Stucker2007

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A contribution to the TC Sources/Open Sources Project



How do we (i) help rescue a resident from “failure” or “discharge”?

Relationship-Centered Care(ii) and the Art of Grasping the Last Thread
Virgil Stucker, April 24, 2007


We are social creatures; our lives are organized around conversations, belonging, relating in interactions that are comprised of patterns (roles, hierarchies, policy requirements, values). Our lives with one another blend like a piece of music; we are musicians who play new notes in each new moment. This is life and it is a wonderful symphony. Generally, we are free to engage with society, with this symphony. As we join a new community we look around to see how others are behaving, figure out the rules, work to fit in, and become good citizens.


Our residents most often do not have the freedom to join in as easily. As they arrive they are dis-engaged and in a dis-eased state; they are “stuck”, not passively but swirling, as if caught in an eddy by the side of a river. We welcome them and as we join together in our daily life, most begin to take their place in the orchestra. Our residents (55 in exit surveys) have told us that they value highly CooperRiis’ opportunities, which help them to re-join community and social life while developing a sense of purpose and belonging. They have told us that in re-joining social life they begin to feel at-ease and are no longer stuck, as they become full citizens of the CooperRiis community.


How do we generally help them to accomplish this?

  1. We design intentional encounters that occur in the fields, in the offices, in the lodges, in the graduate houses and elsewhere. The most intentional amongst us see ourselves as “treaters”.
  1. We offer interventions related to goals in an effort to cause change to occur. We believe that understanding causal factors allows us to predict outcomes or better yet to control them through positive and negative consequences.
  2. We communicate and educate by creating different venues and methods for transferring information to our residents.


Unfortunately, this approach doesn’t work for everyone. Sometimes the most vulnerable can be left behind, despite our best efforts, discharged or left on the porch to smoke. We may begin to feel frustrated and may even feel as though these residents are impediments to the music, creating dissonance and attracting others to their ways.


When this occurs, language such as the following emerges over time:


“He’s too depressed; we need to let him rest…”
“She’s not even hitting 50% participation on the Life Skills Program…”
“He’s able to participate but is just choosing not to do so…”
“Instead of exercising, they are just sitting and smoking cigarettes…”
“She missed her appointment with me; she must not be interested in her recovery…”
“He’s becoming a bad influence on others; we may need to discharge him…”
“She’s more often late for her morning meds and seems to be gaining more and more weight. Maybe she needs Provigil to get her going…”
“He says he can’t work today because his knee hurts; probably a psychosomatic issue, not real…”


What can we do? We’ve lost ‘control’. When we are at the moment of giving up, how can we find that last thread to grasp which just might become a lifeline?


Let’s begin first by recognizing that we should not attempt to be in control. If we are fully honest, we acknowledge that community seems most often just to happen, almost on its own (iii) In order to know what’s really going on and in order to have some influence on the process, we should study moment-to-moment dynamics during our encounters with residents.


We begin to see that the patterns of meaning and relating are continuously self-organizing in the course of interactions. The emergence of social patterns in each moment, both stable and novel is a self-organizing, iterative process; the patterns form spontaneously without anyone’s intention or direction. While we may seek to influence these patterns intentionally and we may even succeed for a time, they are ultimately unpredictable and beyond our control.


Have you been in conversations where you or the other person tossed in a small idea that evolved into something much larger than you had ever expected? Think of the morning when Lisbeth suggested to Don that they should consider creating a program to help individuals recover from mental illness. (Actually a big idea…) In conversation at a Kiwanis meeting, a woman at my table was talking about her brother who makes Native American flutes. I asked, “What’s a Native American flute?” Her brother came to the Art Barn one day to show us his flutes… the rest, as they say, is history. In my own life, someone once handed me a publication called “Friends Journal” in 1975, saying it had some interesting information in it about a place called Gould Farm… I never intended to spend most of my working life working at and helping to create places like Gould Farm.


What about you? How many small ideas introduced into conversation have had a major impact on your life? How many threads have become lifelines or themes that have ultimately defined who you are? On the other hand, how many of you really became the person that your 8th grade career paper envisioned?


Regarding our dis-engaged residents, the question becomes… How can we create and facilitate conversations where our introduction of small ideas may have the likelihood of having a major impact on their lives? …where our discovery and grasp of a thread might become their lifeline?


First and foremost be aware that how we see one another affects who we are! Let’s return a moment to the negative phrases, which we sometimes use to describe our residents who are in trouble. We must replace these negative images and genuinely and honestly “see” these dis-engaged residents as engaged. We enter into conversation and relationship already “seeing” the resident as integrated with the community… We love them… see them as already a part of us.


Great and moving conversations may be conducted by any staff member. Consider that great conversations may start like a game of “ping-pong” and grow into something far beyond what was ever intended.


First we select our conversation partner. This partner will be a resident who is near the abyss… all else has failed and yet our relationship with them (our alliance) is intact. Even through our logical conclusion is to give up, our heart will not allow us to do so.


We find our partner and position ourselves, ideally eye-to-eye with the resident. From the depths of our heart we launch a conversation with questions like, “I’m curious… how are you… you seem to be going through a very difficult time… I’ve missed you… what’s on your mind? …what can I do to help? I care about you.”


The “ping-pong” begins. We are:

  • Fully present,
  • Engaging,
  • Open, receptive and allowing diversity,
  • Listening deeply…


As the conversation continues we trust the process and ourselves. The unfolding of the moment-to-moment is non-linear, perhaps even chaotic, and the outcome is uncertain. The deeper we listen, the greater will be our empathy and the more meaningful will be the exchange of ideas.


  • We offer small differences or ideas that may create some off-centeredness.
  • We prepare for these small offerings to amplify.
  • We go with the process, with the opening direction, looking for threads to grasp.
  • Our careful guidance of the emerging flow can feel almost serendipitous and synchronous.
  • Be aware. The amplifying small ideas and the gathered threads can cascade into change, into a significant shift…
  • As it does, we allow the moment to blossom; the resident owns it.
  • As they find their voice, they will emerge with clarity of direction, and
  • We need only show them that we believe in them… at this moment they will have returned to community.


This approach relieves us of burdensome and unrealistic expectations of control and their constant shadow, the specter of failure and shame… It shows how small actions can sometimes, unpredictably, amplify into transformational patterns. It shows how we influence each other by how we show up to each other.


We should hold our intentions lightly, let go of control, and attend to and trust the process. This process invites us to be less preoccupied with how to obtain desired results and instead pay more attention to what we are doing together, right here right now.


We maximize our ability to assist our residents with recovery by walking with, recreating with, exercising with, living with, dining with, and being with them in conversation. We, too, are healthiest when we are open and allow our innate desire to improve the human condition to flourish.


By the way, these intense conversations, need not occur only as a last ditch effort. The secret is that they can occur right up front as well, as soon as you notice that you have a genuine and caring relationship with a resident.


We believe in our residents sooner than they believe in themselves, and each of us needs to help them know daily of our belief.



Notes

i. “We” is defined here as the staff of CooperRiis (www.CooperRiis.org) which I opened in 2003 and directed through most of 2007. After finishing this start-up phase we (my wife and I) have returned home to Massachusetts.


ii. What I have learned about Relationship-Centered Care came from Tony Suchman, a former colleague and friend. His document “A New Theoretical Foundation for Relationship-Centered Care” is attached. What I have written here borrows heavily from his work and his words. In my own way, I am hoping also to have contributed to the advance of this type of care by my added analysis.


iii. The Philosophical Basis of Community

First, let’s step back a moment and consider this concept of “community”. In philosophy the study of metaphysics attempts to discover the basic building blocks of reality. How does this apply? Consider the more commonly held belief that something ‘hard’ like the atom is the basic building block. If we also see people in this way, too, concepts like “the drive to survive” (“survival of the fittest”) describe community interactions; ‘community’ becomes more often the “market” where we sell and trade items and ourselves in the competitive quest to be the best. A very negative perspective on this process is offered by Thomas Hobbes, who believes the normal state of nature to be “war”.
I believe that the basic building block of reality is process, not stasis. It is not a hard block at all, but a bundle of energy in flux. The pattern of the interactions of these bundles with their soft and fuzzy edges becomes society or community. These relatively stable patterns are supported by values and norms. The pre-Socratic philosopher Heraclitus was the first person in western philosophy to recognize the flux. He is known for recognizing that “you can not step into the same river twice”. Albert Einstein is one of our modern thinkers who recognized that we are fundamentally inter-related bundles of energy, known by our relativity to one another, in other words by our relationship.
This view of changeable reality helps one to embrace chaos and worry less about control. This view encourages openness to change and receptivity for diversity. Life is exciting and you may be surprised by what is around the corner. If you have faith in the process of life, as I do, you begin to recognize that the normal state of nature is “philanthropy”, the ancient Greek word that translates as the “love of mankind”. Our basic drive is to promote human welfare; it is natural for us to be in community with a meaningful sense of belonging. Those who win are not the competitors who gain the most money and toys; the winners are those who are best at creating community and including vulnerable individuals who would otherwise be left behind.
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