Decision making and self determination are similar but different; how the decision making process reflects the thoughts and intentions of persons with disabilities is important.
Supported decision making is to support persons with disabilities so that they can make their own decisions as much as possible, and to confirm their intentions and estimate their preferences. In cases where it is difficult to estimate the will and preference of the person even if the support is exhausted, the act and mechanism of support provided by persons concerned, such as social workers, in order to consider the best interests of the person as a last resort.
According to “Supported Decision Making Guidelines for Provision of Welfare Services for Persons with Disabilities” , it is necessary for the business operator, family, guardian of adult, and other concerned parties to gather together to promote decision support while clarifying the basis of judgment, in principle, to shift to less restrictive life based on the degree of judgment ability and life scene and the effect of the staff and environment related to persons with disabilities. The specific flow of supported decision making is as follows: 1) when a situation that requires decision making occurs; 2) staff and related parties should assist the person in making the decision themselves. However, there are persons with disabilities who have difficulty making decisions on their own. In such cases, support is provided through the following steps; 3) select a supported decision making manager and assess information about the person’s decision making; 4) hold a decision support meeting with multiple parties, including the person with disability, family members, and staff to discuss the estimation of the person’s decision and the best interests; 5) prepare a service support plan that reflects the decision making results. After decision support, services are actually provided, monitored, and evaluated to ensure that support is in line with the individual’s wishes. The above flow of supported decision making is generally equivalent to the mechanism of care management. In light of the flow of supported decision making, in cases where it is still difficult to confirm the will, legal systems such as the adult guardianship system and the support program for self-reliance in daily life have been prepared as legal and institutional mechanisms to guarantee the rights of persons with disabilities.
2. Two Approaches for Decision Making
Regarding supported decision making in the situation where persons with disabilities and professionals are faced as shown in Stage 1) 2), supported decision making is provided in the form of listening to persons with disabilities’ words and judging what they want to appeal by observing person’s attitudes and situations, but there is no system to guarantee the quality of decision support at this stage. Instead, professionals use the social work approach as a measure of competence to help the persons make decisions. At present, a problem-oriented approach is generally used in which the persons focus on their needs and problems and take an attitude of solving them to remove obstacles to their daily lives.
Under these circumstances, a solution-focused approach (referred to as “SFA”) has emerged, focusing on the future of what persons with disabilities want to be able to do in the future. SFA differs greatly from traditional social work approaches in that it focuses on solutions and changes rather than on causes and problems. SFA focuses on the natural strength and resources of the persons. The goal is to come closer by clarifying the solution image, such as what persons with disabilities are doing well and what they want to do. To this end, it is asked specific questions about the resources that the persons already possess and their ability to act. Typical examples of specific questions are scaling questions, coping questions, miracle questions, and exception questions. By making good use of complement that strengthens the words and deeds of the persons in addition to questions, the solution image that the person desires is clarified, and the change that has already occurred is utilized for the solution, and the solution is constructed in cooperation with the person.
However, many social workers have a history of education and training in problem-oriented approaches and it is not always easy to switch to SFA . In addition, it has been pointed out that SFA which focuses on verbal questions and reframing based on their narratives can be applied to persons with disabilities who are limited in their ability to express their will . However, even if it is objectively observed that they are unable to correctly recognize the situation and there are restrictions on their expression of will, the words uttered from their mouths contain some meaning and value, we have to respect them.
In fact, it is a matter of course justified that in the field of support, persons with disabilities should consider their view of life and will after examining them, and then support them while avoiding oppressive interference. However, even if the estimation of their will and the consideration of the best interests of theirs are considered, there is still room for interference in the judgment of the specific value of the social workers, and there is a possibility that it will drive the person in a certain direction . Supported decision making is pointed out that it is limited to “support” which allows for decisions with specialty in welfare services and it is a strong point of view of the individual model that asks the decision ability of persons with disabilities . It is a kind of paternalism that supporters speak for themselves from the start, assuming that there are constraints in their decision making.
Rather, it is desirable to encourage them to speak and to share the content of their statements, while allowing image the decision making to be restricted.
Self-determination involves a variety of supporters involved, such as not requiring a supporter or leaving the decision to someone in the decision-making process. It is considered that self determination is based on the viewpoint of a social model that made possible in the interrelationship with society, includes creating a society that encourages self determination . Therefore, SFA, which draws out a solution through the mouth of the individual by focusing on strength and resources, is considered to have the effect of amplifying the breadth and quality of decision making for the persons with disabilities.
The purpose of this study is to examine the significance of applying SFA to people with limited expression, to compare SFA with problem-oriented approach based on Bradshaw’s Taxonomy of Need.
One case supported by social worker of the home nursing support office was the subject of analysis. The survey period analyzed support records from June to November 2018. Excerpts from the supporting records used problem-oriented approach and SFA. In particular, SFA was used to describe concretely how the questions were asked and how the cases responded. While analyzing the records, the lack of description was checked with social workers each time. The validity of the analysis was confirmed by the authors and a social worker, and efforts were made to ensure the objectivity of the classification.
As an ethical consideration, we explained to the subject the gist of the research, confidentiality, not to use it for any purpose, and to ensure anonymity. And we proceeded with the research after obtaining his consent.
4.1. Case Summary
Mr. A is a man in his 40s with intellectual disabilities (Suzuki Binet Intelligence Scale IQ 62) but can have simple conversations. He lives with her parents in their 80s. He works at a vocational facility for the intellectual disabled and earns about 80,000 yen a month.
Mr. A has been involved in bank transfer scams several times, and he still has to pay back his credit card loan. The room is messy and there is no place to step on it, and it interferes with life. His mother managed his bankbook as a curator and handed out monthly allowance. However, he used a dating site by cashing, and he had debt where his mother did not know. He explained that he used a dating site or bought a DVD or Blu-ray player with the money he borrowed, but the details were not clear and his mother figured it out. Therefore, debt restructuring was advanced by utilizing the support program for self-reliance in daily life and adult guardianship system. SW is involved as a consultation support specialist and a curator for him and meets him twice a month.
The goal of the support was to keep his room clean and to manage money properly. At first, he was distrustful of the supporters around him, and he had a delusion of persecution such as “The helper throws away the things in my room.”. Even so he had been aware of the difficulty of money management and he had been victimized by a bank transfer scam, he had been unable to rely on others to manage his own money.
Therefore, SW noticed his strength of “seriousness” and supported him. He had a lot of negative reactions to the supporters around him, but through the use of a solution focused approach with complementation and questions, his awareness and thinking have been positively reframed little by little. He realized that the supporters around her were trying to support him, and gradually opened his heart and built a relationship of trust. At the same time, he talked about his true feelings and his will were expressed more frequently. Supporters around him, who thought it was difficult to deal with him, noticed his change and deepened their understanding of him, and as a result, their teamwork became stronger.
4.2. Utilization of SFA
Support records included a total of 28 consultations, all of which were delivered on a problem-oriented approach. Among them the use of SFA was confirmed 4 times.
[Scene 1] A person under curatorship contacted me and asked me to keep my bank card. It seems that the person under curatorship was involved in the money transfer scam. At his request, he kept his bankbook and pocket money.
SW “Even if you wanted money, it must have caused trouble to people around you, right?”
Mr. A “I was scared by the scam. I don’t want to be scared anymore, so please keep it.”
SW “You’ve decided to leave it to me often. Your father and mother will be relieved. Let’s think about what we should do from now on.”
In this context, a problem-oriented approach was first used to identify and understand the problems. Next, while listening to his speech, the SFA was used to “Compliment” his decision to deposit with his own judgement.
[SCENE 2] Mr. A contacted me saying, “I can’t trust the council of social welfare. They throw away things in my room without permission. I also contacted the city government office, but I was refused to be able to help. So I told the Council of Social Welfare to cancel the support program for self-reliance in daily life.” SW said, “If you couldn’t clean up your garbage a year ago, didn’t you promise to use a contractor to dispose of it?” but he did not seem to accept it saying, “They don’t listen to my opinion.”. SW created an opportunity to discuss the matter with Mr. A, his mother, the council of social welfare and his curator.
Mr. A “I can’t trust the council of social welfare.”
SW “What did they do then?”
Mr. A “They did it ... but I still don’t like it.”
SW “But can anyone be so kind? That’s how they are worried a lot about you.”
At this point, SW used the “Exception Question” to raise awareness of the positive aspects of the council of social welfare and reframed a shift from pointing out problems to taking a stance toward solving them. Indirectly complementing the coop also led to a smooth team approach.
[SCENE 3] Regarding the debt, Mr. A said, “I would like to consider a lump-sum payment if it reduces the amount of payment.” and SW consulted with legal support center to see if there was any overpayment.
SW “What will happen to you if you repay all at once?”
Mr. A “I want to graduate from the council of social welfare as soon as possible.”
Mr. A “I don’t want them to be offended. I want to use money freely.”
SW “What do you think is necessary to graduate? How can you graduate?”
Mr. A “If I can manage my money properly. When I finish paying off my debt.”
SW “That’s right. Let’s think about a goal together.”
In this situation, SW examined the future vision of the purpose of early repayment and what to do after repayment, while asking appropriate questions by utilizing “Miracle Question”. SW also added some indirect complements to encourage Mr. A to think about it.
[SCENE 4] His house was in a state of garbage. He promised to clean up the house by himself for a year, but as he couldn’t do it, the contractor finally disposed of the garbage. At first, Mr. A was not convinced that others could clean up his room. However, as soon as he looked at the cleaned room, he was completely satisfied, and started to say, “I want you to come to see the room.”.
SW “That’s great. How did you suddenly become able to do it?”
Mr. A “I prefer a pretty one.”
SW “How do you keep it clean?”
Mr. A “I clean up on my day off with a helper.”
In this scene, he used “Coping Question” to raise the awareness of his coping ability and helper’s help. In addition, SW added complements to encourage himself and enhance self-affirmation. It also complemented the helpers, encouraging them to trust others, and led to a smooth team approach for supporters.
From this case, SFA was found to have the following three features compared with the problem-oriented approach: 1) expand behavioral options, 2) increase motivation, 3) bring out ability. It was also found that SFA could be used for persons with disabilities with poor decision-making capacity.
5.1. SFA Expands Behavioral Options for Persons with Disabilities
In general, questions are divided into open and closed questions. Persons with disabilities can think and express their opinions in response to open questions. However, when decision-making is limited, it is often thought that it is difficult to find an appropriate answer on one’s own with open questions. Or even closed questions may fall into yes-tendency, where answering as the social workers say yes without fully understanding the intent of the question. Excessive consideration may be seen, such as preparing answers based on the values of social workers and asking disabled people to answer in simple words.
The key to SFA is the question. Scaling question is a closed question that selects the degree of the problem from a limited number. Coping question is an open question, but because it is a verbal question that recalls past events experienced by persons with disabilities, it is possible to think and answer by themselves. What is common to all of these is that the questions are very easy to understand and provide an opportunity to rethink how they view the problem. For the latter, it also has a reframing feature that allows them to look at it in a different way, bypassing the existing framework.
In this case, SFA was mainly used in decision making, especially when judgment was required. For example, in a situation where Mr. A in [Scene2] refuses support, saying “I can’t trust the council of social welfare.”, the assumption of total denial is corrected by utilizing the exception question, “What did they do then?”. In [Scene3], “What will happen to you if you repay all at once?” and the miracle question to discuss the solution he wants.
Even if an option is presented by considering the estimation of the will and the best interest of the disabled among social workers, it is only an option based on the specific value judgment of them. Even if persons have intellectual disabilities and limited ability to express their will, by using SFA, they can present their own choice from their own mouth and guarantee that they will make their own decision.
5.2. SFA Increases Motivation for Persons with Disabilities
The problem-oriented approach aims to compensate for the weakness of people with disabilities by focusing on life issues. In addition, persons with disabilities are regarded as passive beings called “a person who receives support” and tend to prioritize the value of their supporters by aiming to solve their living problems rather than their own will. In this case, the goal of “the cleaning of the house is done by the person himself over a year” was set. However, this goal was not achieved, and there were some cases where the supporters were unable to provide the planned support as they had imagined such as he showed them distrust.
As the reason for this, the goal of “The cleaning of the house is done by the person himself over a year.” was drafted from the viewpoint of supporters, and although Mr. A agreed to the plan, it was insufficient to promote concrete action goals and motivation. In other words, they were not aware that his personal belongings were causing trouble to other family members, and he did not understand why he had to clean up by himself, because he could not imagine the clean room after cleaning up.
Eventually, the contractor disposed of the garbage in the room, and he became interested in keeping the room clean by seeing the real thing in the room. In the case, the awareness of the coping ability for maintaining the cleanliness of his room would have been promoted before the contractor lend, if social worker told him to the specific image after cleaning by using miracle question such as “What are the advantages of cleaning up the house?”. Also, by visualizing the solution image using Solution Map , he could have been promoted to participate in more substantial problem solving.
SFA contributes to empowerment through a series of processes that make peoples aware of what they want, draw up a concrete image of the solution and results, recall an existing solution, and choose a step toward the solution. . Even for those who are limited in their ability to express their will, SFA can be used to encourage them to take concrete actions toward resolution by recalling the solution image. If the action repertoire of the individual at that time is insufficient without reaching a solution image, it is required to provide support by assistance in setting up the environment and providing assistance to realize the behavior to the solution .
5.3. SFA Treats Persons with Disabilities as Competent and Brings Out Their Abilities
In the [Scene 1], complementation was used to raise awareness that the bank transfer swindle is causing trouble to family members. In [Scene 2 - 4], there was a change that Mr. A, who had originally refused to clean up the room, was encouraged to reframe by using the question of SFA, and finally said, “I want you to come and see the room.”. In the course of the support process, there were originally few words and actions from him to SW. With the support of SFA, he opened his heart to the supporters around him and established a relationship of trust. And the frequency of voluntarily expressions of his will increased. In other words, it can be said that the proper use of SFA promoted the voluntary action of persons with disabilities to solve problems.
Here, this paper summarizes the difference between the problem-oriented approach and SFA based on Bradshaw’s Need Theory  (see Table 1). First, problem-oriented approaches often lead to the resolution of living difficulties based on social worker. Comparative need and normative need, which are judged by the values and social standards of social workers in advance, is used first. Support is developed in the flow of assessment, planning and intervention for persons with disabilities using the normative need as a model. In this case, felt need and expressed need by them has only a supplementary meaning. In other words, they are is made to feel the need by showing normative need of social worker, and the need is expressed in the form of “Yes” or “No”. In short, normative need predominates, and the decision making of them becomes subordinate.
Even in SFA, comparative need and normative need exists for social workers. However, the basic stance of SFA is that social workers stand one step lower than the persons with disabilities, and normative need of the them are not expressed to them from the beginning. Persons with disabilities are given time to think about the need they have sensed through questions and follow the procedure of expressing need in their own words. In other words, there is a great difference in whether normative need is expressed to them.
Table 1. Difference between the problem-oriented approach and SFA based on Bradshaw’s Need Theory.
SFA assumes that persons with disabilities already have solutions, and it is important to have them express their opinions in an attitude that they do not know anything. . Certainly, even if SFA is asked there are quite a few cases in which the same kind of needs as “choice” by prescriptive needs of supporters are expressed by them. However, the process in which they ask themselves whether there is a need that was first sensed, realize it by themselves, and express need in their own words is very important in decision support. Social workers have to believe they are able to answer questions and dare to wait to express their needs. This is the practice of empowerment for them, which leads to motivation and ability to solve problems.
The increase in the frequency in which Mr. A talk to SW means the increase in the frequency of actually expressing the felt need. The more persons with disabilities experience opportunities for decision-making and self-determination by SFA, the more often they will be able to express their views and contribute to broadening their choices in life.
In this study, we show that SFA has a certain effect on the voluntary decision making of them, even for the persons with the constraint of the will expression. The process of encouraging persons with disabilities to voluntarily express their opinions without first giving of social workers can be said to be closer to “self-determination” at a point farther away from their values. SFA is expected to play an important role in overcoming the patriotism by waiting for their own choices and decisions and respecting their will.
7. Limitations and Recommendations
More detailed examination is needed on whether SFA respects decision making of persons with disabilities rather than problem-oriented approach. Although the cases were targeted at persons with mild intellectual disabilities, it is necessary to consider how to utilize SFA in cases of severe disabilities. Further research is needed on concrete strategies for effective use of SFA in cases persons with limited decision making such as dementia or developmental disorders.
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