"Don't just believe what you read on my file": Re-authoring patient stories - Ep. 86

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 seated. 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 catalog of episodes, check out our website, socialworkstories.com. But for now, on with the episode. Happy 2024, everyone. Welcome to the Social Work Stories podcast. It is so great to be back. I am Dr. Min Fox and I am here. But yet another year with my wonderful friend, a colleague Liz Murphy. Hi, Liz. Yes, another year. Hi, Mim. Hello, everyone. And yes, happy 2024. What a big year. Do you realise Liz would be podcasting now for five years? I didn't know that actually. 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. 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. How was your first summer Liz in your retirement? It still feels like I'm on Christmas holidays quite frankly. 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 alive. It feels like a holiday. And hopefully for the rest of my life, I feel like that. That's wonderful. 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 spruke to our listeners that if they've even 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. We'll 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 practising. So please, you'll be doing me a favour 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 now. I love that, Liz. 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? We 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 Liz and tell your stories. I mean, gosh, everyone's doing such incredible work out there every single day. We need to get this stuff, keep them going. And you know what? I'll just leave it with the fridge magnet statement. Have Mike 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 the time and the space to do that now. You know, Liz, I think you've just, I think you've just designed our next social work stories podcast t-shirt. Have Mike. We'll travel. I love it. Hey, maybe we can, maybe we can make these t-shirts up for those people who were sharing their stories. That would be beautiful. Oh, all right. Next team meeting. Okay. Let's get on with this. And it's 2024 and the idea is a flowing. I love it. I love it. So to kick us off, 2024 is, 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. 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 to actually have a therapist in this setting, emergency setting, using narrative therapy. We don't often see it 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 specialised too, narrative therapy. You know, you're going to hear words like, I love this one, invisibilise. I can barely pronounce it. Totalising, reauthoring, decolonising, rehumanising, amazing words. And I have a feeling this is going to be one of those episodes, Mem, that I hope our uni lecturers will recommend because it really is using narrative therapy in a very, in a beautiful way in an unusual setting. It's also just very much theory framed, these stories as well as value framed. The values and the theories are centre, are the centre of everything here. So I think absolutely as an exercise, as you're listening everyone, just see where it is that you can anchor the theory and the values too within it. It's very explicit and we'll talk about it anyway afterwards. And 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. 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. First of all because the two stories that I'll share throughout this podcast story are from Aboriginal patients who are 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-sanitised 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 guys of privacy. In the emergency department environment, structural 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 their clinical pathways is rough. Ideally, this process should occur in consultation with patients, but in fact the much of the decision making lies in the hands of clinical teams. The role of social work is often to 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. The stories that I want to share with you today is a practice innovation that I undertook about how to explore narrative practice of reauthoring and how that could influence the stories that get told and recorded about people experiencing homelessness who present to a emergency department environment. So that we can all take steps away from dominant, pathologising discourses which totalise 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 on neglect of social housing for many decades, family and relational violence or getting visual blised 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 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. 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 and global 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. Throughout this practice innovation I use clinical data mining with a narrative lens to analyse the top 10 most frequently presenting patients. Eight in-depth interviews were then conducted and a social story, checklist and a collective document were co-authored. Importantly the collective document and reauthorising documentation. Takes particular care to the use of words, to use the words of participants, externalising problems from individuals so as to not colonise their story with my words interpretation or the influence of pathologising discourses. Significantly most of the 10 files that I 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 location of problems in broader social contexts. There was minimal reference to the explanations of health behaviours or asking the patient what sense they made of 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 pathologising 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 the staff member of the hospital, that it felt like that the next time you went, that staff member always seem to be there. And so it always carries on every time and then she tells her friends and then it's like a domino for link and they all hold a bad opinion of you." And what happens when a client doesn't need to fit into an assessment or treatment pathway? What does that motivate the clinician to do? To accept, to protest, to resist, to advocate? To acknowledge that systems are 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." 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." 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 that 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 and 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." 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. 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 these 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 multi-storyed account of the patient's experiencing homelessness, 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, we may inadvertently become complicit in the reproduction of power relations in a therapeutic context. As such, this work consciously adopted a decolonizing and critical data mining research methodology to seek to resist dominant western biomedical ways of conceptualising healthcare and research. Central to the practice innovation was a 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 more dignified. So in the second phase of the project, whether we're 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 out of 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 a 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 in a 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 it be like us to know or speak about if we weren't talking about your housing situation? 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 one knowledge is gained about surviving and how to keep yourself safe. What is it that you would want others to know who aren't 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? There were questions that sought to query whether there was a dissonance between how clinical staff conceptualised 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 as trauma, loneliness or a lack of connection get in the way of being able to maintain housing? So given the timeframe available in the podcast, I've chosen to share briefly two stories to demonstrate the reauthoring interview and documentation process. So Elliott had been homeless for approximately 20 years on and off. When I reviewed his file, the dominant single story line that had been documented was about his mental health. He was noted to be of Aboriginal background, but there was no really acknowledgement of this or Elliott'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 it 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 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. 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 run around 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 put you even further behind. We discussed 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 easy going. I'll only reactive someone else is acting up and then I'll arc up back. And this interesting lid led to a storyline about not putting up with bullshit from other people who might be giving hospital staff a hard time. It was that this behavior was sometimes misinterpreted as Elliot being verbally aggressive but really it spoke to his commitment about people speaking respectfully to each other. 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 on nurses to know about you. And he said, "Education's 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." Following our interview I wrote up our conversation in a counter 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. Elliot said that it felt good to hear his words and knowledges reflected back. And we 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. And Elliot 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 were 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 onto his medical record, I then shared the letter with his case manager who hadn't known many of these things about Elliot and who now intended to start further conversations as a result of hearing the story. Ethically what these exchanges reinforce to me is the centrality of relationships and the importance of collecting stories across time, of doing of the doing of respect and dignifying 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 the dominant totalising 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 difficulty historian, avasive, failing at detox but he was also calm and polite. It was 10 years after Simon first presented to Ed that he had elisted entry from social work, at which point other storyline started to emerge. That Simon had worked for many years prior to the alcohol problem that he'd had a disrupted 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 an 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 now share excerpts of. Dear Simon, thank you for speaking with me that when you were 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 do not know another way because it's affected many and the other members of your family. You shared your thoughts to the hospital staff, get sick of you coming to hospital and that sometimes you felt you've had to prove how secure and that many times staff have just seen the alcohol problem. We discussed that when staff just see 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 changes possible. Being able to give up drugs has led you to maintain this belief that overcoming the 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 would learn this value of the belief from your grandmother. Over the years you've also learnt the skill of patience and to stress 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. 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 was 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-centred in the process and be transparent with them if 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 they're often moldable 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 were marked in here in the story. It had been important and that many things had stuck out for them. Their patience lives are multi-stored that when we see the skills and knowledge about 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. There awareness of the power differential and accountability in their documentation. Another aspect of the practice innovation was a checklist for the social story resistance and this came out of acknowledgement that they needed to be an ongoing tool to assist clinical staff in shaping double-stored 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 pathologise 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 to your visibility to the assumptions that can be made when totalising stories are told and to bring forward preferred ways of describing self and what the person holds as precious. And before bringing this podcast story to a bit of a close I want to acknowledge that I've sought to be aware throughout of my own professional power and I refuse to make totalising 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 inside of knowledge and the reciprocity that can occur between clinicians and patients. It's required deep listening in the spirit of respect, dignifying and rehumanising practices and the embodiment and enactment of core social 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 folk that you routinely meet with so that we can walk alongside people in a more trauma-informed, honouring way. You know, even just let's start right at the beginning. The way that this 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 very much so and I think she describes it as structuralist ideas and verses 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. Yeah and so what she, as you say, the contradiction starts with the pathologising language that's used, yeah. they're narrowing down the person's experience to even one word descriptions, one word descriptions that are a diagnosis for instance are just homeless. But how many times, I remember that so clearly is 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 work talks about those dominant discourses that actually happen in the environment because homeless presentations are absolutely whether it happens so often. And the lingering nature of those labels too, MIM. So that's the other thing that you can actually be labeled with something from the previous admission, but it can haunt you. Oh, let's just say for instance, you are being assertive and actually wanting to voice your concerns. All that takes is that one word, let's just go with aggressive. And that can actually live with you in 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. Yeah, it is so easy for someone to flippantly write something in a note that then hangs over the future presentations of a person into that system, right? And that it's no balls. What is written in that first note, snowballs into actually character assassination as you go on and 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. The social worker used a word that I haven't heard for a while, but was often used in my course back in the 80s and that is the deserving word. Yes. 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 had 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's story. He's an example 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 that is frequent flyers that will often be referred to for people like Simon who have had many admissions. And that 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 flyers. Absolutely. So yeah, and I think the other thing that the social worker really helped me to understand was the importance of the contextualisation that social workers can bring to the person's story within the documentation, right? Yeah, yeah. And often, you know, the social workers aren't as 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 it's 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 does person-centred care actually mean with every word that you write? I love that. And this whole story made me think about a piece of a student that Ben Joseph is our producer on social work stories, but also is the host of social work discoveries. And he and I just had a student on placement in our hospital emergency department looking at homelessness. And it was really interesting. 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 preventing them from having this high-level person-centred 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 the story to those experiences. 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 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. That's right. That we are 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 have some support around this time. But it may not have been. That's right. 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. Yeah. Does the word homelessness describe your circumstances? Or would you use a different word? I absolutely love the phrasing of these questions, Liz, right? They are absolutely. If you think about how we how we teach to the positioning of questions and this concept of exploratory exploratory interviewing, this is absolutely examples of how we open up the discussion beyond the referral. I agree, Mim, and I think if anyone's wanting to, I guess use these questions in different ways. I found myself pausing throughout the listening and writing these questions because that is a 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. 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's 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 ask those questions and then she highlighted the importance of deeply listening to what this person had to say. I'm going to shape my questions in a way that you're going to respond in the way that I needed to respond within the time that I needed to respond. Totally. Well, it's amazingly essentialist and reductionist to say that the person sitting across from me is only their homelessness or is only their trial protection issue or is only their domestic violence situation. I mean, ultimately, this is person-centered 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 is this is how to step it out and do it. But see, this is my thing about health, right? I think we waste a lot of time doing this same old same old. So we can use Elliot as an example from this from this recording right? So we could go in and go homeless right. I'm just going to organise some emergency housing and good luck with that by the way. I'm just going to 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. Yeah, but in Elliot's case, that good use of questioning was able to highlight the fact that there was 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 plonking him in a hotel for a few nights. Do you know what I mean? How often in health do we respond in the same way and are wasting Elliot's time? Absolutely. Probably not at all. I mean I would say that. And actually not helping him achieve the goals that he has. Not the goals that the health system has, the goals that he has. Yes. Absolutely. Why don't we just shift a gear and move into her innovation, her innovative project. And I'd like your take on it in terms of the research work that you do and maybe some commentary about. This is a really interesting project that she's worked on and I know you've got some thoughts on that. 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 the presentations that she's seeing and be able to deconstruct to analyse 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 ethic 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 about special other students, for 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 screening. And the way that she's asked those questions is that they're grounded in these ideas of challenging discourse. 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, and really beautifully articulated 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 that 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 worker student, or a social worker practitioner who is wanting to engage with formal research in this way, or if you are, or when you're later on and you're practicing and you realise 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, Liz, 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 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, Liz. But 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, it's just for me, Liz, just social work perfection. Look, well said as usual, Mim, I agree. I agree that 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 reauthoring with Simon and Elliott 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, can you imagine having this one over the lunchroom? I mean, what an amazing conversation to be encouraging colleagues to reflect on. Like, who are you working for? So often people are going, you know, a 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. Absolutely. Absolutely. Go holy heck, yeah. I really do need to be able to do that. Let's reorientate. That's right. Let's reorientate our entire position. That's why I say positionality is so important in this. Absolutely. Whether you're coming out from a practice perspective or a research perspective, you need to know who you are. How are you actually engaging with those 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, Liz, particularly if you're a social worker. But I really think that 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 represent 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 recognised it, how do we shift our perspective? And that's in those conversations with colleagues, as well as in those therapeutic conversations with the person that's there. Exactly. So you have to, 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 pathologising, was not diminishing their life experience. And was actually telling the story that Simon and Elliot wanted to tell her. 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 Elliot's commitment to education, for instance. Simon's history in terms of his work and the times when he has struggled with alcohol and times when he hasn't. So those different stories that she was then not only able to read back to Simon and Elliot, but also the clinicians. And there's where one would hope, and I've got to hold on to this, that it would have impacted on those clinicians in a way where I go, "Oh, okay." I didn't realise that that was a case with Simon and Elliot. That's right. And you really hope those light bulb moments will actually click in. I've got to hold on to that one, then. The other thing I'd like to hold on to is the being the fly in the wall when Elliot and Simon Simon, listen to their stories read back. So I've used therapeutic letters before when I was a counsellor and they're very powerful tour. I've never, again, once again, I've never seen it using the AD setting and I think she acknowledged that there would have been a bit of time pass between when they told the story and I listened to it and when I re-roached 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 Elliot to have heard of. Absolutely. A different story read to them. Absolutely. This is reminding me of an episode that we did around narrative therapy with women in the forest. Do you remember? Yes, I do. In the show notes, we'll link back to that episode. It was very much about that reauthoring of the experience that people had had. 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 you but for you, right, by others around you. Yeah. I just think that's a hugely important therapeutic technique. I want to talk about this more and more with you. I know there's so much to say Liz. I think we will wind it up simply because it is going to be one of those episodes that both of us will encourage our listeners to listen to more than once because it is so late and as you've said beautifully in the past, 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 thoughts? Yeah, yeah, yeah. Always. 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, so narrative therapy was particularly big in the 90s, I mean, it still is big, but 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, event 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. Not 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 that's worth considering as a clinician. Like, yeah, if you're going to 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 you could absolutely go straight into your practice right tomorrow, really. Yes. I'm, if I can encourage people to just do things differently. And in this case, you will get a different response, a different, and it will, it will feel different in terms of how you and that and your patient, your client, your consumer have a conversation. 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, allow each other to see your practice in action, and then to give you some constructive feedback because we know this is how we learn. 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. I might, might feel a bit fumbly to start off with, but I was wondering if I could, you know, do things that will be differently. Well, they'll tell you pretty quick. If you got it right. That's where the feedback will become from. That's it. That's it. 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. At least, I absolutely love it. So good to be back on the pod. 2024. Isn't it just? Loved it. No. We've got lots of things planned. We do. I know we've 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, Liz. Yeah. Indeed, Mem. On that note, there will listen to us until next month. Take care. Take care, everyone. Bye for now. 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 favorite 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, socialworkstories.com. The Social Work Stories podcast is made by Liz Murphy, Dr. Mem Fox, Justin Stesch, Dr. Ben Joseph, and Maddie Stratton. Thanks so much for listening.