Journal of Community & Applied Social Psychology

J. Community Appl. Soc. Psychol., 15: 353367 (2005)

Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/casp.835

When Multi-problem Poor Individuals

Values Meet Practitioners Values!

LILIANA SOUSA* and CARLA EUSEBIO

Department of Health Sciences, University of Aveiro, Portugal

ABSTRACT

Every intervention process can be thought of as a journey of partnership between people, as well as
an intellectual journey of ideas and an emotional journey of relationships. This exploratory study
aims at reaching a better understanding of three questions: (i) What values do individual heads of
multi-problem poor households and practitioners show regarding their relationship? (ii) How might
those values inform the interaction between them, in positive and/or negative ways? (iii) What might
the value system which organizes the interaction between the participants be?
This study was carried out using a critical incidents technique and was based on a sample com-
prising two sub-groups: 100 heads of multi-problem poor families and 97 professionals. Findings
reveal the following individual values: heads of multi-problem poor families value instrumental sup-
port, relationships and effectiveness; while professionals appreciate relationships, obedience to
their own instructions and (in)effectiveness. These value systems seem to frame the interaction in
games of responsibility avoidance that lead to the individuals disempowerment, disguised in an aura
of adequate impotence. Copyright # 2005 John Wiley & Sons, Ltd.

Key words: values; practitioners; multi-problem poor families

INTRODUCTION

Biases in values and beliefs are pervasive in all aspects of practitionerclient interaction
and the question is not one of whether the practitioners values will confront those of the
family or individual but how (Aponte, 1985). This issue gains importance since both cli-
ents and practitioners enter the intervention process with pre-existing beliefs about what
relationships should be like, and what features make them satisfying and rewarding. Addi-
tionally these value complexes are then filtered in a variety of ways through each indivi-
dual and their relationships. So, the main task to be addressed is to understand what values

* Correspondence to: Liliana Sousa, Department of Health Sciences, University of Aveiro, 3810-193 Aveiro,
Portugal. E-mail: lilianax@cs.ua.pt
Contract/grant sponsor: FCT (Foundation for Science and Technology); contract/grant number: 39644/SOC/
2001.

Copyright # 2005 John Wiley & Sons, Ltd. Accepted 11 June 2005
354 L. Sousa and C. Eusebio

and beliefs practitioners and clients hold regarding their relationship, and how they might
inform the interaction between them in positive and/or negative ways. Consequently, a
better understanding of interaction patterns and the impact of those patterns on the inter-
vention process may be attained.
The values and beliefs practitioners and clients hold regarding their relationship assume
a particular importance when multi-problem poor families/individuals and practitioners
from social and health services interact, since this relationship is usually a long-term
one, involving several members of the family, professionals from different areas of exper-
tise (social workers, psychologists, doctors, . . . ) and from various public and private
health and social agencies.
Actually, multi-problem families are characterized by the presence of severe symptoms
affecting an indeterminate number of members. Nevertheless, the central attribute of
multi-problem families is disorganization, which is taken to an extreme. Many factors
contribute to that situation, the most common are chaotic hierarchy, the reduction of rules
to a minimum, which promotes acting out, repeated ruptures and reconstitutions of rela-
tionships, and predominantly negative patterns of verbal and nonverbal communication
(Kaplan, 1986; Linares, 1997). Incorrectly, multi-problem families have consistently been
connected to poverty and low socio-economic status. Actually low-income families con-
stitute a more visible group and an important core, but a family matching the definition can
be found in any social, cultural and economic context. In this context, multi-problem poor
families are usually multi-assisted, since the several problems they live attract intervention
from a wide range of social protection services. Although a lot of value research is done, it
is not easy to reach conclusions about what a value actually is. Schwartz and Bilsky (1987)
have come to the conclusion that most definitions have a number of similarities, namely:
concepts or beliefs; about desirable end states or behaviuors; that transcend specific
situations; guide selection or evaluation of behaviour and events; are ordered by relative
importance. The definition used by Rokeach (1973) is the most cited and satisfies most of
the above elements. It designates a value as an enduring belief that a specific mode of con-
duct or end-state of existence is personally or socially preferable to an opposite or con-
verse mode of conduct or end-state of existence. In short, it can be said that a value is a
special kind of preference. Even so the definition of a value in intervention processes
should assume a slightly different meaning than normal usage of the word. Normally a
value refers to a moral principle. In therapy it should mean the belief that a certain
way of thinking or behaving is better or more functional than another way of thinking
(Virkler, 2000).

VALUES AND BELIEFS IN THE INTERVENTION PROCESS

The power of mythological themes and values to influence peoples lives has captured the
interest of many therapists and theorists, especially in the field of family therapy (Papp &
Imber-Black, 1996). Examples include Ferreira (1963) who first coined the phrase family
myth to describe the focal point around which important family processes evolve. Reiss
(1981) used the term family paradigm in describing family perceptions about the world
outside the family and the familys place within that world. Watzlawick (1978) used the
expression world image and Boszormenyi-Nagy and Sparks (1973) used invisible loyal-
ties to describe the guiding mythologies that dominate peoples lives. Aponte (1985)
addresses the theme of negotiation values in therapy, emphasizing the force of the
Copyright # 2005 John Wiley & Sons, Ltd. J. Community Appl. Soc. Psychol., 15: 353367 (2005)
 Values in the intervention process 355

interaction between the values of the therapist and the family around the issues they are
dealing with. Pare (1996) wrote about meaning and family therapy, stressing that the previous
preoccupation with behavioural sequences and family structure is being replaced by an inter-
est in beliefs and stories embedded in language. Anthropologists and sociologists (such as
Bruner, 1986; Goffman, 1986) have written extensively on the impact of cultural myths
and societal values on the customs and current practices of individuals and societies.

Sources of beliefs and values

A persons values are drawn from family life, social networks, educational experiences,
and community and socio-political organizations. However, practitioners and clients have
specific sources of values.
Following Imber-Black (1988), practitioners common sources of values and beliefs
are: current theories that are passed off as a truth rather than a lens that makes certain
information available; prejudices about categories of families such as poor families or
racial minorities or prejudices about life-style preferences, kinds of family organization
or specific symptoms; reports by other professionals which are often written as a definitive
truth and are couched in static, categorical language and nearly always omit the interac-
tional or contextual dimension (individualistic labels abound); information shared at case
conferences, for example, focusing on family/individuals deficits and specific experi-
ences with a given family.
Multi-problem poor families/individuals values can also emerge from a wide range of
experiences, such as: former experiences with social or health agencies/professionals; cri-
tical incidents with helpers and with members of the family; socio-cultural backgrounds or
as part of an intergenerational legacy.

Professionals and individuals common values

Previous literature and research permits us to identify a set of beliefs and values com-
monly held by practitioners.
First, depending, in part, upon their expertise and theoretical affiliation, there is a value
held among many practitioners that their work is technical and/or scientific, in any case
free of moral and social value biases. This is not only untrue, but also impossible, since prac-
titioners attempting to ignore the role of values in their intervention create either of the two
negative situations (Bergin, 1991): (i) the client may interpret the practitioners noncommit-
tal moral stance as tacit approval; (ii) the practitioners value system inevitably emerges to
influence the questions, reactions and interpretations he/she chooses. It would be more
appropriate if practitioners were explicit about their values because, as argued by Bergin
(1985, p. 107), the more subtle our values, the more likely we are to be hidden persuaders.
Second, practitioners feel they have an obligation to provide clients with the best care
possible, so that clients may improve the quality of their lives. Often this belief is distorted
and misinterpreted as: the best care is what the practitioners decide.
Third, practitioners values emerge also in relation to the family/individual character-
istics. Low-income multi-problem families/individuals are more likely to suffer from
some degree of under-organization, requiring the practitioners assistance to encourage
further development and refinement of the structure of the relationships among the family
members and for the family within its social context. Therefore, the practitioner is more
likely to become involved with the family/individual in the application of value principles
to practical operations related to the formation of hierarchies and rules.
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356 L. Sousa and C. Eusebio

Fourthly, practitioners often believe that family/individual problems arise only from
family and/or individual circumstances, but research has shown that services for multi-
problem poor families usually contribute to the disorganization in these individuals/
families. Because services are often fragmented and uncoordinated, they are less effective
than they might be; and because interventions are focused on individuals and problems,
they do not tap the healing possibilities that reside within families and communities
(Minuchin, Colapinto, & Minuchin, 1998). A variety of dire effects, especially for
multi-problem poor families, have been documented, namely: fragmentation and decon-
textualization, which stigmatize patients and alienate them from their families (Elizur &
Minuchin, 1989); a weakening of family boundaries and cohesiveness, dilution of
the family process, and a greater dependency on larger systems (Colapinto, 1995;
Imber-Black, 1988) and disempowerment and repression (Boyd-Franklin, 1989).
It should also be mentioned that research and literature on the common beliefs and
values of multi-problem poor families/individuals are rather scarce. However, it has been
shown that families have different values from professionals and what they can expect
from them: some feel that the improvement of their lives depends to a great extent on
the professionals; others, owing to less gratifying prior experiences, give up seeking help
from formal services and finally, another group only resorts occasionally to the services,
and in very specific situations, e.g. unemployment (Matos & Sousa , 2004).

OBJECTIVES

In practice, without attending to the transactions over values between the professional and
the individual, the practitioner cannot gain mastery over this fundamental force shaping
the intervention process. Thus, this exploratory study aims at getting a better understand-
ing on three questions: (i) What values do individual heads of multi-problem poor house-
holds and practitioners reveal regarding their relationship? (ii) How might those values
inform their interaction, in positive and/or negative ways? (iii) What might the value sys-
tem which organizes the interaction among all participants be?

METHODS

The research design is based on the critical incidents technique (CIT), since critical inci-
dents may shape and affect all interactions not only between the protagonists, but also
when one of the protagonists enters a similar new interaction (Imber-Black, 1988). Exam-
ining critical incidents allows us to recapture the personal perspectives of meaningful
experiences, and so can help us to see a wide range of personal meanings, dynamics across
time and reflecting the interpersonal context in which they are expressed, thus revealing
some of values held by the narrator. But more distinctive than this is the metaphorical
property of the CIT, its capacity to conjure up and illuminate less accessible aspects of
experience.
More specifically, the CIT is a set of procedures for gathering and analysing reports of
incidents that involve certain important facts concerning behaviour in defined situations
(Flanagan, 1954, p. 335). Incidents typically include two features: a description of the key
player in the incident and the outcomes. A critical incident may be a commonplace, every-
day event or interaction; but it is critical, in that it stands for the one who lives it (Tripp,
Copyright # 2005 John Wiley & Sons, Ltd. J. Community Appl. Soc. Psychol., 15: 353367 (2005)
 Values in the intervention process 357

1993). Critical incident data are anecdotal, i.e. a story of how someone acted, responded
to, felt or thought about an event.
Data collection was carried out by five trained interviewers in two stages: first the
family members, and then the professionals. It was decided to start with the clients since
their opinion is often ignored or relegated to a secondary plane, and also because it was a
way of identifying the professionals with more impact on clients from their own point of
view. The interviews, all of which were taped and transcribed, were carried out at the
families homes and the professionals workplaces, during approximately 20 minutes.
They were introduced with the following invitation:
Wed like you to think about an episode you have lived involving (i) a professional [for heads of
households], (ii) a multi-problem poor family [for professionals], which remains strongly
recorded in your memory. Then, please describe the episode and specify whether you felt that
the episode was positive or negative!

Some professionals tended to relate not a critical incident, but to link a series of events, so
it was necessary to guide them towards the detailed description of an incident. With the
members of both sub-groups, it was necessary to ask for more detail about the incident
during the account: Where it took place? Who was present? What was the role of each
person? How the narrator felt?

Sample
The sample in this study consists of two sub-groups: heads of multi-problem poor families
and professionals. The family sub-group comprises 100 individuals (identified by social
workers as fulfilling those criteria), 72% of whom are female. The average age of respon-
dents is 48.1 years.
After the analysis of the incidents related by individuals, the professionals sample was
defined in order to match, in number and area of specialization, as mentioned by the pro-
fessionals. Therefore, 99 professionals were interviewed: 27 doctors from the NHS
(National Health System); 3 private doctors; 4 nurses; 36 social workers; 9 volunteers;
6 administrative staff; 7 local authority employees; 3 police officers; 4 teachers. In Portu-
gal, several services and professionals support multi-problem poor families, often simul-
taneously. In fact, the various areas of formal support are somewhat unarticulated, with the
result that intervention may be fragmentary. Families are in contact, often over long per-
iods of time, with diverse institutions and professionals.

Data analysis
The data analysis process was carried out in parallel and independently for each sub-
group. The process comprised two stages: the definition of value categories and the clas-
sification of incidents into the previously defined categories.
The initial moment of analysis aimed to define categories, the creation and testing of the
categorization system was an iterative process of successive refinement, involving two
independent coders. Each coder read all the incidents and developed a list of categories
and sub-categories. Both coders then met in order to compare and discuss both proposals,
until agreement was reached. Lastly, each coder randomly categorized 30 incidents in
order to confirm that the categorization system fitted the episodes. In this process, coders
also agreed on the incidents that should be removed because they did not report incidents,
or were somehow not related to the main research question. In a second moment, another
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358 L. Sousa and C. Eusebio

two coders independently categorized the incidents. The list of categories and sub-cate-
gories was given to them, together with a definition and criteria for assignment plus an
example of incidents that would fit the category. After each rater had independently ana-
lysed all the incidents, they met and registered their agreements as well as their disagree-
ments. The inter-judgment agreement (this score was reached by dividing the number of
agreements by the total number of agreements plus disagreements) was 81% for the indi-
viduals and 75% for the professionals sample; this reliability is quite high (Miles &
Huberman, 1984). Finally, the two coders discussed the incidents on which they disagreed,
and this discussion led in both cases to total agreement on all incidents.

RESULTS

Heads of multi-problem poor families values

The results of the categorization process lead to the identification of four categories of
values, each of them characterized by a positive and a negative components. Instrumental
support consists in the granting of financial support (subsidies or payment of everyday
expenditure) and support in goods (food or medicine). The heads of the multi-problem
poor families believe that the attribution or not of instrumental support is relevant. Con-
sidered positively, the instrumental support granted is taken to be satisfactory and
responds to the individual/family needs.
I was behind in my house payments, and the social worker paid it for me. It was a small help, but
it allowed me to keep my house so it was very important.

Considered negatively, the instrumental support is taken to be insufficient, not made avail-
able or unsatisfactory, or is felt to have been unfair in relative terms (another person/
family in a similar or better situation has received more support). Relationship is asso-
ciated with the way professionals establish the interaction with the individuals. Individuals
value empathic and emotional supportive involvement by professionals.
The doctor gave me a lot of support, helped me to have hope, not to give up!

In negative terms it means that professionals show aggressiveness, indifference and/or are
unfair when judging individuals intentions or behaviour. (In)effectiveness exists when
the action of professionals results in the resolution or not of the problem presented by the
individuals.
Ineffectiveness:
I went to the hospital, they prescribed drugs which I took and I was ill all the same. I had to go
back again and take a whole other load of medicine!

Waiting time is a more contextual category. At this level individuals reveal their appre-
ciation for being attended to in a short period of time after requesting help (e.g. a medical
consultation or a meeting with a social worker) and show their dissatisfaction when they
have to wait for a long time or the bureaucratic process is too slow and/or complex.
Long waiting time:
I went to the health centre at 6 in the morning, and got an appointment. I waited till midday and it
still wasnt my turn, I had to go home and get the children ready for school and I lost my
appointment!

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 Values in the intervention process 359

Table 1. Heads of multi-problem poor families values (%)

Categories Positive, % Negative, %
(117 incidents) (171 incidents)

1. Instrumental support
1.1. Satisfactory 32.5
1.2. Unsatisfactory/unfair 32.7
2. Relationship
2.1. Professionals show sympathy and 35.9
involvement/emotional support
2.2. Professionals are aggressive and/or indifferent; or 27
judge families behaviour and intentions unfairly
3. (In)effectiveness
3.1. Professionals effectiveness 29.9
3.2. Professionals ineffectiveness 19.3
4. (Long/short) waiting time
4.1. Short 1.7
4.2. Long; delay or slowness of bureaucratic processes 21

Afterwards each incident was labelled in one of the categories and considered positive
or negative according to the interviewers classification. From the 100 heads of household
interviewed, 90 reported 288 usable incidents: 117 (40.6%) related positive events and 171
(59.4%) recounted negative situations (Table 1). It is also worth noting that negative and
positive incidents tend to be opposites within the same category. Negative incidents occur
mainly in the sub-category unsatisfactory/unfair instrumental support, which is over-
scored (32.7%), when compared with the remaining categories. Positive incidents con-
verge into three major categories that represent 98.3% of the positively reported incidents:
relationship (35.9%), instrumental support (32.5%) and effectiveness (29.9%).
Some of the incidents (18564.2%) mentioned professionals or other agencies staff,
while others referred in general to social and health agencies (10335.8%). Incidents
referring to institutions show a higher incidence of negative episodes (70.9%) than those
referring to professionals/staff (53%), e.g. negative images seem to be powerful when
based on events not involving personal relationships. Nevertheless, negative incidents
have a higher percentage in both situations. Two groups of professionals represent 41%
of all incidents: social workers (23.3%) and doctors (17.7%) from the NHS (National
Health System).
Social work activities in Portugal are diffuse, and social workers can be found in a vari-
ety of environments. As well as individual casework, there are strong traditions of com-
munity work so it is common to observe social workers associated with projects tackling
housing, education and poverty problems. A wide range of organizations employs social
workers, for example: Regional Social Security Centers, Health Centers, hospitals, non-
profit private organizations. In this way, social workers constitute the professional group
with which most multi-problem poor families come into contact and in a variety of formal
support contexts. These groups were analysed in more detail (Table 2).
As for the NHS doctors, the Portuguese Health Service (NHS) follows the principle of
universal coverage, offering a global health package that includes primary health and hos-
pital care, nurses and a range of other diagnostic and therapeutic services. Primary health
care services are provided at Health Centres where each beneficiary must register with a
family doctor. When the family doctor deems that specialist treatment is required, the
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360 L. Sousa and C. Eusebio

Table 2. Families values about social workers, doctors and the NHS (%)
Categories Social workers Doctors (NHS)

Positive, % Negative, % Positive, % Negative, %

N 38 N 29 N 14 N 37

1. Instrumental support
1.1. Satisfactory 34.2
1.2. Unsatisfactory/unfair 48.3 12.7
2. Relationship
2.1. Professionals show sympathy 25.7 71.4
and involvement
2.2. Professionals are aggressive and/or 26.1 62.2
indifferent; or judge families behavior
and intentions unfairly
3. (In)Effectiveness
3.1. Professionals effectiveness 39.5 28.6
3.2. Professionals ineffectiveness 17.2 32.4
4. (Long/short) waiting time
4.1. Short 2.6
4.2. Long; delay or slowness of 10.3 9.6
bureaucratic processes

patient is referred to a specialist doctor for examination either at a public hospital, or by a

private doctor contracted to work for the NHS.
Social workers are the only group receiving more positive episodes than negative. Posi-
tive and negative events with these professionals have to do with relationship and instru-
mental support, while positive episodes are concerned also with effectiveness. Doctors
receive a higher percentage of negative episodes (72.5%). Their positive impact on
families seems to be linked to relationship (e.g. showing a kind behaviour, and giving
an adequate and sufficient information about health conditions and treatment) and to
effectiveness (diagnosis and prescription result in the improvement of the clients health
status); while negative incidents are associated with the same categories, but from the
opposite perspective, so relationship is characterized by hostility, lack of information
and coldness, and ineffectiveness is visible when treatment has not resulted in the
improvement of the status of the patients health.

Professionals values
The categorization process reveals four categories of values emerging from professionals
responses, each of them showing a positive and negative ingredient. Professionals per-
ception of family relationships refers to the judgements made by the professionals on the
subject of family interactions: as positive, professionals consider the families demonstra-
tion of caring and committed interaction, while as negative they classify families that are
negligent and/or abusive.
Families are caring and committed:
The woman, mother of eleven children, went often to school to find out how her children were
doing (the children were spread over several classes and schools). She took with her a notebook
where she took down the important things that were said in order to talk with her children at
home.

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 Values in the intervention process 361

Relationship emerges from the way individuals set up the interaction with professionals.
It is assessed as positive when clients show empathy and it is judged as negative when
clients are aggressive, manipulative and/or ungrateful.
Families are aggressive, manipulative and/or ungrateful:
I asked the families who received subsidies to give me the documents with the income of the
family unit. I analysed these and saw that some of the families no longer needed support since
their income had risen. I began to cut some of the subsidies. I sent letters to the families justifying
my decision. At the time, all the families came. They got together, caught me alone and began to
complain. I began to explain my reasons. They assaulted me verbally. I was protected by a desk,
but they almost attacked me physically.

Regarding (dis)obedience of professionals instructions, professionals appreciate

families that obey their instructions; since disobedience, from their point of view, will
result in unsuccessful outcomes.
Clients follow professionals instructions:
I have a patient who has many anxieties and fears. He telephones me twice between his monthly
consultations and says that talking to me helps him overcome his fear. I have tried to help him
overcome this anxiety, indicating that he should not phone between consultations. He did not
phone between the penultimate and ultimate appointments and when I saw him, he commented
that he had followed my indications and had managed to overcome the crises of fear without
needing to phone.

(In)effectiveness refers to the professional appreciation of the result of their intervention

strategies, for example whether they have resulted or not in family or individual improve-
ment or recovery.
Professionals perceive their effectiveness in helping families:
This is a case of two youngsters with mental problems. They belonged to a family of low socio-
economic status, marked by alcoholism and ill-treatment. When we integrated them in a residential
area, this constituted a turning point in their lives, regarding health, food, hygiene and affection.

Then each incident was categorized and considered positive or negative, according to the
respondents classification. From the 97 professionals interviewed, 95 reported 177 usable
incidents: 82 (46.3%) mentioned positive episodes and 95 (53.7%) negative events
(Table 3).

Table 3. Professionals values (%)

Categories Positive, % Negative, %
(82 incidents) (95 incidents)

1. Professionals perception of family relationship

1.1. Families are caring and committed 4.9
1.2. Families are negligent and/or abusive 14.7
2. Relationship
2.1. Families show empathy 37.8
2.2. Families are aggressive, manipulative and/or ungrateful 38.9
3. (Dis)obedience to professionals instructions
3.1. Clients follow professionals instructions 8.5
3.2. Clients do not follow professionals instructions 30.7
4. (In)effectiveness
4.1. Professionals perceive their effectiveness in helping families 48.8
4.2. Professionals perceive their ineffectiveness in helping families 15.9

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362 L. Sousa and C. Eusebio

Table 4. Doctors and social workers values about multi-problem poor families
Categories Social workers Doctors (NHS)

Positive, % Negative, % Positive, % Negative, %

(33 incidents) (42 incidents) (27 incidents) (20 incidents)

1. Professionals perception
of family relationship
1.1. Caring/involvement 7.4
1.2. Negligent/abusive 9.7 15
2. Relationship
2.1. Families show empathy 39.4 51.9
2.2. Families are aggressive, 30.2 45
manipulative and/or ungrateful
3. (Dis)obedience to professionals
instructions
3.1. Clients follow professionals 6.1 18.5
instructions
3.2. Clients do not follow 32.7 28
professionals instructions
4. (In) effectiveness
4.1. Professionals perceive their 54.5 22.2
effectiveness in helping families
4.2. Professionals perceive their 27.4 5
ineffectiveness in helping families

Positive incidents occur in two main categories: relationship and effectiveness;

negative incidents concentrate on relationship and disobedience of professionals
instructions (Table 3). Positive and negative ranking by category is parallel, the only
exception relates to the category (in)effectiveness, which as a positive category is ranked
first, and as a negative category is ranked in third place. Table 4 highlights results invol-
ving doctors (27) and social workers (36).
Social workers mentioned more negative episodes while doctors related more positive
incidents (Table 4). Curiously, families related more negative episodes involving doctors
and more positive episodes involving social workers (Table 2).
The sources of positive images, for both groups of professionals, came from the same
categories (relationship and (in)effectiveness), yet the order is different: the doctors
main source of positive episodes is relationship, while social workers highlight (in)ef-
fectiveness. The main sources of negative incidents for social workers areclients dis-
obedience of professionals instructions and professionals feelings of ineffectiveness in
problem solving; and for doctorsrelationship and clients disobedience of profes-
sionals instructions.

DISCUSSION

First we will consider the question: What do the interviewees responses tell us about their
values regarding their relationship? (Figure 1).
Professionals and heads of multi-problem families share a value both from negative and
positive perspectives: relationship. This value is emphasized in complementary views:
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 Values in the intervention process 363

Positive Negative
Individuals Professionals Instrumental support Relationship
Relationship Instrumental support
Effectiveness
Professionals Individuals
Relationship Relationship
Effectiveness Disobedience of professionals instructions

Figure 1. Individuals values regarding relationships with practitioners.

Note: Only categories representing 25% or more of positive and negative critical incidents were
used.

individuals value the way professionals relate to them, while professionals appreciate the
type of involvement families develop with them. Emphasis is placed on the way the inter-
action is established by the other party, so participants believe that the relationship
becomes positive or negative depending on the way the other party engages in the inter-
action and overlooks their own role in the development of the interaction.
Another shared value is effectiveness, but only as a positive ingredient. Both parties
perceive effectiveness as depending mostly on the competence of professionals. A value
common to families and professionals emerges: professionals are the experts and are
therefore responsible for the effectiveness of intervention.
On the other hand, it is also possible to identify unshared values, namely: from the per-
spective of the heads of multi-problem poor families, instrumental support arises both as
positive and negative; while (dis)obedience of professionals instructions emerges only
from the professionals point of view, and mainly from a negative angle. Thus individuals
from multi-problem poor families expect to receive instrumental support from profes-
sionals, which is not emphasized by professionals. And, professionals think individuals
should obey their instructions, because doing so, they will achieve better results, but this
is not a priority for individuals.
The values differ, although only slightly, according to the professional involved
(Figure 2). The data disclose that the individuals appreciate, both in social workers and
doctors, the categories: relationship and effectiveness. Nevertheless they believe social
workers should provide instrumental support, which is not expected from doctors. This
is quite understandable since social workers can, at least in the Portuguese context, decide
on the attribution of subsidies, whether in goods or money, to the families. On the profes-
sionals side, the situation is similarboth doctors and social workers value positively the
categories: relationship and effectiveness; both assess negatively the categories: relation-
ship and disobedience to given instructions, and only social workers highlight the category
ineffectiveness.
The second question to be considered is: How might those values inform the interaction
between multi-problem poor individuals and professionals in positive and/or negative
ways?
It seems important to note that both individuals and professionals have mentioned
slightly more negative than positive events. Shamai and Sharlin (1996) consider that
the negative attitudes that professionals develop while working with challenging clients
and the negative attitudes individuals develop towards demanding professionals can lead
to a coalition of despair.
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364 L. Sousa and C. Eusebio

Positive Negative
Instrumental support Relationship
Social workers Relationship Instrumental support
Effectiveness
Individuals
Relationship Relationship
Doctors Effectiveness Ineffectiveness

Positive Negative

Social Individuals Relationship Ineffectiveness

workers Effectiveness Relationship
Disobedience of professionals instructions

Doctors Individuals Relationship Relationship

Effectiveness Disobedience of professionals instructions

Figure 2. Values involving individuals-doctors and individuals-social workers.

Note: Only categories representing 25% or more of positive and negative critical incidents were
used.

The values related to (in)effectiveness and (dis)obedience of professionals instructions,

permit the identification of some habitual interaction patterns: professionals assume the
power to prescribe change and expect clients to follow the stipulated orders strictly; clients
assume that effectiveness, as well as ineffectiveness, depends on professionals; profes-
sionals assume that effectiveness depends on their own competence, but believe ineffec-
tiveness to be the result of clients disobeying their instructions.
Simultaneously, a conflicting value emerges: from the clients perspective, ineffective-
ness is the professionals failure and from the professionals point of view, it is the indi-
viduals failure. While the clients perspective is coherent, the professionals perspective
seems paradoxical: on the one hand, they want control over the intervention, and on the
other hand, they tend to blame clients for its failure.
(In)sufficient instrumental support is significant for multi-problem poor individuals,
being both positively and negatively construed, but it is not valued by professionals. This
value is linked to the following interaction pattern: clients demand instrumental support
from professionals, while professionals want individuals to change other aspects of their
life; different expectations are not discussed or negotiated, consequently each participant
believes goals are clear. Conflicts can easily arise because clients feel professionals are not
interested in their problems, while professionals believe clients just want to live off the
welfare-society.
From the perspective of individuals, two groups of professionals (social workers and
doctors) emerge as having more impact. Relationships between clients and doctors are
usually distant; doctors (more than social workers) are socially and culturally invested
with power, so it is not surprising that, in interaction with multi-problem poor individuals,
both actors feel that doctors have power over clients. In this case, the people who have
power over others assume they can conceal information and instructions; those with little
power are intimidated into silence. Social workers are usually not so hidden behind a mask
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 Values in the intervention process 365

of superiority, probably because they maintain a more regular and often informal contact
with individuals.
Finally the third question to be discussed is: What might be the belief system that orga-
nizes the interaction between the participants?
The belief system that organizes the interaction seems to be characterized by blaming
others instead of oneself. Some individual values emerging from the data, along with
their potential interaction, support this belief system. First, both participants consider that
relationships will be positive or negative depending on the involvement of others. This
circumstance is likely to promote a rigid relationship, because whatever happens, each
participant is not going to think about what he/she can do or even assume a negotiation
posture. Second, the individuals from multi-problem poor families place the professionals
in the position of experts (effectiveness as a result of professionals actions), while pro-
fessionals also place themselves in the position of specialists, but only up to the point
where they prescribe or instruct the clients. After this moment everything depends on
the clients desire or choice to follow what was stipulated. Third, instrumental support,
specially coming from social workers, is more valued by the heads of multi-problem poor
individuals, than by professionals. Consequently, clients might blame helpers if they do
not grant this kind of support.
This game blaming others, particularly when relationships or interventions run a nega-
tive course, permits both participants to assume a position of adequate impotence. The
feeling of impotence exists because each party feels unable to promote good relationships
or effectiveness; furthermore, it is adequate because each party blames the other for those
outcomes, feeling that the improvement of relationships and/or effectiveness does not
depend on themselves. So adequate impotence can be depicted through the dissatisfac-
tion of both participants with the outcomes, but neither of them believe they have any
responsibility and attribute the responsibility to the other party.
At the same time, professionals place themselves and are placed by the individuals in
the role of parenting (taking care of the individuals). Consequently, the belief system
seems to overshadow the interaction with a sense of sterility since in any case it results
in the individuals disempowerment: (i) if the intervention carried out by the professionals
turns out to be effective, individuals feel that professional support is the answer, while
professionals feel the response to individuals problems is in their hands, (ii) if the inter-
vention turns out to be ineffective, professionals believe clients are unable to do any better,
while clients feel that the professionals have failed.
So the belief system might be framing the interactions in values of conflict or emptiness.
Emptiness arises when each participant tends to wait for the others to act: the professional
waits for the individual to follow their instructions; and the individual waits for a solution
coming from the professional. In this case, apathy will be the main characteristic of the
interaction. Conflicts will emerge when one or both of the participants tries to tell the other
to do something, and the other feels that is not their job. Conflicts often lead to referrals to
other professionals or agencies, and dropouts. In these belief systems, themes like coop-
eration, negotiation and empowerment of the individuals are absent. This probably means
that clients and professionals adopt a linear lens to give meaning to interactions, even
when circularity is a relevant element of professionals theoretical discourse. Actually,
in the major theories of family intervention, much more attention is paid to what the thera-
pist does to the clients to promote change than to what the client does. Not much is
known about effective therapy from the clients perspective and about what professionals
expect family members to do.
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366 L. Sousa and C. Eusebio

CONCLUSION

By identifying central themes that operate in the intervention process, practitioners are
able to develop effective interview questions and design useful interventions. In this
exploratory study, critical incidents descriptions were used to frame overarching beliefs
and values aiming at a better understanding of how the beliefs of heads of multi-problem
poor families and professionals may be interacting and organizing a belief system that
informs their interactions.
In making the beliefs and values explicit, practitioners can introduce a new code for
reading troublesome aspects of their relationship with clients and offer new possibilities
for changing them. By identifying the overarching themes that operate at the interaction
level, practitioners might generate a new frame for viewing problems that span many dif-
ferent levels of experience. Such connections enable clients and practitioner to gain new
perspectives on old problems (Papp & Imber-Black, 1996).
The results of our study indicate that the belief system is not characterized by compro-
mise, negotiation, individuals empowerment or collaboration. Instead, it may be marked
by expert influence and responsibility avoidance. Consequently, this belief system tends
towards the disempowerment of clients and the feeling of adequate impotence from both
participants.
The main limitations of this study concern the sample. Heads of multi-problem poor
families were identified by social workers, which might constitute a bias in the results;
the only criteria for individuals to be included was to be the head of a multi-problem poor
family, and little is known about factors such as history and reasons for being involved
with professionals. On the other hand, professionals were included in the sample because
they stated that they had worked with multi-problem poor families/individuals, but little
else is known about their role.
Finally, future studies should consider: identification of myths among professionals,
since it is known that many misunderstandings arise when different professionals are
working with the same family, and also because professionals have myths and stereotypes
regarding different areas of expertise; study of the way in which myths between families
and professionals are related to the evolving process of change and treatment success,
since there is a general scarcity of data concerning the link between interaction and inter-
vention success.

ACKNOWLEDGEMENTS

The authors would like to thank Claudia Ribeiro, Daniela Figueiredo, Susana Pires and
Margarida Cerqueira, for their participation in the data collection and data analysis. This
study was funded by the FCT (Foundation for Science and Technology) Project No.
39644/SOC/2001.

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