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PAID in their People Acknowledging Acknowledging Boston, MA Choices Vaccine Permit No. 58183 Understanding and MSW and Elspeth Slayter, MSW and Elspeth Slayter, Lamont D. Simmons, EdD, EdD, Simmons, D. Lamont History Support as we Virtual Annual Earn 5.5 CEUs! , Director of Diversity, Equity, and Equity, of Diversity, , Director Inclusion, Newton Public Schools Inclusion, Public Newton P. 17 P. SAVE THE DATE: October 8, 2021 THE DATE: SAVE 1.5 CEU! Uma Naidoo, MD Uma Naidoo, Mental Health Details and registration coming soon: naswma.org coming Details and registration Kathy Lopes, LICSW Lopes, Kathy This is Your Brain Brain Your is This School Social Work Conference Work School Social Keynote: Antiracist Practice Principles for School Social Workers School Social for Principles Practice Antiracist Keynote: Impacts Mood and on Food: How Food Food How on Food: You Are You Inside: Wherever Wherever Your Own Your Time, From Social Work Earn On CEUs P. 9 Post Traumatic Traumatic Post Practice 1.5 CEUs! CE InstituteCE Intersectionality, Intersectionality, Rose Singh, MSW, and Rose Singh, MSW, Lisa Johnson, PhD, MSW, MSW, Lisa Johnson, PhD, Connecting Critical and Anti-oppressive and Anti-oppressive Elspeth Slayter, PhD, MSW PhD, Elspeth Slayter, Cultural Competence, Competence, Cultural Disability Social Work: 5.5 CEUs in your hand! in your CEUs 5.5 , author of “ , author of Virtual Earn 2 CEUs! and Healing” Upcoming Virtual Continuing Education Offerings: Education Virtual Continuing Upcoming FOCUS continuing education courses education FOCUS continuing P. 2

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with The IntersectionsThe of Historical Mass Karen Zilberstein, LICSW Karen Zilberstein, Accessible ServicesAccessible for Diverse Families Diverse for The System is Down: is Down: System The 2 2021 Social Work CE Institute – FOCUS Continuing Education Courses

YOU ARE HOLDING 1.5 CEUs IN YOUR HAND! How it works: Read this CE program, complete the Post-Test and Evaluation, and mail to the Chapter office with your check. Score 80% or better and NASW will mail you a certificate for your CEUs. It is that easy! The System is Down: Creating More Accessible Services for Diverse Families

Karen Zilberstein, LICSW

additional funding to grant them. On the one hand, the Learning Objectives Fragmented and Underfunded Systems system allows states to try and meet local needs. On the other, no incentives exist to meet those needs, making At the completion of this program, participants should service quality and availability vary widely from be able to: American families struggle with a variety of needs that propel them to enlist different types of services. One in state to state or even between counties. Other sources of revenue, such as reimbursements from insurance 1. Describe the obstacles families face in obtaining six American children live in poverty, out of which 73 companies, also influence the availability of services. care. percent are children of color (Children’s Defense Fund, 2020). One in six American youth are diagnosed with Starting in 1975, a series of laws mandating educational 2. Identify ways social workers and a developmental disability, and one in five will suffer equality for children with disabilities were passed, but psychotherapists can ease burdens on families. a debilitating mental disorder at some point (Boyle et sufficient resources were also not allocated to funding al., 2011; Merikangas et al., 2010). Approximately 70 3. Consider what structural reforms are needed to them. In 2016, grants appropriated by Congress covered percent of American adults have experienced a traumatic alleviate current problems. less than 10 percent of what states spend on specialized event and just under 20 percent develop posttraumatic education (Chingos, 2017). The remaining monies stress disorder (Kessler et al., 1995). Thirty-eight come from a combination of state and local taxes. As a percent of Americans identify as racial minorities, About the Author consequence, considerable disparities in education also many of whom suffer negative health effects from exist within and across cities and states, with wealthier experiencing racism (Comas-Diaz, 2016). Dislocation, Karen Zilberstein, LICSW, school districts generating more financing and resources substance abuse, violent communities, incarceration, as is a psychotherapist and to meet students’ needs than poorer ones. Clinical Director of the well as many other hardships also impact families, with Northampton, Massachusetts many suffering multiple adversities. When children and The end result of limited and decentralized funding is an chapter of A Home Within. families have numerous needs, their situations become uneven, disorganized, and inadequate system for serving A former Adjunct Professor more complex and service delivery trickier. Despite a children with mental health problems and disabilities. for 12 years at Smith College high need for services, many families find it difficult Demand for services far outstrip supply (Anderson et School for Social Work, she to access the supports and services that would benefit al., 2017; Marshall et al., 2017). Schools and mental has published numerous them. health agencies often struggle to fully meet the needs of journal articles on various the clientele they serve. As one director of an outpatient Underlying the difficulties with service access and aspects of psychotherapy mental health agency explains, delivery lie a variety of difficulties that vary with the and mental health care. Her types of policies and funding that govern the various We have data about the ages, socioeconomics, and narrative nonfiction book, programs. Some systems are disorganized because diagnoses of our clients, and we look at it to help Parents Under Pressure: they grew in a haphazard way (e.g., the mental health determine what services to provide. But it is hard to Struggling to Raise Children in an Unequal America, system), others have been purposefully structured start up new programs or treatments. A lot is guided was released in 2019 and won two 2019 Next in complex ways to keep rolls small (for instance, by reimbursement. If the insurance companies won’t Generation Indie Book Awards. The book examines Medicaid and welfare benefits), and still others have pay it, we can’t afford to do it. We eat some costs how well America’s systems of care supports families simply never been allocated sufficient funding to fulfill and do things, anyway. But all our outpatient clinics and what reforms are needed. their mandates (school districts). Across the service lose money. There is very little other funding besides Email: [email protected] sector, limited funding for programs, siloed agencies, insurance. Insurance drives policy and services. and strict requirements for gaining services has led (Zilberstein, 2019, p. 35) Website: https://karenzilberstein.info/ to a lack of integration and accessibility. Looking at examples from the mental health system, Medicaid, When programs must rely upon rigid and inadequate welfare, and schools demonstrates the difficulties streams of funding, it limits how many families can involved. be helped, and in what ways. In order to stay within Introduction budget, programs or states must cut services, install From its inception, the mental health system has never stricter eligibility restrictions, or keep waiting lists Note: The material in this course was first developed been well organized, creating difficulties that have (Center on Budget and Policy Priorities, undated). As a by the author in her book, Parents Under Pressure: yet to be remedied. In previous centuries, individuals service coordinator for DDS notes, Struggling to Raise Children in an Unequal America with psychiatric difficulties or disabilities were either (Zilberstein, 2019), and draws frequently on examples All these resources are limited. Just think about cared for by family members or placed in schools and from that work. numbers. There is only so much availability. So, institutions that were of poor quality and sometimes often, we rely on families reaching out to us. Social work aims to enhance the lives of the most downright abusive. Residents experienced sexual abuse, Families are not always offered services because vulnerable, but how well does the profession achieve unsanitary conditions, and were made to work without we can’t fund everyone and everything. Sometimes its goals? Despite the many services and benefits pay. In the 1970s, a series of lawsuits by parents and we don’t share information, if we feel that the family provided to individuals, families, and communities, the advocates against those schools and facilities, as well as won’t qualify for, or be prioritized for, that service. service sector remains difficult for many consumers to the arrival of new drugs that could control psychiatric That’s hard for us, as professionals. The answer is access. It consists of what Blum (2015) terms “dense symptoms, forced the dismantling of the offending more funding across the human services systems. bureaucracies,” fragmented and underfunded systems institutions. The resulting deinstutionalization helped There’s just not enough. (Zilberstein, 2019, p. 34) that cannot meet current needs. Biases and barriers are fuel new service systems that aimed to provide care in particularly stark in poor communities of color, boxing homes, schools, and the community. Another consequence is that many types of services them out of needed benefits. In order to improve the that families might need cannot be delivered. As the While the new arrangement created a range of delivery of services, the field must make a coordinated outpatient director notes, effort to recognize obstacles and initiate reforms. specialized school and community services that greatly benefit families, community care organizations We see families with intensive needs. They need a lot This course provides an overview of some of the never received enough funding or attention to fully more support. In-home therapy is great, and I value difficulties inherent in the current service system meet needs. In 1963, President Kennedy signed the what they do, but families sometimes need basic and what can be done to address them. Areas to be Community Mental Health Act to finance community- things. Like they could use someone in there who considered include the structure of services, the biases based treatment facilities, but adequate resources were could be a parent advocate, or a nurse, or a PCA, and hurdles they present, the impact on families, never allocated. In 1980, President Carter signed the or just help them go food shopping. Basic needs. But workers, and the social work profession, and the cultural Mental Health Systems Act, hoping to restructure their difficulties need to be very severe to get that and socio-political factors and beliefs that undergird and improve the sector. Soon after, President Reagan kind of help. (Zilberstein, 2019, p. 36) current theories and practices. While this course looks repealed the legislation, instead funding mental health particularly at the struggles of families raising children services through block grants to states. Unfortunately, Rigid streams of funding also tend to result in siloed, with disabilities or mental health difficulties, or who block grants tend to lead to fixed funding levels that rather than integrated services. Mental health care are involved in the child welfare system, the issues and are not necessarily adjusted to inflation or increased can be accessed in different ways through community solutions discussed are similar and relevant to how need, forcing their value to erode over time (Center on mental health centers, private practitioners, schools, services are provided to other consumer populations. Budget and Policy Priorities, undated). Block grants the juvenile justice system, and other entities. A lack also do not mandate a certain level or type of service of coordination and integration of services amongst delivery. States thus retain significant decision-making agencies complicates the delivery of services and makes power over their mental health systems and how much it difficult to cover adequately the span of families’ 2021 Social Work CE Institute – FOCUS Continuing Education Courses 3 needs. In the words of the outpatient director, Racial Bias in Service Delivery high proportion tend to be impoverished (IOM & NRC, 2014). Despite the system’s emphasis on counseling and In the mental health field, there is no system for The pandemic and Black Lives Matter movement have education, extensive evidence suggests that when poverty coordination amongst agencies to ensure that all made it patently clear how structural inequities impact and parental stress decline, children’s outcomes improve needs and specialties are covered. We can coordinate politics, policing, and health, but inequalities and racial and their risk of experiencing maltreatment diminishes. well within our agency, but outside is harder. We don’t biases also exist in social service delivery systems. States In studies, increasing concrete services (funds for always know what other agencies are doing or where with some of the strictest rules and least generous welfare housing, utility bills, and other financial assistance) to send people for problems we don’t cover. And programs are those with larger shares of black residents predicts decreased maltreatment (Cancian et al., 2013; because there is little integration across agencies, (Mettler, 2018; Sohn, 2017). Negative stereotypes of Pelton, 2015). Moving a family to a better neighborhood there are lots of gaps in services or a family could be those who game the system, such as “welfare queens,” or school also results in improved outcomes (Chetty et getting services from different places, which can be recipients from the “inner city,” or immigrants coming al., 2016). Unfortunately, such interventions are rarely difficult for them. (Zilberstein, 2019, pp. 33- 34) from other countries, which are used to argue for limiting available in today’s service environment. As a supervisor While some parts of the service sector are difficult to benefits, tend to evoke racialized images. Disparities with the Department of Children and Families in San navigate because they evolved in a haphazard way, other are also rampant in the mental health, school, and child Francisco notes, welfare services. benefits have at times been made purposively hard to As a worker, there aren’t ever enough resources, so discourage usage. When Arizona faced budget problems Biases and inequities limit the accessibility of mental you are always making these very tough decisions, in 2009, it cut welfare benefits, shortened time limits, and health services for residents of color. Across the country, because you can’t really do as much as you want. We imposed numerous eligibility restrictions for receiving communities with high proportions of people of color are can’t actually get someone a house, but we can afford aid. As a consequence, Arizona’s Temporary Assistance more likely to be situated in mental health deserts lacking to get them therapy to adjust to the idea of not having for Needy Families (TANF) caseload declined nearly high quality care (Alegria, 2010; Snowden, 2012). a house. So that’s what you get. (Zilberstein, 2019, p. 80 percent between 2006 and 2017 (Floyd et al., 2018). Compared to whites, families of color are also more 53) In 2011, Kansas implemented stricter sanctions on likely to lack or lose health insurance, which restricts As a consequence, poor families and families of color those not meeting welfare work requirements, causing their access to mental health services (Sohn, 2017). In a can find themselves caught in cycles of disadvantage. many families to lose assistance. Four years later, study on mental health access (Kugelmass, 2016), callers approximately 70 percent of those families remained identifiable by voice as black or white and middle or Parents of color can also experience microagressions in deep poverty because they could not find steady working class requested appointments via voicemail from that deter them from participating in many different employment that paid sufficiently (Floyd et al., 2018). 320 psychotherapists in New York City. White middle types of services. Microaggressions are “unconsciously For low-income parents, even small additional costs class help seekers received the most callbacks and were delivered … subtle snubs or dismissive looks, gestures, in obtaining aid can prove prohibitive and cut down the most likely to be offered consultations. and tones.…[that] impair performance … by sapping on usage. One researcher found that a $10 Medicaid the psychic and spiritual energy of recipients and by Even when mental health services are available, clients premium increase in Wisconsin led to 12 – 15 percent of creating inequities” (Sue et al., 2007, p. 273). When from nonwhite ethnic groups are less likely to begin or enrollees exiting the program (Dague, 2012). Posey-Maddox (2017) studied black families living in a remain in treatment (Alegria et al., 2010), despite higher predominantly white Wisconsin suburb, only two of the exposure to racism, trauma, and other adversities that Many parents find applying for services or renewing fifty-six parents in the study recounted no episodes of are known contributors to emotional difficulties (Comas- benefits difficult, and low-income families can find racial bias in their interactions with the school system. Diaz, 2016; Snowden, 2012). Whereas a high proportion the hurdles particularly steep. A Morning Consult Families described receiving stares and comments about of distressed European Americans engage mental health national tracking poll (January 04-08, 2020) of 4400 how they looked, found their perspectives overlooked, services, fewer than a third of African, Latinx, and Asian adults in the general population found that 27 percent were assumed to be poor, urban, and not involved with Americans do so (Lopez et al., 2012; Sue et al., 2012). of respondents said they would find it difficult to shift their children’s education, and viewed as threatening their work schedule to attend a non-work meeting, 25 and criminal. Many felt discouraged from participating percent had received a government document they did Because the child welfare system tends to in school activities, which inadvertently reinforced not understand, and 31 percent had forgotten to pay focus its interventions on parenting education stereotypical beliefs. “The narrative,” said a black mother a bill on time. Fifteen to 20 percent said they would and counseling, rather than addressing in another study, “is you people don’t care. You people have difficulty finding a needed document and nine aren’t good parents. You are not involved enough in your percent reported losing a government benefit because poverty, the system tends to perpetuate children’s lives” (Zilberstein, 2019, p. 131). of paperwork errors. High administrative and research structural inequities, especially amongst demands, as well as the need to visit distant offices Blum’s (2015) study of mothers with children with families of color who are disproportionality disabilities similarly found a difference in how white, and sometimes wait in long lines proves especially poor. daunting for families or individuals who lack stable work middle class families versus families that were low- schedules, reliable transportation, bank accounts, or income or of color experienced the service sector. White, internet access. Throw in the need to apply for multiple middle class mothers faced stigma and isolation from their communities, whereas poorer families and those types of benefits--welfare, housing subsidies, specialized Race-based biases also impact what services are from racial minorities experienced more communal equipment or aid for a family member with a disability, delivered and how. Cultured views of how emotions acceptance but greater professional judgment. School or other services--and it is easy to see how a family can should be expressed and handled limits accurate personnel and psychiatric professionals blamed mothers get overwhelmed by applications and paperwork. diagnosis (Alegria et al., 2010). Often the distress of of color and those who were low-income for not doing Asian Americans is overlooked (Sue et al., 2012), while enough to help their special needs children. Professionals For parents of children with disabilities or behavioral Black and Latinx youth tend to be over-diagnosed with were also more likely to report marginalized families to difficulties who may also need to obtain services from conduct disorders for the same difficulties for which their the child welfare system, where they faced surveillance a multitude of other sources--psychiatry, schools, white peers receive diagnoses of ADHD or depression and sometimes lost custody of their children. outpatient mental health, occupational or speech therapy, (Baglivio et al., 2017). As a consequence, black youth the Department of Social Services (DSS), the Department are more likely to get diverted into punitive rather than As with other types of adversities, experiencing of Mental Health (DMH), or welfare and housing, ameliorative interventions. In school assessments, microaggressions and discrimination serve as risk factors amongst others-- navigating a decentralized and siloed black students more often than whites receive labels of for poorer physical and mental health (Comas-Diaz, service sector can be complex and time consuming. As a Emotionally Disturbed (ED), a designation denoting 2016; Sue et al., 2012). The cumulative toll of repeated service coordinator for DDS notes, behavioral problems, rather than Learning Disabled exposures to racial bias can be severe. As one parent For this, you’ve got to apply in this avenue, and (LD), which focuses on intellectual needs, again explains, apply here, and apply here. As opposed to, ‘Here are impacting the types of services they receive (Mandell et At no point, could we relax our gaze or warrior all your needs.’ A lot of what DDS does is to help al., 2008). stance. If you are to remain truly aware and own families navigate the system, assist them with getting In the child welfare system, similar types of how difficult this is, you can literally feel the pain in applications, and letting them know about different disproportionality exist that negatively affect families your body. The tension, the headaches, the sleepless opportunities, but it’s still a complicated process. Who and communities of color. Black and Native American nights. The tightening at the base of your belly. Fear. is funding what, and providing what, is confusing for children are overrepresented at all points along the child Uncertainty. Lack of confidence. The realization that families. (Zilberstein, 2019, p. 33) welfare continuum: from black and Native American your presence is not wanted (Zilberstein, 2019, p. families being reported and investigated for abuse and 132). The amount of research, time required to submit neglect, to being placed out-of-home more often, and to applications, and ongoing need to coordinate with Too often experiences of race-based trauma and experiencing longer stays in foster care (Barbarin, 2020; numerous providers takes a toll. Studies indicate that structural inequities are overlooked in the delivery of Pryce et al., 2019; Summers, 2015). In 2014, thirty-two families of children with special needs find managing services (Comas-Diaz, 2016) Microaggressions and signs percent of children in foster care were black, compared the service sector arduous (Blum, 2015; Marshall et al., of racial trauma often go unrecognized by practitioners to their rates in the general child population of only 16 2017; Zilberstein, 2019). Time lags between referrals and, even when acknowledged, may not be adequately percent (Summers, 2015). Underpinning these inequities and receipt of services, understanding eligibility addressed or rectified. are professional biases in decision-making, higher requirements, miscommunications, misunderstandings, rates of economic disadvantage and structural racism and the requirement to meet with and coordinate leading to increased scrutiny of minority populations, numerous different providers and satisfy their demands Cultural Attitudes Underlying systemic biases towards punitive rather than ameliorative for information and paperwork are amongst the reasons interventions, and a dearth of culturally competent Problems with the Service Sector given. As one parent described, “My husband has services. dyslexia. When we went to IEP meetings, they started Part of the reason America has never established an throwing out all of these terms and scores, and he felt Because the child welfare system tends to focus its organized, unbiased, and robust service sector derives like his head would explode.” (Zilberstein, 2019, p. 174) interventions on parenting education and counseling, from deeply rooted cultural ideologies that influence rather than addressing poverty, the system tends to socio-political trends and institutions of helping. An perpetuate structural inequities, especially amongst underclass of poor workers and indentured servants families of color who are disproportionality poor have labored on America’s soil since its founding and

(Duva & Metzger, 2010). Most families enter the child THE SYSTEM IS DOWN welfare system because of neglect, not abuse, and a CONTINUED ON PAGE 4 4 2021 Social Work CE Institute – FOCUS Continuing Education Courses have never been granted much means for upward inequities ends up burdening those with the least Every day. (Medical ethicist quoted in Zilberstein, mobility (Isenberg, 2016). Discrimination against resources and highest hurdles. It asks the most 2019, p.36) non-white residents began with the taking of Native vulnerable to cope the most. Exaggerated responsibility American lands, the institutionalization of over two for individual wellbeing requires families to manage hundred years of slavery, and subsequent laws that environmental risks, while leaving government and The Impact of Neoliberal Beliefs on discriminated against blacks in housing, education, civic institutions with little to no accountability for Social Work labor, law, and other domains. Despite policies that providing needed supports. The end result is inadequate clearly disadvantage certain segments of the population, interventions that do not address root causes and that Neoliberal beliefs have also impacted the structure of American ideals of equality, opportunity, and the ability increase inequality. As Linda Blum notes, social work training and how social work interventions to persevere and overcome all odds remain (Isenberg, Many causes of ill health and health inequality in are delivered. Despite social work’s origins that 2016). In fact, Americans tend to prioritize individual the United States are because of large, political, emphasized community supports and environmental liberty and self-reliance more than their European institutional causes, not personal ones. Our lack of change, the field has increasingly turned towards counterparts, who place a higher value on state enforcing the Clean Water Act, or the Clean Air Act. micro interventions aimed at helping individuals. In intervention to ensure no one is in need (Pew Research Racism. Poverty. Where people have to live because 2017, 92 percent of MSW graduates reported working Center, 2015). The differing attitudes can be traced they can’t afford housing. Parents having to work, directly with individuals, families, or groups rather into divergent policies in which the supports America be in school. Or with health issues of their own. than with communities or in public policy, advocacy, or offers families are stingier and harder to access than in Kids or family members with needs. The emphasis administration, up from 85 percent just two years earlier other wealthy nations, with the gap growing larger in on personal responsibility and health maximization (Mattocks, 2018; Salsberg et al., 2018). While direct the last half century (Edin & Shaefer, 2016; Lindhert & ignores the entire social environment. (quoted in service provides many benefits, other important needs, Williamson, 2016). Zilberstein, 2019, p. 185) as will be discussed, can only be achieved through While after the devastation of the Great Depression community investments and policy reforms. (1929 – 1933), the government showed greater interest Changes in the profession also extend to the workplace, in providing citizens a safety net, the twin emphases of The Impact of Neoliberal Beliefs on where higher demands, funding limitations, and individuality and resilience have increased in American Families policy mandates restrict what service providers can discourse over the last 50 years, along with economic accomplish. Neoliberal ideas favoring efficiency, cost policies favoring the free market and private sector over Neoliberal ideals about individualism and resiliency saving, and productivity have led to low pay and high government programs. The Social Security Act of 1935 have also drifted into family domains, affecting caseloads, leaving little time for essential thought, established a safety net that grew to aid many people, parenting practices. Over the centuries and decades, learning, supervision, coordination, or going the extra including the elderly, unemployed, poor, individuals parenting in America has become increasingly child- yard (Epstein, 2019; Garrett, 2016). Stressful working with disabilities, and veterans. Public benefits peaked centered and focused on methods that promote conditions and stagnant wages generate high turnover, in the 1970s, after which a stalling American economy autonomy and achievement in children, traits favored which also hamper the ability to nurture a stable, expert, led to changed political attitudes towards government in neoliberal societies and high-income job markets and effective workforce (Beidas et al., 2016; Edwards help. By the 1980s, neoliberal philosophies became (Deming, 2015; Greenfield, 2016). Child-focused & Wildeman, 2018). The quality of services suffers prominent and promoted the idea that success derived parenting favors affective parent-child interactions, when social workers are expected to meet the needs of from individual choice and effort, rather than social or discipline through reasoning and explanation, providing families facing complex and precarious circumstances public benefit. choices, supporting child assertiveness, and providing with too little time or resources (Epstein, 2019). The opportunities to learn and practice a wide range of ability to institute innovative and more effective Most psychotherapists do not have sufficient cognitive and social skills. More active involvement programs is handicapped. of parents is required in this type of parenting than has training in advocacy and other forms of typically occurred in other cultures or historical eras As the social work field turns increasingly towards intervention that could be used to help (Quinn & Mageo, 2013). In fact, it does not reflect direct care and work with individuals and families, clients gain the material and environmental parenting styles or family structures seen in most parts an increasing number of social workers provide supports they need. of the world, or even within different populations within psychotherapeutic services. Although psychotherapy the United States, earning it the designation WEIRD is currently in great demand and can be quite helpful, (western, educated, industrialized, rich, and democratic) it, too, tends to have an individual focus, limiting its by a group of psychologists (Henrich et al., 2010). Time, use. Most contemporary psychotherapeutic theories President Reagan popularized the term “welfare queen” knowledge, and resources are also needed for its full and interventions center on how individuals make during his 1976 presidential campaign as he strove implementation. For parents of special needs children, sense of, adapt to, or overcome their circumstances to undermine support for public programs. Under the pressure can lead to herculean efforts to do more and and experiences through learning new skills, redefining his administration, the social safety net underwent more: meaning, or forming stronger connections to and gaining support from a therapist, parent, partner, or steep cuts as fiscal policies favored corporations over What is striking is how relentless it was, how group (Holmes, 2017; Masten, 2018; Zilberstein, 2019). workers. Programs designed to help the poor, such as many different sources of expertise they sought. Although some therapists incorporate spirituality, direct Food Stamps, welfare, Medicaid, education aid, energy The mothers might find someone who is helpful, help, civic action, and referrals to community resources assistance, training, and employment, absorbed the but they couldn’t stop, they had to keep going, had into their practices, in general, less consideration is biggest hits, while priorities benefitting the middle class to keep thinking there is probably more, another given to what broader resources could be leveraged remained stable. Reduced spending for social supports piece, another kind of specialist, or a more accurate to resolve problems. Most psychotherapists do not disproportionately affected single mothers, blacks, and diagnosis. They continually wondered, ‘Is there more have sufficient training in advocacy and other forms low-income families and helped fuel burgeoning income I could be doing? Is there something I am missing?’ of intervention that could be used to help clients gain inequality and other indicators of social inequity (Floyd (Blum quoted in Zilberstein, 2019, p.31) et al., 2018). the material and environmental supports they need (Goodman et al., 2020; Zilberstein & Popper, 2016). Yet Alongside neoliberal cultural values and fiscal policies As a consequence of these expectations and efforts, when social workers and psychotherapists provide direct that emphasized individual responsibility for coping mothers of children with disabilities are two to three support, it not only helps clients achieve goals, but and success, interest in resiliency spiked. For the first times as likely to suffer anxiety, depression, and stress strengthens the working relationship and enables further part of the 20th century, social science research focused than parents of typical children (Tint & Weiss, 2016). collaboration (Goodman et al., 2020). on how to ameliorate risk, but in later decades, a shift Over a quarter of parents report that they need to stop working or cut back hours to care for a child’s special towards resilience occurred (Garrett, 2016; Masten, Individually oriented interventions such as needs and almost as many disclose that their child’s 2018). In 1980, the PsycInfo database logs over 33,000 psychotherapy may also be best matched to clients health conditions create financial problems (The articles with key words “resilience,” “resiliency,” or from western societies that emphasize individuation. 2009/10 National Survey of Children with Special “resilient,” compared with only 86 between 1900 and For many cultures, healing does not occur in the private Health Care Needs). Families with fewer resources 1980. Increasingly, researchers and professionals have offices of practitioners but in spiritual and communal find the toll even higher. Faced with challenging child also sought to insert resilience building strategies into realms. Fellowship and the collective expression of behaviors, one in three families with substantial social psychotherapeutic and parenting interventions (Forbes emotion through prayer, singing, and praise assume supports and financial security fare well, while in & Fikretoglu, 2018; Holmes, 2017; Masten, 2018). After therapeutic functions in the Black church (Dempsey et families without sufficient income and adequate social all, when help and support are scarce, and families must al., 2016). Connection to and harmony with the land supports only 1 in 100 report a high quality of life depend on themselves, resilience becomes a highly and cosmology bestow comfort and resilience to the (McConnell et al., 2014). Unfortunately, the current sought-after trait. Inuit people of the Canadian Arctic (Kirmayer et al., social service sector is not adequately denting the 2011). In Japan, Naikan counseling methods direct While resiliency can help individuals and families burdens of many families or providing all the types of clients to meditate on their indebtedness to others for overcome hardship, the concept also contains services they need. As those who work in or study the help and seek care in order to reduce self-indulgence limitations. Studies suggest that an over emphasis field note, on individual resilience, rather than on aspects of (Koc & Kafa, 2019). Although communal resources community and policies that confer security, is No matter how much support a family is getting, and interventions can boost families’ well-being and misguided. In a study of disadvantaged, rural black there is still a lot 24/7 that they have to deal with. resiliency, insurance and other forms of reimbursement youth’s psychosocial adjustment, researchers found It’s life-long. Sometimes I think what families need rarely allow for them to be used as interventions. that youngsters high in self-control and competence, is respite support, someone to provide childcare who showed social-emotional resiliency, also who is knowledgeable about their child and can let exhibited substantial markers of poor metabolic health them take care of other things and themselves. (DDS Solutions and premature aging (Brody et al., 2013; Miller et worker quoted in Zilberstein, 2019, p. 36) al., 2015). The effort required to beat the odds by Reimaging social work and the service sector will Real help would be having someone say, ‘How persevering through poor schools, rampant poverty, and require changes in numerous tiers: from how providers can I help you today and tomorrow and every day, discrimination inflicted a cost. work with clients, to institutional changes, to broader physically help you? Can I sit with your child so policy initiatives and the changing of cultural norms. The practice of holding individuals and families that you can take a shower?’ That’s what they need. As with any types of reform, smaller measures directed responsible for thriving in the face of structural 2021 Social Work CE Institute – FOCUS Continuing Education Courses 5 at the individual level of service provision are easier make the effort to build strong relationships with clients. allot staff time to form relationships with and learn to implement than larger changes to organizations and Social support can also be facilitated by providers when about other providers’ work and to consult with clients policies, but substantial change cannot occur without they connect clients to other services or help them think on the best methods of working together (Rumping et attention to each of the levels. through and locate additional sources of support. There al., 2018). are often family members, friends, or others who live There should be an evaluation of organizations’ internal Providing More Effective Advocacy in the clients’ communities who are willing to help, cultures to determine how well they support workers if asked. Exploring with clients where unleveraged and clients of different races, genders, and cultures and Individual Level Supports sources of support may lie can bear fruit. Social workers (Kugelmass, 2016; Lopez et al., 2012; Posey-Maddox, can help families explore whether other resources exist 2017). A sample racial justice assessment tool can be On the individual, casework level, more attention that might lend when they cannot locate any potential found at https://www.njjn.org/uploads/digital-library/ needs to be paid to getting clients the resources they helpers within their existing circles. These resources AssessingOurOrganizations_RacialJustice%20(1)%20 need and breaking down the silos that keep various may include groups, other parents willing to act as (1).pdf, one of many such tools that can be used as a services distinct. Every provider, from caseworkers mentors or lend a helping hand, religious organizations, basis for evaluation and development. As noted in this to psychotherapists, should take the time to inform or personnel in schools or other agencies. Assistance tool, institutional change requires goals, benchmarks, themselves of the resources in their communities and can vary from offering companionship, running errands, and indicators for measuring success. In order to create how various systems work. They should be aware of providing transportation, offering childcare, or any other reasonable objectives and criteria, agencies need to how clients obtain welfare benefits, housing help, fuel task or backing a family might need. comprehensively analyze the needs of clients in their assistance, or specialized services such as occupational geographic area and decide the best methods to meet therapy, neuropsychological assessments, speech those needs. Data on services and outcomes should be and language services, substance abuse services, or Social workers, especially those with training in mental health, are well positioned to analyzed so as to determine whether or not disparities specialized school services, amongst others. They exist according to race or other factors. Amongst the should know about how to access different levels facilitate collaboration and coordination topics to be considered are whether cultural beliefs and kinds of care through various departments and because they can provide important interfere with service delivery and how inclusive is the institutions (such as DMH, DDS, child welfare, juvenile psychoeducation to other systems, generate agency culture as reflected in the following questions: justice, and psychiatry). Advocating effectively means a fuller perspective on a child and family’s not only having an awareness of existing resources, 1. Are definitions of family and parenting broad enough but also the culture, policies, language, jurisdictions, needs, and use professional authority to help to accommodate different family formations and procedures, and constraints that govern each system sway reluctant systems. parenting styles? (Zilberstein & Popper, 2016). Without such knowledge, 2. Are signs of distress accurately identified across helping clients obtain services can be difficult. As cultures, so that they are neither missed nor overly an educational advocate notes about obtaining an pathologized? Individualized Educational Program (IEP) for children, When families have few social supports, social workers should try and determine what barriers exist 3. Do staff and clients of different races and genders feel The IEP language is difficult. The process is not that keep them isolated (Thompson, 2015). Obstacles comfortable within the organization? transparent, the rules are many, and they change all to forming supportive relationships may involve the time. It is unbelievably hard for a parent to know living in a community with limited resources or in a 4. Does the staff reflect the people served? the existing resources, what specific interventions a dangerous neighborhood in which trust in others is low. child needs, and how to fight for them. There is, more Families in which intergenerational abuse, neglect, 5. Does the organization’s leadership partner with or less, a formula, so parents can get resources, if or substance misuse problems have occurred may not representatives of underrepresented groups to find out they know the route. (Zilberstein, 2019, p. 128) know dependable adults or may have trouble feeling what sorts of changes would benefit them? confidence in others. For those families, exploring and Effective advocacy occurs in partnership with a client’s overcoming barriers should be a prime focus. Helping 6. Are staff of different races, cultures, and genders wishes and includes empathy and validation of the clients learn whom they can trust, how to determine if given a voice and chances for mentorship and client’s goals, exploration of existing opportunities and someone is dependable, and, if necessary, developing leadership? barriers, as well as instrumental and relational support the skills necessary for mutual relationships should be for achieving agreed upon aims (Goodman et al., 7. Are microagressions recognized and confronted? prioritized. The work may also need to include helping 2020). Social workers should help clients think through clients learn to recognize their needs and ask for help, their needs and locate services, as well as educate and Agency directors also need to spend substantial time as well as explore other beliefs or needed skills that empower them to advocate on their own behalf. When considering the needs of staff. In order to do their interfere with obtaining supports. In a culture in which structural barriers are encountered, discussion should jobs well, workers need good wages, opportunities independence, individualism, and “pulling oneself center on the best way to approach them and whether or for growth, supervision, and learning, and input into up by one’s own bootstraps” is glorified, individuals not the provider should actively intervene to help. One how they perform their jobs. They need incentives to and parents can feel that asking for help is a sign of of the advantages of providers actively advocating on stay and build the depth and breadth of knowledge weakness. Psychoeducation on the importance of social clients’ behalf is that empathy for and understanding of necessary for expertise (Beidas et al., 2016; Edwards & supports for physical and emotional well-being should the barriers faced by clients is enhanced when providers Wildeman, 2018). Agencies benefit when workers are be offered. do not simply hear about their clients’ frustrations, but given the time to research and assemble new programs, experience them (Goodman, et al. 2020). which also necessitates allocations of funding. While Assessing and Making Change on such investments may be costly in the short term, they Advocacy is also needed to change structural and pay off in the long run. Efficiency and productivity racial inequities that impact clients and society. Case Institutional Levels result from effective and innovative interventions, workers, mental health workers, and other providers Leaders of human service organizations and institutions rather than the other way round. Successful, innovative who witness inequities and their deleterious impacts need to examine their agencies’ policies to determine practices are best created when the workforce partakes can address them through advocacy, allyship, and what barriers for equitable and accessible service in their construction and finds the purpose and process activism (Melton, 2018). As allies, they can use their provision exist in their ranks and how to overcome meaningful (Epstein, 2019; Leiva et al., 2020; Longhi, power and professional knowledge in the service of them (Alegria et al., 2010; Epstein, 2019; Snowden, 2019). Without innovation, little will change. As the those with less privilege. As activists, they can advertise 2012). A review should be made of all policies and leader of a large, public social service agency notes: the damaging consequences of racial discrimination, practices to ascertain whether and how they contribute The problem is that we put people in paradigms that economic hardship, and other types of inequality and to social inequities. Questions to examine include are wrongly conceived. When we change the system, the importance of reducing them (Bullock, 2019). Social whether some groups are disadvantaged in their abilities we still keep the paradigm. Put new workers in the workers should also examine their own biases about to gain or keep services because of transportation, same equation and you will get the same results. race, culture, gender, income, and other circumstances cost, or times that the services are available. Language Those of us who work and manage large organiza- and identities pertaining to clients and strive to reduce barriers can also impact a families’ ability to utilize a tions need to try every day to make them more how those prejudices influence their work. They must service. Attempts should be made to employ workers humane. (Zilberstein, 2019, p. 188) call out unfair practices and advocate within their speaking the languages prevalent in the community, to Social workers can provide services better fitted to their organizations for reforms that counter bias and correct enlist the help of interpreters, and to make written and clientele when they address organizational biases and inequities. oral communication accessible to those with different barriers, partner with families to meet needs in flexible levels of education or with pre-existing disabilities. More efforts also need to be made to promote ways, provide advocacy and support for clients in Requirements for paperwork should be manageable and collaboration amongst siloed services in order to remove navigating systems and services, and spend more time sufficient help given for completing it. Families should stresses on families and improve service delivery. and resources nurturing the workforce. Social workers, especially those with training in mental not be disqualified for services because of documentary health, are well positioned to facilitate collaboration mistakes. Support must be given to families in any task and coordination because they can provide important that makes accessing services difficult. Strengthening Community psychoeducation to other systems, generate a fuller An assessment should also be made as to what extent Families thrive best when they live in communities perspective on a child and family’s needs, and use programs are hamstrung by rigid rules and funding that promote wellbeing. Affordable housing, safe professional authority to help sway reluctant systems. and what can be done to reduce resulting service neighborhoods, quality schools, economic opportunities limitations. Partnering with families to build flexible that provide living wages, anti-racist police institutions, Building Social Supports for Clients interventions rather than fitting them into existing greenspaces, mutual aid amongst community members, services would make the work more effective. Doing and recreational opportunities are just some of the so may require building adaptable funding initiatives Social support is robustly associated with well-being protective factors that allow families to prosper (Longhi, and finding new sources of monies, perhaps through across all populations, making the provision and 2019; Maguire-Jack & Wang, 2016; Masten, 2018; private sources, although opportunities remain limited expansion of clients’ social support networks important Petersen et al., 2021). Communities play an important (Weir, 2021). Efforts also need to be made to allow for (Macguire-Jack & Wang, 2016; Thompson, 2015). role in reducing stresses and structural inequities that proper coordination amongst multiple providers serving Social support can be supplied by providers when they THE SYSTEM IS DOWN a single family. In order for that to occur, agencies must CONTINUED ON PAGE 6 6 2021 Social Work CE Institute – FOCUS Continuing Education Courses lead to health and mental health difficulties. They can Often initiatives that begin at a local level can be inequities are better poised to lessen many mental and prevent adversities that lower families’ quality of life leveraged to enact changes in a wider jurisdiction. physical health problems. No matter how skillful the and that then lead to costly interventions that overwhelm Influencing policy and funding initiatives requires data clinician, psychotherapy rarely “heals.” Treatments limited health and mental health services. that shows a program’s efficacy, continuing obstacles, seldom achieve outcomes equal to those attained by Programs that are embedded in communities are as well as the standards and accountability to which it people with fewer hardships (Zilberstein, 2019). Even important because they can best monitor and adapt to adheres (Dorken et al., 1993). When data and education if such cures were possible, psychotherapists already a community’s needs and constraints. Schools, faith- show the positive effects of an initiative, legislatures cannot adequately meet the demand of the country’s based settings, medical offices, workplaces, and other can be more effectively lobbied and new policies and current mental health needs, let alone address the surge trusted organizations are uniquely suited for meeting regulations follow suit. Evidence can also be used in mental health difficulties created by the COVID-19 the needs of families because they have a wide and to change cultural norms, which then affects which pandemic (Panchal et al., 2021). Expecting a fragmented non-stigmatizing reach. They can serve as vehicles policies law makers are more likely to support (Bullock, and under-resourced mental health system to heal a for promotion and prevention by offering information 2019; Petersen et al., 2021). nation’s woes is unrealistic. and awareness, support, and integrated mental health interventions (Leiva et al., 2020; Mendel et al., 2020). Strengthening Social Work Conclusion They can also detect health and mental health problems so that they can be addressed early (Petersen et al., In order to meet contemporary challenges in service Social work and society would benefit from a changed 2021). A community focus is important because delivery for individuals and families, social work narrative that emphasizes how families could better different locales serve populations with disparate education and practice would benefit from a number of thrive if a comprehensive service sector promoted needs and contain unique challenges and resources. changes. Social work students, even those going into wellbeing through multiple domains. Ignoring the As a result, a solution that works in one place may not direct service fields, should be required to learn skills important needs of individuals and families and the be well suited for other settings. As one community in macro practice (Mattock, 2018). They should learn constraints placed on social workers to address them organizer notes, “You can’t come in and dictate. You about the different systems in which clients interact— leads to worsening conditions that reverberates through have to work with the community. Find out what is housing, schools, criminal justice, child welfare, and society. When adversity rises, so does demand for needed. What a family resource center looks like in financial aids etc.—and how to advocate on behalf of services, which taxes already overburdened schools, Athol should not look anything like one in Boston.” clients (Goodman et al., 2018). Social workers should mental health services, courts, child welfare, and other (Zilberstein, 2019; p. 186) also strive to learn how to collaborate across agencies institutions, which are not positioned to meet the need. to leverage community resources on behalf of clients. When that happens, agencies must restrict access or A better understanding of how policies affect services Ignoring the important needs of individuals shift burdens back onto parents, perpetrating difficulties and how research and information affect policies could and families and the constraints placed and creating impossible dilemmas for families and the also enable more social workers to promote the needs overworked, under-resourced workers and institutions on social workers to address them leads of their clients by lobbying legislatures for needed trying to support them. The field must work to redress to worsening conditions that reverberates resources. Lastly, training on implicit bias and the this situation by coming to a new understanding of through society. impact of structural inequities on health and mental the needs and pressures on families, providing more health will equip social workers to deliver services preventative supports, giving social workers increased that better meet the needs of culturally diverse clients tools to meet demands, and fighting for changes on (Comas-Diaz, 2016). the community and legislative levels that lead to more Communities should strive to form comprehensive The social work field would also benefit from an integrated and effective services. responses to their population’s difficulties. Since mental increased investment in the workforce. Wages need health difficulties are often linked to other adversities to increase both as a way to decrease costly turnover in an individual or family’s life, broad approaches References and to take better care of workers on whom agencies to wellbeing should be pursued. Coalitions and and clients depend (Beidas et al., 2016; Edwards collaborations amongst agencies such as schools, anti- Alegria, M., Vallas, M. & Pumeriega, A. (2010). Racial & Wildeman, 2018). Instead of an emphasis on poverty responses, mental health treatment, homeless and ethnic disparities in pediatric mental health. Child productivity, the workday needs to allow more time for services, as well as other social supports can be knit and adolescent psychiatric clinics of North America, reflection, learning, collaboration, and innovation. While together to serve vulnerable families (Longhi, 2019; 19(4), 759 – 774. in the short run, those changes may decrease efficiency, Mendel et al., 2020). In doing so, communities can in the long run, they will lead to more effective Anderson, J. et al. (2017). A scoping literature review leverage the different strengths and knowledge of interventions, which may prove more efficient and of service-level barriers for access and engagement with providers to fashion interventions that are easier to less costly. Increasing workforce capacity to meet the mental health services for children and young people. access, culturally well-suited to the population, and growing need for more mental health and social work Children and Youth Services Review, 77, 164–176. more likely to succeed. professionals will be enhanced by salaries that attract Bailey, D. (2000). The federal role in early intervention: Service delivery and access would also improve if talent and allow workers a decent standard of living. Prospects for the future. Topics in Early Childhood families could locate and engage multiple services Special Education, 20(2), 71 – 78. at once. An integrated system that allows families to apply for numerous services at once would go far Changing Cultural Beliefs Baglivio, M., Wolff, K., Piquero, A., Greenwald, M., in decreasing the current complexity of applying to & Epps, N. (2017). Racial/ethnic disproportionality numerous programs for different types of help and the Before changes can be made on the individual, in psychiatric diagnoses and treatment in a sample probability of families giving up or falling between the community, or policy levels, cultural beliefs that of serious juvenile offenders. Journal of Youth and cracks. It would also help providers, who often scramble interfere with public acceptance of new initiatives will Adolescence, 46, 1424–1451. need to be challenged and altered. The pandemic and to find resources in an ever-changing service landscape. Barbarin, O. (2020). Racial disparities in the U.S. child In this technological age, it should not be hard to create Black Lives Matter have already begun that shift, as news organizations increasingly report on structural protection system etiology and solutions. International a standardized intake process from which an automated Journal on Child Maltreatment: Research, Policy and inequities, racism, and the need for government database could direct potential clients to relevant and Practice, advance online publication. non-duplicative health, housing, disability, mental intervention. The dialogue must continue to stress that health, and other services. A single form, which allows individual effort is not always sufficient to overcome Beidas, R., Marcus, S., Wolk, C., Powell, B., Aarons, consumers to check numerous boxes and provide the barriers and that the public and private sectors need to G., Evans, A., Hurford, M., Hadley, T., Adams, D., supporting data all at once, could centralize and ease provide more assistance to vulnerable individuals and Walsh, L., Babbar, S., Barg, F., & Mandell, D. (2016). A prospective examination of clinician and supervisor the process. To respect confidentiality, information that families. Rather than promoting a view that resilience is an individual trait, more emphasis should be placed on turnover within the context of implementation of is not relevant to other services could be automatically evidence-based practices in a publicly-funded mental redacted when sent to that program. Communities how communities promote resilience and the importance of preventative measures (Masten, 2018). Pressure will health system. Administration and Policy in Mental should also publish comprehensive databases of Health and Mental Health Services Research, 35(5), 640 build on governments to act when those cultural beliefs services that providers and consumers can search easily – 649. online, on a single website. Such systems would save change widely. Opportunities and funding for new tremendous time for clients, workers, and agencies. programs will hopefully follow. Blum, L. (2015). Raising generation Rx: Mothering kids with invisible disabilities in an age of inequality. New The relentless pressure on parents to do more and more York: New York University Press. Changes on the Policy and Legislative for their children also needs to be lifted. Policy makers Level and voters need to understand that families require Boyle C., Boulet S., Schieve L., Cohen R., Blumberg material and social supports to function well. Only S., Yeargin-Allsopp M., Visser, S., & Kogan, M. (2011). parents with the most resources can thrive amidst the Trends in the prevalence of developmental disabilities in Since communities and agencies provide the benefits numerous stresses imposed by an ailing family member, US children, 1997–2008. Pediatrics, 27,1034-1042. that they are incentivized to administer, changes need to poverty, racism, and other adversities (McConnell et occur on the policy and legislative level, which creates Brody, G., Yu, T., Chen, E., Miller, G., Kogan, S., & al., 2014). Stresses need to be reduced, including those that impetus. Legislation can either stimulate or block Beach, S. (2013). Is resilience only skin deep? Rural introduced by systems of care, by gargantuan efforts to African Americans’ socio- economic status-related risk services through funding and regulations that govern engage, retain, and coordinate services, and from feeling and competence in preadolescence and psychological the monies programs receive and how they function blamed, shamed, or surveilled (Blum, 2015). Parents adjustment and allostatic load at age 19. Psychological (Bailey, 2000; Dorken et al., 1993). State and federal should not be expected to be so child-centered that their Science, 24(7), 1285–1293 governments also have the ability to fund research own health and wellbeing is sacrificed (The 2009/10 that establishes and tests innovative solutions and to Bullock, H. (2019). Psychology’s contributions to National Survey of Children with Special Health Care disseminate information that changes cultural norms and understanding and alleviating poverty and economic Needs; Tint & Weiss, 2016). behavior (Anderson et al., 2018; Petersen et al., 2021). inequality: Introduction to the special section. American Psychologist, 74(6), 635 – 640. Policies and legislatures can be influenced by research, The mental health system is currently asked to rectify lobbying, and voting, problems whose solutions belong in other sectors. Cancian, M., Yang, M. & Slack, K. (2013). The effect Interventions that reduce adversities and structural of additional child support income on the risk of child 2021 Social Work CE Institute – FOCUS Continuing Education Courses 7 maltreatment. Social Service Review, 87(3), 417-437. from indigenous perspectives. The Canadian Journal of Chisholm, D., Gronholm, P., Egbe, C., & Thornicroft, Psychiatry, 56(2), 84–91. G. (2016). Promotion, prevention and protection: Center on Budget and Policy Priorities (undated). The Interventions at the population- and community-levels problems with block-granting entitilement programs. Koc, V., & Kafa, G. (2019). Cross-cultural research on for mental, neurological and substance use disorders in Retrieved from https://www.cbpp.org/the-problems- psychotherapy: the need for a change. Journal of Cross- low- and middle-income countries. International Journal with-block-granting-entitlement-programs Cultural Psychology, 50(1), 100 – 115. of Mental Health Systems, 10, article 30. Chetty, R., Hendren, N., & Katz, L. (2016). The effects Kugelmass, H. (2016). “Sorry, I’m not accepting new Pew Research Center (November 2015). Global support of exposure to better neighborhoods on children: New patients”: An audit study of access to mental health care. for principle of free expression, but opposition to evidence from the moving to opportunity project. Journal of Health and Social Behavior, 57(2), 168–183. some forms of speech. Retrieved from http://assets. American Economic Review, 106(4), 855–902. pewresearch.org/wp- content/uploads/sites/2/2015/11/ Leiva, L., Zavala-Villalon, G., Antivillo-Bruno, A., Pew-Research-Center-Democracy-Report- FINAL- Children’s Defense Fund. (2020). The state of America’s Torres, B., & Ganga-Leon, C. (2021). Implementation November-18-2015.pdf children. Retrieved from https://www.childrensdefense. of a national mental health intervention in educational org/policy/resources/soac-2020-child-poverty/ communities: What do successful teams do differently? Posey-Maddox, L. (2017). Race in place: Black Journal of Community Psychology, 49, 133-151. parents, family–school relations, and multispatial Chingos, M. (June 15, 2017). How progressive is school microaggressions in a predominantly white suburb. funding in the United States? Brookings Institute. Lindhert, P., & Williamson, J. (2016). Unequal gains: Teachers College Record 119(110304), 1–42. Retrieved from https://www.brookings. edu/research/ American growth and inequality since 1700. Princeton, how-progressive-is-school-funding-in-the-united-states/ NJ: Princeton University Press. Pryce, J., Lee, W., Crowe, E., Park, D., McCarthy, M., & Owens, G. (2019). A case study in public child welfare: Comas-Diaz, L. (2016). Racial trauma recovery: A Longhi, D., Brown, M., Barila, T., Reed, S., & Porter, County-level practices that address racial disparity in race-informed therapeutic approach to racial wounds. L. (2019). How to increase community-wide resilience foster care placement. Journal of Public Child Welfare, In A. Alvarez, C. Liang, & H. Neville (Eds.). The cost and decrease inequalities due to adverse childhood 13(1), 35 – 59. of racism for people of color (pp. 249- 272). American experiences (ACEs): Strategies from Walla Walla, Psychological Association: Washington, DC. Washington, Journal of Prevention & Intervention in the Quinn, N., & Mageo, J. (2013). Attachment Community (Online). reconsidered: Cultural perspectives on a western theory. Dague, L. (2014). The effect of Medicaid premiums on USA: Palgrave MacMillan. enrollment: A regression discontinuity approach. Journal Lopez, S., Barrio, C., Kopelowicz, A., & Vega, W. of Health Economics, 37, 1 – 12. (2012). From documenting to eliminating disparities in Salsberg, E., Quigley, L., Acquaviva, K., Wyche, K., & mental health care for Latinos. American Psychologist, Sliwa S. (April, 2018). Results of the nationwide survey Deming, D. (2015). The growing importance of social 67(7), 511 – 523. of 2017 social work graduates. The Council of Social skills in the labor market. (Working Paper Series No. Work Education and National Workforce Initiative 21473). Cambridge, MA: National Bureau of Economic Maguire-Jack, K., & Wang, X. (2016). Pathways from Steering Committee. Retrieved from https://www.cswe. Research. neighborhood to neglect: The mediating effects of org/Centers-Initiatives/Initiatives/National-Workforce- social support and parenting stress. Children and Youth Initiative/Survey-of-2017-SW-Grads-Book-FINAL- Dempsey, K., Butler, S., & Gaither, L. (2016). Black Services Review 66, 28–34. churches and mental health professionals:Can this Executive-Summa.aspx collaboration work? Journal of Black Studies, 47(1), 73 Mandell, D., Davis, J., Bevans, K., & Guevara, J. Sohn, H. (2017). Racial and ethnic disparities in health – 87. (2008). Ethnic disparities in special education labeling insurance coverage: Dynamics of gaining and losing among children with Attention-Deficit/Hyperactivity Dorken, H., VandenBos, G., Henke, C., Cummings, N., coverage over the life-course. Population Research and Disorder. Journal of Emotional and Behavioral Policy Review, 36(2), 181-201. & Pallak, M. (1993). Impact of law and regulation on Disorders, 16(1), 42-51. professional practice and use of mental health services” Snowden, L. (2012). Health and mental health policies’ An empirical analysis. Professional Psychology: Marshall, J., Ademan, A., Kesten, S., Natale, R., & role in better understanding and closing African Research and Practice, 24(3), 256 – 265. Elbaum, B. (2017). Parents experiences navigating American-White American disparities in treatment intervention systems for young children with mild Duva, J., & Metzger, S. (2010). Addressing poverty as a access and quality of care. American Psychologist, language delays. Journal of Early Intervention, 39(2), 67(7), 524–531. major risk factor in child neglect: Promising policy and 180 – 198. practice. Protecting Children, 25(1), 63–74. Spetz, J., Stone, R., Chapman, S., & Bryant, N. (2019). Masten, A. (2018). Resilience theory and research Edin, K., & Shaefer, H. (2015). $2.00 a day: Living Home and community-based workforce for pateints with on children and families: Past, present, and promise. serious illness requires support to meet growing needs. on almost nothing in America. New York: Houghton Journal of Family Theory & Review, 10, 12 – 31. Mifflin Harcourt. Health Affairs, 38(6). Retrieved from https://www. Mattocks, N. (2018). Social action among social work healthaffairs.org/doi/10.1377/hlthaff.2019.00021 Edwards, F., & Wildeman, C. (2018). Characteristics practitioners: Examining the micro-macro divide. Social Sue, D., Capodilup, C., Torino, G., Bucceri, A., of the front-line child welfare workforce. Children and Work, 63(1), 7–16. Youth Services Review, 89, 13–26. Holder, B., Nadal, K., & Esquilin, M. (2007). McConnell, D., Savage, A., & Breitkreuz, R. (2014). Racial microaggressions in everyday life. American Floyd, I. Burnside, A., & Schott, L. (November, 2018). Resilience in families raising children with disabilities Psychologist, 62(4), 271–286, p. 273. TANF reaching few poor families. Center on Budget and behavior problems. Research in Developmental Sue, S., Cheng, J., Saad, C., & Chu, J. (2012). Asian and Policy Priorities. Retrieved from https://www.cbpp. Disabilities, 35, 833–848. org American mental health: A call to action. American Mendel, P., O’Hara, J., Zhang, L., Stockdale, S., Dixon, Psychologist, 67(7), 532 – 544. Forbes, S., & Fikretoglu, D. (2018). Building resilience: E., Gilmore, J., Jones, F., Jones, A. Williams, P., Sharif, The conceptual basis and research evidence of resilience Summers, A. (2015). Disproportionality rates for M., Masongson, A., Kadkhoda, F., Pulido, E., Chung, children of color in foster care (fiscal year 2014). training programs. Review of General Psychology, B., & Wells, K. (2021). Engaging community networks 22(4), 452 –468. Retrieved from https://www.falmouthinstitute.com/files/ to improve depression services: A cluster-randomized LW060/NCJFCJ%202014%20Disproportionality%20 trial of a community engagement and planning TAB%20Final.pdf Garrett, P. (2016). Questioning tales of ‘Ordinary intervention. Community Mental Health Journal, 57(3), Magic’: ‘Resilience’ and neo-liberal reasoning. British 457 – 469. Journal of Social Work, 46, 1909 – 1925. The National Survey of Children with Special Health Care Needs Chartbook 2009–2010. Rockville, Melton, M. (2018). Ally, Activist, Advocate: Addressing Maryland: U.S. Department of Health and Human Goodman, L., Wilson, J., Helms, J., Greenstein, N., & role complexities for the multiculturally competent Medzhitova, J. (2018). Becoming an advocate: Process Services. Retrieved from https://mchb.hrsa.gov/ psychologist. Professional Psychology: Research and cshcn0910/more/pdf/nscshcn0910. pdf. and outcomes of a relationship-centered advocacy Practice, 49(1), 83 -39. training model. The Counseling Psychologist, 46(2), 122 -153. Thompson, R. (2015). Social support and child Merikangas K., He J., Burstein, M., Swanson, S., protection: Lessons learned and learning. Child Abuse Avenevoli S., Cui, L., Benjet, C., Georgiades, K., & Neglect, 41, 19–29. Henrich, J, Heine, J, & Nonrenzayan, (2010). The Swendsen, J. (2010). Lifetime prevalence of mental weirdest people in the world. Behavioral and Brain disorders in U.S. adolescents: Results from the National Sciences, 33, 61-83. Tint, A., & Weiss, J. (2016). Family wellbeing of Comorbidity Study- Adolescent Supplement (NCS-A). individuals with autism spectrum disorder: A scoping Isenberg, N. (2016). White Trash. New York: Viking. Journal of the American Academy of Children & review. Autism, 20(3), 262–275. Adolescent Psychiatry, 49(10), 980-989. Greenfield, P. (2016). Social change, cultural Weir, K. (2021). There’s a new push to reach evolution, and human development. Current Opinion in Mettler, S. (2018). The government-citizen disconnect. underserved communities. Monitor on Psychology, Psychology, 8,84–92. Russell Sage Foundation. 52(1), p. 64. Holmes, J. (2017). Roots and routes to resilience and its Miller, G., Yu, T., Chen, E., & Brody, G. (2015). Self- Zilberstein, K. (2019). Parents under pressure: role in psychotherapy: A selective, attachment-informed control forecasts better psychosocial outcomes but faster Struggling to raise children in an unequal America. review. Attachment & Human Development, 19(4), 364 epigenetic aging in low-SES youth Proceedings of the Amherst, MA: Levellers Press. – 381. National Academy of Sciences of the United States of America, 112(33), 10325 – 10330. Zilberstein, K, & Popper, S. (2016). Clinical IOM (Institute of Medicine) and NRC (National competencies for the effective treatment of foster Research Council). (2014). New Directions in child Pancahl, N., Kamal, R., Cox, C., & Garfield, R. children. Clinical Child Psychology and Psychiatry, abuse and neglect research. Washington, D.C.: The (February 20, 2021). The implications of COVID-19 21(1), 32 - 47. National Academies Press. for mental health and substance use. Kaiser Family Foundation. Retrieved from https://www.kff.org/ Kessler, R.C., Sonnega A., Bromet E., et al. (1995). coronavirus-covid-19/issue-brief/the-implications-of- Posttraumatic stress disorder in the National covid-19-for-mental-health-and-substance-use/ Comorbidity Survey. Archives of General Psychiatry, 52,1048–1060. Pelton, L. (2015). The continuing role of material factors in child maltreatment and placement. Child Kirmayer, L., Dandeneau, S., Marshall, E., Phillips, Abuse & Neglect, 41, 30–39. M., & Williamson, K. (2011). Rethinking resilience THE SYSTEM IS DOWN Petersen, I., Evans-Lacko, Semrau, M., Barry, M., CONTINUED ON PAGE 8 The System is Down: Creating More Accessible Services for Diverse Families 1.5 CEUs - POST-TEST

Circle all correct answers. There is only one correct answer per question. 1. Families utilizing numerous benefits and services, usually find: 8. Improving the delivery of services requires: a. A well-organized system a. Increased focus on parenting interventions and counseling b. Helping providers become more efficient b. Complex administrative hurdles c. A multi-level approach that coordinates services across numerous domains c. Services that can be shaped flexibly to their needs d. Building resilience in clients d. Easy, streamlined paperwork 9. Social workers can help clients with insufficient resources by: 2. States with some of the strictest rules and least generous benefits are: a. Encouraging them to be more responsible a. Wealthier states b. Helping them think through and advocate for their needs b. States in the Northwest c. Helping them prioritize paperwork and waiting in line over other obligations d. Providing parent education and counseling c. Those with a larger share of white residents d. Those with a larger share of Black residents 10. Social workers can help clients with insufficient social supports by: a. Addressing barriers to locating and utilizing social supports 3. Compared to their white peers with the same difficulties, Black and Latinx b. Helping them become more self-sufficient youth are more likely to be diagnosed with: c. Helping them become more resilient a. Trauma d. Friending them on social media b. Depression 11. Social service organizations can improve services by addressing which of the c. Conduct disorders following concerns? d. Learning differences a. Making sure policies do not contribute to racial inequity b. Making sure services are accessible to families with fewer resources 4. Families of special needs children tend to NOT experience which of the c. Partnering families to build flexible interventions following: d. All of the above a. Higher rates of isolation in middle class samples 12. Social work interventions should help build community by: b. Increased risk of child welfare involvement a. Requiring that clients who receive benefits engage in community service c. Higher rates of depression and anxiety b. Restricting funding for individual level interventions d. Greater life satisfaction c. Setting up neighborhood watch groups d. Making sure that communities offer quality opportunities for education, 5. Interventions that decrease poverty improve child outcomes. recreation, mental health, housing and other needs True or False 13. Which of the following is NOT a structural or policy level factor that affects 6. Which of the following characterizes neoliberal values and policies? social work interventions? a. Types of funding available a. Emphasis on building community b. Legislative laws and policies b. Focus on individual responsibility c. Data, standards and accountability c. Concern with rectifying structural inequities d. Providers’ individual background or beliefs d. Family supports and benefits valued 14. Building better supports for families will require: 7. In what ways have neoliberal values affected the social work profession? a. More social workers trained in macro systems work b. Shifting more social workers into direct care a. Emphasis on micro interventions c. Increasing social workers’ caseloads b. Emphasis on efficiency and productivity d. Training social workers to help families become more resilient c. High caseloads and staff turnover d. All of the above

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YOU ARE HOLDING 1.5 CEUs IN YOUR HAND! How it works: Read this CE program, complete the Post-Test and Evaluation, and mail to the Chapter office with your check. Score 80% or better and NASW will mail you a certificate for your CEUs. It is that easy! Disability Social Work: Connecting Critical Cultural Competence, Intersectionality, and Anti-oppressive Practice

Lisa Johnson, PhD, MSW, Rose Singh, MSW, and Elspeth Slayter, PhD, MSW

The Planned Change Process and what could be improved upon vis-a-vis process or Learning Objectives content. If a change did not occur, the client and social worker should reconsider the goals and objectives to The “planned change process” is the foundation for At the completion of this program, participants should make alterations focused on achieving the goal. be able to: much of social work practice in the United States that is focused on the development and implementation 1. Understand how critical theoretical perspectives of an approach to change behaviors, a condition or History of the Planned Change Process can inform social work practice with the circumstance that will improve the life of a client in disability community. some way (Kirst-Ashman, 2012). This process can be As critical consumers of knowledge for social work applied at multiple levels - micro, mezzo and macro practice, it is important to note that the planned change 2. Apply the framework, inclusive of the planned - and with a spectrum of populations. This process is process was developed in the context of the United change process, to disability social work. one that social workers can use to plan and implement States and may be somewhat culture-bound based on 3. Identify elements of the disability social work change with clients and client systems. the era in which it was developed and who was involved practice framework for use within one’s own in academic social work at that time. Based first in the Consisting of a series of steps that can be summarized as professional context. United States, the social diagnosis-informed social client engagement, assessment, intervention, termination casework model developed by Mary Richmond is also and evaluation, the planned change process provides a informed by the problem-solving model put forth by About the Authors basic framework from which social workers can frame Helen Harris Perlman (1957). their practice with clients and client systems. Although Lisa Johnson, PhD, MSW, is an associate professor of the planned change process is visualized as linear in the Mary Richmond is well-known as the person who social work and has served as interim dean and BSW current model, it is not linear when put into practice. developed the concept of social diagnosis, in which a program coordinator. Dr. Johnson has practiced in both For example, work with a client might vacillate between person and their problem is considered within the larger the child welfare and healthcare fields and worked assessment and intervention as the client-social worker socio-political context (Richmond, 1917). Richmond is with complex systems for non-profit development and relationship evolves or as new challenges arise or also known for the development of the social casework community organizing. Her research and scholarship become clearer. framework in which she highlighted the importance interests encompass child welfare; diversity, equity, of including clients in the solving of their problems Although this model is at times conceptualized (Richmond, 1922). and social justice; workforce development; disability differently with respect to the number of steps included, studies, and social work education. Email: ljohnson2@ the following is a summary of the commonly used The problem-solving process builds on Richmond’s salemstate.edu. steps in the planned change process. The first step, work and can be thought of as a synthesis brought engagement with the client, refers to the beginning together from several sources including Perlman’s Rose Singh, MSW, is a social work practitioner, interaction between client and social worker. As the background in the humanities and her philosophical educator and PhD student in Canada. Rose brings relationship develops differently for every client and reflections together with her knowledge of two decades of direct practice experience working in every circumstance, there is not a set timeframe in psychodynamics and the social sciences. In this process, the social services sector, with a focus on supporting which engagement happens. Skills used by social the social worker supports the client in learning how youth and adults living with disabilities, mental health workers during the engagement step include active to analyze problems while providing consultative concerns, and substance use. Rose teaches courses listening, use of eye contact (depending on cultural education in the art of effective problem solving. on direct practice, theory, social justice, and critical preferences, traditions and expectations), demonstration Perlman had significant clinical expertise, and her approaches to social work practice and policy in the of empathy and reflection on what the client is engaging process demonstrates strong emphasis on the importance areas of disability, mental health, and addictions. Rose’s in. This step is all about fostering rapport and trust of the helping relationship in direct practice (Perlman, research and scholarship interests include social justice between the client and the social worker. 1957). Perlman formulated a unique, cognitively and human rights in social work, and currently center focused and client-centered problem-solving process for on critical social work education, disabilities, online The second step, assessment, is led by the social worker social work practice. learning and teaching, and emerging technologies. who gathers, analyzes and synthesizes information from Email: [email protected]. the client in order to develop a picture of the client’s Over time, these ideas were shared and further functioning, needs and strengths. Assessment is the developed by social workers and came to be known Elspeth Slayter, PhD, MSW, is a professor of social foundation of the action steps that follow it. According as the planned change process, supplanting the work who identifies as a member of the disability to Johnson and Yanca (2010), there are five important problem-focused language. Though there is a dearth community. She teaches child and family policy, activities in the assessment step: identifying the need; of information about the origins of the term “planned forensic social work, disability practice and evidence- honing in on the nature of the problem; identifying change process,” authors Kirst-Ashman and Hull (2010) based research courses. Dr. Slayter has practiced as a strengths and resources; collecting client data and are often credited with bringing this idea to the fore of forensic social worker in child welfare, public criminal analyzing all of the above information for development social work education through their textbook writings defense, juvenile justice, and education settings. Her into an implementable plan. on generalist practice. equity-focused research and consulting centers around disability, race, ethnicity in the addiction and child The third step focuses on the implementation of an welfare service sectors. Email: eslayter@salemstate. action plan that is guided by goals and objectives co- Critiques of the Planned Change edu. created by the client and the social worker. These goals Process and objectives are to be put into place by the client and the social worker together. In some iterations of the Despite the widespread use of the planned change Introduction planned change process, this step can include planning process, there are important critiques of the process and intervention implementation, as well as a follow- that we must consider. First and foremost, there are This article presents our disability social work practice up post-termination step. In our conceptualization of always limitations to a generalist framework, which model (“A Model for Social Work Practice with the the model, the fourth step, termination, takes place once is not considered a treatment modality in and of itself. Disability Community”), which follows the social goals and objectives have been met and there is no more As in any consideration of practice approaches, it is work planned change process, and is informed by the need for social work services. This involves a situation important to consider who developed the model and theoretical perspectives of critical cultural competence, in which the client and social worker reflect on the work who has been left out of the development of the model. intersectionality, and anti-oppressive practice. We that they have done together before closing out the first review the planned change process as a facet of professional relationship. social work practice. We then offer an overview of key theoretical perspectives that inform our practice model, The fifth step, evaluation, may be considered important including their application to disability social work to engage in throughout the planned change process practice. Next, we introduce a model for disability social and may also be an aspect of termination. During the work practice with a detailed case example following previous steps, the social worker is ethically mandated the work of a social worker and client using the to always evaluate how the client is doing throughout planned-change process. Finally, we offer a comparison the course of the social work process through either of the proposed practice model to existing disability implicit or explicit evaluation (i.e., supervision vs. practice models. formal data analysis). When the goals have been met, the client and social worker should review the goals and objective and evaluate what change did take place DISABILITY SOCIAL WORK CONTINUED ON PAGE 10 10 2021 Social Work CE Institute – FOCUS Continuing Education Courses

Considering that this model was created in the context of A critical approach to social work prompts us to examine a number of conceptual domains: cognitive (critical White1 middle class culture, some have raised questions the methods, structures, beliefs, and knowledge that awareness and critical knowledge), behavioral (critical about whether the approach may be unsuitable for clients inform our professional practice. This critical approach skills) and affective (critical empowerment)” (p. 318). from other cultures or social strata. Some argue that the also leads us to grapple with the simultaneous roles of Critical awareness encompasses awareness of cultural planned change process might be especially ill-suited social work as an agent of social control and a threat to differences—between and within groups—and self- to people who are thought to rely on less organized the status quo. The profession of social work, like most awareness. Critical knowledge focuses on learning with and less focused approaches to difficulties (Sue, 1981; culturally and socially bound institutions, defaults to a an understanding of the dynamic nature of culture. Both Galan, 2001). Further, the model does not take into position of maintaining, often unintentionally, systems of critical awareness and critical knowledge underpin the account other ways of doing social work, such as the privilege and oppression. With intentional and ongoing use of critical skills in intercultural interactions. Finally, use of religious helping, the ways informal kin networks critical awareness and action, however, social workers critical empowerment attends to power imbalances in function or the non-professional helping approaches can act against, instead of in concert with, oppressive relationships and the environment. The Critical Cultural found in Indigenous communities. The discipline of processes and outcomes. Competence model was developed with specific attention social work has both pulled from (e.g., family group to multicultural healthcare environments but has potential conferencing) and ignored (e.g., suicide prevention for use in a variety of areas. interventions) these communities in practice over the Theoretical Perspectives last century (Baskin, 2016, Cox et al., 2019, Drywater- Application to disability social work practice. As Whitekiller, 2014; Pon et al., 2011; Wexler & Gone, We highlight three theoretical perspectives that are Dupré (2012) notes, “the disabled people’s movement... 2012). Along the lines of this critique is that professional informed by the critical perspective and are useful affirms and celebrates the existence of disability culture problem-solving is only one approach and one that may for disability social work practice: critical cultural as characterized by several agreed upon assumptions: restrict the ways in which a client tells their story, thus competence, intersectionality, and anti-oppressive disability culture is cross-cultural; it emerged out of failing to consider alternative thinking and reflecting practice. These complementary perspectives emerged a disability arts movement and its positive portrayal 2 approaches. in social work in temporal (the 1970s and 1980s) and of disabled people is not just a shared experience of geographical (the United States and Canada) proximity to oppression but includes art, humour, history, evolving Another major critique of the planned change process is one another. language and beliefs, values and strategies for surviving that it is not data-driven or evidence-based in its origin. and thriving” (p. 168). Critical cultural competence As Perlman developed this model when research was supports recognition of the personal and positive not a major factor in social work practice, her supporting Critical Cultural Competence elements of disability culture, while aligning with documentation was taken from clinical and anecdotal the social model of disability in its critique of ableist sources, as well as her clinical experience. In other Cultural competence originated in social work as a social, political, and economic systems. In working with words, when creating her model, Perlman used the now- response to the increased focus on multiculturalism that individuals and families, this construct brings attention discredited authority-based argument in her research emerged in the 1980s (Nadan, 2014). Cross, Bazron, to the power dynamics inherent in many service systems, (Gambrill, 1999). Authority-based practice is based Dennis, and Isaacs (1989), Green (1982), and Solomon especially those engaged in involuntarily. Furthermore, on what is known as “practice wisdom” as opposed to (1976) are acknowledged as the progenitors of cultural critical cultural competence prompts the self-reflection evidence-based practice (DeRoos, 1990). competence, which has become one of the most and critical examination necessary to recognize one’s prominent constructs in social work education, practice, own biases, perspectives, and position within cultural Finally, the most recent critique of the planned change and research (Danso, 2018; Garran & Werkmeister- and social systems. Finally, this construct helps us avoid process is presented in the South African context (van Rozas, 2013; Nadan, 2014). essentializing disability experiences, identities, and Breda, 2018). In thinking about how best to apply the contexts. planned change process to post-Apartheid South Africa, Cultural competence is defined as a “set of congruent in which a developmental approach to social work is behaviors, attitudes, and policies that come together in Limitations of this framework for disability social noted as ideal, van Breda (2018) considers two major a system, agency, or among professionals and enable work practice. There is much less application of critiques. First, the planned change process “gives that system, agency, or those professionals to work cultural competence or critical cultural competence primacy to the economic vulnerability of society, and effectively in cross-cultural situations’’ (Cross et al., to disability in the literature than to other identities, this commitment must be evident in case work for it 1989, p. 3). Cultural competence is also a process by experiences, and practice areas. One reason for this, as to be regarded as ‘developmental’” (p. 77). Second, which individuals and systems respond respectfully and Dupré (2012) notes, is that the field of social work has in proposing needed changes to the planned change effectively to people of all cultures…in a manner that not embraced an understanding of disability culture. process, van Breda (2018) calls for such a process to recognizes, affirms, and values the worth of individuals, Cultural competence and intercultural practice are most lift up the rights of clients while fostering the agency families, and communities and protects and preserves the often addressed as related to race, ethnicity, language, of clients in both their own living context and in their dignity of each ((National Association of Social Workers and religion. Therefore, there are fewer theoretical and relationship with social workers and other helping (NASW), 2015)). empirical explorations of critical cultural competence in professionals. This author suggests that change can disability social work to inform practice. Also, though be accomplished by “fostering a highly democratic we have seen a highlighting of disability culture by and participatory helping process; placing the person The profession of social work, like most disabled people’s movements, it remains that disability is and the development of the person, rather than the culturally and socially bound institutions, not uniformly or universally viewed as a social/cultural problem, at the centre of the helping process...and defaults to a position of maintaining, often identity. This has implications for how identity- and promoting resilience, independence, self-sufficiency and unintentionally, systems of privilege and culture-bound perspectives are applied when working community-connectedness, rather than dependency and oppression. with disabled people who do not hold disability as a worker-centredness” (van Breda, 2018, p. 77). While van cultural identity. Finally, though the “critical” element Breda’s (2018) writing is focused on the South African of critical cultural competence attends to the notion of experience, these critiques have applicability to practice practitioners adopting an expert stance regarding culture, in the United States as well. there remain concerns that the element of “competence” Recently, a more critical approach to cultural competence in the construct lends itself to essentialism (Dupré, 2012; has emerged with the argument that “awareness, Despite these limitations, the planned change process has Nadan, 2014), especially as related to disability “types.” some utility working with clients and client systems. Our knowledge, and skills alone are inadequate for culturally adaptation of the planned change process addresses some empowering social work research [and practice]; they of the aforementioned limitations by applying a critical should be harnessed for social change” (Danso, 2015, Intersectionality lens and employing concepts related to disability-positive p. 574). Critical cultural competence refers to “social social work practice. workers’ ability to engage in high-level action-oriented, The history and development of intersectionality is not change-inducing analyses of culture and diversity- static and continues to shift. Kimberlé Crenshaw, an related phenomena” (Danso, 2015, p. 574). This concept American lawyer and scholar, is credited with naming Critical Perspective also recognizes issues such as intersectionality, power the term intersectionality. The idea and conceptualization differentials in the worker-client relationship, and of intersectionality, however, may be traced back The critical perspective, which stems from the work examination of one’s social location or social position further. Guy-Sheftall (2009) notes the contributions of of social philosophers linked to the Frankfurt School, held in society based on social characteristics (Lusk et Anna J.H. Cooper (1858-1964) to Black feminism and evolved as a response to both totalitarian and positivist al., 2017). intersectionality, as evident through Cooper’s writings thinking gaining popularity in post-WWI Western Europe on the racism and sexism experienced by Black women Keenan (2004) further expands on the importance of (Salas et al., 2010). Since then, the critical perspective in the Southern United States. Hancock (2005) outlines infusing a critical lens into cultural competence through has been applied to various fields and areas of study. In how W.E.B. Du Bois (1868-1963) wrote about race and the idea of informed not-knowing, which, while attesting social work, the critical perspective is both a lens through class as well as race and gender, developing early ideas to the importance of lifelong learning, can guard against which we analyze our practice within complex social on how identities and oppressions existed and operated essentialism or over generalization. There is recognition structures and a guide for reflexive engagement with together in political contexts. that “knowledge is always partial, perspectival, and individuals, groups, communities, and systems. constructed through the lens of understanding, meaning, Activism and social movements led by women of color and interests of one’s social position” (p. 543). Using during the 1960s and 1970s further contributed to the a critical lens in the practice of cultural competence development of intersectionality. Francis Beal and 1 Debates regarding how to write about identity abound. One article includes the practice of cultural humility, which Toni Cade Bambara published work examining the that captures the spirit and scope of these debates as related to race is presented by the Columbia Journalism Review (Perlman, 2015), which incorporates an ongoing commitment to self-evaluation recommends capitalizing Black, but not White. Arguments in favor and self-critique as a way of maintaining an engaged 2 Debates about the right language to use in talking about disability of capitalizing White are made by Appiah (2020) and the National learning and an other-oriented stance (Hook et al., 2013; are ongoing. For many years, “person-first” language has been deemed Association of Black Journalists (2020) who argue for the explicit rec- Tervalon & Murray-Garcia, 1998). a respectful approach to describing people with disabilities, and for ognition of White racial identity through capitalization. The language in some practitioners and communities, it still is. More recently, many the present document reflects the wishes of the authors, who choose to Almutairi, Dahinten, and Rodney (2015) developed a disability rights advocates have rejected person-first language and have capitalize both Black and White when referring to racial identity. When embraced disability-first or identity-first language with an unapologetic discussing concepts such as Whiteness and White supremacy, we do not Critical Cultural Competence model “comprised of four embrace of disability as a social (and cultural) identity. In this article, use capitalization. We encourage the readers of this work to make their key components: critical awareness, critical knowledge, we use identity-first language due to the preference of the authors; own decisions about language use based on a thoughtful review of the critical skills and critical empowerment that fall into however, in practice, always take the lead of the person or people with literature and based on their contexts. whom you are working. 2021 Social Work CE Institute – FOCUS Continuing Education Courses 11 interconnected impacts of racism, sexism, classism, and capitalism in the lives of Black women (Collins & Bilge, 2016). The Combahee River Collective, through their Anti-oppressive Practice advocacy and activism, brought attention to the multiple oppressions - racism, sexism, classism, and heterosexism - experienced by their members and communities (Collins & Bilge, 2016). During the 1980s, contributions Pre-Engagement Engagement Assessment Intervention Termination Evaluation to intersectionality are linked to a number of activists, • engage in self- • acknowledge • center the • respect the • honor the • co-construct writers, and scholars including (but not limited to): reflection and the limitations client's dignity of risk dignity of risk measures of Gloria Anzaldúa, Angela Davis, bell hooks, Gloria Hull, self-assessment of your own narrative • support self- • recognize progress or knowledge success June Jordan, Audre Lorde, Trinh Minh-ha, and Cherríe • acknowledge • recognize that determination power and disrupt • be open to disabililty and • engage circles dynamics and • center the Moraga (Bubar et al., 2016; Collins, 2015; Collins & cultural learning from intersecting of support imbalances client's Bilge, 2016; Hulko, 2009; Mehrotra, 2010). imperialism and others identities are • foster between and narrative of multi-systemic • employ inter- socically community among worker, their Kimberlé Crenshaw was instrumental in bringing the privilege and identity/ inter- constructed inclusion client, and experience oppression institution term intersectionality to the forefront. Crenshaw (1989) cultural • recognize how • remember: • ongoing engagement policy and “nothing about argued that Black women experience racism and sexism element of techniques institutional us without us” in the legal system and shifted these terms to include professional norms are women of color. At the time, in the legal system, racism practice and socially work with constructed was commonly understood in reference to men of color individuals and • identify circles and sexism in connection to White women. Crenshaw family systems of support (1989, 1991) brought forward that these forms of oppression were not mutually exclusive and operated together in distinct ways for women of color. Patricia Hill Collins has also contributed immensely to the Critical Cultural Competence Intersectionality theorizing and conceptualization of intersectionality. Collins (1990, 2000) proposed interlocking models of oppression as opposed to additive models in which Practice Model for Social Work with Disabled People multiple oppressions are not viewed in binaries (e.g., Black or White or female or male) and, instead, are that arises when future or current social workers are post-modernist, Indigenous, post-structuralist, critical considered to function together. Collins (1990, 2000), learning about intersectionality. Fellows and Razack constructionist, anti-colonial, and anti-racist (Baines, for example, highlighted the racism, sexism, and (1998) describe that competing oppressions cannot 2007, 2011; Brown, 2012) with queer and disability classism experienced by African American women, yet be deemed hierarchical and being marginalized does perspectives more recently added (Baines, 2017). By acknowledged that these oppressions also impact many not make one exempt from being implicated in the building on numerous progressive frameworks, anti- other groups. In this view, using the interlocking model, oppression of others. Fellows and Razack (1998) refer oppressive practice is positioned as a transformative oppressions exist interdependently. to the latter as the “race to innocence” (p. 339). Razack approach to social work (Lai, 2017). While the roots of intersectionality remain in activism, (1998) further explains that addressing one aspect of Anti-oppressive practice centers on recognizing and social movements, and scholarship by women of color, marginalization cannot be separated from challenging all challenging power and oppression, seeking equity, intersectionality has expanded considerably and is now forms of oppression, whether one is impacted by specific inclusion, and social justice for oppressed persons, found across disciplines (Collins, 2019). Intersectionality subordinations or not. Given the saliency of certain groups, and communities, while emphasizing broader has also developed in definition, meaning, and issues in society, it is crucial to consider the historic and political, systemic, and structural understandings and application over the decades (Cho et al., 2013; Collins, current contexts of oppression. explanations of social work and society (Baines, 2007, 2015; Collins, 2019). Broadly, Collins and Bilge (2016) Application to disability social work practice. 2011, 2017; Dalrymple & Burke, 1995, 2006; Dominelli, describe intersectionality as an “analytic tool” and a Intersectionality in disability social work practice 2002; Morgaine & Capous-Desyllas, 2015; Payne, 1997, “way of understanding and analyzing the complexity allows for a more comprehensive appreciation and 2005, 2014). With social work typically focusing on in the world, in people, and in human experience” (p. understanding of a person and communities’ experiences. individual practice and the problems of people accessing 11). Intersectionality, as Collins and Bilge (2016) note, A disabled person has personal and social identities, services (Baines, 2007; Sakamoto & Pitner, 2005), anti- considers “social inequality, power, relationality, social which impact their daily life and realities. Their social oppressive practice moves beyond this limitation by context, complexity, and social justice” (p. 53). They location further determines opportunities that may considering the personal, cultural, and structural levels emphasize intersectionality in praxis, its belonging to or not be available to them. Interlocking systems of of oppression experienced by persons and communities social movements, and its connections to transformation oppression, such as the ableism, racism, and sexism they (Campbell, 2003; Mullaly, 2010; Mullaly & West, 2018). and social justice (Collins & Bilge, 2016). Given the may experience, often exclude them from many facets of significance of these ideas to social work, scholars and society. Understanding and acknowledging the roles of identity practitioners have contributed to the understanding and social location are fundamental to anti-oppressive and applications of intersectionality within the social While significant, the disability or disabilities people practice. Baines (2007) explains that identity is how a work profession (see, for example, Bubar et al., 2016; live with are not their entire being and are connected to person is associated or categorized with either dominant Hulko, 2009; Joseph, 2015; Mattsson, 2012; Mehrotra, other aspects of who they are (MacDonald, 2016). For or marginalized groups, with social location being 2010; Pease, 2010). Contemporary social work has instance, they may also be a student, a parent, a member how they are situated within the “webs of oppression generally integrated intersectionality as a broad term of a faith community, and hold a particular job title or and privilege” (p. 24). Oppression is rooted in the that encompasses all forms of oppression and groups role. However, disabled persons are often defined by unacceptance of differences and the prejudice and of people. Not always are the key contributors and others through an ableist lens, placing this disability discrimination of certain identities and groups (Dumbrill developments of intersectionality fully recognized in social identity at the forefront (Touchie et al., 2016). & Yee, 2019; Mullaly, 2010; Mullaly & West, 2018). social work. Current and future social workers may Using an intersectional lens, social workers may view the Examples of such oppressions include ableism, racism, not have an appreciation or give credit to the feminists entirety of a person’s experience. sexism, heterosexism, cissexism, classism, and ageism and activists of color who brought this theorizing (Dumbrill & Yee, 2019). Less mentioned in anti- and work forward. Thus, an acknowledgment of how Limitations of this framework for disability social oppressive practice are the impacts of colonization, intersectionality came to be before being incorporated work practice. Intersectional social work practice and imperialism, or globalization in creating and shaping the into social work is intentionally included in this course. scholarship, with a focus on disability, is an emerging power, privilege, and access to resources inherent among area (see, for example, Johnson et al., 2020; MacDonald, dominant groups (Baskin, 2016; Dumbrill & Yee, 2019; Oppression and privilege. People accessing services 2016; Wehbi & Lakkis, 2010). Despite a recent growth Pon et al., 2011; Pon et al., 2016; Yee & Wagner, 2013). and social workers alike have various personal and social in interest in disability and intersectionality, it is a identities that position them as oppressed and privileged. limitation that there is not extensive literature to draw on Critical consciousness raising, as proposed by Sakamoto How one defines and understands themselves signifies to inform our work. Numerous social workers already and Pitner (2005), is important to anti-oppressive social their personal identity, whereas how others define and apply an intersectionality lens in practice, and many work practice. This action involves an ongoing process view them refers to their social identity (Hulko, 2009). future social workers will certainly bring considerations of critical reflection and analysis of the social worker’s Collins and Bilge (2016) emphasize that identity is a of intersectionality and disability to their work and assumptions, values, biases, and worldview, of the power “starting point for intersectional inquiry and praxis and contribute to this evolving area. dynamics in the helping relationship and shifting this to not an end in itself” (p. 101). They explain that identity empower the people and communities the social worker can be a way to form coalitions, collective action, and Anti-oppressive Practice is engaging with, while also addressing broader social transformative movements (Collins & Bilge, 2016). injustices (Pitner & Sakamoto, 2005; Sakamoto & Pitner, Coming to know and understand how identity may 2005). Anti-oppressive social workers aim to engage in With a more recent introduction in the United States impact people and communities is imperative to social this process of critical consciousness raising throughout (Morgaine & Capous-Desyllas, 2015), anti-oppressive work practice. Oppression and privilege experienced as their practice. a result of specific identities, for instance, gender, sexual social work practice traces its development from orientation, race, class, age, or disability, denotes one’s radical and structural social work in Canada (Baines, Application to disability social work practice. Anti- social location (Hulko, 2009). Interlocking systems of 2007; Sakamoto & Pitner, 2005), critical social work in oppressive social work, according to Carter, Hanes, and oppression such as racism, sexism, ableism position Australia (Fook, 2002; Ife, 1997; Healy, 2005, 2014) MacDonald (2012), must recognize ableism in discourse and marginalize one’s social location (Hulko, 2004). and anti-racism and anti-discriminatory social work and in practice. Ableism prevents the inclusion and Awareness and analysis of how identities are privileged practice in Britain (Dumbrill & Yee, 2019; Macey & participation of disabled persons in society. Recognizing and marginalized, in addition to the interconnectedness Moxon, 1996; Williams, 1999). Anti-oppressive practice, multiple oppressions, including ableism, and working between interlocking systems of oppression and as Dumbrill and Yee (2019) outline, is an “umbrella of with disabled persons and communities to challenge social location, are a central component to social theories and perspectives” (p. 230). As it has evolved, work practice. Ranking oppressions is often a concern anti-oppressive practice has expanded to draw on DISABILITY SOCIAL WORK additional theories, which include feminist, Marxist, CONTINUED ON PAGE 12 12 2021 Social Work CE Institute – FOCUS Continuing Education Courses these oppressions, gives way for social workers to deepen marginalization in traditionally oppressed being able to engage in meaningful work that does not practice anti-oppressively (Wehbi, 2017). Building communities, such as the disability community (Danso, put receipt of her health care benefits at risk in order on the social model of disability, Carter, Hanes, and 2015). to manage the care she needs for her disability, which MacDonald (2017) propose an anti-oppressive model of is identified as autism. Before reaching out to Regina, disability for social work. This approach deconstructs Acknowledging sociocultural differences is vital when Josie spends time considering how her own presence as dominant notions of disability, while centers on thinking about critical awareness, especially as they a White, middle class social worker from the suburbs individual, community, and societal change (Carter relate to our clients’ disability identity. Recognizing of a major city (who also does not identify as disabled) et al., 2017). Specific practice skills for working anti- disability identities links back to our need to take an might impact the process of building a relationship with oppressively with disabled persons, as outlined by Carter intersectional approach in understanding ourselves in Regina. Further, she considers how her worldview and et al. (2017) include: critical consciousness raising; relation to our clients - which is in turn part of anti- values relate to messages she received while growing up deconstruction; viewing disabled persons as the experts; oppressive practice. Assessing our individual attitudes and how this may impact her future work with Regina. empathy; addressing grief and loss; reframing; advocacy; and values are important, along with recognizing or mediation; peer support; and community engagement watching out for the potential challenges associated (pp. 160-162). Anti-oppressive social work practice, with cross-cultural interactions as there are a range of Central to anti-oppressive practice is the idea according to Sandys (2017), addresses the barriers disability cultures present in the United States. Being that social workers must see disabled people disabled persons experience when seeking social roles able to have awareness of disability-related cultural not only as clients, but partners who are also of importance to them, whether this is being a post- differences is vital to the self-awareness required for allies, advocates, and activists who can teach social work practice with disabled people (Almutairi et secondary student, gaining employment, volunteering, us about their cultures and realities or participating in the community. Anti-oppressive social al., 2015). workers recognize and emphasize the valuable place In particular, social workers need to be aware of the disabled persons and communities have in society (Carter potential consequences of disability cultural diversity et al., 2017; Sandys, 2017; Wehbi, 2017). while also recognizing the social determinants of Acknowledging that history and language are powerful Limitations of this framework for disability social intersectional power relations based on disability and influencers of perspectives and practices, Josie takes work practice. Anti-oppressive practice with a focus on other social identities (Almutairi et al., 2015). With time to consider the history of mainstream social work disability is less explored in academic literature, despite respect to the gathering and use of critical knowledge, the with various Black communities, which, when involved, the relevance and application of this approach in working authors are focused on developing a conceptualization was often oppressive. She also learns about the historical with people with disabilities (Sandys, 2017). Social of any disability culture our client might identify with roots of formal and informal mutual social aid in Black workers seeking to practice anti-oppressively should not as well as gathering information about any potential communities that addressed the needs and fostered the be limited by this lack of information. Anti-oppressive communication challenges during cross-cultural resilience of community members prior to the advent practice literature, including that centered on disability, interactions (which may often be between disabled and of mainstream social work and in response to instances offers ideas and ways to work alongside disabled persons non-disabled people, for example) (Almutairi et al., of exclusion from or harm done by dominant systems. and communities (Carter et al., 2017; Sandys, 2017; 2015). At this stage, it is also vital for social workers to Given what she learns about history and language Wehbi, 2017). Social workers seeking to practice anti- question their connection to and operation within the influencing practice, Josie notes that it will be important oppressively must be up for the challenges of doing political state as it relates to disability justice (Baines, to ask Regina about how she describes herself with social justice social work in an ethical and meaningful 2017). regard to race, ethnicity, disability, and other identities, way. and how she understands her own experiences with While this pre-engagement step is framed as the initial service systems. Additionally, Josie happens across step in the process of work with a client, the above- an article that explores the complexities of written described types of reflective and reflexive considerations expressions of identity, specifically whether or not to A Model for Social Work Practice with need to be engaged in on an ongoing basis as case capitalize the racial identity categories of Black and the Disability Community dynamics shift and evolve by continually employing White. Josie researches this further and finds that there is a critical lens to examine one’s own perspectives and no definitive standard. She determines that it is most to After this review of the planned change process and the practices as well as the structures and systems with follow the lead of the client. three theoretical stances that inform the six-step practice which the client is interfacing. Also, maintaining a stance model (e.g., intersectionality, anti-oppressive practice, of informed not-knowing, recognizing the limitations of and critical cultural competence), we developed a model, Josie also seeks to learn more about various disability current knowledge and the need to engage in ongoing perspectives and experiences among Black Americans. which is focused on practice with disabled people. This learning is important (Keenan, 2004). model views the planned change process through the Reflecting on her learning, Josie reminds herself that while book learning is important, her client Regina will lenses of the tripartite theoretical frameworks presented Social workers can engage in a range of considerations be the best guide to understanding her culture and any above, with disability-specific applications in each stage in the pre-engagement step as an act to disrupt cultural other factors that play out in her life. Josie recognizes of the process. imperialism in the form of mainstream, non-disability that in practice, cross-cultural considerations could go justice-oriented practice (Baines, 2017). For example, unaddressed. She prepares herself for working with the social worker should consider their varying social Pre-engagement Regina by thinking about how she can bring up their identities, world views, and how these might impact their different and shared social identities and how she and work with the specific client in question. Questions to Pre-engagement is a step not explicitly found in other Regina might be able to build a bridge to co-construct consider might include: “How will my social identities iterations of the planned change process, which typically goals, objectives, and an intervention plan for their work impact client engagement?”, “How might my world begin with engagement. We added pre-engagement as a together. Another aspect of Josie’s pre-engagement work views get in the way of seeing things from my client’s key initial step to highlight the importance of engaging will involve considering how Regina prefers to refer to point of view?”, or “What social welfare system cultural in reflective and reflexive practice regarding one’s her race or ethnicity (as well as other social identities) in norms do I practice that might get in the way of a fair, positionality (with special attention to intersectionalities), written documentation. assessment of cultural competence, practice of cultural client-specific assessment?” By engaging in this form humility, and preparedness to engage in anti-oppressive of reflexive and reflective practice, social workers can practice. subvert dominant cultural paradigms (about who needs Engagement and deserves help and in what ways) that may, when The tenets of anti-oppressive practice call for social subconsciously implemented, oppress clients (Baines, The engagement phase is a prime opportunity to learn workers to engage in reflectivity and reflexivity about 2017). from a client more about their disability culture (if who we are as social workers, and what and how we any) and any other cultures the client is affiliated with. do things (Baines, 2017). Central to that process is a As previously, the planned change process in general, and This first step is also the time to learn about the client’s consideration of practitioners’ social identities and how our model in particular, may be implemented at multiple experience of disability and other oppressions as well they may lead to privileged or oppressed positions. levels of practice. a multi-part case example follows to as privileges (Danso, 2015). While doing this work, Considering this ‘positionality’ is vital for social workers demonstrate how the critical theoretical perspectives that social workers will utilize the knowledge they have to engage in prior to meeting clients who may have inform this model could be applied to micro/mezzo-level gained during pre-engagement, while simultaneously different positionalities. Reflectivity is about unearthing social work practice. Though the case study primarily acknowledging the potential limitations of that the actual truth embedded in what professionals do, focuses on micro- and mezzo-levels of practice, the knowledge. Central to anti-oppressive practice is the idea versus just what they say they do (Schön, 1983, 1987). influence of macro-level issues is acknowledged as part that social workers must see disabled people not only Reflexivity, by contrast, is the ability to look inwards and of the narrative. as clients, but partners who are also allies, advocates, and activists who can teach us about their cultures and outwards to recognize how society and culture impacts Example: Josie, a licensed clinical social worker based realities (Baines, 2017). Also important is the ability to practice as well as how we ourselves influence practice. in an outpatient mental health center, receives a referral add to that knowledge by centering the personal expertise The reflective and reflexive social work practitioner to work with Regina, a new client. Josie is tasked with of clients on their life, while being open to learning from will want to ask: “How do I create and influence providing Regina with counseling to address challenges others. This is an evolving and shifting process. the knowledge about my practice that I use to make she is facing with family members and work colleagues. decisions?” In embracing reflectivity and reflexivity, Given that much of the agency’s current work with social workers move beyond ‘just knowing’ how well A key part of the engagement process in practice with clients is occurring remotely due to the COVID-19 disabled people is understanding how disability identity practice is going, which is a form of implicit evaluation pandemic, Josie will need to utilize a telehealth platform that is subjective by nature. does—or does not—fit into their worldview and self- or phone to connect with Regina. concept, regardless of the social worker’s own disability identity. Just because a person has a disability, it does Reflexivity and reflectivity tie especially well to The case file Josie reviews includes an intake form filled not mean that their disability is the reason they are the critical cultural competence model described in out by the client and records from the agency’s previous seeking services. Instead, consider disability as a social this course. Critical cultural competence posits that involvement in Regina’s life. Josie notes that Regina identity in an intersectional approach to engagement. awareness, knowledge, and skills are not enough for identifies as a Black woman and that she grew up in a This engagement work could include gathering doing empowerment-oriented, anti-oppressive practice rural area in western Massachusetts where her family has knowledge from the client about how they prefer to refer (Danso, 2015). Social work practice without the use of a lived for generations. Josie reads that Regina is a high to themselves, how they prefer to communicate, and critical cultural competence lens may lead to ineffective school graduate who tries to maintain a balance between or low-quality services (Casado et al., 2012) and may how they learn best - on top of identifying their primary 2021 Social Work CE Institute – FOCUS Continuing Education Courses 13 concerns and presenting problems. In discussions of A social worker’s embrace of an intersectional with Regina about their differing social identities in how anti-oppressive practice works, social workers framework with the skills of anti-oppressive practice order to ask Regina to reflect on how her social location have acknowledged that language is a force in political and critical cultural competence includes a focus on a may impact or inform her presenting problems. Regina struggles - especially when it comes to disabled people social worker’s actions toward enacting key aspects of says that as a Black woman, she sometimes feels (Baines, 2017). critical awareness and knowledge during cross-cultural marginalized in ways her autistic friends who are White interactions with clients and their identified circles “just don’t get.” Josie and Regina discuss how the Example: Social worker Josie grounds herself as she is of support. This process includes the need for social experiences of people within a group can differ due to the about to meet Regina and reflects on the pre-engagement workers to create space during assessment meetings interactions between multiple manifestations of privilege work she did. Josie turned to literature authored by Black to negotiate and establish disability culture-specific and oppression in their lives. The goal of this line of American women who have shared their experiences meanings related to presenting problems and modes conversation is to co-create a narrative assessment related with disability and mental health services. Other of operation. Recognizing any intersectionalities and to the presenting problems and plans for work together reading focused on learning more about autism, rural social constructions of disability identity as well as that include an understanding of both the personal and communities, and related topics, but ultimately, she will other intersecting identities should be central to this systemic issues at play. look to Regina as the expert in her own life, from whom negotiation. This process of negotiation will help social she can learn. workers to determine a culturally appropriate approach Intervention to practice and care planning that centers the client’s Josie and Regina meet virtually on video via a telehealth narrative of their strengths and needs (Almutairi et platform. Josie begins by introducing herself, explaining Once the social worker and client have co-constructed al., 2015). In addition to the interpersonal aspects of confidentiality and agency policies related to their goals and objectives, a care plan can be developed, the engagement step, social workers must also work work together, including their current need to meet and the social work interventions can commence in to recognize the social construction of policy and remotely due to the COVID-19 pandemic. Josie aims to partnership with the client (Baines, 2017). Ideally, the institutional norms that are related to disability or the start where the client is and asks Regina to share more social worker’s anti-oppressive intervention should focus disability community. about herself, beyond what is in the case file. Josie not only on integrating the disabled person into society, also asks Regina what she would like to work on. Josie Centering the client’s narrative in the assessment phase but should also address ways that society, in micro form, thoughtfully moves into a conversation about what it can also include embracing the disability rights concept can be changed (Baines, 2017). These interventions might be like for Regina to be working with someone of “nothing about us without us” in co-deciding what will foster community inclusion, a key disability rights with different social identities than herself. Josie presenting problems are—and are not! Another way this concept focused on access to the community for disabled mentions that she recognizes that there might be things has been conceptualized is “about us, by us,” according people. Additionally, self-determination on the part of that a White, suburban woman who is not disabled might to the late Massachusetts-based disability rights advocate the client will be respected while inclusion of circles of not understand or know to focus on, but that she is open John Winske (Disability Policy Consortium, 2020). This support will be promoted where appropriate. to being pointed in the right direction. Josie’s action is links to the aspect of critical cultural competence referred Example: Once Regina and Josie have co-constructed demonstrative of a power-sharing approach that attempts to as critical empowerment. Critical empowerment both an assessment as well as goals and objectives to narrow the potentially hierarchical gap between social goes beyond the social worker’s recognition of cultural for their ongoing video work together (a.k.a. “the worker and client. Regina explains that she identifies as a differences, thinking about how the perception of power intervention”), the nature of the work is chosen, and Black woman who has more recently embraced her own imbalance functions in the client’s social, historical and the work process commences. Ideally, this process will disability. Regina tells Josie that she is very involved in political contexts (Almutairi et al., 2015). For example, include a conversation about how the pair will know the Autistic Self Advocacy Network (ASAN), and Josie a social worker could share their assessment of the client when services are no longer needed (in order to facilitate makes a note to learn more about this organization in with the client in order to obtain feedback and allow the termination, later). As Regina has had a choice in how order to understand Regina’s worldview better. She asks client to have some agency in how presenting challenges the intervention is structured, this conversation will Regina to talk about how various parts of her identity are categorized and framed. In situations where the social support her engagement with the process. In her work (e.g., her gender, her race, her disability) interact and worker is present due to legal sanctions, the picture is with Regina, Josie will be sure to weave in intervention influence her life experiences. For example, she asks muddied, and requires even more of an attempt to offset approaches that recognize both Regina’s desire to more about Regina’s experience as a female with autism given the power relations inherent in that situation. that the dominant narrative of the autistic experience fully integrate into work and family environments in any appears to be male. By directly bringing up these topics, Social workers also need to focus on identifying areas needed ways and addressing micro-options for how these Josie is working to be transparent about working toward where they can respect the dignity of risk, or the right environments can be more inclusive for Regina and other creating a positive relationship with Regina, one in which of disabled people to be able to learn and grow from disabled people. she will feel supported. As the engagement process goes access to everyday risk. As goals and objectives are Josie approaches her work from multiple fronts. First, she on beyond the first meeting, Josie is sure to demonstrate being identified by the social worker and client, the conducts different reality-based role plays with Regina what she has learned from Regina in her second, social worker should assess for areas in which they to practice noticing social cues, which will help with third, and fourth meetings—and beyond—by taking a might be able to allow clients the dignity of risk. For Regina’s inclusion in her workplace community. Second, culturally responsive approach that ideally helps Regina example, a young mother with an intellectual disability regarding the need for structural change, as Regina and to feel heard and seen, such as sharing what she has is noted by social workers and nurses in the hospital to Josie work together, Regina feels increasingly more learned from reading about the ASAN. forget to feed her new baby. Upon further exploration, comfortable advocating for herself to her manager the social worker learns that the young woman can read around neurodiversity acceptance. At Regina’s request, Josie recognizes that it is also important to honor and digital but not analog clocks. Replacing the clock in the the manager encourages the workplace’s diversity implement the three theoretical frameworks that guide hospital room and obtaining a digital watch allow for committee to take on the challenge of learning more this model in her documentation work, as well as other the mother to have an opportunity to meet her baby’s about neurodiversity and exploring the structures in aspects of client-centered practice. This includes utilizing needs appropriately. In this scenario, the dignity of risk is the workplace that may or may not promote inclusion. a critical cultural competence lens in thinking about allowed for in a safety net context. how she writes about Regina in her case notes. For This includes recognition of the larger issue of greater example, considering how she will document in a way Example: In her first meeting with Regina, Josie potential for law enforcement involvement in situations that respects how Regina wants to be referred to (e.g., was very focused on building rapport in a culturally involving Black disabled people - something that Regina capitalizing Black) while meeting agency or professional responsive manner, but she was also beginning to make could be at risk of during one of her pushing incidents at documentation requirements. observations about Regina as part of her assessment work (McCauley, 2017; Thompson, 2021). process. As Josie uses the agency-mandated clinical Third, Josie also works with Regina’s family via a assessment tools in her work with Regina, she is mindful Assessment telehealth platform to identify opportunities to do things of whether or not these tools utilize a culturally-sensitive differently, in ways that make sense to how Regina or culturally-specific lens. She makes sure to integrate Social workers should be drawing on the critical skills likes to operate, in order to address a small way that the critical perspectives with the information gained from discussed as part of critical cultural competence as family culture can be changed. This might mean, for the clinical assessment tools. Josie also reflects on well as the reflective and reflexive skills associated example, building in a daily time for Regina to share new the differences between meeting clients virtually on with anti-oppressive practice as the assessment step information about her passion for endangered species video compared to in-home sessions as it relates to the launches. Considerations of intersectionality in client of mammals across the world with her family. Having application of anti-oppressive practice techniques, for assessment dovetail with both approaches. Recall this time-limited discussion allows Regina to talk about example. that intersectionality is a tool for contextual analysis topics she is passionate about without overwhelming and assessment (Cho et al., 2013; Collins & Bilge, In order to create a disability-positive process, Josie loved ones who might otherwise experience this as a 2016; Crenshaw, 1995). This framework posits that thinks about the “nothing about us without us” credo that constant topic of conversation. In doing this, Josie is “people simultaneously occupy multiple positions many disability rights advocates call for (something she aware of how shared familial and cultural norms intersect (positionalities within the socio-political and structural has learned about on the ASAN website) and uses it to with personal identities and experiences and need to be fabric of society)” (Ortega & Faller, 2011, p. 31). Using inspire her approach to assessment. This translates into addressed all together using an intersectional perspective. this lens, we consider how potential inequities clients Josie asking Regina to step outside of herself to describe The technical challenges involved in conducting family experience are not caused or maintained by a single the person and situation she sees, using her own words counseling via video with Regina’s family during this factor alone (such as racism, sexism, or ableism). Instead, to describe both strengths and challenges. She also asks time have been particularly difficult, but Josie has used inequities may be created and may continue due to the Regina to dialogue with her friends in the ASAN chat similar strategies of checking in with the family during interactions between multiple manifestations of privilege room about the challenges she is facing, in order to help the telehealth sessions as she uses with Regina. and oppression. Systems of advantage based on social Regina build community and develop new perspectives. At various points during their work together, Regina and identities are enacted and enforced internally (within Using Regina’s language for conceptualizing a presenting Josie move their individual sessions onto the telephone individual people), interpersonally (between individuals problem can be an empowering action. For example, due to challenges related to Internet access for the video and groups), institutionally (within organizations) Regina describes how her colleagues have a hard telehealth platform. This presents a challenge for some and structurally (among institutions, across society) time with her “tics.” Exploring further, Josie learns of the role-playing that the duo is working on together (Lawrence & Keleher, 2004). These separate systems that the comment refers to incidents in which Regina given the need for Regina to develop skills in the area of work together to organize and justify both privilege and is compelled to touch or push someone if they have oppression (Collins & Bilge, 2016; Connor, 2006). accidentally bumped into her. This has led to conflict. DISABILITY SOCIAL WORK Josie can also look back to the conversation she had CONTINUED ON PAGE 14 14 2021 Social Work CE Institute – FOCUS Continuing Education Courses identifying visual cues in interpersonal interactions. Josie “interview practices that align with the community’s which had major implications for independent living works to check in with Regina on video and telephone to cultural norms could reduce power differentials in the potential. The ILM resulted in the development of many make sure that their process is a fit for Regina’s needs. interview process. Interviews should be conducted in independent living centers nationwide (Oliver et al., Questions she may ask include: “How are the role plays ways that acknowledge and respect personal and cultural 2012). going for you?”, “What are you gaining from these role idiosyncrasies. Using cultural concepts and expressions plays towards your therapeutic goals?”, and “Is there or inviting participants to suggest ways for conducting The shift from institutional to independent living was not anything we should change in how we are doing this interviews within the community would enable coupled with sufficient funding for supporting disabled work together?” This also involves Josie needing to participants to feel validated regarding their culture or people in the community (Dunn & Langdon, 2016; attend to and respond to subtle cues that Regina may self-esteem” (p. 581). These considerations extend to the Larson, 2016). This lack of funding continues to date, share in their interactions virtually or on the telephone. data analysis and data reporting process as well (Danso, with contemporary social welfare programs often being 2015). linked to a person’s ability to obtain paid work (Duffy & Elder-Woodward, 2019). However, disabled persons Termination Consideration of implicit as well as explicit evaluation commonly experience ableism and inaccessibility when data should be engaged in - especially with respect to seeking work or when already employed, and often It is vital to recognize power dynamics and imbalances how clients view their experience with the intervention have additional expenses increasing their costs of living especially as they relate to structural issues of privilege (Danso, 2015). Implicit evaluation is focused on informal (Saffer, Nolte, & Duffy, 2018). Until these barriers are and oppression as well as the social worker’s role discussions and informal observations. Going back to addressed or removed, sufficient and specific disability authority and the client’s vulnerability during the considerations of intersectionality are equally important support benefits are needed not only to reduce the termination step of practice (Baines, 2017). For example, at this step. As a framework, intersectionality encourages poverty levels of disabled people but to ensure a more issues of power dynamics can arise during termination practitioners to move beyond viewing and responding than adequate standard of living (Saffer et al., 2018). regarding decisions about when and how services to social inequities through a disability-only or a race- and relationships are terminated - especially when the only lens and causes people to understand and respond For social workers practicing under the ILM model, such services/relationships are involuntary. Even if mandated to these inequities at once (Collins & Bilge, 2016). as those in independent living centers, it is important involvement is not the case, honoring the client’s dignity As there is no singular way to be a person of color or to resist professionalizing the work “on the basis of an of risk will be a central concern for an anti-oppressive to be a person with a disability, service systems must expertise in impairment as a cause of social need” as social work practitioner. Ideally, the co-constructed be envisioned and built with inclusive equity in mind. this would be an oppressive act (Oliver et al., 2012, p. intervention will have led to changes in the client’s life Intersectionality is an essential conceptual tool as it 152; Hiranandani, 2005). Rather, social workers need to allowing for them to resume life without the support of a offers insight into the interactions between various social commit to the removal of barriers causing disability—in social worker and, therefore, allowing for the dignity of identities and society, while also offering an opportunity an equal partnership with disabled people. Specifically, risk. to evaluate, name, assess, modify, and build services that “the problems of disabled people, or social workers, are will reduce or eradicate intersectional inequities. Using not resolved by the incorporation of empowerment as an Example: Regina voluntarily sought out assistance from an intersectional frame is a form of social action at the instrumental competence” (Oliver et al., 2012, p. 152). Josie’s outpatient mental health center in order to address evaluation step. her challenges at work and at home. Over time, Regina Our model aligns with the ILM model of practice in how came to really enjoy her weekly virtual counseling Example: As Josie begins the process of termination, it addresses both the personal and social aspects of living sessions with Josie, even though the work was hard and she reflects that the termination and evaluation phases with a disability and the need for social workers to defer they sometimes experienced technical difficulties. Josie are closely intertwined. Using an anti-oppressive to the client as an expert on their own needs. became an important part of her life. Josie has started practice approach, she and Regina began their work by The Disability Competent Care (DCC) model was to notice that Regina’s work life has begun to stabilize, identifying measures of progress or success for use in developed by The Lewin Group in conjunction with as has her family life. Regina has been able to learn the continuous evaluation of the intervention process. By disabled people and service system consultants and more about how to notice social cues and respond to touching on these measures during each session through adopted by the Council on Social Work Education them appropriately in a way that fosters her community the use of electronic tracking tools, Josie can help Regina (CSWE) as a guiding framework for practice (Disability inclusion. She has also started to do a better job of document her process on what brought her to seek help. Competent Care Working Group, CSWE, 2019). This managing her tics in a way that promotes the potential This creates a visual map for Regina to look at and DCC model is noted to take a person-centered approach for continued community inclusion. Finally, Regina respond to. This also helps Josie to meet the National to providing social work that is focused on supporting has developed a greater sense of empowerment related Association of Social Workers’ Code of Ethics (2017) people with functional limitations in achieving best- to advocating with her family and employer regarding requirement to evaluate all practice. This evaluation possible functionality. This process is conceptualized disability and inclusion. interaction lays a foundation both for feedback about as including work with an interdisciplinary care group how the process of treatment is going and also for having Using an anti-oppressive practice lens, Josie recognizes that views and supports clients as unique people versus a conversation about termination when the time is right that her role as a social worker comes with a certain just a diagnosis or condition per the medical model of (based on the outcome data!). This type of data-driven authority. She reminds herself of Regina’s potential disability. In addition to responding to a client’s physical evaluation is known as explicit evaluation. Josie also vulnerability around the termination of services, and clinical needs, DCC also takes into consideration leads Regina in intersectionality-informed discussions given the positive relationship and even potential their social, emotional, intellectual, and spiritual needs. that may be thought of as implicit evaluations, related dependency that has developed. It is important, though, Further, this model supports both self-determination and to how, in the end, Regina feels her intersecting social to acknowledge dignity of risk in clients moving on community inclusion with a focus on providing supports identities may have played into the intervention process, independently with their lives without the support of a and services that allow for home-based self-sufficiency. and her approach to addressing her challenges. therapeutic presence. There are seven pillars which, taken together, comprise the concept of DCC. These pillars include understanding Reminding Regina of their conversation about when the DCC model, participant engagement, access, they thought services would no longer be needed, Comparison of this Practice Model to primary care, care coordination, long-term supports and Josie brings up the topic of termination. As there has Existing Disability Practice Models behavioral health. For more information about this mode, been a precursor to this conversation, Regina is more view https://www.resourcesforintegratedcare.com/. prepared to think about termination than she might Two disability practice-related frameworks have been have been. Regina agrees that her presenting problems identified in the United States context: the independent In discussing the DCC, the CSWE calls for “moving have been well addressed, and that she understands living model and the disability competent care model. away from a medical model of disability perspective the need for termination, but asks to be able to contact The independent living model (ILM) is very similar to to a constructionist or social model approach” (p. 7). It Josie for support once in a while, if she needs it. Given the social model of disability. The ILM conceptualizes does not seem, however, that the DCC model focuses that Josie’s agency allows for this via a specialized disability as a social construct located in society (i.e., on addressing or removing the barriers experienced by aftercare program, she agrees to periodic check- the social model of disability) versus being located in disabled persons and communities (Oliver et al., 2012). ins, acknowledging that this could be preventative in an individual body part (a.k.a. the medical model of The DCC model may also be critiqued for not having an addressing any challenges Regina may encounter in the disability) (Oliver et al., 2012). The focus of the ILM is explicit inclusion of disability culture. In her work on future. advocating for independence for disabled people with the disability culture and cultural competency in social work, acknowledgement that they are their own experts about Marilyn Dupré (2012) writes that social workers need to Evaluation what they need, and which services are ideal to meet move beyond an assumption of the possibility of cultural those needs (National Center for Independent Living, competence, to an embrace of learning about disability 2020). Thought of as driven by ‘consumer control,’ many culture. Our model builds on the utilitarian DCC At the assessment stage, the social worker and client co- believe the ILM was initiated by disability civil rights model by layering on steps for practice infused with constructed goals and objectives as well as identified legend Ed Roberts and his group of ‘Rolling Quads’ at considerations stemming from intersectionality, critical measures of progress or success. These goals and the University of California at Berkeley, often thought of cultural competence, and anti-oppressive practice. objectives feed directly into how the evaluation step as the birthplace of the disability civil rights movement should be accomplished. At the evaluation step, which and the independent living movement (McCrary, 2017). should be continuous throughout the planned change Conclusion process, client-approved measures of progress or success In addition to being heavily influenced by the civil rights should be considered carefully, centering the client’s movement of the 1960s and 1970s, the ILM was also Keeping A Model for Social Work Practice with the Disability narrative of their experience during the intervention jump-started by the process of deinstitutionalization. Community in mind as you approach your work with process. This reflection may result in the use of explicit During this time period, people with significant disabled people, think about the ways you can infuse your evaluation techniques that are qualitative in nature disabilities began to have some opportunities to live practice with the theoretical perspectives of critical cultural as opposed to the use of quantitative data collection in community-based settings as opposed to nursing competence, intersectionality, anti-oppressive practice, and instruments that may not be culturally appropriate homes and other institutional settings—although quasi- the tenets of disability-positive practice: the dignity of risk, across a range of social identity categories (Danso, institutional settings such as group homes and other self-determination, circles of support, community inclusion, 2015). Even with qualitative inquiry as part of the shared living arrangements sprung up at this time as well. and the “nothing about us without us” credo. Consider your explicit evaluation process, power differentials should These factors caused disability civil rights advocates own personal and social identities, experiences of privilege be noticed and balanced in the interview setup (Rubin to speak out for equal opportunity in figuring out how and oppression, and ways you can be reflexive and reflective & Babbie, 2014). For example, Danso (2015) writes to live, work, and participate in the community, all of in approaching your practice with disabled clients. 2021 Social Work CE Institute – FOCUS Continuing Education Courses 15 References Dalrymple, J., & Burke, B. (2006). Anti-oppressive practice, social Joseph, A. (2015). Beyond intersectionalities of identity or care and the law (2nd ed.). Open University Press. interlocking analyses of difference: Confluence and the problematic of “anti”-oppression. Intersectionalities: A Global Journal of Social Almutairi, A., Dahinten, V., & Rodney, P. (2015). Almutairi’s critical cultural Danso, R. (2015). An integrated framework of critical cultural Work Analysis, Research, Polity, and Practice, 4(1), 15-39. competence model for a multicultural healthcare environment. competence and anti-oppressive practice for social justice social Nursing Inquiry, 22(4), 317-325. work research. Qualitative Social Work, 14(4), 572-588. Keenan, E. K. (2004). From sociocultural categories to socially located relations: Using critical theory in social work practice. Appiah, K. (2020, June 18). The case for capitalizing the B in Black. Danso, R. (2018). Cultural competence and cultural humility: A Families in Society, 85(4), 539-548. The Atlantic. https://www.theatlantic.com/ideas/archive/2020/06/ critical reflection on key cultural diversity concepts. Journal of time-to-capitalize-blackand-White/613159/ Social Work, 18(4), 410-430. Kirst-Ashman, K.K., & Hull, G. H. (2010). Understanding generalist practice (International edition). Brooks/Cole, Cengage Learning. Baines, D. (2007). Anti-oppressive social work practice: Fighting for DeRoos, Y. S. (1990). The development of practice wisdom through space, fighting for change. In D. Baines (Ed.), Doing anti-oppressive human problem-solving processes. Social Service Review, 64, 276- Kirst-Ashman, K. K., & Hull, G. H., Jr. (2015). Generalist practice practice: Building transformative politicized social work (pp. 1-30). 287. with organizations and communities (6th ed.). Brooks/Cole. Fernwood Publishing. Disability Competent Care Working Group, Council on Social Work Lai, D. W. L. (2017). Social work theories and practice models. In Baines, D. (2011). An overview of anti-oppressive practice: Roots, Education Council on Disability and Persons with Disabilities, S. Hick & J. Stokes (Eds.), Social work in Canada: An introduction theory, tensions. In D. Baines (Ed.), Doing anti-oppressive practice: (2019). Curricular resource on disability and disability-competent (4th ed., pp. 74-103). Thompson. Social justice social work (2nd ed., pp. 2-24). Fernwood Publishing. care: Diversity and justice supplement. https://cswe.org/Centers- Initiatives/Centers/Center-for-Diversity/Curricular-Resource-on- Larson, G. (2016). Mental health disability: The forgotten terrain. Baines, D. (2017). An overview of anti-oppressive practice: Roots, Issues-of-Disability-and-Di.aspx In J. Robertson & G. Larson (Eds.), Disability and social change: theory, tensions. In D. Baines (Ed.), Doing anti-oppressive practice: A progressive Canadian approach (pp. 188-204). Fernwood Social justice social work (3rd ed., pp. 2-29). Canadian Scholars’ Disability Policy Consortium. (2020). About us, by us. https://www. Publishing. Press. dpcma.org/dpc-publication-about-us-by-us Lawrence, K., & Keleher, T. (2004). Structural racism. https://www. Baskin, C. (2016). Strong Helpers’ Teachings: The value of Drywater-Whitekiller, V. (2014) Family group conferencing: An intergroupresources.com/rc/Definitions%20of%20Racism.pdf Indigenous knowledges in the helping professions (2nd ed.). Indigenous practice approach to compliance with the Indian Child Canadian Scholars’ Press. Welfare Act. Journal of Public Child Welfare, 8(3), 260-278. Lusk, M., Terrazas, S., & Salcido, R. (2017). Critical cultural competence in social work supervision. Human Service Brown, C. G. (2012). Anti-oppression through a postmodern lens: Dominelli, L. (2002). Anti-oppressive social work theory and Organizations: Management, Leadership & Governance, 41(5), 464- Dismantling the master’s conceptual tools in discursive social work practice. Palgrave Macmillan. 476. practice. Critical Social Work, 13(1), 34-65. Duffy, S., & Elder-Woodward, J. (2019). Basic income plus: Is Macey, M., & Moxon, E. (1996). An examination of anti-racist and Bubar, R., Cespedes, K., & Bundy-Fazioli, K. (2016). UBI consistent with the goals of the independent living movement? anti-oppressive theory and practice in social work education. British Intersectionality and social work: Omissions of race, class, and Social Alternatives, 38(2), 19-27. Journal of Social Work, 26(3), 297- 314. sexuality in graduate school education. Journal of Social Work Education, 52(3), 283-296. Dumbrill, G., & Yee, J. Y. (2019). Anti-oppressive social work: Mattsson, T. (2012). Intersectionality as a useful tool: Anti- Ways of knowing, talking, and doing. Oxford University Press. oppressive social work and critical reflection. Affilia, 29(1), 8-17. Campbell, C. (2003). Anti-oppressive theory and practice as the organizing theme for social work education: The case in favor. Dunn, P., & Langdon, T.-L. (2016). Looking back, rethinking McCauley, E. (2017). The cumulative probability of arrest by age Canadian Social Work Review, 20(1), 121-126. historical perspectives and reflecting upon emerging trends. In J. 28 years in the United States by disability status, race/ethnicity and Robertson & G. Larson (Eds.), Disability and social change: A gender. American Journal of Public Health. 107(12). 1977-1981. Carter, I., Hanes, R., & MacDonald, J. (2012). The inaccessible progressive Canadian approach (pp. 27-44). Fernwood Publishing. road not taken: The trials, tribulations and successes of disability McDonald, J. E. (2016). Intersectionality and disability. In J. inclusion within social work post-secondary education. Canadian Dupré, M. (2012). Disability culture and cultural competency in Robertson & G. Larson (Eds.), Disability and social change: Disability Studies Journal, 1(1), 109-142. social work. Social Work Education, 31(2), 168-183. A progressive Canadian approach (pp. 137-166). Fernwood Publishing. Carter, I., Hanes, R., & MacDonald, J. (2017). Beyond the social Fellows, M. L., & Razack, S. (1998). The race to Innocence: model of disability: Engaging in anti-oppressive social work Confronting hierarchical relations among women. Journal of McCrary, L. (2017). Re-envisioning Independence and Community: practice. In D. Baines (Ed.), Doing anti-oppressive practice: Social Gender, Race & Justice, (1), 335-352. Retrieved from https:// Critiques from the Independent Living Movement and L’Arche. justice social work (3rd ed., pp. 153-171). Canadian Scholars’ Press. scholarship.law.umn.edu/faculty_articles/274. Journal of Social Philosophy, 48(3), 377-393.

Casado, B., Negi, J., & Hong, M. (2012). Culturally competent Fook, J. (2002). Social work: Critical theory and practice. SAGE Mehrotra, G. (2010). Toward a continuum of intersectionality social work research: Methodological considerations for research Publications. theorizing for feminist social work scholarship. Affilia, 25(4), 417- with language minorities. Social Work, 57(1), 1-10. 430. Galan, F. J. (2001). Experiential approach with Mexican-American Cho, S., Crenshaw, K. W., & McCall, L. (2013). Toward a field of males with acculturation stress. In H. E. Briggs & K. Corcoran Morgaine, K., & Capous-Desyllas, M. (2015). Anti-oppressive intersectionality studies: Theory, applications, and praxis. Signs, (Eds.), Social work practice (pp. 283-302). Lyceum. social work practice: Putting theory into action. SAGE Publications. 38(4), 785-810. Gambrill, E. (1999). Evidence-based practice: an alternative to Mullaly, B. (2010). Challenging oppression and confronting Collins, P. H. (1990). Black Feminist thought: Knowledge, authority-based practice. Families in Society, 80, 341-350. privilege: A critical social work approach (2nd ed.). Oxford consciousness, and the politics of empowerment. Unwin Hyman. University Press. Garran, A. M., & Werkmeister-Rozas, L. (2013). Cultural Collins, P. H. (2000). Black Feminist thought: Knowledge, competence revisited. Journal of Ethnic and Cultural Diversity in Mullaly, M., & West, J. (2018). Challenging oppression and consciousness, and the politics of empowerment (2nd ed.). Social Work, 22, 97-111. confronting privilege: A critical approach to anti-oppressive and Routledge. anti-privilege theory and practice (3rd ed.). Oxford University Press. Green, J. W. (1982). Cultural awareness in the human services. Collins, P. H. (2015). Intersectionality’s definitional dilemmas. Prentice-Hall. Nadan, Y. (2014). Rethinking ‘cultural competence’ in international Annual Review of Sociology, 41(1), 1-20. social work. International Social Work. Advance online publication. Guy-Sheftall, B. (2009). Black Feminist Studies: The case of Anna doi:10.1177/0020872814539986 Collins, P. H., & Bilge, S. (2016). Intersectionality. Polity Press. Julia Cooper. African American Review, 43(1), 11-15. National Association of Black Journalists (2020, June 11). Statement Collins, P. H. (2019). Intersectionality as critical social theory. Duke Hancock, A-M. (2005). W.E.B. Du Bois: Intellectual forefather of on capitalizing Black and other racial identifiers. https://www.nabj. University Press. intersectionality? Souls, 7(3-4), 74-84. org/news/512370/NABJ-Statement-on-Capitalizing-Black-and- Other-Racial-Identifiers.htm Connor, D. (2006). Michael’s story: “I get into so much trouble Healy, K. (2005). Social work theories in context: Creating just by walking”: Narrative knowing and life at the intersections frameworks for practice. Palgrave MacMillan. National Association of Social Workers. (2015). Standards and of learning disability, race, and class. Equity and Excellence in indicators for cultural competence in social work practice. NASW Education, 39, 154-165. Healy, K. (2014). Social work theories in context: Creating Press. frameworks for practice (2nd ed.). Palgrave Macmillan. Cox, L. E., Tice, C. J., & Long, D. D. (2019). History of social work National Association of Social Workers. (2017). Code of Ethics. . In Introduction to social work: An advocacy-based profession (2nd Hiranandani, V. (2005). Towards a critical theory of disability NASW Press. https://www.socialworkers.org/About/Ethics/Code- ed., pp. 23-37). SAGE Publications. in social work. Critical Social Work, 6(1), 1-21. Retrieved of-Ethics/Code-of-Ethics-English from: https://ojs.uwindsor.ca/index.php/csw/article/download Crenshaw, K. (1989). Demarginalizing the intersection of race /5712/4667?inline=1 National Center for Independent Living (NCIL) (2020). About and sex: A Black Feminist critique of antidiscrimination doctrine, Independent Living. https://ncil.org/about/aboutil/ feminist theory and antiracist politics. University of Chicago Legal Hook, J. N., Don, D. E., Owen, J., Worthington, E. L. Jr., & Utsey, Forum, 1(8), 139-167. S. O. (2013). Cultural humility: Measuring openness to culturally Oliver, M., Sapey, B., & Thomas, P. (2012). Social work with diverse clients. Journal of Counseling Psychology, 60, 353–366. disabled people (4th ed.). Basingstoke, Palgrave Macmillan. Crenshaw, K. (1991). Mapping the margins: Intersectionality, identity politics, and violence against women of color. Stanford Law Hulko, W. (2009). The time- and context-contingent nature of Ortega, R., & Faller, K. (2011). Training child welfare workers from Review, 43(6), 1241-1299. intersectionality and interlocking oppressions. Affilia, 24(1), 44-55. an intersectional cultural humility perspective: A paradigm shift. Child Welfare, 90(5), 27-49. Crenshaw, K. (1995). Mapping the margins: Intersectionality, Hulko, W. (2004). Social science perspectives on dementia identity politics, and violence against women of color. In K. research: Intersectionality. In A. Innes, C. Archibald, & C. Murphy Payne, M. (1997). Modern social work theory (2nd ed.). Macmillan Crenshaw, N. Gotanda, G. Peller, & K. Thomas (Eds.), Critical Race (Eds.), Dementia and social inclusion: Marginalised groups and Palgrave. Theory: The key writings that formed the movement. The New marginalised areas of dementia research, care, and practice (pp. 237- Press. 254). Kingsley. Payne, M. (2005). Modern social work theory (3rd ed.). Macmillan Palgrave. Cross, T. L., Bazron, B. J., Dennis, K. W., & Isaacs, M. R. (1989). Ife, J. (1997). Rethinking social work: Towards critical practice. Towards a culturally system of care: A monograph on effective Longman. Payne, M. (2014). Modern social work theory (4th ed.). Macmillan services for minority children who are severely emotionally Palgrave. disturbed (Vol. 1). CASSP Technical Assistance Center, Georgetown Johnson, L. M., Slayter, E., & Livingstone, A. (2020). Locating the University Child Development Center. https://archive.org/details/ intersections of disability, race and ethnicity in adoption rates among Pease, B. (2010). Undoing privilege: Unearned advantage in a towardsculturall00un foster children. Adoption Quarterly, 23(2), 110-134. divided world. Zed Books.

Dalrymple, J., & Burke, B. (1995). Anti-oppressive practice, social Johnson, L. C., & Yanca, S. J. (2010). Social work practice: A care and the law. Open University Press. generalist approach (10th ed.). Allyn & Bacon. DISABILITY SOCIAL WORK CONTINUED ON PAGE 16 16 2021 Social Work CE Institute – FOCUS Continuing Education Courses

Perlman, H. H. (1957). Social casework: A problem-solving process. University of Chicago. Disability Social Work: Connecting Critical Cultural Perlman, M. (2015, June 23). Black and White: Why capitalization matters. Columbia Journalism Review. https://www.cjr.org/analysis/ Competence, Intersectionality, and Anti-oppressive Practice language_corner_1.php 1.5 CEUs - POST-TEST Pitner, R. O., & Sakamoto, I. (2005). The role of critical Circle all correct answers. consciousness in multicultural practice: Examining how its strength becomes its limitation. American Journal of Orthopsychiatry, 75(4), 1. As discussed in this course, critical theoretical 6. According to the model presented in this article, 684-694. perspectives that inform social work practice with the elements of the pre-engagement phase should be Pon, G., Gosine, K., & Phillips, D. (2011). Immediate response: disability community include: (Select all that apply) included throughout the planned change process. Addressing anti-Native and anti-Black racism in child welfare. a. Critical Cultural Competence True or False International Journal of Child, Youth and Family Studies, 2(3/4), b. Intersectionality 385-409. 7. Critical consciousness raising, as proposed by c. Anti-oppressive Practice Sakamoto and Pitner (2005), involves an ongoing Pon, G., Giwa, S., & Razack, N. (2016). Foundations of anti-racism d. Evidence-based Practice process of: (Select one) and anti-oppression in social work practice. In A. Al-Krenawi & J. a. Consistently calling out individuals who use the R. Graham (Eds.), Diversity and social work in Canada (pp. 38-58). 2. In which phase of the practice model presented in Oxford University. this article would Josie begin to learn more from wrong language Regina about her disability identity and culture? b. Reflecting on the power dynamics in the help- Razack, S. (1998). Looking White people in the eye: Race, gender, (Select one) ing relationship and shifting this to empower the and culture in courtrooms and classrooms. University of Toronto people and communities the social worker is Press. a. Pre-engagement engaging with b. Engagement Richmond, M. E. (1917). Social diagnosis. Russell Sage Foundation. c. Holding listening circles for social workers c. Assessment d. Considering how to have clients complete Richmond, M. E. (1922). What is social casework? An introductory d. Intervention description. Russell Sage Foundation. identity-based questionnaires 3. How might social workers use elements of the Rubin, A., & Babbie, E. (2013). Essential research methods for disability social work practice model within their 8. A key element of anti-oppressive practice is: (Select one) social work (3rd ed.). Brooks/Cole. own professional contexts? (Select all that apply) a. A sole focus on individual experiences of oppression Saffer, J., Nolte, L., & Duffy, S. (2018). Living on a knife edge: The a. Read about the intersectional disability justice b. Attention given to how oppression based on responses of people with physical health conditions to changes in movement disability primarily impacts families disability benefits. Disability & Society, 33(10), 1555-1578. b. Choose whether to use identity first versus person c. Development of a taxonomy of ableism Sakamoto, I., & Pitner, R. O. (2005). Use of critical consciousness first language and use it consistently regardless of in anti-oppressive social work practice: Disentangling power context or client preference d. Consideration of the personal, cultural, and dynamics at personal and structural levels. British Journal of Social c. Develop an awareness of disability rights groups structural levels of oppression experienced by Work, 35(4), 435-452. in Massachusetts persons and communities Salas, L. M., Sen, S., & Segal, E. A. (2010). Critical theory: Pathway d. Identify disability culture and empowerment 9. The concepts “reflectivity” and “reflexivity” mean from dichotomous to integrated social work practice. Families in resources to connect clients to Society, 91(1), 91-96. practically the same thing. 4. Which of the following is not a key component of Sandys, J. (2017). Anti-oppressive social work with disabled people: Almutairi, Dahinten, and Rodney’s (2015) Critical True or False Challenging ourselves to do better. In S. Wehbi, & H. Parada (Eds.). Cultural Competence model? (Select one) Re-imagining anti-oppression social work practice (pp. 95-108). 10. Josie’s work with Regina on co-deciding what a. Critical values Canadian Scholars’ Press. presenting problems are and are not is an b. Critical knowledge Schon, D. (1983). The reflective practitioner. Temple Smith. example of which of the following disability c. Critical skills Schon, D. (1987). Educating the reflective practitioner. Jossey-Bass. d. Critical empowerment practice principles as noted in the model presented in this article? (Select one) Solomon, B. B. (1976). Black empowerment: Social work in 5. Kimberlé Crenshaw is responsible for the original oppressed communities. Columbia University Press. idea and conceptualization of intersectionality. a. Identify circles of support b. Respect the dignity of risk Sue, D. W. (1981). Counseling the culturally different. Wiley. True or False c. Foster community inclusion Tervalon, M., & Murray-Garcia, J. (1998). Cultural humility versus cultural competence: A critical distinction in defining physician d. Honor “nothing about us without us” training outcomes in multicultural education. Journal of Health Care for the Poor and Underserved, 9, 117-125. Please perform the following steps: Thompson, V. (2021, February 10). Understanding the policing of ‰ Complete and return this entire page. A score of 80% or better is passing and we will send a certifi- Black disabled bodies. Center for American Progress. https://www. cate of completion for 1.5 CEUs to you. americanprogress.org/issues/disability/news/2021/02/10/495668/ understanding-policing-black-disabled-bodies/ ‰ Please enclose check payable to “NASW-MA” (Sorry, credit cards not accepted for this offer.)

Touchie, M., Thomas, M., Porter, J., & Regan, L. (2016). Privileging ‰ Mail to: NASW-MA, 11 Beacon Street, Suite 510, Boston, MA 02108 the voices of people with disabilities. In J. Robertson & G. Larson (Eds.), Disability and social change: A progressive Canadian Please indicate whether the following learning objectives were achieved: approach (pp. 9-26). Fernwood Publishing. 1. Understand how critical theoretical perspectives can inform social work practice with the disability community. Van Breda, A. (2018). Developmental social case work: A process Achieved in full 5 4 3 2 1 Not Achieved model. International Social Work, 61(1), 66-78.

Wehbi, S., & Lakkis, S. (2010). Women with disabilities in 2. Apply the framework, inclusive of the planned change process, to disability social work. Lebanon: From marginalization to resistance. Affilia, 25(1), 56-67. Achieved in full 5 4 3 2 1 Not Achieved Wehbi, S. (2017). Disability rights and justice activism: Lessons for anti-oppressive community organizing. In D. Baines (Ed.), Doing 3. Identify elements of the disability social work practice framework for use within one’s own professional context. anti-oppressive practice: Social justice social work (3rd ed., pp. 137- 152). Canadian Scholars’ Press. Achieved in full 5 4 3 2 1 Not Achieved

Wexler, L., & Gone, J. (2012). Culturally responsive suicide 4. Please provide comments on current course and suggestions for future courses: prevention in Indigenous communities: Unexamined assumptions and new possibilities. American Journal of Public Health, 102(5), ______800-806. ______Williams, C. (1999). Connecting anti-racist and anti-oppressive theory and practice: Retrenchment or reappraisal? British Journal of ______Social Work, 29(2), 211-230. ______Yee, J. Y., & Anne E. Wagner, A. E. (2013) Is anti-oppression ______teaching in Canadian social work classrooms a form of neo- liberalism? Social Work Education, 32(3), 331-348. ______

Contact information: r Member (MA/RI) $20.00 Name______r Non-member $40.00 Address______City______State_____ Zip______Member Number (if applicable): ______2021 Social Work CE Institute – FOCUS Continuing Education Courses 17

YOU ARE HOLDING 1.5 CEUs IN YOUR HAND! How it works: Read this CE program, complete the Post-Test and Evaluation, and mail to the Chapter office with your check. Score 80% or better and NASW will mail you a certificate for your CEUs. It is that easy! This is Your Brain on Food: How Food Impacts Mood and Mental Health

Uma Naidoo, MD

Introduction science and the fascinating nexus of the field of Learning Objectives nutritional psychiatry. Note: Parts of this course are excerpts from the book At the completion of this program, participants should This Is Your Brain on Food: An Indispensable Guide Often, a client will tell me they develop brain fog every be able to: to the Surprising Foods that Fight Depression, Anxiety, afternoon or can’t sleep, or perhaps they feel jittery in PTSD, OCD, ADHD, and More by Dr. Uma Naidoo. the morning. They client may relate these as purely 1. Understand the role of the gut microbiome and psychiatric symptoms. Some of my first questions, how different foods affect both gut and mental therefore, are: “Tell me what you eat for lunch?” and health. We have heard the expression: “You are what you eat,” “What breakfast did you eat? Do you drink coffee, 2. Utilize case vignettes to gain an understanding but have we really thought about it? This relationship and if so, how much?” In nutritional psychiatry, these of how to analyze a client’s diet and lifestyle in was not always known. In fact, in 2018, historian Ian clues are often an uncharted window into their mental order to identify opportunities for improvement, Miller pointed out that eighteenth- and nineteenth- health. I call this paying attention to body intelligence. as well as advise appropriate changes and century doctors were clued into the fact that the Food is information, and if we eat something and “feel nutritional strategies for better mental well-being. body’s systems are connected. This is why they talked something” we should pay attention. Have you ever felt about the “nervous sympathy” among our different satiated by your lunch, productive and alert all afternoon 3. Understand the impact that the COVID-19 organs. In the late nineteenth century, however, on Zoom, and then at the end of the day, thought that pandemic has had on population mental health doctors changed this perspective. As medicine became the afternoon flew by? Or on other days, when every as well as the increased risk that survivors face more specialized, we lost track of the big picture, meeting drags on, you struggle to stay awake, you reach for developing new psychiatric conditions as a only looking at single organs to determine what was for an espresso or coffee to keep going, and still do not screening means when working with clients. wrong and what needed fixing. Of course, doctors did feel alert? Even if this is not the exact scenario for you, recognize that cancers might spread from one organ try paying attention to whatever you feel following your About the Author to the next, and that autoimmune conditions like meals, and think on it a little. UMA NAIDOO, MD systemic lupus erythematosus could affect multiple organs in the body. But they neglected to see that Michelin-starred chef David Focusing on nutrition to optimize brain health organs that were seemingly quite separate in the and, in doing so, preventing and treating mental Bouley described Dr. Uma body might still profoundly influence one another. Naidoo as the world’s first Metaphorically speaking, illness could come from a health concerns such as anxiety, depression, “triple threat” in the food mile away! Compounding the problem was that, rather insomnia, ADHD, and fatigue, is the key. as medicine space: She is a than working collaboratively, physicians, anatomists, Harvard-trained psychiatrist, physiologists, surgeons, and psychologists competed professional chef, and with one another. As one British doctor wrote in 1956, nutrition specialist. Her “There is such a clamour of contestants for cure that Research shows us just how important the gut-brain niche work is in nutritional the patient who really wants to know is deafened rather axis is in our physical health, but also our mental psychiatry, and she is than enlightened.” We know these connections are quite health. Doctors who studied more than two decades ago regarded both nationally and real. A problem in the adrenal gland can throw you into would not have learned about the gut microbiome as internationally as a medical a panic, infections can cause delirium and altered mental it had simply not been discovered in the way we now pioneer in this more newly status. Maladies of the body frequently manifest as understand it. For example, between 2013 and 2017, recognized field. Featured in turbulence of the mind. about 13,000 publications on the gut microbiome were the @DrUmaNaidooWall Street Journal, ABC News, Harvard Health published. This burgeoning area of research is the new Press, Goop, and many others, Dr. Naidoo has a special frontier in mental health. interest on the impact of food on mood and other mental Heart-Brain Connection health conditions. In her role as a clinical scientist, Dr. Nutritional psychiatry is the use of healthy whole foods and nutrients to improve mental well-being and our Naidoo founded and directs the first hospital-based There is a strong connection between emotions, mental fitness. The field of nutritional psychiatry is clinical service in nutritional psychiatry in the United processing, and heart health. The amygdala is the part nascent but booming. Focusing on nutrition to optimize States. She is the Director of Nutritional and Lifestyle of your brain that processes emotions and perceives and brain health and, in doing so, preventing and treating Psychiatry at Massachusetts General Hospital (MGH) & responds to stressors. Activity in it is associated with mental health concerns such as anxiety, depression, Director of Nutritional Psychiatry at the Massachusetts sympathetic nervous system response and inflammatory insomnia, ADHD, and fatigue, is the key. The idea of General Hospital Academy while serving on the faculty output as well as risk of cardiovascular disease. at Harvard Medical School. Dr. Naidoo graduated from food as medicine is central to nutritional psychiatry and the Harvard-Longwood Psychiatry Residency Training To study this connection further, scientists thought that is crucial to finding meaningful, lasting solutions to Program in Boston during which she received several a condition called Takotsubo syndrome (TTS) might mental health problems. Nutritional psychiatry does not awards, including “Junior Investigator Award” from be connected to amygdala activity. TTS is a sudden, exclude the use of prescription medications. the American Psychiatric Association, the “Leadership but usually reversible, heart failure syndrome, often The food you eat can have just as profound an effect Development for Physicians and Scientists” award triggered by acute emotional or physical stressors. After on your brain as the drugs you take. The nutrients from from Harvard, and the coveted “Curtis Prout Scholar comparing about 100 otherwise similar individuals food influence chemicals that directly and indirectly in Medical Education” award as the first psychiatrist with and without TTS, they found that higher amygdala affect your brain and, in turn, change the way you think to receive this honor. Dr. Naidoo has been asked by activity was associated with greater risk of TTS (Radar and feel. The gut microbiota is a huge community of The American Psychiatric Association to author the et al., 2021). Moreover, many of the patients identified microbes that live within our gut. The purpose of the first academic text in nutritional psychiatry. In addition an acute stressor as the final trigger for the condition. gut microbiota is to support our overall well-being, to this, Dr. Naidoo is the author of the book This Is While TTS is still yet to be fully understood, we know including digestive health, sleep, immunity, hormone Your Brain on Food: An Indispensable Guide to the that stress plays a damaging role in the body. It is balance, circadian rhythm, and, importantly, our mental Surprising Foods that Fight Depression, Anxiety, important to take action both in your diet and your daily health. PTSD, OCD, ADHD, and More, which was released in mental health practices to minimize the toll of stress on 2020. In her book, she shows the cutting-edge science your body, mood, and brain. You may hear the term “gut-brain connection” used. explaining the ways in which food contributes to our This is because the gut and brain are connected because mental health and how a sound diet can help treat and they arise from the exact same cells. The central nervous prevent a wide range of psychological and cognitive Gut-Brain Connection system, made up of the brain and spinal cord, is formed health issues, from ADHD to anxiety, depression, OCD, by special cells known as neural crest cells. These cells and others. Subtle changes in distant parts of the body can change migrate extensively throughout the developing embryo, the brain too. The most profound of these distant forming the enteric nervous system in the gut. The Website: www.umanaidoomd.com relationships is between the brain and the gut. Centuries enteric nervous system contains between 100 million ago, Hippocrates, the father of modern medicine, and 500 million neurons, the largest collection of nerve Book: www.book.umanaidoomd.com recognized this connection, warning us that “Bad cells in the body. This is why some people call the gut digestion is the root of all evil” and that “Death sits “the second brain.” It is also why the gut and brain in the bowels.” Now we are figuring out how right he Social Media: @DrUmaNaidoo influence each other so profoundly. As separate as they was. Though we are still on the forefront of discovery, may appear to be, their origins are the same. The two in recent years the gut-brain connection has provided one of the richest, most fertile research areas in medical BRAIN ON FOOD CONTINUED ON PAGE 18 18 2021 Social Work CE Institute – FOCUS Continuing Education Courses organs are anatomically connected throughout our lives course. brain. But over the years, the science has been building by the vagus nerve which is our 10th cranial nerve. The that gut bacteria can affect mental function. About vagus nerve, known as the wanderer or wandering nerve, The autonomic nervous system (ANS) is in charge of thirty years ago, in one of the most compelling studies originates in the brain stem and travels all the way to the a broad range of essential functions, most of which are that first made us aware that changes in gut bacteria gut, connecting the gut to the central nervous system. involuntary. The ANS keeps your heart beating, keeps could influence mental function, researchers reported When it reaches the gut, it untangles itself to form little you breathing, and keeps digesting food. When your on a series of patients with a kind of delirium (called threads that wrap the entire gut in an unruly covering pupils dilate to take in more light in a dark room, that hepatic encephalopathy) due to liver failure. In hepatic that looks like an intricately knitted sweater. Because is the ANS. Perhaps most crucially for our purposes, encephalopathy, bacteria produce toxins, and the study the vagus nerve penetrates the gut wall, it plays an is when your body is under duress, your ANS controls showed that these patients stopped being delirious when essential role in the digestion of food, but its key function your fight-or-flight response, an instinctual reaction to antibiotics were administered by mouth. That was a is to ensure that nerve signals can travel back and forth threat that sends a cascade of hormonal and physiological clear sign that changing gut bacteria could also change between the gut and the brain carrying vital information responses through your body in dangerous or life- mental function. Functional bowel disorders like irritable between them. Think of the vagus nerve like a two-way threatening situations. bowel syndrome and inflammatory bowel disease are superhighway connecting the brain and gut, allowing an example of this because they also come with mood The gut has a profound effect on fight-or-flight, for constant two-way communication, day and night. changes due to bacterial populations being altered (Giau particularly through the regulation of the hormones Following a healthy meal, the breakdown products are et al., 2018). Another example related to anxiety and adrenaline and noradrenaline (also known as epinephrine also healthy and help the gut to function at its best. In depression. Some clinicians feel that adding a probiotic and norepinephrine). The HPA-axis is another crucial nutritional psychiatry we always say a “happy gut is a as part of a psychiatric medication treatment plan can part of the body’s stress machine. It produces hormones happy mood.” also help to lower anxiety and depression. And lastly, if that stimulate release of cortisol, the “stress hormone.” you transfer the gut bacteria of schizophrenic humans Cortisol increases the body’s ability to handle stress, When we eat unhealthy foods, bad breakdown products into the guts of lab mice, those mice also start to show providing a flood of extra energy to deal with difficult get formed, because unhealthy food feeds unhealthy symptoms of schizophrenia. Each of these examples situations. Once the threat passes, the cortisol level microbes, and those microbes create byproducts which highlight how changes in the gut impact mood and returns to normal. The gut also plays an important role cause inflammation in our body. Inflammation in the mental health. gut leads to inflammation in the brain over time (Firth in cortisol release and is instrumental in making sure the et al., 2019). Inflammation is now a significant and body responds to stress effectively. The primary reason gut bacteria have such a profound major underlying cause of mental health issues such effect on mental health is that they are responsible for In a healthy body, all of these brain chemicals ensure as depression, anxiety, cognitive problems, and more. making many of the brain chemicals we discussed in that the gut and brain work smoothly together. Of Unhealthy foods, therefore, start to impact our mental the last section. If normal gut bacteria are not present, course, as in all delicate systems, things can go wrong. well-being through this gut-brain connection. A poor diet production of neurotransmitters such as dopamine, When chemical over- or underproduction disrupts this may worsen your mood. serotonin, glutamate, and gamma-aminobutyric acid connection, the gut-brain balance is thrown into disarray. (GABA) — all critically important for the regulation Levels of important chemicals go out of balance. Other functions of a healthy gut include: of mood, memory, and attention — is impacted. Moods are upset. Concentration is disrupted. Immunity Many psychiatric disorders are rooted in deficits and • Breakdown of complex carbohydrates drops. The gut’s protective barrier is compromised, and imbalances of these chemicals, and many psychiatric metabolites and chemicals that should be kept out of • Production of vitamins and nutrients drugs are tasked with manipulating their levels. the brain reach the brain and wreak havoc. Over and Therefore, if your gut bacteria are so intimately involved over again, we see how this chemical chaos gives rise to • Formation of short chain fatty acids with these vital chemicals, it stands to reason that when psychiatric symptoms, from depression and anxiety to your gut bacteria are altered, you risk doing damage to • Protects against infections loss of libido to devastating conditions like schizophrenia this complex web of body and brain function. and bipolar disorder. • Help with the immune system Different collections of bacteria affect brain chemistry In order to correct those chemical imbalances and differently. For instance, changes in proportions • Support for detoxification restore order to brain and body, you might assume that and function of Escherichia, Bacillus, Lactococcus, we would need a barrage of sophisticated, carefully • Modulation of the nervous system and hormones Lactobacillus, and Streptococcus can result in changes in engineered pharmaceuticals. To a degree, you are right. dopamine levels and may predispose one to Parkinson’s Most drugs used to treat mental conditions do seek to • Regulation of sleep and circadian rhythm disease and Alzheimer’s disease (Giau et al., 2018). alter these chemicals to return the brain to a healthy Other combinations of abnormal gut bacteria may result • Utilization of antioxidants that we eat state. For example, SSRIs boost serotonin in order to in abnormally high concentrations of acetylcholine, fight depression. Modern mental health medications can histamine, endotoxin, and cytokines, which can damage It is also helpful to know are that some of the most provide relief to patients who struggle with a variety of brain tissue. In addition to regulating neurotransmitter commonly prescribed medications in the United States disorders. I do not want to downplay their importance as levels, there are various other ways in which microbiota are selective serotonin reuptake inhibitors (SSRIs), such a therapy in many circumstances. What sometimes gets influence the gut-brain connection. They are involved as fluoxetine or sertraline (brand names are Prozac and lost in discussions about mental health is a simple truth: in the production of other important compounds like Zoloft). More than 90 percent of serotonin receptors, the food you eat can have just as profound an effect on brain-derived neurotrophic factor, which supports the however, are in the gut. This is why when clients begin your brain as the drugs you take. How can something as survival of existing neurons and promotes new neuron taking an SSRI, they may experience gastrointestinal side basic and natural as eating be as potent as a drug that cost growth and connections. They influence the integrity of effects. millions of dollars to develop and test? The first part of the gut wall and the gut’s barrier function, which protect the answer lies in bacteria. the brain and the rest of the body from substances that Transmission of Chemical Messages need to be confined to the gut. Bacteria can also have an The Microbiome effect on inflammation in the brain and body, particularly influencing oxidation, a harmful process that results in The basis of all communication in the body is chemical. cellular damage. When you swallow a pill for a headache, for example, it Behind the scenes of the gut-brain romance is a huge makes its way to your gut where it is then broken down. collection of microorganisms that reside in the gut The chemicals from that pill travel from your gut to your (Carabotti et al., 2015). We call this panoply of different The Brain’s Impact on the Gut brain through the bloodstream, and once in your brain, bacterial species the microbiome. The gut microbiome they can decrease the inflammation and loosen your tense — in both humans and other animals — is another type The gut-brain connection works both ways. If gut blood vessels, too. When the chemicals you swallow of romance, with both parties relying on each other for bacteria can influence the brain, it is also true that successfully exert their effects on the brain, you feel survival. Our guts provide the bacteria with a place to the brain can change gut bacteria. All it takes is two relief from that pain. In the same way that the chemicals live and thrive, and in return they perform crucial tasks hours of psychological stress to completely change in the headache pill reach your brain, chemicals produced for us that our bodies cannot perform on their own. the bacteria in your gut (Galley et al., 2014). In other by the gut can also reach your brain. And chemicals The microbiome is made up of many different types of words, a tense family Christmas dinner or unusually produced by your brain can reach your gut. It is a two- bacteria, with a much greater diversity of species in the bad traffic can be enough to upset the balance of your way street. gut than anywhere else in the body. Each individual gut microbiome. The theory is that the ANS and HPA-axis can contain up to a thousand different species of bacteria, send signalling molecules to gut bacteria when you are In the brain, these chemicals originate from the primary though most of them from what we know, belong to two stressed, changing bacterial behaviour and composition. parts of your nervous system (with an assist from your groups — Firmicutes and Bacteroides — which make up The results can be damaging. For example, one kind of endocrine system): the central nervous system, which about 75 percent of the entire microbiome. includes the brain and spinal cord; the autonomic nervous bacterium changed by stress is Lactobacillus. Normally, system (ANS), which is made up of the sympathetic The microorganisms that inhabit the gut are normally it breaks down sugars into lactic acid, prevents harmful and parasympathetic systems; and the hypothalamic beneficial, but it is inevitable that some are detrimental. bacteria from lining the intestine, and protects your body pituitary adrenal axis (HPA-axis) which includes the This is not necessarily a concern, as your body generally against fungal infections. But when you are stressed, hypothalamus, pituitary gland, and adrenal gland. makes sure that the good and bad bacteria stay at the Lactobacillus fails on all these fronts due to how stress The central nervous system produces chemicals such right balance. But if diet, stress, or other mental or disrupts its functioning, leaving you exposed to harm. as dopamine, serotonin, and acetylcholine that are physical problems cause changes in gut bacteria, that can The brain can also affect the physical movements of critical for regulating mood and processing thought cause a ripple effect that leads to many negative health the gut (for example, how the gut contracts), and it and emotion. Serotonin, a key chemical deficient in the effects. controls the secretion of acid, bicarbonate, and mucus, brains of depressed and anxious people, plays a major all of which provide the gut’s protective lining. In some role in regulating the gut-brain axis. Serotonin is often The idea that the microbiome plays such an essential instances, the brain affects how the gut handles fluid. talked about because of its role in mood and emotion. role in bodily function is relatively new in medicine When your brain is not functioning well — for example, Interestingly, more than 90 percent of serotonin receptors (think about how often you have heard of bacteria as when you have depression or anxiety — all these normal are found in the gut. In fact, some researchers believe “germs that will make you sick,” rather than as a helpful and protective effects on the gut are compromised. As a that the brain-serotonin deficit is heavily influenced by team of microorganisms that performs a vital service), result, food is not properly absorbed, which in turn has the gut. We will explore this in more depth later in this particularly when it comes to bacteria’s influence on the 2021 Social Work CE Institute – FOCUS Continuing Education Courses 19 a negative effect on the rest of the body since it is not your mental and physical health. the gut microbes. Fermented foods and prebiotic foods getting the nutrients it needs. have been shown to relieve symptoms of depression and Simple Nutritional Strategies to Help Heal any promote healthy hormone function. Probiotic-rich foods An example from research is provided by a survey Imbalance (Inflammation) in the Gut: include plain, unsweetened dairy or non-dairy yogurts, Mireia Valles-Colomer and her colleagues conducted • Increase your daily servings of vegetables to about 80 and fermented foods like miso, sauerkraut, and kimchi. in April 2019 of more than a thousand people, in percent of each plate Prebiotic foods include legumes, oats, garlic, onions, and which they correlated microbiome features with well- asparagus. being and depression. They found that butyrate- • Eat fiber. Fiber helps to nurture and feed the gut producing bacteria were consistently associated with microbes. Fiber can be found in vegetables, fruit, Spices and Herbs: Spices and herbs not only at flavor to higher quality-of-life indicators. Many bacteria were beans, nuts, seeds, and healthy whole grains. Fiber your food, but also have antioxidant and antidepressant also depleted in people with depression, even after cannot be found in animal or seafood. benefits. Some spices and herbs include: correcting for the confounding effects of antidepressants. • Turmeric: The active ingredient in turmeric, • Eat prebiotic foods, such as garlic, onions, leeks, They also found that when the dopamine metabolite curcumin, is incredibly anti-inflammatory and protects bananas, oats, apples, and asparagus 3,4-dihydroxyphenylacetic acid, which helps gut the brain from toxic damage that leads to depression. bacterial growth, is high, mental health is improved. Make sure you add a dash of black pepper to activate GABA production is disturbed in people with depression • Add some fermented foods to your meals, such as kefir, kombucha, miso, or sauerkraut the brain-food benefits of curcumin. Turmeric’s active too. ingredient also decreases anxiety and changes the corresponding brain chemistry, protecting the hippo- Food’s Influence on the Brain Foods that Boost Mood campus because stress can deactivate the hippocampus. Turmeric is an anti-stress spice. Turmeric can be added to smoothies, salads, soups, and even tea. Food influences your brain directly and indirectly. When Information from the foods we eat is communicated to food is broken down by the microbiota into fermented our brain and impacts our overall mental health. More • Saffron: Saffron may be effective in increasing good and digested materials, its components directly influence than 90 percent of the receptors for the neurotransmitter mood neurotransmitters in the brain and has shown the same kinds of neurotransmitters discussed in this serotonin, which is responsible for mood and cognition, to be just as effective as antidepressant medication in course (e.g., serotonin, dopamine, and GABA), which are located in the gut, highlighting just how powerful this reducing symptoms. It is an expensive ingredient, but travel to the brain and change the way you think and food-mood connection is! Eating patterns high in healthy, a little goes a long way. You can also speak to your feel. When food is broken down, its constituent parts can wholesome foods are correlated with positive mental doctor about a supplement. also pass through the gut wall into the bloodstream, and health while diets higher in processed, sugary foods are certain metabolites can act on the brain that way as well. associated with symptoms of poor mental health, such as • Oregano: Similar to vitamin D, oregano is a great depression and anxiety. supporter of the immune system and our gut health. Some foods promote the growth of helpful bacteria, Its active ingredient, carvacrol, has been shown to while others inhibit this growth. Because of that effect, Luckily, we can take advantage of this relationship be an effective neuroprotectant and antidepressant in food is some of the most potent mental health medicine and modify the foods we eat as a way of improving animals. available, with dietary interventions sometimes achieving our mental health. The following are some of the most similar results to specifically engineered pharmaceuticals, powerful nutrients and foods for improving mental health Extra Dark Natural Chocolate: Super dark chocolate at a fraction of the price and with few if any side effects. to get you started: (cacao) is a probiotic food great for your gut and On the other hand, food can also make you sad — certain brain. Cacao flavanols are great antioxidants that beat Omega-3 Fatty Acids: Omega-3s are essential fatty food groups and eating patterns can have a negative oxidative stress in the brain and, by doing so, fend off acids (essential meaning that our bodies cannot make impact on your gut microbiome and your mental health. stress. Chocolate is full of micronutrients including them, we have to obtain them through the food we eat) Slowly cutting back and limiting the following will help magnesium that fights off inflammation in your body and that are incredibly anti-inflammatory and support a improve your mood and lower your anxiety over time: brain. Chocolate also increases blood flow in the brain, healthy brain and reduce mood and anxiety symptoms. improving cognitive function. Find an unsweetened and • Highly processed, ultra-processed foods which have Fatty fish, including sock-eye salmon, sardines, and raw version with 80 percent cacao or more. Real dark added stabilizers, dyes, colorants, and binders that mackerel, are good sources of omega-3s. Choose wild chocolate is also rich in serotonin, a chemical used in impact our mental fitness caught fish rather than farmed fish, when possible, to medications to treat anxiety and stress. This effect was increase the many mood-boosting benefits of omega-3s. • Junk foods and fast foods which often contain hidden researched in a population study of more than 13,000 It is important to clarify the difference between omega-3s ingredients such as refined sugar, making them poor adults and found that, even after adjusting for factors like and omega-6s. Omega-6 is another type of essential fatty choices for your mental and metabolic health age, sex, body mass index (BMI), and daily sugar intake, acid. Once ingested, omega-3s and omega-6s compete dark chocolate consumption specifically, but not milk or for enzymes to be converted into their usable forms by • Trans fats and unhealthy PUFAs (processed white chocolate consumption, was associated with a 70 your body. Omega-6s are found in vegetable oils and vegetable oils) percent reduced risk of depression. are super prevalent in the modern American diet, while • Added and refined sugars. There are over 200 other omegas-3s are more challenging to find. Consuming too names for sugar that are used on food labels which you many omega-6s inhibit omega-3s from accessing the Vitamins and Supplements may not recognize as sugar (e.g., brown rice syrup). enzymes necessary for the conversion into its usable form. Therefore, it is crucial to consume the optimal It is best to get nutrients from healthy whole foods first, • Alcohol which worsens mood because it works as a ratio of omega-6 to omega-3 (2:1) instead of 20:1, which when possible. In addition, factors like stress play a huge depressant is the typical ratio consumed in the standard American role in our lives as do environmental toxins, pollution, diet. Fortunately, simple diet changes and, if needed, • Artificial sweeteners(e.g., aspartame, saccharin, and imperfect sleep, and more. For this reason, supplements supplements, can help balance your omega fatty acids sucralose) may fill that nutritional gap. There is definitely a place and improve your health. for vitamins and supplements. Before taking them, There are observable changes to gut microbes within 24 Folate: Folate is an important vitamin that supports the consult your doctor who may wish to check your blood hours of eating. There is strong evidence that diets high function of our neurotransmitters and keeps our brains levels. This includes supplements for omega-3s, vitamin in added sugars can cause harmful cellular inflammation running at full throttle. Studies have shown it to be D, and magnesium. in the gut, which is associated with depression and associated with decreased symptoms of depression and anxiety. Diets like the Mediterranean diet are linked to slower cognitive decline. Folate is found in leafy greens a lower risk of depression when compared to Western like spinach, romaine, collard greens, swiss chard, and Food and Medication diets, indicating that fresh whole produce, unprocessed mustard greens. grains, lentils, beans, fish and seafood, healthy fat, and Nutritional psychiatry does not exclude the use of nuts may be good for lowering the risk of depression Vitamin D: Vitamin D supports our immune system and medications to treat depression. In fact, some people while highly processed foods and added refined sugar promotes the growth of healthy gut bacteria, which have may still need to take a prescription. Never stop taking may increase risk (Harvard Health Publishing, 2019) been associated with reduced symptoms of depression, medication without consulting your doctor for guidance. (Parletta et al., 2019). anxiety, and schizophrenia. Very few foods naturally Nutritional psychiatry is an additional tool in your mental contain vitamin D. Sunshine is the best source of vitamin health tool kit to feel better. In some situations where D, so spend about ten minutes each day outside. It is depression may be quite severe or ongoing, food may not Ways to Improve the Gut Microbiome important for a healthy body and mind to consider simply be enough to lift that. That said, food can always supplementing as many of us are deficient. Always help how you are feeling and even contribute to helping When we make healthy food choices, for example, by discuss this with your doctor. your mood while you take medication. Additionally, eating a lot of vegetables, beans, lentils, nuts, and seeds eating healthy foods will help fend off the side effects of that feed the microbes with the fiber that helps them Berries: Blueberries, strawberries, and blackberries weight gain from some medications. thrive, they can then perform their role to maintain good are filled with antioxidants and fiber which decrease health. Conversely, when we eat junk foods, fast foods, inflammation and feed the “good” bacteria in the gut. processed foods, ultra-processed foods, and food with Client Advisement Magnesium: Magnesium is an important anti- added sugars, they feed the bad microbes in the gut, inflammatory mineral that helps calm the nervous system leading to inflammation, and later, to leaky gut. Stress, To help better explain how to work with clients, this to reduce anxiety. Magnesium also improves sleep, which poor sleep, medications, smoking, alcohol and street section will cover working toward how best to advise a is crucial for a good mood. It can be found in avocados, drugs, and exercise also impact the gut microbiome. client. almonds, chickpeas, and bananas. In nutritional psychiatry I cannot stress enough that “we Prebiotics and Fermented Foods: Fermented foods are what we eat” in that the food we consume impacts and prebiotics are powerful in their ability to reset our mental health and well-being. Pay attention to your our microbiome which help the gut have positive body intelligence; what your body tells you when you eat conversations with our brain. A probiotic supplement something is vital information you can use to improve BRAIN ON FOOD helps with physical and mental health and prebiotics feed CONTINUED ON PAGE 20 20 2021 Social Work CE Institute – FOCUS Continuing Education Courses

Case Vignette: Beatrice We did the following: following a COVID diagnosis, 20 percent are diagnosed • Paid attention to self-care in his daily routine by with a new psychiatric disorder (Taquet et al., 2021). Another study by the same researchers found that if you Beatrice was a 39-year-old Asian American female building in time for exercise four days of the week, follow the patients for 6 months, the number goes up to who lived with her beloved dog in the Back Bay area including running outdoors which he enjoyed and 34 percent (Taquet et al., 2020). That means 1 in 3 people of Boston. She was referred by her gastroenterologist. allowed for sun exposure to help his vitamin D levels who get diagnosed with COVID will be diagnosed During our first appointment she said, “Please just take with a new psychiatric condition within 6 months. This me out of my misery and give me Zoloft.” It is not often • Asked his wife to help him prepare a hearty, colorful number is higher than for cases of other viruses, such that someone so boldly approaches an appointment salad for lunch and healthy snacks such as zucchini as influenza. The more severe the case of COVID, the with a psychiatrist. After a complete initial evaluation, I sticks and homemade salsa for dipping higher risk there is for psychiatric changes. This study uncovered that 18-months prior she had received a major • Avoided the fast food he had been buying for lunch reviewed over 81 million patient health records and promotion at work. From living at home, walking her had a control group who had not been diagnosed with dog daily, going for runs, and preparing most meals and • Switched to drinking only water and bought a COVID (as there are obviously confounding variables lunches for work at home, she was traveling most days 20-ounce glass water bottle which he refilled at least with pandemic stress). While these psychiatric conditions of the month. She began eating for convenience. Since four times daily ranged from dementia to Parkinson’s to stroke, by far she exercised regularly, she had not gained significant the most prevalent diagnosis was mood disorders. These weight, but her meal quality had plummeted. Between • Cut back to two small cups of coffee early in the day primarily included anxiety, depression, and insomnia. airline snacks, airport fast food, and late-night bar fridge so it did not cause insomnia The researchers hypothesize that the link between these snacks in hotels, she was simply eating very differently. two is somehow related to the viral invasion of the CNS Since she has business meetings almost every night, she • Switched to plain almond milk in his coffee with no or the neural effects of the immune response, but it is was drinking one-two glasses of wine at night compared sweetener unclear as of now how they are directly correlated. It is to one glass at a weekend dinner with friends. She was • Gave up energy drinks, soda, and diet soda also possible that a psychiatric diagnosis may be a risk experiencing heightened anxiety, which she thought was factor for COVID-19. related to work stress. • Drank green tea for an afternoon pick-me-up which improved his focus In addition to impacting our mental health, this pandemic As we teased the details apart, she realized she had has also impacted how and what we eat, in a way that is not consumed a healthy, homecooked meal that entire • Asked his wife to hide the kids’ snacks as he adjusted contributing to such mental health trends. Long lines at month. She was drinking more coffee to stay alert as an environmental control measure grocery stores, food shortages, and efforts to reduce the because her sleep was disrupted due to her flying most frequency of shopping trips led individuals to purchase days of the week. She stopped walking her dog, whom • Got home earlier and ate dinner with his family more processed, shelf-stable foods and frozen dinners, she had loaned to her young niece. She also stopped her while decreasing their intake of fresh, nutritious, and meditation practice. She was fatigued, her sleep cycle • Learned mindful eating, so he was eating more slowly fiber-rich produce. Similarly, while quarantined, many was disrupted, her period was sometimes delayed and and savoring his food took up baking as a coping mechanism or turned to food irregular, and she felt poorly. • Asked his wife to make healthier dessert options for for comfort. While the family members and roommates The issue was gut inflammation related to poor diet. the entire family to eat together of these amateur bakers surely enjoyed the byproducts She wanted to try to use nutritional strategies and avoid of their new hobby, the consumption of these “comfort • Took short walks after dinner with his wife to decom- medication. I assessed her clinically, and even though foods” are actually “discomfort” for the brain and can press and chat about the day she was feeling anxious, she was functioning in her life be detrimental over time. Foods such as baked goods, or with no acute psychiatric risk factors. We worked on those high in sugars and refined flours, are inflammatory These changes were done slowly and over time so that an improved eating plan, which also included planning and support an unhealthy gut and poor metabolic health. changing a few healthy habits did not feel overwhelming. ahead for travel. We did the following: We can take advantage of the gut-brain connection by Within two weeks he noticed that he was sleeping better, modifying what we eat to support both our metabolic • Worked on a healthy, nutrient-dense meal plan feeling lighter, more alert, and in a more hopeful mood. health and mental health, as well as our immune system, that included snacks for travel (e.g., raw almonds, He lost 18 pounds in a year, which he has since kept off, in efforts to subdue the evolving silent pandemic of poor hazelnuts, and macadamia nuts with a few extra dark and still uses the above plan to stay the course. He may mental health as the COVID-19 pandemic continues and chocolate chunks in each bag; and fresh fruit like gain one or two pounds over the holidays, but he knows in its aftermath. apples and clementines) he just needs to follow his “rinse and repeat plan” as his wife calls it, to get back on track. Most importantly, what Eating in a way that could optimize your immune system and • Planned ahead for travel, making sure she asked for a began as a nutritional psychiatry treatment plan, is how your brain/mental health is important, especially right now. small fridge in her hotel room so she could stop at a he lives. local supermarket to buy crudité and hummus, and but a healthy salad for lunch Advising Clients on Nutritional COVID-19’s Impact on Mental Health • Made a plan to re-start her meditation and mindfulness Strategies practice again, beginning with meditation five-minutes twice daily and building up from there to include yoga, The start of the COVID-19 pandemic made us hyper- Approaching a client about using nutrition as a strategy journaling, and CBT-i aware of health and hygiene in efforts to keep ourselves to feel better is something that should be done carefully, well. We learned which supplements to take to strengthen as there are many diet wars that we face in the media, • Brought a metal water bottle (which she carried empty) our immune systems, what songs to sing while washing and these leave many people confused. I consider myself to fill at the airport so she was always hydrated our hands, how to properly wear masks, and how far diet agnostic and so it matters little what I eat, rather apart we should stay from others to protect our physical how I can help someone use nutrition to improve how • Limited herself to a glass of wine for work dinners by health. Efforts to protect our mental health during these they are feeling. Rather than judge someone’s diet, my learning to sip slowly and only drink a half glass, then unprecedented times, however, fell by the wayside and role is to help clients make slow and steady tweaks that switch to a sparkling water with fruit which resembled we are now facing the repercussions. will help their overall mental fitness. In my opinion, any a cocktail, so she did not feel the peer pressure to reach move away from the standard American diet, called the for another alcoholic drink Statistics prior to COVID-19 showed that more than 40 SAD diet for a reason, is good. Before beginning, always million Americans were dealing with a mental health discuss your client’s food allergies or intolerances. If they It took us six months of consistent work, but she felt results concern — more than the populations of New York are not sure, they should talk to their doctor. within a week, which helped motivate her to keep going. and Florida combined (Mental Health America, 2016). Mental disorders are among the most common and costly Nutritional psychiatry follows specific guidelines of Case Vignette: Carlos causes of disability (Healthy People, 2019). Depression using food as medicine for mental health. In addition to and anxiety are on the rise. Suicide is a top cause of specific nutrition guidelines, I also suggest some of the death, no matter what age group. We are grappling with following depending on the clinical situation: Carlos was a 39-year-old male who was struggling with a mental health crisis, no matter how many people are in • Consider a “spring clean” for your kitchen: Clean weight gain and low mood. He worked in high-end real denial about it. estate and had a lovely wife and two young children. He up your fridge and pantry of highly processed foods, ran his own company and was successful but stressed. With COVID-19, the mental health statistics are much refined carbohydrates, processed vegetable oils, added He would get home after the family ate dinner, to a worse. In fact, mental health is the silent pandemic. In sugars, processed meats, and artificial sweeteners. It homecooked meal; however, despite a hearty plate of March 2020, we were forced into quarantine which, by is hard to say no to Doritos and Snickers if you have food, he always craved ice cream or snack from his kids’ definition, is isolating. Those living alone were suddenly them within arm’s reach. Aside from being highly school snack cabinet. At the end of every evening, he faced with extreme loneliness with no end in sight. addictive, these foods are also detrimental to mood and would find himself eating cookies, snack bars, ice cream Systematic reviews have shown loneliness and social overall mental health (Gearhardt & Hebebrand, 2021). and having two glasses of wine before he felt satiated. He isolation to both be associated with poor mental health Instead, fill up your fridge with fresh vegetables and gained 15 pounds in a year and noticed he was feeling and cardiovascular disease, a metabolic risk factor for fruits, and your pantry with nuts, seeds, lentils, and a lack of joy despite his immense business success and COVID-19 mortality (Leigh-Hunt, 2017). On top of legumes. These foods bring the desired nutrient fiber to beautiful family. this, we faced the fear of an unknown virus and fear for your gut microbes and help them thrive. the health of ourselves and loved ones, which increased • Try mindful eating: In this busy world, even if you Carlos came to me requesting therapy and an SSRI anxiety levels and reduced our capacity for quality sleep are working from home, some days I am hopping on a medication he read about. We discussed his lifestyle and (Rajkumar, 2020). COVID-19 has killed millions of different virtual platform every hour, often missing the he admitted he was exercising less often, sleeping poorly people worldwide, and with such loss comes grief and Zoom link and reaching out to my team in panic. I had (often for hours on the couch every evening), and staying sadness. Depression rates are currently reported to be to stop, take a breath, and realize that I had to schedule awake during the day with coffee and energy drinks. higher than before the pandemic and are associated with lunch into my day or else I would forget to eat. During After discussing his pain points, we decided that he increased alcohol and tobacco use and overall poor health my lunch break, I decided to stop to spend at least 15 may benefit from a low dose of medication, but we also behaviors (Stanton et al., 2020). wanted to the careful about the potential weight gain side minutes savoring my food, ignoring the buzzing and effect. A nutritional psychiatry eating plan became key. Research has shown that in the first three months beeping of my devices by leaving them at my desk. I 2021 Social Work CE Institute – FOCUS Continuing Education Courses 21

had to really work on this to bring back mindful eating, • 2 tablespoons coconut oil Legey, S., Aquino, F., Lamego, M. K., Paes, F., Nardi, A. E., Neto, a cornerstone of self-care. Mindful eating was re- G. M., Mura, G., Sancassiani, F., Rocha, N., Murillo-Rodriguez, searched in diabetes and found that training in mindful • 2 tablespoons cinnamon powder E., & Machado, S. (2017). Relationship Among Physical Activity. eating and diabetes self-management helped improve • 1 tablespoon of ginger powder Leigh-Hunt N, Bagguley D, Bash K, Turner V, Turnbull S, Valtorta dietary intake, modest weight loss, and glycemic N, Caan W. An overview of systematic reviews on the public control (Miller et al., 2012). • 1 teaspoon nutmeg health consequences of social isolation and loneliness. Public Health. 2017 Nov;152:157-171. doi: 10.1016/j.puhe.2017.07.035. • Increase the fiber in your meals:Make fiber-rich Epub 2017 Sep 12. PMID: 28915435. vegetables the protagonists of your meals. Aim Method: for 75-80 percent of your plate to be colorful, 1. Preheat the oven to 300F Level, Mood and Anxiety States and Quality of Life in Physical polyphenol-rich vegetables such as leafy greens, Education Students. Clinical practice and epidemiology radishes, cucumbers, eggplant, zucchini, mushrooms, 2. In a small pan, place the coconut oil, spices, and honey in mental health : CP & EMH, 13, 82–91. https://doi. or tomatoes. The more abundant and varied your diet, on low heat. Stir well without letting it burn. org/10.2174/1745017901713010082 the better the biodiversity of your microbiome and the 3. In a large bowl mix all the other ingredients and toss in Mental Health and Mental Disorders. HealthyPeople.gov website, health of your gut. the liquid oil and spices mix. Mix thoroughly and place https:// www.healthypeople.gov/2020/topics-objectives/topic/ mental-health-and-mental-disorders. Accessed September 29, on a baking sheet. • Love your leafy greens: Aim for 6-7 cups of leafy 2019. greens a day. The greener, the better. Spinach, arugula, 4. Place in the oven and roast for 30-45 minutes checking romaine, cilantro, parsley, swiss chard, and dandelion Miller, C. K., Kristeller, J. L., Headings, A., Nagaraja, H., & (and MIXING!) every 10 minutes to avoid the granola greens are filled with folate, a key nutrient for our Miser, W. F. (2012). Comparative effectiveness of a mindful eating burning mental health. intervention to a diabetes self-management intervention among adults with type 2 diabetes: a pilot study. Journal of the Academy 5. Once it’s done, take it out and let it cool down. Store in • Practice gratitude: Gratitude has been shown To help of Nutrition and Dietetics, 112(11), 1835–1842. https://doi. a glass jar and enjoy! an individual’s mental well-being as well as to help org/10.1016/j.jand.2012.07.036 with emotional regulation (Kyeong et al., 2017). While 6. You can top it with coconut yogurt and mixed berries Miller I. The gut-brain axis: historical reflections. Microbial a simple step, it has a powerful impact on our mental for breakfast or have it alone as a snack Ecology in Health and Disease. 2018;29(2):1542921. doi:10.1080/ fitness. Try keeping a gratitude journal or simply think 16512235.2018.1542921. about two-three things you are grateful for from the prior day when you awaken each morning, even if that Dr. Uma’s Mood-boosting Golden Milk Mucci, F., Mucci, N., & Diolaiuti, F. (2020). Lockdown and was a “bad” day. Orienting yourself to the positives isolation: Psychological aspects of COVID-19 pandemic in the general population. Clinical Neuropsychiatry: Journal of Treatment helps brain health. Ingredients: Evaluation, 17(2), 63–64. • 1 cup almond milk (or oat milk for extra creaminess) • Sleep is key: You may be aware that getting good New State Rankings Shines Light on Mental Health Crisis, Show sleep is linked with better mental health, but you may • 1 teaspoon organic turmeric powder Differences in Blue, Red States. Mental Health America website, not be aware just how important it is to get a good October 18, 2016, https://www.mhanational.org/new-state- quantity and quality of sleep every night. There is • 1/2 teaspoon raw honey rankings-shines-light-mental-health-crisis-show-differences-blue- a significant connection between your gut and your red-states. Accessed September 29, 2019. brain in relation to sleep. Your gut bacteria directly • Pinch of black pepper (important to get the anti-anxiety Parletta N, Zarnowiecki D, Cho J, Wilson A, Bogomolova S, communicate with your brain to determine sleep benefits of the turmeric!) Villani A, Itsiopoulos C, Niyonsenga T, Blunden S, Meyer B, patterns. When this circadian rhythm is disrupted, your • 1/4 teaspoon grated nutmeg Segal L, Baune BT, O’Dea K. A Mediterranean-style dietary metabolism is disturbed. This often causes weight intervention supplemented with fish oil improves diet quality and gain. It also changes the levels of hormones such as mental health in people with depression: A randomized controlled serotonin. Sleep disruption is shown to shift the type of Method: Heat all the ingredients except the nutmeg in a trial (HELFIMED). Nutr Neurosci. 2019 Jul;22(7):474-487. doi: bacteria in your gut, even after just one night, which is medium saucepan over medium heat for about 5 minutes. 10.1080/1028415X.2017.1411320. Epub 2017 Dec 7. PMID: highly linked to brain health. Sleep is also restorative, Pour into your favorite mug, sprinkle with nutmeg, and 29215971. and if it does not happen, it could cause chronic fatigue ENJOY! Radar, A., et al. Stress-associated neurobiological activity and other more serious brain conditions. associates with the risk for and timing of subsequent Takotsubo syndrome, European Heart Journal, 2021. • Movement: When someone is so depressed that they References cannot get out of bed, talking about “150 minutes” Rajkumar, Ravi Philip. COVID-19 and mental health: A review of exercise will be overwhelming. Movement can Breit S, Kupferberg A, Rogler G, Hasler G. Vagus Nerve as of the existing literature, Asian Journal of Psychiatry, Volume start with walking a dog or walking to get a cup of Modulator of the Brain-Gut Axis in Psychiatric and Inflammatory 52, 2020,102066,ISSN 1876-2018, https://doi.org/10.1016/j. coffee or the newspaper. Stretching between zoom Disorders. Front Psychiatry. 2018 Mar 13;9:44. doi: 10.3389/ ajp.2020.102066. calls and walking while taking a work telephone call fpsyt.2018.00044. PMID: 29593576; PMCID: PMC5859128. Stanton, R., To, Q. G., Khalesi, S., Williams, S. L., Alley, S. help to keep your blood circulating and your brain Carabotti M, Scirocco A, Maselli MA, Severi C. The gut-brain J., Thwaite, T. L., Fenning, A. S., & Vandelanotte, C. (2020). alert. Exercise has been linked to improved mood and axis: inter- actions between enteric microbiota, central and enteric Depression, Anxiety and Stress during COVID-19: Associations reduced anxiety. Research suggests that individuals nervous systems. Annals of Gastroenterology. 2015;28(2):203–9 with Changes in Physical Activity, Sleep, Tobacco and Alcohol increase their physical activity in order to positively Use in Australian Adults. International journal of environmental affect their mood state (Legey et al., 2017). Firth, J., Veronese, N., Cotter, J., Shivappa, N., Hebert, J. R., Ee, research and public health, 17(11), 4065. https://doi.org/10.3390/ C., Smith, L., Stubbs, B., Jackson, S. E., & Sarris, J. (2019). What ijerph17114065 Is the Role of Dietary Inflammation in Severe Mental Illness? A Review of Observational and Experimental Findings. Frontiers in Taquet, M., Geddes, J. R., Husain, M., Luciano, S., & Harrison, Conclusion psychiatry, 10, 350. https://doi.org/10.3389/fpsyt.2019.00350 P. J. (2021). 6-month neurological and psychiatric outcomes in 236 379 survivors of COVID-19: a retrospective cohort study using The incredible field of nutritional psychiatry emphasizes Galley JD, Nelson MC, Yu Z, et al. Exposure to a social stressor electronic health records. The Lancet. Psychiatry, 8(5), 416–427. the value in using food as medicine and that what we disrupts the community structure of the colonic mucosa- https://doi.org/10.1016/S2215-0366(21)00084-5 associated microbiota. BMC Microbiology. 2014;14(1):189. eat has a direct impact on the function of our digestive doi:10.1186/1471-2180-14-189. Taquet, Maxime et al. (2020) Bidirectional associations between tracts, our brains, and ultimately our mental health. It COVID-19 and psychiatric disorder: retrospective cohort studies puts the power back into our own hands to choose foods García-Montero C, Fraile-Martínez O, Gómez-Lahoz AM, Pekarek of 62 354 COVID-19 cases in the USA. The Lancet Psychiatry, that will make our bodies and our minds happy. With L, Castellanos AJ, Noguerales-Fraguas F, Coca S, Guijarro LG, 8(2),130-140. proper education, we each have this power at the end García-Honduvilla N, Asúnsolo A, Sanchez-Trujillo L, Lahera of our forks, highlighting the potential that nutritional G, Bujan J, Monserrat J, Álvarez-Mon M, Álvarez-Mon MA, Valles-Colomer M, Falony G, Darzi Y, et al. The neuroactive psychiatry has in reversing the silent pandemic of poor Ortega MA. Nutritional Components in Western Diet Versus potential of the human gut microbiota in quality of life Mediterranean Diet at the Gut Microbiota–Immune System mental health, especially during COVID-19. and depression. Nature Micro- biology. 2019;4(4):623–32. Interplay. Implications for Health and Disease. Nutrients. 2021; doi:10.1038/s41564-018-0337 13(2):699. https://doi.org/10.3390/nu13020699

Recipes Giau V, Wu S, Jamerlan A, An S, Kim S, Hulme J. Gut microbiota and their neuroinflammatory implications in Alzheimer’s disease. Nutrients. 2018;10(11):1765. doi:10.3390/ Dr. Uma’s Brain Food Granola nu10111765; Shishov VA, Kirovskaia TA, Kudrin VS, Oleskin AV. Amine neuromediators, their precursors, and oxidation Ingredients: products in the culture of Escherichia coli K-12 [in Russian]. Prikladnaia Biokhimiia i Mikrobiologiia. 2009;45(5):550–54. • 1 cup crushed walnuts The concept of “food addiction” helps inform the understanding • 1 cup crushed almonds of overeating and obesity: Debate Consensus Ashley N Gearhardt, Johannes Hebebrand The American Journal of Clinical Nutrition, • 2 ½ cups oats Volume 113, Issue 2, February 2021, Pages 274–276, https://doi. org/10.1093/ajcn/nqaa345 Published:15 January 2021 • 2 tablespoons flax seeds https://www.health.harvard.edu/staying-healthy/mediterranean- • 2 tablespoon hemp seeds style-the-healthy-fats-and-healthy-carbs-diet

• 1 cup sunflower seeds Kyeong, S., Kim, J., Kim, D. J., Kim, H. E., & Kim, J. J. (2017). Effects of gratitude meditation on neural network functional • 1 cup pumpkin seeds connectivity and brain-heart coupling. Scientific reports, 7(1), 5058. https://doi.org/10.1038/s41598-017-05520-9 • 3 tablespoons raw local honey or Manuka honey BRAIN ON FOOD CONTINUED ON PAGE 22 22 2021 Social Work CE Institute – FOCUS Continuing Education Courses

This Is Your Brain on Food: How Food Impacts Mood and Mental Health 1.5 CEUs - POST-TEST

Circle all correct answers. 1. Takotsubo Syndrome (TTS), a sudden heart failure syndrome often triggered 6. Which of the following foods help heal inflammation in the gut? (Select one) by acute emotional stressors, is connected to the ______, or the part of a. Coconut Oil the brain responsible for processing emotions and responding to stress, b. Fermented foods highlighting the heart-brain connection. (Select one) c. Agave a. Frontal cortex d. Fast foods b. Occipital lobe c. Amygdala 7. Turmeric is incredibly anti-inflammatory and beneficial for mental health d. Cerebellum symptoms but must be combined with a pinch of black pepper for the curcumin to be bioavailable. 2. Nutritional psychiatry utilizes only dietary changes to improve mental True or False health symptoms, acting as an alternative to traditional psychiatric care, and excludes the use of prescription medications. 8. Loneliness and social isolation, as was experienced during the COVID-19 True or False pandemic, has previously been associated with: 1. Poor mental health 3. What is the purpose of the gut microbiota? 2. Diabetes 1. To support digestive health 3. Cardiovascular disease 2. To support immunity 4. Cancer 3. To support hormone balance a. 2 and 3 4. To support mental health b. 1 and 3 a. 1 and 3 c. 1 and 4 b. 1, 2 and 4 d. None of the above c. 1, 2, 3 and 4 9. One in _____ people who survive COVID will be diagnosed with a new d. None of the above psychiatric condition within 6 months. a. Five 4. Eating unhealthy foods feeds unhealthy microbes, leading to ______, which b. Ten we now know to be an underlying cause of mental health issues. c. Fifteen a. Low blood sugar d. Three b. Inflammation c. Hunger 10. Nutritional psychiatry follows specific guidelines of using food as medicine for mental health. Which of the following are also suggested? d. Gastrointestinal pain 1. Mindful eating 2. Practicing gratitude 5. Which of the following foods are associated with increased anxiety? (Select all 3. Cleaning out the kitchen that apply) 4. Movement a. Leafy green vegetables a. 1 and 2 b. Stevia b. 1, 2 and 4 c. Probiotics c. 3 d. Processed vegetable oils d. 1, 2, 3, 4

Please perform the following steps: ‰ Complete and return this entire page. A score of 80% or better is passing and we will send a certificate of completion for 1.5 CEUs to you. ‰ Please enclose check payable to “NASW-MA” (Sorry, credit cards not accepted for this offer.) ‰ Mail to: NASW-MA, 11 Beacon Street, Suite 510, Boston, MA 02108

Please indicate whether the following learning objectives were achieved: 1. Understand the role of the gut microbiome and how different foods affect both gut and mental health. Achieved in full 5 4 3 2 1 Not Achieved

2. Utilize case vignettes to gain an understanding of how to analyze a client’s diet and lifestyle in order to identify opportunities for improvement, as well as advise appropriate chang- es and nutritional strategies for better mental well-being. Achieved in full 5 4 3 2 1 Not Achieved

3. Understand the impact that the COVID-19 pandemic has had on population mental health as well as the increased risk that survivors face for developing new psychiatric condi- tions as a screening means when working with clients. Achieved in full 5 4 3 2 1 Not Achieved

4. Please provide comments on current course and suggestions for future courses:

______Contact information: r Member (MA/RI) $20.00 Name______r Non-member $40.00 Address______City______State_____ Zip______Member Number (if applicable): ______2021 Social Work CE Institute – FOCUS Continuing Education Courses 23

YOU ARE HOLDING 1 CEU IN YOUR HAND! How it works: Read this CE program, complete the Post-Test and Evaluation, and mail to the Chapter office with your check. Score 80% or better and NASW will mail you a certificate for your CEU. It is that easy! Understanding and Acknowledging History as we Support People in their Vaccine Choices

Lamont D. Simmons, EdD, MSW and Elspeth Slayter, PhD, MSW

contextualize our conversation, we have to address the Noted medical historian Harriet Washington, author Learning Objectives racial, ethnic, and disability disparities that exist in the of Medical Apartheid: The Dark History of Medical current health care and social service landscape. We Experimentation on Black Americans from Colonial At the completion of this program, participants should can start by looking at race and ethnicity. According to Times to the Present, points out that trying to understand be able to: the Centers for Disease Control and Prevention, Black a problem without history is like trying to treat a and African American people, Latinx and Hispanic medical patient without taking a medical history. The 1. Summarize the long history of medical people, and American Indians and Alaskan Natives die historical context provided in this course will assist you experimentation on oppressed communities of COVID-19 about two times as often as white people in supporting the people and communities you work - communities of color and the disability (National Center for Health Statistics (NCHS), 2021). with, in making decisions about whether or not to get community - that creates a problematic backdrop We see that 1 out of 735 Black and African Americans vaccinated. Our perceptions of vaccines reflect the for vaccine acceptance. are dying from the disease, according to recent data seriousness of the diseases they are related to as well 2. Recognize the need for professionals to build (APM Research Lab, 2021). For White Americans, as popular values, culture, human risk assessment, and trust with BIPOC and disability community that figure is 1 in 1,030. The disability community politics, but acceptance of a vaccine is never totally members as it relates to vaccine decision-making constitutes 26 percent of the adult U.S. population determined through a rational balancing of risks and (Centers for Disease Control and Prevention, 2021a). benefits because that decision differs from person to 3. Integrate choice and self-determination in This community is more likely to be institutionalized – person (Allen, 2020). vaccine decision-making for BIPOC and in congregate care like nursing homes, assisted living, disability community members into case practice. The truth is that vaccines may be a “hard sell” since and group homes – making it near impossible for them they prevent rather than cure disease and may seem to isolate themselves as a preventative measure while scary even though they are generally quite safe. About the Authors waiting for the vaccine. We know that COVID-19 has Successful vaccination campaigns rely a lot on trust hit this community harder than the non-institutionalized in the people that are going to be administering them. community. Others with disabilities require care at Lamont Simmons, EdD, MSW, is on the faculty in Trust in science, as well as trust in government, are not home, which while less risky than staying a nursing the School of Social Work at Salem State University always high in the communities we serve - especially in home, for example, still exposes people to the vectors in Massachusetts. He has practiced social work communities of color and in the disability community. of infection that disabled people cannot do much to in child welfare, mental health, and school-based Existing knowledge tells us that people’s willingness to avoid because health care workers are coming in on settings. His research frames the experiences of be vaccinated links and connects to either their access a daily basis (Pulrang, 2021). One fear affecting the students in social work education in relation to their to vaccines or trust issues related to vaccines (Wallis, disability community from the start of the pandemic is persistence and academic success. He has interest 2021). Your work on this issue relates heavily to the that the government and fellow citizens do not care if researching persistence among men of color, first- trust factor. they die. This idea is rooted in over a century of on-and- generation college students, and non-traditional off encouragement for what is known as “Eugenics” We can look back approximately 120 years ago to use age undergraduate students. Dr. Simmons has also – or, colloquially, the concept that society is better history as our guide. In the late 1800s and early 1900s, worked on projects related to microaggressions, anti- off without disabled people, and that they are “better government workers fighting smallpox epidemics sent racism, diversity, equity, and inclusion. As a scholar- off dead” (Pulrang, 2021). We must not forget that public health vaccinators out with police to enforce teacher, Dr. Simmons endeavors to cultivate student communities of color and the disability community people getting a vaccination shot. For example, they growth through active learning experiences, critical are not separate - there are overlaps and intersections would enter factories where smallpox cases had been reflection, and by providing a healthy balance of between them. reported, lock the doors, and force all workers to get challenge and support. He holds membership in several vaccinated in what was known as a “vaccination line” professional organizations including the Association There are widespread conspiracy theories related (Allen, 2020). That vaccine sometimes caused people of Baccalaureate Social Work Program Directors, to the COVID-19 vaccine across our populations. to have swollen arms, fever, and bacterial infections. Black Administrators, Researchers, and Scholars, In commenting on conspiracy theories, Romer and Vaccination could, therefore, cause people to lose the Council on Social Work Education, the Greater Jamieson (2020) say: income for up to a week. Of course, there was resistance Boston Association of Black Social Workers, and the Conspiracy beliefs regarding the coronavirus to getting vaccinated. Imagine the tone that this set in National Association of Black Social Workers. Email: pandemic in the US were widespread and persistent the community around vaccine acceptance. [email protected]. over four months, more likely to be held by either Today, we have a politically divided nation. There is a persons with conservative political ideology or lot of evidence that trust in science is low, and experts, Elspeth Slayter, PhD, MSW, is a professor of social in disadvantaged racial-ethnic groups and more including politicians, are often distrusted. If we look at work who identifies as a member of the disability likely to be associated with the use of conservative views about vaccinations for children, we see hesitancy community. She teaches child and family policy, media outlets. Additionally, persons with non-White in parents. It must also be acknowledged that efforts to forensic social work, disability practice and evidence- racial-ethnic identity and those using social media fight COVID-19 in the United States have been clumsy based research courses. Dr. Slayter has practiced as a were more likely to believe that the MMR vaccine is and chaotic at best, leaving Americans to doubt the forensic social worker in child welfare, public criminal harmful. Conspiracy beliefs and their associations competence of their governments and institutions in defense, juvenile justice, and education settings. Her with perceptions of vaccine harm present continu- addressing the disease. This may make it challenging for equity-focused research and consulting centers around ing challenges to the control of the coronavirus people to embrace the promises of a COVID-19 vaccine disability, race, ethnicity in the addiction and child pandemic because of their persistence and associa- campaign. welfare service sectors. Email: eslayter@salemstate. tion with non-acceptance of recommended action, edu. especially mask-wearing, and increasing unwilling- ness to receive a vaccine when it becomes available. Vaccine Hesitancy Confronting these conspiracy beliefs will require Introduction action by journalists and commentators, especially Vaccine hesitancy is well-studied in public health and those with politically conservative audiences, to medicine, and social service workers such as social Today, we are talking about vaccine choice for a range increase acceptance of medically recommended workers should be familiar with this research. “Vaccine of communities, the disability community as well as a actions to control the pandemic. (p. 263) hesitancy” refers to the delay in acceptance or refusal range of communities we will refer to as people who are This is potentially important information to pay of vaccines despite the availability of vaccine services Black, Indigenous, and other People of Color or BIPOC attention to in listening to the people and communities in the face of contagious diseases (World Health communities. And it is important to remember that these we serve. The people and communities we serve may Organization, 2021). Vaccine hesitancy is about access communities have significant overlap too. For example, have been exposed to a range of conspiracy theories as well as affordability and availability of the vaccine - one in four members of Black and African American about the COVID-19 virus or the vaccine, ranging from and the value of the vaccine to the intended audience. communities have a disability as do one in six Latinx or the origin of the virus being a Chinese bioweapon or How well people trust the idea of vaccination is a Hispanic community members (Courtney-Long et al., coming from “bat soup” to the availability of a range of factor in vaccine hesitancy too. Trust in vaccination is 2017). Our approach to discussing the historical context miracle cures that may supersede the need for a vaccine. related to the factors of effectiveness, safety, reliability, around vaccine choice is intentionally intersectional. All of this may lead people to feel hesitant about taking the competence of health care systems in general, and While the core of this article addresses how to the COVID-19 vaccine and we must explore the reasons people’s beliefs about the motivations of policymakers understand and acknowledge history as we support for this before we engage in discussions with the people who are addressing vaccination. the people and communities we serve in their choices we support and serve on this topic. But no topic is more around whether or not to receive the COVID-19 important to explore than that of medical mistrust rooted vaccine, we begin with important contextual data. To in the history of medical experimentation. VACCINES CONTINUED ON PAGE 24 24 2021 Social Work CE Institute – FOCUS Continuing Education Courses

Vaccine hesitancy is a complex as well as a context- nor were members of the disability community. BIPOC episode has created a lasting distrust among elements specific phenomenon that varies across time, place, and communities and prisoners were especially impacted of the disability community - and in the families of specific type of vaccine (e.g., MMR vs. COVID-19 by these experiments (Conhan, 1994). Sometimes this disability community members. vaccines). Additionally, vaccine hesitancy is influenced experimentation was framed as “medical treatment.” This by factors which can include complacency, convenience, is part of why this history creates such a problematic and and also confidence. Although vaccine hesitancy is a challenging foundation for vaccine hesitancy and even Case 2: Injection of Guatemalan well-studied phenomenon, to date, very little effort has vaccine fear among the populations we all work with Nationals with Syphilis been made to spend COVID-19 funding on preparing today. people to be willing to take the vaccine. Rather, a Despite taking place in the Central American country majority of funds have been focused on creating and Many of these experiments violated U.S. law. While of Guatemala, this international case has application to manufacturing the vaccine in record time. There is others were sponsored by elements of the U.S. practice in the United State as Massachusetts is home data from the Kaiser Family Foundation about vaccine government purportedly set up to protect and serve to many people with Guatemalan roots and a local hesitancy in the U.S. population by a few racial and our population, such as the CDC and the U.S. military professor broke the story (see, for example, Reverby, ethnic groups. We know, for example, that Black and (Conhan, 1994). It has more recently become known 2011). This made national news within this past decade African American and Latinx and Hispanic adults are that these activities were often secretive and took place and has reverberated in Central American communities more likely to want to “wait and see” what happens with without the awareness or approval of the government. (Rodriguez & Garcia, 2013). The U.S. Public Health other people’s vaccinations before making a decision While there has been a lot of ethical, professional, and Service - a government agency - led experiments on about their own shot (Hamel et al., 2021). legal fallout around these instances, leading to changes in humans in Guatemala because they could not run how experiments are conducted, the harm in the memory them legally in the U.S. Medical doctors and nurses The literature gives insight into how to address vaccine of the communities that were impacted remains. It is that deliberately infected Guatemalan soldiers, sex workers, hesitancy. Standard responses by medical professionals memory that we have to honor and address in our work. prisoners, mental health patients, and even orphans with to vaccine hesitancy in the non-COVID-19 literature syphilis without giving them informed consent, resulting The following are four examples of historical cases that, include the following practical tips, which have some in at least 83 people dying between 1946 and 1948. application to social service professionals as well (Shen we argue, potentially inform the collective experience of & Duby, 2019). It is important to note that this list is our clients’ potential reluctance to accept a COVID-19 The story of one woman’s experience of being infected presented from a medical provider’s perspective, and vaccine despite their potential higher risk for suffering with syphilis as a nine-year-old girl is recorded in an may differ somewhat from how people in social services from the virus (Diament, 2020; MacDonald & Ostroff, article by The Guardian newspaper. She tells of being might approach discussions with the people they serve 2020). All four of these cases have implications for the called to the medical office of her orphanage as a young (using a more self-determination-oriented perspective): current experiences that people have with the medical girl, being told to spread her legs, and being shot in her system yesterday, today, and tomorrow. One example private parts with a needle, infected with syphilis, with 1. Start early with encouraging people to get the vaccine relates to the disability communities, one relates or consider getting it no consent or choice process whatsoever. On October 1, specifically to the Guatemalan community, and two relate 2010, U.S. President Barack Obama, Secretary of State 2. Present vaccination as the default approach to Black and African American communities. It must Hilary Clinton, and Secretary of Health and Human be reiterated that the communities we serve are often Services Kathleen Sebelius formally apologized to 3. Build trust with the provider multiply marginalized, owning or experiencing more Guatemala for the ethical violations that took place. than one social identity at a time, such as race, ethnicity, Guatemala condemned the experiment as a crime against 4. Be honest about side effects and disability. We know, for example, that there are many humanity with a paired lawsuit (Carroll, 2011). disability community members of color, so while our 5. Provide reassurance about the robust vaccine safety case examples may at first sound discrete or siloed, they Linking a discussion of the treatment of Central system may very well be not like that at all. Americans in this study to the present topic, while many 6. Focus on protection of the person and community via Americans of Central American origin are citizens, for the vaccine undocumented immigrants, there may be other concerns Case 1: Hepatitis Injection with Children about getting vaccinated as well. These might include 7. Address the reality of limited pain experienced with with Intellectual Disabilities concerns about having their personal information shared the shot with the U.S. Immigration and Customs Enforcement, The United States Centers for Disease Control also known as ICE. We know that this has been a We feel that this approach to vaccine hesitancy needs and Prevention’s (2021c) current non-binding prominent factor in the delivery of social services to be contextualized by the social history surrounding recommendation is to offer vaccines to disabled and in recent years (Križ et al., 2016). Undocumented medical experimentation on BIPOC and disability chronically ill people – “aged 16—64 years with immigrants might not show up for vaccination unless communities and will present a modified framework for underlying medical conditions which increase the risk of authorities are open about what information is being you to consider after reviewing this history. serious, life-threatening complications from COVID-19” collected as people get the vaccine, what that information – in Phase 1c of the vaccine rollout. will be used for, what it cannot be used for, and where it To study this connection further, scientists thought that is going to be shared. This may be especially challenging a condition called Takotsubo syndrome (TTS) might be In this case, we are talking about children with after reports last December from President Trump’s connected to amygdala activity. TTS is a sudden, but intellectual and developmental disabilities (IDD). administration asking for personal data including names, usually reversible, heart failure syndrome, often triggered The children involved in this experiment lived at the birth dates, and addresses after the vaccination (Stolberg, by acute emotional or physical stressors. After comparing Willowbrook State School in Staten Island, New York. 2020). (While we are talking about Spanish-speaking about 100 otherwise similar individuals with and without This was a large institution with hundreds of students people, here are some Spanish language resources for TTS, they found that higher amygdala activity was who were intentionally given live hepatitis injections you: https://www.cdc.gov/spanish/inmunizacion/index. associated with greater risk of TTS (Radar et al., 2021). in an attempt to track the development of the viral html and in Massachusetts https://www.miracoalition.org/ Moreover, many of the patients identified an acute infection. The researcher also wanted to determine the resources/covid19/coronavirus-espanol/). stressor as the final trigger for the condition. While TTS effectiveness of gamma globulin injections as protection is still yet to be fully understood, we know that stress against hepatitis. This study began in 1956 and lasted for plays a damaging role in the body. It is important to take 14 years until 1970. Parents were unduly induced to give Case 3: Medical Experimentation on action both in your diet and your daily mental health their consent. For example, when the main school was Black and African American People practices to minimize the toll of stress on your body, closed to new admissions in 1964 due to overcrowding, mood, and brain. parents were told there were openings in the hepatitis There is an extensive legacy of medical experimentation unit for children who could participate in the study. He on Black and African American people that has occurred justified the deliberate infection of children with IDD by in United States since the slavery era, leading to Understanding and Acknowledging claiming that due to the high rate of hepatitis infection significant mistrust. Collusion between slaveholders in the school it was practically inevitable that these History and doctors who exposed slaves to significant risk in children would become infected anyway. This became sadistic, and excruciating experiments was widespread a huge scandal after the fact, and parents and disability Vaccines are an aspect of science, which is often (Miller, 2007). For a detailed history of the early era advocates were horrified (Rothman & Rothman, 1984). associated with experiments and research. Over time, of this experimentation, watch “How the bad blood started” an episode of the 1619 podcast series by the numerous unethical scientific experiments have been Children with IDD in a facility such as Willowbrook New York Times (https://www.nytimes.com/2020/01/23/ conducted on people in the United States and beyond cannot fully understand the risks of participating in a podcasts/1619-podcast.html). While some may say - especially people from oppressed communities. study. Parents were coerced into having their children that slavery times are long gone and that we do not These experiments were either conducted without the participate. Parents who wanted care for their children need to speak of them anymore, we may need to revisit knowledge or consent of the people involved or they may not have had other options for placement. And that statement when we listen to the Black and African were illegally conducted. Much of the experimentation in the end, it is not appropriate to use a vulnerable, American community about how present-day experiences we are talking about took place in the 19th - 20th institutionalized population for medical experimentation. connect to the past from slavery through present times. centuries, the latter of which is well within the recent Injecting the hepatitis virus into children with IDD to Miller (2007) reflects on Dr. Harriet Washington’s memory of many of the people you serve and support in deliberately infect them does not respect them as persons encyclopedic documentation of these atrocities in her your practice. - a basic tenet of research ethics. There is no compelling book Medical Apartheid, referenced previously, saying: reason to study viral hepatitis in children before studying The scientific experiments referred in this course it in adults, for example. It has been pointed out that We learn of sterilization of black mothers, injection of include exposure to chemicals and biological agents - although approximately one thousand adults were radioactive substances into uninformed and unaware some might even view these as weapons. By that, we working at the school at the time, none of them were research subjects, seduction and trickery of parents are referring in some instances to infection with deadly enlisted for the same study. The bottom line is that so that they allowed their children to participate in or debilitating diseases as well as human radiation, hepatitis was widely prevalent among the children with high-risk experiments and invasive surgery, and even injection of toxic chemicals, torture experiments, surgical IDD due to overcrowding and lack of good sanitation, release of dengue-, malaria-, and yellow-fever-bear- experiments (sometimes without anesthesia), tests something the staff should have been responsible for ing mosquitoes in African-American neighborhoods involving mind-altering substances, and many other addressing in the first place, but instead, someone in as part of an experiment by the Army Chemical Corps atrocities. Children were not left out of this treatment, power focused on conducting this experiment. This to test the efficacy of disease-bearing mosquitoes as a 2021 Social Work CE Institute – FOCUS Continuing Education Courses 25

form of biological warfare. Even death did not bring once it became available, but they did receive free according to a report issued recently by the Centers for respite; black cadavers were stolen from cemeteries to medical exams, free meals, and burial insurance. In Disease Control and Prevention (Stolberg, 2021). As of be used in white medical schools. (p. 1380) 1972, a news story caused a public fury resulting in an March 3, 38 states publicly shared race and ethnicity data investigation determining that participants had been on vaccinations and these data suggest, for example, that This legacy of medical experimentation in Black and misled. Even when penicillin became the treatment of vaccination rates for Black and African American people African American communities is felt to this day. choice for syphilis in 1947, researchers did not offer it are half as much as White people, with an even larger Some 70 percent of Black and African Americans to the participants in the study. The participants were gap for Latinx and Hispanic people (Walker et al., 2021). believe that people are treated unfairly based on race never given the option of leaving the study, even when This indicates that BIPOC communities are receiving or ethnicity when they seek medical care (Kum, 2020). this treatment was widely available to others (Centers for vaccines at percentages or rates below their level of This experience is in part informed by a history of Disease Control and Prevention, 2020). The Tuskegee representation of the general population, indicating unequal access to health care which is intensified by Experiment has become a national outrage that is well disproportionality. the COVID-19 pandemic - this is known as medical known in Black and African American communities. racism. In its 2018 annual report, the Agency for We also know that there are reports of majority-Black Healthcare Research and Quality (2020), part of the U.S. and African American areas struggling to deal with Department of Health and Human Services found that 40 Summary of Lessons from Case Studies non-resident White people who are coming into their percent of the measures of healthcare quality the agency communities to be vaccinated, namely jumping “lines.” assessed were worse for Black and African American These four case studies document a series of ways in Now that vaccines are available to the general public, people as compared to White people. This, of course, is which BIPOC communities and the disability community this can further reduce the relative proportion of Black disproportionately hurting Black and African American have been oppressed in medical experimentation, and and African American people who are getting vaccinated. lives both physically and economically (Kum, 2020). For how this might impact their willingness to be vaccinated The fact is that the country’s population over the age of example, A November 2020 study by the American Heart for COVID-19. In reflecting generally on the history 65 is significantly more White than other age groups. Association showed that Black and African American of the medical treatment of the BIPOC communities in Therefore, a color-blind approach to vaccine distribution people have made up nearly 60 percent of COVID-19 particular, Dr. Samuel Roberts, a public health historian, will likely prove to be problematic to the BIPOC hospitalizations in the U.S. (Christensen, 2020). This talks about how our current debates about COVID-19 communities (Blackstock, 2021). is a disproportionate number that researchers relate to reflect similar patterns to how these communities have societal structures reinforcing health disparities due to been treated historically. He summed this up by saying Massachusetts-specific data come from a combination socioeconomic status, lack of access to health care, and that history often “rhymes” with the present (Roberts, of the U.S Census Bureau (n.d.), a Boston Globe article to Black and African Americans being more likely to 2021). (Cromar, 2021), and a vaccination tracker run by the work in essential jobs that put them at risk (Kum, 2020). Kaiser Family Foundation (Coronavirus (COVID-19), For example, Dr. Roberts points out that all of the 2021). Looking at race data, White people make up 81 All BIPOC communities continue to experience medical focus we have been reading about on access to hospital percent of the whole population and have made up the racism in health care, including barriers to COVID-19 treatment for COVID-19 mirrors the historical lack of same proportion of the vaccinated population. Black testing and treatment. And the disease has killed nearly access to hospital treatment for BIPOC communities. and African American people make up 9 percent of two times as many Black and African American, Latinx With respect to the calls for social distancing, this the population, but only 6 percent of the vaccinated and Hispanic, and American Indian and Alaskan Native reflects the historical recognition that people in BIPOC population, representing slight disproportionality. Asian people as White people (Centers for Disease Control and communities cannot follow these guidelines due to people and Pacific Islanders make up 7.2 percent of Prevention, 2021b). The death of Dr. Susan Moore is higher likelihoods of living in overcrowded situations. the population but only 5 percent of the vaccinated emblematic of this. She was a Black/African American On stay-at-home orders, historically and presently, population, another slight disproportionality. And finally, doctor in Indiana who publicly decried her experience this has not been a possibility for people in the BIPOC while American Indians and Alaskan Natives only make of bias in her medical treatment for COVID-19. She communities who are working and do not have the up 0.5 percent of the population, they make up 1 percent succumbed to her infection in late December 2020 benefits of a welfare state that pays them to stay at home. of the vaccinated population, which is good news, (Wallis, 2021). None of this builds trust in the medical And with respect to all the focus on preparedness vis- because the disproportionality is in the right direction. establishment when it comes to vaccines. a-vis ventilators and Personal Protective Equipment Looking at ethnicity, which is counted separately (PPE), there has not been attention on long-term data from race, Latinx and Hispanic people make up 12.4 Therefore, it is not surprising that the Black and African surveillance or other preparations for pandemic responses percent of the whole population, but only 5 percent of American people we work with might exhibit iatrophobia in BIPOC communities. Finally, there is the question of the vaccinated population. This, unfortunately, also or the fear of doctors when confronted with the medical what Dr. Roberts refers to as the “moon shot” vaccine represents disproportionality. necessity to see a physician or get vaccinated, for which has not addressed historically informed issues example. One cannot assume that we can necessarily of equitable distribution that beg questions about our In Philadelphia, Blacks and African Americans make up expect people to line up willingly for the vaccine. vaccine delivery infrastructure. He also poses the 40 percent of the population, but so far only 14 percent Encouraging people to take the vaccine and to believe in question: “What bioethical discussions were held in have been vaccinated in the city. Latinx and Hispanic the medical systems offering the shot may leave aside the advance about vaccine access for BIPOC communities?” people make up 15 percent of the population but only history of negligence - and abuse that is well documented With all of this context in mind, we can sum our 4 percent of vaccinated people. In Chicago, Black and (Wallis, 2021). Dr. Zachary Berger, a bioethicist and exploration of medical history by saying that structural African American People make up 30 percent of the associate professor of medicine at the Johns Hopkins ableism and racism have led to a strong likelihood of lack population, but only 15 percent of vaccinated people. For School of Medicine posits that to help people trust the of trust in health care institutions, government, academia, Latinx and Hispanic people, that number is 29 percent vaccines, it is important that “sources of authority” from and industry. Disparities related to these structural of the whole population compared to 17 percent of the within people’s own communities need to speak out in problems have been noted for a long time but have not vaccinated population (Johnson, 2021). favor of the vaccine - and those sources of authority may always been addressed by social work practitioners. include social workers. Now that we have considered these data points, we can examine how to address these problems of disparity We do have some data on what Black and African Inequities in Access to the COVID-19 on a more macro level. We have four suggestions from American people are thinking about the COVID-19 health equity expert and emergency physician Dr. Uché vaccine itself. According to some studies, there are a lot Vaccine Blackstock. Dr. Blackstock calls for structural changes of concerns about side effects. In a recent Kaiser Family we can advocate for to address the disparities discussed Addressing the racial, ethnic, and disability inequities in Foundation survey, for example, 71 percent of vaccine- in this course (Blackstock, 2021). access to COVID-19 vaccination will also be important hesitant Black and African American people surveyed in the conversations you have with the people and reported this was their number-one concern, whereas 59 First, she advocates that BIPOC communities must communities you serve. We know, for example, that percent of all other people disinclined to get the shot had be prioritized for the vaccine. Strategies prioritizing members of the disability community were enraged this view. Black and African American people surveyed “essential workers” and “people with underlying medical that they were not prioritized for vaccine access by the were also two times as likely as others to worry they conditions” to include BIPOC communities are not CDC despite what are often higher risk statuses. This might get COVID-19 from the vaccine (Altman, 2020). enough, she argues. Access to the vaccine is a major left each state to make its own decision about this high- Given high levels of medical mistrust, for which there is issue and the logistics of access have not been worked risk population. States chose to not make a decision good reason, there is a need for medical professionals to out well enough for these communities, she feels. about this group or to prioritize people with IDD in be upfront and transparent about vaccine information - Second, the vaccine needs to come to the people “where congregate care settings even though people with IDD in both the good and the bad. they are at,” and in their communities - especially given the community were equally at-risk. In California, where the lack of Internet access and/or digital literacy on top this population was reduced from a higher to a lower of the history of medical mistrust, she says. Third, broad- Case 4: Tuskegee Experiment phase, causing waves of protest and angst linked to the based, thoughtful and culturally responsive public health history of disregard for the lives of this population due to campaigns that provide education about the vaccine Finally, we want to share the case of the Tuskegee eugenic beliefs that disabled lives were not worth living. are vital to the communities. She argues that we need Experiment because it has had such an incredibly View disability justice activist Alice Wong’s (2021) community health workers, and trained volunteers negative impact on the Black and African American Twitter feed for more on that, for example. We now from the communities to do door-to-door community communities in the U.S. and we believe this may relate have a disability vaccine access data tracker showing organizing and outreach about the COVID-19 vaccine. to vaccine hesitancy as well. For about 40 years between what each state is doing regarding decisions about Finally, she argues that the government must mandate 1932-1972, the U.S. Public Health Service, working people with disabilities (see: https://disabilityhealth.jhu. the collection of racial and ethnic demographic data of alongside the Tuskegee Institute, began to research edu/vaccine/); however, concerns about access for the those who are vaccinated, to help target public health the natural history of syphilis in 600 Black or African disability community remain. efforts toward Black and African American communities American men – 399 with syphilis, 201 who did not so we can track our progress with this disease and our There are racial disparities in access to the vaccine. have the disease. They did not gather what is known vaccination efforts. All of these things are tangible steps In speaking about President Biden’s administration’s as informed consent. Researchers told these men they you can act on in partnership with other community approach to addressing the pandemic, Dr. Marcella were being treated for what was known as “bad blood.” agencies and groups (Blackstock, 2021). That was a local term used to describe syphilis as well Nunez-Smith has said “Equity is our North Star here,” as anemia, and even fatigue. People who participated however, the federal government has gathered race and in the research did not get any treatment for syphilis ethnicity data for just 52 percent of all vaccine recipients, VACCINES CONTINUED ON PAGE 26 26 2021 Social Work CE Institute – FOCUS Continuing Education Courses

To help make these things a reality, there are political Altman, D. (2020, December 15). Real progress is possible on MacDonald, A., & Ostroff, C. (2020, December 23). Covid-19 things you can consider as well. For example, you can vaccine hesitancy. Coronavirus (COVID-19). https://www.kff. is deadlier for people with autism, down syndrome: Now take a macro-level approach and look into whether org/coronavirus-covid-19/perspective/real-progress-is-possible- families are pushing hard for vaccines. The Wall Street Journal. you support the Anti-Racism in Public Health Act, on-vaccine-hesitancy/ https://www.wsj.com/articles/covid-is-deadlier-for-people-with- autism-down-syndrome-now-families-are-pushing-hard-for- which lawmakers originally introduced in September APM Research Lab (2021, February 4). The color of vaccines-1160872981 2020. It would require the federal government to begin coronavirus: COVID-19 deaths by race and ethnicity in the U.S. developing race-conscious public health approaches https://www.apmresearchlab.org/covid/deaths-by-race Mass.gov. (2021). Massachusetts’ COVID-19 vaccination through two programs within the Centers for Disease phases. Department of Public Health. https://www.mass. Control and Prevention - including infusing an anti-racist Blackstock, U. (2021, February 1). Opinion: White Americans gov/info-details/massachusetts-covid-19-vaccination- approach to the COVID-19 response. This bill would are being vaccinated at higher rates than Black Americans. phases#phase-1- Such inequity cannot stand. The Washington Post. https://www. tackle glaring disparities in racial equity while declaring washingtonpost.com/opinions/2021/02/01/racial-inequality- Miller, J. (2007). [Review of the book Medical apartheid: The structural racism a public health crisis. This bill is co- covid-vaccine/ dark history of medical experimentation on Black Americans sponsored by Massachusetts Representative Ayanna from colonial times to the present, by Harriet A. Washington]. Pressley, Massachusetts Senator Elizabeth Warren, and Carroll, R. (2011, June 8). Guatemala victims of US syphilis Psychiatric Services, 58(10), 1380-1381. https://doi. Congresswoman Barbara Lee (from California who is study still haunted by the ‘devil’s experiment’. The Guardian. org/10.1176/ps.2007.58.10.1380 also a social worker!). https://www.theguardian.com/world/2011/jun/08/guatemala- victims-us-syphilis-study National Center for Health Statistics (NCHS) (2021). Provisional death counts https://www.cdc.gov/ Centers for Disease Control and Prevention. (2020, March 2). coronavirus/2019-ncov/downloads/covid-data/hospitalization- Suggested Guidance on Supporting People The Tuskegee timeline. U.S. Public Health Service Syphilis death-by-race-ethnicity.pdf who are Making the Vaccine Choice Study at Tuskegee. https://www.cdc.gov/tuskegee/timeline.htm Pulrang, A. (2021, January 31). Disabled people are waiting, So how should you go about supporting the people Centers for Disease Control and Prevention (2021a). anxiously, for lifesaving Covid-19 vaccinations. Forbes. https:// Disability impacts all of us. https://www.cdc.gov/ncbddd/ you work with in their vaccine decision-making? We www.forbes.com/sites/andrewpulrang/2021/01/31/disabled- disabilityandhealth/documents/disabilities_impacts_all_of_ people-are-waiting-anxiously-for-lifesaving-covid-19-vaccinati recommend considering the following framework for us.pdf ons/?fbclid=IwAR1GZ1DyIXa8xpHNwYgfnXSrX9mo1ysHlR your conversations. This framework was developed by ahujTcWgd-VNobHlvRQhmGa0k&sh=7832e32049b7 thinking about guidance from Dr. Bisola Ojikutu from Centers for Disease Control and Prevention. (2021b, February Massachusetts General Hospital as well as advice from 18). Risk for COVID-19 infection, hospitalization, and death by Recht, H., & Weber, L. (2021, January 29). As vaccine rollout the organization Mental Health America. Dr. Ojikutu is race/ethnicity. COVID-19. expands, Black Americans still left behind. Kaiser Health an expert in racial and ethnic disparities in infectious Network. https://khn.org/news/article/as-vaccine-rollout- https://www.cdc.gov/coronavirus/2019-ncov/covid-data/ expands-black-americans-still-left-behind/ disease. Mental Health America is an organization that investigations-discovery/hospitalization-death-by-race- recognizes the ways in which racism undermines mental ethnicity.html Reverby, S. (2011). “Normal Exposure” and Inoculation health. We think this also extends to thinking about how Syphilis: A PHS “Tuskegee” Doctor in Guatemala, 1946–1948. ableism undermines mental health as well. Their wisdom, Centers for Disease Control and Prevention. (2021c, February Journal of Policy History, 23(1). 1-23. together, informs this guidance: 19). CDC’s COVID-19 vaccine rollout recommendations. COVID-19. https://www.cdc.gov/coronavirus/2019-ncov/ Roberts, S. (2021). The COVID-19 pandemic and healthcare 1. Acknowledge root causes of vaccine hesitancy vaccines/recommendations.html disparities: Historical context [Screencast]. https://www. screencast.com/t/0jehXjSExbB6 2. Help people think about vaccination as a social Centers for Disease Control and Prevention. (2021d, March 8). responsibility to family and community COVID-19 vaccine: Helps protect you from getting COVID-19. Rodriguez, M.A., & Garcia, R. (2013). First, do no harm: https://www.cdc.gov/coronavirus/2019-ncov/vaccines/index. The US sexually transmitted disease experts in Guatemala. 3. Consider reframing vaccination as a form of html American Journal of Public Health, 103(12), 2122-2126. empowerment https://dx.doi.org/10.2105 percent2FAJPH.2013.301520 Centers for Disease Control and Prevention. (2021e, March 4. Emphasize the right to choice and self-determination in 8). How to protect yourself & others. https://www.cdc.gov/ Rothman, D., & Rothman, S. (1984). The willowbrook wars. vaccine decision-making coronavirus/2019-ncov/prevent-getting-sick/prevention.html Harper Collins.

5. Encourage people to do their research. As Mental Christensen, T. (2020, November 17). Black, Hispanic people Shen, S. C., & Dubey, V. (2019). Addressing vaccine hesitancy: hospitalized for COVID-19 at disproportionately high rates. Health America notes, “Fear is often based in the Clinical guidance for primary care physicians working with American Heart Association News. https://www.heart.org/en/ parents. Canadian family physician Medecin de famille unknown, so learn as much as you can. Consider news/2020/11/17/black-hispanic-people-hospitalized-for-covid- canadien, 65(3), 175–181. what is worrying you, whether it’s the side effects, 19-at-disproportionately-high-rates#:~:text=Black percent2C how recommendation decisions are being made, or percent20Hispanic percent20people percent20hospitalized Stolberg, S.G. (2020, December 8). Some states balk after uncertainty about how the vaccine works, and make percent20for percent20COVID percent2D19 percent20at C.D.C. asks for personal data of those vaccinated. The New sure you’re informed.” percent20disproportionately percent20high percent20rates,-By York Times. https://www.nytimes.com/2020/12/08/us/politics/ percent20Thor percent20Christensen&text=Black percent20and cdc-vaccine-data-privacy.html 6. Engage in critical thinking so you can distinguish facts percent20Hispanic percent20people percent20made,among from opinions percent20racial percent20and percent20ethnic percent20groups US Census Bureau. (n.d.). Table. Quick facts: Massachusetts: United States. https://www.census.gov/quickfacts/fact/table/ 7. Stay up-to-date and consider following a vaccine Conahan, F.C. (1994). Human experimentation: An overview MA,US/PST045219 tracker. Also avoid consuming too much news via on cold war era programs (Report No. GAO/T-NSIAD-94-266). United States General Accounting Office. Walker, A.S., Singhvi, A., Holder, J., Gebelhof, R., & Avila, Y. social media. (2021, March 5). Pandemic’s racial disparities persist in vaccine Coronavirus (COVID-19). (2021, March 2). State COVID-19 rollout. The New York Times. https://www.nytimes.com/ 8. Look toward officials you trust. As Mental Health data and policy actions. https://www.kff.org/coronavirus- interactive/2021/03/05/us/vaccine-racial-disparities.html America notes, “Many American voters say they trust covid-19/issue-brief/state-covid-19-data-and-policy- their personal physician, Dr. Anthony Fauci (Director actions/#raceethnicity Wallis, C. (2021, January 7). The best evidence for how to of the National Institute of Allergy and Infectious overcome COVID vaccine fears. Scientific American. https:// Diseases), and the Food and Drug Administration Courtney-Long, E.A., Romano, S.D., Carroll, D.D., & Fox, www.scientificamerican.com/article/the-best-evidence-for-how- regarding vaccine safety. The Centers for Disease M.H. Socioeconomic factors of the intersection of race and to-overcome-covid-vaccine-fears1/ Control and Prevention and World Health Organization ethnicity influencing health risks for people with disabilities. Journal of Racial and Ethnic Health Disparities, (4), 213-222. Wick, J., & Smith, H. (2021, January 23). Young L.A. ‘vaccine are also reputable sources.” https://doi.org/10.1007/s40615-016-0220-5 chasers’ crowd unofficial standby lines in hopes of a shot. Los Angeles Times. https://www.latimes.com/california/ 9. Think about the benefits compared to the risks Cromar, A. (2021, February 21). Ayanna Pressley, Elizabeth story/2021-01-23/standby-lines-backdoor-vaccine-access given that the vaccine has been approved under an Warren renew efforts to pass anti-racism in public health bill. Emergency Use Authorization requiring that benefits Boston Globe Media Partners https://www.boston.com/news/ Wong, A. [@SFdirewolf]. (2021, January 29). CN: eugenics, outweigh known and potential risks. policy/2021/02/02/ayanna-pressley-elizabeth-warren-anti- ableism, death [Tweet]. Twitter. https://twitter.com/SFdirewolf/ racism-public-health-bill status/1360787566715310087 10. Make decisions in your best interest. As Mental Health America notes, “If the anxiety surrounding Diament, M. (2020, December 17). Disability advocates World Health Organization (2021). Vaccine hesitancy: What it means and what we need to know in order to tackle it. https:// vaccination is too much to cope with, it’s okay to step urge people to get vaccinated against COVID-19. Disability www.who.int/immunization/research/forums_and_initiatives/1_ away from it all for a bit.” Scoop. https://www.disabilityscoop.com/2020/12/17/ disability-advocates-urge-people-to-get-vaccinated-against- RButler_VH_Threat_Child_Health_gvirf16.pdf?ua=1 covid-19/29126/ We hope that this framework will assist you in guiding conversations with the people and communities you Hamel, L., Kirzinger, A., Lopes, L., Kearney, A., Sparks, G., work with as you navigate conversations about vaccine & Brodie, M. (2021, January 22). Vaccine hesitancy. Kaiser decision-making given the fraught sociohistorical we Family Foundation COVID-19 Vaccine Monitor. https://www. have reviewed in this course. kff.org/report-section/kff-covid-19-vaccine-monitor-january- 2021-vaccine-hesitancy/

Križ, K., Slayter, E., Iannicelli, A., & Lourie, J. (2012). References Fear management: How child protection workers engage with non-citizen immigrant families. Children and Youth Agency for Healthcare Research and Quality. (2020, April). Services Review, 34, 316-323. https://doi.org/10.1016/j. 2018 national healthcare quality and disparities report. https:// childyouth.2011.11.001 www.ahrq.gov/research/findings/nhqrdr/nhqdr18/index.html Kum, D. (2020, December 28). Fueled by a history of Allen, X. (2020, August 17). Trust, fear and solidarity will mistreatment, Black Americans distrust the new COVID-19 determine the success of a COVID vaccine. Kaiser Health vaccines. Time. https://time.com/5925074/black-americans- News. https://khn.org/news/trust-fear-and-solidarity-will- covid-19-vaccine-distrust/ determine-the-success-of-a-covid-vaccine/ 2021 Social Work CE Institute – FOCUS Continuing Education Courses 27

Understanding and Acknowledging History as we Support People in their Vaccine Choices 1 CEU - POST-TEST

Circle all correct answers. 1. How has the long history of medical experimentation on oppressed 5. Health policies centered on eradicating structural oppression that will foster communities - communities of color and the disability community impacted long-term trust among oppressed communities are needed because: (Select all vaccine acceptance? (Select one) that apply) a. It has created a problematic backdrop for vaccine acceptance for BIPOC com- a. This will help to address historical inequities related to medical atrocities expe- munities rienced by these communities b. It has created a problematic backdrop for vaccine acceptance for the disability communities b. Health policy has nothing to do with vaccine acceptance in the long term c. It has not created a problematic backdrop for vaccine acceptance for any com- c. Health policy has nothing to do with structural oppression in the long term munities d. It has created a problematic backdrop for BIPOC communities and the disability 6. Standard approaches to addressing vaccine hesitancy among people and community communities served include: (Select all that apply) a. Starting early with encouraging people to get the vaccine 2. Practitioners must understand the history of problematic medical b. Presenting vaccination as the default approach experimentation before acknowledging and accepting people’s truth before seeking to support them in vaccine decision-making because: (Select all that c. Building trust with the provider apply) d. Being honest about side effects a. People should not have a choice about whether to get the vaccine e. Providing reassurance about the robust vaccine safety system b. This fosters respect and self-determination f. Focusing on protection of the person and community via the vaccine c. It is important for history to inform current practice with the people we serve g. Addressing limited pain experienced with the shot d. Different populations experience the medical system differently

3. Professionals must build trust with BIPOC and disability community members as it relates to vaccine decision-making because: (Select all that apply) a. People should not have a choice about whether to get the vaccine b. This fosters respect and self-determination c. Building trust between practitioner and persons served is a best practice in pro- moting vaccine acceptance

4. Integrating choice and self-determination in vaccine decision-making for BIPOC and disability community members into case practice is vital because: (Select all that apply) a. People should not have a choice about whether to get the vaccine b. This fosters respect and self-determination c. It helps to address historical inequities related to medical atrocities experienced by these communities

Please perform the following steps: ‰ Complete and return this entire page. A score of 80% or better is passing and we will send a certificate of completion for 1 CEU to you. ‰ Please enclose check payable to “NASW-MA” (Sorry, credit cards not accepted for this offer.) ‰ Mail to: NASW-MA, 11 Beacon Street, Suite 510, Boston, MA 02108

Please indicate whether the following learning objectives were achieved: 1. Summarize the long history of medical experimentation on oppressed communities - communities of color and the disability community - that creates a problematic backdrop for vaccine acceptance. Achieved in full 5 4 3 2 1 Not Achieved

2. Recognize the need for professionals to build trust with BIPOC and disability community members as it relates to vaccine decision-making. Achieved in full 5 4 3 2 1 Not Achieved

3. Integrate choice and self-determination in vaccine decision-making for BIPOC and disability community members into case practice. Achieved in full 5 4 3 2 1 Not Achieved

4. Please provide comments on current course and suggestions for future courses:

______

Contact information: r Member (MA/RI) $15.00 Name______r Non-member $30.00 Address______City______State_____ Zip______Member Number (if applicable): ______28 2021 Social Work CE Institute – FOCUS Continuing Education Courses

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