It never seems to settle

There are some issues that I deal with on a regular basis on my caseload that get easier each time they come up.  I understand the process better, the attending paper work is more familiar, and the questions the clients and families ask - while worded differently - are essentially the same.  Overtime I develop 'short-cuts', I find a connection on the 'inside' of those bureaucratic government systems and can make 1 phone call instead of my clients having to make 15 to get the same information. To my clients, these are small acts of kindness, or efficiencies at the very least, that translate into small victories on what seems for many a relentless and vast battlefield.

But yesterday, suspicions were confirmed that a daughter of a client, who is also POA had been taking a large sum of money out of her mom's account weekly for at least 2 years.  She felt entitled as POA to something, to some form of compensation.  As a daughter, she felt she had a right to borrow against her future inheritance. She said there was a 'verbal' agreement between herself and her significantly demented mother; surely that must make it legitimate.  I am constantly surprised by these stories - even though, I hear them all the time. 

Adult abuse and neglect seem almost always crimes of opportunity (at least financial abuse).  Blatant, premeditated, and intentional in action, vulnerability is identified and then exploited by those motivated by desperation, greed, and often a sense of entitlement.  Now it may seem harsh to say its all intentional and premeditated, but these situations do not equal a kid finding a quarter on the counter and deciding to take it to go buy candy.  These situations are involved - from the planning, to the crafting of alibi's and stories of justification, to the execution of the plan itself.  I am amazed at the level of surprise that accompanies someone getting caught with their hand in the cookie jar.  Most signficantly, I am amazed that these situations even occur.  It just never seems to settle.

a new kind of vulnerable

I was having a conversation with a family the other day who were expressing the reality that their ability to financially support the care of their aging parent was fast approaching an end; they were terrified, anxious and burdened by a sense of deep failure. They had already wrestled and fought their way through an earlier and equally difficult predicament - the realization that they could no longer emotionally and physically support their parent at home - the health care needs and the physical toll of caring were simply too much, even with significant formal and informal daily and hourly support. It was a decision in many ways that was long overdue ( at least from the vantage point of the onlooker); the family was exhausted the client was frail. They took solace in the fact that at least at the time of this decision, they were financially in a position to afford private facility care, while they waited for a subsidized bed. The move was immediate, mom settled in well and the family regained a sense of emotional and physical equilibrium. Everyone's need were taken care of; it was looked at as one of those win-win situations.

What no one anticipated though was the devastating impact of a simple change in wait-listing policy. When mum was in the community it was a crisis; her care needs exceeded the capacity and availability of formal health care resources and had overwhelmed the family's capacity to carry the balance of care required. The only viable and realistic option was placement in a care facility; it was clear that her need for placement was considered 'urgent'. Who would have thought that the short term 'fix' the family was able to provide, in terms of paying privately for a facility bed while awaiting a subsidized bed, would have such a punishing outcome as a result of a policy change. Now that she is 'safe and sound' in a facility bed she is no longer considered in need of urgent placement - effectively she has landed on a snake (as in the game snakes and ladders) and has slipped way back in line for a subsidized bed - even though she has been waiting for over a year. The only way she gets to the top of the wait-list, the only condition upon which she would qualify as 'urgently in need of a subsidized bed' is if she and her family were no longer able to pay privately for care; in essence, she and her family have to be flat broke with no other options before the 'system' reconsiders her level of need. Its not that a bed magically appears when this happens - the stars are not so easily aligned - its just that now she fits the criteria for being urgently wait-listed. What happens in the mean time (while the wait is still on for a subsidized bed to become available) is that the she and the family are presented with a few options, of which they are left to decide on the lesser of two evils: one, she can return to the community and be cared for by a collective of informal and formal supports (which was already tried and clearly was insufficient for the level of care required); or two, be admitted to hospital and await placement from there (an undignified, extremely disruptive option for the client, to say nothing of a flagrant misuse of an already overtaxed resource). Simply put the demand for subsidized extended care facility beds significantly outweighs the supply - the 'system' says their hands are tied, there is no money, there are no options - well, no good options anyway.

This is a new and emerging kind of vulnerability - one that explodes from the fragility and precarious nature of an increasingly under-resourced system of care. The trickle down impact of policies written far away from the front lines of care devastates families and clinicians alike. Clinicians are forced into a position of somehow defending a broken system which has reneged on the most basic of promises: to provide continued access to quality health care without financial or other barriers and to protect, promote and restore the physical and mental well-being of residents of Canada. (FYI: these are the stated objectives of Canadian health care policy).

While the system seems okay with offering solutions that are known to be insufficient (returning a client to the community where their needs exceed the capacity of formal and informal resources) and / or are not in the best interest of the patient (ie, will do more harm than good), front-line clinicians do not have the same protected luxury. We are the ones who have to look into the weary and exasperated eyes of patients, their families and caregivers and tell them that the system can no longer guarantee or safeguard their well-being. Where does this leave us? The impact of these policies contravene the objectives of Canadian health care policy, and arguably also contradict the ethical standards of practice of many, if not all, of the professional health care disciplines.

It has occured to me that while responding to adult abuse and neglect falls within the domain of health care (at least in the province of BC), it is an uncomfortable fit at best. Situations of abuse and neglect are not acute or chronic medical conditions and therefore cannot be understood as such. Health care clinicians, for the most part, are driven in their assessment, understanding and actions of any given situation by an epistemological stance heavily influenced by a scientific, biomedical understanding of how things work - cause and effect, for example, and that for every problem there is a solution, and that the success of the fix is contingent on how the individual (body, mind, behaviour) responds to whatever solution is offered.

To be fair, abuse and neglect cases are prioritized and responded to swiftly like other crisis situations. This is where perhaps the fit between these issues and the health care system works. If an adult needs immediate safety, shelter and attention for medical conditions that threaten their health then the system is relatively well resourced to provide for these short-term, medically focused, interventions. But it is in the crafting of long-term, effective, appropriate solutions to these complex situations that challenge and expose the shortcomings of the health care system. Responding to situations of abuse and neglect extend well beyond the expertise of medicine; they are lived experiences born from multiple and intersecting social, cultural and historical factors - only some of which are manifested in the body and mind. Responding to these situations requires a different lens, a different language, a different orientation - a paradigm shift that allows and values an exploration of the whole: person, context, environment and the interpersonal relationships in and from which vulnerability, risk, abuse and neglect emerge.

An Orientation to Practice

With every client encounter, I have an opportunity to change the way that they experience the health care system. The way I orientate myself to my work, the way I enter into the space between myself and my client is integral in creating an environment that encourages change, growth, renewal and healing.

Among other things, I along with my esteemed colleague A.S., have been working on articulating an 'orientation to practice' that captures the essense of a culturally safe approach to working in the area of abuse and neglect with vulnerable First Nation adults.

The front line struggle of 'how to be most effective but least intrusive' in responding to reports of abuse and neglect of vulnerable adults is made even more complex when working across culture with vulnerable First Nation adults. Knowing that historically the very presence of health care clinicians (aka. 'outsiders') in the lives of First Nation individuals and communities has been experienced as 'intrusive', I grapple even more with the question of how to do this work well.

Abuse, neglect, vulnerablity... these are not medical conditions that can be cured or fixed with a 'one size fits all' approach. These are complex relational realities influenced greatly by historical circumstances and diverse social factors, the impact of which are not just experienced in the present but woven through and across multiple generations. Responding to and intervening in situations of abuse and neglect is a complex endeavor that extends beyond the limits of medical expertise. It requires clinicians to broaden the scope of understanding to include the historical, social and cultural context of any given situation, the physical, mental, emotional, and spiritual functioning of the vulnerable adult and how the interplay of these elements contribute to a more accurate assessment of vulnerablity, risk and well-being. In my frontline work in this area of practice it has became clear that a different approach is required, a different dialogue and a different level of engagement, particularily when working with vulnerable First Nation adults, their families and in their communities.

The "orientation to practice' that has been articulated in a recent working paper is a 'hybrid' approach, drawing on indigenous knowledge, valuable concepts and models of cross cultural practice and social work theory, insight from research on abuse prevention and social determinants of health, and anecdotal accounts of community abuse prevention and response projects from First Nation communities across Canada. It is a holistic approach that weaves together aboriginal wisdom and worldview with western clinical practice theory creating a broader lens through which risk and vulnerability can be more accurately assessed and health and well-being can be better interpreted, understood and supported. Of particular importance is the recognition that culturally safe practice requires careful, intentional and respectful collaboration between aboriginal and non-aboriginal health care clinicians, service providers and involved community members. The challenge for the clinician is to find ways to respectfully and humbly enter the 'space between' - creating opportunities for full, even conflicting narratives to emerge, taking the time to listen and understand mulitple perspectives, holding sacred these voices and co-creating meaningful and effective responses that mitigate risk and vulnerability and perserve dignity both for the individual and community.

A social experiment......

A rather larger percentage of my caseload is focused around issues related to adult abuse and neglect. If i'm not directly investigating reports of adult abuse and neglect, I am responding to and collectively grappling with questions and concerns presented by clients, families, and colleagues alike around vulnerability, capability and the intersection of these two concepts.

Over the next several months, the blog will be exploring the complex and challenging issues that arise from working in the area of adult abuse and neglect. For me, some of these challenges include understanding vulnerability in a broader, socially determined context; grappling with what it means to be "least intrusive" in an area of practice that has 'outsiders'(like myself) justified or not, making determinations about someone's capability - necessarily threatening their autonomy, self-determination. Could it be anymore 'intrusive'? In the rush to fix, save and cure - one of the most challenging aspects of this work, is finding ways to enter into these spaces - creating opportunities for full, even conflicting narratives to emerge, taking time to listen and understand multiple perspectives, holding sacred these voices and co-creating meaningful and effective responses that mitigate risk and vulnerability and preserve dignity.

So here's the experiment part: these are some of the challenges that I am faced with on a daily basis. My hope is that as I grapple with these questions in this forum, that readers and followers of the blog post their own challenges and responses - furthering the dialogue, sharing knowledge, expertise and experience and deepening the opportunities for learning and connection.

Embodied Experience

"What happens when my body breaks down happens not just to that body but also to my life, which is lived in that body. When the body breaks down, so does the life. Even when medicine can fix the body, that doesn't always put the life back together again."

Arthur Frank

In health care, the primary focus of care is to diagnose and treat disease, ameliorate pain and suffering, and to champion 'recovery' as the ideal ending of illness. This is all really good and necessary stuff - but is it all there is? I don't think so. The medical narrative that dominates and drives clinical decision making around patient care is limited. It reduces a life to the biological/physiological functioning of body parts - something which can be measured, controlled and fixed if there is a problem. It is a storyline that focuses on the parts that have broken down, not about the whole, which is living the breakdown.

It is the 'whole' that is often considered last, if at all, in the busy world of managed care. To recognize the 'whole' takes more time. Understanding a patient's embodied experience of their health and illness requires a different kind of dialogue and a different level of engagment. It requires us to step into unfamiliar space and allow a rich and nuanced narrative to emerge that gives voice to an experience medicine cannot describe.

Inherently whole, intrinsically well.....

"What would it be like to approach our lives, and to engage in the lives of others, knowing we are all inherently whole, intrinsically well, in need of being drawn forth into the discovery of unabashed completeness? How would this change the entire dance of practitioner and patient? What kind of relationship would be wrought and shaped when seen from, and uncompromisingly held within, this point of view?"

Saki Santorelli
from Heal Thyself: Lesson on Mindfulness in Medicine

Reading this quote, takes me in lots of different directions. It is a personal and professional challenge to view myself differently and to view those with whom I work differently. It is a quote that has changed me personally and influence my desire to 'capture' and articulate how I work - or aspire to work (an 'orientation to practice') with clients in my role as a community health care social worker.

The clientele served most commonly by social work are individuals and families who are vulnerable and often marginalized because of circumstances (physical/mental health, social, economic, environmental, cultural, etc.) largely beyond their control. More often than not, they are perceived as 'broken', 'difficult', 'unhealthy' (in reference to their lifestyle, how they live), 'needy'; they are certainly not frequently perceived as 'inherently whole' and 'intrinsically well'.

So how is it that we change the way we view our clients who come to us shattered by life circumstances, weakened by illness or injury, silenced and shamed by stigma? Our actions and interactions with clients do not create wholeness; they do not fix flaws or fill holes. If what Santorelli suggests in the above quote is true, our actions and interactions with our clients facilitate the emergence, the restoration of lives that, while shattered and compromised are still inherently whole.