Dementia and Guardianship: Challenges in Social Work Practice

ABSTRACT

Decision-making within the context of dementia can be an uncertain and problematic process. This study critically examined challenges in social work practice in instances where a legal alternative decision-maker through guardianship proceedings was perceived as necessary. Theoretical perspectives from social constructionism underpinned the research. Five qualitative case studies were investigated. A thematic network analysis showed that the situations were constantly evolving and different players participated by bringing their own perspectives. In this process alliances were formed that reflected underlying dynamics of power. Contested issues included varied understandings of dementia and capacity, and differing constructions of risk, protection, and responsibility. The implications for practice are discussed with social work being well placed to make an important contribution through its traditional roles of negotiation, interpretation, and mediation between those who have discursive rights and those who do not. Ethical reasoning as a basis for decision-making was also of significance.

KEYWORDS:

• Adult Guardianship
• Decision-making
• Dementia
• Capacity
• Social Constructionism
• Social Work

The term “dementia” is used in varied ways but is primarily understood in contemporary Western culture as an illness with a range of associated behaviours requiring particular medical and social responses (Alzheimer's Australia, 2012). It is mostly depicted as having a trajectory of irrevocable decline where the person is perceived to become a financial and emotional burden to others (Australian Institute of Health and Welfare, 2012; Knight, 1998). This raises crucial questions about what it means to be a person with dementia, especially when the ability to make decisions is challenged. This article presents the findings of a study that critically examined these social situations and the engagement of social workers in the adult guardianship process. This process may do harm if used inappropriately or enhance the life of the person concerned by ensuring their needs are met and dignity is maintained. Social workers are actively engaged in the adult guardianship process in a variety of ways, yet within the social work profession the process of guardianship for people with dementia is an area where there is very little research.

Vittoria (1992) argued that guardianship hearings, such as those explored in the case studies discussed in this paper, are “encounters” bounded in time and space. These encounters are sociolegal in that they take place in the context of guardianship law within a particular judicial milieu. A focus on the sociolegal encounter of a guardianship hearing, its preparation and boundaries, may be viewed as the arena where the contested issues that are unique to each situation are played out.

This study was conducted in the State of New South Wales (NSW), Australia. The legislative framework for appointing an alternative decision-maker for issues relating to a person’s lifestyle, such as accommodation, health care, and medical or dental consent and services, comes under the jurisdiction of the Guardianship Act 1987. This Act is administered in conjunction with the Protected Estates Act 1983, which relates to decisions regarding individuals’ capacity to manage finances. Applications are made to the NSW Civil and Administrative Tribunal, Guardianship Division, referred to in this article as the Tribunal. The Tribunal is intended to protect the best interests of individuals in cases where there is a demonstrable presence of some type of disability that impedes their capacity to make lifestyle and financial decisions. For each application the Tribunal requires submission of two health professional reports, one of these being from a medical practitioner. The Tribunal can appoint a legal guardian, such as a relative, friend, or public guardian, for decisions that impact upon lifestyle. It can also appoint the NSW Trustee and Guardian for management of finances.

The legislation was designed to be an institution of last resort; it must be demonstrated that all informal options to resolve issues have been exhausted. In instances of guardianship, a clear case of need must be shown, which places responsibility clearly with family or community services to find some resolution before an application is lodged. This stipulation of need adds to the complexity and uncertainty of these sociolegal encounters because levels of need can be viewed as subjective and open to many interpretations. Therefore this is a crucial area for research.

In Australia legislation relating to guardianship and financial management is the preserve of the Australian states and, although there are many similarities across the states, there is no uniform nationwide legislation. Australia is unique in that, with the exception of the Northern Territory, legislation is entrusted to specialist multidisciplinary tribunals rather than courts. In general, most state tribunals require the demonstration of “disability” and “incapacity” in addition to other factors (Bennett & Hallen, 2005, p. 483). In NSW, with the amendments made to the Guardianship Act in 1997, it became possible for a person to appoint an enduring guardian in a similar way to an enduring power of attorney. This is a less formal legal arrangement commonly completed through a solicitor. If there is any significant dispute, upon application, the Guardianship Tribunal can review, confirm, revoke, or vary the functions contained in the enduring guardian document. However, the focus of this study was upon the appointment of a legal alternative decision-maker through the Tribunal.

Within Australian social work there is a growing body of literature regarding decision-making with people with dementia in areas closely associated with guardianship, for example, entering residential care and older people’s assets (Tilse, 2000; Wilson, Tilse, Setterlund, & Rosenman, 2009). However, the majority of the literature with a direct focus on issues surrounding adult guardianship comes from professions other than social work, such as law and medicine (Bennett & Hallen, 2005; Peisah, Brodaty, & Quadrio, 2006). This literature points clearly to the need for research into how guardianship and financial management applications work in Australia.

In addition to the jurisdictional context, three areas of theoretical importance underpinned this study: the way dementia is understood, the way decision-making capacity is viewed and conceptualised, and how identity in older age is shaped by social contexts. Since the work of Kitwood (1997), the biomedical understanding of dementia has been increasingly challenged. Kitwood’s main argument centred on the concept of “personhood,” focusing on the extent to which being a person depended, not only on biology, but also on social interactions. Acceptance of differences in understanding dementia has resulted in newer approaches that endeavour to address the significance of the involvement of multiple parties. These approaches accepted that power dynamics play a significant role in the relationships between a person with dementia and those they interact with. For Adams (2003), triangular relationships result in different roles that can be played by the third person, or health professional, and a combination of alliances and collusions can be formed. Hughes, Hope, Reader, and Rice (2002) found that ethical differences were reflected in issues such as what were considered to be “the best interests and wishes” of the person with dementia. Professionals spoke of the best interests of the person with dementia in isolation from the person’s social context, whereas family members saw the best interests of themselves entwined with those of the older person.

Shifting discourses also surround the way any subsequent perceived loss of decision-making capacity in a person with dementia is understood. Historically, prior to the 1980s, capacity was considered a binary concept in law; a person either had capacity or did not (Carney & Tait, 1997). More recent understandings of capacity are varied, where the notion of capacity is based on a person’s ability to make a decision about a specific issue, such as where they wish to live. In Australia, there is no standard assessment framework for a person’s decision-making capacity, and diverse opinions exist as to how capacity should be assessed (Carney, 1995; Collier, Coyne, & Sullivan, 2005). These debates centre on cognitive aspects, functional abilities, or a combination of both. Alongside these deliberations there is a growing body of literature that supports the idea that decision-making is done in the context of relationships, rather than by autonomous individuals (Hughes & Baldwin, 2006; O'Connor & Purves, 2009).

How claims are made that a person lacks the ability to make their own decisions, and the criteria taken into account in making these claims, are linked to what is seen as appropriate within a social context. Accordingly, the impact of health and social welfare structures, policies, and services can be viewed as crucial. In parallel with shifting discourses surrounding dementia and capacity, a succession of health and social welfare policy reforms have been implemented that have had an unprecedented impact on the way old age is socially constructed and services are delivered (Biggs & Powell, 2001; Webb, 2006). Trends in Australia have been profoundly influenced by globalisation and the rise of neoliberalism and new public management. As part of the transformation of the Australian welfare state the aged care system is also undergoing substantial restructuring that reflects wider mixed economy and free market principles (Productivity Commission, 2011).

Correspondingly, the concepts of risk and risk assessment in the context of older people’s lives have emerged. Risk is generally viewed as negative and welfare professionals are perceived as having a professional responsibility to provide appropriate safeguards (Webb, 2006). Risk may also be associated with the rise of the culture of blame particularly in the arguments associated with duty of care (Green, 2007; Webb, 2006). In summary, the literature suggested that sociolegal encounters are situated within complex macro and micro levels of contemporary social relationships.

Research Study Design

Sociolegal encounters were explored through the primary research question: In a contemporary Australian health and welfare context, what are the challenges in social work practice with older people, their families, and other professionals in disputed, complex, and uncertain situations where a legal alternative decision-maker is perceived as necessary? The purpose of the study was to provide new understandings of these encounters that would contribute to knowledge within the guardianship and decision-making domain and inform social work practice. The researcher is an experienced practitioner in aged care and the impetus for the study grew out of practice-based social work knowledge.

Theoretical perspectives from social constructionism underpinned the research. While clearly social constructionism is subject to many interpretations, for the purpose of this study it referred to a broad theory of knowledge that has its origins in the publication of Berger and Luckmann’s book The Social Construction of Reality (1967), which drew on the view that as people we construct our own and each other’s identities through our everyday encounters and social interaction (Burr, 2004, p. 13).

The research was structured using a qualitative case study design, which enabled multiple realities to be preserved, along with the different and contradictory views of what was happening in each particular case (Stake, 2000). Particular challenges posed by the case study design included access to potential cases that resulted in uneven inclusion of participants and documents to analyse. Purposive sampling resulted in five case studies being drawn from the caseload of social workers in an aged care service based in a large metropolitan hospital in Sydney (Table 1).

Table 1 Summary of case studies

Case study	Significant players	Data collected	Critical events	Application lodged by	Outcome
Graham: 76, married with two children; diagnosis of Parkinson’s Disease	Wife; community service providers; team members from health service	Five interviews: Graham; his wife; Social Worker G; Service Provider G; Chaplain G Documentary analysis	Safety risk considered high when Graham experienced burns at home	Social Worker G	Order for public financial manager and guardian
Edward: 71, divorced with three children; diagnosis of cognitive issues related to stroke	Son; ex-wife; sister; team members from health service	One interview: Social Worker E Documentary analysis	Son with whom Edward lived hospitalised	Social Worker E	Withdrawal of application for guardian and financial manager at hearing
Maria: 87, partner; no children; diagnosis of Alzheimer’s disease	Partner; community service providers; team members from health service	Four interviews: partner; Social Worker M (2 interviews); Service Provider M Documentary analysis	Partner’s ill health as he could no longer function in role as carer	Service Provider M	Order for private financial manager and guardian (partner)
Jane: 89, widow with two children; diagnosis mixed Alzheimer’s and vascular dementia	Son; community service providers; team members from health service	One interview: Service Provider J Documentary analysis	Repeated police attention after wandering	Service Provider J	Order for public financial manager and guardian
Albert: 88, widower; no children; diagnosis of general dementia	Community service providers; team members from health service	Two interviews: Social Worker A Documentary analysis	Made own decision to enter residential facility after hospitalisation	Application not lodged	Application not lodged

Note. Names have been changed to protect the anonymity of participants.

A meeting was arranged to inform the social workers about the research and invite them to volunteer to participate by contacting the researcher independently. Access to other participants in the case through the social worker was critical to ensure their voluntary participation. The social workers expressed concerns regarding the sensitive issues leading up to a hearing when families were mostly in crises. Issues were also raised about approaching the person with dementia to be included in the research, such as giving informed consent. These concerns were addressed by discussions on the ethical aspects of the research design such as the social worker approaching families at an appropriate time, the participants' right to withdraw at any time, anonymity and, in order to respect personhood, a specific process method of consent (Dewing, 2007) used to include the person with dementia.

Although endeavouring to interview each person with dementia, this was only possible in Graham’s case. The purpose of the research was discussed with Graham before the interview. The researcher was confident that he was able to understand and voluntarily consent. Ongoing consent was monitored during the interview. Consent to interview Graham was also sought from, and given by, his wife. Regarding the other people with dementia, unfortunately Maria died in an aged care facility before she could be interviewed. The three remaining potential participants were excluded due to considerations including being unable to understand the purpose of the interview, an inability to identify an appropriate family member to give consent, or a combination of these factors.

After negotiations with potential social work participants the first five cases referred to the researcher were accepted. These cases were considered typical in that they were complex, involved multiple players, and an application to the Tribunal for an alternative legal decision-maker had been or was about to be lodged. Unlike the other cases, Jane’s was referred by a service provider because there was no active social worker involved at the time of the study. Jane’s case was accepted as it provided this contrasting issue.

Despite the challenges, the breadth and depth of the data collected from these five case studies generated a range of emerging concepts and led to the decision that any more data would not add to the themes being developed and prove to be unwieldy. No claims are made about the representations of the experiences of the participants, as it is the analytic generalisation that is important in case studies, not statistical generalisation.

Four of the five people who were the focus of the individual studies were postwar migrants from four different European countries. The fifth was born in Australia. They had similar characteristics in that they participated in the workforce, were married, bought their own homes, had excellent English speaking skills and generally blended into what could be described as an Anglo-Saxon “middle-class” economic status. All participants associated with each study are identified using the first letter of the case study’s name. For example the social worker in Graham’s case study is referred to as Social Worker G and the service provider Service Provider G.

Data collection methods included 13 semistructured, in-depth interviews. Across the five cases these included six with social workers, three with service providers, two with partners, one with the person with dementia, and one with a chaplain. The format for these interviews was based on Mason’s (2002) ideas for planning qualitative interviews, where smaller research questions were developed from the overall research question. These focused on the process of interaction and negotiation, values, and tensions behind these negotiations and the impact of how dementia and capacity were understood. Seven documents from relevant hearings, correspondence, and government documents were analysed.

A thematic network analysis of the data from the interviews and documents using the framework suggested by Attride-Sterling (2001) was undertaken. This analysis firstly involved the extraction of basic themes; secondly organising themes where categories of basic themes were grouped together to summarise more abstract principles; and thirdly, generating a global theme that encapsulated the principle metaphors in the text as a whole. To organise the data, thematic networks or web-like maps were carried out. This allowed the concepts and interconnecting relationships to be explored by taking each network in turn and then moving material within an individual network, or across the network. NVivo 7 software was used to manage the data. The researcher kept a comprehensive journal documenting notes, which included observations, descriptions, and reflections. The study was approved by the Human Research Ethics Committee, Western Sydney Local Area Health District, and ratified by the Human Research Ethics Committee, University of Sydney.

Findings

The global theme was that of “power plays and contestations.” At the interface of decision-making encounters participants formed alliances that reflected underlying dynamics of power. Diverse and contested perspectives of capacity, risk, protection, and responsibility were evident. Relating this back to the primary research question, it may be argued that a key challenge in social work practice in sociolegal encounters is to recognise and unravel the power plays and deconstruct the contestations. This global theme emerged from three organising themes, which will be discussed with examples from the case studies.

How Professional and Private Contextual Influences Affected Decision-making Alliances

This organising theme revealed that participants’ individual contextual influences affected their decision-making. The participants in each encounter could be separated into two different categories or contexts: “professional” participants, who were social workers and service providers, and “private” participants, including the individual who was the focus of the encounter and their family members. Alliances that reflected underlying power dynamics were formed within these two contexts, for example, between professionals, or across the contexts, such as between a professional and a family member. A core dilemma for all participants was how to form alliances that supported their own decision-making. However, because professional expert knowledge dominated, and ultimately the geriatrician’s authority was accepted by all players, this alliance was the most powerful influence in the outcomes.

Graham’s encounter demonstrated the shifting alliances and underlying power dynamics. Here Social Worker G related the decision to submit an application for guardianship as an inpatient team decision. Initially, Service Provider G stated she was in a negative, powerless position in terms of influencing outcomes for Graham. She recounted that she had advocated for guardianship to Social Worker G and the hospital team over a period of several months. It was not until Graham burnt himself that an alliance was formed between Service Provider G, Social Worker G, and other hospital professionals. Until this event she felt her views were marginalised.

In contrast, Service Provider J’s views were supported by a geriatrician from a hospital team, which consequently put her in a stronger position when making an application to the Tribunal. These differences highlight the varying impact of the role service providers play in the interactions, negotiations, and the implications of these differing roles on the practice and responses of the social workers.

Edward’s encounter, in a community environment, also contrasted with Graham’s in that there appeared to be more room to challenge medical authority. Contrary to the geriatrician’s opinion that Edward was able to make his own decisions regarding financial affairs and lifestyle, Social Worker E opted to submit an application to the Tribunal. The dilemma for Social Worker E was that by deciding to form an alliance with other stakeholders in the private context, she would be implicitly providing legitimacy, through professional power, to the person with whom the alliance was formed.

The significance of how a family member was identified as “responsible” or not by professionals affected the dynamics of power in regard to which allegiances were formed. In Graham’s and Jane’s encounters, family members were perceived as not making responsible decisions and their views were marginalised by those in the professional context. However, in Maria’s encounter, her partner was seen as responsible and was identified as the main decision maker by both Social Worker M and Service Provider M. Social Worker M’s reasoning for forming an alliance with Maria’s partner and Service Provider M was pivotal to this assessment.

In contrast to professional participants, private participants had a unique social history with the person at the centre of the encounter, which had a significant impact in the process of decision-making. The efforts made by the person with dementia to sustain their sense of self was paramount in this context. For example, Graham actively tried to sustain his personal identity. He stated that “ … far as I understand it’s all lies, I don’t need a guardian to look after me and I don’t need one to look after my money, I’m very capable of it … so I am going to defend myself.”

Also in the private context, decisions were commonly made through shared understandings of personal experience and needs. For example, Graham’s wife identified her needs as interlocking with his. She said: “We’ve been married a long time now and you get used to each other and it’s very hard to have to say, ‘Well all of a sudden you’re married … but you can’t live together’”.

How Knowledge Bases Differed and Changed

This theme related to the meaning—constructed by the participants—of dementia and capacity, which supported the process of decision-making and shifted and changed throughout the encounters. The impact of critical events and consequent constructions of risk were crucial in these changing perceptions. Critical events were a commonality in the five encounters. For example, in Graham’s case, a burn precipitated the application to the Tribunal and this event was used to justify the decision and the resulting construction of Graham’s lack of capacity for self-care. Contrary to previous practice, when Graham was discharged home after several admissions over a short period of time, Social Worker G reasoned that Graham lacked the capacity to make a fully informed and reasonable decision about his place of residence and the risks he faced in returning home.

For Graham this presented a dilemma because to demonstrate “adequate awareness,” as stated in a specialist professional’s report to the Tribunal, he must accept the perception that a nursing home was the best option for him. This view of Graham was contrary to his own and was also contested by his wife, who did not perceive changes in his capacity to make decisions.

Another commonality in the five case studies was that to support their narratives regarding constructions of capacity, all the social worker participants used the Mini-Mental State Examination (MMSE) score (Folstein, Folstein, & McHugh, 1975), a well-known test intended to screen for cognitive impairment. In their reasoning the social workers appeared to accept the validity of this tool as it provided some certainty to support their arguments to substantiate lack of capacity, irrespective of the actual score.

In making risk assessments, social workers and service providers focused on physical behaviours, as opposed to emotional health. These physical behaviours, such as losing money, falls, and the lack of an adequate diet, were defined in terms of predictive risks. When the perceived predictive risks were high, the capacity of the person who was the focus of the research case study to make decisions became an issue and they were constructed as lacking in capacity to understand the consequences of these physical risks.

Individual professional participants demonstrated different and subjective constructions of risk and these were being continually redefined throughout the encounters. For example, for Social Worker A the risk factors encountered by Albert were acceptable and she made the decision not to lodge an application for guardianship. However, she related that the same social context was constructed as an unacceptable risk by both a neighbour and a service provider, who lobbied her to “do something” and threatened to withdraw the service. However, due to a fall Albert was admitted to hospital. Social Worker A then advocated to the hospital staff that he be discharged to a residential care facility as she argued that the risk of further physical injury was too high if he returned home.

Alternatively, for those situated in the private context, that is, the person with dementia and their family, risk was a contested issue as it was not perceived in the same manner as those situated in the professional context. A threat was viewed as a joint risk, as opposed to the professional context where the focus on was the individual with dementia. Going into a nursing home was viewed by them as a perilous risk, as opposed to professionals who viewed this as the best outcome. Risk was also constructed by those in the private context in terms of the loss of a partner, loss of a chosen way of life, and of self-esteem.

How Ethical Dilemmas Involved Balancing Rights and Responsibilities

This theme related to the ethical dimensions of decision-making. In the five case studies all participants balanced diverse professional and private responsibilities and the rights of the individual. The challenges faced by social workers involved varied ethical dilemmas centred on responsibility and protection.

The findings show that the responsibility to submit an application to the Tribunal had to be negotiated between the participants. There were no rules or guidelines for this process, which threw up conflicting tensions. This was most clearly revealed in Maria’s encounter, where lengthy negotiations meant that responsibility was passed around between her partner, Social Worker M, and Service Provider M. Because Maria’s partner was viewed as a responsible carer by both of these professionals, they encouraged him, with their support, to be the applicant. However, his ambivalence caused him stress as some days he would agree and others he would not. When his health deteriorated, Social Worker M and Service Provider M negotiated between themselves who would be responsible for the application.

Common in the case studies was that the social workers demonstrated ethical reasoning in balancing rights and responsibilities. Social Worker A commented:

It’s very hard because you’ve got the neighbour, who is an aged care physio, and you’ve got service providers, you’ve got the friends and they are all pressuring. The pressure was enormous and you think, well, am I doing the right thing? I just question myself constantly.

Another commonality involving ethical dilemmas was that participants saw the concept of protection as multilayered. At the surface level was the legal discourse on the need for protection: that the individual was unable to make decisions that took into account risky behaviour and consequently was at high risk of physical harm. This argument was difficult to refute by those who contested it, particularly when linked by professionals to the discourse of unacceptable risk. In the case studies, this was the dominant discourse during submissions to the Tribunal, promoted by the professionals. Albert’s encounter was the exception, where the social worker did not lodge an application. However, the decision to use this argument was based on more complex and diverse reasoning that included weighing up the additional issues outlined below.

Professionals also saw a need to protect themselves from blame. This discourse was given priority by Social Worker E, where the possible financial consequences of not acting to submit an application for guardianship was a driving force. She stated: “I am concerned about the children, that if she [the sister] takes control and has power of attorney, will the children get their fair inheritance?”

Alongside this layer of protection, professionals also wanted to act to protect the rights and interests of others, such as, in Maria’s encounter, a partner in ill health. Another layer of protection involved occupational health and safety issues described by service providers that gave rise to the need to protect direct care staff as well as provide safe physical conditions in the homes of service users. Lastly, at the personal level there was a need for the family carers to protect both themselves and the person who was the focus of the encounter in areas such as lifestyle change and in confronting changing abilities.

Discussion

The findings of this research are congruent with, and add new knowledge to, the literature regarding power dynamics and the formation of alliances and partnerships in decision-making (Adams, 2003; Adams & Clarke, 2001). The findings regarding contextual influences and inherent power dynamics can provide direction for social work practice in similar sociolegal encounters. Recognising these interactions means that effective social work practice can ensure all participants’ views on critical and contested issues are taken into account in decision-making, particularly voices that become marginalised. The findings from this study also support those of recent studies that attention must be given to the way in which “family” itself is understood and that decision-making is a dynamic process taking place within a relational context (O'Connor & Purves, 2009).

Further challenges highlighted by this study revolve around how to respond to critical events and how constructions of capacity can evolve at the interface of critical events. Also at this interface is the discourse of risk, where constructions of risk for older people can be based on the probability of a future event happening and a professional focus on ways to manage this. Ultimately, incapacity to make a decision in particular areas, such as where to live, is a legal determination by the Tribunal. However for social workers considering whether to become an applicant, supporting families or writing reports, it is crucial that there is reflection upon this interface. In judging an individual’s understanding of the consequences of particular actions different people value different outcomes. If a party involved in an encounter is arguing that the threshold of significant risk of harm has been crossed, and there are concerns about decision-making capacity, the questions to be asked are who is defining this, on what basis, and will the appointment of an alternative decision-maker solve the problem?

It has been argued that over recent decades the role of social work has changed from a service-orientated, relationship approach to one of assessment and case management with an emphasis on the management of older people (Biggs & Powell, 2001; Powell, 2006). Also, that the social work professional has become increasingly dependent on complex and often contradictory rules, regulations, procedures, and policies to be followed (Webb, 2006). However, alongside this are developments in social workers’ understanding and approach to ethical issues, which may be viewed as one of the most significant developments in the profession in the last 30 years (Banks, 2006). For example, the use of reasoning when values conflict in ethical dilemmas. The findings of this study show that an understanding of ethical developments, such as ethical decision-making occurring within the context of managing power relationships (Australian Association of Social Workers, 2010), are particularly relevant and may help to counteract the notion that there is little space for professional judgement and discretion in decision-making.

It must also be borne in mind that this research was carried out just prior to Australia’s aged care system undergoing substantial restructuring and, at the time of writing, the sector was in considerable flux. It remains to be seen how the implementation of these substantial structural changes will impact on social workers, other professionals, older people, and their families. The Australian Association of Social Workers (2013) has raised issues such as the development of a website and call centre, at the expense of establishing regional agencies, which are equipped with adequate resources to provide comprehensive information, needs assessment, and structures to ensure continuity in services. It may also be argued that self-directed packages and the higher costs of care will add to the complexity of decision-making in sociolegal encounters. Alternatively, some older people may fall through the gaps in service provision.

Philp (1979) argued that social work can present a picture that is not immediately visible to others and this is a traditional role that differentiates it from other professions. The major implications of the findings of this study for social work practice are that in a contemporary health and welfare context the profession is well placed to make an important contribution through its traditional roles of negotiation, interpretation, and mediation between those who have discursive rights and those who do not.

Acknowledgements

This article presents the findings of a PhD study. The author would like to acknowledge the invaluable guidance, support, and constructive feedback of her cosupervisors, Professor Barbara Fawcett and Dr Rosalie Pockett, University of Sydney.