I went to an art talk recently. Yeah, get me! The speaker was fascinating and, as she discussed some of the great artists of our time, she repeatedly described them as “unconventional”, “different” or “a little crazy”. Whatever words we choose, she was talking about people whose talents were inseparable from ways of thinking and living that sat outside social norms. Their distinct individuality making them the artist, and crucially the person, that they were.
It made me wonder what would happen if people like L.S. Lowry, Lucian Freud or Tracey Emin came to the attention of Adult Social Care before they became celebrated artists. Would we have recognised their individuality, creativity and purpose, or would we mainly have seen risks that needed managing? Put simply, can social care cope with difference?
Social care talks constantly about strengths, assets and person-centred practice. But what happens when somebody’s strengths do not look like strengths to us? What happens when the things that make life meaningful sit well outside the norms we are comfortable with? Artists like Lowry, Freud and Emin provide an interesting thought experiment. Lowry’s later life might today raise concerns about significant self-neglect and isolation, regardless of the fact that he may have fallen short of Care Act eligibility. Freud’s gambling could prompt questions about financial harm and risk. Emin’s openness about alcohol, excess and chaos might easily be viewed through the lens of safeguarding rather than artistic expression. Imagine the raised eyebrow of the celebrated ‘My Bed’ installation on a slide at a risk meeting. How long would it realistically take for someone somewhere to raise the ‘possibility of neglect’, or the first stage of ‘hoarding behaviours’?
Whilst those concerns about all three may not necessarily be wrong, the risks they encounter in their lives as a result of their uniqueness were real. The challenge in social care is often in deciding whether we are responding to harm or responding to difference, and that’s a crucial question when it comes to rights-based practice and adult safeguarding. Sometimes the things that appear problematic to us are woven into a person’s identity, relationships, creativity and sense of purpose. And even if the difference is a result of someone’s ill-health rather than their personality, it must still be respected. Which reminds me of Wye Valley NHS Trust v Mr B, where the judge said, “In some cases, of which this is an example, the wishes and feelings, beliefs and values of a person with a mental illness can be of such long standing that they are an inextricable part of the person that he is. In this situation, I do not find it helpful to see the person as if he were a person in good health who has been afflicted by illness. It is more real and more respectful to recognise him for who he is: a person with his own intrinsic beliefs and values. It is no more meaningful to think of Mr B without his illnesses and idiosyncratic beliefs than it is to speak of an unmusical Mozart.” As with Steven Neary etc, Mr Justice Peter Jackson on the money again.
Anyway, back to art. These three artists were brilliant (and Emin still is), but they were also deeply unconventional. Their obsessions and excesses were not always things sitting outside their identities waiting to be fixed. Sometimes they were part of the very things that made their lives meaningful. And this for me is where social care has a difficult job. If our role is to support people to live the lives they choose, we must be prepared to accept that “ordinary” means something different for every individual. Some people are chaotic. Some are obsessive. Some collect things. Some drink. Some gamble. Some live in ways that many of us would find deeply uncomfortable. That does not automatically make their lives wrong, nor should that ever prevent us from offering support and helping people make changes. Crucially, if we accept individuality, we also have to accept the ambiguity and risk that often comes with it. Our role is not to ignore harm, but neither is it to pull people back towards conventionality simply because we are uncomfortable with where they stand. Social care has got to be that good in what it does that it can live with, and work through, the complex dichotomy that individuality, personality and free will gives us. So, its more than just free personal care.
In 2016 I wrote about Elsie from Someone to Safeguard (read here). Her life looked chaotic through my eyes as a social worker, but not through hers. She lived surrounded by cats and relied on “John’s voice” to help keep herself safe. To me there were obvious risks and obvious reasons to want change. But Elsie’s cats were not simply a problem to be solved, and John’s voice was not simply something to be eliminated because it did not fit my understanding of how somebody ought to experience the world. They were part of how Elsie made sense of her life and maintained her sense of safety and identity. Her strengths and assets existed within that unconventional world until I arrived armed with referral forms, professional solutions and, ultimately, mental health legislation that brought about the end of the life she had chosen. If we remove everything that looks unconventional, we may eventually be left with a person who is considerably safer by our standards but considerably less themselves.
So, what does strengths-based practice mean if we can only recognise strengths that look familiar to us? What does asset-based practice mean if we only value assets that fit neatly within our own social norms? And what does person-centred practice mean if the person has to become more like the people doing the assessing before we are comfortable with their life?
I do not want to romanticise neglect, gambling or drinking. People can be harmed by their own choices and by the choices of others, and sometimes we absolutely need to intervene and always keep the hope alive for people to make changes. But there is a difference between recognising harm and deciding that a life should be made safer, tidier and more conventional simply because other people are uncomfortable with it. This is where I think the Mental Capacity Act matters enormously. We assume capacity. We support people to make their own decisions. We do not decide somebody lacks capacity simply because they make choices that many others would not make. These are enshrined principles, which despite pressure in some quarters for us to redefine in order to intervene (interestingly anyone noticed that we rarely experience pressure from anywhere to redefine MCA to further enable P?), must be at the heart of strengths-based practice, otherwise strengths based practice is rebadged care management.
There is a long history behind this approach. The history of health and social care, psychiatry and institutional care are littered with examples of people being judged against prevailing ideas of normality and then having society decide their lives needed correcting. The old asylums were not populated solely by people whose experiences we would now recognise as serious mental illness. People could be labelled, confined or treated because they were eccentric, troublesome, poor, difficult or simply failed to conform to what society expected, particularly women.
That history should make us uncomfortable because every generation has its own version of normality. We might not routinely lock people away simply for being different, but we can still be tempted to make people fit. Sometimes we move people into lives dominated by rules, routines, care plans, risk assessments, medication schedules, bedtimes and organisational systems. The infrastructure we build to keep people safe can, unintentionally, become the infrastructure through which we make their lives conform.
I am not suggesting contemporary social care is equivalent to institutionalisation. It plainly is not. But some of the assumptions beneath excessive risk aversion should give us pause. They can include a belief that a life must first be made safer before it can be a good life, that a tidy home is necessarily a better home, that conventional routines are necessarily better routines, or that behaviour which troubles us is necessarily a problem for the person themselves. Perhaps the real test of strengths-based practice is not whether we can identify strengths in people who live fairly conventional lives. Perhaps it is whether we can recognise strength when it looks strange to us. Whether we can see purpose in a life that does not immediately make sense. Whether we can distinguish harm from difference. Whether we can tolerate somebody being unconventional without making our discomfort their problem. Sometimes the thing we are most tempted to take away from someone in the name of safety is precisely the thing that makes their life theirs. Their own gloriously ordinary way of living.
Lowry, Freud and Emin were not simply “unconventional”, “different” or “a little crazy”. They were more than that. They were uniquely human. And understanding, respecting and celebrating what is human is the start and end point of social care. We just need to get the middle bit right.
