Reconciling Paternalism and Empowerment in Clinical Practice: An Intersubjective Perspective

American social work has characteristically embraced at least two differing streams of practice. One has emphasized a paternalistic approach akin to the medical model. In these approaches, a client's right to self-determination may be superseded by what the social worker determines is in the client's best interest (Reamer, 1983). Thus, in these approaches, the worker is in an overtly superior hierarchical role to the client or patient and is viewed as the expert. The second model has originated from the "empowerment" approach. In this model, social workers view clients as possessing inherent strengths, resources, and knowledge, which the social worker, by dint of her or his authorized role, may be in a position to help foster (Simon, 1994). In empowerment approaches, the client or patient is viewed as the expert. Although there is considerable overlap between these two divergent streams of social work practice, they do, nonetheless, represent two distinct helping paradigms. The focus of this article is based on the assumption that the dichotomy between these two streams of social work practice is artificial and that social workers should, therefore, consider how best to integrate these approaches to support client development. An intersubjective perspective is considered for the ways it provides a basis for better understanding the importance of integrating a focus on both client strengths and client vulnerabilities. PATERNALISTIC MODEL The early model of social work embodied what may be conceptualized as an emphasis on a client's vulnerabilities, a type of environmental medical model. Indeed, Goldstein (1992) noted the distinction even in the root derivations of the words "pathology" and "strength." Pathology is derived from the early Greek concept of "pathos," which is associated with the elite and scholarly and is typically detached from worldly experience. However, "strength" is derived from an Anglo-Saxon root and depicts the natural world of the living. Within the paternalistic tradition, social work's origins may be found in the concept of "moral deficiency." In the late 1800s, the Charity Organization Society (COS) saw moral conversion as its unifying mission. "Poverty was attributed to drunkenness, intemperance, ignorance, and lack of moral will. Change was to come about not through provision of monetary assistance, but through persuasion and friendly influence" (Weick, Rapp, Sullivan, & Kirsthardt, 1989, p. 350). Consequently, social workers were labeled as "friendly visitors" within the COS, and the early focus of social work was on the frailty of human beings. With the advent of the social sciences and the empirical method, social workers sought to discover the causes of clients' problems. Focusing on a client's problems forged the development of a problem-solving, linear approach to practice. This shift toward a scientific basis to social work practice secured the worker in the position of superiority, as the worker defined the problem, identified its cause, and was positioned to either provide or withhold crucial resources to a needy client. The client assumed a dependent position in relationship to the worker. Later, the adaptation of social science methodology by social workers provided a so-called "neutral" standpoint from which to practice, in contrast to the religious/moral base that had preceded it, and offered social work a chance to standardize its methods and legitimize itself as a profession, and not just a calling. (The same issue was raised by former NASW executive director Josephine Nieves when she objected to Newsweek columnist Joe Klein's characterization of social work as a "calling" and not a profession ["Newsweek's Klein Called on Gaffe," 1996]). In its promise that virtually any problem could be solved if it were properly identified, social work sought to incorporate what Schon (1983) later termed "the myth of technical rationality" into its repertoire of helping skills. …