The Accidental Community by gjjur4356


septemBer 2007

                                               volume 30   Number 3                 Newsletter of the BC AssoCiAtion of soCiAl Workers

                                          The Accidental Community
                                          The devastating losses of the 1980s engendered not only the
                                          ‘AIDS crisis’ but a strong sense of communities fighting together
                                          to end it. The HIV support group at St. Paul’s Hospital has met
                                          weekly since 1989 and has embodied the history of the epidemic.
                                          Few would have anticipated that the emerging issue today would
                                          be HIV and aging. (full article on page 04) >>

                                                                                                               Women’s heAlth issues

                     THE BCASW QUALITY                INTEGRATED SERVICES                    THE PROMISE OF                 VICTIMIZED FROM
                     OF WORK LIFE SURVEY              FOR WOMEN                              PRIMARY CARE                   BOTH SIDES

                 8                            12                                    14                                 16
                     Social workers give us           Treatment for substance use            It’s time to put our           Immigrant women in
                     a snapshot of working            and mental health must be              knowledge of health            violent relationships face
                     conditions                       trauma-informed                        promotion into practice        multiple barriers
                                          From the BCASW Office
                                             words        lindA korBin, msw, rsw, executive director

S    eptember is the unofficial start of the ‘new year’, and                                                      Every year, as we review the Conference evaluations,
     the month that hundreds of students will begin or                                                      we take note of many participants’ comments that include
continue their Social Work education in BC. Seven Social                                                    words such as ‘invigorating’, ‘inspiring’, ‘energizing’, and
Work schools within the province will graduate the newest                                                   ‘replenishing’. Possibly it’s because over the two days,
members of our profession, and we welcome you all!                                                          social workers re-connect with what brought them into
       You have chosen Social Work because you intend to                                                    the profession in the first place, and leave with renewed
make a difference — and you’ve done so, I hope, with a sense                                                vigor and pride. In addition to attending the keynotes
of optimism and determination, and a strong commitment                                                      and workshops, they join social workers from around the
to social justice. But there is a certain irony in our welcome,                                             province over lunch and dinner, sharing stories about
given the results of our recent survey of working conditions                                                their work, their challenges, their successes, and a sense
for social workers, published in this edition of Perspectives.                                              of camaraderie. In a profession which can isolate one by
       How do you welcome someone to a work life                                                            geography, organizational structure or heavy workloads,
characterized by stress, overwork, low morale and other                                                     connecting with others can be very sustaining.
consequences of ‘the high cost of caring?’ Where the                                                              So, students, welcome to the profession. There may
fulfillment we experience is offset by the frustration of                                                   be times when it seems you spend as much time fighting
working within systems with built-in barriers to working effectively and                the system as working with your clients, feel overwhelmed and exhausted
leading balanced lives? Where we have to continually fight not only for the             and wonder just what you got yourself into — but as you meet the many
rights of our clients but for healthy working conditions?                               exemplars of Social Work, and realize just how substantial Social Work’s
       Our profession may struggle, but it also is flourishing. You need only           contribution has been to improving the wellbeing of our citizens and
look at the program for the forthcoming BCASW Fall Conference, and the                  enriching our communities, I think you will decide it’s all worth it. You are
fourteen workshops being offered, to appreciate the breadth and depth of                joining a profession that has a proud history and a rich future. P
Social Work practice and the remarkable contribution our profession has
made to the development and delivery of our health and social services. Social
workers are leaders in research, leaders in practice, leaders in education and                   We hope to see you at the
leaders in program development, and they have been catalysts for inventive
programming, responsive services and systemic change.                                              BCASW Fall Conference
       At the conference you will hear from the social workers who pioneered
support programs for people with HIV, who created the templates for
                                                                                                  October 26 and 27, 2007
treating domestic violence; researchers who will inform us about best practices            Program information at
in child welfare, about youth who self-mutilate, effective treatment for male
batterers, solvent use among aboriginal youth; on practicing in a multicultural                and in your conference brochure
context - and so many more. They are what Social Work is all about.

 Perspectives is a publication of the British Columbia Association of Social Workers                              editor for this issue:
publications mail agreement no. 1685732                                                                           Linda Korbin,
please return undeliverable canadian addresses to:                                                                guest editor:
British Columbia Association of Social Workers                                                                    Cristine Urquhart
Suite 402, 1755 West Broadway
                                                                                                                  editorial committee:
Vancouver, BC V6J 4S5                                                                                             Molly Smith and Deb Wandler
tel 604 730 9111 web email
                                                                                                                  Layout, design and editing
Publication occurs four times a year. Articles up to 1,500 words will be considered, but publication is not
                                                                                                                  Heather MacNeil
guaranteed and copy may be edited to fit the space available, or for legal or other reasons. The views
expressed in articles published in Perspectives are not necessarily those of the BCASW or the Editorial
Committee. For reprint permissions and back copies, please contact the BCASW office.
perspeCtives SEPTEMBEr 2007
                  The Accidental Community
                              Built for a future people with HIV/AIDS did not believe
                              they would see
                  words         mAry petty, PHD, rSW

                  S    ocial workers—as activists involved in gay liberation movements,
                       community organizers, health care practitioners, educators and
                  researchers—were among the first to respond to the AIDS crisis that, by
                                                                                                     their place in the constellation of community responses to AIDS. As the
                                                                                                     epidemic expanded and as effective treatments became available, medical
                                                                                                     services and other institutional responses subsumed grassroots efforts like
                  the early 1980s, was threatening the very existence of urban gay men’s             support groups and many disintegrated by the mid 1990s. The St. Paul’s

                  communities in Canada. Today, antiretroviral treatments have changed the           group seemed to have remained an important source of support as well as an
                  way we understand HIV/AIDS and have had a significant impact on the lives          example of community continuity as it embodied the history of the epidemic.
                  of many of our HIV positive clients. Still, increasing numbers of new infections   The complex and freewheeling group discussions made it clear that the group
                  continue to devastate regions of the world and many of the communities in          met a range of individual crisis needs as well as forming space for developing
                  which we practice.                                                                 a sophisticated understanding of contemporary issues for people living with
                        The AIDS epidemic has had a tremendous impact on me, both personally         HIV. (Although the group is open to anyone who is HIV positive, the majority
                  and professionally. My experience in the epidemic began in the early 1980s         of participants have been gay men.)
                  when gay journalists began covering news of a deadly disease striking gay men.
                  I was studying for my MSW in the U.S. when I participated in one of the first      the “ACCidentAl Community” reseArCh projeCt
                  of many “AIDS vigils” that would become a regular part of my life over the         In 2003, another St. Paul’s social worker, Wallace robinson, and I began to
                  next decade. I got my “AIDS 101” from friends who were living with AIDS: the       collaborate with academics and community members (former and current
                  medical aspects, the day-to-day struggle, and the impact of health care policy     group members) in a research project, “Accidental Community,” focusing first
                  on individual lives. Between 1985 and 1994, I lived in Halifax as the epidemic     on the support group—its history in the context of the AIDS epidemic and,
                  emerged in that city. A small group of activists—including social workers, other   more recently, on the place of the support group and other hospital services
                  health care professionals and people with AIDS (PWAs)—staged an amazing            in the larger social support network we associate with the West End and its
                  fight for services, government recognition of the epidemic and an end to the       gay community. The research uses open-ended interviews, social mapping,
                  discrimination that PWAs were experiencing. We protested, organized, and,          ethnographic observation, historical research, and participant diaries to describe
                  like others across the country, held vigils and                                                                    the life of the long-running support group
                  memorials for our friends.                                                                                         and its members. We are attempting to weave
                                                                                                                                     together the complex history of adaptation by
                  soCiAl Workers At st. pAul’s                                                                                       individuals in this broad context.
                  hospitAl Were leAders in                                                                                                  Meeting weekly at St. Paul’s since 1989,
                  responding to the Aids Crisis                                                                                      the HIV support group offered solace and
                  I moved to Vancouver in 2000 and began                                                                             solidarity in a time of crisis; it also played a role
                  working at St. Paul’s Hospital in the                                                                              in the fight for rights and resources at a time
                  Immunodeficiency Clinic (IDC) whose                                                                                when right wing policy proposals threatened
                  beginnings date back to the 1980s when two                                                                         “solutions” such as quarantine. Almost twenty
                  social workers, Cheryl Jolliffe and Judy Krueckl,                                                                  years later, this support group retains its role
                  were leaders in organizing the hospital’s                                                                          as a vehicle for information about treatment
                  response to the AIDS crisis. Among the many                                                                        and disability management and continues to
                  services created at that time was a support                                                                        serve as a space for debate about the politics
                  group for PWAs. When I joined the social work department in 2001, I inherited      of HIV and the gay community. In particular, we have seen the emergence of an
                  the role of group facilitator for “Picking up the Pieces” as the group had been    issue that not many anticipated at the height of the crisis: HIV and aging.
                  called since its origin in 1989.
                        In part because of my own history in the epidemic, I was impressed           Community AdvoCACy And ACtivism yield results
                  with the longevity of this support group. Early community responses around         Early in the second decade of AIDS, aging was not on the minds of gay men
                  the globe had included support groups, but, borne of a time when medical           living with HIV, especially among those who had seen too many miracle drugs
                  treatments were limited to palliative care, such groups seemed to have lost        prove more toxic than lifesaving. Many men used what little energy they had
                                                                                                                                                             perspeCtives SEPTEMBEr 2007
to build a community to fight back against discriminatory laws and for access             Newer members of the group, recently diagnosed, clearly appreciate the
to treatment. But while some lived to see results, many more died before             wisdom and knowledge of those who have been living for many years with
any changes occurred. Thus, the community built during the first decade of           HIV (some for 25 years, as they often remind the group during “check-in”).
the epidemic was the altruistic product of men’s labor (and that of the many         Although they use concepts that belie their experience in psychosocial and
lesbians who joined the fight against AIDS from within the gay community)            twelve-step groups, a language often at odds with the gay liberation bent of
for a future they did not believe they would see. In many cities, groups like        long-term members, they describe their reasons for participating as including
ACT-UP (the AIDS Coalition to Unleash Power) militated for the early release         a sense of belonging, mutual support, like-mindedness, and the need for
of medications. Some of these became available and proved to have at least           information.
some effect (early dosage levels were infamously toxic).
      As the 1990s progressed, North Americans living with HIV/AIDS saw              people Aging With hiv fACe unique struggles
improved access to medication and social supports, thanks in no small                Despite the differing histories of its members, the support group provides a
part to concerted community advocacy and activism. In the BC context,                context for sharing the challenges of aging with HIV. Aging with HIV can be
additional income assistance benefits for people with HIV, dedicated social          confusing and fraught with grief, despondency, and loneliness. Long-term
housing, specialized clinics, a palliative care unit at St. Paul’s, and a plan for   survivors, as well as other older HIV positive men, face the struggle of adapting
the development of a community hospice/day program (the Dr. Peter Centre)            to life with a chronic illness. They struggle with managing their health and
all took shape during this period. And in 1996, a uniquely catalytic moment          dealing with HIV treatment, but they also express fears of aging without a
for our community: Vancouver hosted the 1996 International Conference                partner and being socially excluded because they are not employed. For some
on HIV/AIDS, at which results were announced from the trials of what would           of the men with whom we work, these difficulties manifest in depression,
become the first effective treatment for HIV. This was a time of tremendous          and sometimes risky ways of coping with depression. A long-term survivor
local pride among HIV activists and HIV doctors and care providers, as               may discover that party drugs can mediate the loneliness and even provide a
Vancouver basked in the limelight for its (now) forward-looking policies and         sense of “community,” opportunities for sex, and more abundant energy.
research activities, both of these importantly indebted to the community                   Long-term survivors, while often thankful to be alive, struggle with the
response—including the actions of members of the support group—to earlier            interruption of, first, what they imagined to be their life trajectory many years            05
and highly discriminatory proposals from the Social Credit Party.                    ago, and second, with the confusion of continuing to live twenty years beyond
      By the late 1990s, rates of HIV infection among injection drug users in        what they expected in 1985. They suffer from multiple losses in the past and
Vancouver’s downtown eastside rivaled cities in the developing world. These          face losing friends from aging-related illnesses in the present. They witness
individuals were also St. Paul’s patients, and the aggressive levels of diagnosis    the deaths of their elderly parents and their own declining health, often in a
and recruitment into services and treatment of this new group resulted               foreshortened timeframe. Some older positive men find themselves at a place
in a perception that HIV in the gay community had been solved or was relatively      where the balance of treatment burdens and quality of life has been tipped.
less important.                                                                      They may struggle with the decision to end treatments and face debilitating
      By 2000, the group was an interesting mix of long-term survivors who           illness and death. Nevertheless, even on days when the most fragile members
toughed out the hard years and men who were newly diagnosed but in the               are at their weakest, they make the effort to come, share, and hear what others
post-protease inhibitor, relatively de-politicized new context. Many of the          have to say.
newly diagnosed members who joined after 2000 are between the ages of 50                   For both members and facilitators, the support group has been a useful
and 70—in fact, age peers of the long-term survivors. These group members            vehicle for thinking about social and cultural issues in the epidemic. Many
have brought with them a new sensibility: where the early members were               describe feeling disillusioned about the “gay community.” The devastating
able to feel anger at a homophobic society and an indifferent medical system,        losses of the 1980s engendered not only what we know as the “AIDS crisis,”
older men who have been infected after 2000 express a sense of shame                 but a strong sense of communities fighting together to end it. As HIV infection
about becoming infected at this point in their lives when they “should have          became a more chronic, manageable illness in the mid 1990s with onset of the
known better.”                                                                       HAArT era, many gay men living with HIV identified a loss or absence of this
                                                                                     community—one reason why many of these men join and find companionship
the Wisdom And knoWledge of ‘elders’ Brings A neW                                    in support groups and other HIV related gatherings and activities. P
sense of hiv Community
                                                                                     An article based on findings from the Accidental Community Project will be published in
As the two different demographic groups shared their experiences and fought          the Journal of Gay and Lesbian Social Services later this year. See Robinson, W.A.; Petty,
through their differences, an entirely new sense of an “HIV community”               M.S.; Patton, C.K.; & Kang, H. Aging with HIV: historical and intra-community differences
developed within the group, but it is neither the kind of bond of the early          in experience of aging with HIV.
years, nor a shift to a psycho-social group model. Instead, long-term members                                                        Photos courtesy of John Kozachenko.
now frequently share their stories from the early years of group, describing
the strong bonds formed as they faced dying from AIDS and living in a climate
of attack. This conveys the group’s history, but it also offers new members a
different rationale for participating in the group than they probably imagined
when the first walked through the door. Instead of simply learning the facts
about their new situation, they are treated to the knowledge of “elders.”

perspeCtives SEPTEMBEr 2007
           Seen But Not Heard
                         Elderly women talk about their hospital experience
           words          Amy freemAn, msw, rsw

               “All the nurses see in me is an old shriveled up lady who is crabby…
           We’re only seen in our present state of pain, not as the person we once

           were. They could use a little more understanding.”

           T     his article is based on a qualitative research project which explored older
                 women’s perceptions of their experiences in hospital 1. It offers insight
           into elderly women’s age-specific needs and a discussion about Social Work’s
           role with them.
                  Elderly women make up the majority of our rapidly expanding
           senior population. They are more dramatically affected than men by
           problems associated with aging such as a greater risk for chronic illness,
           reduced economic resources, social isolation, increased need for care and
           institutionalization. It is not surprising then, that elderly women are more
           reliant upon the health care system than older men or younger adults. While
           their presence has been noted, and at times lamented, their voices have                             A further age-specific problem frequently identified was lack of
           been alarmingly silent. Interestingly, recruiting participants for this study did            attention to dentures. Several women addressed the importance of having
           not prove problematic. An ad placed in a local paper quickly netted 11                       their dentures properly cared for both from a nutritional perspective as well as
           participants between the ages of 70 and 93 who had had a hospital stay in the                a question of self-esteem.
           last year. Hospitalized elderly women had a story to tell about their care.                         Another age-specific problem frequently mentioned by these women
                  The women’s stories suggest the system failed to attend to their age-                 were gaps in care related to hearing problems. The elderly women who had
           specific needs. The women identified six critical gaps in care: bathing, mobility,           hearing impairments were doubly challenged to make their needs known
           nutrition, care of dentures, communication and emotional caring.                             to staff.
                  In terms of bathing, one elderly woman described how the hospital                            The final perceived gap in care in was emotional caring. These women
           policy of one bath a week left her no choice but to rely on her daughter for a               inevitably linked their hospital stay to the possibility of death. The women
           daily bath. This woman was incontinent of bowel and bladder and suffered                     identified the importance of having staff available to them who were attuned
           from skin breakdown, requiring a daily bath and the application of a special                 to their fears.
           cream. “There should be trained staff to do that (bathing); one shouldn’t have to rely              To cope with gaps in care, the women developed two compensatory
           on a daughter.”                                                                              strategies: lowering their expectations and developing alternative supports.
                  Several women had difficulty obtaining walking assistance and suffered                       The women lowered their expectations so that they would not be
           falls shortly after discharge. As one woman noted, “Family are quite important to            viewed as demanding. They described the staff as overworked and thought
           the whole (hospital stay). I mean one is supposed to walk, but the nurses wouldn’t have      patients should have the sense to request help sparingly: “Some people
           time to walk you when you can hardly stagger”.                                               just sit there and expect the nurses to do everything …. I don’t want to make more
                  In terms of food service, the most common problem was that the                        work for people who are already overworked”. Complaining, then, was viewed
           women could not access their meals without help. One elderly woman noted,                    pejoratively by the women.
           “I think there is a problem with older people who can’t feed themselves well. The                   The primary supporters to whom elderly women turned were their
           staff doesn’t have time to really come and feed them. There’s too many people                families. However, the women did not see family care as auxiliary care.
           in that boat to be looked after properly if their family isn’t coming. I mean, they don’t    rather, it was described as an essential feature of their care in hospital.
           care if they eat or not, and it’s too much trouble to try to feed themselves, so they just   “You better have family to help you”, stated one participant.
           don’t. I saw lots of that. A lot of those trays just get carted away again”.                        This study supports the need for empowerment-oriented Social
                                                                                                        Work practice with older women. In this model, Social Work intervention
               Freeman, A and O’Connor D (2002) Canadian Social Work review, Volume 19, Num-
                                                                                                        is conceptualized on a continuum that ranges over four dimensions:
           ber 1 pp. 65-84
                                                                                                        the personal, interpersonal, environmental and political.
                                                                                                                                                               perspeCtives SEPTEMBEr 2007
      At the personal level, the women’s strategies for adapting to the systemic
limitations were related to a sense of hopelessness that they could change or
challenge the system. Social workers can encourage elderly women to see their
concerns as valid issues, not whiney complaints.
      At the interpersonal level, social workers can assist families by helping
                                                                                   Women’s heAlth perspeCtives
them to negotiate the system more effectively on behalf of their elderly
members. However, there is a danger here. While family is to be commended
for their efforts, in the long run their good intentions mask the serious gaps     guest editor          Cristine urquhArt, msw, rsw
in care, leaving the system with little incentive to increase its resources.
      With respect to the hospital environment, social workers have a pivotal
                                                                                                                   This issue of Perspectives illustrates the
role in working to create better care. As members of the interdisciplinary team,
                                                                                                            complexity of women’s health and the necessity of
social workers can begin to make visible how “normal” hospital practices are
                                                                                                            providing tailored health and social services to women
disadvantaging elderly women. This would include advocating for care that
                                                                                                            and girls. Advocates in women’s health share their
recognizes elderly women’s unique physical and emotional needs.
                                                                                                            wisdom using examples from policy, research and
      The health care system is currently characterized by staff shortages, time
constraints, and fiscal cutbacks; better individual care will not be attained
                                                                                                                   We are bombarded by health information that
simply through effective one-on-one interventions and education. Social                                     describes prevalence rates, symptomatology and
Work prides itself as the profession that brings to the health care team a                                  progression of illness based on the general population
contextualized perspective of the individual. We need to bring this vision                                  averages. Developments in women’s health over
to the management table if we are to help the hospital and broader health                                  the last several years have shown again and again
care system understand how policies and practices are affecting the people         that women and girls’ bodies are different from men and boys and our
they serve and to highlight the benefits of incorporating changes. P               experience of health and wellness is interconnected with overall social
                                                                                   determinants of health.
                                                                                         Common themes are woven throughout the articles including that
                                                                                   women’s health cannot be separated from the larger social, political and
                                                                                   economic contexts of their lives. Biological differences are only one piece
                                                                                   of what makes women’s health needs unique. The barriers women face
                                                                                   in accessing care are multiplied by various forms of oppression, including
                                                                                   racism, poverty, and homophobia as well as punitive policies as evidenced
                                                                                   in policies on mothering and substance use. Furthermore, services for women
                                                                                   should be holistic and collaborative reflecting the interconnections between
                                                                                   women’s health concerns such as violence, mental health and substance use.
                                                                                         In order to support social workers in their practice with women, it is
                                                                                   imperative that information be accessible and reliable for both themselves
                                                                                   and the women they are supporting. A number of Canadian women’s health
                                                                                   related resources and publications have been developed in the last year that
                                                                                   highlight the importance of a gender analysis of services for women. This
                                                                                   issue will profile two new resources that offer information to social workers
                                                                                   that will support their work in diverse roles including practitioners, educators,
                                                                                   policy makers and researchers.
                                                                                         Working with leaders in women’s health at the British Columbia Centre
                                                                                   of Excellence for Women’s Health has impacted me both professionally and
                                                                                   personally from the way I receive and interpret information — to how I support
                                                                                   women in my practice, as well as my own health and worldviews. I hope
                                                                                   that this issue of Perspectives inspires readers to reflect on their practice with
                                                                                   women and supports continued developments in policy, research and practice
                                                                                   to improve women’s overall health and access to care. P

                                                                                   Cristine Urquhart, MSW RSW is the Provincial Training Consultant for the ActNow BC
                                                                                   — Healthy Choices in Pregnancy initiative.

perspeCtives SEPTEMBEr 2007
          The BCASW Quality of Work Life Survey
                    Social workers give us a snapshot of working conditions
          words         miChAel CrAWford, msw, rsw and
                        lindA korBin, msw, rsw

          S    ocial work is a tough profession and if we didn’t know that before or
               during our university education, most of us discovered that harsh reality
          soon after we started our first social work job.
                                                                                           Who responded to the survey
                                                                                           Of the 450 completed surveys, two were rejected due to inconsistent and
                                                                                           improbable responses, leaving 448 participants.

                Social work professionals work with some of the most disadvantaged              •   83.7% were female
          people in our society and we often do so within rigid bureaucracies and               •   the average age was 43, with more than half aged between
          with too few resources. Stir in a good measure of public disdain, or at best              30 and 49
          indifference, for our work and that’s a prescription for stress, burnout, or          •   participants averaged 12.79 years of social work practice with most
          compassion fatigue.                                                                       (63%) having less than 15 years experience
                Over the past few years, anecdotal evidence seems to suggest that social        •   responses were received from across the province, with the largest
          workers in British Columbia are experiencing more difficult and demanding                 number (31.5%) from the Metro Vancouver region. A surprisingly
          working conditions than in the past. Salaries may well be slipping behind the             large percentage of respondents (30.5%) worked in rural and small
08        rising costs of living, benefits may be shrinking, and working conditions may             urban communities (under 50,000 population).
          be deteriorating.                                                                     •   one in eight respondents is a member of a visible minority group.
                A change of government in BC in 2001 resulted in changes to social                  One in ten respondents indicated they were a person with a disability,
          programs and service delivery models. New initiatives, modified funding                   with mood (mental health) and mobility most frequently reported.
          schemes, reorganization, layoffs, and budget cuts have produced an uncertain          •   more than half (56.4%) had a BSW as the highest degree, 43.4% held
          work environment and placed more stress on social workers.                                an MSW and only one reported a doctorate in social work. More than
                When the BCASW was informed that the Ontario Association of Social                  one-third held an additional non-social work degree and almost one
          Workers (OASW)1 was surveying their members regarding their working                       in ten received some social work training outside of Canada.
          conditions, the Association decided to follow suit. The BCASW survey,                 •   most worked in direct practice (78.6%), in front line positions
          launched in 2006, sought to establish a baseline of social work salaries,                 (71%), in the public sector (64.9%) and in agencies with more than
          benefits and working conditions. This data will be used to support advocacy               25 staff (67.5%). Almost two-thirds (61.6%) worked in unionized
          work undertaken by the BCASW and will serve as a benchmark against which                  employment.
          data from future survey research can be measured.                                     •   almost one-third (30.6%) reported holding more than one job and
                                                                                                    of these more than one-quarter (26.6%) held more than two jobs.
          the survey                                                                                Almost three-quarters of the recipients considered their primary
          The OASW survey was modified only slightly for use in BC to ensure that data              employment to be full-time.
          can be used for comparison across other jurisdictions conducting research             •   most respondents received supervision from other social workers
          based on the original survey instrument. The research was approved by the                 (65.7%). Those that didn’t are supervised by nurses (6.5%),
          BCASW Board of Directors and vetted through Thompson rivers University                    business or administration staff (6.7%), and allied health
          research Ethics Board.2                                                                   professionals (3.8%).
               The survey was uploaded to SurveyMonkey™, an online survey website,
          and BC social workers were asked through email messages, word of mouth,
                                                                                           WhAt We leArned
          the BCASW website, and in Perspectives to log on and complete the survey.
          The survey remained open and data were collected over an 11 month period         Data from the survey indicate that respondents are working in jobs that
          ending in February 2007. The survey consisted of 68 multiple-choice and          demand a great deal from them and leave them frustrated. Worse, working
          open-ended questions. Quantitative data analysis was undertaken utilizing        conditions are deteriorating and social workers may be losing hope that they
          SPSS 12.0 for Windows.                                                           will be able to perform their duties in a manner that serves clients well.

                                                                                           WorkloAds Are inCreAsing
                                                                                           More than two-thirds (70%) reported that their workload had increased over
                                                                                           the past year with only 1.8% of respondents noting a decrease in workload.
                                                                                                                                                perspeCtives SEPTEMBEr 2007
                                                                                                            Another wrote: “I am generally exhausted in this career as I care very
                                    Respondents' Area of Practice
                                                                                                            much about my clients …”
          domestic violence
                                                                                                            And sometimes it is never enough: “I put in a lot of extra time, for
                                                                                                            which I am not paid. Even so, I am always left with the feeling at the
              sexual abuse
                                                                                                            end of the day that I am not doing any part of my job well or as well as
   child/youth mental health
                                                                                                            it should be done”.
           substance abuse

             family services
                                                                                                            yet soCiAl Workers still find time to
                child welfare
        adult mental health
                                                                                                            Social workers contribute significantly as volunteers in
              medical health
                                                                                                            their community. Four out of ten respondents performed
                                0        5         10        15         20         25        30      35
                                                                                                            volunteer work, averaging about four hours per week.
                                                                                                            Of these volunteer workers 43.9% have more than one
                                                                                             volunteer position. Three quarters of their volunteer work took place in the
       More than half of respondents (54.8%) noted that employers are not                    non-profit community organization sector.
replacing employees when they leave or retire and almost two-thirds (61.9%)
report that employers have trouble filling vacancies. Problems associated with               soCiAl Workers feel underpAid for the Work they do
filling vacancies include no qualified applicants (86.8%) and low and non-                   The average income for full-time employed respondents was $53,225 and
competitive salaries (57.4%). Almost three-quarters of respondents (72.4%)                   for part-time or casual employed respondents was $36,127. Full-time
believe that employers do not hire sufficient staff to complete the work to an               employed BSW respondents earned an average of $47,159 compared to an
acceptable standard.                                                                         average annual income of $61,287 for full-time employed respondents with
       “…my agency was hit by every round of cuts and many important programs were           a MSW.
lost, and … I have lost the rest of my team to ‘restructuring’ so that I am now doing what         Though some expressed satisfaction with their salary, others felt
was once two jobs and three positions in half the time…”                                     ‘saddened and angered’ by what they considered poor compensation for
                                                                                             their level of education and responsibility. Many expressed frustration that
the hours Are long                                                                           their income doesn’t enable them to get out from under their huge student
Full-time employed respondents worked an average of 36.53 hours per week                     debt load. There were complaints about salaries not keeping up with cost
and part-time employed respondents worked an average of 25.62. But that’s                    of living increases, inadequate living allowances in isolated communities
not the whole story - almost two thirds worked overtime, either compensated                  (“my propane costs are $1000 per month”), a “pink wage ghetto”, the need to
(pay or time in lieu) or unpaid – and 4 out of 10 reported their overtime has                take on additional jobs to make ends meet, taking a $10/hr pay cut to move
increased over the past year.                                                                from Alberta, not having a pay differential for BSWs and MSWs, and being
      The numbers are notable: an average of 4.45 hours of compensated                       paid less than other professionals with less education, even within the same
overtime each week for full time employees and an average of 3.8 hours for                   workplace.
part-time.                                                                                         Most respondents received core benefits as part of their job. About three
      Significantly, more than one-third of respondents (38.2%) report they are              quarters received paid vacation, paid medical leave and extended health and
working an average of 4.85 hours per week in unpaid overtime. Over a year,                   two thirds had a pension plan. Only one in five had a group rrSP. respondents
based on a 48 week work period, this translates to 39,843 hours of donated                   were less likely to receive other benefits such as life insurance (53.8%), long-
work by those respondents alone!                                                             term disability insurance (62.9%), paid education leave (54.7%), and access to
      Many social workers expressed frustration over the strain of balancing their           EAPs (58%).
ethical obligations, to which they are strongly committed, with the realities
of funding and service cuts, heavy caseloads, and administrative obligations.                stress levels Are high
Driven by personal conviction, they have felt compelled to put in extra time so              Seventy per cent of social workers reported high levels of job stress, resulting
that the level and quality of services to their clients are not compromised. But             in more frequent illness (43.5%), feeling depressed (46.6%), worry about
they have done so at a price:                                                                making mistakes (24.9%), and irritability with clients (28.6%) and co-workers
                                                                                             (45.4%). Not only do these results raise the alarm about personal health and
 “I generally enjoy my job, but it is exhausting and there is not enough workplace focus     wellbeing, they have profound implications for workplaces with regard to
on self-care - they will let you work until you get sick (which I learned the hard way).”    service delivery, employee recruitment and retention as they seek to restructure,
                                                                                             reorganize and reduce while demanding more and more from their workforce.
A healthcare social worker: “I am doing a job that would keep two full time people
                                                                                                   More than half of respondents say they are more rushed than three years
busy. I am proud to say that Social Work service is highly valued and utilized by my
                                                                                             ago, and about two thirds report they are usually or often rushed at work. More
interdisciplinary team...however, my practice is becoming extremely stressful just due to
                                                                                             than half usually or often skip lunch or eat at their desks. reasons for feeling
sheer volume. I am working far too much overtime, and I will not be able to sustain this
over a prolonged time.”
                                                                                                                                                         continued on next page...
perspeCtives SEPTEMBEr 2007
          Survey...continued from previous page
          rushed included staff shortages, work volume, workload complexities, and                       “The level of service has deteriorated in the mental health/counselling field in our area.
          increased documentation.                                                                       Long-time staff have commented that morale is the lowest they have ever seen. I am
                More than a third (37.8%) usually or often go to work when sick. Half                    resigning from my position, as have many of my staff and colleagues. Our system is in
          the respondents indicate their workloads are rarely or never covered when they                 crisis, and our clients, many of whom are First Nations, are without adequate service
          take a vacation.                                                                               provision.”
                As one social worker put it, “social workers feel trapped between their personal
          and professional need to help clients and the knowledge that their physical, emotional         “I love being a health care social worker AND it is increasingly difficult to feel good about
          and spiritual bodies are no longer capable of managing their workloads.”                       the work I can do given the increasing strain and the lack of political will to address
                “My work in child protection has been… hazardous to my health and well                   the social determinants of health. I am getting crispy after 20 + years of committed
          being”, wrote one, while another observed that “constant staffing shortages and                practice.”
          underfunding make transformation a nightmare. Taking care of workers needs to
                                                                                                         From a 30 year veteran: “the situation has deteriorated so much — I remember being
          become a priority for MCFD if it wants to move forward”.
                                                                                                         surrounded by very dedicated staff, not so overworked as to exclude creative programming
                A social worker employed by an aboriginal child welfare agency
                                                                                                         and research (non existent now), good collegial relationships (now just watching each

          commented on “unrealistic workloads” that have increased dramatically over the
                                                                                                         other get old and worn out) and a real optimism about what we were doing for/with
          last few years, compounded by “an unhealthy work environment” – that now have
                                                                                                         clients. We have been part-timed, underpaid, overworked, underappreciated, undervalued,
          her seeking work elsewhere.
                                                                                                         persecuted, reviled, commodified, dehumanized. Cogs in the machine. It would not be
                Others have left the government/non-profit sectors to go into private
                                                                                                         adequate to get a pay raise. The systematic neglect and abuse of social workers needs to
          practice: “I am MUCH less stressed and able to enjoy my work and clients now AND
                                                                                                         be addressed, along with a complete re-evaluation of appropriate wages.”
          cannot afford benefits, get no paid holidays and take full risk and responsibility for my
          professional and personal life — which still works better. Without our own physical and        From a recent social work graduate: “Overall I am unsure of where I should head in
          mental health we do not have much of positive worth to offer others.”                          my relatively new social work career, as there seem to be problems in all arenas of the
10        hArAssment is pervAsive
          Workplaces should be free of harassment; however, 40.6% of respondents                         there is support for professionAl development;
          reported unwanted, unsolicited, or intimidating attention, comments                            opportunities to AdvAnCe vAry
          or behaviour in their workplace. Harassment took many forms including                          Most respondents have access to skills training or upgrading (85%) and most
          racially based (12.7%), sexual orientation (12.5%), gender (19.9%), general                    (87.5%) are allowed work time off to attend. Training typically takes the form
          intimidation (32.4%), long-term harassment or abuse (14.1%), and violence                      of one or two-day workshops (63.6%) and is agency-based (41.3%).
          (14.5%).                                                                                            Approximately one-third of respondents believe that there are some
                Slightly more than one-quarter (27%) of respondents experienced threats                  or many opportunities for advancement within their organization; however,
          to their person, family or property, almost all of them originating from clients               nearly half said there were none.
          or clients’ families and friends (86%). Co-workers (4.7%) and supervisors
          (2.3%) also made threats to respondents.                                                       it’s A ChAllenge to BAlAnCe Work And fAmily
                “Clients threaten, spit, throw things etc. at us and we only get three debriefing        Almost half of respondents have caregiver responsibilities involving children
          sessions per year. Even the RCMP get to have a partner and protective gear - in addition to    (76.7%), dependent adults (20.3%), and support for relatives, friends and
          counselling. If I could do it all over again, I would never choose social work. My education   neighbours. Asked to indicate on a scale of one (very difficult) to ten (not
          cost me a great deal of money; now it’s costing me my health.”                                 difficult) how well they balance work and personal caregiver responsibilities,
                                                                                                         respondents’ average score was 4.87.
          morAle is suffering                                                                                  What social workers found helpful in balancing their responsibilities was
                                                                                                         supportive supervisors (92.9%), flexible work hours (92.8%), being able to work
          “Sometimes I really wonder why I went into this field and why I am still here”.
                                                                                                         from home (74.1%), taking unpaid leave (76.1%), varying work hours (91.8%),
          “We are no longer treated as human beings by our employers. Our work gets less respect,        receiving personal calls at work (89.4%), and taking paid leave (84.3%).
          even though there’s more of it.”
                                                                                                         teChnology is Both friend And foe
          “Social workers in health care are frequently denigrated, their skills not appreciated,        On the positive side, technology has improved respondents’ ability to
          and their positions considered expendable or available to other professionals (especially      communicate (60.7%), allowed more independent work (38.8%), increased
          nurses). Health care professions generally are becoming less desirable as the system           productivity (29%), allowed work with others outside of the office (33%), and
          becomes increasingly in crisis. Positions are harder to fill and vacant for increasingly       made responding to others more immediate (47.5%). Negative effects include
          long periods. Turnover rates are growing, and less qualified staff must be employed,           lack of adequate training to use the technology (17.4%), a demand to be
          increasing workloads and stress. This will worsen as we baby-boomers age. Thank God            constantly in touch (25%), an increased volume of work (32.1%), and generally
          I’m retiring now!”                                                                             feeling more rushed (28.1%).

                                                                                                                                                                        perspeCtives SEPTEMBEr 2007
despite it All soCiAl Workers Are sAtisfied With their
CAreer ‑ But Wouldn’t neCessArily reCommend it to
       Yes, the hours are long and the work is stressful and exhausting, but
despite that, respondents overall were satisfied with their career. On a scale of
one (very dissatisfied) to ten (very satisfied), respondents averaged 6.38.
       Nonetheless, respondents were reluctant to recommend a Social Work
career to a child or another person. Only 30.9% were certain they would
                                                                                                                            highs and lows: Canadian
recommend the career to others. Many suggested that they would recommend                                                    perspectives on Women
the career to others if working conditions changed for the better.                                                          and substance use
       Some were unequivocal about not recommending Social Work as a
career:                                                                                                                     CAmh publications, 2007
“I strongly believe that most people would not enter the profession of social work if they
understood the workload and stress load and inadequate compensation we receive”.                                            edited by nancy poole and lorraine
“I can find no justification for anyone to become a social worker in the current climate,
and question how university schools of social work can continue to supply fresh bodies
for consumption. There should be a moratorium on social workers, a save the social
workers movement, a refusal to cooperate and a withdrawal of service.”                       H     ave you ever wondered how often women are diagnosed with a
                                                                                                   concurrent addiction and mental health disorder? Or what the differences
                                                                                             are across the country or among cultural groups? What about the latest
“I have a daughter who is studying to be a psychologist. I would have liked to have          research on substance use, eating or mood disorders? In Highs and Lows:
recommended Social Work as a profession but given the abuse social workers have              Canadian Perspectives on Women and Substance Use, the authors review the
suffered at the hands of government over the 30 years of my practice I just couldn’t         latest approaches and provide case examples and research (qualitative and        11
do it”.                                                                                      quantitative) of girls and women who use psychoactive substances.
        For others, Social Work has been the right choice:                                         The book presents two Canadian surveys that show trends in substance
“I love the career I have chosen and find it meaningful and satisfying”                      use over the last 15 years. These surveys highlight differences between
                                                                                             substance use for women and girls compared to men and the general
“I still love being a social worker, and would not trade this for the world!”
                                                                                             population. What becomes abundantly clear are the unique patterns and
“The work is sometimes challenging, demanding, frustrating, and often very rewarding…        needs for women and girls and how these needs have increased over time.
I feel fortunate for the experience.”                                                              The authors review age, substance of choice or concern, mental health,
                                                                                             ability, culture, and pregnancy/ mothering, and go so far as to review how the
                                                                                             media views mothers who use substances. The authors begin to unravel the
WhAt’s neXt?                                                                                 complex and rich landscape of working with women and girls. The book will
Online surveys such as this cannot guarantee that the results are representative             guide both those who seek help and those who offer help and support.
of the views of social workers in BC. However the results do provide some                          The final two sections demonstrate creative and innovative theoretical
glimpse into the working conditions of BC social workers.                                    frameworks and treatment options being offered to women and girls across
     BCASW will conduct further analysis of the data and use the findings to                 the country. These sections explore what can be and is being done for
advocate for improved salaries, benefits, and working conditions for social                  women and stimulates one to consider the various possibilities in providing
workers. A number of social work associations across Canada are doing similar                better service.
surveys of their members, with the overall goal of establishing a national data                    Highs and Lows offers 40 chapters of concise, well presented material
bank from which regional and national comparisons can be made. This survey                   from highly respected clinicians, researchers and advocacy leaders across
has provided a baseline, and we will re-survey our members in a few years to                 the country and is a guide to those who are fearless enough to ask these
see what has changed. P                                                                      questions surrounding substance use.
                                                                                                   Highs and Lows is designed as a resource book. readers have the
     Your comments and questions about this report                                           opportunity to review each chapter as situations arise in their daily work.
     are welcome. Please forward them to the BCASW office                                    There is therefore repetition in the book, as overlapping concepts are
     at                                                                      presented in the different chapters; however, I have yet to come across such a
                                                                                             richly textured review as what is offered in the pages in this book. P
                                                                                             Kirstin Bindseil MSW, RSW is the Advanced Practice Clinician for the Women and
    Thank you to Joan MacKenzie Davies, Executive Director, Ontario Association of Social
                                                                                             Addiction Service at the Centre for Addiction and Mental Health in Toronto
Workers for permission to use and modify the OASW Quality of Work Life Survey.
    Thompson rivers University research Ethics Board provided permission and oversight
for the data analysis and report writing portion of the project only.

perspeCtives SEPTEMBEr 2007
            Trauma-Informed Integrated Practice
                        It’s much more effective than ‘services as usual’

            words nAnCy poole, ma

            T    rauma and violence are a
                 common experience in the lives
            of women and girls, particularly
                                                                                                                                           integrated counselling in a trauma-
                                                                                                                                           informed policy and service context
                                                                                                                                           was more effective than services

            those who also live with substance                                                                                             as usual; and that collaborative
            use and mental health problems.                                                                                                approaches involving consumers,
            There can be serious health and                                                                                                providers and system planners in
            social consequences when services                                                                                              all aspects of the policy design,
            and policies fail to pay attention                                                                                             implementation and evaluation
            to the way trauma experiences,                                                                                                 of services are foundational to the
            substance use and mental health                                                                                                effectiveness of this work [12, 14].
            issues are connected.
                  Violence and trauma including                                                                                             BC progrAms Are
12          childhood abuse, sexual abuse,                                                                                                  Applying this model
            and intimate partner violence                                                                                                   suCCessfully
            are common in women. The                                                                                                        In BC, some community-based
            Canadian research Institute for                                                                                                 addictions services and women-
            the Advancement of Women                                                                                                        serving agencies have built on
            reports that half of Canadian women have survived at least one incident            the SAMHSA study findings to develop and refine women-centred, trauma-
            of sexual or physical violence and that four out of five victims of family-        specific support integrated with support on mental health and substance
            related sexual assaults are girls [1]. Substance use and mental health             use issues. Some examples of these organizations are Battered Women’s
            problems frequently co-occur among women who are survivors of violence,            Support Services in Vancouver, Pacifica Treatment Centre in Vancouver and
            trauma, and abuse, often in complex, indirect, mutually reinforcing ways           the Women’s Sexual Assault Centre in Victoria, all of which have developed
            [2]. The overlap is not restricted to a small group of women — as many             integrated group programming for women. Support for further development
            as two thirds of women with substance use problems report concurrent               of such programs, their integration into mental health/substance use and
            mental health problems, often related to their experiences of surviving physical   related systems, as well as systematic evaluation is crucial [15, 16].
            and sexual abuse as children or adults [3-6]. Aboriginal women are more            All organizations offering this programming have identified challenges to
            severely impacted by violence and trauma [7-9], including intergenerational        providing sustainable, visible, integrated support to women on these three
            effects of trauma, often connected to the impact of residential schooling on       issues. Of particular relevance to social workers is the referral process to these
            their parents/grandparents [10].                                                   integrated groups, as this requires sensitive discussion of the interconnection
                  Lack of recognition in our service delivery and health and social policies   of the issues for women, and of women’s readiness for group work.
            to the ways experiences of trauma are connected to both alcohol and drug           Participating organizations have prepared women for involvement in these
            use and mental health problems can be devastating for girls and women.             groups in a number of ways, including offering open ended introductory
            Women who have sought help for trauma and mental health issues report              sessions on coping skills, prior to women making the decision to attend a
            misdiagnosis, extended suffering, overprescription of anti-anxiety and anti-       longer closed group programming [4].
            depressant medication, and even retraumatization through their encounters                Transition houses have also taken their role seriously in the development
            with service providers who are not sensitive to their needs [4, 11, 12].           of integrated care. A study was undertaken by a team of researchers
                  Models for the delivery of integrated support for women on substance         associated with the British Columbia Centre of Excellence for Women’s
            use, mental health and trauma related issues have been developed and               Health in collaboration with the BC/Yukon Society of Transition Houses in
            evaluated. For example, the Women, Co-Occurring Disorders and Violence Study       2002-3. The study examined the use of alcohol and other drugs by women
            funded by the US Substance Abuse and Mental Health Services Administration         as they entered domestic violence shelters, and again three months later after
            found that women with trauma, substance use, and mental health problems            they had left the shelters. Thirteen transition houses, located in both urban
            were able to reduce these problems when integrated models that were                and rural areas of BC participated in the study. Women interviewed in the study
            “trauma-informed”[13] and financially accessible were provided; that               reported significant reductions in their use of alcohol and stimulants in the
                                                                                                                                                      perspeCtives SEPTEMBEr 2007
period following their stay in a shelter [17]. Women described how their                 •     partnering with services providing integrated programming on
experience of violence and use of alcohol and other substances were                            trauma, mental health and substance use issues, to advocate for
interconnected in complex ways and influenced by individual, relational,                       system-wide availability of these services as well as to ensure access
and structural factors such as financial concerns, mothering, social support,                  by individual women needing support.
and mental and physical health issues. The research underlined how women
                                                                                         For a list of references cited in this article, please contact BCASW.
who are leaving violent relationships are receptive to the advice and support
that transition house staff can provide about alcohol use, and related health       (This article is adapted from an information sheet prepared by researchers at
and social issues connected to their experience of violence. The study also         the BC Centre of Excellence for Women’s Health as members of an Ad Hoc
highlighted how women leaving violent relationships desperately need                Committee of women’s health advocates from across Canada convened by the
integrated, informed, support on safety, substance use, housing, income             Canadian Women’s Health Network (CWHN) and the Centres of Excellence for
support, child custody issues and related issues during this period.                Women’s Health (CEWH) in anticipation of the Standing Senate Committee on
                                                                                    Social Affairs, Science and Technology’s Final report on Mental Health, Mental
soCiAl Workers CAn trAnsform their prACtiCe                                         Illness and Addiction in Canada, chaired by Senator Kirby. For the full report,
Given how social and structural issues are interconnected, social workers           Women, Mental Health and Mental Illness and Addiction in Canada: An Overview, see
working with women, their children and families have a role to play beyond Health.pdf) P
making referrals to specialized programming, but to actually provide trauma-        Nancy Poole is a Research Associate with the BC Centre of Excellence for Women’s
informed and substance-informed support in their own practice with women.           Health.
As has been identified by social workers who have attended educational
sessions associated with the ActNow BC Healthy Choices in Pregnancy
initiative, often it is as simple as recognizing how the risky or problematic
“behaviours” of mothers (such as substance use in pregnancy) have originated
to cope with experience of trauma and other forms of violence. Then our
response can be more compassionate and comprehensive. New social policy                                                                                                 13
on utilizing strengths-based approaches in the delivery of child welfare services
may provide a more welcoming context for such work with women, and may
begin to address long created barriers to integrated care that includes support
for mothering.

soCiAl Workers hAve A pArt to plAy in overComing the
systemiC ChAllenges in AddiCtions, mentAl heAlth And
soCiAl WelfAre systems
Currently in Canada, addictions and mental health systems are being merged,
with the medicalized approach of the mental health system most often
dominating, at the expense of multifaceted, comprehensive and women-
centred addictions and trauma informed approaches. The challenge in
merging addictions and mental health systems (and linking them to social
service systems) is to, at the same time, improve them by making them more
accessible, comprehensive, integrated and continuous. Attention to trauma
needs to be a key component in the design of treatment options as well as in
research that can guide this practice.
      Given the impact and interaction of trauma, mental health and substance
use problems in the lives of Canadian girls and women, developing policies and
programs that support integrated approaches to treatment, harm reduction
and prevention must be made a provincial and national priority. There are
many ways in which social workers can be involved in improving the response
to women, including:
      •    working in partnership to expand and enhance public and
           professional access to information on the interconnections among
           trauma, mental health and substance use
      •    delivering women-centred, trauma-informed and substance-
           informed support in daily practice

perspeCtives SEPTEMBEr 2007
           Better Primary Health Care for Women
                          It’s time to put our knowledge of health promotion
                          into practice
           words           Ann pederson, msc

           I  n 1974, Canada became the first national                                                                       perspective of women’s health, the recent

              government in the world to initiate a                                                                          round of primary health care reforms paid
           discussion      about      the     non-medical                                                                    inadequate attention to the implications of
           determinants of health with the release of                                                                        “sex” and “gender” in the purposes, vision,
           A New Perspective on the Health of Canadians                                                                      organization, and delivery of primary health
           (Lalonde 1974). The Lalonde report introduced                                                                     care (Pederson & Donner 1997).
           the term “health promotion” through its
           model of the “health field concept” which                                                                         Why seX And gender Count
           argued that personal biology, individual                                                                          There are several ways in which ‘sex’ (the
           lifestyles, the physical environment, and the                                                                     biological differences between female
14         organization of health care determined health.                                                                    and male bodies) and ‘gender’ (the
           Today, the Public Health Agency of Canada                                                                         socially constructed roles and attributes
           names a dozen “determinants of health”1                                                                           differentially assigned to women and men
           and Canada continues to be recognized as                                                                          on the basis of their sex) are important in
           a leader in health promotion theorizing,                                                                          primary health care (Pederson & Donner
           research, and demonstration projects                                                                              1997). For example, women’s reproductive
           (O’Neill, Pederson, Dupéré & rootman BCASW member, Molly Smith, balances work with a healthy, active              functions mean that women have different
           2007). Yet at an international conference on lifestyle.                                                           sex-specific needs than men with respect
           health promotion in Vancouver in June 2007,                                                                       to birth control; perinatal care; managing
           Monique Bégin, former federal Minister of Health and Welfare, suggested that menstruation and menopause, and female infertility; and periodic breast
           “Canada deserves an A-plus for knowledge about what determines health, but and cervical cancer screening. Some health conditions are more prevalent
           an F when it comes to putting that knowledge into practice” (Gram 2007).        in women than men, including breast cancer, eating disorders, depression,
                 A few years ago, discussions were underway about how innovations and self-inflicted injuries. There are also conditions that appear to be sex-
           in primary health care reform held promise for a revitalized role for social neutral such as heart disease, a disease for which the signs, symptoms, and
           workers (CASW 2003). The demonstration projects funded by a federal optimum treatment appear to vary between women and men. We also
           Primary Health Care Transitions Fund are now complete and evaluations see differences in women’s primary health care needs arising from their
           are underway. Though in its roots primary health care holds great promise gendered roles—which continue to define women as the major paid and
           as a framework for promoting health and bringing an understanding of the unpaid caregivers of children, persons with disabilities, the elderly, and the
           ‘social’ into the health field, the recent round of experiments may not have ill. Further, gender stereotypes, such as the assumption women are indeed
           taken the concept of ‘primary health care’ to its fullest potential. Instead of available to provide care for others, or that women express pain to a greater
           focusing on the links between health and the social determinants of health, extent than men, may continue to operate within health care.
           most of the recent initiatives in primary health care in Canada have focused          Each of these processes mean that primary health care should be
           on management strategies and the use of various economic incentives and organized and offered in ways that reflect the particular—and varied—needs
           disincentives as mechanisms for organizational change. In particular, from the of women and girls. This is because women are not homogeneous but vary
                                                                                                      with respect to important social locations arising from differences in economic
               The determinants of health include: income and social status; social support net-
                                                                                                      status, education, age, sexual orientation, language, disability, and race.
           works; education and literacy; employment/working conditions; social environments;
                                                                                                      Indeed, scholars are increasingly calling for researchers and practitioners to
           physical environments; personal health practices and coping skills; healthy child devel-
                                                                                                      undertake an “intersectional” analysis so as to understand the important ways
           opment; biology and genetic endowment; health services; gender; and culture (Public
                                                                                                      that gender, race, and class affect women’s health (reid, Pederson & Dupéré
           Health Agency of Canada. Population Health: What Determines Health? http://www.
  retrieved August
           16, 2007).
                                                                                                                                                          perspeCtives SEPTEMBEr 2007
ACCess to primAry heAlth CAre is proBlemAtiC for                                                 To date, 50 peer interviews have been conducted to develop a portrait
mArginAlized Women                                                                         of the experiences of women using primary health care services in the DTES.
The health and health care needs of women in the Downtown Eastside                         A series of discussions with health and social service providers is planned to
of Vancouver (DTES) reflect a complex social context of marginalization,                   share the results of the study and to examine their implications for care
poverty, homelessness and “survival sex,”(McKeown, reid, Turner & Orr                      and numerous presentations on the PAr aspects of this work have already
2002). For example, female injection drug users in the DTES have mortality                 taken place. Critical to the analysis of this work and its translation into
rates almost 50 times higher than women in the rest of BC (Spittall 2006).                 recommendations for the organization and delivery of care will be an
The disproportionate representation of Aboriginal women among Canada’s                     intersectional analysis of the roles that gender, race, and class play in the
most disenfranchised is reflected in the DTES, where approximately 70%                     shaping of the health and health care experiences of women in the DTES.
of Vancouver’s Aboriginal population resides. Seventy percent of sex trade                 In addition, the fact that this work was initiated by the VANDU Women’s
workers in the DTES are Aboriginal women and mothers of at least one child                 Group and that the members of the group are involved in all aspects of the
(Burgelhaus & Stokl 2005). Aboriginal women are the fastest growing group                  project helps it to be a mutual learning environment for the researchers and
of HIV-positive people in the DTES and are three times more likely to die from             women group members alike.
HIV/AIDS than other women in Vancouver (Joseph 1999). Women who are
using illicit drugs in this context also suffer from violence-related injuries and         the promise of primAry CAre
chronic pain, mental illlness, poor nutrition, infectious disease, and sexually-           With greater attention to the particular manifestations of sex and gender
transmitted infections as well as health problems arising from the substance               in the DTES—gendered patterns of substance use, homelessness, violence,
use themselves such as lung and throat damage.                                             illness, health care utilization, and responses by health care providers—primary
      For women living and working in the DTES, primary health care would                  health care holds the promise of being able to address the health problems of
seem to be a critical approach to enhancing their health because of its                    the DTES. Better partnerships among health and social services researchers,
comprehensive approach to health and social issues. Yet access to appropriate,             practitioners and policy makers are needed to address the complex social,
respectful primary health care can be problematic. A research project is currently         economic, political and environmental conditions which shape the health
underway to try to address some of the problems with access to primary health              of some of Canada’s most marginalized people. Social work, with its                   15
care in the DTES, from the perspective of the women themselves.                            attention to process of marginalization, its commitment to anti-oppressive
                                                                                           practice, and its understanding of social processes as mechanisms for
the vAndu Women CliniC ACtion reseArCh for                                                 producing health, has important contributions to make to the field of health
empoWerment study                                                                          promotion and to primary health care. It is time to put the promise of health
(VANDU Women CArE) is a community-driven, qualitative Participatory                        promotion—to enable people and communities to increase control over and
Action research (PAr) project examining the primary health care experiences                improve the conditions that shape their health—into practice. P
of women who use illicit drugs in Vancouver’s Downtown Eastside. Harm
                                                                                           Ann Pederson is Manager, Research and Policy, British Columbia Centre of Excellence
reduction services do not always attend to the particular needs or experiences
                                                                                           for Women’s Health. References cited can be requested from BCASW.
of women who use illicit substances in the DTES, and may thereby perpetuate
or exacerbate some of the conditions and experiences particular to women.
This project has brought together members of the VANDU Women’s Group,                        kudos to our memBers
and academic researchers from the BC Centre of Excellence for Women’s
Health2 and the UBC School of Nursing to form the research team3. The                        Fraser Health Authority’s Above and Beyond Program recognizes outstanding
purpose of this research is to develop an equitable, ethical, and collaborative              achievements of employees, physicians and volunteers. Twenty recipients
partnership between researchers, health service providers, and women who use                 from 172 nominees were recognized this year, including BCASW member
substances that will document and analyse the primary health care experiences                Joanne Paul, for Service Delivery Excellence. Joanne, with Mission Mental
of women who use drugs while also supporting their health, well-being,                       Health, was the very first part-time Case Manager for Aboriginal Services
and leadership.                                                                              in Mission and was instrumental in mobilizing the Aboriginal Services in
                                                                                             the Fraser Valley both in terms of working together as well as in setting up
    The British Columbia Centre of Excellence for Women’s Health and its activities          annual education sessions.
and products have been made possible through a financial contribution from Health
                                                                                             Lori McPherson, a student in the Terrace Social Work program at UNBC
Canada. The views expressed herein do not necessarily represent the views of Health
                                                                                             was awarded both the Minerva Foundation Award and the BCASW Northern
                                                                                             Branch Bursary. The Minerva Foundation Award is one of UNBC’s largest Donor
    Throughout this paper, we use the terms “research team” and “researchers” to include
                                                                                             Awards which is designed to promote leadership among BC women. Both
academic researchers and research assistants, the project’s Community research Facili-
                                                                                             awards recognize academic performance and community service in their
tator, VANDU leadership, and VANDU members who work together on this project. We
                                                                                             selection criteria.
also wish to reiterate that VANDU membership includes women who are both current
and former drug users.
                                                                                             Linda Prochaska was elected to the board of the BC Bereavement
                                                                                             Helpline for 2007-2008. She is a past president of the Helpline.

perspeCtives SEPTEMBEr 2007
             Victimized from Both Sides
                          There are barriers at every turn for immigrant women in
                          violent relationships
                           BCASW member Shashi Assanand, RSW, is the executive director of Vancouver Lower Mainland Family Support
                           Services. Shashi founded the agency in 1991. She designed it from its inception and it has grown to offer a wide range of
                           programs for persons affected by family violence. The programs are offered in twenty-four languages. All the programs

                           are interconnected and all face the common issue of empowerment of immigrant women – creating independence for
                           women. Perspectives editorial committee member Molly Smith interviewed Shashi about her work:

                     shAshi, WhAt issues do you see As speCifiC to                                 also brings with it growth and economic independence. It gives her confidence
             immigrAnt Women And Women from visiBle minority                                       and freedom to make choices. Employment puts demands on her to change.
             groups in the ConteXt of fAmily violenCe?                                             She may become more aggressive, assertive and outspoken. These qualities
             Very often immigrant women and visible minority women are victimized from             may threaten the husband’s role in the family. He may expect her to work but
             both sides. On the one side, the culture they come from persecutes them if            he may not realize that this change in her confidence will be inevitable. He may
             they break the silence to protect themselves. On the other, the system of the         exercise control in order to prevent what he perceives as “Canadianization” or
16           dominant culture assumes violence is accepted in many immigrant cultures.             “liberalization”. On the other side the wife — with the knowledge that she can
             Therefore, intervention and/or adequate programs may not be provided as               now support herself — may resist control and rebel against it. This often results
             they are considered to be unnecessary.                                                in conflict and leads to violence. An immigrant woman also realizes that the
                                                                                                   Canadian social and legal systems will support her if she is, in any way, abused
             NO CULTUrE ACCEPTS VIOLENCE! Anyone who claims that violence is an                    by her husband. This empowers her to take a step rather than suffer in silence.
             acceptable form of behaviour in a particular culture is misrepresenting that                In many traditional cultures, women are raised to believe that their role is
             culture to suit his own purpose. Violence exists at every economic, educational       to be subservient to men and decision-making is considered a male privilege.
             and social level. Abuse knows no cultural or racial boundaries and affects all age    A woman’s father, husband and, eventually, her son will make the decisions.
             groups. It is prevalent throughout the world. Women in many cultures are still        Her inexperience and perceived inability to make decisions will often compel
             in the mode of thinking that self-sacrifice is required in order to keep the family   her to continue to live in a violent relationship.
             together. These women continue to tolerate violence, and society, instead of                Marriages in some cultures are arranged by family members. Cultural and
             taking stock of the cost of their values, allows the violence to continue.            familial ties will force her to stay in the marriage, even if the incompatibility
                                                                                                   in the relationship leads to marriage breakdown and violence. In extended
                      WhAt BArriers prevent immigrAnt And visiBle                                  families, in-law relationships often compound the problem. When conflict
             minority Women from getting the support they need?                                    occurs, a woman will have to face not only her husband but many other
             Family honour takes precedence — at any cost. A fundamental value of                  individuals if she decides to take any legal action.
             immigrants, especially from eastern cultures, is family togetherness. The                   Many children have a very difficult time coping with the expectations of
             entire extended family forms a unit and is the social, economic, and political        two very different worlds. When children go to school, they are influenced by
             system as far as the individual is concerned. In many cultures, family honour         Canadian values, such as individualism and independence. This sometimes
             takes precedence over everything else. Maintaining the family’s sanctity is           becomes a serious point of conflict between parents and children. The
             imperative at any cost. Most of the responsibility to preserve this honour and        rebelliousness that teens express during the identity separation process is
             sanctity rests on the shoulders of the women in the household. As a result,           foreign behaviour to many immigrant parents. These parents never had to
             when women facing family violence access the justice system, they can be seen         struggle to find their own identity: they adopted the identity of their families. A
             as destroying the family and the community and are therefore ostracized.              lack of appropriate parenting skills sometimes forces women to stay in abusive
                   In many cultures, the man is the primary wage earner and the principal          relationships for fear that, as single mothers, they will be unable to cope with
             decision-maker. The woman is the nurturer and the performer of the                    the changing needs of their children.
             household duties. Most often the education level of the woman is irrelevant:                The inability to speak English confines women to the home and increases
             the expectation is that she draw education from her home life. When she               their vulnerability to abuse. It makes them dependent on their spouses and
             comes to Canada, this role is diffused and many other responsibilities are            other members of the family, including the children. This allows others to
             added. In Canada, there is often an economic need for two incomes to support          exercise control over them. As the language skills of the husbands and children
             the family, and the woman must find a job. This newly acquired responsibility         improve, immigrant women find themselves even more isolated in their own
                                                                                                                                                           perspeCtives SEPTEMBEr 2007
homes. Given a language barrier, women are unable to access any information         Social workers need not fear the immigrant cultures. They need to understand
on their legal rights or services that offer help. A woman unable to speak          both the cultures of origin and the Canadian culture. With sensitivity and
English who becomes a victim of violence faces a hurdle every step of the           understanding, they need to look at the root causes and help immigrants to
way. If she calls 911, the police will arrive often without an interpreter. There   find a balance between their culture of origin and their newfound culture and
have been times when the police have used the husband to interpret for her,         keep the best of both. P
or used another family member, who may not give a full picture because they
want to save the family name. She will continue to face cultural and language
barriers in dealing with the police, transition houses, courts, probation
officers and other service providers. The fear of having to deal with the system
without fully understanding the language is in itself enough to keep a woman
from accessing the system.
      English classes are available to immigrant women but eligibility for these
classes, the quality of the classes offered and whether they meet the needs
of the women are further complications. More problems arise when women
have to find the time, energy and motivation to attend classes after they have
taken care of the house, children and their jobs. Then the prospect of leaving a
battering situation becomes even more frightening.
      If an immigrant woman manages to overcome these obstacles, she must
become gainfully employed to support herself and her children. She becomes
an easy target for exploitation by her employer. All these difficulties are
bound to further affect the woman’s self-esteem, whose loss she already
suffers in the battering relationship.

         WhAt ABout the legAl stAtus of immigrAnt
Abuse may occur when a woman has come to Canada as a visitor or as a
refugee and then gets married. The sponsorship application by her husband
takes a number of years to be processed by immigration. If, during this time,
the man abuses her and she takes steps to leave him or report him, she faces
the danger of losing her claim to landed immigrant status. If he withdraws his
sponsorship, her right to stay in Canada will cease. This leaves her no option
but to stay in the violent situation. Her only option is to leave Canada. These
women do not qualify for social assistance. refugees also do not qualify for
other services except a very few that are authorized by the department of

       so WhAt do you see As the AnsWer for these
Women Who Are trApped in violent situAtions?
We must educate women and their families. Safety is the prime concern:
she must have a safety plan. She needs to learn how to assert herself and
not get killed. You have to know that you do have a choice and walk away.

perspeCtives SEPTEMBEr 2007
           Straight from “The Source”
                      It’s the online portal to women’s health data
           words joCelyn WentlAnd and mArie dussAult

           I  n addition to sex and gender,
              many social, economic,
           and cultural factors are major
                                                                                                                                            may be further exacerbated
                                                                                                                                            if women do not have
                                                                                                                                            adequate health benefits at

           determinants of health. There                                                                                                    work and delay medical
           has been much debate in                                                                                                          treatment due to work and
           women’s health movements on                                                                                                      home responsibilities. Women
           the need to recognize biases in                                                                                                  belonging to ethnically diverse
           health care and to examine how                                                                                                   populations may be at greater
           women’s health is potentially                                                                                                    health risk if cultural and
           affected. Developing core                                                                                                        language barriers prevent them
           indicators of women’s health                                                                                                     from using health care services.
           improves the ways in which                                                                                                       For example, women from HIV-
           women’s health is monitored                                                                                                      endemic countries (defined as a
           and helps to accurately                                                                                                          country which has an HIV rate of
           monitor women’s health status                                                                                                    1% of the adult population) are
           (Women’s Health Indicators                                                                                                       at great risk of contracting HIV/
           Project, Health Canada, 2002). Although the government recognizes the                AIDS (Public Health Agency of Canada, 2007). This may be due to cultural and
           importance of incorporating gender-based analysis (GBA) into health                  religious stigma surrounding HIV/AIDS, as well as rigid gender roles that do
           literature few research projects incorporate GBA, which, at the most basic           not support women’s rights to their bodies in terms of safer sex.
           level, result in data not being disaggregated by sex. At a more complicated
           level, the data does not reflect the social and biological differences between       introduCing “the sourCe”
           women and men in terms of how either gender experiences disease, illness, or         In order to highlight the importance of women’s health issues, The Women’s
           access to health services.                                                           Health research Network, BC Women’s Hospital, and the BC Centre of
                                                                                                Excellence for Women’s Health are launching The Source/La Source —
           Why gender BAsed AnAlysis is importAnt                                               Women’s Health Data Directory ( The Source/
           Women and men have differences both in the way they experience illness and           La Source is a bilingual web-based tool to assist researchers, policy makers,
           in the way they interact with the health system and access health services.          health planners, and students to identify provincial and national sources of
           For example, although women are more likely to see a physician regarding             health data and reports for girls and women in British Columbia and Canada.
           overall health concerns, they are less likely to be screened for chronic             It is a portal which provides users with access to provincial and Canadian
           obstructive pulmonary disease because COPD continues to be treated as a              data on a number of similar health indicators, in an interactive user-friendly
           male health issue.                                                                   interface.
                                                                                                      The directory is organized into three categories: Health Status, Health
                “Social differences can have a greater impact on                                Determinants, and Health Services. Health Status refers to the data on the
                women’s health than biological differences”                                     presence of disease, disability, well-being, and mortality of women, such as
                                                                                                the experience and impact of chronic disease. Health Determinants are social
                  A number of issues arise when looking at specific subpopulations of
                                                                                                factors that affect not only women’s health status, but also the way in which
           women. Arthritis is one of the most prevalent health conditions for Aboriginal
                                                                                                women access health services; for example, the effects of women’s substance
           women. However, arthritis is not listed as a key health issue such as diabetes and
                                                                                                use on their health and ability to cope. Finally, Health Services includes
           HIV/AIDS and, as a result, we have limited information on Aboriginal women’s
                                                                                                indicators that reflect the use, accessibility, appropriateness, and quality of
           experience of arthritis and how this affects their daily lives. Low income may be
                                                                                                the health care system in meeting the needs of women, such as access to and
           a risk factor for women’s health. Women with low incomes have a higher rate of
                                                                                                utilization of cervical and breast cancer screening.
           cardiovascular disease, which may be related to other issues, such as smoking,
           physical inactivity, and less access to proper nutrition. These health issues

                                                                                                                                                       perspeCtives SEPTEMBEr 2007
 hoW CAn soCiAl Workers use the sourCe?
 The Source/La Source will be useful to social workers because it addresses the
 social determinants of health, such as physical and sexual violence, substance
 use, and the experience of chronic diseases. It will appeal both to individuals
 who need quick access to statistics available in prepared reports, as well as
 individuals who wish to investigate a topic more in-depth and need access to
 comprehensive data. Further, the directory will give users a snapshot of what
 kind of data is available and identify gaps in the literature. It will also provide
 links to additional documents and websites that offer materials on women’s
 health from a women-centered perspective.
        The Source/La Source will not only be a portal to data on women’s
 health, but will also highlight the ways in which women’s health is different
 by providing a gender-based analysis on each indicator. The information
 provided through this lens will add to the understanding of both biological
 and social differences between women’s and men’s experience of health
 and illness. Social differences are extremely important to highlight because
 these differences sometimes have a greater impact on women’s health than
 biological differences. For example, women with low incomes may smoke to
 escape daily life and the stresses they face including childcare, household, and
 work responsibilities. These stressors may be further magnified if the woman
 is a lone mother. This type of information is crucial in designing, for example, a
 smoking cessation program which targets women.
 Better informAtion = Better CAre
 Improving access to the evidence base for women’s health will better inform
 women’s health policy development and improve the care provided to women
 and girls. The Source/La Source will be a valuable tool for a variety of users who
 will gain straightforward access to the data and learn about the importance
 of analyzing data from a gender-based perspective at the same time.
 Its development is an ongoing process and the directory will be continuously
 expanded, updated, and improved based on user feedback and reviews. P
       * The project is funded by the Women’s Health research Network (WHrN) as part of
 their Women’s Health Surveillance project funded by the Michael Smith Foundation for Health
 research. Health Canada is supporting the bilingual development of the directory.


                   Lynn E. Superstein-Raber
                         Ph.D.,R. Psych, NCPsyA

                      Phone (604) 263 1417
                       301 2309 West 41st Avenue
                                  Vancouver, BC
                                 License number 01364

perspeCtives SEPTEMBEr 2007
                  Giving Advice to Family and Friends
                            What could be more normal — or more dangerous?
                  words        Bill engleson,rSW
 tough ChoiCes:

                  I am the only social worker in my extended family. A first cousin, with whom
                  I was once very close, has asked if I would meet with a friend of hers whose
                  children have just been removed by child welfare authorities in the next
                  town over. My cousin knows I have had child welfare experience and hopes
                  I can offer some ideas on how her friend can successfully interact with the
                  involved social worker, and also, perhaps, utilize my services as an advocate.
                  My cousin is emphatic that there is no abuse and that the whole removal
                  was ‘a big mistake.’ Just to complicate matters, I am aware that the social
                  worker, though considered very professional, has a reputation of being hard-
                  nosed and not especially client-centered. I truly would like to re-establish the
                  close bond I once had with my cousin and am tempted to get involved.
                  Given that most social workers belong to some form of extended family,
                  several aspects of your situation may not be all that uncommon. One of the                With regard to the reputation of the social worker involved in her friend’s
                  risk/rewards inherent in having specialized information is that family and          case, you have an obligation to refrain from the distribution of rumor. The
                  friends might reasonably expect you to assist them or offer advice if called        reality is that Child Protection is a stream of social work which engenders
                  upon. What could be more normal?                                                    strong opinion. As you undoubtedly know, involuntary clients compelled to
                         Though your Code of Ethics does not speak to the thorny topic of one’s       be in that milieu have diminished options. While they have every right to be
                  private life trespassing on professional pasture, or vice versa, there are some     treated fairly and respectfully, there may be little or no choice as to who their
                  relevant ethical admonitions which might apply. For example, when the Code          worker is.
                  requires that “a social worker shall not exploit the relationship with a client           While other Standards may also be pertinent, 3.5 allows that social workers
                  for personal benefit, gain or gratification,” it is a caveat that requires you      “assist potential clients to obtain other services if they are unable or unwilling,
                  to think long and hard about the wisdom of incorporating a wistful desire           for appropriate reasons, to provide the requested professional help.” The friend
                  to have an improved familial relationship by injecting yourself into a third        clearly has to deal with her situation. An offer to point her in an ‘appropriate’
                  party situation. Offering second hand advice to your cousin and expecting           direction might be useful. It may also seem a reasonable compromise to
                  her to relay it meaningfully to her friend would, at the least, be slipshod and     your cousin’s request, though that should remain a secondary, inadvertent
                  unprofessional. Meeting with her friend would in actual fact transform the friend   benefit. All in all, these particular Standards may provide you sufficient
                  into your client. In any case, even if you don’t speak directly to your cousin’s    leeway for a viable, tolerable, ethical exit strategy this time. P
                  friend, one could argue that, by offering advice which may influence how the
                  friend manages her situation, you have contrived an awkward professional
                  affiliation, one, in some ways, more complex than a dual relationship.              exclusion of liability
                                                                                                      This column is intended to stimulate thinking and critical analysis and to encourage a free exchange of competing views
                         Your Standards of Practice may provide possible direction. For example,
                                                                                                      about ethical problems encountered in social work. The names of those who submit an ethical dilemma are not published
                  1.7 explains that “social workers are aware of their own values, attitudes and      and identifying information is modified to ensure confidentiality.
                  needs and how these impact on their professional relationships with clients.”               The analysis provided is not offered as legal or professional advice, nor is it intended in any way to be relied upon as
                  You have identified that you want to make amends with your cousin. In this          a practice prescription to be followed in similar situations. The statements and opinions expressed herein are those of the
                  situation, that could be viewed as your primary motivation. Her solicitation        individual author and not those of the Editorial Committee of Perspectives or BCASW. Any reliance upon this analysis shall
                                                                                                      be at the user’s own risk, without any legal recourse to the author or the Association for any claim, whether in negligent
                  to entice you into her friend’s dilemma is an inappropriate vehicle to ignite
                                                                                                      misrepresentation, or otherwise. Practitioners should seek specific advice from colleagues on specific factual circumstances
                  redress between the two of you. While your cousin has some measure of
                                                                                                      and, where appropriate, consult with legal counsel or the body that regulates standards of practice. Questions and
                  culpability, you, as the professional social worker, have the ethical obligation    comments about this column, and ethical dilemmas may be sent in confidence to Linda Korbin c/o Perspectives or to:
                  to draw an irrefutable line in the sand.                                  

                                                                                                                                                                                             perspeCtives SEPTEMBEr 2007

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