Comments on the proposed changes for working with the cognitively impaired in Denmark

This post has been percolating for nearly half a year — about as long as the blog has been dormant. But now I rear my head from the depths of exam prep and… Amuse myself with more sociological pondering.

I’ve previously written about the fraught and nearly disassociative relationship concerning use of power in working with the cognitively impaired. In Denmark, the trend has (quite deliberately) been to actively and explicitly limit the ways in which disabled citizens can be coerced and manipulated against their will. The intent seems to be a distancing from the crimes of the not-so-distant past, where the ‘undesirables’ were subjected to all manner of horrifying abuse.

The Danish legislation governing, among other things, the care of citizens with cognitive disabilities, is ‘the Law of Social Service’. This fall, a broad political commission proposed new [legislation] [nyeregler] in this field.

The stated intent is to un-muddle the waters, as it were. Fix certain ambiguities, ensure carers are not committing crimes by doing the commonsense “right thing”, et cetera. The balance is shifted slightly toward ‘care’ versus ‘independence’ — in certain contexts,

The opening paragraph emphasizes the need for the rules governing this field to ensure, first and foremost, the rights of citizens. It goes on to voice the tension in also ensuring care, dignity and safety for a vulnerable demographic. A need to act counter to the independence of another, if necessary for the realization of the latter goal, should be explicitly allowed.

So far so good. There seems to be an acceptance of the fact that caring sometimes means acting on behalf of, or curtailing the actions of another. There is, however, some distancing still evident. This is to be a last resort, if ‘social-educative efforts’ have proven insufficient to persuade the citizen willingly. In other words, we only acknowledge that caregivers are put in a position of power over another when it is made explicit; the more subtle ways of control and manipulation are unvoiced and under-debated (outside the professional discourse at least).

The proposal refers to an audit performed in 2017 of practices vis-a-vis the rules. This audit revealed a) the standing legislation sometimes became a barrier to fulfilling the obligations of care; and b) this led to professional uncertainty as to when a certain intervention would be classified as care work and when it would be considered a breach of the principles of independence.

This is not a mere semantic distinction. Curtailing the independence of another requires formal reporting of the incident. The intent of this practice, as clearly brought out through both the audit and the proposal under discussion, is to allow for reflection over the incident. This so as to avoid such measures being necessary in the future, as well as creating a trail of documentation. However, my impression, from personal experience, is that the former is under-emphasized, with the latter perhaps being considered an invitation to blame, if not exactly an admission of wrongdoing. This leads to (sometimes severe) underreporting. This outcome is also reflected in the 2017 audit.

A discussion of (some of) the proposed updates

The proposal states two key shortcomings in the current rules:

1. There must currently exist a preexisting decision at the municipal level allowing an intrusion upon the right of self, thus preventing legally escorting a citizen in from the cold in mere underwear, for example.
2. The field of welfare technologies has outpaced the legislation. GPS tracking chips in citizens at risk of wandering, floor sensors in case of falls, et cetera. As it stands, these fall under a general ban of surveillance of common citizens, and are considered loosened somewhat for this demographic.

There are 16(!) proposed amendments in total. Some reiterate the points outlined above (all are to support care, dignity and well-being and/or prevent harm), but some warrant further discussion:

• The 3rd point seeks to allow ‘physical guidance’ of a citizen, for their sake or the sake of others in their environment. This is mostly an affirmation of general practices i believe; I certainly have had no compunctions placing a guiding hand on an arm or a shoulder. This is further supported by this not being considered a limitation of independence, and thus not requiring a formal report.

• Point 4 seeks to make explicit where on the twin axes of care versus neglect/self-determination versus control the professional carer should act. There are allowances made for physical restraint if deemed exceptionally necessary in situations of personal hygiene, without the need for permission from authorities. The caveat that such permission should be sought if the need for restraint is deemed to be recurring is couched in affirmations of practices again, a ‘mirroring of the needs in practice’. This despite the conservative phrasing; such permission can only be granted for the next 12 months, for instance.

• In points 5 and 6, the curtailing of independence is explicitly allowed, for instances of imminent harm or danger to the citizen, other citizens, or possessions and valuables. These however, are to be reported formally. Points 7, 8 and 14 discuss this professional duty further; the assisted living facilities have a responsibility to document plans to minimize , and actively utilize these reflexively in developing a workplace culture to that end. The municipalities and control instances likewise have a responsibility in following up on reports of intrusions upon the right to self.

  I refer to my previous paragraph in expressing a certain pessimism in regard to using reports of explicit force as tool for developing workplace culture. I do not see this reality as being impossible to realize; I am, however, somewhat dubious as to this being something that can be willed into existence politically. A cultural change as to the purpose and beneficiaries of such reports seems necessary first.

• Point 10 refers to a dilemma that has been voiced in Danish press as well as seen in my own professional experience. Permission can be given to lock doors or windows in a citizens private living area, if they are considered prone to wandering without grasp of consequences. One door must remain unlocked, however. This seems to be an attempt to address the reality of not being able to keep perfect watch at all times.

• The term welfare technologies is added in points 11-12, to allow for electronic monitoring of certain at-risk individuals. Emphasis is, again, on ensuring care, dignity and safety; with the overall intent of increasing quality-of-life and increased opportunities for expression of self.

  Perhaps alarmingly, a commission is to be formed to determine which (kinds of) welfare technologies are permissible. More bureaucracy never hurt anyone, right? Right?

• Apparently, there currently exists no need for the care facility to inform the citizens custodians et al. about interventions such as these. Point 16 seeks to remedy this, which I find hard to fault.

All in all, this proposal seeks to address specific shortcomings as to the intersections of commonsense interventions as part of the responsibilities of care and the right of any citizen to agency, self-determination and independence of will. Secondarily, there is an attempt to dislodge certain ambiguities as well as bring the legislation more in line with the realities of social care. So far, so mostly good.

Aside from my perceived need to re-frame the act of reporting infringements of power, this document also encapsulates the semi-professional status of professional caregivers (social educator is the closest translation available from the Danish socialpædagog). Professional autonomy is constantly under political impingement, which point 4 is a very explicit example of. Social care can be described, at least partially, as navigating that 4-cell matrix of neglect/care vs independence/abuse of power. On one hand, clear expectations and allowances are informative and supportive; on the other, there is the risk of losing professional justification and identity. Which probably is an idea for another post.