Category: Trauma-directed care & leadership

Health Equity and the Social Determinants of Health Are NOT Synonyms

Successful health equity strategies must be inclusive, and focus on all marginalized and minoritized persons and their communities. Any lesser view will continue to yield a faulty health equity equation. 

I delayed writing this blog to not compete with a recently published article in CMSA Today on The Social Determinants of Health: Case Management’s Next Mandate. It’s a quick 5-minute read if you haven’t gotten to it yet. However, that additional week gave me time to review another important and slightly longer read, the National of Academies of Science, Engineering, and Medicine report, Federal Policy to Advance Racial, Ethnic, and Tribal Health Equity 

Report Overview and Missteps

This well-intended report from the National Academies highlights the mandate for macro-level oversight of three disparity domains, as reflected in the title. There was affirmation how the social determinants of health and mental health (SDoH and MH) and the policies that shape them contribute to hindering and advancing health equity. Valuable recommendations included:

  • Creating a permanent federal body responsible for improving racial, ethnic, and tribal equity across the federal government
  • Development by Congress of a score card to assess the impact on health equity of all proposed federal legislation in the future, and
  • Having Federal agencies conduct an equity audit of their current policies. 
  • Collecting more accurate and complete population data for minoritized communities; those social (racial) groups that are marginalized or persecuted due to systemic oppression. 
  • Improving coordination among federal agencies
  • Supporting better inclusion of community input, and 
  • Increasing federal support and access for state and local programs.

These recommendations were sound, as the communities highlighted all face considerable obstacles in accessing optimal physical and behavioral health. Yet, the report suffers from two common flaws that I often identify when reviewing published works on this topic:

  1. Aligning health equity attainment only with the SDoH and MH, and 
  2. Viewing only racial and ethnic populations in the context of the discussion.

Health Equity and the SDoH Are Not Synonyms

Few things annoy me more than short-sighted views of the healthcare horizon in the context of our health equity challenge. I get especially irritated when health disparities are attributed to the SDoH alone. For example, I often hear presenters discuss high mortality rates for minoritized populations and attribute these poor outcomes to poverty and low socioeconomic status, unemployment, and lesser education. Maternal mortality for Black Women is >2.6 X that of White Women, though this particular data point was independent of income, education, or other elements commonly associated with health disparities. 

These faulty views impede accurate comprehension of the full scope of factors obstructing health equity, including systemic and structural racism, implicit and explicit biases, and the political determinants of health (PDoH). This erroneous perspective perpetuates generations of historical, experiential, and other event traumas endured by these populations. Patients continue to be blamed for their poor health outcomes rather than the system (and its providers) that created the chasms in care to begin with. 

Inadequate data to reflect minoritized populations has led to a risk-management ripple-effect. Faulty algorithms have been identified across clinical decision-making and interviewing models leading to inaccurate risk assessment, treatment recommendations, and medication dosages. Poor operational and fiscal outcomes intersect with quality and safety concerns, especially when the data used does not accurately reflect the clinical needs of the population. 

Health Equity Includes More than Race and Ethnicity

Achieving health equity involves taking dedicated action to improve the access, quality, and experience of healthcare for all individuals, populations, and communities. There is no doubt that race and ethnicity are key constructs for research attention and action, with abysmal morbidity and mortality rates. The National Academies report notes:  

  • Life expectancy for non-Hispanic Whites at 78.9 years of age compared to 75.3 for Blacks, and 73.1 for the American Indian and Alaska Native populations.

However, other marginalized populations face equally worrisome barriers to equitable care access and treatment. Of equal importance are gender orientation, age, and individuals with physical, cognitive, developmental, and mental health disabilities, to name a few areas. These populations are too often left out of health equity discussions:

  • Sexual and gender minority (SGM) populations have a higher incidence than non-SGM of developing chronic diseases (e.g., asthma, arthritis, diabetes, kidney disease, hypertension, cardiovascular disease, heart attack, stroke, and chronic obstructive pulmonary disease (COPD)), and more frequently deal with barriers to care from discrimination, let alone cost.
  • People living with disabilities (PLWD) have poorer health than the general population and are at a greater risk of injury and of developing non-communicable chronic diseases and age-related health conditions at earlier ages. 
  • Rampant gender disparities present in pain management, especially for those who identify as women. They experience “gendered treatment” across healthcare settings and with symptoms devalued or dismissed by their healthcare providers. This study’s results were also independent of socioeconomic status, education, or other health-related social needs.

The President of the National Academy of Medicine, Dr. Victor J. Dzau is correct that “Addressing the nation’s racial and ethnic health disparities is an imperative for the medical community.”; I would also add the priority for behavioral health given the current societal demand; after all, there is no health without mental health and visa-versa. However, efforts that limit health equity strategies to racial and ethnic disparities are short-sighted. Successful diversity, equity, and inclusion imperatives require the voice of every societal stakeholder across the entire cultural schema. 

Health Equity Actions Advance

Attaining health equity involves dedicated action to improve the access, quality, and experience of healthcare overall. This translates to intentional work by everyone, from those in data analysis, and learning and development, to persons specializing in process improvement and data measurement. This means:

  1. Developing quality metrics for health plans, health systems, and other entities that focus on more than reactive, short-term return on investment metrics, such as readmissions, patient engagement, and patient satisfaction. These antiquated data points only blame patients for poor outcomes through use of language such as “non-compliant”, rather than put accountability for change in the hands of providers. 
  2. Ensuring quality improvement efforts reduce unnecessary care utilization (e.g., ED visits, hospitalization), while simultaneously increasing access to preventative and primary care, behavioral health, and specialty care; this means adding concordant providers and approaches to care, which has been addressed in prior blog posts.
  3. Shift case management back to a proactive vs. reactive model; discharge planning is not the sole priority. Instead, case management competencies must highlight swift assessment of patients and their support systems, care coordination, interprofessional collaboration, effective communication, and outcomes management, while heeding professional ethical and compliance standards.
  4. Educate policy makers on inclusive health equity frameworks such as by Peterson et al. (2020). This robust framework accounts for equity and justice at the core of health outcomes, multiple and interacting spheres of influence, and a historical and life-course perspective (e.g., historical, experiential, developmental traumas). 
  5. Reinforce a sense of belongingness by everyone, especially persons from underserved communities. All patients and their families should feel seen, heard, and safe in the healthcare sector. This outcome can be measured by patient reported outcomes measures (PROMs), employee satisfaction and engagement surveys, and methods that involve analysis of these measures through demographics of race, ethnicity, and gender, sexual orientation, gender identity, physical and developmental disabilities, and socioeconomic status.

The Call to Action

“Our industry achieves the highest level of health for all persons, only when all voices are included. Communities that commit to health equity make all persons feel valued, and do so via concerted and ongoing attention. It is only through this all-encompassing effort that avoidable inequities are identified and addressed, historical and contemporary injustices are eliminated, and healthcare disparities are mitigated.” (Fink-Samnick & Garrett, 2023). 

Successful health equity strategies must be inclusive, and focus on all marginalized and minoritized persons and their communities. Any lesser view will continue to yield a faulty health equity equation. All populations deserve better.

The Smallest Advocacy Actions Can Yield the Greatest Reward

My recent travels reminded me how much satisfaction can be gained by advocacy on behalf of a larger group of individuals.

The universe provides us interesting lessons, and usually when we least expect them. That mantra about the journey being as meaningful as the destination applies to this blog, but in a different way than you might expect. While the theme of this post alludes to the importance of equity and response to trauma, it is not my traditional fierce messaging. Instead, this post offers my reflections on the rewards that can come from contributing to the greater good.

Where it Started

This last month has been full of conference travel, with my usual array of presentations and panel discussions. I was honored with the publication of my fifth book (The Ethical Case Manager: Tools and Tactics) and also inducted as a Case Management Fellow (FCM™) by the Case Management Society of America (CMSA), and the first social worker to do so. These accolades are important career milestones for which I’m grateful. Yet, these milestones paled in comparison to one experience that occurred around the same time. That event reminded me how much satisfaction can be gained when one small action is taken on behalf of a larger group of individuals.

These past weeks saw travel challenges for much of the population. The experiential trauma for all traveling during this timeframe was palpable, and due to events that were usually beyond each person’s control. This loss of power left travelers reeling. There were flight delays courtesy of extreme weather conditions, workforce shortages, and flight cancellations. There was even a substation fire that prompted a lengthy hold on flight departures and arrivals at one large international airport.

Who sat at airports for endless hours or days, in hopes of getting to their anticipated destination? How many slept on airport furniture or even floors? Who missed conferences, business meetings, family, or other long-awaited celebrations? Who missed flight connections by a matter of minutes? How frustrating to see your connecting flight at the neighboring gate upon landing, but unable to sprint off the plane quickly enough to get on board!

Where it Went

I was among the lucky ones. While several of my flights were delayed, I always got to my destination. Yet, the experiences for one flight impacted me greatly. I was heading home from a conference in Miami. That event fell during the initial, and often chaotic, June vacation week. The flight was loaded with travelers embarking on international trips, and catching connections at my destination, Dulles Airport in Herndon, Virginia. 

A large band of thunderstorms delayed our departure from Miami by 90 minutes and threw passengers into a panicked state. Some individuals had planned their trips for months, while others had sudden family and business emergencies to manage abroad. Even once we were in the air, flight attendants worked continuously to calm upset passengers throughout the aircraft and contact various airlines to hold connecting flights, as possible. Some of these flights were also delayed, which somewhat eased the worry of already tired and, in some cases, traumatized passengers.

Upon landing at Dulles, an announcement was made by the flight attendant to allow travelers with connecting flights to disembark first. I had a sneaking suspicion that this action would be hard to implement and wasn’t wrong. Everyone stood up to grab their bags and deplane. Here was my opportunity to help! I was close to the front of plane and in a pivotal position to be an enforcer of this one simple and logical request. Little did I know that I had a collaborator seated nearby who was equally committed to doing the right thing, and for all passengers.

My collaborator sat directly across the aisle from me, and spent most of the trip consoling the passenger next to her. This person was visibly upset about the disruption to her travel. The flight attendants were able to confirm that this passenger’s connection flight was three gates away and being held for her arrival. Yet, her worry remained at a fever pitch.

My collaborator and I stepped up simultaneously and into action. We realized that some people might not feel empowered to get off the plane, especially those persons sitting toward the back. We directed passengers who did not need to run for a flight to stay in their seats. There were some interesting expressions and explicatives shared, though everyone ultimately got our drift and pitched in to support the efforts. Within minutes, close to 180 passengers successfully (and gratefully) deplaned. My aisle-mate and I were among the last passengers to leave, and with appreciation of the flight crew.

How it Mattered

I slowly walked to the airport shuttle, then turned around to see my collaborator behind me. We smiled at each other and chatted about our actions. We treated others as we would want to be treated if in the same situation. We advocated for the human condition, which was what I was trained to do as a board-certified case manager and clinical social worker. She and I were also in agreement about one key takeaway from this experience, which more than equaled, if not exceeded any of my recent accolades. Our advocacy takes all forms. Yet, even the smallest advocacy actions can make the biggest difference to others, and in turn, can provide us the greatest reward.

Part 2: Wholistic Health Equity Determinants and the LGBTQIA++ Community

This Part 2 post continues exploring the pervasive impact of Wholistic Health Equity Determinants (WHED) on the LGBTQIA++ community. Focus is on the rising incidence of trauma and mental health conditions across the community and the expanding advocacy, funding, as well as resources to mitigate the WHED.

I appreciate the buzz about my last blog; it’s a quick read if you missed it. To catch you up, the LGBTQIA++ community face pervasive Wholistic Health Equity Determinants (WHED): SDoH, SDoMH, PDoH, and the systemic racism that perpetuates them. Discrimination, dismissal, and rejection trigger trauma across every demographic, and intensify integrated health incidence across this population. This Part 2 post explores the unprecedented exacerbation of behavioral health conditions and escalation in mental illness for the the LGBTQIA++ community. Additional focus is placed on novel resources to mitigate the physical, behavioral, and psychosocial health disparities faced by this population.

The Behavioral Health Landscape

     Let’s be clear, the LGBTQIA++ community is a marginalized population with morbidity and mortality rates that are worse than other groups. Increasing attacks on the community’s legal rights have amplified the impact of historical, experiential, and event traumas for the population. 

The following data sources span The Trevor Project’s 2023 U.S. National Survey on the Mental Health of LGBTQ Young People, the 2020 National Survey on Drug Use and Health, and other research.

Suicide

There has been a dramatic uptick in suicidal ideation and gestures among LGBTQIA++ individuals, especially for the community’s youngest members:

  • 41% considered attempting suicide:
    • 46%: Ages 13-17 and 34%: Ages 18-24
    • Of those who attempted suicide: 
      • 17%: Ages 13-17
      •   9%: Ages 18-24
      • 22%: Native/Indigenous 
      • 18%: Middle Eastern/N. African
      • 17%: Multiracial
      • 16% Black
      • 15%: Latinx
      • 11%: White
      • 10%: Asian American/Pacific Islander

Mental Health and Access to Care

The incidence of mental health faced by the community is alarming with higher rates for depression and anxietycompared with non-community members. The prevalence of post-traumatic stress disorder impact upwards of 47% of the community.

Yet, the rates for mental health realities faced by LGBTQIA++ youth concern me greatly:

  • 67%: symptoms of anxiety
  • 25%: symptoms of depression
  • 56% who wanted mental health care were unable to get it:
    • 47%: afraid to talk about their mental health with someone else
    • 41%: didn’t want to get their parent’s/caregiver’s permission
    • 40%: afraid that they wouldn’t be taken seriously
    • 38%: couldn’t afford it
    • 27%: were not out about their authentic self and were afraid of being outed
    • 23%: didn’t feel they would understand their sexual orientation or gender identity
    • 20%: parent/caregiver didn’t allow them to go
  • <50% of transgender and nonbinary youth found their school to be gender-affirming
  • 30% said their mental health was poor most of the time or always from anti-LGBTQ policies and legislation.
  • Nearly 66% affirmed how hearing about potential state or local laws banning people from discussing LGBTQ people at school made their mental health worse.

Persons with Disabilities

Members of the LGBTQIA++ community have a higher likelihood of disabilities, whether physical, cognitive, or intellectual. Incidence is upwards of 40% of persons, though fewer of these disabilities are often expressed by individuals or formally identified.

As an already marginalized group, individuals with disabilities may feel “unseen” and experience more profound stigma and discrimination. Cumulative effects of this marginalisation can occur over the life course, with older members of the community experiencing higher rates of disability, depression, anxiety and isolation than the general community, and decreased social support. They are less likely to advance academically, with fewer persons attending college or attaining beyond a 2 or 4-year degree.

Transgender, non-binary, or gender non-conforming people with disabilities can often feel silenced. Abundant literature affirms they are more likely to experience chronic illnesses, including cardiac disease, high blood pressure, high cholesterol, diabetes, stroke, arthritis, and asthma compared to persons living without disabilities.

Substance Use

The community experiences substance abuse at higher rates than their heterosexual counterparts:

  • LGB Adults: 2X as likely
  • Trans Adults: 4X as likely

21.8%: Diagnosed with an alcohol use disorder vs. 11% of the general population

Advocacy and Action

Advocacy and action have ramped up for dedicated funding, legislation, and program development. Educating industry stakeholders is vital, as is ensuring mentoring and support for LGBTQIA++ youth, adults, and their families. Registries of providers, practitioners, and treatment specialists who offer concordant care are essential. Here is a list of novel community-focused efforts:

  • The Department of Housing and Human Development has launched a new LGBTQIA++ Youth Housing initiative. HUD will partner with local communities, service providers, and young people directly impacted by residential insufficiency to address barriers to housing and shelter access. The recent press release lists further details
  • GLADD provides a clearinghouse of population-specific resources for advocacy, legal, and other general information across the life span. Military members and veterans can access specific linkages to various entities such as OutServe and the Service Members Legal Defense Network.
  • The Human Rights Campaign strives to advocate and promote equity for all persons within the movement. Their massive resource database encompasses topics to empower allies and other community stakeholders from coming out to maneuvering college, elections, hate crimes, health and aging, parenting, religion and faith, and workplace support. 

HRC’s Foundation supports the National LGBTQIA++ Health Education Center, which provides educational programs, resources, and consultation to healthcare organizations to optimize quality, cost-effective care for the population. Accessible webinars span topics as behavioral health, population-based health, trauma-informed care for Trans and Gender Diverse Patients, reproductive health.

  • NAMI offers general guidance on mental health issues faced by the community, and considerations for seeking LGBTQIA++-competent care.
  • Rainbow Labs in Los Angeles, addresses the bullying, isolation, and lack of support often faced by Queer and Gender non-conforming youth (QGNC). The organization provides mentorship, support groups, and linkage with safe individuals, advocates, and programs. One Bold Summer is a free 8-week summer mentoring initiative for QGNC youth (ages 12-18) that pairs QGNC youth with mentors. 
  • SAGE is the largest and oldest U.S. organization dedicated to improving the lives of LGBTQIA++ older adults. The group has been on the forefront of advocacy for elders, quality of long-term care, housing, and other resources. Their National Resource Center on LGBTQ+ Aging hones in on the unique needs of community older adults such as caregiving, elder abuse and neglect, benefit programs, financial, and other health-related social needs.  
  • SMYAL is among a growing number of locale-based housing programs that ensure safe, LGBTQ-affirming support, through tiered residential options: transitional housing, extended transitional housing, and rapid re-housing. Residents can access a range of courses and community engagement opportunities including nutrition and cooking classes, financial literacy, healthy relationships and communication, and resume workshops.
  • The Trevor Project provides 24/7 information, support, and resource connection for LGBTQIA++ Youth around the world. Mechanisms allow for immediate access to trained counselors via call, text, or chat, and linkage to an international community for LGBTQ young people

What’s Next?

I have been a fierce ally of the LGBTQIA++ community for well over 45 years, with countless family, friends, and colleagues in this space. Despite efforts to address the massive WHED faced by the community, innumerable challenges remain. The list of resources in this post is a broad swipe of efforts on the move.

Blog readers are encouraged to contribute resources as they know of them. The work to mitigate WHED for this population will take the collective and concerted action of us all!

Wholistic Health Equity Determinants and the LGBTQIA++ Community

Too little emphasis has historically been placed on this population’s challenges in addressing these determinants, as in accessing quality concordant health and behavioral health care, managing their psychosocial health and reflective resource needs, and activating action to mitigate their abysmal health outcomes. Systemic racism further perpetuates each of these disparities, triggers trauma that activates physical illness, while also compromising individual safety. It is time to shift this trend.

A number of this blog’s followers expected me to review the recent (May 2023) Federal Reserve Report, The Economic Well-being of US Households in 2022 this week. The report poses interesting implications about the Wholistic Health Equity Determinants discussed in my last post. While this topic is of interest to my health equity lens, a more critical focus beckons.

With PRIDE in full stride, the dire needs of the LGBTQIA++ community will receive prime attention today, and for my next several blog posts. Too little emphasis has historically been placed on this population’s challenges in addressing these determinants and continues to be the norm. The community still struggles in accessing quality concordant health and behavioral health care, managing their psychosocial health and reflective resource needs, and activating action to mitigate their abysmal health outcomes. Systemic racism further perpetuates each of these disparities. It triggers trauma that further exacerbates physical and behavioral health, while also compromising individual safety. Time to shift this trend.

Recent Realities

The recent article in Health Affairs by Auerbach & Fox nailed it: “significant evidence suggests that virtually all LGBTQ++ populations are at elevated risk of preventable illness, injury, and death.” This article and previous works by the Kaiser Family Foundation, University of Wisconsin’s Institute for Research and Poverty, and HRC arm us with considerable data to advance action!

Poverty and Food Insecurity

An increasing incidence of the LGBTQIA+ community live close to the federal poverty level:

  • 34% have incomes below 200% (of the FPL) vs. 25% of non-LGBTQIA++ people.
  • 39% earn $30,000 a year or less annually. 
    • 28% of lesbian and bisexual women compared to 21% of heterosexual women. 
    • 23% of gay and bisexual men compared to 15% of heterosexual men.
  • 32% of transgender persons earned an annual income of under $10,000 compared to 23% of heterosexual persons.
  • Lesbian couples have the highest poverty rates followed by heterosexual couples and male same sex couples.

In general, across the community:

  • 30% are unable to pay their bills.
  • 67% used all or most of their savings for healthcare expenses.
  • 52% had trouble paying medical bills in the past 12 months or had difficulty paying for necessities (e.g., food, heat, or housing) 
  • 41% borrowed money from family or friends.
  • 2x as likely to experience food insecurity than other populations at rates upwards of 30% of the population. One recent study reported female sexual minorities as: 
    • 52% more likely to experience nutrition obstacles, and
    44% more likely to report household SNAP assistance than their heterosexual counterparts. 

Unemployment

Unemployment rates loom large for the community:

  • 22% of adults vs. 16% of straight and cisgender counterparts
  • 29% of transgender adults, 30% of bisexual women

Amid the pandemic these numbers soared with surveys revealing as high as:

  • 28% of LGBTQIA+ report that they, or another member of their household experienced a job loss vs. 23% of the rest of the population, and
  • Close to 50% report their work hours reduced.
  • 45% of the population reported challenges paying their rent or mortgage vs. 32% of the remaining population.

Quality of and Access to Necessary and Concordant Care

The Kaiser Family Foundation yielded concerning results in the context of chronic illness management:

  • 47% have an ongoing health condition that requires regular monitoring, medical care, or medication.
  • 21% have a disability or chronic disease that keeps them from participating fully in work, school or housework.
  • 34% of those on Medicaid with a disability or limiting chronic disease report the following experiences with providers:
  • Not believe they were telling the truth (16% )
  • Suggest they were personally to blame for a health problem (13%)
  • Assume something about them without asking (21%)
  • Dismiss their concerns (29%)

Trauma and Chronic Illness Exacerbation

The community’s higher rates of exposure to psychosocial stressors contribute to higher rates of chronic and autoimmune illnesses. The higher incidence of individuals to poverty, unemployment, homelessness, interpersonal violence, as well as family and peer abandonment, contribute take their toll across LGBTQIA++ populations.

Research notes high incidence and prevalence reported for the onset and exacerbation of migraines, respiratory issues, HIV/STIs, diabetes, heart attacks, hypertension, arthritis, visual/hearing impairment, and stomach/gall bladder trouble, along with substance use and addiction. Neurological symptoms can be especially fierce in response to the expansive psychosocial stressors faced by individuals.

But Wait, There’s More

The pervasive WHED struggles of the community contribute to higher rates of discrimination, trauma, and, ultimately, more intense behavioral health conditions and mental illness. The incidence of suicidal ideation, gestures, and completed actions are at record levels, and for the youngest members of the LGBTQIA++ community. This topic deserves its own blog post and where I’ll go next time.

In addition, there must be defined recommendations for industry action. Reports have noted a variety of recommendations that ensure protective factors are in place for members of the community; these may include having healthcare providers and practitioners promote inclusion and belongingness, as well as expanding access to concordant treatment specialists. Emphasis has also been placed on individuals reducing isolation, leaving rural areas and residing in more urban areas, seeking higher levels of education, being employed, being married, not growing up in poverty or becoming a parent at a young age. 

These  factors make for a nice wish list but may not directly eliminate the immense disparities that have plagued the community for centuries. More can and must be done. Stay tuned for my next bi-weekly post. 

Trauma Amid Roe v. Wade Despair 

Amid my concern of the massive societal impact from overturning Roe v. Wade, lies the intersection of this decision’s havoc with every iteration of trauma.

Roe v. Wade has been overturned, and like many, I’m devastated. There will be mass impact of this decision across systems and sectors for generations to come. As I pondered a unique way to approach this blog post, one chronic theme came to mind. Amid my concern for all populations, lies the intersection of this decision’s havoc with every iteration of trauma.

Here are the facts: There is Pervasive Trauma

  • Vulnerable and marginalized populations live with rampant access to care obstacles; historical, experiential, and medical trauma are embedded within in the DNA of each person. 
  • The Turnaway Study released last Spring revealed stark facts of trauma’s wrath for women denied an abortion.
    • They are 4X as likely to end up living in poverty, stay with abusive partners, suffer from poor physical and mental health, plus have decreased aspirations. 
  • Collective Occupational Trauma for practitioners will further escalate as they reconcile:

There Will be More Trauma to Come

We can also expect:

  • Thousands of unplanned births and the potential for increased maternal morbidity and mortality; There will be trauma.
  • Increased mental health challenges for persons dealing with unwanted pregnancies; There will be trauma.
  • High rates of suicidal ideation, gestures, and action for victims of rape, sexual assault, and interpersonal violence who are forced to carry a pregnancy to full-term; There will be trauma.
  • A ripple effect for college-aged students facing an unwanted pregnancy, and forced to raise children on college campuses, delay, or give up hopes of earning a degree; There will be trauma.
  • Persons with chronic conditions, medical, psychiatric, and intellectual disabilities often face often life-threatening conditions when forced to maintain a pregnancy. “Abortion restrictions do not only endanger people who don’t wish to be pregnant. Many people who want biological children have conditions that put them at higher risk of adverse outcomes and miscarriages…this poses clear psychological risks, as well as physical ones”; There will be trauma
  • A rise in adverse childhood experiences scores for children born of unintended pregnancies, and for persons exposed to adverse life experiences; There will be trauma.
  • Threats to other rights and freedoms of ALL vulnerable and marginalized populations across the diversity, equity and cultural inclusion landscape; There will be trauma.

Moving Forward

Many associations and entities have already published position statements opposing the overturning of Roe V. Wade. This list of resources will fuel your advocacy energies:

ACLU

Center for Reproductive Rights

Center for Trauma-informed Policy and Practice

Guttmacher Institute

Human Rights Campaign

International Partners for Reproductive Justice (Ipas)

Keep Our Clinics

NARAL Pro-Choice America

National Abortion Federation

National Black Women’s Reproductive Agenda

National Latina Institute for Reproductive Justice

National Network of Abortion Funds

PACEs Connection

Planned Parenthood

Rape, Abuse, Incest National Network (RAINN)

Women Have Options

There are other countless other resources, and I invite all to add resources to this list. In the meantime, seek support by reaching out to each other: family, friends, colleagues, and counseling. Stay fierce, advocate, and ensure appropriate care for those in need. There will be ongoing emotions to reconcile as society contends with the new reality. We must be ready to ensure necessary health and mental health intervention, and for every person. After all, There will be trauma.

Advocacy Amid Anguish for the Frontline Workforce

The Surgeon General’s advisory is landmark action whose priority is only emphasized by the latest horrific mass shootings, now at 213 and counting. We are way beyond burnout with advocacy amid the anguish mandated, and through an interprofessional effort.

My initial intent was to dedicate this week’s blog post to the Surgeon General’s Advisory. The document highlights the industry mandate for stakeholders to be accountable for action that mitigates workforce burnout: 

  • healthcare organizations 
  • insurers 
  • health technology companies 
  • policymakers
  • academic institutions 
  • researchers
  • communities

However, we are way beyond burnout! The battle cry by industry advocates is fierce. Workforce retention, turnover, and patient quality are beyond their tipping points; “more must be done or there will be nobody left to render care”. The Surgeon General’s advisory is landmark action whose priority is only emphasized by the latest horrific mass shootings, now at 213 and counting for 2022 alone.

Intensifying Collective Occupational Trauma

Society witnessed the worst of humanity: the death of 19 innocent children and two teachers in Uvalde, TX, followed so closely to the intentional murder of 13 persons in Buffalo, NY. Both events serve as added evidence of the severe collective occupational trauma inflicted on every practitioner and provider of care. My colleagues and I face these issues as human beings, as well as professionals, which is a felt in the most intimate and unique ways. 

Front-line practitioners and first-responders face unparalleled pressures in caring for victims or being forced to announce their deaths. Conveying that intimate information to loved ones carries an overbearing responsibility. Underneath a provider’s, often stoic, presentation lives interminable grief, pain, and loss, as they struggle to accept their inability to save the victim. The honor of caring for these fatalities bring an intense level of responsibility. Behavioral health professionals face a similar burden in rendering emergency and continuing mental health intervention to providers, witnesses, family, and community members. Recurrent workforce retruamatization has an especially fierce impact. The anguish contributes to rapidly escalating incidence of PTSD, suicidal ideation, and action across the workforce. Rates were high enough pre-pandemic, and continue to rise. The fusion of mental and physical health engulfs the body yielding escalation and exacerbation of chronic illness, auto-immune disorders, and other ailments; the workforce is being decimated.

Debriefing and Activating Advocacy

I’ve spent the better part of these past few weeks debriefing with past and present students, clinical social workers whom I supervise and mentor, experienced colleagues. Everyone is hurting in a unique way. Some need solace, while others require cues to stop doomscrolling. All demand action; workforce resource support and gun safety reform legislation are at the top of the list. 

Our emotions empower advocacy to heed the ethical tenets of autonomy, beneficence, fidelity, justice, and nonmalfeasance. Prioritizing these tenets ensures quality intervention for every patient and population, but also all health and behavioral health professions. Activating these principles looks different for each discipline. Yet, while each one shares distinct priorities, there is shared recognition of how interprofessional collaboration and advocacy will yield change including:

The industry must do better; our entire interprofessional workforce deserves far more. We must advocate amid the anguish, yet be ensured appropriate mental health support. How will you advocate for change? Feel free to add your comments about this blog post below, as well as other valuable resources. 

Managing the Doomscrolling Dichotomy

Doomscrolling (or doomsurfing) is a recent addition to Merriam-Webster and other dictionaries: addictive surfing or scrolling through bad news, even though negative in scope. The dynamic is impacting rising numbers of persons across the globe, along with their physical and behavioral health; this includes the professional workforce. Here are 5 ways to manage the doom scrolling dilemma.

A versions of this article was initially published by the CGI Newsletter, and appears with permission.

You have a break in the day and decide to catch up on your favorite social media feeds;  suddenly it’s 30 minutes later. What began as a look at your BFFs Facebook feed spiraled to viewing headlines, graphics, and disturbing images of recent events. You are sucked into a vortex of posts across platforms and apps, distracted from everything on your calendar: social, occupational, or education activities. Emotions bubble up: anger, bewilderment, frustration, rage, sadness. You become unable to focus, sleep, and feel crispy around the edges. Welcome to the world of doomscrolling: a dynamic impacting rising numbers of persons across the globe.

What it Means

Doomscrolling (or doomsurfing) is a recent addition to Merriam-Webster and other dictionaries: addictive surfing or scrolling through bad news, even though negative in scope.  Society has been exposed to a pervasive cycle of negative news these past two years including the pandemic, cultural, racial, and ethnic disparities, and the recent Ukraine crisis. It becomes easy to get caught up consuming mass quantities of online news in a single sitting.

The impact of these events on our wholistic health is telling. Growing studies speak to rising incidence of severe anxiety, depression, and psychological distress from over-consumption of pandemic-related media (Bendau et al., 2021). Daily social and traditional (e.g., new portals, magazines) media use exacerbates onset and exacerbation of depression and post-traumatic stress disorder (Price et al., 2022). Poor mental health negatively impacts sleep, putting further stress on the immune system; the interconnection between psychopathology and chronic illness is well-documented in the literature (Isvoranu et al., 2021).

The professional workforce walks a slippery slope with the doomscrolling dilemma, particularly those in behavioral health, integrated care, and related roles. Practitioners are faced with increasing numbers of patients seeking treatment for anxiety, depression, insomnia, and other symptoms related to the negative news cycle. Yet, each practitioner, is also a human being, striving to set limits on their own over-exposure to the media. Balancing professional self-care with respect for patient autonomy and rendering of effective treatment becomes the sharpest of double-edged swords. Professionals must limit their (over) exposure and potential collective occupational trauma, while intervening effectively with patients: an ethical dilemma of its own!

Why We Do It

            One quick answer is, misery loves company. Reading about negative events validates negative feelings felt by individuals. The more one seeks to satisfy this need, the more doomscrolling advances to addictive habit. Striving to stay informed about current events devolves into a vicious cycle where stress increases and cortisol levels rise. A myriad of health issues can result: increased blood pressure and glucose levels, migraine headaches, insomnia, or autoimmune disorders (e.g., lupus, multiple sclerosis, rheumatoid arthritis, Sjögren’s syndrome).  


What to Do About It

Here are 5 strategies to inform your efforts:

  1. Limit Social Media Bandwidth: Read one article in the morning, listen to a podcast from that favorite platform (or news outlet) you trust. 
  2. Take Social Media Breaks: Don’t get sucked in or your energy will be sucked out. You may stay off social media certain times of the day, or for longer periods of time (e.g., during the workday, weekends, or for several months).
  3. Use Body Scanning, Breathing, and Other Trauma-informed Tactics: Doomscrolling can trigger prior traumas. A colleague recently shared how use of trauma-informed interventions made the difference, for both clinician and patient. Regular body scans are an asset: take that nice deep breath, then start at the top of your head and move down your body. Note any sensations that appear: ringing in your ears, pressure around or behind your eyes, a tight neck or back, tingling in your chest or gut. 4-7-8 breathing is an asset as well. 
  4. Sleep Hygiene Strategies: Doomscrolling and insomnia are a dyad. Sound strategies that address both disruptors include:
    • Declare a screen-free sleep space.
    • Keep traditional items nearby, such as a notepad or book. Jot down thoughts that wake you up or read to tire your eyes without using a digital screen.
    • Detox devices by turning off notifications and removing apps; block apps and distracting websites using Freedom or other like-platforms. 
    • Avoid heated or emotional posts within an hour of bedtime
    • Keep screen-free hours one hour prior to bedtime and over the sleep cycle.
  5. Stay Proactive and Consistent: It is easy to fall off the Doomscrolling wagon. Stay vigilant; like any addiction, it won’t take much to fall down the rabbit hole and re-engage. Take control of doomscrolling before it takes control of you!

Have other thoughts? Feel free to add them below!

Trauma-Informed Leadership: The Antidote for Collective Occupational Trauma

Workforce sustainability, retention, and quality of care are among the adverse side effects of the current interprofessional emergency

The healthcare workforce is amid a unique epidemic, coping with the ravages of collective occupational trauma. Physicians and nurses have been heavily impacted, but also an endless list of behavioral health professionals (behavioral analysts, counselors, social workers, psychologists), case managers, community health workers, medical assistants, nutritionists, pharmacists, phlebotomists, public health workers, rehabilitation professionals, respiratory therapists, not to mention those professionals employed in other sectors (e.g., school and occupational health nurses). Workforce sustainability, retention, and quality of care are among the adverse side effects of this interprofessional emergency.


An Emotional Plea

A recent article by the Hastings Center posed an emotional plea; “the pandemic has laid bare the significant shortcomings of a health system rooted in an unsustainable financial model that exploits the physical and emotional labor of its nurses”. A Time Magazine cover story, was equally riveting with a focus on physician suicide that brought me tears; the respected workforce is concerned for its ability to “emotionally, physically, and mentally face the tsunami of patients” who need care. Data out of Canada reveals prevalence of physician burnout, upwards of 68%. Succinctly stated, the healthcare workforce is under attack with unparalleled rates of mental health, substance use, and post-traumatic stress disorder. The daily deluge of data is overwhelming with the severity of workforce trauma evident; the recent report out of the CDC focused on public health workers and was my breaking point: high incidence of depression, anxiety, PTSD, and suicidal ideation all detailed. The research is validating and valued, though yields a chilling reality: organizations and employers must implement trauma-informed leadership (TIL) models to bolster their staff, before they have none left.

Collective Occupational Trauma in High Gear

We are past the point of no return, 80% of healthcare professionals are ready to exit the industry. Practitioner burnout from vicarious trauma is a long-standing dynamic that has only intensified amid the pandemic. Earlier this year, I published a blog post, 10 Ways to Tackle Collective Occupational Trauma and Restore Resilience. I remain alarmed about the ongoing pandemic pressures and their impact on the workforce. A fierce dynamic is in motion, the Cycle of Collective  Occupational Trauma (the graphic viewable on the original blog post, click the embedded URL above). Intense levels of collective induced stress are experienced by the population and passed to involved practitioners as collective infused trauma. In addition, these personnel are exposed to a wide range of all-encompassing professional and personal stressors. Collective occupational trauma results, and ultimately leads to PTSD if not addressed: acute and chronic sleep disruptions (e.g., nightmares, insomnia), diet challenges (e.g., gastrointestinal upset), physical health issues (e.g., headaches, back or joint pain, psychophysiologic disorders), and behavioral health symptoms (e.g., brain fog, motivation, depression, anxiety, substance use, suicidal ideation and action). Academic, occupational, and social activities of daily living become impaired and imperiled.

Trauma-Informed Leadership as Antidote for Collective Occupational Trauma

I’m confident most readers of this blog know the value and success of Trauma-informed care (TIC). For those less familiar, five principles are intentionally woven into each interaction, bolstering intervention with individuals who have experienced or perceived trauma, whether single event or ongoing experiences: safety, choice, collaboration, trustworthiness, and empowerment. The intervention can be implemented in any setting with patients, their support systems, as well as those persons rendering their care.

TIC also serves as an antidote to mitigate collective occupational trauma, and can be aligned through Trauma-informed leadership (TIL). This unique approach expands on Servant, Transformational, and other leadership models that encourage managers “step-up and in” to support staff. TIL shifts the long-held “process and roll” culture of healthcare organizations. Instead, a new atmosphere is created where leadership and staff relationships are nurtured with actionable efforts: partnering toward meaningful, reciprocal interactions that empower (staff) resilience. TIL strategies include, but are not limited to these 10 tactics:

  • Encouraging staff to “Take 10”, whether:
    • 10 seconds to breathe
    • 10 minutes for fresh air, grounding, or use of the Calm App
    • 10 hours, or a mental health day to restore resilience
    • 10 days, yup, it’s vacation time
    • 10 weeks or 10 months means a whole different conversation, and potentially a job change
  • Providing attention to staff health, mental health, and well-being:
    • Monitor for signs and levels of stress: from agitation, sadness, frustration, to more profound forgetfulness, chronic illness exacerbation, depression, or anxiety.
    • Decrease behavioral health stigma through discussion & referrals for intervention, as needed
    • Support and model self-care
  • Engaging in 2-way communication:
    • Don’t just tell staff what to do, but also why
  • Staying visible and accessible to staff
  • Recognizing not only staff limits and vulnerability, but acknowledging those as the leader
  • Building team camaraderie vs. opposing fronts of leadership and staff, or among staff
  • Providing encouragement when, and where possible
  • Establishing and addressing the root cause of retention issues
  • For virtual roles, ensuring visual interactions where leaders “see” staff several times during the week; cameras and webcams on!
  • Recognizing culture shifts are not achieved by a “one and done” approach; stay consistent for the long-term win.

Let these times inspire your opportunity to rebuild, fortify, and sustain the workforce. TIL is a solid means to accomplish this endeavor. Feel free to reach out to me with questions at efssupervision@me.com.

This blog post originally appeared on PACEsConnection

Workforce Trauma, Shortages, and Retention are Interprofessional Challenges: Resolution Tactics

Disregard for the health, mental health, and well-being of all members of the workforce is a grave concern. What tactics can be implemented?

The full scope of professionals must be recognized for their sacrifices and dedication to patient wellness; anything less is unacceptable.

 One year ago, I wrote how the pandemic, and other societal narratives prompted a new dimension of collective occupational trauma; an already worn workforce was forced to wrestle with constant and intense levels of suffering. As we enter 2022, and year 3 of COVID’s wrath, this trauma remains unrelenting. Pervasive burnout, retention issues, and staff shortages are ravaging disciplines and settings, cumulative costs into the billions. These realities put quality patient care at severe risk.

     Global data emphasizes the impact of chronic and recurrent COVID-waves for front-line physicians and nurses; no doubt these disciplines have endured, and continue to take a powerful hit; >80% ready to leave the industry. The ‘Great Resignation’ is decimating healthcare, the sector experiencing the largest job transition rates and among the highest number of job openings. Concern exists whether there will be enough practitioners to render care. However, what of other disciplines? Disregard for the health, mental health, and well-being of all members of the workforce is a grave concern.

The Entire Workforce Mandates Attention

     The health and behavioral health workforce is vast and comprises many professional disciplines: behavioral health professionals (behavioral analysts, counselors, social workers, psychologists), case managers, community health workers, medical assistants, nutritionists, pharmacists, phlebotomists, psychiatrists, public health workers, rehabilitation professionals, and respiratory therapists, etc. Valued personnel are also employed by other sectors (e.g., schools, businesses, prisons), such as teachers, occupational health, and school nurses, to name a few. Each of these groups have suffered more than their share of deaths, illness, and long-haul syndrome disability; the mental and emotional toll of their work yielding intense emotional trauma across:

Despite these graphic realities, too many personnel are excluded from industry/employer recognition for their contributions to the pandemic, whether awards or merit raises. Even media focus on these individuals is limited. A recent article discussing, hazard pay, focused on nurses and doctors alone; why are others not deserving?

     A vicious cycle unfolds where stressed, underappreciated team members experience a higher incidence of negative mood, emotional exhaustion, and thus, increased medical errors. More than 250,000 medical errors and 100,000 deaths annually were attributed to workforce frustration pre-pandemic; poor team member communication and fragmented care ensued with a ripple effect of order entry mistakes, medication, and treatment missteps, among other occurrences. Considering all the disciplines to interact with patients, at what point does the risk to patient care become too great?

Professional Advocacy is a Mandate

     There must be greater advocacy and action to acknowledge the vital interprofessional contributions rendered by entire workforce. Professional associations, their leadership, and those in positions to do so, must assert influence to promote the value of their requisite members. Language promoting self-care and professional advocacy has started to appear in standards of practice and ethical codes. However, these efforts must continue to amplify. Many colleagues actively use their social media presence to write articles, blogs, and other messaging to lead this charge; more must join the discussion and advocate for action through employers, and the industry overall. Media attention to this cause must be swift, fierce, and consistent.

There must be collective accountability across the professional landscape to acknowledge, and reconcile this issue, spanning academia, credentialing and regulatory entities, professional associations, and of course, employers. Workforce sustainability directly impacts quality health and behavioral healthcare, ultimately saving lives and dollars. Reaching this goal takes the expertise and contribution of each interprofessional team member.

How this goal is accomplished varies across each setting and far from a cookie-cutter approach, spanning:

  • tangible acknowledgements and recognition (e.g., free staff meals, merit raises or other benefit enhancements, staff appreciation awards, weekly formal and informal “shout-outs” of workforce contributions)
  • investment in staff professional development, as in payment for professional association dues, credentialing, continuing education
  • implementation of on-site mental health programming
  • scheduling teamwork celebrations
  • flexible scheduling as possible
  • plan departmental/organizational townhall meetings with actionable items and follow-up on deliverables
  • ensure staff mentoring and support programs
  • have informal staff-check ins
  • effective communication by leadership with staff (include the why of each action)
  • provide a culture where all persons, and their input are valued and respected
  • deliver and demonstrate consistent verbal appreciation
  • ensure professional regulations, credentialing entities, and associations highlight professional self-care and advocacy in all standards, and hold requisite workforce members and employers accountable to uphold the language
  • set a tone of mutual respect in academia and education programs through collaborative programs, events, and classroom activities (e.g., co-teaching across disciplines and programs) that empower interprofessional learning
  • implementation of Trauma-informed Leadership models and strategies (PS: my last blog post will jump-start this action)
  • Have other ideas? Add them below in the comments section

The full scope of professionals must be recognized for their sacrifices and dedication to patient wellness; anything less is unacceptable.

This blog post originally appeared on PACEsConnection

Bio: Ellen Fink-Samnick is an award-winning industry subject matter expert on interprofessional ethics, wholistic health equity, trauma-informed leadership, and supervision. She is an esteemed professional speaker, author, and knowledge developer with academic appointments at George Mason University and the University of Buffalo. Ellen is a clinical supervision trainer for NASW of Virginia, and serves in national leadership and consultant roles. She is also a Doctoral in Behavioral Health Candidate at Cummings Graduate Institute of Behavioral Health Studies. Further information is available on her LinkedIn Bio and website