Ep. 86 “Don’t just believe what you read on my file”: Re-authoring patient stories
J S
0:05
Welcome to Social Work stories, a podcast exploring social work practice through stories and critical reflection. This podcast is recorded on Aboriginal country which was never ceded. We acknowledge the traditional custodians and cultural knowledge holders of these lands, and pay our respects to Aboriginal elders past, present and emerging. We offer a warm welcome to any indigenous listeners who are part of our podcast community around the world. If you have thoughts or feedback for our team, or just want to find our whole back catalogue of episodes, check out our website Social Work stories.com. But for now, on with the episode
MF
Mim Fox
0:55
Happy 2024 Everyone. Welcome to the Social Work stories podcast. It is so great to be back. I'm Dr. Fox, and I am here for yet another year with my wonderful friend and colleague Lis Murphy. Hi, Lis.
LM
Lis Murphy
1:10
Yeah. Hi, Mim , and hello, everyone. And yes, happy 2024 what a big year.
MF
Mim Fox
1:18
Do you realize Lis we've been podcasting now for five years?
LM
Lis Murphy
1:22
I didn't know that actually.
MF
Mim Fox
1:24
Yeah. So the Social Work Stories Podcast has been going strong for five years. It's a celebration I think. We've done so many episodes now and heard so many incredible stories from our colleagues. It's been such a gift, hasn't it? Like, I feel quite humbled by it.
LM
Lis Murphy
1:39
It has been a gift and, you know, Mim that I'm retired. My fellow listeners don't know this that I've retired from Health. And certainly my intention is to not retire from the podcast because like you say it's something that brings sheer joy to certainly to both of us. Listening to the stories of our friends and colleagues and sharing them with our friends and colleagues, and my mum and dad.
MF
Mim Fox
2:06
How was your first Summer in your retirement?
LM
Lis Murphy
2:10
It still feels like I'm on Christmas holidays, quite frankly. I'm growing vegetables and I'm, you know, renovating and I'm hanging out with grandchildren and friends. And yeah, it feels like I'm still on holidays and hopefully for the rest of my life I'll feel like that.
MF
Mim Fox
2:26
That's wonderful.
LM
Lis Murphy
2:27
But yeah, and look, Mim before we get cracking into this story, I did want to say because I have more time for podcasting, I just wanted to spruik to our listeners, that if ever you've thought that you'd like to share a story, but had kind of you know, maybe procrastinated, maybe put it off, maybe didn't know how to go about doing it. What I want to say to our listeners is, I am here to help you with that. I am here to help you shape the story will have a great conversation over zoom. Especially if you're on the other side of the world, we can have a chat about it, I can help you shape it, it would be my absolute pleasure to do that. Because after all, I need to live vicariously through my social work colleagues and friends now that I'm not practicing. So please, You'd be doing me a favor more than anything. So all you need to do is contact us at the Social Work Stories Podcast and we'll put all our details in the show notes. So just drop us an email. And I can respond very quickly.
MF
Mim Fox
2:58
I love that Lis and you know, every time you and I have worked with people to shape their stories, it's such an amazing experience, isn't it, you get really close to the story and to the practitioner as well in hearing the really intricate work that they do. So I really do encourage everyone as well to come and spend some time with Lis and tell your stories. I mean, gosh, everyone's doing such incredible work out there every single day. We need to get this stuff get thing going.
LM
Lis Murphy
4:06
And you know what, I'll just leave it with this fridge magnet statement, "Have mic can travel." So I also am more than happy to if I can, come right to your door with my microphone and we can do it together like that. I've got I've got the time and the space to do that. Now.
MF
Mim Fox
4:26
You know, Lis, I think you've just I think you've just designed our next Social Work Stories Podcast t shirt. "Have mic, will travel. I love it.
LM
Lis Murphy
4:36
Maybe we can. Maybe we can make these T shirts up for those people who were sharing their stories.
MF
Mim Fox
4:41
That would be beautiful.
LM
Lis Murphy
4:44
All right, next team meeting. Okay, let's get on with this.
MF
Mim Fox
4:46
And it's 2024 and the ideas are flowing. I love it. I love it. So to kick us off 2024 Lis, we have this phenomenal story. Actually a couple of stories in one , and this is from a emergency department hospital social worker, who is doing some beautiful stuff therapeutically, but also combining some research in there as well. It's a gorgeous combination.
LM
Lis Murphy
5:14
I'm with you. And I'm just chuckling to myself, because we always start with, oh, this is a spectacular story. We love this. I love it. But But the other thing I wanted to mention about this particular story, it is Narrative Therapy lens that this social worker uses. And it's so interesting Mim, to actually have a therapist in this setting, emergency setting using Narrative Therapy, you don't often see it in this in this particular domain of practice, right. And so that's why it's also very, very special. It's an innovative research project. But it's also a therapeutic project, that's really very, very interesting. And before we launch into it, I encourage students, clinicians, to really listen to the language that this social worker is using. Because there's lots of words there that are very, very specialized to narrative therapy, you know, you're going to hear words like, I love this one, "Invisiblise", I can barely pronounce it "totalizing, re authoring, decolonizing, rehumanizing," amazing words. And I have a feeling this is going to be one of those episodes, Mim, that I hope our our uni lecturers will recommend because it really is using Narrative Therapy in a very in a beautiful way & in an unusual setting.
MF
Mim Fox
6:48
It's also just very much theory-framed this story, these stories, as well as value-framed. The values and the theories of center, are the center of everything here. So I think absolutely, as an exercise, as you're listening, everyone, just see where it is that you can anchor anchor the theory and the values too within it. It's very explicit. And we will talk about it anyway afterwards.
LM
Lis Murphy
7:16
Then just finally, I think the setting is such a beautiful contrast to what this social worker is doing with her clients. It very much is, in some way, the complete opposite to what she's trying to do, especially in terms of documentation with these patients. So have a listen. And there's lots that we want to talk about from different angles when we come back.
SW
Social Worker
7:44
I want to acknowledge and extend my respect to any Aboriginal elders, people or practitioners who may be listening to this podcast story. This is important for me to begin in this way for many reasons. Most of all, because the two stories that I'll share throughout this podcast story are from Aboriginal patients who are accessing accessing health care in the hospital where I worked. The practice context is a busy Metropolitan Hospital, specifically in the emergency department. It is a busy bustling environment with all kinds of different presentations, pages and phones are often going off. Visually, it's a clinical read sanitized environment. And there is not a great deal of privacy with that stiff blue curtain that can be pulled around the patient bed for the guise of privacy.
SW
Social Worker
8:33
In the emergency department environment, structuralist ideas of people needing to be managed, fixed, referred on or needing clinicians as experts to assess and intervene and manage them and to make decisions about the best clinical pathways is rife. Ideally, this patient this process should occur in consultation with patients. But in fact, much of the decision making lies in the hands of clinical teams. The role of social workers often help people resolve some kind of psychosocial distress that will enable the person to either be discharged or proceed to another part of the hospital.
SW
Social Worker
9:05
The stories that I want to share with you today is a practice innovation that I undertook about how to explore narrative practice of re authoring and how that could influence the stories that get told and recorded about people experiencing homelessness who present to emergency department environments. So that we can all take steps away from dominant pathologizing discourses which totalized people's identities with little regard for the broader context of that person's set of circumstances such as poverty, trauma, mental health, addiction, underfunding or neglect of social housing for many decades, family and relational violence or get invisiblised by systems that seek to efficiently triage, assess and discharge people from hospital environments. As such, this is a story that's deeply anchored in social work, values of dignity, human rights, valuing of personhood and justice doing. Justice doing in the sense of exploring how clinicians use professional power, how we hold awareness of our professional privileges and how we do daily practices of accountability in our work.
SW
Social Worker
10:05
Before I go on, I think it's important for me to locate myself in the work that I come to this space as an educated now middle class, able bodied Anglo woman in a senior clinical role. It's absolutely critical that I hold this awareness of the intersections that I hold, and how this may affect my practice or how it might be experienced by the people that I serve. This acknowledgement of my intersections is part of a deliberate intention to be de-centred but influential, meaning to not privilege what I think I know and also to allow for other forms of knowledge and skills to be given visibility.
SW
Social Worker
10:37
Throughout this practice innovation, I use Clinical Data Mining with a Narrative lens to analyze the top 10 most frequently presenting patients. Eight in-depth interviews were then conducted in a social story checklist and a collective document or co authored. Importantly, the collective document and reauthorizing documentation takes particular care to the use of words or to use the words of participants externalizing problems from individuals so as to not colonize this story with my words, interpretation or the influence of pathologizing discourses. Significantly, most of the 10 files that are reviewed, did not have any social history documented, or only use single word descriptors to describe individuals such as "mental health, alcoholic, homeless health conditions, intravenous drug use, or risk of aggression." There wasn't any record really of trauma histories, or locational problems in broader social contexts.
SW
Social Worker
11:32
There was minimal reference to either explanations of health behaviors, or asking the patient what sense they made or the continued presence of these problems in their lives, which resulted in them so frequently presenting to hospital. So it influenced my thinking as to who gets to decide what a deserving or undeserving presentation is, what do these pathologizing discourses inform on our thinking and decision making? What allow certain words to become accepted, and therefore unquestioned. This was evidenced by the concerns of project participants in the collective document where they said, "don't just believe what you read on my file, or what your colleagues say about me." And "That if you have a bad interaction with a staff member at the hospital, that it felt like that, the next time you went, that staff member always seemed to be there. And so it always carries on every time and then she tells her friends, and then it's like a domino falling. And they all hold about opinion of you."
SW
Social Worker
12:23
And what happens when a client doesn't neatly fit into an assessment or treatment pathway? What does that motivate the clinician to do, to accept to protest or resist to advocate to acknowledge that systems is oftentimes designed in ways to exclude those that do not present in a certain way. And in the collective document participants said, "A number of us agree that you can tell as soon as another person walks up to you how this is going to play out. Some of us felt that in a hospital situation that you have to convince someone how unwell you are or actually be hospitalized before they'll take you seriously or want to know your story."
SW
Social Worker
12:57
And what happens when a client does protest? Do clinical staff question what it is that the consumer is protesting against, and where does the right to have an opinion about one's own life go in clinical settings? And so participants in the collective document said, "Some of us have shared stories of being judged and pigeonholed by staff." And if they protested about how they were spoken to that they were told they were being aggressive. "One of us said they have the power, and you just have to cop it." And another one of us said, "That all I have in my life is my name, I've got no power, give me a chance to know the real me."
SW
Social Worker
13:32
So this project, therefore sought to bring forward what was absent but implicit in the clinical environment. About what good patients do, What it is the job of clinicians to assess and form judgments about people, and what are the presumptions about needing to manage people who are actually surviving on their own, that a quick discharge, is a good discharge, that if people wanted to find a way out of their circumstances then they would. For example, the hospital staff might say, "Well, we've offered them emergency housing, and they didn't take it, they must want to be homeless."
SW
Social Worker
14:03
And so the project invited me to ask clinicians about whether they could understand that identities are socially constructed. And to understand that taking an accurate psychosocial history becomes critically important in understanding how individual lives are influenced by history, culture, gender, sexuality, class, and other broader relations of power. And that we need to make room for other forms of knowledge and ways of knowing.
SW
Social Worker
14:28
So I wanted to challenge clinical staff to think about To whom do they think they were responsible or accountable to? To the system, or the person they were writing the documentation about? And could multidisciplinary staff clearly and succinctly identify what ethics were guiding their practice? What accountability practices would the staff be drawing upon that would tell them that they were holding themselves accountable to the patients that they were working with? And so by turning the compliance lens back on clinicians and inviting them to see a more multistoried account of the patients experiencing homeless. And as I was inviting them to reflect on how if we don't see the broader context of people's lives because of busy systems, requirements and processes, then we may inadvertently become complicit in the reproduction of power relations in a therapeutic context.
SW
Social Worker
15:15
As such, this work consciously adopted a decolonizing and critical data mining research methodology to seek to resist dominant Western biomedical ways of conceptualizing healthcare and research. Central to the practice innovation was the question of whether the community that was being consulted, had a focus on relationships, and did it bring forward alternative knowledges and make health practices of documenting and care planning, planning more dignifying.
SW
Social Worker
15:42
So in the second phase of the project, where they were in depth clinical interviews, there were questions around whilst there was questions around what led to the person's homelessness I also made it clear that they didn't have to answer any questions. And that discussion could include things that they wish to speak about, not just what I was interested to know about. How if I asked questions, and in what order would vary according to how the discussion organically unfolded, and there was a real ethic of care towards the participant to ensure that the discussion continued to feel supportive and helpful to them, that there was space for pause and silence for careful tracking of words to bring forward deep understanding and respect. I elected not to record the interviews as many individuals that I worked with, who might be experiencing homelessness and mental health and addiction issues might feel distrustful of being recorded due to previous negative experiences with hospitals. I was transparent that I would take some notes to capture their words to reduce the likelihood that I would be interpreting or speaking on their behalf. There were questions which sought to challenge the assumption that homelessness might be the biggest problem facing the individual when they presented to the emergency department, such as, "If you had to give a name to the biggest problem facing your life, what would it be?" "Does the word homelessness describe your set of circumstances? Or is there a word that you would prefer that we use?" And "What would you like us to know or speak about if we weren't talking about your housing situation?"
SW
Social Worker
17:09
There were questions that sought to bring forward alternative knowledge and skills and ways of responding. Such as, "Through the experience of being without housing, much hard won, knowledge is gained about surviving, and how to keep yourself safe. What is it that you would want others to know who are experiencing homelessness that has been helpful to you? And what are the skills that you've developed since being without housing that you value? And what has helped you through difficult times?"
SW
Social Worker
17:34
There were questions that sought to query whether there was a dissonance between how clinical staff conceptualized that person, and whether it was in alignment with how that person saw themselves and what they gave value to. So there's questions such as, "What assumptions have people made about you that didn't fit with how you saw yourself?" "What gives dignity and meaning to your life?" And "What would you hold precious or not want to give up if you were to be housed?" "Can you tell me one thing that might surprise the doctors or nurses to know about you?" And "Does trauma, loneliness, or a lack of connection get in the way of you being able to maintain housing?'
SW
Social Worker
18:07
So given the timeframe available in the podcast, I've chosen to share briefly two stories to demonstrate the RE authoring interview and documentation process. So Elliot had been homeless for approximately 20 years on and off. When I reviewed his file the dominant single storyline that had been documented was about his mental health. He was noted to be of Aboriginal background, but there was no real acknowledgement of this or Elliot's connection or disconnection to community, country and family. We started with a story about time and the difficulty Elliott sometimes had in keeping to a timeline. Elliott attributed this to his mental health. And then when it wasn't good that the timeline gets thrown out of the window and stuff happens. And this makes it hard and you can get into trouble medically. This echoed others in the collective document who said, "Please give me time and don't rush me. Some of us have experienced that when people are too busy, they just judge you straight away. One of us explained that when there was not enough time to say what they wanted, that he ended up just giving up because he thinks that it's not worth it, that the staff member wasn't interested anyway, and that they've formed their own opinion."
SW
Social Worker
19:16
Importantly, Elliott did have strong views on the biggest problem that had been affecting his life when he was homeless. And he said, not having a mailing address. If you don't have this, you're absolutely stuffed. This led to a discussion about the ways in which systems can make it hard for people to enact change in their circumstances. That systems can always expect you to be going here and there and can give you the runaround, when you might have extremely limited funds with which to transport yourself around. And if you don't have money for fares, then you run the gauntlet of getting a fine which puts you even further behind. We discuss the assumptions that can be made about people experiencing homelessness, and Elliott said it's always on the file different times different statement gets made. "People think you're aggressive. I'm actually pretty easygoing, I'll only react if someone else is acting up, and then I'll arc up back." And this interestingly led to a storyline about not putting up with bullshit from other people who might be giving hospital staff a hard time. It was this behavior, sometimes misinterpreted as Elliott being verbally aggressive. But really, it spoke to his commitment about people speaking respectfully to each other.
SW
Social Worker
20:23
I asked Elliot about what he would want to be talking about if we weren't talking about his housing situation. And he said, "Being well is actually really important to me. Staff do not see how unwell I really am a lot of the time, that they're not doing anything, but I actually had no money and was having a lot of a tough time." And I asked him, "What did that knowledge make possible for you?" He said, It dulled the aggression and pain, it also helps me to keep going, because I'm always trying to get myself out of the situation and get a job. I've even tried to go to uni a few times." I asked him then about "what might surprise the doctors or nurses to know about you?" And he said, "Education is really important to me, losing my mind at times has been really hard. I'm also really good at reading rooms and people. And I know a lot about medicines."
SW
Social Worker
21:11
Following an interview, I wrote up our conversation and a camera story. And I read it aloud to Elliot over the phone to ensure that the counter story accurately reflected his words, skills and knowledges in a way that felt okay for him. Elliott said that it felt good to hear his words and knowledge as reflected back. And were able to have a further rich conversation about what it might mean for someone to have a space where they can talk about things that they want to talk about, not just what clinicians want to talk about. An Eliot advised me that because we were staying focused on what he wanted to talk about that he now felt comfortable to open up about problems that he was experiencing, and to share what it was that he was doing to take steps away from the problems that are in his life. He agreed that it would be useful for his current mental health case manager to know about some of the things that he'd shared in our second conversation, and that they could get a letter of the counter story letter. So after uploading his counter story on to his medical record, I then shared the letter with his case manager who hadn't known many of these things about Elliot, who who now intended to start further conversations as a result of hearing the story. Ethically, what these exchanges reinforced to me is the centrality of relationships and the importance of collecting stories across time of doing of the doing of respect and dignified practices such as deep listening, and that clinicians will actually end up with a much richer, more authentic person centered account of the people that we work with.
I now want to share Simon's story. He had presented about 161 times in the past 10 or 11 years, much was written in his clinical notes about his tendency to present after- hours, and a dominant totalizing storyline being recorded about Simon was his ongoing relationship with alcohol misuse. He'd often present requesting detox, but was described by staff as a difficult historian, evasive, failing at this detox, but he was also calm and polite. It was 10 years after Eliot, after Simon, first presented to ED that he had listed entry from social work, at which point other storylines started to emerge that Simon had worked for many years prior to the alcohol problem, that he'd had a disruptive childhood with significant trauma, that he liked cooking, cleaning and playing video games and that he was a dad. Significantly for the bulk of his presentations to emergency he hadn't been identified as being of Aboriginal background.
I first met Simon in the ED when he presented seeking health care. And I asked him about whether he did identify as Aboriginal and he confirmed that he did, but he often doesn't disclose as he doesn't want to be treated any differently. In this initial meeting, it was ethically challenging for me as to how to handle this feeling that it was important unspoken story. But knowing that in an ED environment, there's no privacy, there's considerable time pressures, and that I needed to focus really on building relationship and trust with Simon before he might want to tell me further about that story. We wrote up his counter story in the form of a therapeutic letter, which I'll now share excerpts of;
“Simon, thank you for speaking with me when you're recently in hospital., I very much appreciated the generosity of your time and sharing of your wisdom. When we started talking, I mentioned to you that I had reviewed your medical record and I could see quite clearly your commitment to trying to get into detox, despite many years of the alcohol problem trying to take over your life. You mentioned to me that sometimes the alcohol problem has you telling yourself that you don't know another way because it's affected me and the other members of your family. You shared your thoughts the hospital staff get sick of you come into hospital and it's sometimes you felt you've had to prove how sick you are. And that many times staff have just seen the alcohol problem. We discussed that when stuff just the alcohol problem. You don't feel valued as a whole person. You told me that you felt like you couldn't keep doing the alcohol problem in the same way anymore. Because the alcohol problem prevents you from dealing with the deep down stuff and it invites you to think and to not bring this stuff up.”
“Even though you think it might help you one day, you told me that it was important to you to never forget who you are. And you also shared your belief that change is possible. Being able to give up drugs has led you to maintain this belief that overcoming an alcohol problem is possible. And you also wanted to maintain your commitment to the belief that you can do anything you shared with me that you had learned this value or the belief from your grandmother, over the years or you've also learned the skill of patience and distress less and that you like to sit by the water and watch the boats. This helps you to feel calm and think of your big brother.”
SW
Social Worker
25:38
And so now I just want to speak a bit about the ethical dilemmas that came up in the process. Because the reality of doing these letters was a bit tricky for me, given that sometimes there's a gap between when I did the interview with Simon or Elliot, when I wrote the letter up and then shared the letter with them. That it was important for me to remain de-centered in the process and be transparent with the things got in the way of me responding quickly, that it wasn't about me not valuing their time or priorities. But the reality of my practice context is situated in an environment where there are often multiple competing priorities. It also felt that for every part that I completed, there were many other steps that might be valuably taken. For example, when I did Simon's letter, I shared this with my ED colleagues by doing an in-service about my practice innovation. Fortunately, my nursing colleagues were all really open to this and remarked that in hearing the story, it has been important, and that many things that stuck out for them. That patients’ lives are multistoried, that when we see the skills and knowledge, that this makes a difference in how we can think about the person, that it's important that we acknowledge their efforts to overcome problems, that health interventions have an impact on how people feel about themselves, and whether they feel encouraged or discouraged to continue, and that it was new for them to consider that clinicians have a power differential over patients. And finally, that as a result of hearing the counter story, they thought they would be more mindful of their words, their awareness of the power differentials and accountability in their documentation.
And other another aspect of the practice, innovation was a checklist for the social story resistance. And this came out of acknowledgment that there needed to be an ongoing tool to assist clinical staff in shaping double storied conversations, so that this could be used to bring forward alternative knowledges that might serve to balance and outweigh the expert knowledge of the medical model, which has a tendency as we know, to pathologize individuals rather than problems. And so there was a real focus on asking the person what they felt the main problem was to identify their skills, knowledge and ways of responding. To identify what sustains a problem, do give visibility to the assumptions that can be made when totalizing stories are told, and to bring forward preferred ways of describing self and what the person holds us precious?
In before bringing this podcast to a little bit of a close, I want to acknowledge that I've sought to be aware throughout of my own professional power, and to refuse to make totalizing knowledge claims that my colleagues sometimes asked me to. And I would rather use my professional privilege to create space for subjugated knowledges and different forms of relationship based on respect for our insider knowledge. And the reciprocity that can occur between clinicians and patients is required deep listening in the spirit of respect, dignifying and re humanizing practices, and the embodiment and enactment of core social work values and theories. I hope that you found this story influential in getting you to think about how you can translate key ideas that I've spoken about to your practice context, and the folks that you would certainly meet with, so that we can walk alongside people in a more trauma informed, honouring way.
MF
Mim Fox
28:58
You know, Lis let's start right at the beginning, the way that the social worker describes the hospital environment just takes you right back into the context, the stark nature of the environment, the blue sheets, lining the beds, the cold environment that they're in. It really, it's really setting you up for a sort of juxtaposition, a complete contrast to then the beautiful work that she's actually doing. Right. It's setting that tone.
LM
Lis Murphy
29:32
Very much so. And I think she describes it as structuralist ideas. And versus what we often talk about in health as our so called partnering with patients. When we know the reality is especially in an ED setting, that that often is not the case. And so what she like as you say the contradiction starts with the pathologizing language that's used, the narrowing down the person's experience to even one word descriptions, one word descriptions that are a diagnosis, for instance, such as homeless.
MF
Mim Fox
30:10
But how many times I remember that so clearly Lis, working in hospitals, just that notion of the “difficult patient,” that notion of the person who is just not making it super easy for the staff to just do what they see as their role in that moment, as opposed to coming from the experience of the person. And I love the way the Social Worker talks about those dominant discourses that actually happen in the environment, because homeless presentations, absolutely where that happens so often.
LM
Lis Murphy
30:41
Ad the lingering nature of those labels too Mim. So that's the other thing that you can actually be labelled with something from a previous admission, but it can haunt you. Or let's just say for instance, you are being assertive and actually wanting to voice your concerns, all it takes is that one word. Let's just go with “aggressive,” and that can actually live with you into future admissions. Yeah, it's absolutely amazing. And I love the way that she is able to capture that, especially for those people who have never really worked in hospitals or even been a patient, you know, the power of the documentation is so important for people to understand, especially our social work students.
MF
Mim Fox
31:35
Yeah, it is so easy for someone to flippantly write something in a note that then hangs over the future presentations of the person into that system, right? And that it snowballs, what is written in that first note snowballs into actually character assassination, as you go on and on and on, and really impacts the care that people receive. And the actually massive life events for them, where they could potentially be discharged to what sort of services and supports they could receive, how they and their family or friends or loved ones are treated within the system. The impact is immense actually.
LM
Lis Murphy
32:18
Mim the social worker used word that I haven't heard for a while, but was often used in my course back in the 80s. And that is that the “deserving” word? And it was really interesting to reflect on how that can be, I guess the impact of documentation on that theme on that sense of the person, that staff actually can carry a sense of the deserving with them in the way in which they treat especially when the issue of homelessness. Yeah, I found. And I thought that was just something really worth kind of focusing on how careful we need to be. The other example I thought about labels and documentation was in Simon story. Here's an example of other of a man who had had 167 admissions. Now, in many of the EDS that I've worked in, there's this dreadful expression that hopefully social workers don't use. Certainly, my social students are told to never use it. And at’s “frequent fliers” that will often be referred to people like Simon who have had many admissions. And that will could I wouldn't even be surprised if that might even have been in his documentation. But again, the power of just that one label, like frequent fliers.
MF
Mim Fox
33:50
Absolutely.
LM
Lis Murphy
33:52
So yeah, and I think the other thing that the social worker really helped me to understand was the importance of the contextualization that social workers can bring to the person story within that documentation, right?
MF
Mim Fox
34:06
Yeah, yep. And often, you know, the social worker is under so much pressure, to write quick, succinct notes. To actually just get it done quickly, they don't have much time, they're moving on to the next case, or at the end of a really busy day. And just quick, quick, quick, but actually the power of giving words, the written word to that story, to be able to communicate, actually this individual's experience in life to the rest of the team. And to have that then linger in the notes. I think this social worker really painted that picture incredibly well, of why that is so important to give time, and thought and consideration, and what are the values that are underpinning your documentation?
So what is that? What does person centered care actually mean with every word that you write? I love that. And this whole story made me think of a student that Ben Joseph, who's our producer on Social Work Stories, LIs, but also is the host of Social Work Discoveries. And he and I just had a student on placement in a hospital emergency department looking at homelessness. And it was really interesting and I'm going to do a shout out now to Artemis, who is one of our Masters of Social Work qualifying students, because she did a piece of work around what are some of those barriers and challenges for people who are homeless in an emergency department? And what is what is preventing them from having this high level person centered care? And what happens then with where they go in the end? And how are those decisions made? And how is that flagged? And what resources do they actually end up supporting them? And so what I love about this story is it's given the story to those experiences.
LM
Lis Murphy
35:54
Mim I was interested in some of the questions that the social worker used around the issue of homelessness, for instance, you know, “what led to homelessness? What, what do you actually want to talk about with me?” Because sometimes the presumption can be that the issue is homelessness. But I think she asks, “If you had to give a name to the biggest problem in your life, at the moment, what would it be?” It might not be the homelessness, but as social workers, because our colleague has said, you know, Simon's back in, and because Simon's, you know, had homelessness as an issue in previous admissions, the assumption could be that that's what Simon's wanting to talk about, or, or have some support around this time, but it may not have been.
MF
Mim Fox
36:46
That's right. That's right. And often it isn't, often it's because something else has happened in their world, that actually has been part of this current presentation, that actually this issue of homelessness has had a larger trajectory than this, you know, half an hour that you're getting with them in the emergency department.
LM
Lis Murphy
37:07
Yeah. “Does the word homelessness describe your circumstances? Or would you use a different word?”
MF
Mim Fox
37:14
I absolutely love the phrasing of these questions, Lis. Right? They are? Absolutely. If you think about how we, how we teach to the positioning of questions, and this concept of exploratory interviewing. This is absolutely examples of how we open up for discussion beyond the referral.
LM
Lis Murphy
37:38
I agree MIm. And I think if anyone's wanting to, I guess, use these questions in different ways that we, you know, I found myself pausing throughout the listening and writing these questions, because that that is the very nature of Narrative Therapy, is to construct questions that actually allow the person to tell a bigger story than some of the ones that we might, you know, using a more structuralist lens might be using within the emergency context, for instance, or elsewhere. And the other question Mim was, “What else would you like us to know about you?” And what this opens up, of course, is, what is what are some of the other parts of your story that you think are important for me to hear the moment? So that, that contextualizing of what's going on in life at the moment, that's important for us to hear about. Now. I love the fact that she was able to, to ask those questions. And then she highlighted the importance of deeply listening to what this person had to say, yeah, not the, I'm going to shape my questions in a way that you're going to respond in the way that I need you to respond within the time that I need you to respond.
MF
Mim Fox
38:55
Totally. Well, it's, it's amazingly essentialist and reductionist to say that the person sitting across from me is only “homeless,” or is only “the child protection issue,” or is only “their domestic violence situation.” I mean, ultimately, this is person centred care, we are coming at this person, we are speaking with this person as a whole holistic being, so we have to be pushing those boundaries and looking beyond those labels. And this is what I love, this is how to step it out and do it.
LM
Lis Murphy
39:27
But see, this is my thing about Health, right Mim? I think we waste a lot of time doing the same old, same old. So we can use Elliot as an example from this recording, right? So we could go in and go homeless, right? I'm just going to organize some emergency housing and good luck with that, by the way, I'm just gonna ring Link to Home and we'll sort it out and he'll get a few days in a you know, a local hotel, whatever. But in Elliott's case, that that good use of questioning, was able to highlight the fact that there is a real systems problem for him that his major issue was his lack of an address in order to be able to access certain government support and systems because he didn't have an address. Now, that's not going to be sorted out by plunking him in a hotel for a few nights. Do you know what I mean? Like how often in Health do we respond in the same old way? And wasting Elliott's time? Because, probably not at all
MF
Mim Fox
40:35
Not helping him, not happy helping him achieve the goals that he has, not the goals that the health system has, the goals that he has.
LM
Lis Murphy
40:46
So, Mim, why don't we just shift gears and move into her, her innovation, her innovative project, and I'd like your take on it in terms of, you know, the research work that you do, and maybe some commentary about this, this is a really interesting project that she's worked on. And I know you've got some thoughts on that.
MF
Mim Fox
41:12
Yeah, this is, I mean, what's beautiful about this is that this is inherently a practice-based research project. So this social worker has come at a clinical issue, and thought about how she could take, take the presentations that she's seeing, and be able to deconstruct, to analyze and represent those as findings. Now, a lot of social workers in practice, often will want to do research that is about their client presentations. And we often have a lot of issues ethically around that, and getting projects through human research ethics boards, when we're in those situations. And it's usually because of the lack of thinking through the ethical stance, of how we ask the questions, how we're de-identifying the people, how we're actually treating people as data.
Now, I know that a lot of social workers out there are thinking, Oh, I'm never going to do research ever. But one of the beautiful things, especially our students, but one of the beautiful things about social work is that we're all about creating change. So as soon as you've been working for a while, what actually happens is that you start to see gaps, and you start to ask questions about what you're seeing around you. And that's where research comes in. And essentially, that's where practice-based research shines, because the questions that you come up with come from your practice. Now in this sort of situation, the story that we've just heard, there's a couple of stories we've just heard is that what she was drawing on, you'll notice is that she read out some communication with the clients, she read out some of what would be interview transcripts, and those would have all gone through ethical process, ethical screening. And the way that she's asked those questions is that they're grounded in these ideas of challenging discourse. Yeah. And so coming at it from what is the positionality of the social worker doing the research, what theories is framing their approach to their research, is actually that really key starting point, which she has really beautifully articulated in this in these stories here.
I really think as well, there's something here about the role of storytelling in research. And we often as researchers get stuck in this ridiculous paradigm of quantitative versus qualitative and what's better, what's worse, and what's more, what is truth and what's not? And what this social worker is doing is demonstrating not just the foundational principles of qualitative research, which is about the truth is actually perceived from different perspectives and understood in different ways. She's actually really clearly showing you how storytelling is a method of research. And that's something I really want our listeners to take on. Now, if you're thinking about research, if you're a social work student, or a social work practitioner who is wanting to engage with formal research in this way, or if you are, or one you're later on, and you're practicing, and you realize that you're starting to see gaps. I want you to take this idea on that storytelling is actually a fundamental research method.
So as we've talked about on this episode, it's an intervention method. It's a narrative therapeutic approach, but it is also a research method. And that's really, really important. This is something I'm really interested in Lis that I do a lot of work with social work practitioners, particularly in Health around and I think it's core to social workers, being research, being researchers, and seeing research as a source of change creation, because actually, we are all about Storytelling, whether we are researchers, whether we are practitioners, whether we are educators, we are all about change creation. And so for me, storytelling is our umbrella that brings together those things.
And I know that's a bit of a rant from me Lis but I think it I don't think any of our listeners are going to be surprised, after listening to other episodes that this is where you and I are coming from today that you're so embedded in the beauty of the clinical process and the intervention that happened. And I'm so inspired by the research method that was demonstrated here. And the coming together of those two concepts and ideas is just for me, there's just such sweet perfection.
LM
Lis Murphy
45:44
Look, well said as usual Mim. I agree, I agree that like it's, it's a classic clinical intervention, and as you say, research embedded in it. And I was really fascinated with not just the work and we'll get to the re-authoring with Simon and Elliot in just a minute. But I was also interested in the questioning of her colleagues. Now, at one stage, she's talking about chatting with or asking clinicians really, really important questions like, “Who are you responsible to? What ethics guide your practice? What are your accountability practices?” And now imagine having this one over the lunchroom? I mean, what an amazing, amazing conversation to be encouraging colleagues to reflect on, like, “Who are you working for?” So often people are gonna say, you know, “We're very patient centered.” But is that really who people are working for? And I think to actually have the time to sit down and unpack that with someone. Like you say, Mim could actually be change initiating. You, actually go “holy heck, yeah. I really do need to re-orientate.”
MF
Mim Fox
47:06
Yeah, that's right, let's re-orientate our entire position. And that's why I say positionality is so important in this. Absolutely. Whether you're coming at it from a practice perspective, or research perspective, you need to know who you are. How are you actually engaging with his ideas? And what is your thinking and approach to the dominant discourses that you're seeing around you? That is fundamentally what's happening, right? Because once you see a dominant discourse, you can't unsee it Lis, particularly if you're a social worker.
But I really think that it makes it makes what is invisible, visible. And so I think that's the point where you get to say, “Okay, now I see how the words that we use and the titles that we give, and the notes that we write about people who are present as homeless in the emergency department, facilitate a negative and systemic systemically unfair scenario. Now that we've done that in discriminatory scenario, now that we've done that we've recognized it, how do we shift our perspective?” Yeah, and that's in those conversations with colleagues, as well as in those therapeutic conversations with the person themselves.
LM
Lis Murphy
48:24
Exactly. So she had to have that conversation with her colleagues because when she uploaded Simon and Elliot's story, that had been written in a way that was not pathologizing, was not diminishing their, life experience, and was actually telling the story that Simon and Elliot wanted to tell, right? So imagine, I want to be in the heads of these clinicians, when they read those stories, what shift took place in them, when they read about, you know, Elliott's commitment to education, for instance, Simon's you know, history in terms of his work. And, and the times when he has struggled with alcohol and times when he hasn't, like, so those different stories that she was then not only able to re read back to Simon and Elliot, but also the clinicians, and there's where one would hope Mim, and I've got to hold on to this, that it would have impacted on those clinicians in a way where they go, “Whoa, whoa, okay. I didn't know that. I didn't, I didn't realize that that was the case with Simon or Elliot.”
MF
Mim Fox
49:45
That’s right. And you really hope those light bulb moments will actually click in.
LM
Lis Murphy
49:49
I've got to hold on to that one Mim. The other thing I like to hold on to is the being the fly on the wall when Elliot and Simon listened to their stories read back. So I've used therapeutic letters before, when I was a counselor, and they're very powerful tool, I've never again, once again, I've never seen it used in the ED setting. And I think she acknowledged that there would have been a bit of time passed between when they told the story when “I listened to it and, and when I rewrote it, and read it to them.” But despite all that, to have heard their story told from that perspective, I can't but imagine that it would have been important for Simon and, and Elliot to have heard a different story read to them, about them.
MF
Mim Fox
50:43
Absolutely this is this is reminding me, Lis of an episode that we did around Narrative Therapy with, with women in the forest. Do you remember? And, and in the show notes will link back to that episode. But it was very much about that re authoring of the experience that people had had. And I think that's so powerful, isn't it to be able to have an external person say to you, “Here is how you're telling your story right now. But here's another way that we can actually reorientate. And we can challenge some of those ideas that are perpetuated not just in new, but for you. Right by others around you.” Yeah, I just think that's a hugely important therapeutic technique.
LM
Lis Murphy
51:35
Mim, I want to talk about this more and more with you. But
MF
Mim Fox
51:40
I know, let's just say, Lis.
LM
Lis Murphy
51:42
I think I think we will wind it up, simply because it is going to be one of those episodes that that both of us will encourage our listeners to listen to more than once, because it is absolutely so late. And as you've said beautifully, Mim. It is that nexus with research, as well as clinical practice and innovation that is captured so beautifully in this story.
Can I tell you just one funny story about me and Narrative Therapy Mim? All right. So so that people can, you know, if I can actually sacrifice my professional self to, you know, people's learning, let me do so. But when Narrative Therapy was particularly big in the 90s, I mean, it still is big, but it when it first kind of came out, there were many of us that tried to incorporate it into practice, including myself, I was working in oncology at the time. And the way in which we had to think differently about questioning was, you know, like, it bent my brain.
So I would work with another colleague, to construct questions differently. And it does require that it's like any new skill, you actually do need to think about restructuring your questions to what you might have been doing previously. And so I would, you know, it would bend my brain to come up with these questions. And I would turn myself inside out and, and in the process, my poor patient, so what I would do is, I would have to ask this colleague to come and sit in the sessions with me, to help me a little bit with this questioning that always with, you know, wonderful patients that were, you know, very tolerant of my learning arc.
But I share it because I think it is one of those things, it's worth considering as a clinician, like, yeah, if you're gonna be looking at different ways to kind of change up your practice, do it with a colleague. You know, there are some beautiful questions here that can absolutely to go straight into your practice, right? Tomorrow, really, if I can encourage people to just do things differently. And in this case, you will get a different response, and it will feel different in terms of how you and that and your patient, your client, your consumer, have a conversation.
MF
Mim Fox
54:12
Yeah, it's that it's that call out to firstly, be creative in your practice and to stretch yourself. But secondly, to use your colleagues as a peer community, to actually, you know, lean on each other, get feedback from each other, and allow each other to see your practice in action. And then to give you some constructive feedback, because, Lis, we know, this is how we learn.
LM
Lis Murphy
54:37
And the other even better teacher, of course, is our client, or our patient, of course. And I would always be saying right up front and being transparent, like this social worker talks about. “I'm going to be trying a few different questions on you. It might feel a bit fumbly to start off with but I was wondering if I could, you know, do things a little differently?”
MF
Mim Fox
54:59
Well, they'll tell you pretty quick, if you got it. That's where the feedback will be come from. I love it real time feedback. That's it. But often, you know, you go, as students we’re observed all the time. But then you go into practice and however many years later, it could be, it could be years since someone ever saw you in practice. And how do you know that your skills are continuing to develop and continuing to grow? Unless actually you get that external feedback? So I love it. Absolutely. Love it.
It's so good to be back on the pod in 2024.
LM
Lis Murphy
55:32
Isn't it just loved it. We started with a big story!
MF
Mim Fox
55:37
I know we got lots of good things planned this year. We're glad you're all in for the ride. We hope you're taking care of yourselves and spending time doing wonderful things. Let's let this year be a year of breathing of replenishment & nourishment. And just really good solid practice Lis.
LM
Lis Murphy
55:57
Indeed Mim on that note, farewell listeners until next month. Take care.
MF
Mim Fox
56:05
Take care everyone. Bye for now.
JS
J S
56:14
Thanks for listening to the Social Work Stories Podcast. All of the stories we share are de-identified to respect and protect the people involved. We create this podcast because we're passionate about building the Global Social Work community and strengthening our practice no matter the context. If you want to help us grow the podcast tribe, and continue the work we do, we would love it if you can subscribe or follow the podcast in your favourite podcast app. That way, you'll be sure to get every episode as soon as it's released. While you're in your podcast app. If you can leave us a five-star rating and write a review it would mean so much to us. You can connect with us on Instagram, Twitter, Facebook, and LinkedIn where you can share our posts with your friends to help spread the word. And you can always find us at our home on the web, social work stories.com The Social Work Stories podcast is made by Lis Murphy, Dr. Mim Fox, Justin Stech, Dr. Ben Joseph and Maddy Stratton. Thanks so much for listening.