John McKnight

Personalized Service and Disabling Help

(1977)

 



Note

In this essay the author examines the professionalization of human needs, i.e. the fact that, in our society, every need becomes associated to a professional expert charged to define and satisfy it.
This reality has two very negative side effects: (a) new needs are created just to justify the role and occupation of professional experts; (b) the common human being becomes unable to solve any personal problem and delegates everything to the experts.
This is why McKnight introduces the expressions "disabling help" and "disabling professions" to designate a very dangerous path that would lead to the disappearance of personal autonomy and capacity and the rising of professionals to a position of general control.

 


 

The business of modern society is service. Social service in modern society is business.

This fact is reflected in the language employed. Professionals and their managers now speak of educational “products”, health “consumers” and a legal “industry”. Clients are defined as “markets” and technocrats – an entirely new breed of professionals – are developing methods to market services, using business accountancy systems. Computers measure and store psychological “inputs” and family “outputs”.
There are “units served” and “units of service” and sophisticated economists, statisticians and planners deal with the production and consumption of social services in the same way as the production, consumption and maintenance of physical goods is accounted for. Furthermore, and this is of central importance, every modernized society, whether socialist or capitalist, is marked by the growing percentage of service in its Gross National Product, not only of services such as postal deliveries, catering, car repairs etc, but social services such as marriage guidance, birth control, counselling, education, legal arbitration, care of the young, the adult and the old in all its ramifications, and all hat falls under the general heading of social help.

This stage of economic development is distinguished by its unlimited potential since service production has none of the limits imposed by goods production – limits such as natural resources, capital and land. Therefore, the social service business has endless possibilities for expansion as there seems to be no end to the needs for which services can be manufactured.
Modernized nations are therefore best defined as service economies. They are serviced societies and they are peopled with service producers and service consumers – professionals and clients.

The politics of serviced societies are gradually being clarified. Public budgets are becoming strained under the service load. Many national and local governments find themselves involved in the unprecedented politics of deciding between competing services – should we give more to education and less to medicine? Within the service sectors there are equally difficult dilemmas. Should we cut back on tax-paid abortions or should the available money be used for free 'flu vaccine?

These dilemmas are often resolved by the apolitical ideology of service. White old-fashioned politics, rooted in a goods economy, allowed a civic debate as to whether a nation needed mote wheat or more steel, more automobiles or more houses, the new service politics is a debate as to whether we should have more doctors or more teachers, more lawyers or more social workers. Politically the question becomes whether we should trade health for learning, or justice for family well-being. These choices create an impossible politics in traditional terms.

While our political traditions make it possible to decide between wheat and steel, it seems politically impossible to decide between health and education because health and education are not alternatives amenable to choices: they are services. Indeed, the allocation of services is so immune to political debate that many governments resolve the dilemma by deciding that we will have less wheat and more education, less steel and more medicine.

This is not to suggest that these choices are correct or incorrect, or even that they define appropriateness. Rather, it is to say that the apolitical nature of service is so pervasive that it is difficult for the public and policy makers to recognize that the creation and allocation of services are the central political issue in many modernized economies.

The political immunity of the services is best understood in terms of the symbolic referent of service.
Services are something one pays for.
The “good” that is paid for is care.
Care is an act that is an expression of love. We say “I care for her more than anyone” or “I am taking care of my mother and father”.

Thus, service is to care which is to love and love is the universal, apolitical value.

Symbolically then, the apolitical nature of service depends on its association with the unlimited universality of love. Ask any servicer what is ultimately satisfying about his work and the answer will most commonly be framed in terms of wanting to care for and help people. Press on and the answer is usually that the individual “loves people”.

Since love is not a political issue, care is not a policy question and service becomes the one business that is an unlimited, unquestionable and non-political “good”.
While this analysis may seem overly symbolic, consider the political use of the language of social service in the United States. When the first major programme to provide governmentally insured medicine was proposed, it was not described as a policy to expand access to and income for the medical system. It was called Medicare.

In a recent address the President of the American Federation of Teachers noted that there are thousands of unemployed teachers and a large new supply graduating from teacher training institutions. He dealt with this economic dilemma by noting that large sectors of the society need education – the pre-school, adult and elderly population. In order to meet this “need”, he called for a new government programme to guarantee the life-long educational rights of all Americans. He called it Educare.

In the law schools of the United States, law students number forty per cent of all the practising lawyers in the country. A recent study asked the leaders of the American Bar what they thought could be done to ensure that this flood of new lawyers could provide their service and have an adequate income. The most common response was to suggest the need for a publicly supported programme that would guarantee the rights of all people to legal services. The name that was universally applied to such a programme was Judicare.

It is clear, therefore, that the word “care” is a potent political symbol. What is not so clear is that its use masks the political interests of servicers. This fact is further obscured by the symbolic link between care and love. The result is that the politico-economic issues of service are hidden behind the mask of love.
Behind that mask is simply the servicer, his systems, techniques and technologies – a business in need of markets, an economy seeking new growth potential, professionals in need of an income.

It is crucial that we understand that this mask of service is not a false face. The power of the ideology of service is demonstrated by the fact that most servicers cannot distinguish the mask from their own face. The service ideology is not hypocritical because hypocrisy is the false pretence of a desirable goal. The modernized servicer believes in his care and love, perhaps more than even the serviced. The mask is the face. The service ideology is not conspiratorial. A conspiracy is a group decision to create an exploitative result. The modernized servicer honestly joins his fellows to create a supposedly beneficial result. The masks are the faces.

In order to distinguish the mask and the face it is necessary to consider another symbol – need.
We say love is a need. Care is a need. Service is a need. Servicers meet needs. People are collections of needs. Society has needs. The economy should be organized to meet needs.
In a modernized society where the major business is service, the political reality is that the central “need” is an adequate income for professional servicers and the economic growth they portend. The masks of love and care obscure this reality so that the public cannot recognize the professionalized interests that manufacture needs in order to rationalize a service economy. Medicare, Educare, Judicare, Socialcare and Psychocare are portrayed as systems to meet need rather than programmes to meet the needs of servicers and the economies they support.

Removing the mask of love shows us the face of the servicers who need income, and an economic system that needs growth. Within this framework, the client is less a person in need than a person who is needed. In business terms, the client is less the consumer than the raw material for the servicing system. In management terms, the client becomes both the output and the input. His essential function is to meet the needs of servicers, the servicing system and the national economy. The central political issue becomes the servicers' capacity to manufacture needs in order to expand the economy of the servicing system.

Within this analytic framework, pejoratives are inappropriate. After all, a serviced society provides an economy, a structure for social organization, and service workers motivated by the ethical values of care and love. If these service system needs are legitimate, clients can be viewed as needed, rather than in need, and we can get on with the business of researching, developing, manufacturing and marketing services without the necessity to project professional need upon citizens. We can deal in political and economic terms with the needs of servicers, freed of the apolitical mask of love.

The problem with this political resolution is political reality. Throughout modernized societies a troublesome question is being raised by the citizenry. In popular terms it is:
Why are we putting so much resource into medicine while our health is not improving?
Why are we putting so much resource into education and our children seem to be learning less?
Why are we putting so much resource into criminal justice systems and society seems less just and less secure?
Why are we putting so much more resource into mental health systems and we seem to have more mental illness?

As if these questions were not troubling enough, a new group of service system critics are asking whether we are putting more resources in and getting out the very opposite of what the system is designed to “produce”. In medicine, this question is most clearly defined as iatrogenesis – doctor created disease. The new critics’ question is not whether we get less service for more resource. Rather, it is whether we get the reverse of what the service system is supposed to “produce”. In the terms of Ivan Illich, the question is whether the systems have become counterproductive. Do we get more sickness from more medicine? Do we get more injustice and crime with more lawyers and police? Do we get more ignorance with more teachers and schools? Do we get more family collapse with more social workers?

This is the question that is most threatening to the previously apolitical service systems because, while services defined as embodiments of care and love are a political platform; while services that are understood as being less effective than they have in the past are a political possibility; while it is even politically feasible to remove the mask of love and recognize services as systems in need of resources in order that economies may grow, it is politically impossible to maintain a service economy if the populace perceives that the service system hurts more than it helps – that professional service can become disabling help.

In the last few years, the progressive leaders of the service business have recognized the counterproductive threat. Their response has been to develop new strategies to deal with the counterproductivity of service systems. They have called upon the skills of another profession – the managers. Their assumption is that while professional servicers are unable to control the harm they induce, the managerial profession can become the modern reformer, controlling and directing the systems so that counterproductivity is neutralized, while at the same time protecting the political support for the growth of the service system.

The new service manager, translating his skills from the goods production sector, sees four elements to be manipulated in rationalizing the service system: budgets, personnel, organizational structure and technology. Therefore, the service manager is now busily at work instituting cost control systems, developing personnel training systems, restructuring delivery systems and introducing new technologies.
The most progressive managers have used their advanced marketing skills to develop a fifth manipulation – preparing the client. They recognize that if there is no need for service, it is possible to manufacture a need. If the popular perceptions of need do not fit the service, social service managers have developed techniques that can persuade people to fit the service through advanced marketing systems.

Will these professional management techniques stabilize the service business by eliminating counterproductive effects?
Certainly the capacities of modem management systems are impressive. Aided by the apolitical ideology of the services, one might well prophesy a collaboration between the servicers and their managers to coalesce into an irresistible force that will henceforth direct the economic policies of modernized economies.
An alternative view suggests that there may be a counterbalance – indeed an immovable object – that faces the irresistible force: a new ideology that assigns to the state the coordination of total disservice.

If such an object exists, it is found in the human necessity to act rather than be acted upon; to be citizen rather than client. It is this human imperative that suggest that even the best managed service systems will be unable to overcome popular recognition of the disabling impacts of modernized professional service.
The remainder of this essay attempts to identify the disabling effects of modernized service systems and to suggest the political consequences of the conflict between the irresistible force of client-making and the immovable object of citizen action.

 

PROFESSIONALIZED ASSUMPTIONS REGARDING NEED

Three disabling effects grow from professionalized assumptions of need.

First is the translation of a need into a deficiency. A need could be understood as a condition, a want, a right, an obligation of another, an illusion or an unresolvable problem. Professional practice consistently defines a need as an unfortunate absence or emptiness in another.
One is reminded of the childs riddle asking someone to describe a glass that has water in its lower half. Is it half full – or half empty? The basic function of modernized professionalism is to legitimize human beings whose capacity it is to see their neighbour as half empty. Professionalized research increasingly devotes its efforts to extending the upper rim of the glass in order to ensure that it will never be filled – even by the results of “effective service”.
In a servicing economy where the majority of the people derive their income from professionalized “helping” and GNP is measured by services rendered, nations need an increased supply of personal deficiency. Thus, a society that purports to meet need defined as personal deficiency is more accurately understood as an economy in need of need. The comic distortion could be societies of neighbours whose income depends upon finding the deficiency in each other. The political consequence is neighbours unable to act as communities of competence with the capacity to perceive or act upon solvable problems.

The second disabling characteristic of professionalized definitions of need is the professional practice of placing the perceived deficiency in the client. While most modernized professionals will agree that individual problems develop in a socio-economic-political context, their common remedial practice isolates the individual from the context. The effect of this individualization leads the professional to distort even his own contextual understanding. Because his remedial tools and techniques are usually limited to individualized interaction, the interpretation of the need necessarily becomes individualized. The tool defines the problem rather than the problem defining the tool.

A recent study of children who became state wards exemplifies the process. The children were legally separate from their families because the parents were judged to be unable to provide adequate care for the children. Therefore, the children were placed in professional service institutions. However, the majority of the professional case records portrayed the children as the problem. Quite correctly, officials who were involved in removing the children from their homes agreed that a common reason for removal was the economic poverty of the family. Obviously, they had no resources to deal with poverty. But there were many resources for professionalized institutional service. The service system met the economic need by institutionalizing an individualized definition of the problem. The negative side effect was that the poverty of the families was intensified by the resources consumed by the “caring” professional services. In counterproductive terms, the servicing system “produced” broken families.

The individualizing, therapeutic definition of need has met a counteracting force in some of the “liberation” movements. The civil rights and women's liberation movements are cases in point. Their essential ideological function is to persuade minorities and women that they are human beings who are neither deficient nor dependent upon systems purporting to meet their “needs” through individualized professional help. Instead, these movements struggle to overcome the individualized deficiency oriented “consciousness” communicated by the professional service ideology by affirming individual competence and collective action.

The third disabling effect of professionalized definitions of need results from specialization – the major “product” of advanced systems of technique and technology. We all know that this process creates highly specialized, intricately organized service systems that provide magnificent organizational problems for the new service managers. Vast human and financial resources are now devoted to the rationalization of these systems, providing politically acceptable criteria justifying economic growth through the service sector.
What is less clearly understood is that these systems impose their mirror image on the citizenry. As the systems are a set of managed parts, so the client is necessarily understood and processed as a set of manageable parts, each with its own service mechanic. These complex service systems remind one of those table mats in some restaurants that show a cow divided into parts locating the steak, the roast, the ribs and the tongue.

In like manner, professionalized service definitions increasingly translate need in terms of people in pieces. We need podiatrists for our hooves and Eye, Ear, Nose and Throat men for our snouts. Our psyche, marriage, relationship with our children, in fact our most intimate and personal activities are divided into separate bits and pieces.
Modernized professions also piece us out in time.
Service professionals now assure us that we live through a set of needs defined by age. Professionals have “found” seven life crises (formerly known as the seven ages of man) from infancy to death, each requiring its helping professional. Elizabeth Kubler-Ross has advanced the process by giving us five phases of death. Her work ensures a new set of helpers for stage one of dying, stage two of dying, etc. Following these dying therapists will be research professionals attempting to decide why some people skip, say, stage two or three of dying.

While individualizing need may disable by removing people from the social context, the compartmentalization of the person removes even the potential for individual action. People are, instead, a set of pieces in need, both in time and space. Hopefully, the pieces can be put together again to make a human unit of sufficient residual effectiveness to pay for “its” servicing.
To sum up, professionalized services define need as a deficiency and at the same time individualize and compartmentalize the deficient components. The service systems communicate three propositions to the client:
- You are deficient
- You are the problem
- You have a collection of problems.

In terms of the interest of service systems and their needs, the propositions become:
- We need deficiency
- The economic unit we need is individuals
- The productive economic unit we need is an individual with multiple deficiencies.

 

THE PROFESSIONALIZED ASSUMPTIONS REGARDING THE REMEDY OF NEED

These professionalized definitions of need produce a logical and necessary set of remedial assumptions, each with its own intrinsically disabling effects.

The first of these assumptions is the mirror image of the individualized definition of need. As you are the problem, the assumption is that I, the professionalized servicer, am the answer. You are not the answer. Your peers are not the answer. The political, social and economic environment is not the answer. Nor is it possible that there is no answer. I, the professional, am the answer. The central assumption is that service is a unilateral process. I, the professional, produce. You the client, consume.

There are, of course, an impressive set of professionalized coping mechanisms that have been developed by sensitive servicers to deny the unilateral nature of professionalized service. They are described as group-orientated services, peer-orientated services, client-orientated services, and community-orientated services. Each of these rhetorical devices is a symbolic attempt to deal with the anxieties of servicers who need to deny the unilateral nature of their relationships.

While it is clear that many humanistic professionals seek a democratic definition for their role, it is difficult to perceive the bilateral component beyond the clients' payment, whether out of pocket or through taxation. Indeed, a basic definition of “unprofessional conduct” is “becoming involved with the client”. To be professional is to distance – to ensure that the relationship is defined in terms that allow the client to understand who is really being serviced.

In spite of the democratic pretence, the disabling function of unilateral professional help is the hidden assumption that “You will be better because I, the professional, know better”.

The political implications of this assumption are central to anti-democratic systems. Indeed, it is possible that societies, dependent on economies of unilateral professional servicing, are systematically preparing their people for anti-democratic leaders who can capitalize upon the dependencies created by expert, professionalized helpers, who teach people that “they will be better because we, the professional helpers, know better”.

A second disabling characteristic of professionalized remedial assumptions is the necessity for the remedy to define the need. As professionalized service systems create more elegant techniques and magnificent tools, they create an imperative demanding their use.
The problem with these beautiful, shiny, complex, professional tools and techniques is that their “benefits” are not easily comprehended by the public. Therefore, we see the professions developing internal logics and public marketing systems that assure use of the tools and techniques by assuming that the client doesn't understand what he needs. Therefore, if the client is to have the benefit of the professional remedy, he must also understand that the professional not only knows what he needs but also knows how the need is to be met.

Thus the complex professional remedial tools have come to justify the professional power to define the need – to decide not only the appropriate remedy but the definition of the problem itself. Increasingly, professions assume that in order to deal with deficiency, they must have the prerogative to decide what is deficient.

There is no greater power than the right to define the question. From that right flows a set of necessary answers. If the servicer can effectively assert the right to define the appropriate question, he has the power to determine the need of his neighbour rather than meeting his neighbour's need.
While this power allows the professional to use his shiny new remedy, it also defines citizens as people who can't understand whether they have a problem – much less what should be done about it.

Modernized societies are now replete with need defining research. Professionals have recently “discovered” tool-using needs called child abuse, learning disabilities and, “removal trauma” (the need for therapy for children who are traumatized because they are removed from their alledgedly  traumatic families). Brigitte Berger suggests, in a recent article, that baldness will soon be defined as a disease because underemployed dermatologists will decree it to be one. The final institutionalization of the process is a new programme developed by a famous clinic in the United States: the programme provides a costly opportunity for people who don't feel anything is wrong to find out what problems they have that meet the needs of new tools.
When the capacity to define the problem becomes a professional prerogative, citizens no longer exist. The prerogative removes the citizen as problem-definer, much less problem-solver. It translates political functions into technical and technological problems:

Once the service professional can define remedy and need, a third disabling remedial practice develops. It is the coding of the problem and the solution into languages that are incomprehensible to citizens.
While it is clearly disabling to be told you can't decide whether you have a problem and how it can be dealt with, the professional imperative compounds the dilemma by demonstrating that you couldn't understand the problem or the solution anyway. The language of modernized professional services mystifies both problem and solution so that citizen evaluation becomes impossible. The only people “competent” to decide whether the servicing process has any merit are professional peers, each affirming the basic assumptions of the other.

While there are fascinating inter-jurisdictional disputes among servicing peers, these conflicts rarely break the rule that it is only the professional who understands the problem and the solution. The internal conflicts are power struggles over which professionals shall be dominant. A professional who breaks the rule of professional dominance will be stigmatized by all the disputants and loses his place on the rungs of the ladder to success. The politics of modernized professional power is bounded by peer review. Modem heretics are those professional practitioners who support citizen competence and convert their profession into an understandable trade under the comprehensible command of citizens.

The critical disabling effect of professional coding is its impact upon citizen capacities to deal with cause and effect. If I cannot understand the question or the answer – the need or the remedy – I exist at the sufference of expert systems. My world is not a place where I do or act with others. Rather, it is a, mysterious place, a strange land beyond my comprehension or control. It is understood only by professionals who know how it works, what I need and how my need is met. I am the object rather than the actor. My very being is as client rather than citizen. My life and our society are technical problems rather than political systems.

As the service professions gain the power to unilaterally define remedy, need, and code the service process, a fourth disabling characteristic develops. It is the capacity of servicers to define the output of their service in accordance with their own satisfaction with the result. This fourth capacity develops in a service profession just as the citizen is totally and definitely transmogrified into a critical addict.

Increasingly, professionals are claiming the power to decide whether their “help” is effective. The important, valued and evaluated outcome of service is the professional's assessment of his own efficacy. The client is viewed as a deficient person, unable to know whether he has been helped.
This developing professional premise is contested by the consumer movement. The movement is a valiant last stand of those disabled citizens who lay final claim to the right to evaluate the effects or “outputs” of professionalized service.

The basic assumption of the movement is that citizens are enabled because they have become powerful consumers. In this assumption the movement is a handmaiden of the serviced society. It implicitly accepts the service ideology. Citizens are as they consume. Citizen welfare is defined by equitable, efficacious consumption. The service system is a given good. The citizen role is in evaluating the output. While citizens may not understand the service system, the consumer movement assumes they do know whether the system's output helps or hurts.

Professionally managed service systems are now dealing with this remnant citizen role as consumer. The result has been an increasing professional focus on manipulating consumer perceptions of outcomes. Thomas Dewar, in a paper titled The Professionalization of the Client, describes how the service systems are training citizens to understand that their satisfaction is derived from being effective clients rather than people whose problems are solved.
The paradigm of this process is the school. Unlike most servicing systems, the school is transparent in its institutional definition of the client's role. The school client is evaluated in terms of his ability to satisfy the teacher. The explicit outcome of the system is professional approval of behaviour and performance.
The professional imperative is now universalizing the ideology of the school, communicating the value of effective clienthood. Negating even the client “output” evaluation, modernized professional services increasingly communicate the value of being an effective client as the proof of the system's efficacy.
Once effective “clienthood” becomes a central value in society, the consumer movement as we know it now will be stifled and will wither away.

The service ideology will be consummated when citizens believe that they cannot know whether they have a need, cannot know what the remedy is, cannot understand the process that purports to meet the need or remedy and cannot even know whether the need is met unless professionals express satisfaction. The ultimate sign of a serviced society is a professional saying, “I'm so pleased by what you've done”. The demise of citizenship is to respond, “Thank you”.

We will have reached the apogee of the modernized service society when the professionals can say to the citizen:
We are the solution to your problem.
We know what problem you have.
You can't understand the problem or the solution.
Only we can decide whether the solution has dealt with your problem.

Inverted, in terms of the needs of professionalized service systems, these propositions become:
We need to solve your problems.
We need to tell you what they are.
We need to deal with them in our terms.
We need to have you respect our satisfaction with our own work.

The most important research issues in modernized societies involve an understanding of the needs of servicers and the mechanics of their systems. These systems are obviously important. They provide incomes for a majority of the people. They support national economies. It is, of course, no secret that they are consistently failing to meet their own goals in spite of magnanimous applications of money and personnel. It is becoming more and more evident that rather than producing “services” they are creating sensitive but frustrated professionals, unable to understand why their love, care and service does not re-form society, much less help individuals to function.

We should, therefore, reorient our research efforts toward the needs of servicers. After all, they are a growing majority of people employed in modernized societies and they are an increasingly sad, alienated class of people in need of support, respect, care and love. Modernized societies need to determine how we can help these professionalized servicers while limiting their power to disable the capacities of citizens to perceive and deal with issues in political terms.
And if we cannot do that we should at least understand the political impact of the disabling nature of professionalized definitions of need and remedy.

Professionalized services communicate a world view that defines our lives and our societies as a series of technical problems. This technical definition is masked by symbols of care and love that obscure the economic interests of the servicers and the disabling characteristics of their practices.
The sum of these disabling characteristics is an ideology that converts citizens to clients, communities to deficient individuals and politics to a self-serving debate by professionals over which service system should have a larger share of the Gross National Product.

The foregoing analysis is not an argument for the reform of professionalized service in order to remove the disabling effects. Rather, the analysis suggests that the disabling effects are intrinsic to modernized professionalized service. Whatever benefits they might provide can only be assessed after we recognize them as essentially self-interested systems with inherently disabling effects. Within this framework, the political definition of a citizen can be restored. The inherently disabling effects of professionalized services can be assessed and balanced against their possible benefits. Policies can be developed that select those service benefits that overbalance the intrinsically disabling effects.

In the meantime, the politics of modernized societies will be the conflict between the irresistible resistance of the service business and the immovable object created by citizens who have experienced the disabling help of privileged professional servicers who wear the mask of love.

 


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