Friday, November 20, 2020

Under the same sky, seeing different horizons

By David S. Prescott, LICSW


An interesting situation arose at a program where I consult on treatment for people with complicated backgrounds and complex needs. At the start of the flu season, many clients were declining to have a flu shot. However, these were the same clients who routinely take antidepressant and antipsychotic medications are known to have fairly significant side effect profiles. At first, this made no sense to me. I wondered whether this was due to historical concerns about the effects of vaccinations that have since been loudly debunked, but they were unfamiliar with those concerns. In some cases, they stated that they didn’t want the irritation of the shot itself. Others said they were concerned about side effects such as flu-like symptoms. In my mind, very little made sense until I considered the interpersonal circumstances. The clients had worked closely with a specialist to determine the most effective medication regime. The professional involved had worked to gain their trust by providing information, asking questions, and – importantly – discussing side effects as well as reminding them of their rights in order to obtain truly informed consent.


The flu shots, in contrast, were offered by different staff members who did not take these processes as seriously and had a very different relationship with the clients. All of this reinforced research findings regarding the importance of building alliances in establishing treatment compliance. In order to come to terms with the surface issue of flu-shot motivation, it’s necessary to understand a much broader background of trust, mistrust, and the processes by which each is earned. As the saying goes, we all live under the same sky, yet see different horizons.


Of course, this is just one example of the effects of trust and trustworthiness on activities that contribute to health. It shows that the one recent survey, conducted on behalf of The Undefeated, sheds light on the experiences of people of color as well as those from majority culture backgrounds. Among their findings:


·         “About half of Black adults say they would not want to get a coronavirus vaccine if it was deemed safe by scientists and freely available, with safety concerns and distrust cited as the top reasons. By contrast, most White adults say they would get vaccinated, and those who wouldn’t get a vaccine are more likely to say they don’t think they need it. Majorities of Black adults also lack confidence that the vaccine development process is taking the needs of Black people into account, and that when a vaccine becomes available it will have been properly tested and will be distributed fairly.”


As with the clients I encountered in treatment, considering the context is vital:


·         “The share of Black adults who believe it is a good time to be Black in America has plummeted in recent years . . . Just a quarter of Black men now say it is a good time to be a Black man in America, down from 60% in 2006, and just a third of Black women (34%) now say it’s a good time to be a Black woman, down from 73% in 2011. Yet almost six in ten Black adults (57%) believe the current protest movement and fight for racial equality will lead to meaningful change that will improve the lives of Black people in the United States.”


Given that this represents the views of so many people, it’s hard not to imagine that it represents the views of the clients of color who are in our treatment programs. It is not difficult to imagine that both our current situation in the US and elsewhere (which we have blogged about here and here) and past horrors, such as the forced sterilization of black women and the Tuskegee Syphilis Study, live on in the memories of many.


Meanwhile, a recent study appearing in The Lancet, has found that the presence of psychiatric concerns within the past year is itself a risk factor for COVID-19. Although perhaps not surprising, it highlights the deep connection between physical and mental health, for better or worse.


What are the implications of these recent findings?


First, unless we are directly asking our clients for their perspectives, we may be missing important information about their experiences, and therefore not have the working relationship with them that we believe we have. Where many treatment providers may see “treatment-interfering factors” our clients maybe seeing a legacy of harm and guarding against it.


Second, when we do not have a comprehensive understanding of how they view the world and haven’t taken their perspectives into account, we should not be surprised when our attempts to develop treatment and safety plans fail. Although we may comfort ourselves saying that our clients are responsible for their actions and should be bringing their concerns to us, this is simply not how these things work.


Most importantly, it is crucial for majority-culture clinicians to develop an understanding the history of interventions used against People of Color rather than for their benefit.


Unless we (evaluators, treatment providers, supervising agents) can create a safe space, we may end up in the same place that the study of history finds. Our clients of color have not forgotten the lessons of history, will be under the stresses of inequity, unfairness, and outright racism, and therefore be more prone to the physical and mental health conditions that lead to COVID-19 and other illnesses resulting in foreshortened futures and early death. They will be less likely to engage fully in interventions that have historically been used against them, or worse, will create an appearance of going along to get along with the goal of returning to less restrictive conditions as soon as they can. 


These conditions serve no one. Meaningful participation in treatment can build healthier lives and safer communities. If we are not addressing the very real conditions that clients of color face, how can we consider ourselves to be effective? 


We may think that these conditions don’t apply to us as individuals, but recent events show otherwise, from Selma, Alabama, to Ferguson, Missouri, and from Breonna Taylor to George Floyd.

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