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Social and Caring Professions in European Welfare StatesPolicies, Services and Professional Practices$

Björn Blom, Lars Evertsson, and Marek Perlinski

Print publication date: 2017

Print ISBN-13: 9781447327196

Published to Policy Press Scholarship Online: September 2017

DOI: 10.1332/policypress/9781447327196.001.0001

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On the unnoticed aspects of professional practice

On the unnoticed aspects of professional practice

Chapter:
(p.193) Thirteen On the unnoticed aspects of professional practice
Source:
Social and Caring Professions in European Welfare States
Author(s):

Rasmus Antoft

Kjeld Høgsbro

Maria Appel Nissen

Søren Peter Olesen

Publisher:
Policy Press
DOI:10.1332/policypress/9781447327196.003.0013

Abstract and Keywords

The chapter focuses on some mostly unnoticed, but crucial, aspects of professional practice among welfare professions. One such aspect comprises of the informal and strategic forms of negotiations occurring within professional practice and how they relate to various forms of complexity. The text illustrates informal and strategic negotiations by using examples from empirical research on different groups of service users (e.g. people with dementia, unemployed, families with complex problems). A central assertion is that knowledge about such negotiations is vital in terms of understanding how professional practice is actually conducted and works. Such knowledge can enhance professional creativity, confidence and capability to act.

Keywords:   professional practice, service users, welfare professions, confidence, capability, professional creativity

Introduction

In the policy for implementation of the Social Investment Package of the European Commission 2013-14, European welfare states were encouraged to invest in welfare and to reform welfare states. It was emphasised how they should ‘streamline governance and reporting’ with a focus on ‘monitoring financial, economic and social outcomes’, and ‘building evidence based knowledge and policy’ (European Commission, 2013). Denmark seems to comply with these discourses of governance. Currently, the prevailing ideas of governing and reforming welfare services are focused on so-called evidence-based research (EBR), policy and practice (EBP) (Hansen and Rieper, 2010; Høgsbro, 2010). For example, the National Board of Social Services promotes a combination of evidence-based methods, systematic knowledge production, and cost-benefit and cost-effectiveness analysis to be implemented in practice (Nissen, 2015). In Denmark, there has not yet been a comprehensive and coherent research programme exploring the consequences of this form of governance. Albeit it is assumed that EBR and EBP will improve welfare services, there is currently no evidence that it will in fact enhance quality and accountability in professional practice. On the contrary, a major critique of EBR and EBP is that the inevitable contextual conditions of welfare services and the complexities of professional practices are ignored (Pawson, 2006).

Professional practice is dependent on the capacity to perform professional discretion in complex contexts and situations dealing with ambiguous problems, which do not prescribe a certain solution. Within this realm it becomes extremely important that professionals have the capability to act with constant care. This capacity to deal with what is not evident is often considered a constitutive element (p.194) of professional practice (Grimen, 2008). If this inherent ambiguity of professional practice goes unnoticed, there is a risk that efforts to streamline performance will be counterproductive, because it would not facilitate, and in worst case would undermine, professional discretion. Accordingly, the aim of this chapter is to make visible some important aspects of professional practice that go unnoticed in the realm of EBR and EBP. We show how professional practice is far from streamlined due to contextual and situational complexities – and how in particular negotiation in ‘fuzzy’ realities, reflection on risks and cooperation despite controversies are crucial in terms of handling these ambiguities. We do that progressively throughout the chapter, providing an analysis of cases, each and together illustrating this point. The cases derive from a collection of Danish qualitative research projects, each concerned with professional practice. At the end of the chapter, we discuss the implications of the analysis for research and professional development.

Negotiation in ‘fuzzy’ realities

The concept of negotiations is a metaphor for what takes place in interactions between actors in a specific social setting (Levin and Trost, 2005). According to Anselm Strauss, whenever or wherever professionals interact to organise professional work practices and shared tasks, negotiations occur. Negotiations often occur when rules and policies for practice are not inclusive, when there are disagreements between professionals, when there is uncertainty and when change is introduced (Strauss, 1978). When social order – the shared agreements, the binding contracts that constitute the grounds for an expected, non-surprising, taken-for-granted, even ruled orderliness of everyday practice – is disturbed, parties will attempt to create a negotiated order enabling shared work tasks to be solved. These negotiations unfold in arenas of work practice contextualised in specific organisational and interprofessional settings, and they often function as unnoticed practices of day-to day routines of organising professional work. Andrew Abbott defines such social arenas as ‘fuzzy’ realities in which a number of issues are at stake for the involved professionals (Abbott, 1988). In such settings, professional boundaries are crossed and become fluid, compromises are made, and negotiations on the right theories and methods for problem solving unfold. The following example is an illustration of this.

(p.195) An informal and strategic endeavour

The following example of negotiations in a fuzzy reality derives from a field study on power and negotiations in interprofessional relations (Antoft, 2005).1 The study focused on the micro processes of diagnostic work on people with symptoms of dementia. By analysing interactions between municipality dementia nurses, general practitioners, hospital nurses and doctors in the arenas of shared diagnostic work, the study showed that processes of negotiation were not just about getting the work done, but also about setting the boundaries for gaining control of or giving up professional (‘dirty’) work. Dirty work refers to tasks that are viewed as physically, socially or morally tainted (Hughes, 1971), and as a consequence are less attractive to the professional’s aspiration for professional status and identity. The following case exemplifies how dementia nurses and GPs interact and strategically negotiate how diagnostic work should be done.

The scene for this case is the investigation of an elderly woman of 89 years, who is suspected to be suffering from dementia. The patient is struggling with other diseases, including depression and possible colon cancer. The starting point of the diagnostic work is the Aalborg Municipality dementia assessment model and its formal guidelines for diagnostic tools and division of labour between dementia nurses and GPs. Yet there is no agreement between the parties as to the right time to stop the diagnostic process, and be satisfied with the investigation result. Following the dementia assessment model, the GP makes an initial diagnosis of the elderly woman’s condition and contacts the dementia nurse to initiate cooperation on investigation of dementia symptoms. After examination and diagnosis of the patient’s symptoms, the GP decides that it is not appropriate to send the patient on to a CT scan and further diagnostic work in the secondary sector. A CT scan and an examination by a specialist doctor at a hospital are the preconditions to medical treatment for dementia. The GP explains that he is aware of his power base, a position that allows him to dictate certain actions. But he stresses that the diagnostic process does not stop just because the GP can. It is based on a professional and personal assessment of what is in the patient’s interest. Again, arguments relating to the patient’s age and other potential diseases appear. But the GP’s actions and decisions are not negotiable. When he decides that the diagnostic process should stop, his decision is non-negotiable. However, the nurse suggests what the GP should do in this particular case; the patient pathway should be completed with a referral to the secondary sector. Although the nurse is critical towards the GP’s reasoning for not continuing the investigative work, she is still satisfied with the results of the work carried out. The doctor makes a written diagnosis that can be taken as a legitimate basis for (p.196) a special follow-up with health and social care initiatives in the municipality. The dementia nurse withdraws from the conversation with the GP without further confrontation. She does not try to convince or persuade the GP to continue the assessment project. It is accepted that it is the doctor’s decision and that he sets the premise for collaborative work and potential negotiations in this specific patient pathway.

Negotiating processes takes different forms. In this specific case, the GP sets the agenda for the shared diagnostic work and obtains a non-bargaining position, where the nurse’s role is defined by the GP’s position in the professional hierarchy and his ability to set the agenda. The GP’s knowledge of the patient’s multiple diseases and everyday life situations becomes decisive. But the nurse’s strategy changes during the process. As the GP stops the patient pathway, even though the nurse disagrees with the decision, she withdraws from the negotiating arena, since the diagnostic work being done will enable future work with the patient within the municipality.

However, the nurse’s narrative entails another interesting strategy for pursuing the agenda of the municipality and her profession. In other cases, where the GP for multiple reasons does not wish to engage in collaborative work on diagnosing patients with symptoms of dementia, the municipality has adopted a practice whereby dementia nurses are given the authority to make a preliminary diagnosis based on their specialist knowledge and tools for assessing symptoms of dementia. As a consequence, the diagnostic work becomes a cross-boundary activity in which the formal division of labour between doctors and nurses becomes fuzzy. In cases of dementia, this practice was often accepted by the GP, since this type of psychiatric diagnosis and work with demented people was considered dirty work. There is no treatment for the disease, only for the symptoms, and dealing with the patients and their families was time-consuming and considered by some GPS to be a nuisance, and, as a consequence, dirty work.

The example here illustrates how professional practices are characterised by informal negotiating processes and strategic action, and that the outcome of these processes depends both on position in the division of labour – the shadow of hierarchy – and on the professional knowledge and judgement applied in the diagnostic process. The result of such processes is not necessarily agreement on the right model for problem solving, and a logically rational connection between goals and actions might not exist (see, for example, Svensson, 1996; Allen, 1997). This becomes even clearer in the following case.

(p.197) A conversational, linguistic and dynamic process

The next example further emphasises the informal negotiated character of professional decision making by addressing the details of language use in institutional practice. The excerpt derives from a meeting concerning the residual working capability of a client, who has worked for 17 years as laboratory technician, which has led to constant pains in her neck, shoulder and arms.2 It is taken from a study of employment-oriented social work, demonstrating interprofessional interaction at a Danish jobcentre.3 The professionals – two caseworkers and a medical consultant – use different types of knowledge, discussing the future of a client, who has been declared to have no remaining working ability. They are drawing on common sense and caseworker experience as well as knowledge from the social and medical sciences in delicate negotiations, thus displaying competing versions of the client’s situation. They even try to present themselves as accountable (Eskelinen et al, 2008), and, having reached a conclusion, join in a rationalisation of the decision made. Both the colleague and the medical consultant agree with the conclusion drawn by the caseworker in charge based on statements made by the rehabilitation centre concerning the clients working capability. But although they agree with the conclusion they do not relinquish their position or arguments entirely, but add ‘accounts’ – explanations, justifications and excuses (see also Scott and Lyman, 1968) – for their consent, for example by referring to consequences, and the lack of lenient jobs available and alternatives in general. This means that decisions are not obtained as a rational choice between alternatives. Rather, it seems as if decisions are constructed as inevitable conclusions that need to be explained afterwards. Furthermore, processes rather than decisions as such become visible when looking into the ‘black box’ of professional practice (Boden, 1994). (p.198)

25:30

SA1

“… but if the damage has occurred in her shoulder and arms …”

25:33

SA2

“Well, I can see that, but how is she managing at home then, I think. … I don’t believe that she doesn’t do anything at all <no>, that she is sitting in a chair <no> with armrests, and then she is just sitting there …”

25:46

SA1

“I don’t believe that either, because that’s not the way she is. She is actually more like …”

25:50

SA2

“I, I can’t understand, if she is not capable of managing something alternating … I can’t understand that <no>.”

26:10

LK

“Well, these people, who are very perfectionistic and put big demands on themselves, they have really problems when they get a health problem, because then they don’t feel – they are just like ‘on-off’ or ‘either-or’ <yes, yes>, so, if they can’t deliver 100%, then it’s no good <no> …”

26:27

SA2

“No, but still …”

26:29

LK

“And if you work a little with this experience related to performing a piece of work, then it might be, you might move some way, but it needs to be done that piece of work.”

26:38

SA1

“Yes, that’s just what the rehabilitation cen … <yes>”

26:42

SA2

“Yes, but just make a pot of coffee once or twice …”

26:46

SA1

“Yes, but it isn’t …”

26:49

SA2

“We can put forward some suggestions as regards, what we believe, she can, whether we can find it or not …”

26:57

LK

“Then she is on unemployment benefit, yes. But the question is whether the process has taken place inside her head <yes>. We don’t know that.”

The excerpt shows how competing versions of categorisation of the client are put into play (25:30; 25:33; 26:57), how the discussion at a specific point tends to threaten the caseworker in charge (26:29; 26:38), and thus how negotiations are not simply discussions of matters of fact but include the face and the accountability of the professionals involved. Negotiating competing versions of categorisation of the client and rationalising a decision made, or, rather, a conclusion/consensus obtained, the excerpt demonstrates how participants soften their own argumentation without abandoning it, for instance when one of the participants says to the caseworker in charge (whose position is the one accepted in the conclusion) that she ‘had no other choice under the circumstances’. Another way of doing this is by arguing that in principle the original suggestion is still valid, but may not realistic at this point in this case. Thus, even if her conclusion is contested, the caseworker in charge obtains consent from the other participants. The case indicates how decision making appears to be a matter of negotiating competing versions of categorisation rather than a matter (p.199) of medical diagnosis and choice of treatment. When it is not obvious which version to choose, there is a risk related to knowledge, as the next example shows.

Reflections on risk

In professional decision making, the process of obtaining knowledge cannot be reduced to a process of making rational choices between alternatives based on full information. On the contrary, professional practice is constantly challenged by both a ‘surfeit’ and a ‘deficit’ of knowledge (Von Oettingen, 2007): Professional practice is often overburdened by interactional complexity providing a surfeit of knowledge, while at the same time professionals face problems shrouded in genuine uncertainties and deficits in knowledge. In contrast to this, expectations of performance often appear discursively as ‘necessities’ with a reference to generalised assumptions about ‘reality’. Professional practice is situated between these forms of knowledge, and the difficult task of reconciling them is at heart in many informal negotiations. What is at stake is the risk of ignorance: the possibility that at some point in the future, it will be recognised that certain forms of knowledge, which might have contributed to solving a problem, were not, but could have been, obtained. As such, the risk of not knowing and the need for reflection is a crucial element of professional practice. However, research has pointed out how expectations of performance combined with risk awareness can be counterproductive. Standardised forms of risk assessment based on generalised knowledge are often introduced for the purpose of minimising the risk of ignorance, to promote safety and prevent harm. However, there is also a risk that such standardised efforts do not work as expected if they undermine the space for professional discretion and reflection (Taylor and White, 2006; Broadhurst et al, 2010; Munro, 2011). The following case from child welfare exemplifies this by showing how general expectations in relation to risk assessment can interact with and lead to problems of reflection and professional discretion (Nissen, 2005, 2006).4

A mother with an addiction to unspecified pills and hash is pregnant. The caseworker worries, but since the mother expresses a willingness to stop smoking hash and is looking forward to becoming a mother, she refers the mother and her new-born child to a 24-hour family treatment institution. The purpose is to investigate and assess her parental skills. At the institution, professionals use a standardised model for systematic assessment. However, they find it difficult to get a picture of the parental skills of the mother mainly because the mother (p.200) is reluctant to participate in the everyday activities of the institution. Some of the professionals start to worry. They think the mother is isolating herself and the child. They find her reasons for not participating in everyday activities ‘strange’ and ‘paranoid’. They wonder if there is something ‘psychiatric’ at play, and address the risk of not being able to observe the mother; they might overlook something important. Other professionals, assigned as the mother’s contact persons, assess the mother differently. They emphasise the mother’s need for care and parental skills training. They propose a motivating strategy combined with close observations. At an assessment meeting among the professionals, divergent experiences of the mother and her behaviour are discussed. Despite alternative perceptions of the interactional complexity, the growing risk awareness among some of the professionals becomes decisive. Consequently, it is decided that the mother should be forced to participate in everyday activities and should not be allowed to leave the institution at weekends. It is also decided that the mother should undergo a neurological investigation to find out if her capability to learn has been harmed. This assessment is later conveyed at a meeting with the mother, the contact persons and the caseworker. At this meeting, both the mother and the caseworker question the knowledge of the professionals. The mother questions the professionals’ capability of knowing the child’s needs, given the fact that the child is still a baby. The caseworker questions the professionals’ knowledge of substance abuse and challenges related to becoming ‘clean’. She implies that they have not initiated the right treatment – professional counselling. In addition, she emphasises how treatment should not be about changing the mother’s personality and preference for being a ‘loner’. In light of this, the contact persons abandon the institutional agenda and accept the agenda of the caseworker.

This example illustrates how professionals are situated between the experience of interactional complexity in everyday practice and expectations of performance related to the assessment of parental skills. Situated in this position, the professionals are extremely aware of the risk of ignorance. This risk awareness and orientation towards expectations of performance create a process that may be counterproductive to reflection. Professional work is inevitably challenged by both a surfeit and a deficit in knowledge. This problem can only be handled through reflection, by embracing the inherent uncertainty of professional knowledge, and by recognising the problems of obtaining ‘true’ knowledge. An increase in risk awareness combined with high expectations of performance in relation to risk assessment can undermine this. Streamlining professional knowledge to avoid uncertainty does not reduce risk; rather it hinders reflection and increases the risk of ignorance. A major problem within this process (p.201) is the reluctance to address and explore controversies in a cooperative way, which is the theme of our final example.

Cooperation despite controversy

Rational explanations legitimising professional interventions are crucial to professionals. This seems to be particularly urgent when legitimising interventions in the lives of people who are not supposed to be able to take care of their own interests (Høgsbro, 2002, 2010). Services cannot be legitimised by reference to the satisfaction of users deemed unable to take care of own interests and partly unable to understand their own situation. But the international discourses of disability are not unambiguous, and accordingly, they might become a point of departure for internal controversies and intense discussions among the professionals loaded with anger, confusion and ambivalence. To be responsible for the situation and the possible future of people in extremely vulnerable situations calls for a professional commitment where failures and questions of professional as well as personal responsibility and identity are of great concern. Research has revealed strange and unexpected examples of these ambiguities in advanced rehabilitation programmes for people with schizophrenia, drug abuse, autism, attention deficit hyperactivity disorder (ADHD) and traumatic brain injuries (Høgsbro, 2002, 2007, 2010; Høgsbro et al, 2003, 2012, 2013). The following case concerned with training programmes for preschool children may serve as an example (Høgsbro, 2007):5

In the evaluation of training programmes for preschool children with autism, parents as well as professionals were identified as referring to two different discourses. One emphasised a caring and protecting environment that guarded the children from demands they could not live up to, and the other emphasised daily challenges that could develop their competences. Both discourses referred to UN conventions on disability rights saying that member states had to enhance the possibilities of people with disability so they could be on equal terms with ordinary people. But the first discourse understood this as being accepted on own terms and the other discourse understood it as being offered the best training possible that could help them meet ‘normal’ standards. The first discourse regarded the second as leading to the loss of self-respect, and the second regarded the first discourse as leading to segregation. Both regarded the other as breaking with the UN standard and ignoring the wellbeing and future perspective of the children. Both referred to a huge body of international research literature on autism. The conflict was loaded with feelings that touched the identity and responsibility of both parents and professionals. In their daily (p.202) practice the professionals asked themselves if they were actually betraying the children when accepting their deviance or if they were causing them stress by making too many demands. The parents asked themselves if they were depriving their children of opportunities in the future by accepting special education for people with autism, or if they would alternatively deprive them of happiness and self-respect by choosing an ordinary school with all the inherent pressure and social competition among ordinary children. Both groups were seeking information on the internet and were well informed about conflicting theories and research findings in the field.

This example shows how deeply discourses and professional conflicts, identity and ethics are interwoven, involving feelings such as professional dignity, self-respect and issues of legitimacy. Similar examples could be taken from brain injury rehabilitation as well as services offered to people with dementia, drug abuse, schizophrenia, ADHD and so forth. In every one of these fields, different discourses support different models of intervention and rehabilitation.

Some of the main arguments for EBR and EBP are related to these serious controversies within the professional world. Professionals, users, politicians and decision makers on all levels are looking for research that might reduce risk and put an end to controversies. But as our example shows, professional practice addresses individual circumstances and specific contexts and settings to a degree that demands cooperation and negotiated judgements built on the experiences of the actors involved. In these instances, EBR is only one of several sources. Dialogue and cooperation among professionals and users are equally important. Disagreements must be made visible and thus easier to tackle, and standardised concepts of rehabilitation and aid have to be adjusted to local and individual contexts. This does not eliminate risk, but enables the development of professional discourses.

Conclusion and implications for professional development

Whenever or wherever professionals interact to organise professional work practices and shared tasks, negotiations occur. These negotiations unfold in arenas contextualised in specific organisational and interprofessional settings, and they often function as unnoticed practices of the day-to day routines of organising professional work. Although unnoticed in the discourses of EBR and EBP, our analysis shows it is possible to explore such negotiations – for example by using ethnomethodological and conversation analytical approaches enabling us to ‘look inside professional practice’ (Hall and White, (p.203) 2005; Olesen, 2005, 2012) to discover the ‘invisible trade’ (Pithouse, 1987) and to identify activities and language use in the shaping of interprofessional cooperation and boundary work, decision making and rationalisation (Hall et al, 2013). Our analysis also suggests that we pay attention to reflections on risk as an inevitable aspect of professional practice in modern society (Beck, 1992; Luhmann, 1993; Warner and Sharland, 2010). It is important to explore the relationship between governmental attempts to prevent failure and the space for both professional reflection and discretion. Finally, the analysis implies that strong and generalised discourses may lead to deeper conflict and ambivalence, stress and confusion among professionals, if they are not identified and explicitly understood as collective dilemmas and controversies. If the controversies are made visible through dialogue and cooperation, they can be used to develop professional self-respect, pride, identity and means of orientation and can create the means for adjusting interventions. Systematic reviews and means of accreditation (‘streaming performance’) are addressing these issues in a formal centralised way that should move the psychological strain on front-line professionals to a level of professional, scientific and political decisions based on ‘evidence’ (Høgsbro, 2013). But simultaneously the complex preconditions for professional practice and discretion go unnoticed. Recognising the unnoticed aspects of practice – negotiations in ‘fuzzy’ realties, reflection on risk, and cooperation despite controversies – may lead to a more informal and decentralised approach to professional development. However, it would include how professional practice actually works and would emphasise procedural transparency, aims, reasons and shared knowledge rather than compliance to scientifically legitimised forms of practice. It would make visible the conditions that enable professionals to act with constant care in everyday situations.

Notes

(1) The example is from a PhD dissertation. The study was conducted in 2002-04 as a qualitative single case study based on observations of interprofessional encounters, focus and single interviews with health professionals and document studies on patient journals, policy documents and so on.

(2) The excerpt includes about one minute of meeting talk with a few omissions marked with an ellipsis ; <> indicates feedback from other participants; the numbers in the first column are minutes and seconds from the beginning of the talk, which lasted about 40 minutes. SA1 is the caseworker in charge; SA2 is her colleague. Both are trained social workers. LK is a medical consultant from another organisation.

(3) The study was based on observations, sound recordings of encounters and meetings, interviews and documents collected during a joint one-week stay at a Danish jobcentre in the spring of 2005, repeated in the autumn of the same year.

(p.204) (4) The example derives from a qualitative comparative field study in two 24-hour family treatment institutions. The study was a part of a PhD project exploring programmes and professional practices in relation to assessment and decision making.

(5) The example derives from an evaluation of rehabilitation and training programmes for preschool children following either principles of Applied Behavior Analysis or the TEACCH-inspired (Treatment and Education of Autistic and Related Communications Handicapped Children) ordinary Danish training programmes. The evaluation comprised observations, interviews, psychological tests and questionnaires emphasising both discourses and outcome of training.

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Von Oettingen, A. (1997) ‘Pædagogiske handlingsteorier i difference mellem teori og praksis’ [Pedagogical theories of action in the difference between theory and practice] in A. Von Oettingen and F. Wiedemann (eds) Mellem teori og praksis. Aktuelle udfordringer for pædagogiske professioner og professionsuddannelser [Between theory and practice. Contemporary challenges for pedagogical professions and professional education], Odense: Odense University Press.

Warner, J. and Sharland, E. (2010) ‘Editorial: special issue on risk and social work’, British Journal of Social Work, 40(4): 1035-45. (p.208)

Notes:

(1) The example is from a PhD dissertation. The study was conducted in 2002-04 as a qualitative single case study based on observations of interprofessional encounters, focus and single interviews with health professionals and document studies on patient journals, policy documents and so on.

(2) The excerpt includes about one minute of meeting talk with a few omissions marked with an ellipsis ; <> indicates feedback from other participants; the numbers in the first column are minutes and seconds from the beginning of the talk, which lasted about 40 minutes. SA1 is the caseworker in charge; SA2 is her colleague. Both are trained social workers. LK is a medical consultant from another organisation.

(3) The study was based on observations, sound recordings of encounters and meetings, interviews and documents collected during a joint one-week stay at a Danish jobcentre in the spring of 2005, repeated in the autumn of the same year.

(p.204) (4) The example derives from a qualitative comparative field study in two 24-hour family treatment institutions. The study was a part of a PhD project exploring programmes and professional practices in relation to assessment and decision making.

(5) The example derives from an evaluation of rehabilitation and training programmes for preschool children following either principles of Applied Behavior Analysis or the TEACCH-inspired (Treatment and Education of Autistic and Related Communications Handicapped Children) ordinary Danish training programmes. The evaluation comprised observations, interviews, psychological tests and questionnaires emphasising both discourses and outcome of training.