The health care professionals face a dilemma when they encounter or suspect that their elderly patients might have been abused. It is because there are no specific laws addressing elderly abuse or neglect which results in not having a clear focus of what actually constititues an elderly abuse. (Quote pg 50). There are efforts to implement laws such as Maintenance of Parents Act by the state to protect elderly in some ways however, there is no laws which calls for mandatory reporting of elderly abuse cases. Hence this creates a predicament on part of the doctors as to whether or not to report cases of abuse. Due to the absence of a clear and proper framework or solution for the hospital professionals to strictly adhere to, such a situation causes an elderly to be trap in a vicious cycle of abuse. This has underlying consequences in the future as more cases of elderly abuse may become undetected.

From the social workers and policy makers perspective, they believe that more can be done in training healthcare professionals and social workers in terms of understanding and detecting elderly abuse. In addition, they believe that more care giving centers can be set up to reduce stress of the care givers and serve as an intervention for abuse cases. This solution is can be very useful in the long run as it helps to protect elderly and helps to consell and educating the stressed caregiver which eventually helps to prevent the elderly from being further abused. However, one area of concern would be that the availability and increasing number of caregiving centers and residential homes can also create a room for misuse whereby children of the elderly for their convenience and in order to discard their responsibility as they might use such places to dump their parents there. Thus, there has be stricter regulations with regards to the admission into the caregiving centers.

After considering all the different perspectives being offered pertaining to elderly abuse, in my view, I would support and favour health professionals, social workers and policy makers view especially with the view that the state has to adopt stricter and harsher laws when it comes to elderly abuse. The absence of mandotary reporting of elderly abuse, creates the main problem for allowing elderly abuse cases to go unreported. Furthermore with the absence of a clear framework of what actually constitutes elder abuse or how this social issue can be tackled it creates a form of helplessness on the part of the healthcare and social work professionals as they are not being able to intervene in elderly abuse cases promptly. In my view once the state has come up with a clear set of laws specifically addressing to elderly abuse and once there is an the implementation of mandatory reporting then it becomes easier for the healthcare professionals and social workers to be better equipped in intervening in elderly abuse cases.

In conclusion, as discussed in this paper, elderly abuse is one of the key social issues which the states has to constantly look into as elderly abuse requires lots of intervention programmes, training and education of the public and social work professionals. Elderly abuse can have serious consequences on the mental health of the elderly and they might lose their dignity in living as a normal human and their basic human rights such as the freedom to fight against any abuse and discrimination against them is being lost. Therefore it becomes a necessity to ensure that these group of elderly not just will have the proper healthcare facilities but it is also our society’s outermost duty to ensure that the elderly age with dignity and they spent their last years in a protected and non abusive family environment.

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1. AIM/OBJECTIVE

The purpose of this paper is to examining the concepts of hold-up and how power plays an important role in how the problem of hold-up is resolved. And also look at possible strategies or solutions for the buying organisation to avoid hold-up.

2. METHODOLOGY

This paper will examine the work of Klein and Chang & Ive in answering the concept of hold-up in the supply chain and also will examine the pre-contractual and post-contractual issues leading to hold-up. The first part of the assignment looks at how concept of incomplete contracts led to problem of hold-up in case of the General Motors and the Fisher’s case.

In the second part of the assignment, is about how other factors like asset specificity and lock-in leads to hold-up problems post contractual in reference with the construction projects. Also look at the case of hold-up in the IT industry in regard to the Flash – Apple clash.

And finally critically evaluating the different cases and conclude by deriving a strategy or mechanism in avoiding or minimising the risk of hold-up’s for buying organisations.

3. INTRODUCTION

Hold-up is a situation where there are two parties (say, buyer and supplier) and one party has to make specific investments for the trade. If the investment is specific only to that customer, then the supplier is vulnerable to hold-up and on the visa-versa, if the product designed is specific to the raw material possessed by the supplier then the buyer is bound to have higher risk of hold-up (Klien, 1996). The party with the higher power seeks to achieve the quasi-rents [1] . Hold-up on the transactions cost economics is the problem of short-sightedness.

Hold-ups can occur under various situations both pre-contractually and post-contractually. As explained by Williamson (Williamson, 1985), it could be Opportunistic behaviour of supplier pre-contractually or Klein’s theory of uncertainty in the market condition or the issue of moral hazard or bad behaviour by the buyer that leads to the hold-up situation.

As explained by Klein, “the buyer/supplier conflict can be due to unanticipated events that occur during their contractual term; like reduced/increased cost or demand, which clearly puts one party with the higher bargaining power and thus changing the power dynamics in the relationship. The party with the higher power tries to breach the contract or be opportunistic in order to achieve the quasi-rents.” (Klien, 1996)

Williamson’s concept of feasible foresight/farsightedness could be a possible solution for the buying organisations to avoid or negate the issue of hold-up. People are boundedly rational and having a myopic view is a problem. Klein looks at the role of contracts in solving the problem of hold-up and says the assessment of self-enforcing range of the contract and a better written contract can avoid the situation.

“The ways of solving or taking into account the problem of hold-up has been in the core of transaction cost economics. There have been occasions where both parties know that there is a possibility in hold-up in future but considering the cost and time involved in defining each and every contingency in the contract is not feasible” (Fares, 2006).

Below I will be discussing a few cases where hold-up was evident and what corrective actions were taken under different circumstances.

4. HOLD – UP: CASE ANALYSIS

There have been numerous cases of hold-up discussed in the transaction cost economics and the one that is most spoken about is the General-Motor and the Fisher’s Case. In this assignment, I will be discussing three different cases focusing on contractual issues, moral hazard, asset specificity and the issues with time in Hold-up.

4.1 General Motor & Fisher’s Case of Incomplete Contracts [2]

“This has been the most spoke about case in economics in relation to the issue of hold-up. In a nutshell, it is a case where both parties signed a contract in 1919 for the supply of automobile bodies by Fisher to General Motors. Fisher, the manufacturer or supplier in this case had to make specific investments in stamping machines and dies for General Motors. This was a long term contract(over a ten year period) and also General Motors set a price formula, Fisher’s Variable cost plus 17.5%(to cover the capital and overheads). Ideally General Motors(henceforth GM) designed the contract in such a way that they can create a hold-up over Fisher. GM had even threatened to reduce the demand if Fisher did not come down on price, which would mean that the investment made by Fisher would not be efficiently used.

But what really happened was not expected by both the parties. Up till 1919, most of the cars had wooden bodies but there was a huge rise in demand for steal body cars in 1919 which lead to a huge rise in demand for Fisher’s products. GM had no other supplier to replace with and even doing so would lead to a high switching cost. This could also be a problem of myopic view by GM, who view the price in a long term perspective and ignored the market potential/demand. The unanticipated increase in demand gave Fisher the upper hand and used the contractual terms to its strength in attaining the quasi-rents. They moved farther from GM location and created the extra-income through the formula set by GM in price determination. Fisher found that the contract was over the self-enforcing range and was in a favourable position for it to profit out off the contract if it breaches the contract. This provided as an incentive to Fisher.

Both the parties new that the contract was not completely perfect and believed that the contact was optimal designed to minimize the probability of hold-up. GM had only two options available to resolve the problem, first to terminate the contract and find a new supplier. This would mean that the huge market demand cannot be satisfied and the switching cost becomes very high. The second being, renegotiating with Fisher and provide a lump sum payment to keep the contract running. Without question, GM had to settle for the option two as the time span was very limited and GM did not have much of an option in suppliers then. Thus the problem of imperfect or incomplete contracting leading to hold-up is evident in this case.

In this case, to prevent the ex-poste problem of contracting, GM should have had the farsightedness view towards contract and defined a contingency plan in case there is a drastic change in the market condition to renegotiate the contract and derive at a new price. This could have saved quite a lot of time and resources. It should not be just from the price point view but should be a holistic view of the contract. They should have defined the self-enforcing range so that they need not be amended frequently. They were right in defining the power relation pre-contractually but underestimated on the post-contractual drift in power. Also GM should have had better incentive plans in place so that the supplier does not think about breaching certain incompleteness of the contract” (Klien, 1996).

Asset / Process Specificity & Lock-In Situation In Construction Projects [3]

The second is a case with multiple levels of hold-up ranging from small to large in the money involved in the dispute. This is a case in the construction project with three different parameters (uncertainty/unanticipated events in the project, lock-in situation and the amount of money involved in the dispute) of hold-ups identified. In the construction specific project a new form of asset specificity was identified, process specificity” (Chen-Yu Chang, 2007).

“The channel tunnel project is a build-own-operate-transfer project for creating a tunnel for railway network. Both the French and the British governments awarded the project to Eurotunnel, to build and operate the tunnel for 55 years(which after extension is 99 year project). Eurotunnel in-turn sublet the construction to a ten member consortium called Transmanche-Link [4] . The project was at the design stage when TML was assigned and the changes that they had to make in the project had to comply with safety rules of the intergovernmental commission” (Chen-Yu Chang, 2007).

The project started under huge pressure and Eurotunnel, gave out the project to TML under two contracts: “cost-plus contract for tunnelling and lump-sum contract for fitting out and terminals” (Chen-Yu Chang, 2007). Two events that were ungovernable uncertainty that occurred in the first stage where, the conditions for the land, which TML expected it to be better but was in a much worse condition and the delays in signing of the Anglo-French channel treaty delayed the start of the construction. Although the money under dispute was not a large sum at this stage TML had to go for an extension in the project time and there were no concessions made on the cost overruns.

The second round of dispute was on the cost overruns which were outstanding from the previous dispute. By this time both were in a lock-in situation as over ?850 million loan has been drawn out of the bank. Due to the delays caused earlier, there was a step rise in the cost which needed the contract to be re-valued and the new target cost for the project was set but TML had to bear a higher percentage of the cost overruns.

The third dispute was a large sum of money involved, where the requirements of intergovernmental commission and railway companies induced a huge rise in cost on the equipments. TML passed on this added cost to the contractor Eurotunnel. By this time Eurotunnel was in a lock-in situation with TML and had to settle for the needs of TML. Thus TML benefitted out of the incomplete long-term contract signed.

4.3 Flash – Apple War

“The third case is over property rights issue in IT industry. IT and Software industry is prone to hold-up problem. For example, developing an internet page/company basing it on a particular software firm/application which the company doesn’t have property rights is considered equivalent to building a house without owing the land. For any changes that have to be made on the internet, they need the original creator/vendor, which makes it dependant or held-up by the vendor.

Flash is a similar kind of software or platform, where the products built on Flash are at high risk of hold up. Because of this, flash is recently been targeted by firms like Apple and Google, in replacing them with a better source. Apple for its new product iPad, needed to make heavy investment in the ecosystem. Had it used Flash, Apple’s ability to achieve rents from the investment would have been held-up by Adobe. Flash is a more closed software and does not share exclusive information with its clients. This has been a hindrance to many firms and firms are looking for a much open source software and platforms to develop their products.

The issue in the IT sector could be minimized by making a clear contract stating the future maintenance and updating of the software and also define a period when the contract will be re-valued or re-negotiated” (Michael Schwartz, 2010).

5. CRITICAL EVALUATION

After looking at the three above cases some of the prevention measures that a buying organisation could adopt are as follows. It is not always possible for a buying organisations to adopt these is all the situations.

Figure 1: Contractual Process

The above picture depicts the process of contracting that the buyer could you to adopt to avoid or minimize the risk of hold-up in a relationship. The first step for the buyer is to decide on the investment and make a cost-benefit analysis of the investment. Some of the basic questions like is the investment really needed, is it worth entering into the relationship and most importantly before the investment decision is the analysis of the buyer-supplier power relationship.The buyer before entering into contract specific investment in relationship, has to assess the power dynamics and foresee the possibility of shift in power post investment. If it finds itself in a weaker position, certain contractual terms could be added to protect its profits out of the investment. Defining the relationship also clears the fear of buyer falling into a lock-in situation with the supplier. As Williamson says, buyers need to have the farsighted view on the contracts than signing a contract and taking care of the problem later, only to recognise that they have to settle for the second best option.

Then is the writing of contracts. As we have seen from the above case examples, it is clear that all the contingencies cannot be written down in the contract as identifying them is a lengthy process and is an expensive process too. To make an effective contract, we could use both Klein and Williamson’s concept in design a contract which has a self-enforcing range but also had the farsightedness view of the project and identifying opportunistic nature of the supplier. Also it is important at this stage to define the property rights of the product or the process that the supplier is making with the specific investment made. It is also important to define the incentives that the supplier gets for on-time completion of the project and within the budget fixed. This incentive should be made as an attractive offer to the supplier so that the risk of opportunistic behaviour by the supplier can be minimised.

The next step is that the supplier makes the investment and the buyer needs to overlook the spend so that they do not go excessive of the planned budget. The problem in conflicts and lock-in has in most occasion been due to the excessive spends and buyer had always been to have partially paid for the mistakes of the supplier because of the sunk cost or switching cost for the buyer if he had to change the supplier during conflict. The contract should be defined in such a way that over a specific period of time and cost, the contract will be re-opened for negotiations and a performance review been conducted on the supplier.

The fourth and fifth steps are in relation to the renegotiation of the contracts. During the contract stage, the time period of re-negotiation or re-evaluation of the product should also be defined. Even in a long-term contract when the price is fixed on certain parameters, it is better to re-examine the conditions after a few years or after certain unanticipated events like financial crisis or sudden rise in demand to keep a contractual balance and prevent one party from benefiting from the contract.

The final step is the payments for the trade and the buyer’s need to be careful here not to delay the payments as this could lead to conflict and the supplier taking arbitration actions to court. This could also lead to bad reputation and damage the image of the buyer in the market.

6. CONCLUSION

Again, Power relations play an important role for the buyer organisation in defining their contractual terms with the supplier. Power is the universal term in economics and failing to understand it could be costly for organisations. From the case evidence above it is clear that being over-optimistic in design the contracts have made some companies in losing their power post-contractually. Hold-ups are due to unexpected events or sometime a deliberate process due to the lack of time or resources available. There has been no specific method or tool to negate the hold-up issue and depending on the situation the actions are taken. But it is important for buyers to pre-empt the situation and be ready to tackle the situation.

Thus I conclude by saying that in real world all the situations are possible, information asymmetry, opportunistic behaviour supplier, moral hazard behaviour of buyers, lock-in situation, incomplete contracting and hold-ups are the evident result and one needs to craft a well designed contract to evade the situation.

They buyer’s need to keep in mind this statement of “why settle for a silver when you can go for the gold”

The focus of attention of this essay is on ‘The potential for professional misuse of power by health care professionals when working with vulnerable groups’. The author of this paper will address a number of issues as they relate to the topic question, which includes, describing a vulnerable group nominated for discussion and why they are at possible risk, there for outlining examples of misuse of professional power and putting forward strategies to address situations that arise, offering approaches that prevent the misuse of power from happening in the future and summarising legislation and professional codes of conduct involved with client care of the vulnerable group. The group nominated to illustrate the potential for professional misuse of power is those who live with a mental illness. There are a number of reasons why this particular group has been chosen and they include, the idea and notion of marginalisation, and social stigmas associated with having a mental illness. This health care issue is an issue that crosses all social and economic boundaries and divides society. In days gone by, the views held by many in our communities had been consistent with the notion and idea of ‘out of sight out of mind. Thankfully community attitudes are changing so to health care practices towards the treatment of a mental illness. In spite of these changes there still exists the potential for mistreatment and the misuse of power by some professionals who not only exacerbate the problem of the patient but also bring the profession into disrepute.

The following will now discuss as to the reasons why by giving examples of misuse of power that some health care professionals are entrusted with. History teaches us many lessons, the accounts of abuse of mental health clients and patients are many. In describing examples of abuse by care workers the concept of what are boundaries will be discussed. Discussed in the context of what constitutes what is acceptable and what is deemed inappropriate. That is, from the view point of noting the points where medical staff can assert power and to what extent this means in terms of patient rights.

Boundaries can be looked at from a number of points of view. For example boundaries can be seen as those sets of rules that establish the grounds by which one engages. For instance boundaries can be established by clearly defined sets of ordered and structured statements that indicate the manner and way in which clients are dealt with. (http://www.nrgpn.org.au/ 2nd August 2010).

They can come in a number of forms that appear in the shape of; Acts or laws, policies, work place practices and so on. Take the Mental Health Act, for this assignment the Author has used the example of Act content from the Western Australian Act 1996 where Part 7 discloses Protection of patients’ Rights to be given). (Http; /webcache,googleusercontent.com 27th July 2010).

Professional boundaries can be described as those conditions that distinguish between sets of behaviour that may lessen the health outcomes of the patient. The idea and notion of what boundaries represent and mean can best be summed up by saying that they are those sets of conditions that bring about an acceptance of each parties roles and responsibilities in a particular relationship.

In summary they set the standard where by clearly defined sets of conditions establishes a manner of conduct and behaviour that informs the worker what they ought to do at the same time informing them of what this means in terms of their relationship with the patient. In the context of examples of the misuse of power, one could quite easily conclude that the misuse of power occurs when a worker crosses those professional boundaries of trust and neglects their commitments and responsibilities which in turn create the potential for the inappropriate care and treatment, which results in poor outcomes for the client.

With respect to the concern of preventing abuse by health care professionals, the issue of standards and transparent diagnosis and evaluation of a mental illness comes to mind. In turn the issue of creating and maintaining sets of standards are important factors in preventing abuse. Important because they (the standards) establishes mode and method of not only treatment but of means and measures of developing a more structured way of not only appropriately assessing those with an illness but also ensuring that the diagnosis falls within particular guidelines.

In terms of transparent practices, clearly defined guidelines need to be put in place that shows an open and ordered means by which patients are then processed and dealt with. Standards are the key to managing the prevention of abuse of the mentally ill. Standards from the point of view of realising measured and ordered approaches to the practices of caring for the mentally ill as well as guaranteeing fair and equitable management of the patients concerns.

In dealing with the issue and concern of developing approaches to manage the potential for eliminating abuse from happening in the future the proposal for a much broader campaign of drawing the attention of the communities understanding to what is going on makes for a point from which to start.

Measures for eliminating abuse must take on a much broader and wider audience. The issue is both a social one as well as a political one. The effect of such a campaign must take place within all quarters of society. The failure to address the concern as a much broader social issue can have disastrous consequences not only on the client affected by abuse but also on the profession it self. There must be a greater emphasis placed on intake procedures and screening as well as safety checks put in place within the profession. A greater level of management practices that are consistent with standards that place emphasis on treatment outcomes and doctor/nurses skills training must take precedence.

Medical staff must also be aware of all resources like the Australian Health and Ethics Committees resource kit outlining good medical practice in doctor/nurse patient communication. These set of guidelines focus on how doctors (communicate with patients and the need to discuss treatment plans including information on risks, and, restricted circumstances when immediate provision of information may not be desirable). (http://www.nhmrc.gov.au 21st August 2010)

This will help to ensure that levels of safeguards are established and put in place that dictates the grounds upon which patients are treated as well as ensuring that those who provide the service are able to cope with the related concerns in away that creates well ordered work practices.

As mentioned in the above prevention of abuse of mental health patients is a social concern. The stigma and stereotyping that has gone on in the past has only exacerbated and enhanced the typical stereotypes that exist in society for far too long.

The kind of mind sets that exist does not in any way help the situation at all. Failures to recognise the concern in its social context will do little to comfort those who seek and wait for the kind of change that will bring about work place practices that are void of those mind sets described in the above. In order for the above to have any affect it must be accepted that people suffer from mental illness in all quarters of our society. As stated previously it does not discriminate and crosses all cultural and social boundaries both socially and economically. In light of this statement the following will address in further detail the mechanisms where by change can be affected and by what means it can be achieved.

However it must first be acknowledged that social and professional change is not always an easy thing to achieve. It must also be acknowledged that our society is based on sets of principles and ideas that are fundamental to the way it functions and operates. In that context then it must be accepted that we all no matter what our disposition, are afforded rights of consideration and respect.

The kind that are and should be common place within a democratic society that operates and functions on principles of equity and equality for the masses, the kind of principles that entitles each and everyone one of us fair treatment. Based on the position then it should be no surprise that is addressing concerns of misuse of power and the subsequent abuse of power by health care professionals should and must be governed and managed by sets of procedures and practices that are consistent with these principles.

Often mistreatment in the work place can be linked too much broader social images and attitudes. That’s why work place practices must be supported by a much larger body of thought and action that spells out quite clearly that the misappropriation of power against those who have little control over their situation must be enforced. That is in the context of legislation and government and judicial management orders that establish clear and mandatory codes of practices. This in turn must be supported with mandatory and skills based training for professionals to better manage the risk of inappropriate behaviour and actions.

In examining the points raised in the above a case study found in Ethics and law for the health professions 3rd edition, by the authors Kerridge, Lowe and Stewart (2009) illustrates well, a number of important and fundamental concerns when considering issues of misuse of power and behaviours that are inappropriate. For example the authors in setting out the case study of a woman who was suffering from case of low self esteem talked about the type of power relations that are tipped in favour of the psychiatrist.

The authors in summary (describe the outcomes for the women in terms of misappropriate diagnosis and maltreatment with respect to medication and management of the illness. The Authors go on to state that Psychiatrists diagnose patients as having mental illness, institutionalise them against their wishes or free them from imprisonment, give them mind-altering substances and administer electro-convulsive therapy) (which means the application of electric current to specific areas to the head to produce a generalised seizure (Mental Health Act 1996 part 5). These power imbalances are the cause of many of the ethical issues in psychiatry”. Kerridge, et, al (2009, p. 499).

In short if a position had to be taken, as to the primary reason behind the misuse and abuse of power by health care professionals and this can be applied across the industry as a whole, then it would need to be one not to dissimilar to that stated by the authors in the above. That is, much of the concerns that the mentally ill face are based on power relations that are tipped in favour of the professional health care provider. The case study mentioned in the above is one that is all to typical of the kind of mind sets that pervade the profession. This is a prime example of those relations that exists and one which is representative in the way that it seeks to manage the cause and effect of the patients’ condition and in the process takes away not only their rights but also their dignity.

Finally, and in summing up, this paper has attempted to provide a discussion, although brief in detail points for consideration when it comes to issues of the misuse of power towards the mentally ill by some health care professionals. This brief discussion has attempted to highlight not only the need for the management of concerns in a much broader context but also in terms of the internal institutional organisation of treatment of patients. This paper offers for consideration a number of considered points to ponder as they relate to legal and ethical concerns of a other wise stigmatised and marginalised group. Vulnerable they are but not without rights. As a result of considering this topic in more detail, if there is one point of consideration that the author of this paper would like to share as a result of reflection, then it would be this. The responsibilities of health care professionals are enormous. They are the kind of responsibilities that impact profoundly on how patients are engaged and managed. Profoundly, in both the context of their much broader obligations and profoundly in the context of the social consequences of their actions as they relate to the health outcomes of the patient. And finally the above has reviewed the legal and ethical considerations that are fundamental to the practice of health professionals doing what they have been trained to do, engaging the patient in the kind of relationship that in turn helps to prevent the misuse of power by health care professionals.