Cross-Disciplinary Response: A Way Forward

1. Cross-Disciplinary Response: A Way Forward

2. Who is Who Joan Braun Maria Denholme Elm Institute BC Centre for Elder Advocacy and Support (BC CEAS)

3. Objectives To identify effective and practical ways of delivering effective cross disciplinary servicesfor older adults who have been abused. To discuss some of the challenges in cross disciplinary practice. To discuss “lessons learned” from program evaluation of cross – disciplinary services in BC and how recommendations might apply to other cross – disciplinary settings.

4. Outline Introduction Background – Elder Abuse and BC CEAS Cross –Disciplinary Response & Law and Social Work BC CEAS study Three practical strategies Application to other cross – disciplinary settings

5. Elder Abuse and Neglect Types of Abuse Physical Sexual Financial Emotional Neglect Self Neglect

6. Elder Abuse Key factors to consider: Issues of power imbalances; fear of losing support and care of family and friends (especially if caregiver) Abuser is often the family member with the most common being a spouse or partner, followed by an adult child Prevalence 4 – 8% 1 in 12 seniors in BC have experienced financial abuse (defined as losing more than $20,000).

7. Elder Abuse Older adults may not recognize they have been abused and some researchers have compared the dynamic to “undue influence”. When it comes to financial exploitation, older adults often don’t realize they have been manipulated out of money until after the event; even then they may say they wanted to give the money to family or friends.

8. Legal Framework “Vulnerability” is a term that refers to vulnerability to abuse or harm. Different jurisdictions have taken different approaches to protecting vulnerable populations. In the United States, for example, in many states it is mandatory to report abuse of older adults and adult protective services must investigate. In BC there is no mandatory reporting requirements and civil laws setting out protective measures only apply if the older adult is unable to seek help and assistance on his own. The general population is not required to report abuse of older adult. However, health authorities are required to investigate reports of abuse of older adults who are not able to seek help and assistance on their own.

9. Benefits of Cross – Disciplinary Practice Older adults who have been abused regularly have a complex myriad of needs. These needs can best be met by service providers with different areas of expertise and knowledge. Examples from BC CEAS (scenarios & involvement of different professions) If professionals from different backgrounds are involved then it is best if those professionals work effectively together. This is true of service delivery in general but particularly true when it comes to services provided to abused older adults.

10. BC CEAS History Services SAIL Elder Law Clinic – Priority Areas Evaluation and Back Ground to the Study

11. Cross – Disciplinary Practice Challenges - Different professional requirements • Different values • Different “language”/ terminology We will give examples of challenges which may arise and will use the case study from BC CEAS to give examples of how these might be addressed

12. Law and Social Work Why Use Law and Social Work as an Example Every profession has standards or best practice guidelines. Sometimes these may be stringent and it is good to be aware that someone from another profession may be bound or limited by the requirements of that profession. A Few Law & Social Work Professional Differences • Confidentiality • Who is the client • Supervision vs. Collaboration • Conflicts

13. Law and Social Work Why Use Law and Social Work as an Example Key difference: Social workers can provide assistance in a situation and they may provide help several clients or families involved in the situation even if some of those individuals have a conflict between each other. Lawyers can only be involved where one client “retains” the lawyer to act on his or her behalf. The lawyer can only act on the client’s instruction and the lawyer can not represent or help any one involved in the situation other than his or her client. In very rare circumstances a lawyer may represent more than one person but never if there is a conflict between them.

14. Law and Social Work Why Use Law and Social Work as an Example Scope of our Workshop • We are discussing this issue in the context of a situation where the social worker and the lawyer are both representing the same client and where there is not a “conflict of interest” (from a legal perspective). • Due to professional practice standards, a lawyer working at an agency such as BC CEAS will have a very different relationship with a social worker employed by CEAS than a social worker who works for the hospital or government. • We are using illustrations from professional standards for lawyers/ social workers in BC Canada. Standards may differ in other jurisdictions.

15. Law and Social Work On many issues values and principles underlying the practice of law and social work overlap and may even be the same. For example, if a lawyer and a social worker have clients both professionals want the best result for their clients. However, what each interprets as the best result may differ (lawyers focusing on legal result and social workers on broader interests) However, even where the underlying values are shared, how those are defined or interpreted may vary.

16. Law and Social Work EXAMPLE: Autonomy of capable individuals Social Work: The CASW Code of Ethics: Value # 1: Social work is founded on a long-standing commitment to respect the inherent dignity and individual worth of all persons. When required by law to override a client’s wishes, social workers take care to use the minimum coercion required. Principles: • Social workers uphold each person’s right to self-determination, consistent with that person’s capacity and with the rights of others. • Social workers uphold the right of society to impose limitations on the self-determination of individuals, when such limitations protect individuals from self-harm and from harming others.

17. Law and Social Work Example: Autonomy of capable individuals Social Work (continued): The CASW Code of Ethics: - Social workers respect the client’s right to make choices based on voluntary, informed consent. - Social workers uphold the right of every person to be free from violence and threat of violence. Value # 3: In professional practice, social workers balance individual needs, and rights and freedoms with collective interests in the service of humanity.

18. Law and Social Work Example: Autonomy of capable individuals Law Instruction comes from the client. The lawyer has an ethical obligation to inform the client of the potential consequences of a poor choice but should not ‘over ride” the client’s wishes to take another course of action. If the client instructs the lawyer to do something unethical then the lawyer should simply decline to carry out the unethical act. If the client is incapable of giving instruction the lawyer still should not over ride the client’s wishes but instead should withdraw from representing the client.

19. Law and Social Work Example: Justice Social Work Based on ethical principles. This can be found in social work practice standards and is a core value. This also is particularly evidenced in certain social work methodologies such as anti-oppressive practice. Justice is balanced between individuals and communities.

20. Law and Social Work Example: Justice Law Justice and access to justice is a very high value to lawyers. However, justice is not equated with “fairness” but on what a person is entitled to at law and access to the legal justice system. The law can be very “blunt”. A lawyer is concerned about justice for his or her client. A lawyer may also be concerned about issues such as access to justice or justice for oppressed groups through law reform and other initiatives.

21. BC CEAS Study BCCEAS undertook a review of the Elder Law Clinic (ELC) in 2011 The purpose was to consider the clinic in the context of the wider agency, and evaluate whether the elder law clinic was providing services in its priority areas, their outcomes, and how the clinic was integrated into the wider agency. A sample of 20% of the cases registered with the Elder Law clinic and the advocacy program were selected and reviewed (both legal programs were considered together as they had significant overlap in staff and types of clients/calls over the period of the review. The population from which the sample was drawn was all cases entered into the electronic case record system in 2010 (in 2009 the clinic was in its start up phase, so 2010 was first year of full operation). Key findings and recommendations are below.

22. BC CEAS Study Finding: • The review revealed that 50% of calls to the legal programs were in the priority areas for the ELC, but that a proportion of the remaining 50% fell within the priorities of the wider agency. • On some occasions when clients were referred to the clinic because of a legal problem, when it turned out legal services were not appropriate lawyers spent time providing support and assistance of a non legal nature that staff in other BC CEAS programs could have provided. Discussion: • Elders often do not see concerns in light of their legal implications and possible solutions • Elders may not see abuse as abuse and may not identify that they are entitled to legal recourse • Lawyers in the clinic were not always able to identify how to make best use of the skills of staff in other programs such as social work staff, and, on those occasions, the lawyers spent time on file work outside the priority areas.

23. BC CEAS Study Finding: • Only one case in the study sample was taken to a formal tribunal by the ELC Discussion: • For many of the issues which were brought to the ELC there are no formal tribunals to which the case can viably be brought • Elders often do not want to pursue a formal legal solution to issues, particularly of abuse and neglect as the alleged abuser is often a family member or someone else close to them • Some of the cases that were referred out from the ELC may eventually have gone to a formal tribunal either through private counsel or another agency (with all the attendant difficulties in service with less continuity of care) • In some cases ELC lawyers provided service that, while it did not go to a formal tribunal was representational in its character, in some cases it was most effective to have a lawyer perform this representation, in others a skilled social work advocate would have been just as effective.

24. BC CEAS Study Finding: • Some cases were not able to be served through the ELC because the call came from a formal or informal caregiver, or pertained to a client who was not able to instruct counsel Discussion: • Elders have formal and informal supports who are willing and able to advocate for and assist them, but do not have the capacity to instruct counsel • Lawyers are only permitted to accept instruction from the identified client and then have specific rules about what they can and cannot do, even if instructed by the client to do so. • Many people who are capable of assistance and advocacy for elders do not feel equipped to engage in the legal system and legal solutions to concerns.

25. BC CEAS Study Recommendations • Clarify the roles of the social work advocates, legal advocates, and lawyers with clear criteria for their interaction and boundaries • Create partnerships with community social work and legal organizations allowing for increased client recruitment, and increased capacity in the select agencies. • Increase the role of the agency in Public Legal Education and policy development to ensure that elders have both social and legal recourse in matters that concern them and their wellbeing. • Expand the service of the agency to include direct assistance to elders, and public education to all, with regard to advanced planning tools to increase the number of elders whose needs can be served by the agency and to allow for greater control by elders of their care and legal decisions.

26. The ED’s Perspective From the perspective of the executive director – what improvements could be made? • More communication about purpose, goals and professional responsibilities. • More transparency about limitations based on funding and on professional expectations. • Integration of a multi-disciplinary aspect into the service delivery model. This will be fleshed out in the three examples that follow:

27. 3 Approaches Cross – Disciplinary Practice 1) LEARN COMMON LANGUAGE & UNDERSTANDING Professionals from different professions can end up working at cross purposes by having different understandings of the goal of the work, the priorities or the work and how to communicate about the work. Common language can intentionally be chosen and models can be employed to foster understanding: Fordham University Clinic Example.

28. 3 Approaches Cross – Disciplinary Practice 1) LEARN COMMON LANGUAGE & UNDERSTANDING (Cont) “Social Work Practice and the Law: Becoming a Collaborative and Competent Practitioner” by Lynn Slater and Karen Finck, 2011 Springer Based on the author's innovative and nationally recognized prototype for inter-professional work at Fordham University, this is the only volume about social work and the legal system that is written from the social worker's perspective. This book aims to promote the development of a more strategic relationship with the legal system-a partnership that can achieve more creative and just solutions to social problems.

29. 3 Approaches Cross – Disciplinary Practice 2) ASSOCIATE WITH ORGANIZATIONS WORKING IN THE CROSS – SECTION OF THE TWO PROFESSIONS Example: National Organization of Forensic Social Work 460th St, St. K Middletown, CT 06457

30. 3 Approaches Cross – Disciplinary Practice 2) ASSOCIATE WITH ORGANIZATIONS WORKING IN THE CROSS – SECTION OF THE TWO PROFESSIONS (cont) Mission Statement: The mission of the National Organization of Forensic Social Work is to adhere to ethical standards of practice, to advance the field of multidisciplinary forensic social work through training for our members, to engage in policy and program development and evaluation, to facilitate expertise related to civil and criminal law and alternative dispute resolution, and to provide services that improve the effectiveness of our members and the lives of our clients. Vision Statement: The National Organization of Forensic Social Workincorporates a multidisciplinary perspective, among social work and systems of justice, to advocate for social justice in a global society, including populations historically served by social work, to improve outcomes for clients and the community based on respect, integrity, and excellence.

31. 3 Approaches Cross – Disciplinary Practice 3) FAMILIARIZE SELF WITH RESEARCH AT THE CROSS – SECTION OF THE TWO DISCIPLINES A research based approach can “normalize” some of the interesting tension that may exist between desired outcomes by one profession and another or even tension within one particular profession. A research based approach can offer the necessary support for professionals to ask themselves the “difficult questions”.

32. 3 Approaches Cross – Disciplinary Practice 3) FAMILIARIZE SELF WITH RESEARCH AT THE CROSS – SECTION OF THE TWO DISCIPLINES (cont) Example: Therapeutic Jurisprudence TJ has been defined as “the study of the law as a therapeutic agent,”66 a new prism through which to study the substance of law, legal procedures and legal actors. An assumption in TJ is that client concerns transcend the expertise of any one profession. Therefore, the Implenatation of TJ requires collaboration between professions [Robert Madden and Ramnie Wayne. Social Work and the Law: A Therapeutic Jurisprudence Model. Social Work 48 (2003) 338. TJ explores the therapeutic and countertherapeutic consequences of the law on the individuals involved ... perhaps even the community. TJ recognizes that the law is a social force with negative and positive emotional consequences for all the people involved in a particular legal matter. ...It seeks to identify those emotional consequences; assess whether they are therapeutic or countertherapeutic; and then ask whether the law can be changed in ways that can maximize its therapeutic effects.[ Susan Daicoff, Making law therapeutic for lawyers: therapeutic jurisprudence, preventive law, and the psychology of lawyers, 5 PSYCHOL., PUB. POL'Y, AND L. 811, 813 (1999)] TJ found its initial home in mental health law over twenty years ago, but its relevance soon had it being applied in family law,68 elder law,69 and lawyering itself [(Dennis P. Stolle, David B. Wexler, Bruce J. Winick & Edward A. Dauer, Integrating Preventive Law And Therapeutic Jurisprudence: A Law And Psychology Based Approach To Lawyering, In Practicing Therapeutic Jurisprudence 7-9]

33. 3 Approaches Cross – Disciplinary Practice 3) FAMILIARIZE SELF WITH RESEARCH AT THE CROSS – SECTION OF THE TWO DISCIPLINES (cont) Example: Therapeutic Jurisprudence Lawyers can tend to focus on the legal outcome at the expense of non measurable impacts on the client’s emotional state (social workers may sometime focus on well being at the expense of the legal framework). Research based models can give a framework for professionals to take different approaches to doing their work

34. 3 Approaches Cross – Disciplinary Practice 3) FAMILIARIZE SELF WITH RESEARCH AT THE CROSS – SECTION OF THE TWO DISCIPLINES (cont) Example: Therapeutic Jurisprudence Examples of therapeutic cross – disciplinary practice from a forensic social work perspective, including elder specific situations.

35. Application to Other Settings • Clear communication about what terminology means and what the service goals are (they may or may not be the same across profession). • Development of models that bring the best of both professions to the table in a complimentary way. • Transparency about limitations of what can be done by a particular professional based on professional rules, values or best practices. • Professional development through research and professional development on issues at the cross section of the two professions.

36. Questions ????????

37. Organization Contact Information BC Centre for Elder 1 – 604 – 688 - 1927 Advocacy and Support http://www.bcceas.ca (BC CEAS) http://www.elmsbc.ca Vancouver, BC  604-844-7890

38. Presenter Contact Information http://www.joanbraun.ca braun@joanbraun.ca 1-604-780-4870 Maria Denholme, M.S.W. (c) Social Worker, Vancouver Coastal Health Maria.Denholme@vch.ca 1-604-983-6020

39. CASE STUDY Mrs G. contacts an agency you work for. She states that her husband has early onset dementia. He has become quite violent and she is afraid of him. She does not want to leave their house in case he damages the house. As well, she is wondering what her responsibilities are to care for him as she is his only caregiver and he needs help with day to day tasks. She has two grown children who live far away and only visit occasionally. She also tells you she has lost contact with her local friends as she has been so busy caring for him. 1) What could your agency do to help and what is your role there (use an example from the past if not personally involved in service delivery)? 2) What other professionals might be able to help in this situation? 3) What challenges might you face working with service providers from other professions to assist Mrs. G? 4) What strategies can you use to foster more effective working relationships? 5) What additional information do you need from Mrs G. to effectively help and how would you get that information? 6) (if time) Discuss strategies you have used in your own work in order to foster effective cross – disciplinary work.