(a commencement speech)

I am easily overwhelmed by the magic of commencement speeches but this one by David Foster Wallace at Kenyon College in 2005 has a bit of a social work slant to it, don't you think? He talks about perceptions, self-awareness towards a need for the spiritual, and generosity. Take a look if you have the time.

Little-known Facts 1 (that should be more widely known)

Some foreign workers live in bin centres when they don't want to. You know, bin centres, those little buildings in HDB carparks where all the rubbish collected from surrounding apartment blocks is brought to. They are, without fail, very stinky, and have lots of cockroaches. You can barely put a human being inside there for five minutes. Our foreign workers do this because their employers can't afford a place to put them, and there aren't enough dormitories around to house them decently. And the reason there aren't enough places fit for human living to house them, is because we, elitist status-conscious Singaporeans that we are, don't want them seen to be living near us. Think of your friendly neighbourhood cleaner living in a Bin Centre(!), the next time you petition against having decent housing for them near you.

Prisoners are only allowed to reply to two letters a month. [Update: Not a rigid rule, the Prisons Service says.]

The Medisave withdrawal limits are $450 per day for inpatient hospital stay, $300 per day for most day surgeries, $20 per day for senior citizens' daycare at daycare centres (up to $1500 per year), and $300 per year per account for chronic diseases. The chronic diseases in the list are diabetes, stroke, high blood pressure, high cholesterol, various lipid disorders, asthma, COPD. If a person with one or more of these chronic diseases qualifies for Medifund assistance, the $300 per year per account of Medisave of the person and all his immediate family (parents, spouse, children) must still be exhausted first for partial payment, while Medifund covers the remaining cash component.

I know the Medifund income criteria, but I cannot reveal it, not even under pain of death I suppose. Suffice to say that it is not the $1500 household income that is openly used by some other financial assistance schemes. This is because Medifund has a different mission from those other financial assistance schemes. When the government calls it the Medical safety net of last resort, they really mean it. You won't be left alone to be ill if you can't manage.

Role of a Social Worker, Part sqrt(2) of infinite

I'll say this upfront to get it out of the way first. The social work profession in Singapore is less mature than in other countries, for now. At present we have both a low average standard of social work education and few niches of advanced specialization. The Singapore Association of Social Workers is making some plans to change this in the near future. But at the present time this is how it is.

Given all this apparent lack of formal structure, have you ever wondered one rather obvious thing: why do social workers seldom work in pairs when seeing an individual client?

Is it because the work is so simple that it can be handled by one person? Or that the work is of such a nature that it is best handled by one person?

Consider this question for contrast: have you ever seen counsellors work in pairs when seeing (counselling) an individual client. Why, or why not? Is the work so simple that it can be handled by one person? Or is the work of such a nature that it is best handled by one person?

What other jobs does social work bear close similarities to?

Some thoughts to throw to you, dear reader.

Theories of Stages of Grief

I have found a way to come to terms with the issue of clients lying to me, as per the previous post. I discussed it briefly with colleagues and all this can be reconceptualized as the client's "readiness to change", instead of truth detection per se. I now can do my work with an easier heart.

*

Today we talk about grief. Elisabeth Kubler-Ross's model of grief is probably the most well-known, comprising the five stages of denial, anger, bargaining, depression, and acceptance. However that Wikipedia article provides a link to a JAMA 2007 empirical study on another model of grief, Jacobs' model, which according to a reference of that paper has the four stages of numbness-disbelief, separation distress (yearning-anger-anxiety), depression-mourning, and recovery.

That JAMA 2007 paper by Maciejewski et al., contrary to its claims, is not a convincing empirical study of Jacobs' grief stage model on two major counts. First major count: The authors used single items obtained from a scale called the Inventory of Complicated Grief-Revised, formerly known as the Traumatic Grief Response to Loss. The reference given for this Inventory is in a book which I do not have ready access to; however it needs to be proven instead of merely asserted, that a shortened form of a scale has similar explanatory properties as the full scale. Cronbach's alpha test is commonly used as such proof. The authors have not proven this.

In addition, I am most disturbed that even the online version of the paper does not provide the actual single items used in querying the respondents. Surely JAMA, the Journal of the American Medical Association, supports the inclusion of supplementary material. (Later note: Yes it does.) The lack of the actual questionnaire used in the paper can only be a horrific oversight by the authors.

The authors further shoot themselves in the foot by saying in an aggregate letter of response to all preceding letters of response to their paper, that "these [single] items have been evaluated and found to be among the most informative and unbiased in the evaluation of prolonged grief disorder", and that they had "removed [excluded] cases of prolonged grief disorder" from the study sample so to provide a representative sample of grief.

Second major count: As noted by Bonanno and Boerner in a letter of response, even in the earliest months of bereavement, the mean frequency of acceptance experienced by participants was between daily and several times a day, significantly more than any other grief item. Acceptance is the last stage of grief in both Kubler-Ross's and Jacobs' models - grieving is considered to be over when this stage is attained. If acceptance is consistently highest of all grief feelings assessed throughout the study, this only begs the question of what exactly the questionnaire used for assessment was.

The paper does not live up to its claim of being an empirical study of the stage theory of grief.

Homicidal thoughts

me: i have finally acknowledged having homicidal thoughts about my clients, to myself

friend: so late?

me: yeah

because the social worker professional ethics code forbids thinking that the client is bad.

i don't think the ethics code is a good guide anymore

seriously, there are people who will lie to a social worker just to get the financial support they want

(they slip up when i ask them random qns)

me: i think i would rather pursue truth than ethics. in general.

because the truth of "how much are you taking home per month" is probably the most simple truth alive. and they don't even get it right.

me: today i made a phone call to a client's son asking how much he and his siblings earn

he said straight to me, "if i tell you that we all don't earn much, you will give me more money, right?" and he laughed.

no doubt he thought it was funny.

it probably was. but not in a way i can appreciate, or that i choose to appreciate, or that i will ever accept.

me: and he wasn't even someone who was consistently on welfare assistance before

so it was just a simple logical deduction on his part.

how many liars are we subsidizing.

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More to the point, why do I try to learn so much about helping people merely to consistently come across people like this? I swear that giving out financial assistance is bad for the sincere social worker soul.

At some point a person really has to put his (or her) foot down hard and say, enough is enough. You are gaming the system. You are freeriding on the goodwill of others' hard work, others who have produced the resources that generate the money that you so gleefully, spinelessly, inhumanly take. Go forth and die. I will not care.

But of course, we are never supposed to say this to the client.

Cognitive Dissonance as the name of this blog, is more apt than I'd ever thought it would be.

Being Helpful

I have previously written about how different people present themselves differently when coming to look for social workers, and how regardless of circumstances we try to assist the client. But this recent article in TOC bothers me enough that I need to write about it.

Several allegations have been made in the main article as well as in the comments. I have no wish to polarize the comments as many of them do show sympathy for the client mentioned in the main article, by offering concrete suggestions and wondering aloud what wider social changes are necessary for similar situations to be prevented in the future. Generally I find the comments to be fair.

To what extent do we subsidize people's choices?

And how do you explain to your hopeful client, sitting in front of you, you wishing to help him, that his previous actions have compounded his problems to such an extent that merely signing over some money to him will not assure his long-term stability? How do you survey with him his barriers to a successful life? A single consultation will not be enough. People take a long long time to readjust their expectations =)

And, of course, we cannot rely on hearsay to judge this man even before we have met him and he has spoken with us. In person. For an extended period of time. About 45 minutes is the normal length of an in-person conversation. 30 minutes is the bare minimum.

I have had fairly long conversations with clients during which it transpired that their children are earning quite a bit and yet the client does not wish to ask for financial support from them. We are social workers, not ATMs in disguise. If there is some longstanding issue with the client's family relationships, we would like to know so that we can offer help. The client's quality of life remains always important to us. It's not always financial assistance that will alleviate the issues <- this is faintly heretical to some of our clients - again the bit about managing expectations. What we would like to do most often, when time permits, is to provide education in the ways of the world so that our clients can fledge.

The Third Door

There are no poor in this country.


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"Pity those who are somehow unable to open a third door in their hearts or their minds. No one believes them when they talk about ghosts.


The fuss about the two NS deaths this week is already on its way to the third door, which will disappear the moment it has served its purpose.


Goodbye.


There's nothing wrong with Singapore.


Despite being a small island with no natural resources, we have managed to overcome difficulties and become a developed country.


There are no ghosts in this country.

- Mollymeek, 13th June 2008

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A Pencil and Unconditional Positive Regard

We always go out to the reception area to call the client in. I make use of all the customer service skills I've ever learnt in my short life, to welcome him (or her) once he has acknowledged his identity, and then walk a little in front to lead the client to my desk. He follows hesitantly, clutching his documents and hope. The corridor is narrow, so that I cannot walk beside him. This is the best compromise I can find, the first of the many in our interaction.

I use these few moments to take a breath and to strongly resist the urge to weep. Not a trace of anything except unconditional positive regard shows in my face and demeanor, as I invite him to sit, before I take my own seat behind the desk. No social worker weeps where you can see it - it is not polite to the client.

(I mentally clutch at my social work theories the way the client holds his documents. The desk between us provides a focus for my terribly confused feelings at this point - I may not be able to give the client full financial assistance and this desk will enable separation at the end of the appointment without hard feelings. I know that our money does not fall from the sky and to give one family what they ask for may result in deprivation for another family even more needy yet whose only reason for deprivation was that I saw them just a little bit later. So there are rules, government rules, agency rules. I have to suspend my disbelief in the wisdom of the State in deciding precisely those rules.

Those of you who have read my previous posts would know that I dislike systems without transparency but in this instance I do not know where to go to find the demographics breakdown of how much was given to each family under which circumstances. I do not know if such demographics data even exists, whether busy fatigued social workers have taken the time to code their information in formal research studies. I do not know anything at all except some rules.

If things continue in this way I will become a mindless tool of the State. One of my tutors said it well, a long time ago, "You either become an agent of change or you become a changed agent." I must discover or I shall go mad.)

We begin the conversation with our client, eliciting information we need to assess their requirements. From what we can observe during the interview, we know if clients are evading our questions, and we will ask further. Nonetheless, we do not finalize our assessment of the client's honesty except in the final instance where we use a pencil to sign the form to decide how much additional financial assistance to give, on top of what is given according to the rules. There are clients who lie about their finances and their family relationships, and you will know it. They tell you these while sitting across the desk from you, expecting you to bestow the funds that they deserve as a right. But you can only trust them to give you the truth, in those gray areas (which I cannot reveal here lest it inspire others to practise them :) ).

There are all these borderline instances where the clients know the system so well and it simply breaks my heart to give them the benefit of the doubt, although I do and I know that I should. Because you know that if their families had put just a little bit more effort into salvaging their family relationships, there would be a bit more State funds for the person who sat across from you with sad, sad eyes, giving you his documents, answering your questions and talking with you, trying to gracefully ask for some help while being the sole caregiver and financial provider for his grandchildren. And this grandfather would always be the one to say, "Money doesn't fall from the sky, I know. I can manage with the [present assistance I have from elsewhere], and my grandchildren [incidentally still preschoolers] are obedient and smart. We simply have [astronomical sum!] in [organizations'] arrears, is all. We will be fine. It is only the arrears that worry me, we cannot have our [et cetera basic necessities] cut off, the children need to eat."

Our clients' dignity steadies us, but it worries me too. The social workers would know, because we spend the time to talk with them, but taken at face value their claims to be able to get by with only a little bit of assistance are not really viable.

So the pencil strikes as we sign the form, where we give as much as we can give. We have some discretion in our additional recommendations. :) and we hand back the client's documents to him after photocopying them, and we send him out. Where unconditional positive regard meets pencil, the pencil has the final say, sorry. No matter how much we want to treat you well by liking you personally, that liking does not automatically translate into assistance because assistance is a public good, shared in common. (Maybe some would find this unconditional positive regard a bit vacuous, then. You are entitled to your opinion on that. We try to make the client feel comfortable during the conversation.) The ending of this interaction is somewhat businesslike - client gets his assistance, and we do not get weird power kicks from the client thanking us profusely for the State's temporary relief of his woes. It is unnecessary to prolong the leavetaking, although some thanks are customarily exchanged.

And we go out to call the next person in.

Ways to spend the Budget Surplus....

It could have been worse.

More S'poreans eligible for public assistance with relaxed criteria.

Poverty is Poison

... from the New York Times today.

“Poverty in early childhood poisons the brain.” That was the opening of an article in Saturday’s Financial Times, summarizing research presented last week at the American Association for the Advancement of Science.

As the article explained, neuroscientists have found that “many children growing up in very poor families with low social status experience unhealthy levels of stress hormones, which impair their neural development.” The effect is to impair language development and memory — and hence the ability to escape poverty — for the rest of the child’s life.

So now we have another, even more compelling reason to be ashamed about America’s record of failing to fight poverty.