Personal assistance (PA) has a history as a bottom-up initiative starting among disabled people claiming self-determination and liberation from what was seen as an authoritarian and depriving service apparatus (DeJong 1983). To have their services organized as PA was seen as a decisive instrument to realize the individual's right to have control over their own lives (Spandler 2004). As a consequence, the concept of empowerment has been closely linked to the development of PA and the independent living ideology which is the ideological basis for the scheme. Increased empowerment of the users is also the main justification of the arrangement as it is presented in public policy documents. In all the Scandinavian countries, it is emphasized that the person's self-determination should be the basis for PA and the arrangement has been proclaimed to be ‘the crown jewel in promoting the independence for disabled people.1 The official term of the Norwegian arrangement, user controlled PA, illustrates this point. However, empowerment has increasingly become a disputed concept. It signals values most people will have positive associations to, like strength, power and influence. As a consequence, many different actors are eager to claim ownership of the concept, and to assign to it content adjusted to their agendas. For instance, empowerment is a popular concept in such areas as marketing and management literature (Hardy and Leiba-O'Sullivan 1998; Yukl 2007; Barber 2007). Fleming and Ward (1999, 370) refer to empowerment as ‘a conceptual deodorant, used to justify propositions which at root represent varying ideological and political positions, obscuring conflict and difference, and in the final analysis potentially a ‘gilded vehicle’ of social control and professional self-interest’.
Also, within welfare policy, there are different notions of empowerment, reflected in different usages by different actors, and in relation to different levels of practice. Askheim (2012) distinguishes between five approaches to empowerment: empowerment as resistance (counter-power), empowerment as part of a market-logic, empowerment from a therapeutic approach, empowerment as individual self-realization and finally empowerment in the light of Foucault's concept of governmentality.
In recent years, the concept of ‘co-production’ has become popular in welfare policy (Hunter and Ritchie 2007; Alford 2009), and is defined as ‘a particular form of partnership between people who use social care services and the people and agencies who provide them’ (Hunter and Ritchie 2007, 9). Service delivery is seen as a joint venture, and the citizens become active participants in the production of the welfare services they demand (Pestoff 2006). This approach is linked to the changing role of the state as the authorities seek to develop more integrated and responsive forms of steering (Newman 2001). One main reason for this approach is the acknowledgement that the welfare services can only be improved if new kinds of relations between the service users and providers are established. The services must have the users' reality as a starting point and look at them as equal partners in a problem-solving team. Co-production is closely connected to empowerment. ‘Its aim [co-production] is to empower users to take greater control over, and responsibility for their lives’ (Bovaird and Löffler 2003, 194).
With this article, we point out how different usages of the concept of empowerment run contemporaneously through the descriptions of and discussions about PA, but from points of departure in different ideas and notions, leading to different meanings. Such an exposition calls for a more critical overall discussion of our understanding of PA as an empowering service within the welfare state. How is empowerment formulated by different actors and what consequences do the various interpretations have for the development of PA? In what ways are the different interpretations able to fulfil the original intention of PA – to function as a tool of liberation for disabled people? Such discussions can, on the one hand, highlight the uniqueness of PA and, on the other, place the development of PA within a conception of the changing welfare system and the way government governs.
In the following part of the article, we will take a closer look at the concept of empowerment and how the different approaches to empowerment conceptualize different relationships between the state and users of welfare services. We will distinguish between the following aforementioned approaches which we find especially relevant in an analysis of PA: empowerment as resistance [counter-power], empowerment as consumer choice, empowerment as co-production and empowerment as a liberal strategy of dominance in the modern society (governmentality). These four approaches address the concept of empowerment through different dynamics and on different analytical levels. The resistance approach offers an understanding of empowerment as a resistance strategy driven from the bottom-up by the citizens against an authoritarian and oppressive service apparatus. The consumer choice model includes innovations in welfare services inspired by market-based models initiated both from above, by state authorities, and from below, in the form of bottom-up initiatives through which user groups demand the right to freedom and to have more influence on the services they receive. The co-production approach mainly frames the dynamic of empowerment as a top-down process driven by the state. Nevertheless, all three approaches depict empowerment as a process taking place in a relationship between the citizen and the government, either as an antagonistic process or one of partnership. The governmentality approach, on the other hand, offers a kind of overarching critique of empowerment as a strategy of government that influences citizens to act in a certain way. In this approach, empowerment becomes a regime of practices and techniques, regardless of whether the techniques are based on ideologies and dynamics of resistance, consumer choice or co-production.
In the following sections, we will show how these different approaches can be related to different developments and aspects of the PA arrangement and discuss what the consequences of the different interpretations might be. The empirical context of the analysis will be policy documents and research from the Scandinavian countries.
Empowerment as resistance
The concept of empowerment originates from the literature on marginalized people and the process through which marginalized people can mobilize and raise awareness, in order to draw on their own abilities and resources to solve their own problems (Askheim 2012). Important sources of inspiration have been the American civil rights movement (Solomon 1976) and, not least, Paulo Freire's book ‘Pedagogy of the Oppressed’ (1993). In this original notion of the term, empowerment is connected to the mobilization of resistance against the discriminatory and oppressive structures of society. Through creating a common identity and awareness, marginalized people can mobilize power and organize resistance that counteracts their powerlessness.
The process of empowerment as a form of resistance in the welfare area is based on a critique of the welfare state as dominated by a bureaucratic, hierarchical form of governance. The state is seen as unresponsive to the needs and differences of individuals and communities. This critique is allied with a critique of the domination of the definition and forming of user's needs by professional welfare service providers. The professionals are criticized for being part of the repressive system, and the welfare state as a paternalistic structure of government. An important implication of this interpretation is, therefore, that the service users themselves must take the lead to counteract the oppression and fight for their right for full participation and equality in society (Askheim 2012). The process must be led by the users themselves and involve change on different levels, for example, on the individual, group and societal levels. The goal is then, from a bottom-up process, to mobilize the capacity of the users to formulate an oppositional view of their identity, interests and needs (Fraser 1997). In this notion of the concept, the empowerment process begins in the civil society among individuals and groups, as a reaction to oppressive structures within the welfare state.
Inspired by theories where disability is seen as created by social and structural forces, the growing disability movement has been an important forerunner bringing this perspective into the disability area (Campbell and Oliver 1996; Oliver and Barnes 2012). The mobilization of power and resources among disabled people has led to a strong disability movement, raising their voice and influencing the development of disability policy (Bonfils 2006; Hugemark and Roman 2012), The perspective highlights disabled people's role in formulating a criticism of the existing welfare services and in developing the PA scheme with a significant element of user control. Further, it motivates the individual with disability to take control over his/her life and to mobilize and organize so as to become stronger as a group to react against an oppressive society.
Empowerment as consumer choice
The approach to empowerment as part of a market-logic must be seen in the context of the growing importance of market-based models in the welfare sector. The market models are seen most clearly in nations with liberal welfare states, like the USA, but are also an important part of welfare policy, for instance, in the UK (Glendinning 2009; Manthorpe et al. 2010). Also, the Scandinavian welfare states are increasingly under pressure from more market-based models. The efforts to modernize the public sector are largely affected by the ‘New Public Management’ ideology, where the market is an important model (Klausen and Ståhlberg 1998; Peters 2001). Important ingredients of such models are freedom of choice for the user and the conceptualization of service users as consumers. As a consequence, the task of the welfare services is to adapt the services as much as possible to the inhabitants' individual needs.
One of the main principles of the consumer orientation is the idea of the independent, free individual (Dwyer 2000). As a consequence, the principle of the service users' right to choose and decide how their needs are taken care of becomes vital within the welfare policy. Being looked upon as bureaucratic and standardizing, the welfare state is seen as an institution which disempowers and deprives the individual of initiative and responsibility. On the other hand, by letting the market regulate the services, user-oriented, high-quality services will be developed. The services satisfying the users' needs will thrive; those that do not will not survive.
Within the market model, the service users are seen primarily as customers with opportunities for choosing between different providers of services. In consequence, the providers must compete for customers, which results in more power and better and more effective services, with greater responsiveness, for the users.
PA from the consumer choice perspective, thus, points out the way the scheme places the users in the position of consumers in a market of PA providers. Seen from a consumer choice approach, the empowerment process of the users is linked to their right to choose between different providers. With this choice, they exercise their power, through the market mechanism, to regulate the supply of providers by selecting those who best fulfil their needs and expectations.
Empowerment as co-production
The co-production concept focuses on partnership, cooperation and interaction between the different actors in the welfare sector (Hunter and Ritchie 2007; Alford 2009). The emphasis is placed on the users' active participation in different parts of the welfare production. Co-production is referred to as an important element in both the Clinton and the Obama administration's welfare policy in the USA (Alford 2009). In the UK, co-production has been a main strategy through different governments since it was introduced by the New Labour in 2007 (Carr 2012).
The empowering process in co-production is seen as a new form of governance based on a partnership between public authorities and a wide range of actors. A main perspective is that the users are looked upon as competent citizens with the right to have influence over the services which concern them and who have resources and competence to make the services better. In this way, co-production represents an opposition towards both the traditional hierarchical expert model in welfare services and the market model, where the users are left as consumers of the services (Pestoff 2006; Hunter and Ritchie 2007). Government papers often point to the need of involving users formally in the governance of service providing agencies, for example user cooperatives, the user's role as inspectors of quality, user's being involved in the training of staff, etc. By developing a partnership with the users, but also their relatives, network and civil society, the services will get more local and individual adaptations. Thus, the users and the professionals are seen to have a complementary competence (Bovaird and Löffler 2012; Realpe and Wallace 2010). By having relations promoting co-production and co-creation, there will be both qualitatively better and more democratic services.
While both the resistance perspective and the market model operate within a perspective of conflict between the users and the services, the co-production paradigm advocates a basically harmonious approach and a community of interests between the service providers and the users. The users and the professionals are seen to be in the same boat and have common interests in making the services as effective and user-oriented as possible. By engaging the users in the development of public policies, strategies and services, they become partners in delivering public policy, and are seen as key contributors to the innovation and development of a more sustainable form of welfare production.
When co-production has been put on the agenda by the state authorities, one reason is, without doubt, worries about the increasing costs and lack of resources in the welfare sector. Co-production is also seen as a strategy to enhance the productivity of welfare services, leading to cost-reduction, higher service quality and expanded opportunities for participation in public life (Pestoff 2006). In this way, co-production is considered essential for sustaining current levels of welfare service provision in a period in which many countries face economic crises and sharp budget constraints. Another challenge is the growing gap between the increasing portion of the population needing care and the decreasing number of service providing personnel. A Norwegian public report, ‘Innovation in care’, states that challenges in care will arise in the years to come from an increase in both the number of elderly in need of care and new, younger user groups, coupled with a simultaneous shortage of both qualified personnel and volunteers (NOU 2011, 11). It will not be possible for the public to solve these problems alone. It will therefore be vital to integrate other social forces and develop new models for public service production. Such models must involve those who are directly affected by the services in the development and implementation of those services. As a consequence, the focus must be directed more strongly towards the user, his/her family and network and the community as a whole. Thus, an important part of the co-production strategy is to utilize the citizen's own resources and encourage them to take greater responsibility for their own welfare.
The PA scheme is seen, from a co-production perspective, as a top-down approach in which the public authorities and the service professionals are leading the process of empowerment. This process is facilitated by the construction of opportunities for users to become involved and work together with the authorities and professionals as equal partners in the development of the scheme.
Empowerment as governmentality
In this perspective, the concept of empowerment has been linked to criticism of the liberal government. Specifically, this criticism focuses on the imposition of a practice of self-government that shapes the users identity and regulates their behaviour in a specific direction. This criticism originates in Foucault's concept of governmentality. This offers an approach that regards the notion of welfare dependency as a component within a particular mentality of government, and its vocabulary of rules and techniques, in which we govern ourselves (Foucault 2002). As Foucault sees it, power in modern societies is not exercised by repression, but on the contrary through affecting formally free individuals, their acts and self-esteem. In other words, the control of the government is primarily exercised through influence on the self-control of the individual. The intention of this type of influence is to bring forward certain capacities and opinions in the individual, that will in turn cause them to act in the desired fashion.
Dean (1999) points to the way techniques of empowerment can be seen as parts of governmental programmes that seek to optimize the agency of the governed. They seek to establish particular kinds of power relations and to affect a specific use of expertise (Dean 1999, 70–71). Advanced liberal governments practise a form of reflexive government. They strive to promote, and then govern through, technologies that develop more self-actualized and self-managed subjects. A set of techniques and practices have been developed to promote the freedom of the individual as long as it is practised in a way that meets the objectives of the government.
In this scheme, the welfare professions have an important task, making use of certain technologies, instruments, methods and institutional procedures. Especially important is what Cruikshank (1999, 4) calls ‘technologies of citizenship’, defined as techniques of empowerment, consultation and negotiation that are used to shape the individual as an active and free citizen, and through which the individual makes himself/herself the object of control. Accepted opinions of what it means to be a ‘competent citizen’ make up the basis for what the process should end up with. Specific basic, overall norms are fixed as truths, rules and values without being defined or discussed more closely. Therefore, from a governmentality perspective, empowerment should primarily be seen as a disciplining and normalizing practice. It is looked upon as a practice striving for changes which are seen as socially acceptable or desirable.
The governmentality perspective highlights the way the PA scheme disciplines the individual user to become a self-managed subject. The process of empowerment is linked to the development of the user's capacity to manage the services themselves. Through this, the user shows that he/she is a competent citizen who can utilize the PA scheme to advance their freedom, albeit within the parameters set by the government.
PA – a mix of empowerment discourses?
The article so far shows that the different perspectives of empowerment will interpret and put their marks on PA in different ways. At one extreme, PA is seen as a tool of liberation for oppressed groups, and at the other as an instrument for power and discipline for the authorities. Empowerment is presented both as an approach where there is a fundamental conflict between the service users and the service apparatus, and, conversely, as a perspective where a state of harmony and common interests between the service providers and the users is the basic position. In PA, the different discourses are mixed together. As a consequence, the scheme has been characterized as a melting pot of welfare discourses and a hybrid welfare programme (Pearson 2000; Glasby and Littlechild 2009). In literature especially the mix between the resistance discourse and the market discourse have been focused, while the governmentality perspective and the co-production model so far have attained less attention. In practice, the different interpretations of empowerment often exist side by side when PA is promoted and justified. Still, which interpretations become dominant and the manner in which the discourses develop will have consequences for the directions the PA scheme takes as it evolves.
In the following section, we turn to the empirical data to show how the different empowerment approaches can be related to different aspects of the PA models in the Scandinavian countries.
Empowerment perspectives in the Scandinavian PA models
PA is established as a service in all the Scandinavian countries. However, within the shared welfare state model, there are considerable differences between how PA is organized in the three countries. The empirical data used in this article is equivalent to the data used in the article by Askheim, Bengtsson and Richter Bjelke in this journal. Readers can find a more detailed description of the PA models in the Scandinavian countries in their article.
Resistance initiatives and inspirations from the market
In all the Scandinavian countries, the PA programmes started as bottom-up initiatives set in motion by disabled people and their organizations. All these initiatives opposed the policies and service forms designed for disabled people. Beginning in the 1970s, physically disabled people in the county of Aarhus in Denmark were allowed to hire their own assistants after refusing to be institutionalized (Jensen and Evans 2005). In Sweden in 1983, the Stockholm Cooperative for Independent Living (STIL) was established as the first European initiative where disabled people employed their own personal assistants (Hugemark and og Wahlström 2002). In Norway, the first organized efforts with PA were commenced by the National association of persons with physical impairments in 1990 (Andersen et al. 2006).
In Norway, and even more in Sweden, the initiatives had a distinct ideological basis inspired by the Independent Living ideology, with its opposition against what it characterized as a medical ‘rehabilitation paradigm’ where the disabled person's problem was located in the individual and who therefore needed to be changed under the dominance of a professional therapeutic rehabilitation regime (DeJong 1983, 21). As formulated by STIL in late 1980's:
‘We know best what we need. Those of us who want should get the means to run their own services, with better quality at the same cost’ (Ratzka 1996a).
In Denmark, a clear ideology among the users was lacking, but the goals were mainly the same: self-determination and independence.
Studies, both from the Scandinavian countries (Jensen and Evans 2005; Hugemark and og Wahlström 2002; Guldvik 2003; Johansen et al. 2010) and other nations (Benjamin, Matthias, and Franke 2000; Leece and Bornat 2006; Glasby and Littlechild 2009), also clearly document that PA, from a resistance perspective, has been a success. Studies among the users are unambiguous when they report great satisfaction with the scheme and increased independence and self-determination; PA as a tool of liberation has been successful.
The market approach has also been a part of the concept of PA in the Scandinavian countries since the beginning, although in varying degrees. This approach is clearest in Sweden where there are strong individual rights for the users and no demands put on them in terms of being able to manage the assistance, PA is mainly organized as direct payments. In addition to the municipalities, private companies and other organizations, including cooperatives, offer PA. As pointed to by Askheim, Bengtsson and Richter Bjelke in this journal, there are now reactions against the strong consumerist approach and tendencies to re-regulate the arrangement, in order to control and secure quality of the service.
In Norway, and especially in Denmark, PA has been characterized by a more paternalistic profile. In Denmark, PA was organized from the beginning as direct payments to the users, but until recently, the target group has been strictly limited. The users had to have extensive impairments, be able to manage their assistants and maintain a certain activity level (Jensen and Evans 2005). The model also had a more paternalistic profile in Norway, and was subject to public control there to a greater extent than in Sweden. The decisive criterion to get PA in Norway was the user's ability to act as manager for her/his assistants, thus limiting the target group considerably. Even though a user-controlled cooperative was established early in Norway (1991), it was up to the municipalities to make the decisions regarding who should have the employment responsibility for the assistants. PA was defined as an alternative organization of existing services, and private companies had a very modest position (Andersen et al. 2006).
However, in the last few years, the market model seems to have got a slightly stronger foothold in both Denmark and Norway. In Norway, the user organizations have, for some time, been pressuring the state to make PA an individual right as it is in Sweden. In 2013, the Ministry of Health and Care issued a Green Paper where PA was proposed as an individual right for the users in need of extensive assistance, more than 32 hours each week. Persons with a need between 25 and 32 hours each week got the right if PA was not figured to be considerably more expensive than other services (Helse- og omsorgsdepartementet 2013).
As the number of users has grown considerably in Norway, private companies have seen a new market and have started moving into the area (Guldvik and og Andersen 2013). In Denmark, the strict demand on the users to maintain a certain activity level has been abandoned, and the responsibility for the employment of assistants can now be passed on to a cooperative or a private company. A user-controlled independent living-inspired cooperative and a couple of private companies are venturing into the PA market (Socialstyrelsen and Deloitte 2012).
Both in the Scandinavian countries and internationally, an alliance between service users and New Public Management models in the welfare services has promoted a movement towards models that are more market based. The ideological foundation for PA, Independent Living, is also inspired by a market-based consumer orientation. Consumerism is described as one of the main contributors to Independent Living (DeJong 1983). Since the users are seen as those best capable to estimate their own needs and interests, they should have the freedom to choose how their services should be organized and who should implement them. The public monopoly on services is considered to promote paternalism and deprive citizens of independence (Ratzka 1996b). As a consequence, activists and organizations among disabled people have claimed the right to have PA organized as direct payments (Oliver and Barnes 1998; Barnes, Mercer, and Shakespeare 1999). As they see it, PA organized as direct payments will give the users the maximum freedom to organize their assistance as they want it. They can then freely choose who they want to employ as their assistants, the services that will be performed and the work schedule. The Independent Living Institute (ILI) located in Stockholm, Sweden, can be seen as an example of an organization promoting the mix of resistance and consumer position in PA. On their homepage, they present the institute with the following sentence:
However, the consumer orientation in PA meets with criticism from various groups, both among disabled people and researchers. Advocates of the social model of disability criticize the Independent Living ideology for having exaggerated confidence in the market and for not discussing questions of power and structural circumstances creating differences and unfairness (Ferguson 2007; Oliver 1996). They indicate a fundamental difference between the consumer model and what they call ‘a democratic model’ of user control and user participation (Braye 2000; Beresford and Croft 1995). The democratic model is essentially equivalent to what in this article is termed the ‘resistance model’. This model is not only interested in the development of the users' involvement in their services, but also in how the service users could be mobilized and take part in developing a policy preventing and counteracting exclusion, oppression, discrimination and clientification. The focus is on participatory rights rather than welfare needs (Braye 2000, 18). From this point of view, control over the services is part of a greater project aimed at disabled people obtaining full rights to participate as citizens. The consumer model in this way does not have the liberating goals characterizing the democratic or the resistance model.
The Independent Living Institute (ILI) is a policy development center specializing in consumer-driven policies for disabled peoples' self-determination, self-respect and dignity. (http://www.independentliving.org/about.html)
Another criticism against the consumer orientation reflected in the various PA models is that the assumption that the users are always well informed and competent is illusory. Critics fear that it will favour the articulate, informed users and point out that for example the particular contexts and issues for people with learning disabilities have been little considered. In the UK, such a criticism has been marked against the direct payments models which are a main ingredient in the arrangement with Individual Budgets for disabled people (Hall 2009; Wilberforce et al. 2011). Critics fear that persons with competence and capacity to manage the arrangement will be favoured while collective care services provided by the local authorities and which are desired by for instances persons with learning disabilities will be replaced or undermined. In this way, Direct Payments and Individual Budgets, while it represents a good solution for some people because of greater choice opportunities, could be at the expense of others who will get lesser choice. Other critics fear that cost reductions is main objective of the personalization of the services, not least as it is implemented in a period of financial austerity in the UK (Spandler 2004, Netten et al. 2012).
Also in Sweden, the consumerist right-based profile of PA has led to a debate over whether the scheme's approach mainly favours disabled people who possess the best abilities to represent their interests (Barron, Michailakis, and Söder 2000; Lewin 1998). As an individual right, PA should only be rendered when the individual asks for it. This means that the disabled person himself/herself must be active in obtaining PA. On the other hand, disabled people with less capacity to present their needs or who are resigned to their condition or simply powerless will have problems taking advantage of the scheme, and can easily be left out of the reform. As an example, figures show that in the late 1990s, only about 400 persons with mental health disabilities were registered as PA users (Socialstyrelsen 1999).
In addition, critics of the right-based consumer-oriented model in Sweden have asked if the cost of the model is that some users do not get the qualified help and assistance they need (Askheim 2001). There are warnings that users might be passive and lose their functional abilities in the name of user control. Since they do not express any wishes to have a different or a more active life, their assistants find it difficult to intervene and do something about it. Subsequently, there are some who have wondered if ‘more paternalism is necessary to strengthen their individual autonomy’ (Lewin 1998, 226).
In many ways, the resistance discourse and the consumerist discourse that have merged in the PA schemes are opposites in the realm of welfare politics. However, they have found common ground in the demand for a provision of services that is more friendly to the individual consumer. The two discourses have a shared attitude regarding how the welfare services should be organized, and there are also concurring views behind the approaches. In their opposition against clientification and disempowerment, they both share the assumption that the clients are best suited to assess their own problems and needs. Despite these shared features, it seems important to analyse further the possible dilemmas and controversies such an alliance could result in.
Co-production on its way forward
As mentioned, co-production has increasingly become a central concept in welfare policy. It is viewed as a way of developing more coherent and responsive steering from the state authorities, through the promotion of active partnership, cooperation and interaction between the different actors in the welfare state. The approach is presented as particularly relevant under any of the following conditions: when the situation calls for long-term support, when it is important for the support to be highly individualized and site-specific, when different actors and agencies have to work together, when what is needed is likely to change over time and when services are likely to have a major influence on the person's quality of life (Hunter and Ritchie 2007, 16).
Among the Scandinavian countries, it is in Norway that co-production is most explicitly a part of the agenda for future care and welfare policy. The public report ‘Innovation in care’ stated that co-production will be a dominating perspective for the policy in the future (NOU 2011, 11). The principles were confirmed in two White Papers about care policy and public health in 2013 (St. meld. nr. 29 2012–2013; St. meld. nr. 34 2012–2013). Co-production is described as a re-democratization of the services, as the citizens should be directly involved as partners in their service development. However, co-production is getting a more prominent place on the agenda in the other Scandinavian countries also. In Denmark, a broad group of researchers within public management state that a main goal for future public policy is to involve the citizens as active and equal partners in the development of the services (Institut for samfund and globalisering 2012). The chair of the Danish Association of Municipalities has in 2013 launched ‘co-production’ as the main principle for the future welfare policy in Denmark.2 This statement has been followed by the Danish Government in two reports concerning the political strategy in relation to disabled people (Regeringen 2013) and the mental health services (Rapport fra Regeringens udvalg om psykiatri 2013). In Sweden, a report to a parliamentary committee calls for a greater role for citizen participation and direct democracy in continued reforms of the Swedish welfare state (Häggroth 2005). The report concludes that in order to come to grips with the growing democracy deficit, and to renew the legitimacy of the welfare state, citizens should play a greater role in the delivery of the services.
PA fits well into the notion of co-production and partnership. In the report ‘Innovation in care’ (NOU 2011, 11), the PA scheme and the user-controlled cooperatives are mentioned as important examples of co-production. A prominent member of the Norwegian Independent Living Movement was a member of the committee that worked out the report.
The co-production literature stresses that to act as partners the users have to be empowered (Needham and Carr 2009). Accordingly, the user's capacity to participate as a partner in the co-production alliance has become essential. In the Scandinavian countries, the users' ability to act as the managers of the PA arrangement has, consequently, been on the agenda in recent years. The public authorities facilitate and support the development of the users' skills and competences in becoming ‘PA users’ and also in taking control over their life situations. In all three countries, we have witnessed the movement towards more formalized courses and advisory services for PA users. The Norwegian white paper preparing for the inclusion of PA in the Social Services Act states that good training of the users in their role as managers is imperative to the success of the scheme. The users as a consequence are obliged to take part in a training course to get PA (Ot.prp. nr. 8 1999–2000). Compared to the original understanding of the PA scheme as an empowerment process led from the bottom, the positions of the users and the public authorities are here reversed. However, even as the public authorities are increasingly involved in this empowerment process, different initiatives such as courses and advisory services are, in several cases, also managed and driven by user-controlled cooperations. This demonstrates that the users are taking a leading role in this process of development. A noticeably increasing number of brochures, guidelines, websites, etc. have been developed, as well as courses in such topics as employee and legal management, working environment, communication and conflict management, how to do a job interview, follow-up meetings with the assistant, mentor services, etc. These are the results of efforts by both the public initiatives and the user cooperatives.3 In this way, the co-production process seems to be encouraged by both the authorities and the users.
The co-production approach also highlights that working in partnership demands skills and the development of competence among welfare professionals in order to empower the clients/users of welfare services. It should be another kind of competence, based on interdisciplinary approaches and new ways of working together with other groups and partners (Cottam and Leadbeater 2004; Murray et al. 2006).
As a way of empowering the users, co-production can be looked upon in two ways: Firstly, it can be seen as a result of a positive recognition of the resources and competences the users possess, and which the welfare services now realize the importance of. On the other hand, a discussion about the questions of power and power differences is strikingly absent in the literature about co-production. The users' experience of oppression and powerlessness in the asymmetrical relationship with the welfare services, which has been a basis for much of the empowerment literature, is scarcely discussed as a potential problem within the co-production concept. This perspective situates co-production as an innovation strategy initiated by the welfare bureaucracy and not from among user movements and organizations. Hultqvist's and Salonen's warning should be an important reminder when they state that ‘when the discussion about the users’ participation emphasizes cooperation and consensus, the conflicts tend to end up in the shadows. When the conflict perspective is overlooked, the social degradation of certain groups and individuals tends to be neglected’ (Hultqvist and Salonen 2011, 54; our interpretation).
There are, in other words, mixed justifications for the co-production ideology, which are important to be aware of and analyse. There are close links between a critical stance towards the co-production ideology and looking at PA as a kind of governing through self-government, what Foucault has called governmentality.
PA as governmentality
As mentioned above, the basis for the governmentality approach is that power in modern states is mainly exerted through influencing formally free individuals. The individual is seen as capable of acting independently, but the independence should be practised within established norms, rules and standards for what is found right or acceptable in society. In other words, the freedom the independence implies is a freedom within certain frames. Cruikshank (1999, 52) makes use of the term ‘the standard of life’ to illustrate this point, while Barry, Osbourne, and Rose (2001) connect the term freedom to the concepts of order and responsibility: ‘Freedom, in a liberal sense, should thus not be equated with anarchy, but with a kind of well-regulated and ‘responsibilized’ liberty‘(Barry, Osbourne, and Rose 2001, 8).
In disability studies, researchers inspired by Foucault's theories see disability as a product of ‘bio-power’, the practice of modern states and their regulation of their subjects through numerous and diverse techniques for achieving the subjugations of bodies and the control of populations (Foucault 1980). Here the emergence of medical science with its distinction between the normal and the pathological is seen as decisive in constituting disability discursively as a physical or mental deficit (Tremain 2005). Because such definitions are part of constitutive practices, they do more than just label people. They also constitute identities and, in doing so, participate in the maintenance of dominance (Hughes 2005; Liggett 1988). Tremain (2005, 9) criticizes the social model of disability for not taking sufficiently into account the concept of bio-power, but exclusively stick to what Foucault describes as a ‘juridico-discursive’ conception of power where power is construed as a fundamentally repressive phenomenon possessed by external authorities, such as a particular social group, a class, an institution or the state and which reigns over and down upon others and that this obscures the productive constraints of modern bio-power.
From a governmentality approach, PA can also be seen as an instrument for discipline and normalization. PA can not necessarily be used for whatever the user wants. The scheme is set up with rules, controls and audits to ensure that the money rendered to the arrangement is used in a prescribed way. You have to be both ‘disabled enough’, and to use the PA arrangement in ways seen as proper and meaningful, to live up to the norms of being a suitable user of PA.
In Norway, PA is described as ‘an alternative organization of practical and personal help for strongly disabled persons with a need for assistance in their daily lives both inside and outside their homes’ (Ot. prp. nr. 8 [1999–2000]). In Sweden, in 1996, it was stated that the user should have a need of at least 20 hours of help each week in order to have his/her ‘basic needs’ covered before PA was granted. ‘Basic needs’ are defined as ‘help to manage hygiene, to dress and undress, to have meals and to communicate with others’. In Sweden, there have also been a couple of efforts from the authorities to ensure that the money given to PA is used in the intended way and not for other purposes (Statens offentliga utredningar 2005, 100; Statens offentliga utredningar 2008, 77).
Until 2009, users in Denmark had to document a certain activity level to be qualified to get PA. Studies show how this criterion regulated and shaped the users’ behaviour in a certain direction, in order to gain and keep the PA arrangement. Some users became members of different voluntary organizations and took on voluntary work on councils and boards, even though it was not in their interests. Some users continued for many years to participate in education and courses to live up to the standard (Jensen and Evans 2005). The struggle to live up to these expectations and the fear of losing the service functioned as a disciplinary power that shaped the PA user's identity and behaviour in a certain direction. Although this criterion has now been abandoned, the example points out how an advanced liberal government might practise a form of reflexive government, which attempts to promote, and then govern through, forms of technologies promoting a self-actualized and self-managed subject.
In all the Scandinavian countries, it is emphasized that the intention with PA is to make it possible for the user to have an active and meaningful life. The scheme should make it possible for the users to actively take part in society, in the same fashion as other persons of the same age as themselves. As discussed earlier in this article, it is considered troublesome when users do not express the wish to have a more active life. It is thought that they might become passive, and lose some of their functional abilities in the name of user control. From time to time, announcements appear making the worrisome implication that some personal assistants have been buying alcohol for their managers, who have drinking problems (Askheim 2001). The example shows how society's overall norms and values may discredit the PA arrangement without being discussed more closely in relation to the user's self-determination.
By assigning the management of the service to the user, from a governmentality perspective, PA can in many ways be seen as a perfect disciplining instrument within the modern welfare state. The user has to show that he/she is worthy of the State's confidence in order to get PA. Firstly, the user must earn the confidence of the welfare apparatus in order to be granted the main responsibility both for his/her own life and for the management of his/her assistants. Secondly, the user must prove that the assistance is used in proper ways. Such conditions are internalized in the user as self-management, realizing that, if PA is not used as intended, the service will be withdrawn. And such mechanisms will rule independently of whether PA is justified from a resistance model, a consumer choice model or as a co-production project. The frames for what PA could be used for will always be present. As Cruikshank (1999) puts it:
The tactics for empowerment mobilized in innumerable programs […] share a political strategy to act upon others by getting them to act in their own interests. […]. From any ideological perspectives, those interests must be constituted in order to be acted upon. The will to empower may be well intentioned, but is a strategy for constituting and regulating the political subjectivity of the ‘empowered’. Whether inspired by the market or by the promises of self-government and autonomy, the object of empowerment is to act upon another's interests and desires to conduct upon their actions towards an appropriate end. (Cruickshank 1999, 68–69)
Unpacking the concept of empowerment in relation to the PA scheme gives us an insight into the way different notions of the concept can be related to different ideas and developments of the scheme. PA is, in general, one-sidedly presented as a tool of liberation and independence for disabled people. Empirical studies document that the scheme seems to fulfil such intentions. However, the account made here shows that PA, as an empowering tool, could also be analysed from other angles which gives a more complicated and nuanced picture. One way to get a grip on such an analysis could be from a historical perspective. The initiative to establish the PA services has been closely linked to the empowerment process as a form of resistance. However, as the scheme has developed, the government's role has become more significant. We may be witnessing a shift in the paradigm, as empowerment becomes a strategic managerial technique to develop the users as partners and co-producers of the delivery of government policy. The account of the PA arrangement therefore also points out the way the state seems to enhance its capacity to secure political objectives by sharing power with a range of actors, like disabled people and their user-organizations, drawing them into the development of the arrangement. When the users are drawn into the process as partners and co-producers, it implies incorporation into the values of the dominant partner. This, in turn, may tend to reduce the ability of disabled people and their organizations to raise a critical voice. Questions can be raised over whether the different empowerment approaches can be related to a shift in the government regimes developed in the Scandinavian countries during the last 40 years. Or is the governance of the PA arrangement more a result of multiple and conflicting strands, pointing to a multi-faceted link between PA and the concept of empowerment? Given these questions, undertaking concrete studies of PA schemes where different discourses, conceptualizations and theoretical approaches of empowerment are utilized seems to be an important task to get a more complete picture of the arrangement and its place within today's welfare policy. We find that such studies may not only contribute to the growing research in the field, but can also play a role in the political discussions about how to develop the PA services further, and the role of the users and user-organizations in this process.