It was clear that NG was suffering from the traumatic after-effects of his fall, and that this had affected him massively on an emotional level. Physically, although his hip was painful and stiff, he should have been able to resume a moderately active life; instead, he appeared to choose to drift into sedentary habits and to refuse to leave the house. The diagnosis of depression was accepted, and it was noted that NG’s personal hygiene was starting to slip. Furthermore, the effect on his wife was clear, and she appeared frail and distracted now that she was having to put up with NG’s low mood and occasional outbursts of anger. It was clear that a task-centered approach was the best option.
TASK-CENTERED APPROACH
Task-centered work originated wholly within social work, from a famous series of studies by Reid and Shyne (1969), Reid and Epstein (1972a, b) and Reid (1985) (Payne, 2005:99). Moreover Reid (1992:12 in Payne, 2005:99) acknowledges the influence of crisis intervention – which originated from mental health and formulated by Caplan (1965 in Payne, 2005) – on the development of task-centered work (Payne, 2005).
As Neil Thompson notes, “this approach not only means that it’s easier to track a subject’s development, it also forces them to face up to the realities of the problems that they are facing” (Thompson, 2005, p. 85). This can sometimes be a problem: if the individual refuses to acknowledge the problem(s), they will also likely refuse to accept the need generated by the tasks that are set. As Thompson goes on to point out, “it’s often the case that one of the hardest initial roles involves persuading the subject of the importance of setting out and then following the list of tasks” (Thompson, 2005, p. 96).
However, once a task-centered approach has been decided upon, the collaborative nature of the task system can quickly improve the bond between the social worker and the subject. This bond is often tangible in terms of the benefits that it brings to the subject’s willingness to work towards the goals that have been set, and it’s been noted by a number of commentators that “if the social worker is forced to hand his or her role on to a colleague, the subject often gives up on the goals, since the tasks have become highly individualized and tailored to fit the specific relationship that has been established with the first social worker” (Trevithick, 2005, p. 7). It’s therefore important, where possible, to ensure a high degree of continuity in terms of the care provider.
Another advantage of the task-centered approach is that it is, by its nature, limited in terms of time, this means that goals are set with specific deadlines by which they are expected to be complete (Coulshed & Orme, 2006:156). Obviously these goals should be realistic, since no-one will benefit if the work is rushed, but it has nevertheless been shown in a number of studies that it’s very important to generate a feeling that the deadlines set for specific tasks are important and should not, if possible, be missed. As Juliette Oko notes, “deadlines allow for a feeling of steady progress… and of a cumulative improvement over a specified period of time” (Oko, 2008, p. 217). Marsh (2002) argues that the purpose of this practice is to move from agreed problems to agreed goals in a set period of time, however negotiation is needed to achieve and establish the agreement.
The task-centered approach is central to the General Social Care Council (GSSC)’s Code of Practice, which states that regular progress markers should be established in order to ensure that a subject’s treatment is moving in the right direction. The code also encourages social workers to look beyond their initial point of contact and to identify any related areas of concern; in terms of NG, this was particularly relevant because of the behaviour of his wife, who seemed to be suffering because of her husband’s new attitude. Ultimately, a task-centered approach encourages accountability of practice and ensures that social workers keep their clients moving in the right direction and retaining the essential markers of professional practice. Despite criticism that a task-centered approach encourages “a managerial and dogmatic approach that fails to take into account the individual needs of each subject” (Payne, 2005, p. 7), the approach remains at the forefront of social work theory.
INTERVENTION
In assessing NG’s needs, I first went through his file in order to better understand the facts surrounding his traumatic fall and hospital stay. The picture that emerged of NG was that of an active man who was enjoying his retirement (he worked as a secondary school teacher until taking early retirement at the age of 63) until the unfortunate accident that resulted in his fall. It was clear that the fall was in no way a result of his age, and that a similar accident and subsequent injury could have occurred to anyone, of any age. However, NG’s age clearly complicated his recovery, and left him prone to the pneumonia that almost killed him and that clearly took a heavy psychological toll. I consulted his GP, who advised me on the nature of NG’s apparent depression, and suggested that getting through to him on a verbal level might prove hard; he suggested that NG was faking a sudden loss of hearing in order to avoid having to acknowledge attempts to talk to him.
On meeting NG for the first time, it was immediately apparent how difficult it would be getting through to him. For the first hour of the first visit, NG barely acknowledged my presence, and communicated only once or twice with his wife, AG, and this communication was at best in the form of small grunts of acceptance or refusal. I sat with NG and AG for over an hour, engaging his wife in conversation and regularly attempting to engage NG and bring him into the casual conversation that we were having. This approach failed, and eventually AG and I decided that I should try to talk to him alone. Once AG was gone, I introduced myself more formally to NG and explained exactly who I was and what I was doing there. It was extremely difficult to engage with NG on any of the levels prescribed by Chris Trotter, who suggests that “all clients will eventually show some willingness to engage, and it’s up to the social worker to interpret what few signals there might be in order to understand how the client is sending signals relating to the way in which he or she is willing to engage” (Trotter, 2006, p. 17). In other words, Trotter believes that clients will send signals, sometimes very subtle, to indicate how he or she might be willing to engage. However, on this first visit to NG, no such signal was detected.
Since I had been forewarned by the GP and AG that NG might become angry if pushed too hard, I had already decided that it might be necessary to wait until my second visit to fully engage with him. Therefore, after half an hour of talking to him alone, I began to explain clearly and simply what my role was and how I was going to help him. Trotter argues that “by explaining such matters in clinical detail, it might seem scary to the patient, but it might also be encouraging for him or her to realise that there are strong formalized methods of dealing with the problem, and will stress the professionalism and education of the social worker” (Trotter, 2006, p. 37). I explained to NG exactly when I would be returning and what I planned to do, and then I left after briefly giving the same information to his wife, AG, in the kitchen, where NG couldn’t hear us. I also let her know that I was there for her as much as for her husband, and indicated that on my next visit I would seek to spend some time talking to her about how she was coping. She seemed pleased and encouraged by this idea.
On my second visit, I was surprised to find that NG acknowledged my presence in a manner that had been completely lacking before. It had been a week, and he was now willing to vocalize his concerns about the plan I’d explained; he said that he felt it was ‘too much effort’ and that there were other people who would benefit more from my time. I explained that I was there to help him and his wife, and that I would be able to help him return to a more active lifestyle. NG complained that this was pointless; however I was fairly quickly able to encourage him to leave his wheelchair and walk to the garden with me. Once out there, away from AG, I was able to get NG to tell me about the accident and his time in hospital, although he was noticeably reluctant to talk about his life before the accident. It was apparent that, since he and AG had no children, he considered AG to be the entirety of his support network, and that he was therefore reluctant to leave the house without her.
I was eventually able to persuade NG and AG to take a number of short trips out of the house, and it was apparent that these lightened NG’s mood. He was still insistent that AG should accompany us at all times, but was gradually willing and able to walk further distances. After three visits, AG told me that she and NG had settled into a habit of taking a short walk every morning to a local café. I encouraged NG to extend this to occasional trips to the shops, and he agreed that he would work towards accomplishing this task. We also set out a number of other aims, and agreed that when the summer season started he would return to the bowls club and rejoin his friends there. This gave NG both a short term and a long term goal and ensured that he would continue to work on the small, incremental steps that were necessary in order to encourage him to return to a semblance of his former, active life.
In dealing with NG and AG, my role was focused on restoring his confidence in his own ability to ‘get about’, and showing him that while AG was his support network, he could consider his friends at the bowls club as an additional part of that network. NG began to offer his own thoughts on this subject, and began to agree with me when I suggested that he didn’t need to take AG with him every time he went out. I felt that the long term goal of returning to the bowls club was particularly important, since it was apparent very early that he had given up hope of returning to this important social site; the idea that he might be able to return seemed to be a very strong motivating factor, and I credit this with persuading him to take the smaller steps such as going to the café and to the shops.
APPLICATION OF THE APPROACH TO THE CASE STUDY
The task-centered approach is based on a standardized framework that nevertheless allows for significant flexibility in terms of the ways in which the approach can be applied to individual patients. Doel and Marsh (1992 in Doel 2002) highlight that in task- centered work, the priority is to identify areas that the service user is finding a problem and wants change with the intention to get as many of the problems out in the open and in brief form, so that the range of difficulties can be seen.
Neil Thompson suggests that one of the most important aspects of the task-centered approach is the point of entry, i.e. the moment that the social worker first meets the patient, having read the relevant files (Thompson, 2005). As noted above, my initial meeting with NG was difficult, since he resolutely refused to communicate with either his wife or me. Once our relationship had improved over several weeks, I asked NG about this initial problem, and he claimed that it was because he didn’t know me and therefore preferred to ‘keep myself to myself’, and he also apologized for being rude. Obviously it’s unlikely that this simple explanation covers the entirety of the emotions that he was feeling at that time; nevertheless, his attempt to articulate his problems fits in, broadly, with Thompson’s suggestion that it is best for the social worker to try to enter into dialogue as soon as possible in relation to the various problems that are causing the communication problem (Thompson, 2005).
Payne (2005) highlights the use of planning the tasks which is agreed between the social worker and service user. The plan used on this occasion was for both the worker and service user to share tasks to meet the agreed outcomes. However, as a worker I had to acknowledge the power differences between myself and NG (Beckett and Maynard, 2005).
In the subsequent meeting that followed as the second stage of the task-centered approach, goals needed to be agreed (Trevithick, 2005). This enabled NG to establish the goals and not to dwell on the problems. This also helped NG to identify and see the difference between the goals and problems. For example, using the task-centered approach made it possible to identify that the goal was to go out and the problems were to overcome the barriers and risks in between (Coulshed & Orme, 2006). This second stage enabled us to draw up a written agreement, which we would work towards. The planning and implementing involved NG and myself to put the written agreement into action. Moreover it required us both to monitor the progress and ensure that the outcome will be achieved (Doel, 2002; Trevithick, 2005).
I therefore made sure that, on my second visit to see NG, I explained to both him and AG how I felt we should progress, and it was notable that when I arrived for my third visit, expecting to take NG for his first trip to the shops, he and AG had already taken it upon themselves to go for a ‘trial run’ to a local café the day before. This is a clear example of the benefits of using specific tasks to plan an order of progress, since AG admitted that part of the pleasure of the trip came from the fact that they knew they were ‘racing ahead’ in terms of my plans for NG. While such haste might in some cases be harmful, in this case it seemed to help NG enormously.
According to Payne (2005) this helps the service user to see the importance of the task and gives them a framework to follow. Furthermore, doing this ensured that NG does not feel that he is left alone in the process. Payne (1996) suggests that being able to set goals and motivate the service user enables the worker to empower them.
It was clear from an early stage that the task-centered approach would be the most appropriate for NG, since it would allow him to build up his confidence by passing a series of personal goals. Oko argues the case for such an approach, suggesting that “a series of small victories will help the individual work up to the ultimate goal, which is hitting the main target” (Oko, 2008, p. 95). This clearly worked in the case of NG. Furthermore, the process allowed his wife to take part in the recovery of NG’s lifestyle, and a number of commentators, including Thompson, have noted that “it’s important to involve the family so that the social worker and patient relationship doesn’t become an isolated partnership that places recovery solely within a clinical domain… (and) therefore lead to a situation in which the social worker becomes the sole support for the individual” (Thompson, 2005, p. 47); in the case of NG it is clear that AG became a central part of his recovery process, thereby avoiding the potentially tricky situation that would have developed had I become the sole source of this support. It is therefore possible to say that the application of theory was extremely positive in this case, although it’s perhaps also notable that NG’s recovery was a little quicker than might otherwise have been the case.
It should be noted that although a time limit was imposed on the point at which NG was to achieve each of the various stages, these limits were imposed for his own benefit rather than simply because Age Concern’s work required such a limit. Time limits have a crucial role to play in a task-centered approach, since they “enable measured steps to be taken towards a clear goal, in a clear way” (Doel, 2002, p. 74), thereby making the social work process seem less nebulous and more like a real plan with a defined set of actions. I also felt that there was a sense of urgency in this case, since NG and AG’s life had been under a great deal of strain and it appeared that AG, in particular, was suffering a marked deterioration in her health as a result of the problems with her husband. Although it’s impossible to accurately measure such things, I am of the opinion that AG may not have been able to cope with this stress in the long term, and I felt that there would be real questions over the couple’s ability to remain living alone in their own home if the situation was not resolved as soon as possible.
CONCLUSION
The recovery of NG from his post-hospital state was remarkable and effective. When he was released from hospital, NG was depressed and, those who previously knew him described him as, ‘a different man’. The effect on both NG and his wife AG was obvious, and it was clear that this was a situation that needed to be addressed. Furthermore, the belligerence with his neighbours was causing social problems that had the potential to grow into full feuds. It was clear at the start that the situation could only be improved by prompt and careful application of social work principles, mainly the task-centered approach, in order to improve NG and AG’s situation and return them from a position of apparent mutual depression. As Oko notes, “some situations are best saved early on, as later intervention is almost impossible” (Oko, 2008, p. 106); this was one of those situations.
The task-centered approach worked since it allowed steps to be laid out in a clear manner that was both clinical and easy to understand. Although NG was mostly unresponsive when I set these steps out to him on the first visit, he later clearly exhibited signs of having understood and processed them. Furthermore, the task-centered approach was easy for AG to understand, and it was particularly good to see the way in which this husband and wife team approached the steps together. As Malcolm Payne has suggested, “the ideal situation is one in which the social worker becomes the facilitator for the individual’s action, rather than having to try to force them along a route” (Payne, 2005, p. 85); this is exactly what happened in the case of NG and AG. As Payne goes on to note, the task-centered approach is not based on finding “an immediate solution… (but on) determining how best an individual might be able to get his or her life back on track over the short and medium terms” (Payne, 2005, p. 94). This is precisely what happened with NG and AG.
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