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.