BLI: Being Least Intrusive

Being Least Intrusive emerges from the frontline challenges of  practice in responding to situations of abuse, neglect and self-neglect  of vulnerable First Nation adults living in on-reserve First Nation  communities. It is a hybrid approach, which draws on indigenous  knowledge, key concepts from critical social work theory and first-hand  accounts of response and prevention initiatives within First Nation  communities across Canada. It has been developed to assist front-line  service providers (primarily non-aboriginal) in orientating themselves to  respond to situations of abuse, neglect and self-neglect of vulnerable  First Nation / Aboriginal adults in a way that:

• Is Culturally Safe;
• Facilitates a holistic understanding of health and wellness;
• Honours cultural and spiritual diversity;
• Creates space for collaboration and partnership;
• Acknowledges the strengths and resiliency of individuals, families  and communities; and
• Ensures safety, protects dignity and encourages empowerment.

Being Least Intrusive presents a fundamentally different approach to  health care service delivery. It challenges front-line clinicians to:

• Engage in critical practice;
• Understand issues of vulnerability, abuse and neglect in the  historical, social and cultural context in which they emerge and  are experienced;
• Develop a critical self-awareness (understanding how your social,  cultural identity and experience shape knowledge, awareness and  interactions);
• Be thoughtful, intentional and respectful in engagement with  individuals, families and communities.

Being Least Intrusive was developed within the socio-legal context of  British Columbia’s provincial adult guardianship legislation. However,  we believe that the concepts and principles underlying this approach to  practice and process of engagement are applicable across jurisdiction  and geographical regions.  

The following principles and concepts form the foundation of the  Being Least Intrusive tool. Responding to situations of abuse and  neglect of vulnerable adults is a complex endeavor. In the context of  vulnerable First Nation adults, this work presents additional challenges.  Integrating knowledge and awareness of the following principles and  concepts is critical in assisting clinicians to develop a way of being in  practice that facilitates encounters and experiences that reduces risk  and vulnerability and protects the dignity of the client.

Least Intrusive Most Effective

Embedded in the BC Adult Guardianship Legislation are guiding  principles intended to assist clinicians balance the responsibility  to intervene, support and protect vulnerable adults with the often  competing ethical responsibility to respect and protect an adult’s rights  of autonomy and self-determination. Two critical principles are:

• Adults are presumed capable and have the right to choose for  themselves how, where and with whom they want to live—even if  that means living at risk.  
• All adults should receive the most effective but least intrusive form of support, assistance and protection when they are unable  to care for themselves and/or their assets.

Cultural Safety

Cultural safety, a term first used in New Zealand in reference to health care  service with the indigenous Maori people, is an outcome reflected in the  qualitative experience of the client. The client determines whether s/he  has felt that her/his cultural identity, values and preferences have been  respected and taken into account in the care provided and decisions made.  

Cultural Safety is predicated on:

• Respectful relationships & Equitable partnerships  
• Strengths Based & Collaborative problem solving and  decision making  
• Thoughtful, Intentional and Meaningful action

Vulnerability and Capability

Issues of vulnerability and capability are at the heart of adult abuse  and neglect investigations and central in adult guardianship and  substitute decision-making legislation. They are complex individual  and interconnected concepts:  

• Vulnerability is a social condition: it emerges from and in relation to  interconnected factors such as poverty, isolation, ageism, physical  and/or mental illness, education, disability, gender and culture.
• Capability refers to specific tasks and particular categories of  decision making: a person may be capable of certain tasks and  decisions but no longer capable of others.  
• Vulnerability and Capability are both dynamic; they can fluctuate  depending on circumstance.

Attention to an adult’s social environment and the factors that contribute  to vulnerability is critical in giving meaning to the notion of capability and  informing responses that are least intrusive and most effective.

Aboriginal Worldview and Understanding of Health

The aboriginal understanding of health and wellness stands in stark contrast to the definition of health in mainstream healthcare. Central to aboriginal worldview is the belief in the interconnectedness of all things in existence; and, reverence for the intrinsic wholeness, sacredness and value of self and others.

Health and well-being is understood holistically across multiple and interconnected dimensions. It is inclusive of and determined by the

connection and balance between and within:

• The Total Person (body, mind, heart, spirit; across the lifespan: child, youth, adult, elder);
• Their Total Health (physical, emotional, mental and spiritual); and
• The Total Environment (family, community, social, cultural, economic, natural world).

The concepts that define and determine one’s experience of health and well-being include: wholeness, balance, connection or relationships, harmony, healing, learning and growth.

Meaning Centred Practice

Meaning centered practice is  

Inquisitive: clinician engages as ‘humble knower’, curious about the  client’s worldview, meanings and lived experience.

Collaborative: engages in a reciprocal process of sharing knowledge  and exploring meaning.

Respectful: honours diverse ways of knowing and being; creates space  for voice, wisdom and experience of the client to emerge, be heard, be  valued and understood.

Critical: clinician engages in critical self-reflection —cultivating an  awareness of how social and cultural identity and experience shape  knowledge, awareness and interactions.

Being Least Intrusive: The Tool

Being Least Intrusive is a concrete tool that front-line clinicians  can use to guide them through a process of critical preparation,  assessment and reflection. It is divided into three sections, each  with a series of questions that will assist clinicians to develop  a critical self-awareness, gather information that will inform a  more holistic assessment, and engage with clients, families and  communities in ways that are culturally safe and appropriate.

Orientation to Self

• When: prior to engagement
• Action: developing a critical awareness of self: attitudes, values & assumptions, social & power.

1. Who am I (personal and professional role, socioeconomic status, cultural affiliations, worldview, etc)?
2. What is my understanding, attitude, assumptions about the issue of abuse, neglect and self-neglect of vulnerable adults, of vulnerable First Nation adults?
3. Will any of my values or biases impede my role/responsibility in creating a safe environment or safe encounter for the client/family with whom I am working?
4. Who am I in relationship to the client, family, community with whom I work? (How do they see me? understand my role? What is the power differential?)

Orientation to Context

Community and Culture

When: : before case work begins‍

1. What are the resources within the community (social &health care services)?
2. Are there specific protocols of engagement (e.g. cultural traditions, values) with/within this community that I need to be aware of and incorporate?
3. Who can I partner with in this community – who is the most appropriate person (has a knowledge and connection to the client/family, is in a position of trust, can act as a cultural guide and can assist in developing a culturally safe and appropriate support and assistance plan?
4. What is the history of engagement, collaboration that my organization (e.g. community health agency) has had with this specific community regarding service delivery?

Case Specific

When: prior to engagement with client/family/community

1. What are the objective details of this situation? (What are the facts, what is the specific concern reported, who is involved?)
2. Who reported the concerns of abuse & neglect (e.g. family, client, community member, and service provider) and what is their connection to the situation?
3. Will my involvement with the client/family/community be welcome?
4. How will I engage others and still respect the confidentiality, privacy, and dignity of client and family?

Gathering Information

When: over the course of multiple interactions with client and involved family, caregivers, and service providers.

1. How does the client experience his/her own Physical, Mental, Emotional and Spiritual Health?

• What are the words they use to describe their current state of well-being and functioning across these dimensions?
• How do they make sense of the current situation?
• Do they have any specific concerns about any aspects of their health and well-being?
• How do the client’s perspective, experience and meanings differ from those of their family, caregivers and service providers?

2. What is the client’s experience of connection and belonging to:

• Family (who is important to them, what is their role within the family)
• Community (what is important, what is their role within their community)
• Culture (traditions, values, spiritual practices)

Assessment

When: after as much information as possible/relevant is gathered

1. What are the specific factors in the following wholistic dimensions that contribute to the client’s strength and vulnerability?

• Physical well-being (physical functioning, health, activity)
• Mental well-being (cognitive functioning, mental health, learning/education)
• Emotional well-being (self-esteem, sense of control over forces affecting one’s everyday life, livelihood, health)
• Spiritual well-being (cultural identity, engagement, integration of past/present)
• Relationships (connection and belonging to family, extended family, community, land, creation)
• Social well-being (income, security of food and shelter, language, access to support and resources)

2. How will I distinguish my understanding of health and well-being from those of the client, family, and community?

3. How will I distinguish my values regarding standards of care, family relationships, and physical surroundings from those of the client, family, and community?

Orientation to Reflection Process

When: after intervention; happens over time

1. Was I least intrusive/most effective in my intervention? (e.g. was the client’s autonomy and self-determination respected and balanced against the need for support and assistance?)

2. Was my involvement experienced by the client as culturally safe? (was the client’s cultural identity, values and preferences taken into account in the service encounter; was the client engaged in the encounter; was the client involved in developing a respectful and appropriate support and assistance plan; did the client welcome my involvement; was I invited back?)

3. What did I learn about myself (were my values and assumptions about the situation, client, culture challenged?)

4. What has the feedback been that I have received from the client, family, community, colleagues about the process?

5. How could my practice improve?

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Foundational Principles

Cultural Safety

Ball, J. (2008). Cultural Safety in practice with children, families and  communities. Early Childhood Development Intercultural Partnerships,  University of Victoria. Victoria, BC.

Being Least Intrusive  

Background to approach in: Struthers, A., L. Neufeld. (2010). Being  Least Intrusive: an orientation to practice in responding to situations  of abuse, neglect and self-neglect of vulnerable First Nation adults  (Working Paper)

Vulnerability & Capability

(2009). Provincial Strategy Document: Vulnerability and Capability  Issues in British Columbia. BC Adult Abuse / Neglect Prevention  Collaborative. Vancouver, BC.

Aboriginal Framework

Adopting a social determinants of health lens, the Assembly of First  Nations (AFN) developed a wholistic policy and planning model  to highlight gaps in First Nation well-being and identify broader explanatory factors to assist in developing actions and responses to  more effectively address and improve the health of First Nation people.  Underpinning this model is a cultural framework, based on indigenous  knowledge, values and beliefs, that defines health and wellbeing as a  integration of ‘total health’, ‘total person’ and ‘total environment’.

Reading, Jeffrey L.; Andrew Kmetic, Valerie Gideon. (2007). First Nations  Wholistic Policy and Planning Model: Discussion Paper for the World  Health Organization Commission on Social Determinants of Health.  Assembly of First Nations, Ottawa, Ont.

Meaning Centered Practice

Janet Clark offers a research based approach to co-creating meaning  across cultures. Clark, J. (2006). Listening for Meaning: A Research  Based Integrative Model for Attending to Spirituality, Culture and  Worldview in social work practice. Critical Social Work, Vol. 7, No. 1.

Abuse & Neglect Tools

Flowchart of Intervention: a graphic mapping of tools and resources  within a process of response in situations of abuse and neglect within  on-reserve First Nation communities. The process of response itself  can be helpful in guiding front-line service providers in their response  to concerns of abuse and neglect, as well as assist communities build  capacity, identify strengths, resources and service needs, and develop a  coordinated, community based response.

In: Promising Approaches for Addressing / Preventing Abuse of Older  Adults in First Nations Communities. Available at:  

First Nation Re:Act: Assessment and reporting information/ process for  investigating reports of adult abuse and neglect, adapted for use with  First Nation’s individuals and communities across Canada

Acknowledgements:

The development of this orientation to practice would not have  been possible without the direct learning that has emerged  from frontline work and the wisdom and knowledge that  has been shared by our First Nation colleagues, community  leaders and engaged individuals through dialogue and  example, in practice and in partnership. We are grateful for  the support, guidance, feedback and joint exploration that  have come from the following:  

• BC Association of Community Response Networks Wit Works Ltd.  
• VIHA, Home and Community Care Program, Campbell River Kwakiutl District Council - Health Programs

While the tool is specifically directed towards non-aboriginal  clinicians providing services to vulnerable adults in on-reserve  First Nation communities, we have received feedback from a  variety of service providers, community agencies and involved  community members who are interested in using the tool to  enhance practice, build capacity and more effectively and  safely engage with individuals, families and communities in  their service environments; including:  

• RCMP
• Child Protection Agencies
• Financial Literacy Projects
• First Nations and Aboriginal Communities