This and the following chapter together deal with the occupational status of personal assistance work. Personal assistance is generally considered to be a casual or non-professional job. This is in contrast to the traditional 'caring' or 'helping' professions, which tend to be relatively prestigious and characterised in popular perceptions by expertise and authority. As discussed in Chapter 2, part of the significance of direct employment model of personal assistance to disabled people is its transfer of authority from 'provider' to 'recipient' of
assistance. Therefore, it may seem inevitable that directly employed PAs have a 'low' occupational status as subservient to direct employers. However, there is no necessary correlation between this and the low pay and poor working conditions often experienced by PAs. Both PAs and direct employers in my interview sample felt that improvements in the pay and working conditions of PAs, and greater social recognition of their work, was possible and desirable. Therefore these two chapters critically investigate the reasons for PAs' low occupational status and suggest possible means to improve it without undermining the advantages of the direct employment model of personal assistance for disabled people.
Professions and professionalism
Within my interviews with PAs and direct employers, questions of occupational status were often discussed in terms of 'professionalism'. The terms
'professional' or 'professionalism' were used by 15 of my interviewees (8 PAs and 5 employers, as well as both of those who had been both) in relation to PA work, but with several significantly different (and sometimes contradictory) meanings. These disparate senses of the same word arguably correspond to different sociological understandings of professions and professionalism.
'Professional' and related terms can refer to a particular category of
norm associated with either paid work in general or work within those jobs considered to be 'professions'. Which occupations can or should be considered 'professions' is contested and there is not necessarily a consensus definition (though medical doctors and lawyers have often (Malin 2017; van Mook et al 2009a) been considered the archetypical professions); Adams (2010, p.66) claims that "it is unlikely that there is one set of traits that defines a profession across time and place" and Evetts (2013, p.781) argues that “sociologists have been unsuccessful in clarifying the differences between professions and other occupations and identifying what makes professions distinctive".
However, concepts which are frequently considered to be central to the
definition of professions include specialist knowledge (Dahle 2012; Malin 2017) and/or the requirement for specific formal education (Guldvik et al 2014; Witz 1992), autonomy (Freidson 2001; Witz 1992), authority or expertise (Illich 1977; van Mook et al 2009a), duty or responsibility (van Mook et al 2009b), public trust (Evetts 2013; Fournier 1999; van Mook et al 2009a) and confidentiality (Evetts 2013). Professions are generally taken to require specific knowledge and/or teachable skills, which justify their being 'closed' occupations, only allowed to be practised by those with the requisite formal qualifications;
establishing this closure is argued in some analyses to be an intentional part of 'professional projects' by occupational groups seeking professional status (Malin 2017; Witz 1992); however, Adams (2010) argues that the expansion of the ‘knowledge economy’ means that professions are becoming less distinct from other occupational groups in this respect. Malin (2017, p.8) additionally includes in a list of basic characteristics of professions that they are "interest groups... engaged in competition with each other and other groups in society, up to and including the state", that they are "concerned with providing services to people rather than producing inanimate goods" and that extensive training is required to achieve professional status, with the length of training positively correlating with the social status of professions.
Freidson (2001, p.12) argues that a profession comes into existence when "an organised occupation gains the power to determine who is qualified to perform a defined set of tasks, to prevent all others from performing that work, and to
control the criteria by which to evaluate performance". When this monopoly of expertise is established,
"neither individual buyers of labor in the market nor the managers of bureaucratic firms have the right to themselves choose workers to perform particular tasks or evaluate their work except within the limits specified by the occupation".
Professional workers are thus "free of control by those who employ them." Freidson thus describes professions as operating according to a 'third logic', neither that of the market and consumerism nor that of state control and bureaucracy. Members of professions are therefore distinguished from other workers both by the unusually high degree of autonomous control that they have over their work, and by the authority or expertise that they are considered to have in their 'professional field'. However, Witz (1992, p.59) argues that
"the autonomy of professional groups has been somewhat
overstated... professions have been crucially dependent upon state sponsorship. There is then a symbiotic relationship between
professions and the state."
Similarly, Evetts (2013) argues that historically the "acceptance of the authority of professional experts went together with the consolidation of the authority of states" (p.783). Professional authority is therefore not necessarily as distinct from state or bureaucratic authority as Freidson's 'third logic' framework would suggest, and, as Witz (1992) argues, it is necessary to locate professional projects "within the structural and historical parameters of patriarchal capitalism" (p.53). Professions and professionalism can thus be criticised from standpoints critical of capitalism, patriarchy and the state, including those of Marxism, anarchism, feminism and the Disabled People's Movement. Such critiques can be subdivided into those that consider professions and/or professionalism oppressive to 'professional' workers themselves and those that consider them oppressive to the recipients of 'professional' services.
Critiques of professionals from the perspective of those subjected to them
One of the most famous of the latter type of critiques is that made by Illich and co-authors in the book 'Disabling Professions' (1977). As part of a wider critique of capitalist and technological society, Illich argues that the paternalistic
dominance of professions, established through their claims to expert authority, is destructive to human creativity and liberty. Illich claims that "the professional has mutated into a crusading and commandeering philanthropist...
Professionals assert secret knowledge about human nature, knowledge which only they have the right to dispense" (p.19). McKnight (1977, p.83) in the same book argues that "professional distance" is a tool to maintain this monopoly of knowledge and authority:
"a basic definition of 'unprofessional conduct' is 'becoming involved with the client'. To be professional is to distance - to ensure that the relationship is defined in terms that allow the client to understand who is really being serviced. In spite of the democratic pretence, the disabling function of unilateral professional help is the hidden
assumption that 'You will be better because I, the professional, know better'."
Criticism of professional authority, particularly that of the medical and 'caring' professions (or as Finkelstein (1999a, b) describes them, the "professions allied to medicine" (PAMs)), has also been central to the Disabled People's
Movement. These critiques have often echoed those of Illich and his co-authors; for example, Wood (1991, p.200) says that "disabled people's lives are often dominated by professionals and services which de-skill us and turn us into passive recipients of care". Similarly, Davis (1993) refers to professionals such as occupational therapists and social workers as "professional disability
parasites" (p.199) whose "careful crafting of our [disabled people's]
dependence" (p.200) is responsible for disabled people's disempowerment and marginalisation. Davis criticises the language of 'professionals' and 'clients' as making the relationship between disabled people and service providers appear
voluntary when there is in fact no real choice and "they decide what we get" (p.198). Oliver (1999, p.378) directly contrasts the direct employment of PAs - which had recently been legalised by the 1996 Direct Payments Act - with "professional services" provided by local authorities, explicitly in terms of autonomy:
"When given this cash disabled people are using it almost exclusively to purchase our own personal assistance schemes rather than to buy professional services, seeing personal assistance as the key to ensuring autonomy and control in our lives."
These critiques from the DPM are not necessarily of the fundamental concepts of professions or professionalism, but focus on the specific professions with the power to affect the lives of disabled people; however, they fit well with, and arguably add depth to, the broader critique of professional authority from authors like Illich and McKnight (1977). Kelly and Chapman (2015) make an important further critique of the 'helping professions' when they argue that "the moral exaltation of professionals is tethered to the moral denigration of those who use services" (p.46). In this framework, the social status of professionals is dependent on a hierarchy in which they occupy a relative position of greater esteem than the recipients of their services. Therefore, while "[m]any practicing professionals understand themselves as allies to the communities they work with" (p.48), they are not necessarily 'good' allies from the viewpoint of those communities, and relationships between professionals and 'service users' can be seen as "paradoxical adversarial alliances" (p.47), in which professionals can simultaneously occupy the roles of needed and valued helper and of harmful adversary.
In all these critiques, professional authority is contrasted with the principle of subsidiarity (Gordon 2018) common to the DPM and many other ‘grass roots’ or 'bottom-up' activist movements, in which the people directly affected by
something (e.g. disabled people in the case of their assistance needs) are accepted as those who ‘know best’ about that issue and whose perspectives on it should be given priority (see Chapter 8 for further discussion of this). Kelly
and Chapman (2015), for example, contrast the common teaching given to professionals-in-training that "professional knowledge is objective and impartial and that they therefore know better than client groups" with "anti-oppressive scholarship" which "posits that marginalized groups know more about social injustice and their own day-to-day struggles and victories than groups with greater social power" (p.55). The activist scholarship of the DPM, including the theoretical frameworks of the social model and independent living, can thus be seen as an example of ‘situated knowledge’ (Haraway 1988) in counter-claim to the “second-hand knowledge about disability” (Davis 1993, p.200) used to give ‘professionals’ their authority.
Activist scholars in DS have thus called for a fundamental transformation in the relationship between disabled people and 'professionals', and arguably also in the nature of professions themselves. Werner (1995, p.23), for example, argues:
"it is time for non-disabled professionals to recognise the right of disabled persons to self control, and therefore to gracefully step to one side, into a role where they, as professionals, are no longer on top but rather on tap."
Similarly, Kelly and Chapman (2015) argue that it "make[s] strategic political sense for at least some activist and scholarly efforts to work toward changing the norms that govern professionalism" (p.59) and that those working in 'helping professions' must "work actively to form alliances, recognize our implication in adversarial structures and practices, and forge new and unique relationships with clients" (p.60).
Finkelstein (1999a, b) argues that the 'professions allied to medicine', such as social workers and occupational therapists, must be replaced by 'professions allied to the community' (PACs). Finkelstein claimed that the development of PACs was beginning to occur through disabled people's organisations, in particular CILs, which would "generate new services and service providers" and the workers in these would "constitute our own trade union" (1999a, p.23). The
development of a PAC could "[have] the potential to reintroduce innovation, initiative, excitement and personal reward in delivering the community based support that disabled people want" (1999b, p.3) - but, apart from asserting that workers in CILs are "an embryonic Profession Allied to the Community" (1999b, p.6), Finkelstein does not provide any detailed 'job descriptions' for these
proposed new professions. Some authors, such as Shakespeare et al (2018), have described PAs as a potential PAC; similarly, Kelly and Chapman (2015) argue that "informal attendants” (here meaning paid PAs recruited directly by a disabled person through informal networks) “approach the elusive status of political ally” for their employer, an activist in the Canadian independent living movement, in contrast to her more ‘adversarial’ relationship with professionally trained care workers.
Critiques of 'professionalism' as disciplinary discourse
Another critique of professionalism focuses not on how 'professionals' disable their 'clients', but on how ideological mechanisms of 'professionalism' may actually restrict rather than enhance the autonomy of 'professional' workers. Authors making this critique (e.g. Adams 2012; Evetts 2013; Fournier 1999) argue that the concept of 'professionalism' has been applied beyond the
traditional professions and become a normative value within many occupations that do not share the classically 'professional' characteristics (such as specialist knowledge, expertise and autonomous control of work); thus use of the term 'professional' with regard to a job does not in fact necessarily mean that the person doing that job holds 'professional power' on an individual level.
Fournier (1999) argues that the concept of professional competence is defined in terms of responsibility, duty and accountability to clients. This allows the creation of a 'disciplinary logic' in which, while individual professionals have more apparent autonomy than other classes of workers, and are not for
example under the direct command of a manager or supervisor, the condition of their autonomy is their adherence to the norms and duties of their profession. This disciplinary logic has been extended beyond the occupations traditionally considered to be 'professions', producing "norms and work ethics which govern
not simply productive behaviour but more fundamentally employees’ subjectivities" (p.293). Adams (2012) similarly argues that the concept of 'professionalism' is thus "a mimetic response – an attempt by individuals, occupations and organizations to replicate the social, moral and political power of established professions" (p.329). However, where occupations do not
possess that power, and in particular where workers do not have the individual choice and control over their work of traditional 'professionals', the discourse of 'professionalism' can be used by managers as a disciplinary regime for workers, which serves to normalise thought and action within 'acceptable' limits and enforce "neoliberal discourses of obedient, entrepreneurial workers" (p.336) by internalising them in workers' 'professional' identities.
Evetts (2013) draws a distinction between occupational groups which become professionalised 'from within' and 'from above'; while the discourse of
professionalism is one of "dedicated service and autonomous decision-making", which "makes professionalism attractive to aspiring occupational groups", when this is imposed from above (e.g. by managers and supervisors in fields like health and social care) it is "a false or selective discourse because autonomy and occupational control of the work are not included", and is thus "used to promote and facilitate occupational change (rationalization) and as a
disciplinary mechanism of autonomous subjects exercising appropriate
conduct" (p.786). Therefore, while a discourse of professionalism may improve an occupational group's perceived status, it may paradoxically result in less rather than more control by workers over their work.
There is a confluence here with Finkelstein's (1999b) argument that
'modernisation' of social services in the 1990s resulted in a 'de-skilling' process and a redefinition of 'professional' practice in that sector away from individual judgement and discretion on the part of 'professionals' (Finkelstein gives examples from his own experiences of interactions with an occupational therapist and a chiropodist) and towards acting as "rule-following technicians who rigidly follow a covert cost-cutting agenda" (p.2). Finkelstein therefore argues that, as well as disabling their clients, workers in the PAMs are
ability to control [their] own decision-making" (p.6), by the bureaucratic systems they are embedded in; therefore, for Finkelstein, 'social care' professionals do not follow Freidson's (2001) 'third logic' but have become subordinated both to the logic of bureaucracy and (implicitly, given that their 'modernisation' is driven by a "cost-cutting agenda") to that of the market.
Crossley (2017) argues that in the context of contemporary austerity politics, there has been a trend towards the creation of 'new professions' (for example ‘family workers’ or 'social work assistants' in the social work field), which are cheaper than their established equivalents (such as ‘traditional’ social workers). These ‘new professions’ can be seen as embodying the disciplinary discourse of professionalism described by Evetts (2013) as ‘professionalisation from above’, while lacking the autonomy and knowledge-based authority of more traditional professions whose professional status was achieved ‘from within’. While the latter professional groups, such as medical doctors, may retain more autonomy, the compromise with state authority necessary for the maintenance of their status means that their autonomy is never total and they are also not immune to discipline 'from above'; as Fournier (1999, p. 284) argues, "the enrolment of the professions in the network of liberal government is predicated upon the professions subjecting themselves to the liberal rationality of
government." It can thus be argued that even the traditional professions are undergoing a process of ‘de-professionalisation’ (Crossley 2017; Siebert et al 2018), which Siebert et al link to "an ideology of public sector managerialism" and "a political discourse emphasizing rationalism and standardization through accountability, transparency and constant evaluation against targets" (p.332).
It is therefore tempting to argue that the establishment of user-controlled personal assistance, in which the former authority of 'care' professionals over the lives of disabled people has been replaced by disabled people's authority as employers over PAs as employees, is a part of this neoliberal process,
particularly given that arguments involving the lower cost of user-controlled personal assistance, such as those made by Zarb and Nadash (1994), have been used to bring about its establishment (Pearson 2000). PAs can be compared to Crossley's ‘new professions’ in that both are lower-paid and
arguably less 'skilled' jobs, requiring less specialist knowledge and/or training than their predecessors (though opinions on this notably differed between PAs and employers in my research - see later in this chapter and Chapter 6).
However, an important distinction is that PAs are explicitly not intended to have the bureaucratic restrictions of the ‘new professions’, but in being directly accountable to disabled people themselves rather than to administrative hierarchies, the role of PAs is rather to enable the autonomy, and the decision- making ‘authority’ within their own day-to-day lives, of disabled people who would formerly have been disempowered ‘clients’ beholden to the arbitrary bureaucratic restrictions on service provision described by Finkelstein (1999b).
The use of 'professional(ism)' terminology by PAs and employers
The several ways in which the PAs and employers who I interviewed used the language of profession and professionalism reflected varying definitions and characteristics of professions. 'Professionalism' or simply 'being professional' were spoken about by both PAs and employers as a norm of 'correct' or 'appropriate' conduct for PAs, and thus connected to definitions of
professionalism emphasising accountability or duty (Evetts 2013; van Mook et al 2009b); for example Katherine (PA), when discussing the possibility of conflict between the interests of PAs and employers, said: "if as a PA you are
professional and you turn up when you're supposed to turn up and do what's asked of you, I don't think there's a problem". This usage accords with the claim by Malin (2017, pp.22-23) that:
"For many ordinary people the word ‘professional’... implies
competence, efficiency, altruism and integrity. Hence, the converse of this is the everyday notion of what it means to be ’unprofessional’ - to behave incompetently, inefficiently or unethically."
However, in this sense 'being professional' does not necessarily mean