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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