Proceedings, National Conference for Residential Training Centers for the Blind
Albuquerque, New Mexico -- November 13, 2002
[updated with references to Self-Study Guides]
Decisions, Decisions:
Who Knows What's Best for Our Client?
by Dona Sauerburger, COMS
"Should we allow our clients to use black canes instead of white ones?"
This is the question that started me thinking about how these decisions should be made, and who should make them. Other decisions are whether clients should use a cane or a dog guide or rely on visual information; should they use a gas or electric stove and what's the best way to mark their appliances; which route is best for them to get to work; should they use braille or print, and dozens of similar decisions.
What is our role as professionals in making decisions of adult clients? Who knows what's the best decision for our clients? This is a crucial issue for many professions, including rehabilitation teachers, counselors, doctors, physical and occupational therapists, and orientation and mobility specialists.
Some people believe that, for issues that involve the professional's expertise, it is the professional who knows what's best for the client, if the professional has enough information about the client. For the purpose of this paper, I will term this approach to decision-making "P-based" (for "professional-based").
Other people believe that, for issues that involve the professional's expertise, those who know what's best for our clients are the clients themselves, if they have enough information about the choices and their consequences. I will term this approach to decision-making "C-based" (for "client-based").
Responsibilities for professionals:
P-based responsibilities:
Professionals who believe that competent, qualified professionals know what's best for their clients state that their responsibilities include:
learn about the clients and their situation and goals;
based on this knowledge and the professional's expertise, determine what is best for the clients;
advise the clients of what's best, teach them the skills they need to implement those decisions effectively, and help them overcome any reluctance they may have for accepting what is best for them by guiding them to understand the rationale.
Clients of course are free to accept or reject the professional's advice when the program is over, but during the program, clients practice and use the strategies which the professional has determined is best for them.
C-based responsibilities:
Professionals who believe that well-informed clients know what's best for themselves state that their responsibilities include:
inform and help clients learn about the choices and techniques that exist, and the consequences of each choice (the advantages, disadvantages, and risks -- conveyed through discussion or, when appropriate, hands-on experience or training);
after clients understand the choices and consequences, trust them to make decisions about what is best for themselves;
teach clients the skills they need to implement their decisions; and
teach them to gather information about the choices (including resources such as information from consumers, manufacturers, literature, etc.) and how to analyze situations and interpret information to recognize advantages, disadvantages and risks of each choice so they can make informed decisions in the future.
Professionals with C-based and those with P-based approaches to decision-making both should document what they've done.
This is particularly important for the C-based professionals, who are responsible for doing whatever would be reasonably expected to assure that the client understands the risks involved in each option.
Failure to satisfy this responsibility should be considered negligence, and therefore the professional should document those efforts and also document how well the client seemed to understand the risks.
When specific strategies are used to assess or demonstrate risks [such as the those explained in the Self-Study Guides for uncontrolled crossings and for Signals] these also need to be documented in sufficient detail.
After learning of the risks, some clients will decide that what's best for them is an option that most people would think has unacceptable risk.
In these cases it may later become necessary to confirm with documentation that the client understood the level of risk associated with that option.
Applying these principles to instruction:
How would the approach of P-based professionals be different from that of C-based professionals? Some examples of the two different approaches in orientation and mobility (O&M) instruction are:
1. When choosing a cane:
the P-based O&M specialist learns about the clients' needs and abilities, then prescribes which cane is best;
the C-based O&M specialist has the clients try several canes, discusses and/or has the clients experience the advantages, disadvantages, and risks of each in various environments, and has the clients choose what is best for themselves.
2. When determining the best route to a new destination:
the P-based O&M specialist becomes sufficiently familiar with the client and his or her skills and needs, explores the area and various options, and then determines which route is best;
the C-based O&M specialist helps the client to investigate and analyze the various options, discusses and makes sure the client understands the risks, advantages, and disadvantages of each, and the client then determines which route is best.
3. When making street-crossing decisions:
A real-life example of one professional who used both approaches to a street-crossing decision occurred when a woman considered moving into an apartment across the street from her new job, and asked an O&M specialist to help her with orientation.
The street she'd have to cross was a busy two-lane street with no traffic signal or stop sign for a half mile in either direction. The instructor at first took the P-based approach and advised the client that she shouldn't cross there because it was his professional determination that it was unsafe. The client didn't agree. The instructor further explained that a blind woman who worked there felt that it wasn't a safe place for blind people to cross because she was once hit while crossing there. The client still wasn't convinced.
The instructor then did what a C-based professional would have done in the beginning.
He helped the client analyze the intersection and assess the risks of crossing there by using the Timing Method for Assessing the Detection of Vehicles. They found that the client needed 7 seconds to cross the street, but she was unable to hear the cars from the right until they were only 3-4 seconds away.
Once she realized the risks, the client decided not to cross there.
Some clients would have made a different decision after they understood the choices and consequences, because they are willing to accept more risk than was this woman. Are professionals responsible to make decisions about what is safe enough for their clients? Can professionals determine what's best for their clients? The C-based instructors believe that it's not possible for them to do so -- only their clients can make that determination. The P-based instructors believe that they can determine what's best for their clients, and they should not shirk from their responsibility to do so.
How can the professional determine what is best for the client?
What values should professionals use to determine what's best for their clients? For example, are the options that are best for their clients those that provide the most independence, or the most safety? Or is health more important, or comfort and enjoyment, or maybe self-esteem? And how much risk is too much?
The answer lies with the client, based his or her values and culture. For example, many of us consider that what is best for our clients is whatever makes them most independent -- that is the main purpose of many of our rehabilitation programs. But for some cultures, independence is not a goal. According to LaGrow and Craig (1996), natives of New Zealand value interdependence and harmonious relationships more than independence. They consider independence as dysfunctional and disruptive, a sign of immaturity and irresponsibility. Native Australians may even view goals of independence "as an attempt to isolate the individual from the family and break a basic value of Aboriginal life" (p. 21). Thus the goal of the Community-Based Rehabilitation Model developed in Asia is to help clients lead a productive life within their family and community, rather than to make them more independent.
LaGrow and Craig conclude that "the goals for providing O&M service as part of the rehabilitation process and the way it is to be provided must be evaluated in terms of the values and beliefs of the people for whom the service is meant, rather than by standards of best practice developed in another context."
Sometimes our focus is not on independence, but on safety -- we professionals feel that what's best for our clients is whatever is safe. But nothing is free of risk, so what should be considered "safe"? A functional, clear-cut definition of safe that is used in industry (for example to determine whether a product or manufacturing process is safe) is "a thing is safe if its risks are judged to be acceptable" (Lowrance, 1976, quoted in Kraft, 1988, p. 189).
But this means that what the professional considers to be safe (acceptable risk) may not be considered safe by the client, and vice versa. And what one professional considers to be safe may not be considered safe by another equally qualified professional. This must be decided by the client, and will vary from client to client.
Thus, even though we may be experts in determining how much risk is involved in various choices, and even though we know techniques that can enable people to cook, read, shop, and travel more safely, independently, and efficiently than they could without those techniques, we don't know how our clients weigh different values to determine what is "best" for them. They may value safety more than their instructor does, as did my client with macular degeneration who thought it was too risky to cross the entrance to the elementary school on her block. Or they may value safety less, as did a man who chose to cross two lanes at a roundabout even though he couldn't hear some of the approaching vehicles more than 2 seconds away.
And our clients may value independence less than we do, and value efficiency and comfort more. Or they may value companionship or their relationship with a doting spouse more than independence. Or they may value independence more than safety; safety more than efficiency; or the companionship and efficiency of a car pool or meals served in a group dining hall more than independence.
Since we don't know what our clients value most, the only people who really know what options are best for our clients are they themselves.
Does that mean that we professionals are absolved from any responsibilities regarding decisions? No, far from it! It probably would be easier to just tell our clients what we think is best for them and refuse services to those who don't agree or comply, but our responsibilities are much more complex than that, as outlined earlier in this paper under "C-based responsibilities." For clients who are not experienced with making decisions, we need to encourage them to consider the choices and make their own decisions. We may even need to help them learn to make decisions by going through the process of decision-making with them, which involves:
considering all the relevant factors (choices and their benefits/disadvantages and risks)
sorting out their own values and priorities that they will use to choose what is best.
In the process of serving or teaching our clients, we must:
respect their values and decisions, realizing that they may not be the same as ours;
understand that having values different from ours doesn't mean that their values are wrong or that their decisions are not the best ones for them;
try not to impose our own values and pressure our clients to make the decisions that we would make.
When serving our clients, we must teach them to analyze situations, ascertain the options, determine the consequences and understand the risks of each option, and make decisions as to what is best for themselves.
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Kraft, M. E. (1988). Analyzing technological risks in federal regulatory agencies. In M. E. Kraft, & N. J. Vig (Eds.), Technology and politics (pp. 184-207). Durham, NC: Duke University Press.
LaGrow, S. J. and Craig, G. (1996). "Independence / Interdependence: a Cultural Perspective on the Goal of O&M Training" in Conference Proceedings International Mobility Conference No. 8, Tambartun National Resource Center, Melhus, Norway (pp. 20-22)
Lowrance, W.W. (1976). Of acceptable risk: Science and the determination of safety. Los Altos, CA: William Kaufman.
Sauerburger, D. (1989) "To cross or not to cross: Objective timing methods of assessing street crossings without traffic controls," RE:view, Fall 1989
Sauerburger, D. (1995) "Safety Awareness for Crossing Streets with No Traffic Control," Journal of Visual Impairment and Blindness, Volume 89, Number 5
Sauerburger, D. (1999) "Developing Criteria and Judgment of Safety for Crossing Streets with Gaps in Traffic" Journal of Visual Impairment and Blindness Volume 93, Number 7, pp. 447-450.