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Article Excerpt
How social workers in managed mental health care settings exercise their professional authority may have profound consequences for the provision of ethical and value-based services to vulnerable populations. Building upon Gidden's theory of structuration, this article describes the use of critical ethnography as a specific research methodology that may support social workers in the exercise of their authority. This article examines the historical roots of critical ethnography and provides a detailed examination of its underlying assumptions and research procedures. The article concludes with a case example of a critical ethnography conducted within a managed mental health care setting.
Keywords: critical ethnography, managed care, mental health, social work, professional authority
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Front-line social workers in managed mental health care contexts often experience cultural incongruence between management values and their own professional values. Among the most profound are those conflicts that exist between managerial and professional values (Furman, 2003; Scheid, 2003; Shapiro, 1995). Nonetheless, social workers may have opportunities to shape the procedures and practices of their managed mental health care organizations. This article will describe the utility of critical ethnography as a set of methods that may be used to assist social workers in becoming more consciously aware of how they take up their professional authority in managed mental health care contexts.
The revised code of ethics of the National Association of Social Workers (1999) stresses the professional obligation of social workers to incorporate the core values (i.e., service, social justice, dignity and worth of the person, importance of human relationships, integrity and competence) of Social work at all levels of practice, including their practice in organizations. The importance of upholding the core principles and values of social work practice is particularly crucial in today's managed mental health care settings. Indeed, the proliferation of for-profit managed care plans and the funneling of vulnerable individuals and groups into these plans has resulted in decreased quality care for persons with severe mental illness, including persons with fewer economic resources and those from marginalized racial and ethnic groups (Himelstein, Woolhandler, Hellander, & Wolfe, 1999; LaRoche & Turner, 2002; Mechanic, 2002, Mechanic, 1999, Mechanic & McAlpine, 1999; Sullivan, 1999).
Arguably, since its inception, social work has grappled with conflicts surrounding its professional identity. Indeed, as Cloward (1972) commented: "Among the various dilemmas confronting social workers, the most profound, although the least acknowledged or examined, is the conflict between our presumed role as helping agents and our bureaucratic role as agents of social control" [as cited by Racine (1984, p. 42)]. Perhaps nowhere is this conflict more evident than in managed mental health care settings, where social workers are increasingly replacing medical personnel as the more economical and hence preferred providers of mental health treatment (Cohen, 2003).
Despite these challenges, the current privatization of managed mental health care may provide social workers and other mental health professionals with opportunities to more proactively develop and create ethically-based programs and services geared to vulnerable populations. For example, effective case management and decision-making processes, roles that social workers typically assume in managed care settings, may be pivotal in ensuring quality services to consumers (Dobmeyer, McKee, Miler, & Wescott, 1990; Manning, Wells, and Benjamin, 1987; Rogers, Wells, Meredith, Sturm, & Burnham, 1993; Brady and Krizay, 1985). Therefore, the ways that social workers take up their organizational and professional authority in managed mental health care settings may have important consequences to consumers.
Authority has been defined in institutional contexts as "the given right to perform roles" (Kahn & Kram, 1994, p. 17). Historically, there have been at least two very different traditions or approaches to studying roles. The first is a structural view, espoused by traditional sociologists, most notably Talcott Parsons. A structural understanding of roles highlights its normative function, or the expectations that people come to expect from persons occupying particular statuses in the social structure.
Another approach to understanding roles emanates from a social-psychological perspective. This perspective focuses on the active processes involved in "making, taking and playing at roles" (Goffman, 1967). Within this tradition, roles are examined for their dynamic aspects, rather than their place in the social structure. Individuals are viewed as active in the process of taking up their roles.
Critical ethnography may well be suited for a study of how social workers take up their roles, both normatively and proactively, in managed mental health care settings. Specifically, critical ethnography may be used to examine how social work practices in managed mental health care contexts may serve to reproduce or maintain prevailing organizational structures and policies. Also, it may be used to discover how social work practice may change or recreate an organization's structures and policies.
Structuration and Social Practices
The exercise of authority by social workers in managed care settings may be conceptualized as occurring within a dynamic, historical, cultural, and interpersonal process of structuration (Giddens, 1993). Structuration theory posits that practice and structure form a transformational loop, with each influencing the other. According to structuration theory, social practices are influenced by the structures within which they occur, and, at the same time, contribute to the maintenance of those structures. However, feminists and other critics have charged that structuration theory emphasizes the deterministic nature of structure, rather than the transformational potential of human agency.
Giddens described structuration as...
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