Observations of a Danish Social Worker on Social Work Practice in the United States

cancer-patient

I was working as a social worker in Denmark for some at a highly specialised university hospital until I moved to the United States, and I have been wondering about the differences and similarities in working with cancer patient in both places. With 10 years of experience working with cancer patients, their families and palliative care in Denmark, I can see how different Denmark is from the U.S. health and social system. I don’t think it will be fair or even possible to do a one to one comparison of the two countries.

In Denmark, the government plays a major role in providing citizens with fundamental social security and access to healthcare, which dates back to the 1800s. With a comprehensive social security system, most of the welfare state tasks is financed by taxes. In the United States, I have learned most of the social support is provided through non-profit organisations and healthcare is mostly secured by insurance. So with such big differences, I thought it would be interesting to see if there are any common denominators.

In my search for work in the United States a question I often get is do you have experience in working with Afro/American women? In the beginning I wondered a lot about that question, but then it made me really think about how do I define myself as a social worker. Working as a social worker here in the United States at a clinic for low income women with cancer I met many different ethnicities.

Mohammad, a 50-year old man, who was working as a bus driver when I first met him. Originally he was from Iraq, but came to Denmark as a political refugee. He was married and had four children. Mohammad’s wife didn’t speak Danish and she didn’t work. I met Muhammad because he was diagnosed with Colon Cancer and wasn’t able to work much longer.

Being diagnosed with cancer is mostly associated with uncertainty, hopelessness and anxiety of not having any control. Many cancer patients also experience stigma, shame and blame depending on the diagnose. Besides that most people are filled with fear of the disease, many also have concerns of what the diagnose means in relation to work, social life, economy and everyday life. A life threatening disease is an extreme and potentially stressful triggering life event which requires psychological coping.

The best results in our line of work I believe is created by being humble in the approach to the patient and by having a natural curiosity towards the patient’s life story. We must first and foremost see the patient as a person who comes to us for help because they are in a place in their life where they cannot stand alone, and we need most of all take a look at the patient’s individual experience of his or her situation. Whether the individual can adapt to the new life situation depends partly on their degree of resilience.

The first couple of times I met with Muhammad he didn’t say much, I would just talk with him about life in general, so he wouldn’t feel I pressured him into speaking about his situation. In my experience, working as a social worker, a patient in a situation like Muhammad’s is going through a lot of emotions. They may have the feeling of loneliness, lack of understanding from their surroundings, social isolation and financial difficulties.

Moreover they go between accepting the situation, to denial or to have some degree of acceptance. Every time I met with Muhammad I told him you can always come back. I would ask him how his treatment was going and asked about his life in general, this was to not only define him by his diagnose and the disease. Then after a couple of meetings he brought his wife and from there the contact to the family became more frequent. I was Mohammed and his family’s social worker until he died 4 years ago.

Sabrina a young mother of three, was diagnosed with melanoma cancer metastasis to the brain and because of some insurance issue, she had not gotten her treatment and scans. Sabrina’s husband was providing for the whole family and wasn’t home a lot which made Sabrina feel very alone in her situation. Also, Sabrina was going to die and she knew and recognized it.

Speaking with a patient in Sabrina’s situation you need to find out what is most important for her to talk about. Is it emotional support or is it more practical support she needs. First of all, I believe that we should all have an open heart, open mind and listen to the stories the patient has to tell, without race or color in mind.

It is important as a social worker to start a conversation with a patient and imperative to distinguish between the problem and the condition for knowing when to take have a solution-oriented approach, and when we do not need to act, but do something else for the patient. Problems such as financial aid, help to clean, help to care for the children and figuring out what the insurance and pension rules are, can be solved. Conditions are more definable as distressing life events, something the patient has to live with. A burden or a grief to be worn like that I am not able to work longer, I have to die from my children and the disease itself. These circumstances affect the patient on a more emotional and spiritual level.

However, it can be difficult to distinguish between problems and conditions as the patient will often ask questions or talk about the difficult life conditions in a way that invites to problem solving. The patient’s narrative and questions must be recognized and unfolded before we can assess whether it is something we must act on or not. It can be difficult to distinguish in practice, since a situation may contain aspects of both conditions and problems. Here, we must be careful not to solve problems before we acknowledge the losses that the patient has in their changed conditions of life.

I think it’s very important to remember to be truly present with people. We bring knowledge, skills, and compassion to listen in a unique and dedicated way. We need to bear witness to people’s physical and emotional pain without abandoning them or being judgmental in any way. Our role is to create a safe space for the patient to share their joys, regrets, fears, strengths, and sorrows.

I do believe parallels can be drawn between the experiences with patients that I’ve had in the United States and in Denmark. When everyday life is shaken by serious life-threatening disease and families are affected, concerns that arise in both countries are similar in nature regardless of social status and ethnicity.

However, it has surprised me that there is so much focus on ethnicity, especially when I see basically the same problems regardless of race and social status.

It is my experience from what I’ve seen here so far, that here it is more about what ethnicity do you have and what social class do you belong to, that determines how the approach to the patient will be.

A different culture, ethnicity or religion it self does not necessarily accompanied by challenges or the need to have a specific kind of approach.

A cancer – regardless of diagnosis – contains significant psychosocial impacts. In addition to the diagnosis of specific problems, patients often live with fear of relapse, depressed mood, attention and memory impairment, reduced work ability, problems in relationships which, individually or together, may adversely affect rehabilitation and retention of social and cultural status.

It’s essential for a good dialog and contact that we listen with an open-mind and acknowledge the problems coming up during the conversation. Also, it is equally important to see the patient as an individual and avoid judging or being distracted by the patient’s cultural or religious appearance. Otherwise there is a risk that factors such as racism and prejudice will get in the way of the patient receiving the best help.

Assemblymember Tony Thurmond: From Social Worker to Lawmaker

Thurmond
California Assemblymember Tony Thurmond (D)

You only need to take a look at the committees California Assemblymember Tony Thurmond (D) requested to be on in order to get a sense of his top priorities.  When he took office in January, he sought to contribute on Education, Health, Human Services, and the Select Committee on Homelessness.

“That’s exactly where I would expect him to be, knowing him,” said Carroll Schroeder, executive director of the California Alliance of Child and Family Services.

After a couple of decades working with nonprofits serving children and youth, as well as stints on the West Contra Costa County school board and the Richmond City Council, Thurmond says that in his new role as Assemblymember for District 15, he is “advocating for those who have the greatest needs.”

“I’m here for the least of us,” he told an audience at a Planned Parenthood Affiliates of California meeting on a recent Wednesday in Sacramento.

In his first months in office, Thurmond has proposed legislation to establish school-based mental health services and to address chronic absenteeism of children in grades K-3.

He is a bright star for children’s advocates and the service providers he worked alongside, most recently as senior director of community and government relations at Lincoln Child Center in Oakland.

Thurmond has emerged as a leader for the youth services field in what some youth advocates in California see as an era of austerity and erosion of the social safety net under Governors Schwarzenegger and Brown.

“There’s been a disinvestment in children’s services,” says Patrick Gardner, executive director of the Young Minds Advocacy Project. “During the recession, people assumed children were doing all right and there were other areas that needed more attention, and I think the result has been that children have suffered…We need a champion for children, and I think Tony has both the background and the heart to do it.”

Thurmond, who chairs the Budget Subcommittee on Health and Human Services, said he supports the Continuum of Care Reform Plan (CCR) developed over the past three years by the California Department of Social Services, providers, and advocates.

“The result will be better outcomes for kids,” Thurmond said.

The CCR report presented by CDSS to the legislature in January outlines 19 recommendations for transforming the delivery of child welfare services, including the establishment of a Core Practice Model to create consistency throughout the state.

“I came this close to being in foster care,” he said, holding his finger and thumb nearly together. After his mother died when he was six, he was sent to Philadelphia to live with a cousin he’d never met. “It was kinship care but we didn’t call it that back then.”

After getting his bachelor’s degree in psychology from Temple University, Thurmond got his first job as a social worker in Philadelphia.  “All I ever wanted to do was be a helping professional.”

But that first job seemed to him like putting a “Band-aid” on bigger underlying issues facing the clients he served, such as long-term poverty, substance abuse, and lack of access to education.

“I wanted to learn how to work to change systems,” he said, so he completed dual Masters Degrees in Law and Social Policy and Social Work at Bryn Mawr College.

At a recent briefing in Sacramento held by the California Program on Access to Care (CPAC) at the UC Berkeley School of Public Health, Thurmond expressed his support for the restoration of cuts to MediCal benefits and rates. He described his proposed Assembly Bill 1025, which would establish school-based mental health programs that would largely be funded by MediCal.

AB 1025 would establish 30 pilot programs providing school-based mental health services throughout the state. The legislation calls for mental health support to be offered in schools to students who have experienced trauma or other challenges.

Naming education his highest priority, Thurmond has also proposed AB 1014, a truancy prevention bill to address chronic absenteeism for kids in grades K-3 by funding outreach workers who would do home visits and work with families to address whatever is keeping children from going to school.

“Education is my top issue,” he said. “We want to help those kids get back in school so they learn to read by third grade so they don’t drop out and enter the juvenile justice system.”

“From my perspective based on my experience at Lincoln Child Center, home visiting is one of the most effective ways to get kids back in school.”

Reductions to the state’s safety net are a continuing concern for Thurmond. In his remarks to CPAC, he noted that despite acknowledging recent improvements to the state’s fiscal situation, Governor Brown “has talked as a consistent theme about our need to prepare for the future and to save money.”

“We all know,” said Thurmond, “that we have been for the last decade dealing with the great recession and tough cuts…and tightening our belts.”

He recalled the night in 2008 when he was sworn in as a member of the school board.  Despite his “excitement to help kids,” the first decision he was called upon to make just moments after being sworn in was “a vote to close ten schools because the state budget was so bad.”

“And that has been the climate and the culture,” he added, “in every single sector including our health safety net and our social services safety net. Now is the time to make restorations.”

“Everybody’s telling us what can’t be done, and that’s been the narrative for way too long,” Thurmond said in the Planned Parenthood meeting. “What is the cost we pay if we don’t take this action?”

Noting his choice of committees, not the most sought after by new members, Thurmond said simply, “I came up here to do work.”

Social Work and the Welfare State

As a social worker on the Hill, I have had a front row seat during battles over the welfare state. Usually, the main combatants are Republican conservatives who continue their relentless quest to reduce government’s involvement in providing for indigent Americans and Democratic progressives who believe government must be involved to ensure an adequate safety net. Conservatives want relief for the poor and disabled left to private charity. They believe citizens should not be taxed to provide welfare and other social services and should be allowed to willfully give a portion of their earnings and resources to private caregiving entities. They view the welfare state as an unlawful transfer of wealth—taking from those who worked hard to be successful and giving to people who lack the motivation and drive to do for themselves. They believe providing unemployment insurance to laid-off workers reduces their incentive to go out and find another job. They believe individual effort—personal responsibility—should be the driving force of a healthy economy.

Progressives on the other hand believe society is strongest when people work together to achieve common purposes. Jared Bernstein characterizes this debate as YOYO vs. WITT—“you’re on your own” vs. “we’re in this together”. Somehow, I believe there is more to that phrase in the Constitution’s preamble—promote the general welfare—than just providing security and an orderly society. I believe the founders had to believe in a “we’re in this together” philosophy because they knew cooperation was needed as much as competition to ensure progress. You only need to look at Congress today to understand how dysfunctional competition is without compromise.

After centuries of leaving poverty to private charity, we got the English Poor Laws. The economic crash of 1929 and the Great Depression forced the federal government to intervene in order to keep many Americans from starving. Since then we have been in this endless battle to define the parameters of the welfare state. Conservatives have been working nonstop to rollback New Deal policies. They would like to see the privatization of Social Security and the elimination of unions and other collective bargaining efforts. Progressives have been hard at work protecting safety net programs—preventing the block granting of social welfare programs, fighting against cuts in Medicare, Medicaid and food stamps. All the while the economy is spiraling out of control in the favor of the wealthiest Americans. The top 0.1 percent of American families now own as much as the bottom 90 percent.

 

Inequality-Chart

Economic inequality is the mother of the modern day welfare state. Even conservatives are beginning to understand this. Arthur Brooks, president of the free enterprise promoting think tank the American Enterprise Institute, recently declared that it was time for conservatives to make peace with the welfare state—a startling comment from a hard line conservative. My guess is that he understands it is the price that must be paid for such a high level of economic inequality. In a society where income is distributed more equally, there would be a larger middle class which existed in the middle of the last century. There would be more people working because we would have more consumers with more disposable income. We would have less people needing food stamps and less people would be eligible for the Earned Income Tax Credit.

So, where should social workers stand on the welfare state? We should of course fight to ensure there is an adequate social safety net, but at the same time we should be looking for ways to reduce the number of people who depend on a social safety net which requires a more fair and equitable society—concepts that are foreign to conservatives. Those of us—social workers—who take seriously the profession’s commitment to social justice are the best hope for the poor and middle class. However, if we are not able to present a compelling vision about how we become a more just society then we will spend all of our energy trying to protect a burgeoning social welfare safety net.

Democrats lost big time in the midterm elections not because of the low voter turnout. They should not expect better results in 2016 because the composition of the electorate will be more in their favor. Democrats lost because they failed to present ideas to the American people about how progressive policies would make their lives and their children’s lives better. Had they been able to articulate a path to a more just and equitable society, voter turnout would not have been a problem.

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