Journal of Diverse Social Work ~~~ Hunter College School of Social Work ~~~

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1 Journal of Diverse Social Work ~~~ Hunter College School of Social Work ~~~ Inaugural Edition 2010

2 Journal Mission This journal is a forum for Hunter social work students to present and engage scholarship which reflects the academic rigor and sober idealism which are the cornerstones of the Hunter College School of Social Work. Just as Hunter s students regularly display professionally impassioned work in the field, many also create professional quality work in the classroom, deserving recognition for its merit and appreciation for its practical implications. We hope that this journal will serve not only as a forum for the work of current students from year to year, but as a motivation for future cohorts of social work students to conceive of themselves as scholars as well as practitioners in the making. 2

3 Table of Contents Editorial Board, Advisory Board, Administrative Staff... Page 4 Editorial Letter...Page 5 Disparities in the Health Care Experience of Lesbian Patients by Sharon Kaye O Connor Page 6 Improving Mental Health Care for Veterans: Lessons for Social Workers by David Shernoff......Page 10 Conflict Theory and Education: A Case Study at the University of Denver Graduate School of Social Work by Cameron Brown.... Page 15 Karen Horney s Contribution to the Strengths Perspective in Clinical Social Work by Tiffany Hung.....Page 21 The Politics of Physician Assisted Suicide: A Synthesis of Reverence for Life and Individual Autonomy by Dana Kragh...Page 26 Documentary Theatre and Eating Disorders: An Art Based Intervention for Education, Empowerment, and Advocacy by Mikki Jordan......Page 29 Editors & Contributors.. Page 32 3

4 Journal of Diverse Social Work Editorial Board & Managing Editors David Katzenstein ~ Hal Pollack Faculty Advisory Board Dr. George Getzel ~ Dr. Carmen Morano Joanne Messina ~ Dr. Steven Parker Administrative Staff Janet Tyson, Executive Administrator Hazel Chapman ~ Lauren Mazer ~ Yael Shwartz We wish to thank our professors and peers who guided and contributed to this project from its inception to its completion, with special gratitude to Dean Andrea Savage, Dr. Yolanda Mayo, and Dr. Irwin Epstein, for their unwavering commitment to the journal s success. With collective support the notion of a HCSSW student journal has gone from an abstract idea to a compelling reality. We are proud to announce that Cameron Brown and Dana Kragh, members of the HCSSW class of 2011, will be the managing editors for the next edition of the Journal of Diverse Social Work, and wish them the very best of luck in this endeavor. 4

5 Editorial Letter We welcome you to the inaugural edition of the Journal of Diverse Social Work. In this volume, we offer the reader articles on a range of topics which reflect the diversity of contemporary social work practice. In Disparities in the Health Care Experience of Lesbian Patients, Sharon Kaye O Connor illuminates the systemic micro aggressions to which the current health care paradigm actively and passively subjects its lesbian patients. In Improving Mental Health Care for Veterans: Lessons for Social Workers, David Shernoff discusses the unique mental health needs with which veterans returning from combat in Iraq and Afghanistan present, and explores two particular therapeutic programs which are successfully striving to provide this population with necessary and deserved support. In Conflict Theory and Education: A Case Study at the University of Denver Graduate School of Social Work, Cameron Brown argues for the importance of Spanish language social work programs in effectively addressing the needs of the fastest rising ethnic group in the United States, and presents a case study of a pilot program aimed at improving the cultural and linguistic competence of social work students. In Karen Horney s Contribution to the Strengths Perspective in Clinical Social Work, Tiffany Hung discusses the underappreciated and potential impact of Karen Horney on the field of clinical social work, and demonstrates that aspects of Horney s psychoanalytic theory speak to the core elements of social work s strengths perspective. In The Politics of Physician Assisted Suicide: A Synthesis of Reverence for Life and Individual Autonomy, Dana Kragh explores opposing sides of the ideologically fueled debate over physician assisted suicide, and attempts to draw out the central aspects of each position. In Documentary Theatre and Eating Disorders: An Art Based Intervention for Education, Empowerment, and Advocacy, Mikki Jordan proposes a unique treatment modality for eating disorders, enumerating the benefits that documentary theatre can have for a population which is often misunderstood and therefore under treated. David Katzenstein & Hal Pollack, Editors 5

6 Disparities in the Health Care Experience of Lesbian Patients Sharon Kaye O Connor, MSW 2010 Abstract This article explores the challenges experienced by lesbian patients in the health care setting. As the arena of womenʹs health care, particularly the field of obstetrics and gynecology, is focused primarily on the health needs of heterosexual women, lesbian and bisexual women are less likely to obtain the care they need, and are more likely to encounter stigma and negative responses from practitioners when they do seek care. Negative practitioner attitudes as well as a culture of heteronormativity act as deterrents to non heterosexual women obtaining quality and comprehensive care specific to their needs. Along with these challenges encountered in the health care environment, barriers created by policy, such as the inability of lesbian women to obtain health insurance through their partners, and the resulting inability to afford quality health care, also factor in to the overall lacking health care experience for the lesbian patient. W ithin the realm of the health care field, the experience of the patient is an extremely important factor in the perceived overall quality of the care received. Because the patientʹs experience is such a large element of care in general, in a health care situation in which the experience is unpleasant or lacking, it can also be perceived that the care itself is inadequate. Very often in the field of womenʹs health, practitioners operate with the ongoing presumption that their patients are heterosexual, and structure their treatments and interactions with patients accordingly. In other cases, practitioners may harbor strong biases against nonheterosexual patients. As a result of these assumptions and biases, and their resulting practices, the general health care experience queer women encounter as lacking often leads to inadequate or incomplete care, or the avoidance of health care situations entirely (Fields & Scout, 2001). The health care experience from the patientʹs perspective is frequently influenced by several factors, many of which are addressed by the Agency for Healthcare and Research Quality (2008) in its National Healthcare Disparities Report. The factors contributing to the overall patient experience, as discussed in the AHRQ report, are largely based upon communication between patients and their health care providers. The quality of communication between patient and provider can be assessed by the patientʹs perception of the degree to which the provider listens to her, whether or not the provider spends an adequate amount of time with her, respects her questions and concerns, or explains information in a manner that is understandable (AHRQ, 2008). The quality of patient provider communication also depends on the level of comfort the patient feels with disclosing personal information to her provider. In order for successful patient provider communication to exist, it is necessary for the patient to feel able to be open and honest with the provider regarding major issues. For the patient to feel such comfort, it requires the practitioner to exude an attitude of unconditional positive regard. The level of comfort necessary for such disclosure and discussion very often does not exist for the female patient who identifies as gay, lesbian or bisexual (Klitzman & Greenberg, 2002). 6

7 For the purpose of this discussion, the words gay, lesbian and queer will be used interchangeably to refer to woman whose sexual partners include, or have included women, regardless of whether or not their sexual interactions presently include, or have ever included, men. A 2002 study by Klitzman and Greenberg analyzed the potential factors that might have a detrimental effect on communication between lesbian patients and their health care providers. This study addressed the issue that gay women may be less inclined to openly disclose their sexual orientations to their health care providers due to the fear that they will face stigma and the quality of their care will be compromised (Klitzman & Greenberg, 2002). Fields and Scout (2001) recount the story of a young woman who, after telling her gynecologist she was bisexual, was abandoned in the examination room by the doctor, and the exam was then completed by the physicianʹs assistant. Klitzman and Greenberg (2002) found that these women are afraid of facing stigma not only from their healthcare providers but from their employers as well, due to the increased skepticism patients feel regarding their health insurance companiesʹ confidentiality practices. This fear of stigma, and ultimately of discrimination, from those in a patient s life who have access to her personal information, could understandably prevent a patient from disclosing said information to her healthcare provider (Klitzman & Greenberg, 2002). The Klitzman and Greenberg (2002) study also found that among the LGBTQ population, lesbians were less likely than their gay male counterparts to feel comfortable discussing their sexual orientations with their healthcare providers. The study hypothesized that this disparity existed because women were more likely than men to have physicians of the opposite gender of their own, which could lead to a decrease in trust and increase in presumed inability of the physician to understand the patientʹs position (Klitzman & Greenberg, 2002). Although it might be assumed that lesbians would be much more likely to disclose their sexual orientations to providers who were gay themselves, Klitzman and Greenberg (2002) found that this was not necessarily the case. In general, the gay women in their study were less likely than gay men to feel comfortable discussing their sexual orientations, or sex in general, with their physicians. Gay women were also less likely to believe they even had the option of finding a physician who was a lesbian, either due to limitations within their insurance networks or sheer lack of availability of LGBTQidentified physicians (Klitzman & Greenberg, 2002). Because it is often difficult to find physicians who are gay or gay friendly, it could be argued that gay women are so acculturated to the environment of heterosexual physicians (and very often, heterosexual male physicians) that on the rare occasion they do encounter a gay or gayfriendly healthcare provider, they may still feel quite uncomfortable discussing their sexual orientations as they are largely unaccustomed to health care situations in which they are able to do so. Considering the heterocentrist medical culture to which so many queer women are accustomed, it may be greatly beneficial to the lesbian population for insurance companies to allow clients to search specifically for LGBTQidentified or LGBTQ friendly providers in effort to establish a culture in which lesbians are encouraged to feel comfortable discussing their sexuality and sexual orientations (Klitzman & Greenberg, 2002). Another significant element of the disparity existing in the healthcare experience for the lesbian patient is the fact that the non heterosexual patient falls outside of the norm ; the lesbian patient might be quite correct in assuming that medical knowledge and practice has not been designed with her in mind. Rosser (1993) described how the modern medical model was designed primarily with the heterosexual male in mind, giving the example of heart disease and how it is so often mistaken for a male disease by public perception (although this misconception is beginning to change). Heart disease clearly affects both men and women, despite the fact that the majority of funding for heart disease research has gone towards research of heart dis 7

8 ease in males rather than females (Rosser, 1993). Lesbian patients are on the outside of the medical paradigm to begin with due to their gender, and are now at risk of further disenfranchisement, due to their sexual orientation. Rosser (1993) also points out that the field of womenʹs reproductive health care, particularly obstetrics and gynecology, was built upon the framework of heterosexual sexual activity as the norm. The elements of this norm include procreation and womenʹs sexual relations with men. While funding for research surrounding femalespecific issues such as menstrual and postmenopausal difficulties has been extremely limited, the technologies relating to womenʹs health that directly involve procreation (particularly invitro fertilization and amniocentesis, as well as other technologies to assist reproduction) are much more apt to receive adequate attention and funding. This disparity suggests that womenʹs health care issues are generally perceived as more valid or worthy of research when the resulting data and treatment ensure womenʹs ability to procreate and thus be useful to men (Rosser, 1993). Because the health care needs of lesbian women do not necessarily (although they may) revolve around procreation, research in areas of lesbian specific health issues has been lacking. Although lesbians are typically at a much lesser risk for certain diseases that are generally transmitted to women by means of heterosexual sex (such as chlamydia, human papilloma virus, and HIV), gay women are at an increased risk for other diseases less likely to strike their heterosexual counterparts. Campbell (1992), in her work, 1 in 3 Lesbians May Get Breast Cancer, Expert Theorizes, quotes Dr. Suzanne Hayes of the National Cancer Institute, who estimates that one in three lesbians may develop breast cancer in their lifetimes because they are more likely than other women to fall into high risk categories for the disease (as cited in Rosser, 1993, p. 187). It is thought that the risk for breast cancer is higher for lesbians for several reasons. One reason is that gay women are less likely than heterosexual women to have children, and it is thought that women who have not had children are at an increased risk for breast cancer by 80% (Rosser, 1993, p.187). It is also thought that lesbians are at a greater risk of developing breast cancer due to a higher incidence of obesity. Finally, lesbians statistically visit their gynecologists for exams less than half as often as heterosexual women (Rosser, 1993). Aside from the potential discomfort with gynecological visits due to the heteronormative mentality among much of the medical community, this difference in frequency of obtaining care can also be accounted for by the increased regularity with which heterosexual women visit their gynecologists. These visits are often for the ostensible purpose of birth control prescriptions as well as pap smears and screenings for various conditions typically transmitted or caused by engaging in heterosexual sex. During these routine gynecological visits, breast exams and/or mammograms are performed. The frequent employment of these screening tools provide heterosexual women with a greater chance of finding breast cancer (or another potentially serious condition) in its earlier and more treatable stages (Rosser, 1993). Perhaps the largest and most pressing issue facing lesbian health care is the lack of access to health care due to lack of access to health insurance. Because lesbian and gay couples are perpetually denied marriage rights in most geographic areas, many gay women are left uninsured when they are refused coverage under their partnersʹ policies. As quoted by the 2007 AHRQ Report (2008), Health insurance facilitates entry into the health care system. The uninsured are more likely to die early and have poor health status...are diagnosed at later disease stages...are sicker when hospitalized and more likely to die during their stay (p. 114). Even if the culture of health care existed without its current biases and heterosexist practices, a major disparity would remain present as many lesbians would still lack access to health care in the first place. The disparities which are present in the lesbian patientʹs experience of health care are both pervasive and persistent. From the inherent heterocentrist practices quietly passed off as 8

9 standard or normal in the medical arena, to the biases which are held in secret or expressed blatantly by practitioners, to the inability to gain insurance coverage through their partners due to the bigotry that insists their unions are invalid, the lesbian patientʹs experience of health care is vastly different from that of her heterosexual counterpart. Moving forward, it would require nothing short of a shift in cultural consciousness to eliminate these disparities, but there is hope that with effective leadership, education and visibility, the playing field that is the health care experience may be leveled for patients at all points on the sexual orientation spectrum. References Agency for Healthcare Research and Quality, AHRQ (2008) National healthcare disparities report. (AHRQ Publication No ). Rockville, MD: United States Department of Health and Human Services. Retrieved February 26, 2009, from Campbell, K. (1992, October 2). 1 in 3 Lesbians may get breast cancer, expert theorizes. Washington Blade. 1,23. Fields, C., & Scout, S. (2001, September). Addressing the needs of lesbian patients. Journal of Sex Education & Therapy, 26(3), 182. Retrieved February 26, 2009, from Academic Search Premier database. Klitzman, R., & Greenberg, J. (2002, February). Patterns of communication between gay and lesbian patients and their health care providers. Journal of Homosexuality, 42(4), 65. Retrieved February 26, 2009, from Academic Search Premier database. Rosser, S. (1993). Ignored, overlooked or subsumed: research on lesbian health and health care. NWSA Journal, 5(2), Retrieved February 26, 2009, from America: History & Life database. 9

10 Improving Mental Health Care for Veterans: Lessons for Social Workers David Shernoff, MSW 2010 Abstract During the years and decades ahead, it will be imperative for the United States to provide for the wide array of complex and intensive mental health care needs of the nationʹs returning military veterans. This article will attempt a brief summary of the scope and variety of mental health issues presently impacting combat veterans of the United States military, An effort will be made to assess the psychological and psychosocial challenges confronting our veterans after they return from combat theaters. After a brief discussion of the programs most commonly providing mental health care and therapeutic services to veterans and their families, two promising, recently established advocacy organizations working to improve mental health services for veterans will be examined. Attention will be paid to the roles that social workers as clinicians, organizers and advocates can play in addressing the urgent and often unmet needs of the nationʹs veterans.... let us strive on to finish the work we are in, to bind up the Nationʹs wounds, to care for him who shall have borne the battle and for his widow and his orphan.... Abraham Lincoln, Second Inaugural Address, Saturday, March 4, A man who is good enough to shed his blood for his country is good enough to be given a square deal afterwards. More than that no man is entitled to, and less than that no man shall have. Teddy Roosevelt, 1903 A t the time of this writing, approximately 120,000 and 45,000 active duty soldiers are deployed to the theaters of war in Iraq and Afghanistan, respectively. Despite affirmations made by President Obama during his presidential campaign, there is no valid basis for believing that all combat troops will be redeployed from Iraq in the near future. The President has already begun delivering on his campaign promise to increase troop levels in Afghanistan, and the Department of Defense has committed 20,000 additional troops to that conflict in coming months in an attempt at an Afghan surge. The number of veterans who have already completed their tours of duty in both conflicts is large and rising: Since 2002, more than 1.7 million members of the U.S. armed forces have served in an active duty capacity in the Iraq and Afghanistan wars. It will be imperative during the years and decades ahead for the United States to maintain a public mental health infrastructure sufficiently and capably equipped to deal with the ongoing, multiple, complex and intensive mental health care services our veterans will certainly require. This paper will attempt a brief summary of the scope and variety of mental health issues presently impacting combat veterans of the United States military, with a particular focus on Post Traumatic Stress Disorder (PTSD). An effort will be made to assess the psychological and psychosocial challenges confronting our veterans both as they depart for, and after they return from, combat theaters. A limited analysis will then be ventured of the efficacy, and potential areas of improvement, of the programs most commonly providing mental health care and therapeutic services to veterans and their fami 10

11 lies. Finally, the work of two promising, recently established advocacy organizations striving to improve mental health services for veterans will be examined in some detail. As war is inherently horrifying and shocking, soldiers involved in war inevitably experience trauma of some variety. While human beings especially men appear to be designed for combat and possibly possess an innate taste for extreme violence and killing, the actual experience of warfare is profoundly psychologically damaging to the many who have been exposed to, or who have engaged in, it. A small minority of soldiers and combat veterans may deeply enjoy mortal combat on the battlefield, and be gratified by the infliction of harm or even death on other human beings. Those veterans are not the focus of this paper, and it would likely prove difficult to empirically support such a speculative, provocative claim. The battlefield offers endless opportunities for soldiers to sustain psychological and emotional shocks and wounds. Yet perhaps the most damaging element of warfare is its capacity to undermine a person s general sense of security and safety at any given moment. This overall, everyday sense of safety and security that it is safe to walk down the street to a subway station, or that a fellow subway passenger does not, in fact, have a bomb vest hidden beneath his sweater, or that the destination the subway is transporting you to is not laden with mines and explosives and/or populated by fanatical adversaries willing to commit suicide in order to end your life as well, etc. is a kind of prerequisite for normal and adaptive psychological functioning and participation in the social order. In the absence of this overall sense of security, an individual can live in a nightmarish state of acute, constant fear of looming physical danger and threats, a state in which an apprehension of imminent risk or even death never relents and can never be alleviated. This shifting of the normal, daily experience of an individual from a secure to an insecure, vulnerable state is the most widely observable consequence of participation in warfare by soldiers and veterans. PTSD is rooted in this loss of a fundamental sense of security and safety, and in the consequent shifting of daily experience from a secure to an insecure state. As William Tecumseh Sherman memorably phrased it, war is hell. The Roman poet Virgil captured the impenetrability of that private hell to those who have personally and directly endured the horrors of warfare an impenetrability of which caregivers aspiring to treat the invisibly wounded would be well advised to be cognizant and respectful when he said that each of us bears his own hell. According to a major recent study conducted by the RAND Institute, some 20% of combat veterans who have returned from Iraq and Afghanistan are already bearing their own hell, as evidenced by their suspected suffering from PTSD, depression, and general anxiety disorder (Tanelian & Jaycox, 2008, p. 96). Based on the above cited 1.7 million total number of soldiers who have rotated through Iraq and Afghanistan since 2002, roughly 340,000 cases of PTSD and related conditions have either been diagnosed already among, or are presumed to be warranted for, returning combat veterans. Even more disturbing is the RAND report s conclusion that half of those troops and veterans affected are not receiving proper mental health care. Furthermore, physiological conditions such as concussions and Traumatic Brain Injury, conditions that are highly comorbid with PTSD and depression, are likewise not being properly diagnosed and treated. The present reality is that tens of thousands of new veterans returning home every year are suffering from mutually reinforcing psychological and brain injuries, which are diagnosed and treated only half of the time. In addition to PTSD, a high number of returning veterans are suffering from undiagnosed and untreated major depression, anxiety disorders, increased substance abuse, a heightened vulnerability to physical ailments, and are generally unable to reintegrate into the social order. This is a moral outrage and constitutes a social policy failure of great magnitude. There are a number of reasons for this massive failure of public mental health care systems. First and most obvious, longstanding, 11

12 deeply ingrained stigmas associated with seeking mental health care and being treated for mental health conditions persist, especially in the culture of the military. The RAND study found that many of the interviewed service members actively and intentionally avoided subjecting themselves to clinical assessments and care that they believed would have resulted in a mental health disorder diagnosis. A substantial body of research bears out the commonsense claim that stigma impedes people from seeking and fully participating in mental health care services. In particular, the threat of social disapproval and diminished self esteem that accompanies the label accounts for underused services (Corrigan, 2004). There is every reason to suspect that military cultural factors render soldiers and veterans even more susceptible than members of the general public to the adverse and inhibiting effects of stigma. A major study was published in the New England Journal of Medicine in 2004 which, to date, represents the most comprehensive examination of the barriers to proper mental health care faced by both active duty and returning combat veterans. Study participants who met screening criteria for a major mental health disorder were asked what they believed to be the most significant barriers to their receiving mental healthcare. The fear of being perceived as weak and a fear of losing the trust and confidence of their colleagues were the leading reported barriers (Hoge et. al, 2004, p.17). Nearly as commonly, respondents felt that integrating a mental healthcare treatment regimen into their lives and schedules would be a significant challenge. A majority of respondents believed that accessing appropriate treatment would hinder their ability to execute their duties and responsibilities, and there is no good reason to believe that their concerns were groundless. This implies that the military s own systems of mental health care are not adequately integrated into their total provision of healthcare for service members. The military is simply not well prepared for the virtually certain contingency that a large share of combat soldiers will sustain mental health injuries. The healthcare service delivery mechanisms maintained both by the service branches and by the Veterans Administration simply have not integrated mental healthcare preparedness as well as they ought to. Whether this is a greater barrier to care than an excess of caution in receiving potential treatment born of careerist caution remains to be seen. A remarkable advocacy organization called Iraq and Afghanistan Veterans of America (IAVA) was founded in 2004 by Paul Reickhoff, an Iraq War veteran. Its mission is stated simply: to improve the lives of Iraq and Afghanistan veterans and their families. While IAVA is only five years old, it has had significant success in impacting policy discussions and heightening awareness among policymakers and in the media of the multiple challenges facing new veterans as they return from the battlefield. IAVA places a particular emphasis on the need to publicize and destigmatize the discussion of mental health and Traumatic Brain Injury and the urgent need to increase mental health screening and support services among active duty soldiers as well as veterans. IAVA maintains an extensive website which provides clear, easy to access information regarding how to attain mental and physical healthcare services and how to navigate the VA most effectively. The website also allows interested parties to easily contact local, state and federal political representatives on behalf of veterans, and the IAVA is building a rapidly growing lobbying presence in Washington D.C. The most ambitious element of IAVA s legislative agenda is a new GI Bill which would substantially increase educational benefits for service members, sufficient and reliable funding of veterans health care, and mandatory, confidential mental health counseling for all troops returning from combat duty (IAVA 2008 Annual Report, p.6). This last element of the proposed new GI Bill reveals IAVA s explicit goal of placing mental health care for veterans at the heart of its mission and reflects its view that mental health care is inseparable from the overall welfare of returning veterans and their families, and needs to be consistently addressed in a public, open 12