“I’m Going Out of my Mind!”

Decision Making with Clients with

ABISuzanne Evas, PhD

ABI Project CoordindatorBarwon Health, Victoria

Power

The proposition:

• Staff in direct, frequent care roles with clients with ABI hold immense power over those clients.

• This power can be unwittingly, inadvertently, or deliberately used against the client.

• Being aware of this power, why staff hold this power, and being deliberately mindful of one’s decisions and actions can help reduce the risk of misusing this power.

Socially Sanctioned Power Position

Where does this power come from?

• Rise of empiricism/positivism

• Medical Model of Health and Disability

• Industrialisation

• The industry of helping

• Helping professions

• Other “professions” stemming from medical professions

Power in the medical model

• Control over knowledge

• Domination over patients

• Legitimised by administrative & social structures

“Medicalisation of Life”

• Social issues become medical/personal issues

• I.e. brain injury from drink driving a personal misfortune, while social attitudes and structures towards drinking and masculinity rituals go unexamined

• Control and restrictions on people with disabilities, subjugation

WARNING!

HUGE Quote

coming on the next slide

Many benevolent, humanistic clinicians see themselves as servants of the public, offering themselves and their services in a non-controlling fashion. They see their clients as free agents, free to accept or reject the offered services. Their self concept- in part due to indoctrination received during training - is frequently incompatible with action perceived as controlling, directing or dictating client behavior. Yet, here is where so many human service workers deceive themselves, because their roles are not almost always societally sanctioned, but in an endless array of encounters between the server and the served, the server is the interpreter of and agent for the intents of society, and wields a truly amazing amount of power and control, even if he may not consciously perceive himself as so doing.

Wolfensberger, 1972

Social Model of Disability

• Resistance to the medical model

• Disability caused by social attitudes and structures

▫ Culture of tragedy

▫ Culture of embodiment

▫ “Otherness”

• Independence defined as self-determination, not functional physical performance

Socially sanctioned power status over

clients

• Helping personnel associated with medical model

• Staff expected to be “experts” or “in charge”

• Historical socialisation of clients to be subordinate to staff

Autonomous work environments

• Work environment in home/non-conventional work setting

• Lack of direct supervision/peers present

• Engagement in leisure/domestic tasks with client

Decision making impairments in

ABI

• Philosophies of client autonomy emerged from disabled academics with physical disabilities

• Different complexities to implement with clients with cognitive/decision making impairments

Social model ideology in a medical

model formed context

• Self determinism and client centeredness is process focused, not outcomes focused

• The pressures of medical model/treatment type expectations within a process oriented, client center orientation may affect the way a staff makes decisions and the types of choices they make when engaging with clients.

Decision spaces

• Multiple influences affect decisions made every day, every moment

• All voluntary action involves a decision

• Most routine/automatic decisions are made at an almost subconscious level

WARNING!

ANOTHER HUGE Quote

coming on the next slide

(Last one, cross my heart!)

Healthcare professionals exercise considerable influence and power over the lives of patients, subordinates, and colleagues-often in routine and subtle ways. (They) can. . double-check procedures or not check them at all . . .emphasize harmony in the office or tolerate interpersonal squabbles . . . Greet (clients) with honor and respect or hardly acknowledge them. Because such routine actions are a daily part of healthcare delivery, the ethical dimension of ordinary professional life must be explored. Healthcare ethics must probe the ethical significance of seemingly inconsequential situations and help healthcare professionals use their power responsibly within the hectic contexts of their daily tasks.

Worthley, 1999

Influences on decision spaces

▫ Individual Differences

▫ Resource Access and Availability

▫ Values of Independence/Client Autonomy Among Staff

▫ Valuing the Client as “Others”

▫ Staff Autonomy

▫ Valency: Staff Needs Versus Client Needs

▫ Emotional Involvement - Staff/Client Boundaries

▫ Stress/Burnout

The Ethic of Practice: Dignity of

Risk/Duty of Care

• How do we define risk?

• What is driving the decision to override a clients’ choice? What is influencing the staff’s decision space?

Self awareness

▫ Awareness of the Influence of Values

▫ Awareness of Value Differences

▫ Awareness of Power Position

▫ Awareness of Communication Style

▫ Lack of Staff Awareness

Are you able to go outside of your

mind and look in?

• Do you recognise decisions as decisions?

• What values/factors drive your decision making?

• How do you check yourself?

• How do you recognise your ‘triggers’?

• What do you bring from home into your work?

• What to you bring home from your work?

What tool can help develop self-

awareness? • Reflective journaling

• Value mapping

• Supervision check-ins and guidance

• Critical incident analysis

• Peer reflection

• Self-talk

• Others tools/strategies?

The proposition:

• Staff in direct, frequent care roles with clients with ABI hold immense power over those clients. This power can be unwittingly, inadvertently, or deliberately used against the client.

• Being aware of this power, why staff hold this power, and being deliberately mindful of one’s decisions and actions can help reduce the risk of misusing this power.

Questions?

Concerns?

Insights?

Hopes?

Dreams?

Ambitions?

Inspirations?