2019-01-03 calendar... · 2019-01-03 6 canadian association of occupational therapists association...

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Association canadienne des ergothérapeutesCanadian Association of Occupational Therapists1

CAOT Professional DevelopmentPractice Evidence Webinar

Association canadienne des ergothérapeutesCanadian Association of Occupational Therapists

Informed consent in occupational therapy: How colonization and coercion impact

access for Indigenous Peoples

Presenters:

Janna MacLachlan, OT Reg. (Ont.), PhD Candidate

Lisa Boivin, PhD Student

University of Toronto

January 8, 2019

MacLachlan, J., & Boivin, L. (2019, January 8). Informed consent in occupational therapy: How colonization and coercion impact access for Indigenous Peoples. In CAOT Practice Evidence Webinars series. Retrieved from http://www.caot.ca/site/pt/resources/odwebinars?nav=sidebar

These webinar materials are copyrighted to the presenters and may not be distributed or shared without the express permission of the presenters.

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Association canadienne des ergothérapeutesCanadian Association of Occupational Therapists4Photo credit: Cathy McNeil

Lisa Boivin

Video

Lisa Boivin



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Lisa Boivin


Was consent

available in...

Residential schools?

Sixties Scoop?

Tuberculosis sanitoriums?

Forced relocation and expropriation

of lands?

Slaughter of sled dogs?

Sterilization of Indigenous

women?


Lisa Boivin

Video



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“Consent is a process that requires a dialogue between the person proposing the service and the person giving consent for that service or service plan.” (COTO, 2017, p.2)


Lisa Boivin


Acknowledging emotional responses to the topic

•Common to feel a range of emotions, e.g., anger, guilt, defensiveness, sadness•Be gentle with yourself•Focus on reflexivity, listening and openness•Moving past emotional responses opens space for working together



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Key concepts for exploring this topic• Informed consent

• Colonization

• Approaches to practice

– Cultural safety

– Cultural humility

– Critical reflexivity

• Power and privilege

• Worldviews: Indigenous and Western

• Self-determination


Colonization

• Process that employs modes of control to manage a population and/or expropriate land, resources and people (Tuck & Yang, 2012)

• Purpose is to secure wealth and/or privilege and power for colonizers (Tuck & Yang, 2012)

• Often enacted through policies and laws

• Key determinant of health for Indigenous Peoples (Allan & Smylie, 2015)

• Not over


Cultural safety

• Aims to decrease health inequities and social injustices (Beagan, 2016)

• Aims to support respectful, trusting and ethical relationships between client and clinician (Gerlach, 2018)

• Requires understanding of historical and ongoing impact of colonization on Indigenous Peoples (Gerlach, 2018)

• Draws attention to power relations (Beagan, 2016)



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Cultural safety

• Culturally unsafe practice includes “any actions that diminish, demean, or disempower the cultural identity and well-being of an individual” (NAHO, 2008, p. 4)

• Assessed by clients (Beagan, 2016)


Cultural humility

• Aims to redress power imbalances between clients and clinicians

• Critical reflexivity/self-evaluation is key element

• “Difference” is not in the client, but within the relationship between client and clinician

(Hammell, 2013)


Cultural humility

• Clinician aspires to embody:

– Humility

– Flexibility

– Openness

• Client is expert

• Reflect on power dynamics in client-clinician relationships

• Assessed by clients

(Beagan, 2016)



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United Nations Declaration on the

Rights of Indigenous

Peoples (2007)

“free, prior and informed consent”


Worldviews

• “ways of thinking that are formed in social life and function to direct humans in their behavior and life” (Sartini & Ahimsa-Putra, 2017, p. 267)

• Formed within societies• Shapes perceptions of the world around us, like

a “mental lens” (Hart, 2010)• Made up of beliefs, values and understandings

of the world around us


Western/Eurocentric worldview

● Places itself at the centre of history and action ● Universalism (e.g., one right way)

○ Normal vs abnormal

● Hierarchical order (e.g., humans hold power over other life and inanimate objects)

● Linearity (e.g., a beginning and an end)● Centrality of the individual● Objectivity (e.g., knowledge comes from

science)(Norris, 2014)



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Inuit Qaujimajatuqangit

• Diverse knowledges and knowledge sources, including:

– Experiential

– Empirical

– Spiritual

• Knowledge is dynamic, adaptable, evolves to solve problems

– Oral traditions support this as texts privilege one version

• Knowledge production is relational, incorporating experience and innovation

• No universal truths, knowledge is context-dependent


Inuit Qaujimajatuqangit

• Holism

• Humility

• Relationships, resourcefulness, respect

• Maintaining harmony

• Planning for the future


Language

• Represents intellectual system and way of being (McGrath, 2011)

• Were no words in many Indigenous languages for disability and rehabilitation prior to colonization

• Currently almost no commonly used Indigenous language words for occupational therapist across the country



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Association canadienne des ergothérapeutesCanadian Association of Occupational Therapists25Lisa Boivin


Lisa Boivin


Self-determination

• “Indigenous peoples have the right to self-determination. By virtue of that right they freely determine their political status and freely pursue their economic, social and cultural development.”

(United Nations, 2007, p. 4)



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APPLICATION TO PRACTICE


Interactions with health and social services

Indigenous Peoples often actively avoid accessing health care services because of:

• Systemic racism (Allan & Smylie, 2015)

• Lack of respect for Indigenous worldviews

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Parents who do not participate as expected in early childhood programs may be judged as non-compliant (Gerlach, 2018)

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Indigenous children represent 7% of child population but 48% of children in foster care (Turner, 2016)

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In interactions with health care services, Indigenous mothers experience fear of judgement and threat of child apprehension (Denison, Varcoe& Browne, 2014)

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Common assumptions

Indigenous clients can and should trust the health care system.

The Western worldview is good and normal.

Evidence-based practice and best-practice guidelines are appropriate for use with Indigenous peoples.

The approach and values of occupational therapy services are beneficial for and wanted by Indigenous families.

Our bodies and actions are neutral.



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Are informed consent, cultural safety and self-determination possible?

• MMSE required for dementia medication funding

• Standardized developmental assessment• Need for complete assessment before loaning a

wheelchair• Not giving or receiving gifts from clients• Prioritization tools• FIM completion linked to service funding




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Documentation

• Is this “objective” or is it underpinned with cultural values and beliefs?

• What are the implications of this?


Documentation• What if we tried to inject cultural humility into

our documentation?



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Documentation

• Is this “objective” or is it underpinned with cultural values and beliefs?

• What are the implications of this?


Documentation• What if we tried to inject cultural humility into

our documentation?


COTO Standards for consent (2017)

a. Scope and reason for the

referral;

b. Purpose and nature of the

service;

c. Expected benefits and

relevant risks of proceeding with

the service;

d. Likely consequences of not proceeding

with the service;

e. Expected outcomes of the

service(s);

f. Alternative courses of action;

g. The right of the client to withdraw

consent at any time during the

process;

h. Financial arrangements

regarding payment for the service;

and,

i. Legal authority of the OT for

conducting the service.

An OT will ensure the client has been given all the information a reasonable person in

the same circumstances would require in order to make a decision about the services

including:



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Code of Ethics

(COTO, 2011)

OTs are guided by two fundamental values:

• Respect

• Trust


Implications of free and

informed consent

being inaccessible

• Blocks:

– Indigenous self-determination

– Human rights

– Culture (Northern Public Affairs, 2016)

• Clients in a vulnerable position, feel threatened

• Power differential between therapist and client is maintained


Practice implications

• Texts written for broad audiences do not always account for a diversity of contexts and worldviews

• Standardization can be colonizing, blocks diverse ways of knowing

• Following mainstream (Western) practice can override:

– Client-centred practice values

– Opportunities for cultural safety

– Opportunities to practice trauma-informed and anti-oppressive practice

– And block access to free and informed consent



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Service could be perceived as:

• Gatekeeping

• Value-imposing

• Threatening (e.g., social services)

• Intrusive (e.g., needing to ask ++ questions before loaning a wheelchair)

• Exercise of power

• Judgemental

• Lack of choice

• Getting in the way of being human



In other words…

• Epistemic violence

• Cultural imperialism

• Intellectual or medical colonialism



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Key take-home

message

The colonial context in which the interaction between Indigenous client and occupational therapist occurs impedes access to free and informed consent.


Allyship

• “an active, consistent, and arduous practice of unlearning and re-evaluating, in which a person of privilege seeks to operate in solidarity with a marginalized group of people”

(The Anti-Oppression Network, n.d.)


Allyship

“Allies are people who recognize the unearned privilege they receive from society’s patterns of injustice and take responsibility for changing these patterns.”

(Bishop, n.d.)



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What can OTs do?

• Aspire to allyship

• Listen, ask, offer

• Practice cultural safety, critical reflexivity, cultural humility –find and share concrete approaches to this!

• Reflect on power and privilege in client interactions

• Face discomfort


What can OTs do?

• Value diverse worldviews

• Consider representation within profession

• Build relationships

• Seek opportunities for reconciliation and learn what reconciliation means to the people you are working with


What can OTs do?

• Consider who/what expertise is best suited to a context and concern (it might not be us!)

• Consult practice guides (e.g., Gerlach, 2018; CAOT, 2018)

• Seek and value local knowledge and contextually relevant practice information (e.g., child development knowledge written by Inuit Elders)

• Resist, advocate with

– Document injustices

– Raise injustices with managers, those in power



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ReferencesAllan, B. & Smylie, J. (2015). First Peoples, second class treatment: The role of racism in the

health and well-being of Indigenous peoples in Canada. Toronto, ON: the Wellesley Institute.

Beagan, B. L. (2016). Approaches to culture and diversity: A critical synthesis of occupational therapy literature, Canadian Journal of Occupational Therapy, 82(5), 272–282.

Bishop, A. (n.d.). Becoming an Ally. Retrieved from http://www.becominganally.ca/Becoming_an_Ally/Home.html

Boivin L. Image-based storytelling: a visual narrative of my family's story. 2018 09/17; 2019/1;190(37):E1112+.

Boivin L. Searching for Answers in the Garden of Bioethics. Ars Medica. 2015;11(1).

Canadian Association of Occupational Therapists. (2018). CAOT Position Statement: Occupational therapy and Indigenous peoples. Author: Ottawa, ON.

College of Occupational Therapists of Ontario. (2017). Standards for Consent. Author: Toronto, ON.

Crawford A. Dene and Western medicine meet in image-based storytelling. 2018 09/10; 2018/12;190(36):E1085+


References

Denison, J., Varcoe, C., & Browne, A. J. (2014). Aboriginal women’s experiences of accessing health care when state apprehension of children is being threatened. Journal of Advanced Nursing, 70(5), 1105–1116.

Gerlach, A. (2018). Exploring Socially-Responsive Approaches to Children's Rehabilitation with Indigenous Communities, Families and Children. National Collaborating Centre for Aboriginal Health: Prince George, BC.

Hammell, K. R. W. (2013). Occupation, well-being, and culture: Theory and cultural humility. Canadian Journal of Occupational Therapy, 80(4), 224–234.

Hart, M. A. (2010). Indigenous worldviews, knowledge, and research: The development of an Indigenous research paradigm. Journal of Indigenous Voices in Social Work, 1(1), 1–16.

McGrath, J. T. (2011). Isumaksaqsiurutigijakka : Conversations with Aupilaarjuk Towards a Theory of Inuktitut Knowledge Renewal. Carleton University.

National Aboriginal Health Organization. (2008). Cultural Competency and Safety: A Guide for Health Care Administrators, Providers and Educators. Author: Ottawa, ON.


ReferencesNorris, H. (2014). Colonialism and the rupturing of Indigenous worldviews of impairment

and relational interdependence: A beginning dialogue towards reclamation and social transformation. Critical Disability Discourse/Discours Critiques dans le Champ du Handicap 6, 53-79.

Northern Public Affairs. (2016). Volume 4 Issue 2: The Right to Free, Prior & Informed Consent. Retrieved from http://www.northernpublicaffairs.ca/index/volume-4-issue-2/

Sartini, S., & Ahimsa-Putra, H. S. (2017). Preliminary study on worldviews. Humaniora, 29(3), 265-277.

The Anti-Oppression Network. (n.d.). Allyship. Retrieved from https://theantioppressionnetwork.com/allyship/

Tuck, E., & Yang, K. W. (2012). Decolonization is not a metaphor. Decolonization: Indigeneity, Education, & Society, 1(1), 1–40.

Turner, A. (2016). Living arrangements of Aboriginal children aged 14 and under. Ottawa, ON: Statistics Canada.

United Nations. (2007). United Nations Declaration on the Rights of Indigenous Peoples. Retrieved from http://www.un.org/esa/socdev/unpfii/en/drip.html



http://www.becominganally.ca/Becoming_an_Ally/Home.html

http://www.northernpublicaffairs.ca/index/volume-4-issue-2/

https://theantioppressionnetwork.com/allyship/

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Acknowledgements

Janna MacLachlan

Canadian Occupational Therapy Foundation

Northern Scientific Training Program

Lisa Boivin

University of Toronto Fellowship - Rehabilitation Science Institute

Banff Centre for Arts and Creativity


Questions?

Janna MacLachlan, OT Reg. (Ont.)

[email protected]

Lisa Boivin

[email protected]

THANK YOU - Mahsi Cho


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