Constructing “harm” and “ASP” in practice

At a policy level, I have argued, the problem of “harm” to “adults at risk” has been constructed in particular, contingent ways. So too has the type of response we call “adult support and protection”. Some sociology that aligns with this view seems to emphasise the ways that these kinds of constructions constrain the ways we think and act. That is, we have fashioned certain concepts at a professional, political and/or societal level, and now they are the lenses through which we view the world.

Social construction isn’t just about constraints on our thinking, however – just as policy isn’t simply “imposed” onto practice. I would argue instead that quite an active type of construction is inevitably going on at a practice level too. Certainly, professionals are taught that they must spot when “harm” to an “adult at risk” is indicated, and they must activate ASP procedures when they consider that it is. But a number of pieces of research have begun to suggest that the process of determining what comes to count as “harm” and/or as “ASP” is more complicated than this. Most of this research does not come from Scotland. Even less comes from the post-ASPSA Scottish context. A fair bit comes from England, for instance, where they talk about “safeguarding” and “abuse” and sometimes about “vulnerable adults” (17,18,19). I think that the really important messages from these types of findings are transferable across policy and legislative contexts, though, and I’ll come back to explain why at a later point.

Some of the research on which I based my PhD was conducted in Scotland immediately prior to the implementation of the ASPSA. This work produced some findings that conflicted with a policy assumption at that time: namely, that “adult protection” is something that happens when “abuse” to a “vulnerable adult” is suspected or established. In contrast with this assumption, the concept of “abuse” did not seem to be particularly helpful to practitioners in our research, when deciding what was to count as an “adult protection” issue. Sometimes they thought of something as “abuse” but they didn’t think an “adult protection” response was appropriate. Sometimes they thought an “adult protection” response was appropriate to circumstances they didn’t think of as “abuse”. You can read more about this here or here.

In two later papers, I tried to show that this wasn’t just because “abuse” is a tricky concept to define, although it undoubtedly is. And it wasn’t just because practitioners did not know or understand the definitions they were supposed to be working to. This means that re-wording the definitions and training people more thoroughly in them, as happened when the ASPSA was implemented, was not necessarily the “answer” to this “problem”. Rather, I suggested that deciding  to go down a particular route called “adult protection” or “ASP” was never just an issue of identifying a discrete phenomenon, whatever you called it and however you defined it. It was an issue of making judgements about what would happen, if a set of circumstances was defined in a certain way. These judgements might be more or less explicitly negotiated, and they might be more or less consciously strategic. Overall, however, they were arguably better thought of as setting out to achieve something (i.e. a particular response or outcome), rather than just to describe something (i.e. “abuse” or “harm”).

Take the patterns I identified, in those concerns that were channelled into ASP processes as opposed to those that weren’t. In particular, it was very common for concerns about paid carers’ practice to make their way into ASP processes: a single incident of concern was usually enough to make this happen. Meanwhile, there was much more variability in the ways concerns about family carers were dealt with, and it was much more common for concerns to build up over months or years before ASP processes began to be considered. Concerns understood to stem from institutions and their workings were treated differently again. These types of concerns included familiar issues of neglect in residential settings, but also a range of other things that could concern some service users as much as, or more than this: for instance, monitoring that was experienced as excessive and intrusive; disrespectful and/or dismissive professional attitudes; under-resourced services that let people down. Issues across this whole range of institutionally-perpetrated concerns were less likely to be understood to “count” as ASP than concerns perpetrated by individuals. You can read more about this here or here.

I would suggest that these patterns become more comprehensible, once we understand that practitioners were channelling things down an ASP route with a view to what this might achieve, rather than with a view to abstract definitions of “abuse” alone. So, they knew that ASP processes had a great deal of leverage, should the concern be a paid carer’s callous or neglectful behaviour. On the other hand, they knew that many other types of concerns would not be influenced by invoking ASP. For instance, it could be argued that some adults in the sample had suffered or were placed at risk because of the under-resourcing of social work departments, or because of the discharge policy of the NHS. On paper, these types of concern might equally meet the definition of “abuse” or “harm”. But they were screened out of ASP procedures because practitioners knew what such procedures could or couldn’t do.

The particularly variable responses to concerns about family carers was interesting in this respect, because it seemed to be linked in turn to a varied range of ideas about what ASP is and/or what it can do. Some practitioners seemed to think that ASP involved a less consensual, more coercive form of practice. They tended to argue that concerns arising in families might more sensitively be addressed in other types of way. Other practitioners felt able to reconcile ASP practice with flexible and collaborative ways of working. They seemed more able to conceptualise something both as a “family” or “relationship” issue and as an ASP concern. You can read more about this here or here. Why practitioners had such different views about what ASP involves is a subject for more research. However, it might be linked in part to different approaches and processes in different local authority areas, some of which were more flexible and less bureaucratised than others (19).

It could (and undoubtedly has at times) been argued that all these types of consideration should be immaterial, in deciding what is to count as ASP. According to this argument, either something meets the definition of “harm”/”abuse” or it does not. Whether it does so should be the one deciding factor. This flies in the face of the way that many theorists would argue that the social world works, however. Human beings just aren’t like that: they categorise the world in order to influence it, not only in order to describe it. Phenomena like “abuse” or “harm” are continually constructed and re-constructed in these micro-processes (12). Nor is there a bottom-line “truth” to guide practitioners, about the “actual” boundaries of abuse or harm, according to the sociology I have drawn upon before. Studies of social policy and administration over many years and in many types of field have also indicated that practitioners actively interpret policy. In a sense they have to, at the very least when they’re dealing in human lives and human meanings: no top-down prescription will ever capture all the nuances, and all the answers to all the uncertainty that people like social workers have to work through on the ground (20,21). This has been argued and evidenced a number of times in the more developed field of child protection (22,23).

This leaves us with the question of how best to support ASP work in ways that follow the grain of real social processes, and the real ways that policies are translated into practice, rather than trying to work against them, or at least not to an unrealistic degree.

The trouble with “adults at risk”

I wrote a paper towards the end of my PhD that tries to unpick some of the assumptions implicit in current Scottish policy constructions of “adults at risk of harm”. I was trying to get at the nature of the problem that Scottish ASP policy considers itself to be addressing, by trying to pin down its understandings of where the problem comes from and who it might affect.

I approached this task by drawing a series of comparisons with Scottish child protection policy, on the one hand, and Scottish domestic abuse policy, on the other. I wasn’t trying to imply that these other policies are all about the same “kind” of problem, or that they should necessarily be similar in the responses they prescribe. But I did find them to be useful points of reference when trying to get a grip on different ideas about harm, abuse, dependency, vulnerability and power.

I should say as well that, because my starting point was some of the sociology I have written about before, I think it is inevitable that policies will contain assumptions. That is, all policies contain particular representations of the problem(s) they are setting out to address (15). This means I don’t think that uncovering assumptions is in itself a criticism of a given policy. However, it is a good basis for starting to discuss whether these assumptions are helpful ones are not.

If you have access to the journal Disability and Society, you can read my paper here:

If not, please follow this link: Here, you will either be able to download a version of the paper, or you’ll be able to request a copy (all requests approved though – it’s just a copyright thing).

Facts and constructions

I wrote earlier about my impression that the field of ASP is delineated in current Scottish policy in ways that don’t make intuitive sense to many people without a grounding in the field. I also hinted at my view that there doesn’t exist one “intuitive” or “correct” way to define and draw boundaries around the issues and activities that Scottish professionals currently “box” together and call “ASP”. Instead, any given way of defining and drawing these boundaries needs to be understood as a product of its history and of its implicit assumptions: about society and the role of the state, for instance; and about care; and about vulnerability.

We see this in the way that the same issues are understood differently in different cultures and in different historical periods. For instance, some countries have separate policies for addressing the abuse of older people than they do for addressing the abuse of any other adult (7,8). They might define “abuse” and “old age” differently as well. Some might consider abuse within the family to be a distinctive enough phenomenon to legislate about collectively: this would include our concept of “domestic abuse”, many of the issues that we would class as “child protection” and a proportion of the issues that we would class as ASP (9). Others again might draw a different boundary between protection issues and political, cultural and economic issues. Highly prominent in a typology of elder abuse in Africa, for instance, is collectively-perpetrated violence against older women that stems directly from such factors as patrilineal inheritance laws and a belief in witchcraft (10). Some of these different ways of delineating issues might be because different problems face different societies at different points in time. But some are because we understand and group things differently. For instance, the persistent devaluing, even vilification, of people prevented by illness or disabling barriers from supporting themselves through paid work does not always count as an ASP issue in the contemporary UK context. Sometimes it passes for journalism. Sometimes it passes for welfare reform.

As well as the question of what counts as harm or abuse, there is the question of what counts as ASP. The leap to thoughts of allegations, investigations and risk assessments, case conferences and co-ordination of “packages” of intervention drawn from a mixed economy of care is not a leap that welfare professionals in every society and every period of time would make. On the contrary, what counts as an ASP activity here and now makes intuitive sense to us because of the political, cultural and service contexts in which we are immersed.

The idea that we can’t look at the facts about what is happening in our society in a way that is divorced from these contexts, in order to read off the “truth” about harm/abuse and the one “correct” way to design a service response has a lot of support in sociological theory. For instance, some sociologists argue that all social problems are constructed (11). This doesn’t mean that there is never a “real” problem, but it does mean that the particular ways we understand, define and respond to the issues that are accepted as problematic within our society are affected by a range of contingent factors. Often issues of definition, boundaries and approach are fought out in more or less explicitly political contexts. So what we are left with are constructions of problems that are never universally “correct”, though they may be more or less universally accepted as correct in particular cultures at particular points in time.

Similarly, there is a lot of reference in some fields of sociology to “discourses” (12,13). These can be thought of as bodies of ideas and practices that grow up in particular societies and are accorded the status of truth within those societies. They shape the ways that people think and act, the ideas that are accepted and those that are discounted. The power associated with certain societal roles helps to reinforce these discourses: for instance the power associated with being an ASP policy-maker, trainer or practitioner. It is currently accepted in these professional circles in Scotland, for example, that “harm” is a distinctive phenomenon that has something to do with “disability, mental disorder, illness or physical or mental infirmity” (14). It is also accepted that a key part of ASP is investigation. There are lots of forms, procedures and legislative provisions that govern when, how and by whom ASP investigation should be done. Some training to direct care and support workers begins from the premise that referring information on for investigation is the core role of these workers in countering harm. Voices wishing to challenge these truths carry less weight than voices subscribing to them, particularly in settings where ASP is practised, policy developed or training delivered.

So what does it mean for policy, practice and research, if we accept that “harm” and “ASP” are constructed in this sense, and connected in these ways with power? First, there are many things that it does not mean. It does not mean that our currently prevalent ideas about these concepts are “untrue”. The argument is rather that there is no single, underpinning “truth” of this kind, to measure our ideas against. It does not mean that power is necessarily being used oppressively; it pre-supposes instead that power and knowledge will always be linked. It does not mean that harm and abuse are not “real”. Some older people are undoubtedly raped; some people with mental health problems are undoubtedly stolen from; some people with learning difficulties undoubtedly lead diminished and fearful lives. The point is not to question the material reality of this pain and injustice, but to explore the ways we conceptualise certain phenomena as representative of certain kinds of problem, to be responded to in certain kinds of ways. To accept that “harm” and “ASP” are constructed also does not mean that any way of conceptualising and responding to these issues would be as good as any other. But it does mean that there will always be more than one way to understand them. And this means that “facts” alone are not enough to help societies and individuals judge which ways of understanding and responding might work best for them.

One concrete implication of this is for the evaluation of policy and legislative frameworks. To return to a previous example: we know that some national policy frameworks understand the abuse of older people to be a distinctive phenomenon, whilst others group it, or some aspects of it, underneath some broader heading: for instance “domestic violence” or “institutional abuse” or “harm towards adults at risk”. Perhaps none of these alternatives represents the “best” way because it is “true”. Perhaps we should ask instead what effects each grouping has (15). In the Scottish context, for example, what effect has subsuming the abuse of older people within the broader ASP agenda had on the priority that the protection of older people is accorded within the public consciousness? Within professional education and training? When resources are allocated on the ground? (16) There are plenty of other questions we could ask as well, about the effects of the broad shape and the underpinning premises of Scottish ASP policy. For instance, what are the effects of the division that ASP policy implicitly draws between those who are ASP workers and those who are providers of support and care? Do support and care workers perceive differences in their wider roles, and in their relationships with other services, since the implementation of the ASP legislation? Do people who use services perceive differences in the wider services they receive, for instance in the attitudes of their workers towards risk? There is a rich research agenda here, based on these and questions like them, the surface of which has barely been scratched up until now.

“What is your research about?”

When I used to tell people that I was doing a PhD, they would often ask me, “What is it about?” My PhD was about adult support and protection, in the sense made standard by the Adult Support and Protection (Scotland) Act 2007. For people familiar with this legislation and its history, this answer made some immediate sense. For most other people, including academics in many other disciplines, “adult support and protection” rang few bells at all.

If they were asking just out of politeness, we would sometimes leave it at that. But more often, I would try to explain what ASP was. And I wanted to do this in a way that was accurate. In the field of ASP there have been so many struggles over terminology. Phrases that used to be relied upon to sum the field up have been rejected now in Scotland, for reasons that some important stakeholders feel strongly about (6). So reinstating these phrases didn’t feel right, even for the sake of a simple explanation. For instance, people with some knowledge of social care would sometimes ask, “do you mean it’s about vulnerable adults?” And I would fumble through an answer that probably made things more rather than less opaque – trying to explain that the answer is “yes and no” – that ASP is not about a defined group of people who we’re prepared to think of as generically “vulnerable”, but that the idea of “vulnerable adults” is related to ideas that have now developed into ideas about ASP.

Even dated terminology was no help for people with no social care or related background, or people familiar with very different state systems for organising welfare and related services. I once got into a discussion about my research with a Czech professor of philosophy on an overnight train from Amsterdam to Prague. Or I tried to. I still cringe when I think about how little I probably managed to convey – even about the basic subject of my PhD – how very few coherent words I seemed to have to set this out. And I was once asked by an older acquaintance if “adult support and protection” is the study of “battered wives”. Again, I fumbled through a confusing, “yes and no” answer, trying to articulate that it isn’t so gender- or marital-status specific, and there’s this element of “vulnerability” (for want of a better word) tied up in ASP somehow: that it’s a type of “vulnerability” that might come from something like an impairment or frailty, though it doesn’t always have to – it’s more about the circumstances people find themselves in – but it definitely isn’t just about gender. Trying to put this in a way that made some sense raised some puzzling questions for me (5), quite aside from those it no doubt raised for the unfortunate person who had asked the question, and I’ll come back to this later.

So I would try another way. I would try by beginning, “It’s kind of like child protection, except…” and then spend a long time trying to articulate how ASP isn’t like child protection. Or I began, “it’s kind of about abuse, except…” and then spent twice as long explaining how it’s much broader than the kinds of things you might stereotypically think about when you hear the word “abuse”. The term “harm”, now preferred in Scottish policy, was no help at all. You can be harmed if you catch a serious disease or if you’re knocked down by a car, but ASP isn’t really about that.

I would give up comparing it to anything, and just try to start from the beginning. I would explain that it’s about a very broad range of responses to help keep people safe and well where there may be some limits on their abilities to do this for themselves. But then I found it difficult to articulate the distinction between ASP and a much broader swathe of adult services. I also found it was easier to give the impression that ASP is entirely about social care, or entirely about criminality, than to convey that it’s a blend of some parts of these and other things. “So it’s like bath rails for older people things like that?” I might be asked. Well, yes, kind of – but no, not really. “So it’s to do with crime against older people?” “So it’s to do with looking after people who can’t make their own decisions?” Well, yes – but also no.

I don’t mention all this out of any disrespect for people whose expertise lies elsewhere. There are plenty of people whose professional and academic work I don’t understand very much about. I also appreciate that immediate accessibility to those without a grounding in the subject is not necessarily the hallmark of “good” or “authentic” social science. Nevertheless, this almost complete absence of a language to articulate the basic topic of my PhD to almost anyone who wasn’t an adult health or social care professional, or an ASP specialist in a related field such as the police, played on my mind. I thought it might be telling me something quite important. Bear in mind that non-ASP specialists are still pretty likely to have heard of instances that ASP professionals might classify as “harm”, or indeed to have experienced them, first or second hand. We could generally find shared ground over examples. These were typically extreme ones though: Winterbourne View; Steven Hoskin; the Borders case. The more inclusive “box” that ASP draws around the gamut of things that fall within its remit in contemporary Scotland was still not a familiar “box” to many people. They might be more inclined to conceptualise things that are clearly criminal in quite a separate “box” from things that aren’t. They might “box” interactions in families quite separately from staff practice in care homes; or older people’s concerns quite separately from the concerns of younger adults with learning difficulties; or services to adults who lack mental capacity quite separately from services to adults who don’t. They might “box” anything to do with the quality of care provided to those who require it together, blurring the boundary between things that we might call “ASP” and things that we might call “care regulation and inspection” or “care management” or just “care”. In short, they might struggle to see how the kinds of issues that currently “count” as ASP have been conceptualised as similar enough to each other, and different enough from other things, to constitute a distinctive category of phenomena that someone might be doing a PhD about.

Four years later, and I have still found no better way to explain what ASP is than to explain its history. This works better for training sessions or conference presentations, though, than for chance conversations with people who may wish they’d never asked – because I need to start as far back as I can. I need to talk about the long-stay institutions, and the concerns that arose around and within these, and then the different but related concerns that arose with the move to “care in the community”. I need to talk about changing approaches towards “risk” in health and social services, and towards “rights”, and towards “accountability”. I need to talk about the “discovery” of elder abuse and of the abuse (primarily the sexual abuse) of adults with learning difficulties. I need to talk about huge shifts in social work and its relationship with other services, and in particular the introduction of the care management role and the purchaser/provider split. I need to talk about “protection of vulnerable adults” policies and how they developed, and why they were superseded, and all the debates around the legislation we now have.

I also think that people’s own “boxes” for conceptualising things when they’re not steeped in ASP can only really be understood in the context of their histories, and of the building-blocks of sense-making of which they’re made up. For instance, people might be starting from a different set of assumptions about independence and its relationship to dependence, or about what “care” is and why people might need it, or about the distinction between a private issue and a state concern.

And it seems to me that there is just no neutral ground. Or at least, there’s no suitably nuanced shared language by which we can cut to the chase, and say what we “really mean” without all this background needing to be got through or else getting in the way. And if we need to engage with a myriad of trajectories of meaning-making in order to find some common ground, at least when we step out of our professional silos, then this changes the conversation about ASP in my view. It helps us to look more critically at what we’re doing, and what it’s really all about.