What if we are going down the wrong path?

What if the way we are thinking about how to care for the needy among us is leading us down the wrong path?

At present, in Canada, a lot of informal care is provided to people who are facing challenges in life. This informal care is given by family, friends, neighbours and other community members (e.g., members of faith communities). When informal resources are not able to provide all the help that is needed, people can get services from organizations in the non-profit sector or government agencies. These institutions get involved in people’s lives when their degree of need is too high or the duration of their need for support is too long for informal resources to cope with. Categories of people with high and long-term needs include people who are old and infirm, who have debilitating mental or physical illnesses, who are mentally or physically disabled, who are addicted to hard drugs, and who are chronically unemployable.

Focusing on individuals

Most care provided by institutions in the government and non-profit sectors is focused on individuals. The medical model provides the template. Individuals’ specific unmet needs are identified (diagnosed) and relevant services (treatments) are provided. For the most part, needs are compartmentalized, i.e., different agencies address different needs. Almost always, aside from basic interactions like ensuring that someone will be home if a home care nurse is coming to see a bedridden patient, people’s needs for health and social services are addressed in isolation from their social context. Family members, friends, and other members of the person’s social network are not involved in the process of formal service delivery.

Focusing on one need at a time

Despite the array of government programs like pensions, welfare, disability payments, and subsidized housing and the varied services offered by the non-profit sector, places like the Downtown Eastside demonstrate that such programs and services are not enough. Despite the existing social safety net, people are going hungry, sleeping on the street, medicating themselves for untreated illnesses and ending up in jail for crimes like petty theft and prostitution that are committed out of desperation.

Salvation Army lunch line upSome of the flaws in the current social and health care systems are well-known. Most people who live and work in the Downtown Eastside know, for example, that people with complex problems like the combination of drug addiction and mental illness coupled with a low educational level and little work experience need more than medication for their mental illness if they are going to get off the street. Insiders in the Downtown Eastside know that it is usually not enough for a drug user to go into detox. If he comes out and has nowhere to go other than the Downtown Eastside and no friends other than drug users, chances are high that he will start using drugs again.

The efficacy of comprehensive interventions that address not just one of the problems faced by those with complex unmet needs (e.g., by providing housing, job training, counselling, life skills training, and social support) has been proven. But this kind of comprehensive approach is still not the norm.

Making value judgements

Part of the problem is that governments are willing to allocate some money for programs and services to meet the needs of people who are not self-reliant. But they are not willing to spend enough to allow all such people to live dignified lives. Our society defines some people’s needs as legitimate and others’ as illegitimate. The government pays for chemotherapy for children with cancer and individual citizens donate money to send dying kids to Disneyland with no questions asked. On the other hand, some governments and citizens seem unconcerned when aboriginal women go missing. Similarly, the health care system goes to enormous lengths to save the lives of premature babies but does not prevent drug addicts from dying alone in alleys.

Obviously, different calculations are being made based on ideas about people’s misfortune being accidental and unfair vs. self-imposed and therefore deserved. Usually these calculations take into account the ability of the government or donor to provide funds to address social problems. The pool of funds is always limited and in competition with demands for funding for other things.

Thus, decisions about whose needs to meet and how satisfactorily to meet them are made based on how much money and other resources are available and how legitimate the needs are deemed to be. Underlying the idea that unworthy people should not be allowed to take advantage of the system is the belief that people should not get something for nothing and the fear that, if too many of the good things in life are provided for free, everyone will lose the incentive to work hard and the market economy will break down.

Perverse incentives

The system we have developed in Canada to address the problems of people with complex unmet needs is perverse. For example, once people get involved in this system, they are rewarded for being extremely needy and staying that way. In most jurisdictions, people who apply for welfare are eligible only after they have exhausted any savings they have and any informal resources they can exploit. Once they start receiving welfare, they are prevented from keeping any significant amount of money they might receive from other sources, money that might help them get off welfare in the long run.

Eligibility rules in these systems are based on the assumption that some people will try to take advantage of the system, they will try to get money and services they do not really need (a way of defining the situation that masks the fact that judgements are being made about whether the person deserves help). Both the person who asks for help and the professionals who make decisions about eligibility for services get caught in a strange game: the client has to give the impression he or she is completely helpless and incompetent, which can become a self-fulfilling prophecy, and the professional has to pretend that he or she is there to help, all the while looking for reasons to deny services.

IMG_0568Another perversity in this system is that professionals are being paid to provide types of care that perhaps should not be part of the market economy. This happens because we are not paying enough attention to important elements of the helping relationship that go beyond instrumental acts of service. For example, at the same time that UBC was bringing student volunteers into inner city schools to do academic tutoring, sports, music, arts projects, gardening and other activities, another local university established a program to bring its students into schools where they were paid to act as tutors in academic subjects. In my opinion, paying university students to play this role is a mistake.

When a young boy is being tutored by a varsity athlete who is making the effort to come to his school on his own time the child can say to himself, “Wow, this really cool guy is coming here to help me for free! He must really care about me.” The voluntary nature of the relationship is part of the reason why the relationship can raise the child’s self-esteem and prompt the child to see his tutor as a mentor and role model. That same boy being tutored by someone who is being paid forms a different kind of relationship with his tutor. The latter relationship is not governed by informal rules about willingness, reciprocity, mutual consent, and mutual appreciation. It is governed by formal rules about contractual obligations and market value.

Developing systems that pay people to provide certain types of care has created a kind of social confusion that we have not acknowledged. Gift economies where people know and care about each other and where wealth of all kinds circulates freely have been contaminated by the introduction of professionalized social services. There are all kinds of reasons why this has occurred, including women being in the work force and not available to provide informal support, social dislocation resulting from occupational mobility, and fears about vulnerable people being exploited by unscrupulous, unregulated caregivers. These factors need to be taken into account. But so do the obvious cracks in the current social services system.

This system is crazy-making for everyone. Professionals struggle with the expectation that they will be dedicated to their role as a helping professional but that they will not “get involved” with the people they are helping. How do you navigate these “professional boundaries?” For too many people, the answer is to cut yourself off from your feelings, to become numb. Clients struggle with the expectation (and the desire) that they will become normal, that they will get “better,” when they know that if they show signs of becoming less needy, they will likely be cut off from support they rely on.

Other ways of thinking about poverty and marginalization

take care drawing

Instead of asking what society should do about people who are not self-reliant, perhaps we should ask why society expects people to be self-reliant in the first place. In communities where gift economies flourish, no one expects anyone to be self-reliant. Everyone knows they need each other. Everyone makes a valued contribution to the sustenance of the community. Being a skilled member of the community entails knowing how not to be self-sufficient. Put another way, being part of such a community requires skill in drawing out the talents and gifts of others as well as being open about what one needs and knowing how to receive a gift with grace. You have to know how to keep the gifts circulating. This is contrary to the norms of modern consumer culture where everyone is supposed to be a successful, independent individual who can get their needs met by buying products and services in the marketplace.

The prevalence of poverty and marginalization in developed countries is to some extent a structural sign of the failure of free market economies (which, for example, do not tolerate full employment). These problems can also be seen as a sign of the loss of the ethics of gift economies. The infiltration of market-based ideas in the culture has made interdependence and indebtedness into a taboo.

Perhaps we should not just be asking what to do about individuals who are poor and marginalized. Maybe we should ask how our social systems are structured and how their structure could be changed. What do we know about social relations, especially the ways in which cultural norms and expectations shape relationships in social networks and communities? How might this knowledge be applied to strengthen bonds between people? The encouragement given by John McKnight and others to focus on people’s gifts and assets rather than their needs and problems is an important piece of the puzzle. How do we take the next step and make space for poor and marginalized people to contribute to their communities in meaningful ways?

Integrating poor and marginalized people in communities in new ways will require consideration of new roles for people who are capable and well-off, too. How might such people be offered new opportunities to show compassion and generosity? What might traditional gift economies teach us about how wealth can be redistributed? What would it look like if, instead of establishing our social value by consuming the latest and greatest product, we could establish our social value by giving our greatest gifts?

We cannot go back to village life the way it was lived before urbanization. But we might be able to build systems of mutual support and gift-giving which emulate the interdependent networks that used to be more widespread. These systems could be based on the expectation that everyone has strengths and gifts to offer and everyone will at some time be vulnerable and need help. Such systems would need to acknowledge that our skills of interdependence and gift-giving may be rusty and may need practice to develop. How might these skills be strengthened? What role might social media play?

It is important to avoid being naive about how difficult it will be to make significant changes in our approaches to poverty and marginalization. Efforts to strengthen communities (e.g., the health promotion movement) have floundered in the past. But the obvious cracks in the social service and health care systems and the weakening of government support for these systems in Canada point to a need for innovative approaches based on new ways of thinking about the issues, thinking that is informed by input from everyone involved, especially the poor and marginalized themselves.

For more on these topics, see Being on the outside and the other articles in the Reflections section.