James Donnelly, DSW, LCSW

Abstract

Considerations of ethics in health care organizations are frequently focused on the decision making process, both clinically and administratively. Of critical importance, however, for healing and recovery, as well as for the optimum effectiveness of the staff, is the overall human climate of an organization. An approach to an ethics of the human climate of care based upon a social work understanding of the disruption of illness and placement in the lives of residents is presented. This ethic is anchored in the requirements of authentic dialogue as the primary ethical mandate for staff of every level in a health care facility

KEY WORDS:  ethics and long term care, ethical climate of care, ethics and the recovery of meaning, social work perspective on climates of care, care planning in long term care, ethics of dialogue, ethics and leadership in health care.

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One of the most difficult and radical adjustments to aging and illness is the necessity for residence in a long term care facility. Such a placement represents a number of physical, familial and social breakdowns in a person’s life at a time when they are perhaps most vulnerable and dependent. Although any admission to a medical facility for serious illness represents a potential disruption and challenge to a person’s sense of meaning, worth and identity (Donnelly, 1992), admission to a long term care facility most often represents an irreversible change in one’s life circumstance and the challenge of chronic dependency lived out within a context of strangers (Donnelly, 2009a). Discussions of ethics in health care most often focus on discrete and complex treatment decisions. Later trends in organizational ethics focus on organizational decision making processes to insure operational integrity consistent with the facility’s stated values and mission.

The traditional bio-ethics model has been recognized as inadequate to the application of ethics to long term care situations (Hoffman et al., 1995; Moody, 1996). In long term care environments it is the issues of daily congregate living that create the majority of ethical dilemmas experienced by both residents and staff.  Yet even given this broader application of ethics suitable to long term care, ethics is often seen as called upon in reaction to situations that arise rather than a proactive and essential component of our understanding of the meaning of providing health care.

The following essay on ethics in long term care is based upon the author’s experience as a social work director tasked with the establishment and training of Ethics Committees in five long term care facilities in New York City. These facilities are part of New York City’s two major Catholic Health Care Systems. Although the frame represents the core of the values that guide an ethical approach to health care as contained in the Ethical and Religious Directives for Catholic Health Care Services, (2001) of the National Conference of Catholic Bishops  (http://www.usccb.org/bishops/directives.shtml), it does not represent in any official or sanctioned way the positions of the American Catholic Church on issues of health care. This frame, evolved out of the value base of a social work perspective, is meant to communicate in a moving, but clear and comprehensive manner, the centrality of ethics in the provision of health care (Donnelly, 1992, 2009a). It affirms the meaning of health care provision in society as a recognition and affirmation of the dignity and worth of each and every person (Donnelly, 2004).

This assignment afforded the author a unique opportunity to bring a social work perspective to the centrality of ethics in the lives of both staff and residents living and working in a long term care environment.

In long term care facilities, the basic structure of the delivery of care to residents is anchored in the care planning meetings of the interdisciplinary treatment team. Regularly scheduled conferences involving all disciplines as well as the families and residents form the center of this process.  This care plan process serves as the hub for many complex interactions, both among the providers of care and between the providers and recipients of care (Department of Health and Human Services, 2004).  It is structured to insure an integrated and comprehensive assessment of each resident’s needs, a coordinated set of interventions to meet those needs and a method of evaluating the effectiveness of those interventions in order to further reassess and intervene. The over all goal of the care planning process is to maximize the physical, psychological, emotional and spiritual well being of each resident in the facility. In the New York State Department of Health regulations regarding nursing home care, the social work function is charged to assert each patients right to this level of integrated care.

What first comes to mind is that the basic underlying structure of the care planning process is dialogic.

On every level, the foundation of the process is rooted in the quality of the communication between the providers and recipients of care, as well as among the providers themselves. The simple ethical imperative to be truthful would, of course, permeate every aspect of that conversation. There are also the ethical imperatives to be informed in one’s area of expertise, and to find dignified and respectful ways to make the benefit of that knowledge available to both colleagues and residents.

In dialogue, however, there is not only the ethical imperative to be informed and truthful, but also to strive to understand the other with whom one speaks.

Every conversation is contextual. Ethical dialogue requires sensitivity and a desire to understand the overall context of the interaction.  In simple terms, to view the care planning process as a conversation, there is an ethical imperative to understand the context of interaction.

Needless to say, the context of conversation among the disciplines and with residents and their families is broad and complex.  It is set in the web of forces, financial, political and cultural, bearing upon and interacting within the entire national and local health care delivery systems.  The dramatic impact of these changes in reimbursement streams, both current and anticipated, has significantly effected the daily experience of work and care.  Although we won’t focus upon this wider context for the present, it is important to keep in mind that this context is, perhaps, more unstable than it has ever been. Working within this context continuously impacts on the most intimate details of our work and interaction with each other and our residents.

This is all the more reason to clearly address the core context of our purpose as providers of care.

A person is sent to us.  They don’t usually come of their own initiative.  To say that they come to us “willingly” simply because they have agreed to come is misleading. Our residents have been sent by the caprice of life.  Because of a combination of physical, social and psychological mishaps, they have been dislodged.  Few, if any, of their familiar places, their habitual rituals of interaction with themselves, families, others, animals, plants, places and things can now accommodate them.

They are sent and arrive at a place where they are sorely shriven of any familiar context.

The ethical foundations of the care planning process are rooted in what is required of providers of care to be in a true dialogic relationship with people who are experiencing themselves as disconnected within an often unwanted, strange and disorienting context.

To graphically illustrate the requirements of that task, the image of a torn fabric can be useful (Donnelly, 2009a).  The threads, weave and patterns of the fabric are analogous to the habitual and patterned interactions of thoughts, feelings and behaviors one has with one’s body, intimates, community and the world at large. These familiar, mutually created relationships constitute a person’s fabric of meaning. It is within this network of familiar relationships and circumstance that a person positions him or herself in the world to experience life as meaningful and as making sense.

In being dislodged from one’s familiar context, this fabric is torn and the foundations of one’s sense of meaning are severely challenged. What remains is a gaping hole of confusion and fragmented meanings. Unwillingly, they have had thrust upon them the task of finding within themselves and with others some way to begin reweaving the fabric of meaning – in these dramatically changed circumstances.

Their task defines the task of all involved in the operation of the facility and the provision of care. The challenge, to both care providers and residents and families, to reweave the fabric of meaning is the core task of the care planning process and all other aspects of the provision of care; its goal is the re-creation of a context in which it is possible for a person to make sense to himself or herself with family and others within this new and different living environment.

Meeting the challenge of this need for residents and their families – to reestablish a sense of meaning in their lives – is the fundamental ethical imperative for the provision of care in a long term care environment.

Team and staff interactions with residents and families, which are not rooted in this fundamental purpose, risk being experienced by residents and families as assaults to their sense of worth and their capacity for creating meaning (Laird, 1997; Tulloch, 1975).

The challenge for providers of care to be co-participants in reweaving the fabric of meaning meets us on two levels: environmental and individual.

The task is implicitly environmental because it addresses the need to create a human social and emotional climate in which people, wounded on this fundamental level, can find ways to re-create a sense of meaning.  The establishment of such a climate places an equally urgent mandate on each facility staff regardless of position or profession. On the level of this imperative, there is no one more or less important to this purpose.

The task is individual because it is in the moments of each interaction a resident may have with any professional or staff of the facility when this re-creation takes place. On this most fundamental level of healing no moment of interaction is any less important than any other.

What is the ethical challenge for providers of care when face to face with another person who has, literally, been thrust upon them and whose familiar context for a sense of meaning has been shattered?

On a cognitive and emotional level, it is the requirement to be present, open and informed towards this other.  On an experiential level, it is a commitment to endure the discomfort of the other’s experience of strangeness and meaninglessness and, through that discomfort, remain available for relation.

The experience of presence is the preverbal, precognitive experience of life. For a human being and maybe for all creatures large and small, presence is the implicit experience of meaning prior to any further definition. Presence is what occurs “between us” (Buber, 1958, 1965; Donnelly, 2009b) and is the primordial experience of mutuality out of which the threads of the fabric of meaning are woven into new and unforeseen designs. Presence is emotional and psychological availability that transcends task, function or limited goal.

Given the context of the dialogue with our residents, the fundamental ethical mandate for us is the requirement to be present and to contribute to a climate that fosters presence.

There are many inhibitors to presence.

Residents can be caught in the whirlwind of feeling frightened, useless, worthless and meaningless. They are struggling to integrate and incorporate these new and disruptive experiences. Their responses to care may range from depressive withdrawal to physical and verbal assault. To maintain presence with such persons, be available and hold the situation in some viable way, requires a great deal of inner strength, clarity of purpose and contextual support (Winnicott, 1965).

For the providers of care, the myriad inhibitors of presence can be summarized as all those things that contribute to our being preoccupied, scared or unsure. Faced with the ethical mandate of our residents’ need, we individually and collectively are required to address whatever inhibits our availability to the context of dialogue.

Care planning is not talking about people; it is articulating the experience of being with them.

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We communicate to ourselves and each other our values and sense of meaning through the expectations we make upon ourselves and others.  Expectations are powerful but often unrecognized forces in our relationships (Donnelly, 1987, 1992; Gross et al., 1958). When residents come to us with their sense of themselves fragmented and disjointed, their expectations for us will reflect that reality. It isn’t sufficient that facilities provide “orientation” for residents and families to what their rights are or what we expect out of our need to provide care for them. From the very beginning and throughout the entire time they are in our care, expectations about the every day things need to be elicited, clarified and negotiated.  The process of reweaving the fabric of meaning from a resident’s or family’s point of view will primarily take place through the process of negotiating and renegotiating expectations between themselves and with we who are the providers of their care.

The willingness to be present and to negotiate expectations is the heart of ethical behavior in our facilities. This is so because the possibility of recapturing and recreating meaning, so challenged in the lives of our residents, can only be realized in a context of genuine mutuality in relationships.

Although ethical concerns and dilemmas are frequently on the minds of health care workers, formal discussion of ethics is often felt by them to be the purview of experts (Hoffman et al., 1995). Health care workers generally are people who are “attuned” to value issues. In many care settings, however, a comprehensive and integrated view of a value base that can be applied in the daily work experience is often lacking. Ethical dilemmas arise out of problematic situations. Staffs are often faced with these situations without a shared and comprehensive understanding of a clearly articulated value base to guide them. In many settings, for example, there are no formal ethics committees and little or no staff education on ethics. In these circumstances, ethics is a predominantly reactive rather than proactive experience –  frequently confounded by concerns regarding regulatory compliance and issues of liability.

The following conceptualization was developed by the author in an effort to impart a focused and comprehensive frame that could provide an ethical backdrop for understanding the overall meaning of work in a long term care setting. These concepts represent the foundation upon which the author’s approach to orienting and training ethics committees was built.

A foundation for understanding ethics: the axiomatic triangle of values.

There are three core values that can be said to be at the root of all ethics. These are the “givens” of all ethical thinking. Two values address the innate worth of being human. The third is a process value related to how that worth is articulated and affirmed. These values are usually so assumed that most discussions of ethics rapidly proceed to a more detailed and elaborate listing of the many values which are derivative of these three. Presentations of ethics are often experienced as “tree focused” rather than “forest focused”.

The first core value is that of the intrinsic worth of each human person. The second core value is that of the intrinsic worth of all human persons.

The distinction between these two values may seem so obvious as to escape notice of their radical importance. To help visualize their power, each of these values can be seen as an opposite pole of a field; the field of human experience in which all ethical decisions are made in a manner that maintains the validity of both polarities. The earliest discussions of ethics in Plato and Aristotle, for example, struggle to define the Good for both the individual and the community. Plato’s attempts to define Virtue are elaborated in his discussions defining Justice (Allen, 1996).

The essence of all ethical enterprise can be described in terms of the field created by the polarity of these two core values.

Ethics, in this view, is defined as the attempt to articulate, through decisions in living, the meaning of human experience within this polarity, without surrendering either value for the sake of the other.

Because of the potential for perceived and actual conflict between these two values, the field created between them can experientially be characterized by both tension and ambiguity (Tillich, 1951). Approaching life within an ethical framework requires some tolerance for the validity of discomfort with difference, conflict and a certain lack of presumptive certainty. commitment  both values creates the necessary conditions for the possibility of new and integrative meanings to emerge – beyond the assumptions that create the experience of an ethical dilemma.

The third value is a process value. It addresses the means through which the perceived conflict between the first two values can be approached.

The third value is the value of compassion. Compassion is the essential characteristic of ethical thinking and behavior.

Compassion is a concept that, because of the frequency and variety of its reference, is often assumed to be understood  – but not often examined in depth. It is regularly understood in terms of specific acts of empathy or identification. The meaning of compassion, however, cannot be adequately defined in terms of a feeling or momentary act of the will.

Compassion is a stance or fundamental orientation towards being-in-the-world that is characterized by a willingness to allow one’s definition of one’s self to be placed in question by the different reality of another.

The word compassion itself is rooted in the Latin words for ”suffering with” and is usually referenced in situations where we are required to respond to the suffering of another person. However, it is not simply the suffering of another person that is to be experienced in compassion. The essential suffering in compassion is that which is incurred in the allowance of one’s self to be put into question. Taken in this sense, compassion is a value governing all human interaction where difference is experienced; not simply limited to an attitude in face of another’s suffering. Compassion is a value that, paradoxically, requires one to experience the risk of a temporary loss or question of meaning in order for the possibility of a new, more inclusive and integrative meaning to emerge out of a situation of difference or potential conflict of values.

Compassion is the value that reflects a faith in the essential meaningfulness of being human. Compassion is the gateway to being present and a ground for the flower of hope (Buber, 1958, 1965).

In addition to the stance of openness to being placed in question by another’s difference, compassion has another implicit imperative: the imperative to engage the other. To be open to another and engage describes the essential conditions for genuinely mutual dialogue.

Compassion is the condition for conversations that affirm the intrinsic meaningfulness of being human.

This triangle of values leads to an understanding of the foundation of ethics that is rooted in the imperative for genuinely mutual dialogue.  The references to presence and the need to negotiate expectations described in the metaphor of the torn fabric of meaning visually illustrate the conditions for this imperative.

Dialogue is the central operational instrument for addressing all ethical issues.

Implications for the interpersonal climate of care

A major determinant of the interpersonal climate of care within an organization is a commitment to the integrity of its values as reflected in the structure of work and service to consumers. It is here where a social work perspective on ethics can lend clarity to the inseparable link between ethics and being a person in context.

In 2000, The Institute for Ethics’ National Working Group of the American Medical Association published a White Paper, Organizational Ethics in Healthcare: Towards a Model for Ethical Decision-making by Provider Organizations (http://www.ama-assn.org/ama/upload/mm/369/organizationalethics.pdf). This paper is essential reading for anyone seriously considering the importance of ethics for healthcare organizations. After a review of a number of approaches to organizational ethics from business and the professions, it states unequivocally that an healthcare organization is a moral entity in society – in as much as healthcare provision represents an affirmation of the intrinsic worth of every person in that society.

Using the axiomatic triangle of values to further articulate the implication of an organization being a moral entity, the essential ethical mandate for a healthcare organization would be to establish a climate – through its systems, policies and standards for conduct – that promotes and maintains conditions that support genuinely mutual dialogue on all levels. Such an organization could not limit its view of itself to an organizational means to produce a product, but rather as an instrument of society to affirm the intrinsic worth of its members. As such, the climate of care would be characterized as one in which all, both staff and residents, in the organization have opportunities to realize genuine experiences of participation.

From the standpoint of ethics, a healthcare organization needs to see itself more as a community than simply an arena for professional practice or a business.

It would be totally unrealistic to expect healthcare workers to relate to residents in the compassionate manner outlined above, without the support of a community that demonstrates its commitment to that value by how it conducts its business on all levels.

The creation of an ethical climate of care requires minimally:

1. A structure and formal program of enculturation and education of all levels of staff, as well as residents and families, that clearly identifies the mission of the facility in terms of the ethical values outlined above.
2. A conscious planning and creation of opportunities through the structuring of life and work in the facility that provide genuine experiences of participation in the community.
3. A planned program of staff development and education that supports a basic understanding of ethics and the skills necessary to engage in genuine dialogue. Basic listening and communication skills as well as the understanding of cultural and other significant differences are essential competences that an ethical healthcare organization must actively promote and support. For example,  Promises to Keep: Creating an Ethical Culture for Long-Term Care (Mathes et al., 2005), is a model ethics education program for staff in long term care facilities developed by the Center for Advocacy for the Rights and Interests of the Elderly (CARIE;  www.carie.org/pages/ethics.php ).
4. The establishment of an ethics committee that would be responsible to maintain awareness, training and promote motivation for the organization to remain faithful to its ethical understanding of itself and its commitments.
5. A commitment of the organization to see itself within its local, state and national community as a voice for the affirmation of society’s commitment to the intrinsic value of each and all of its members.

Within an ethically informed structure of work in a long term care facility, the experience of the residents and their families with the treatment team is of primary importance. Every aspect of the assessment and treatment process needs to be enacted within an ethical climate of care as outlined above.

In focusing on the professional-resident interaction (including family and significant others), the instrumental aspects of this relationship are ethical by virtue of the quality of the relationship within which they are implemented. Assessment, diagnosis and all treatment planning decisions depend upon the quality of the professional-resident relationship not only for their ethical value but for their efficacy. All aspects of the environment and interactions are in the service of providing the possibility for the reaffirmation and reconstruction of the meaning of lives that have been severely challenged by the events leading to eventual placement in a nursing facility. Neglect of this perspective on professional-resident interaction leads to results that can only be experienced as an assault by people in such a vulnerable state (Laird, 1979; Tulloch, 1975).

The predominant concern of relationship interactions that honor this value is to be committed to make the effort to understand what things mean before any intervention. The process of inquiry into understanding the meaning of events for all concerned is the heart of all ethical behavior. Under the pressure of work, conflict or need for resolutions, decisions and outcomes are too often rushed. Time needs to be taken to understand what the issues are and what are the meanings and values motivating the participants.

An ethical process of inquiry will be the most reliable guarantee of an ethical decision or outcome in any circumstance.

Every interaction with a resident is an occasion for behavior guided by ethics. The issues traditionally addressed in a discussion of ethics and professional behavior with residents, such as dignity and respect, informed consent, autonomy, justice etc., must be understood as opportunities for genuine and mutual dialogue around every aspect of interaction with them.

An essential aspect of creating this possibility is the imperative for all who interact with residents and their families to inquire into and respect the significance of each resident’s story and life prior to placement (Mathes et al., 2005). There can be no bridging the gap between what life once meant and what it could possibly mean under these new and dramatically altered circumstances without understanding what the story of each resident means to them.

It is important, also, to consider the significance of ethics at the root of the meaning of all professions in health care (Donnelly, 1992).

One can see that the very existence of each of the professions evolved out of circumstances in society that were disruptive to personal and communal meaning. The mandate to face this challenge to our sense of meaning forces us on an individual and communal level to rediscover and reaffirm the intrinsic value and meaningfulness of each and all human beings. This challenge helps us understand the creation and evolution of all of our professions as structures in society that are its expression of ethical commitment. That reality carries with it an ethical imperative for collaboration between the professions in any health care setting.  When the interests and concerns of a discipline within an organization take precedence over this fundamental commitment of a profession, the ethical climate of healing is placed at risk.

Chronic pain and the issues of end of life in long term care

The caprice of life as experienced by accident, illness and death is for many the ultimate challenge to a sense of meaning.  Compassion as outlined above may be most frequently visualized in terms of being with those who are facing the dying process. There is in our society, however, a strong trend towards the denial of the reality of death as a valid aspect of human meaning. These contra-values in all of our experience can, and often do, influence how death is approached by staff, families and residents within our facilities as well. They foster a sense of strangeness and distance from the realities of death, disability and illness. These realities are split off from what it means to be human.

Residents, families and direct care staff, professional and non professional, are daily exposed to this challenge. There is an ethical imperative that there be, in the ongoing operation of the facility, structures that support residents and staff in facing the cumulative effect of this exposure (Weingarten, 2003). This particularly is the case in long term care, where time permits staff and residents to bond in significant relationships. There is a continuous exposure to loss for those who work in health care. The residents and their families, as well, are also over exposed to this reality on a daily basis. Opportunities for communal expressions of grief and mourning, as well as for individual support, are an essential aspect of the application of ethical thinking in long term care.

How these issues are addressed from the very entrance into long term care is ethically important. Discussions about advance directives, consents for treatment, decisions for hospitalization, etc., all present opportunities for residents to be listened to regarding their values and attitudes towards their illness and mortality. Family members also need to experience a level of comfort to discuss these difficult issues with each other as well as with staff. Procedures and policies that address the active identification of residents who are entering into the last stages of life need to be in place. There is an ethical mandate to actively assist families, residents and staff to face this reality.

Decisions around special interventions to discontinue or refuse available treatments have been the traditional focus of medical ethics. The importance of these issues cannot be minimized. It is stressed, however, in this current frame that these issues can only be faced in a wounded manner if there has not been sufficient attention paid to the broader ethical issues of community and commitment to dialogue at every phase of a resident’s life in a facility.

Essential to an ethical stance towards end of life issues is the imperative to relieve pain and suffering. Again, this calls for a proactive rather than reactive stance towards this issue. It also calls for a broad view of what constitutes pain. There is in our facilities the potential for a great deal of silent pain; pain that is emotional, physical and, frequently, unable to be expressed.

Evidences of pain, loss and mourning must be actively sought after and addressed.

The paradox of a compassion centered ethic for leadership in health care.

A proactive stance towards ethics in long term care requires a conscious and planned effort at the creation of a realized sense of community among all who live and work in a health care facility. To the extent that this is lacking, the healing climate required to assist our residents to face the real challenges of this phase of their lives will be wounded. Effective, quality care is synonymous with ethical care. To split the two is to risk experiencing the provision of health care as an assault to the intrinsic worth of the persons in our care.

The manner in which people who make up all the various systems in a health care organization conduct themselves can dramatically impact on the ethical climate of care. As stated above, the most powerful ethical climate of care would be characterized by an organization that sees itself as a community more than a business or arena for professional practice. It would be a climate in which the primary modus vivendi is marked by a strong sense of participation; and where the various disparate and potentially conflicting expectations that are the life of any organization are dealt with in a spirit and practice of genuinely mutual dialogue. In such a climate, on both a micro and macro level, there would be an unequivocal commitment to strive to understand what things mean to all participants and stakeholders before decisions are made and actions taken.

Given the forces impacting on today’s health care environments, such a vision of ethics may seem utopian. There is a paradox at the center of this formulation of ethics which is both its strength and its weakness.

Compassion and dialogue, for all their value, cannot be mandated. Behaviors can, possibly, be mandated – but even that is questionable. Compassion and dialogue can be modeled, demonstrated; maybe taught in the Latin root sense of education …e ducare, to lead out of.  This paradox identifies the most crucial element and any aspect of leadership in health care. The primary quality of a genuine and effective leader in a health care setting is the capacity to demonstrate the realities of compassion and dialogue in all venues of operation within the facility. Compassion cannot be reserved only for the special moments of staff, resident or patient need. To strive towards this value and to demonstrate it in all of one’s interactions is the hallmark of leadership within which any management efforts will be effective in the promotion of an ethical and healing environment.

There is no more fertile ground for the demonstration of compassion and mutual dialogue than the management systems of a health care facility. These systems are the arena in which virtually all the disparate and potentially conflicting expectations in the operational life of an organization are experienced. The manner in which the managers broker these expectations is probably one of the most powerful determinants of the ethical climate of care. In this view of organizational ethics, the manager’s role carries a unique ethical imperative relative to its pivotal position in the life of the organization.

.For the management sub system to become an instrument of an ethical climate of care, a number of actualities within that sub system would need to be developed and realized.

1. A shared awareness of and commitment to the values of compassion and dialogue as central to an understanding of the management role and its importance for the reality of organizational ethics.
2. A proactive stance towards collaboration with other managers in the system that transcends the focus department and of immediate projects; an understanding of collaboration as an ethical imperative.
3. Mutual strategic and emotional support of the courage required in addressing difficult situations.
4. A conscious use of available venues such as task forces, committee meetings, staff meetings etc. for the demonstration of compassion and dialogue in action.
5. A commitment to clearly articulate an ethical perspective for staff and residents in user friendly terms.

For social work and the other professions, the assumption of a management role should be identical with a commitment to ethical leadership in the organization as well as leadership in the art of one’s practice. With such an understanding, a commitment to collaboration on all levels is not simply a facet of effective practice but an essential component of the ethics of the manager’s role.

Leadership in health care is here defined essentially as the demonstration of compassion and dialogue.

Whatever the formal commitments to organizational ethics made by the board and senior management, either by proclamation or the establishment of a structure such as an organizational ethics committee, the level of establishment of an actual ethical climate of care will be largely reflective of the understanding and commitment of the management sub system to its role as an ethical leaven in the daily life of a health care organization.

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© 2014  James Donnelly, DSW.LCSW

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South Garden Press, New York

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