As I am progressing through my internship, I have been contemplating the social work concepts of Human Rights and Social Justice recently, as they relate to my placement setting. In my placement, there is strong emphasis on both. However in some instances there are times it seems that these concepts could be in conflict with each other. For example, in reviewing the “list” of suggested human rights as noted in the CSWE Competencies, “freedom, safety, privacy, an adequate standard of living, health care, and education; I keep questioning if these are supposed to be in hierarchical order, or how does one decide how to deal with conflicts? I have already witnessed situations in which I felt that perhaps a client’s freedom and privacy were respected, but it was at the expense of their safety, standard of living, and quality of health care. I do believe that all people should have access to these basic rights and social services, however ultimately providers need to respect an individual’s freedom first and foremost if there is a perceived conflict. Human rights can sometimes seem like a large and distance international concern, however working in a small community it is helpful to remember that we all affect human rights in how we interact with each other, in small ways. "Where, after all, do universal human rights begin? In small places, close to home - so close and so small that they cannot be seen on any maps of the world. Yet they are the world of the individual person; the neighborhood he lives in; the school or college he attends; the factory, farm, or office where he works. Such are the places where every man, woman, and child seeks equal justice, equal opportunity, equal dignity without discrimination. Unless these rights have meaning there, they have little meaning anywhere. Without concerted citizen action to uphold them close to home, we shall look in vain for progress in the larger world." (Roosevelt, 1958) This quote by Eleanor Roosevelt on the tenth anniversary of the Universal Declaration of Human Rights in 1948, reminds us that that human rights start at home with how we treat our neighbors.

Last year Hospice of Humboldt began collaborating with two communities in Trinity County to implement grief support services in Willow Creek, and also in Hoopa, a nearby Indigenous Community. These communities are not only rural, but also remote, and deaths in the community, which appear to be frequent, affect the entire community. An agreement, spanning six months, was developed between the community health clinic in Willow Creek, and the Family Resource Center in Hoopa. However at some point in the implementation process, differences in cultural values and structures began to challenge the relationships between the organizations involved. From discussing the idea for the implementation of the Trinity County grief support groups with the Manager of Grief Support Services for Hospice, it sounds as though Hospice staff had several initial expectations or assumptions, which were based on their past lived experiences, and their own cultural backgrounds or professional training. Hospice staff agreed to drive to Trinity County once a month and provide volunteer grief support training. Based on their dominant white cultural values, and past lived experiences, Hospice staff assumed that when they came once a month to teach courses, the same cohort of students would be in attendance. However over the course of the Trinity County Grief Support training program, the Trinity County facilitators did not meet the expectations of the Hospice staff, and this caused frustration. As I come into the Trinity County Grief Support program, I am attempting to understand what cultural values and structures may be leading to a disconnect between the experts (the Hospice staff) and the Trinity County facilitators (which are in certain ways assuming the role of the client). The actual experience for Hospice staff is that it is difficult to coordinate the monthly meetings with the Trinity County facilitators. Each time Hospice staff make the journey to Trinity County, which they feel on some level is a special exception or gift to the Trinity County facilitators, the attendance at the trainings is inconsistent; former attendees are missing, and new attendees are showing up several sessions into the training program, and then they will disappear again. Clearly there is some level of disconnect between what Hospice of Humboldt staff are expecting from the implementation of the Trinity County program, and what the Trinity County facilitators are expecting. As I switch perspectives and try to understand the reality of how the Trinity County facilitators may be experiencing the Hospice trainings, several questions come to mind. I wonder if the Trinity County staff felt that a mutually respectful relationship was sufficiently established prior to engagement in the official training. Did the Trinity County facilitators and Hospice staff both have a clear expectation of what ‘the plan’ was going to be? It may be possible that Trinity County facilitators, particularly Indigenous staff do not do not feel that a sufficient context of familiarity and relationship, and therefore trust, has initially been established between the Hospice staff and themselves prior to beginning to work together, and particularly to discuss private topics such as family, religious ceremonies, and feelings about death. Or maybe it could be that the general Hospice curriculum did not feel culturally relevant for their community, given the additional factors of multiple losses and complicated grief that significantly impact their population. Perhaps the Trinity facilitators decided the dominant culture’s direct approaches to facilitated grief support would not be accepted in their communities; however they did not feel empowered to openly express their views to ‘experts’ i.e. Hospice staff, and therefore they demonstrated avoidance and disengagement. The staff at Hospice are reevaluating their own values and biases and identifying new ways to approach the Trinity County facilitator meetings. The grief support manager brings some training materials to the meetings, however she also is open to following the ‘flow’ of the meetings and responding to the input she can gather from the Trinity County volunteers. This is allowing room for discussions of Indigenous cultural practices, and how some are in conflict with the group facilitation practices Hospice normally utilizes. Facilitators are openly sharing what ways they will be utilizing some aspects of the Hospice training, but also looking for additional models, which may be more culturally appropriate. I feel that progress is being made toward developing mutually respectful relationships involving trust, and feeling that there is an opportunity for both parties to be the provider versus the client, or the teacher versus the student, which assists in equalizing the relationship.  

Over the past few weeks, I have been reading about grief and loss, and the dying process as part of my internship experience. This has been useful as far as gaining empathy for families who are in these situations, and building a depth of knowledge regarding different experiences individuals may have with grief. While I am reading about death and grief, I keep encountering themes around the importance of love, life, family, and acceptance. If someone has not had the experience of being with a loved one at the end of life, this may seem contradictory. However, being with someone at the end of life, may end up finally teaching us the lessons we need to fully appreciate our lives going forward. This has certainly been the case in my personal life, and I continue to find more appreciation in life as I progress through my internship at Hospice. Which led me to explore a topic around how humans appreciate life and what makes human beings “happy”? How do we know the choices we are making will be worth it? How do we go about making significant choices? In this search, I came across a book called, Stumbling on Happiness, by Daniel Gilbert. The book sounded a bit simplistic, yet Dr. Gilbert is a Harvard psychologist and spoke at the APA convention in 2010 regarding his research on happiness. One of the main themes is how humans spend a significant portion of their life living in the future. We are constantly planning ahead, hoping our hard work pays off, hoping retirement is relaxing, even though we are stressed out at our current jobs…. whatever the situation is in our particular lives. Ultimately however our brains are not able to predict who our future selves will be, and if we will appreciate the choices that our past selves made, or resent those choices, in a similar way to how children may grow up and resent the parents who tried their best, but ultimately did not provide what the child decided was important as an adult. Through various research scenarios Dr. Gilbert explores how and why our brains are not accurate historians, and how comparing to the past causes problems when we use our past experience to make inferences regarding what our future wants, desires, and needs will be. Therefore the bottom line of his suggestion is if we want to know and understand what it is feel like to have a different job, live in a different place, raise a child, whatever the experience is, our best source and most honest source of information is to ask someone who is currently having this experience, and not to rely on our past memory, or other people’s historical memory, when making decisions about our futures. This is a TED Net Talk featuring Dr. Gilbert- http://www.ted.com/talks/dan_gilbert_researches_happiness.html

I am continuing to shadow providers at my internship, and I am learning how varied and the environment and challenges are that each of the client settings presents. I shadowed a social worker that works with patients in nursing homes or assisted living facilities last week. She likes working with these patients, because she feels the care is more consistent and there are less complications around caregiving than when patients are in their home. The visits that we did were to patients in a special unit for dementia diagnoses. From my observations it appeared the patients’ diagnoses could make it challenging to determine causes of pain or decline, as they may not be able to communicate clearly, logically, or remember their symptoms from one visit to the next. One of the patients we visited appeared to be presenting markedly different behavior from prior visits, and the social worker investigated possible causes for this patient’s change in behavior. Due to her particular attention and patience, the social worker was able to spend additional time with one client, and I believe make a possible medical diagnosis, or at least suggestion, which may not have happened otherwise. The patient was awake and sitting up, however she had difficult focusing her eyes, and finding words. The social worker said this was unusual. Normally the patient was either completely asleep or quite interactive and able to go for walks and hold a conversation. However for this visit staff was reporting the patient had almost stopped eating and drinking, and was not getting out of bed or talking for the last week. On one hand, these could perhaps be signs of expected decline at the end of life. However the social worker was not confident of this, and investigated of other possibilities, such as medication changes, however this was not the case. The social worker continued sitting with the patient to see if additional clues could be gathered, even though the patient’s interactions were limited. As the patient dozed, the social worker quietly completed documentation, while still being present for this patient. I sat close to the patient and also tried to observe her and hold her hand. The patient would periodically start a sentence, and then not finish. Several times she said, that she was “confused” or “couldn’t find any of her things.” The fact that we spent a significant amount of time with a patient that was not very responsive, yet were able to still communicate with her a small amount, may have been what assisted the social worker in hypothesizing a possible cause for the patient’s change in behavior. The social worker mentioned that it is common for older people to exhibit signs of confusion if they have a urinary tract infection (UTI), and that UTIs are common in elderly people and frequently go undetected. Therefore after the social worker’s communications with facility staff, the patient, and in combination with her professional judgment, she determined there was a significant possibility the patient had a UTI. This one case study was an excellent example for me to see the challenges associated with working with this population of Hospice patients. On one hand the patient that I visited were in an exclusive facility for high level of care patients. Yet it is difficult for rotating staff, as well as even Hospice team members to have a true sense of the intimate day to day changes that occur with a patient, particularly when the patient themselves is not capable of accurately communicating with staff. Given these challenges, a social worker must be able to access and investigate multiple sources of knowledge, and communicate well with a variety of individuals in order to complete assessments and provide any appropriate interventions.

Different Approaches to Grief Support

At my internship site two different grief support group models are offered, which I will label traditional and alternative models. Both groups support individuals experiencing grief. Yet the atmosphere and energy in the groups are decidedly different. The traditional group openly discusses individuals’ grief and coping, and the agenda for these groups are centered on this ‘deficient’ or loss individuals have experienced. In the alternative group, the atmosphere of the group is one of a social club, and has an air of affirming the survivor’s life, and exploring what is next for them. The opportunity to compare and contract two different models of group facilitation has been exciting and clinically rewarding, as I move from reading about theoretical frameworks toward practice. The traditional support group model at my internship placement involves clients and facilitators coming together and sitting in a circle. The facilitators begin the group session in various ways; they may remind the group members of group etiquette, read a poem, practice a mindfulness exercise, or some combination of these. Facilitators rephrase and reflect back to clients what they heard, and make connections between experiences or stages two clients may have had which have similarities, for example. The clients take turns if they choose, sharing their feelings, struggles, successes, all centrally focused around the event of their loved ones passing. Clients may be at different stages of grief within the group, yet those who have been there longer can offer inspiration and wisdom to others who are just beginning the grieving process. Additionally this model allows everyone in the group the opportunity to hear each person’s story and be apart of their process. Another perspective is that this model may be difficult for individuals who feel burdened by listening to other individuals share their grief, if their own grief is still overwhelming. Also clients could feel uncomfortable with the idea of talking about personal/private concerns in a group setting, depending on their background. An alternative model support group is also offered. The atmosphere of this support group reminds me of a church coffee hour. Two clinicians facilitate the group. The clinician who developed the group describes the approach as being a “lighter touch” to grief support for those individuals who are not as comfortable participating in a traditional group setting (Whitt, 2013). The demographics are mostly retired individuals who have lost lifelong partners. These older individuals may not be comfortable with more modern support group models, which encourage sharing personal feelings publicly. With this model the focus in on building a relationship with and between the clients and the facilitators. Once a sense of relationship, trust, and in some instances friendships is established among clients, then there is a natural progression toward sharing more personal information. In this alternative grief support group the facilitator sets a theme for each session, which is uplifting and life affirming, and usually a surprise for the clients. Themes may be around spring arriving, a person’s birthday, or a special tea party. Additionally the primary facilitator is enthusiastic and excited to greet each client. During the first hour clients and facilitators greet each other, and visit around a large table over coffee and refreshments. The unstructured nature allows clients to have lengthy conversations with each other in dyads or small groups, and for facilitators to have one on one conversation with individuals who may need additional support. The thirty minutes of the group is reserved for sharing a community calendar of events. The calendar gives clients ideas for getting out in the community again by themselves or perhaps with another group member, and is delivered in a humorous manner. The overall the group seems to focus on client empowerment and strengths, in an accessible and developmentally appropriate format for older individuals (Robbins, Chatterjee, & Canda, 2006, pp. 434-435).

Learning to make ethical decisions as a social worker and managing ambiguity around the NASW Code of Ethics will be a significant challenge, and will vary depending on work contexts. As I reflect on the meaning of ethical principles and practice in social work, my first question is: what is the definition of ethics, and whose definition is it? Goldberg Wood and Tully (2006) explores the complex history of ethics and the social science and philosophy of this area of study, as well as how this area relates to the National Association of Social Work (NASW) Code of Ethics. The origin of the word dates back to Greek times meaning custom or character. Ethics are tied to societal ideals, moral values, and cultural norms. Goldberg Wood and Tully’s final assessment is that societies define ethics for their own benefit, and for the purpose of controlling individuals. The NASW Code of Ethics reflects the professional values and ethics of social work as a profession and assists in communicating these cultural norms to new generations of social workers (Goldberg Wood & Tully, 2006). Ethical reasoning and decision making in a professional context can refer to utilizing theoretical principles and ethical codes of conduct as a basis for our decisions regarding policies or client treatment and access. For example, in my current internship at Hospice in bereavement services, federal regulations state that bereavement counseling must be provided for family members of hospice patients, however the federal regulations also state that bereavement services are not reimbursed by Medicare or Medicaid. Given this ‘double message’, services must be provided, but there is no monetary support for them, some organizations could take this as permission to limit bereavement services that are offered and exclude /graduate clients. Yet Hospice has been creative in how they approached this issue, given the rural area we live in, and the limited availability of bereavement supports in our community. There are two bereavement counselors to work primarily one on one with clients. In addition Hospice recruits volunteers to facilitate weekly support groups throughout the community, and recently expanded training opportunities into a local Indigenous community. At Hospice grief support services has made specific decisions around ethic practice regarding inclusive access to services, which supports the concept of social justice for the overall population of our rural community.

I am continuing to shadow practitioners and visiting patients in their homes. This has given me an opportunity to begin interacting with patients some that are close to the end of life. Patients are in different settings: in their home surrounded by family, in someone else’s home, in a skilled nursing facility, or living alone. Each time I visit a different situation, I can feel myself on some level assessing the situation, and judging it, yet also having my world opened wider to the varied ways people live. Ultimately I am struck by how open and inviting people have been with me, when they have so little time left, and they are willing to share stories, feelings, or words of wisdom with me. I am noticing myself observing the patients, who I know are the primary concern, but also what the interactions are between the patient and caregivers, and well as the mood of the caregivers. One situation I found myself feeling judgmental was when I visited a woman who was praying with the Chaplain to live for one more week until her new great grandson came to visit. The patient was not eating or drinking very much, and was quite jaundice. Not knowing the details, I was frustrated that her family could not come sooner. Yet as I observed the Chaplain, she focused on reading to the patient, discussing looking forward to next week, and ensuring her pain was under control so she might be able to eat. One patient I visited was living alone, and she is very close to the end. Her house is immaculate, she is perfectly dressed, and as a stranger I would never know she was ill. Yet as we visited with her, it became apparent that she was experiencing more frequent heart trouble, and was worried that she was going to pass away last week. As she and the Chaplain discussed her recent decline, the Chaplain brought up the possibility of getting a Lifeline service. The patient mentioned several reasons she did not think it was a good idea. The Chaplain allowed that choice, even though the woman had brought up several safety concerns around possibly falling when she had chest pains, and having pain at night when she is alone. These are areas where I understand the NASW Code regarding allowing patient self-determination yet it also feels like it is difficult to determine what is the boundary between self-determination and acceptable risk. Also how do I define ‘acceptable risk’ versus how does someone else define it? This is an area where I will need to remember to not impose my values and ensure I am following the guidelines regarding if a “clients’ actions or potential actions pose a serious, foreseeable, and imminent risk to themselves or others” (National Association of Social Workers, Code of Ethics, 2008).