Advance directives are the primary tool for individuals to communicate their wishes if they become incapacitated and are unable to make their own health care decisions, particularly near the end of life. Despite this, 63 percent of American adults have not completed one, reports the most comprehensive study to date on the subject from researchers at the Perelman School of Medicine at the University of Pennsylvania this week in the July issue of Health Affairs.
A systematic review of studies from 2011-2016 led by Katherine Courtright, MD, MS, an instructor of Medicine in the division of Pulmonary, Allergy, and Critical Care and the Palliative and Advanced Illness Research (PAIR) Center at Penn, found that among more than 795,000 Americans who were part of 150 different studies, 63 percent had not completed any advance directive. Only 29.3 percent had completed a living will that contained specific end-of-life care wishes, and 33.4 percent had designated a healthcare power of attorney.
Completion of advance directives was nominally higher among patients with chronic illnesses (38.2 percent) than among healthy adults (32.7 percent), and was much higher among patients age 65 and older (45.6 percent) compared with younger adults (31.6 percent). One of the primary means to ensure medical teams treat patients according to their end-of-life care preferences is through an advance directive – a legal record signed by a competent individual that guides care decisions when a patient’s poor health prevents them from making the decisions on their own.
“Most experts agree that some form of written directives are a key component of advance care planning, and yet rates of completion are low and do not appear to be increasing,” Courtright said. “We need to address common barriers to completing these important documents on a national level, particularly among chronically ill patients who are at higher risk for critical illness and death.”
The authors note that detractors of advance directives cite the inability of living wills to capture all of the situations one might face near the end of life, whereas proponents of living wills note that many patients wish to protect their loved ones from having to make such burdensome end-of-life care decisions.
The research team makes a few recommendations to address these low rates. First, content and format of advance directives must better represent the issues discussed in advance care planning conversations – such as patient values and goals, along with care preferences. Second, legal barriers to executing an advance directive should be simplified. Finally, efforts to increase advance directive completion should focus on populations at high risk for poor end-of-life care outcomes.
“The treatments most Americans would choose near the end of their lives are often different from the treatments they receive,” Courtright said. Unfortunately, this disconnect can lead to unnecessary and prolonged suffering. Advance directives remain the primary tool for people to communicate their end-of-life care wishes and appoint surrogate decision makers, but improvements to the documents and completion process are clearly needed.
What #NeverAgain Means for Workplace Violence for Helping Professionals
What does the #neveragain movement mean for workplace violence for helping professionals? Social Work Helper hosted a free live discussion with security expert and threat management specialist, Hector Alvarez, on workplace violence prevention and tips.
In early March, Christine Loeber, a social worker and executive director of a veteran treatment facility, was one of three women held hostage and killed by former client and combat veteran, Albert Wong.
The Napa County Sheriff’s Department reports Wong, age 36, shot the three mental health workers in the head with a rifle before self-inflicting a fatal gunshot wound to the head. Psychologists Jennifer Golick and Jennifer Gonzales Shushereba, who was also pregnant, were the other two victims of this horrific incident.
It is believed that Wong was released from services based on information provided by a family member of one of the victims. This incident may seem like an isolated incident, but a quick google search will show how often social workers and other helping professionals are constantly being threatened, hurt or killed by a spiraling client, and those incidents only represent the newsworthy incidents.
According to the OSHA’s Guidelines for Preventing Workplace Violence for Healthcare & Social Service Workers, professionals working in this sector are at the greatest risk for workplace violence. In the guidelines, the Bureau of Labor and Statistics reported 48% of all non-fatal incidents of workplace violence, assaults or violent acts occur in the healthcare or social services. They also report social service workers (social workers, child welfare, and caseworkers) are 7 times more likely to become victims of violence than those working in the private sector.
Watch the replay using this link: https://www.crowdcast.io/e/what-neveragain-means.
Gay, Bisexual, Sexually Abused Male Inmates More Fearful of Prison Rape, More Open to Therapy
There is nowhere to escape in what often is referred to as a “sexual jungle,” especially for the most vulnerable. However, “Zero tolerance” toward prison rape is now national policy thanks to the Prison Rape Elimination Act passed by the United States Congress in 2003. Although this law changed how Americans think about prison rape, few studies have examined how inmates perceive rape and if they feel safe in prison. Even less is known about how their perceptions influence whether or not they ask for mental health treatment while incarcerated.
The most recent National Inmate Survey of 2011-12 of 92,449 inmates age 18 or older shows that among non-heterosexual prison inmates, more than 12 percent reported sexual victimization by another inmate and almost 5.5 percent were victimized by a prison staff member within the past 12 months. In comparison, 1.2 percent of heterosexual prisoners were sexually victimized by an inmate and 2.1 percent were victimized by a prison staff member. These rates are even higher for those with mental illness. About one in 12 inmates with a mental disorder report at least one incident of sexual victimization by another inmate over a six-month period, compared to one in 33 male inmates without a mental disorder.
Using data from more than 400 male inmates housed in 23 maximum-security prisons across the U.S., researchers from Florida Atlantic University conducted a novel study to examine the factors related to fear of rape in prison and the likelihood of male inmates requesting mental health treatment while incarcerated. They focused specifically on prisoners at risk of being sexually victimized in prison: gay or bisexual inmates and those with a history of childhood sexual abuse.
A key finding from the study, published in the Journal of Interpersonal Violence, is that sexual orientation and a history of childhood sexual abuse are significant predictors of male inmates fearing rape as a big threat in prison and voluntarily requesting mental health treatment. Findings from the study reveal that nearly 38 percent of gay and bisexual inmates and 37 percent of inmates with childhood sexual abuse fear rape as a big threat.
Compared with straight inmates, gay and bisexual inmates are approximately two times more likely to perceive rape as a threat and three times more likely to voluntarily request mental health treatment in prison. Inmates with a history of childhood sexual abuse are more than twice as likely to perceive rape as a threat and almost four times more likely to request mental health treatment than inmates who did not report a history of childhood sexual abuse. Notably, this finding is inconsistent with previous research that has shown that there is no significant relationship between childhood sexual abuse and feelings of safety among male inmates.
“The consequences of perceiving rape to be a threat in prison are vast and could contribute to violence among inmates as well as negative mental health ramifications such as increased fear, psychological distress, chronic anxiety, depression and thoughts of suicide,” said Cassandra A. Atkin-Plunk, Ph.D., co-author and an assistant professor in the School of Criminology and Criminal Justice within FAU’s College for Design and Social Inquiry.
Inmates incarcerated for two to five years are nearly three times more likely to perceive that rape is a big threat compared with inmates incarcerated for less than two years. Inmates in prison longer than 18 years are nearly four times more likely to voluntarily request mental health treatment in prison. The researchers also found that Black inmates are twice as likely to seek mental health treatment in prison compared to White inmates.
“Knowing that gay and bisexual inmates and inmates with a history of childhood sexual abuse are more likely to fear rape and seek mental health treatment, prison staff can target outreach and treatment efforts for this vulnerable sub-population,” said Mina Ratkalkar, LCSW, MS, lead author and a licensed clinical social worker pursuing a Ph.D. who conducted the study while she was a graduate student at FAU. “Our study shows that these sub-groups of inmates are receptive to treatment, and our findings have implications for both practice and policy in the United States.”
The sample consisted of a nearly equal number of men in their 20s, 30s and 40s. Black inmates made up about half of the sample, with White inmates comprising about one-third of the sample. Nearly one-third of the sample had previously been in juvenile detention and about one-quarter were incarcerated for the first time in the adult criminal justice system at age 18 or younger.
About 16.4 percent of the sample identified as gay or bisexual. About one-fifth of the men (73) reported a history of childhood sexual abuse, and about one-third of the men reported having received mental health treatment outside of prison.
Language Is Power: Two Things You Need to Know for Practice with Disabled People
Did you know that over one fifth of the United States population has an impairment that leads to a disability? Given this, social workers are bound to engage in practice with disabled people across many service sectors – a reality which leads to the need for disability competence – and that includes competence around language choices.
Whether you are working in child welfare, employee assistance programs, criminal justice or end-of-life care, you will need some guidance on how to approach your work with disabled people in a respectful manner. Here are two helpful things you need to know to be a better social worker in partnership with disabled people.
First, it is always ideal to look to your professional association for guidance. In the case of practice with the disability community, the National Association of Social Workers not only has a disability policy statement, but they also have made a major change to their Code of Ethics (CoE).
The CoE is the guidepost in our profession, and in setting out standards for practice, it names a series of diversity factors, including, for example, race, ethnicity and national origin. Until the most recent revision of the CoE however, disability was the only diversity factor that was not framed in a positive light.
To rectify this, the current version of the CoE replaces the term “disability” with “ability” in order to present a more strength-based framework that can counteract dominant society norms that belie the capacities of disabled people. Specifically, the CoE states that social workers should “obtain education and seek to understand the nature of social diversity and oppression” with respect to people with varying abilities.
While this may be a turn off to people that embrace identity-first language (i.e. disabled people vs. people with disabilities), as a disabled person, I believe that this simple change is helpful, and does not fall into the camp of widely-rejected, outdated and offensive terms such as “differently abled,” “handicapped,” or “special needs” that are often used by well-intentioned people. Check out, for example, Lydia X. Z. Brown’s glossary of ableist phrases.
Second, it is also always a best practice to learn more about the language preferences from our clients’ cultural communities. Lately, not a day goes by on my Twitter feed when I don’t see commentary from disabled people about their preferences for either person-first language or identity-first language.
Check out the #identityfirst hashtag, for example. For many years, social workers were encouraged to use person-first language as a way of showing respect, as opposed to labeling someone as “a schizophrenic,” or “autistic,” for example, both of which were felt to have negative connotations at the time.
Proponents of identity-first language have reclaimed such terms by embracing their disability identity first. For example, a well-known disability rights leader prefers to be called Autistic, and another advocate prefers to be referred to as mad (signifying mental illness).
For social workers new to practice with disabled people, an ideal approach could involve using approaches interchangeably until it is clear what type of language is preferred by the client in question. Remember, language is a key component to client engagement, and, therefore, language is power.
Regardless of whether you are identifying populations with varying abilities, or honoring your clients’ wishes for person-first or identity-first language, the most important thing is to see people for who they are, not for the stereotypes or assumptions that often precede them.
Study Suggests Why Food Assistance for Homeless Young Adults is Inadequate
Though young homeless adults make use of available food programs, these support structures still often fail to provide reliable and consistent access to nutritious food, according to the results of a new study by a University at Buffalo social work researcher.
The findings, which fill an important gap in the research literature, can help refine policies and programs to better serve people experiencing homelessness, particularly those between the ages of 18-24.
“It may be tempting to think of food pantries, soup kitchens and the Supplemental Nutrition Assistance Program (SNAP) as the solution,” says Elizabeth Bowen, an assistant professor in UB’s School of Social Work and lead author of the study with Andrew Irish, a UB graduate student in the School of Social Work, published in the journal Public Health Nutrition. But these supports are not enough. “We’re still seeing high levels of food insecurity, literal hunger, where people go a whole day without eating anything.”
The U.S. Department of Agriculture (USDA) defines food insecurity as “multiple indications of disrupted eating patterns and reduced food intake.” Hunger is a “potential consequence of food insecurity [that] results in discomfort, illness, weakness or pain.” In Bowen’s study, 80 percent of participants were considered to be severely food insecure.
“There has been recent research about housing and shelter use for homeless young adults, as well as work on drug use and sexual risk behaviors for this same population, but I found that not much had been done on the issue of food access,” says Bowen. “It’s hard to even think about housing and health needs if we don’t know how people are eating, or not eating.”
It’s not surprising see a relationship between homelessness and food insecurity, but Bowen warns of oversimplifying what is in fact a more nuanced problem.
“This research is important because we’re establishing a clear indication of food insecurity in this population, which we did not previously have,” she says. “If we’re going to design programs and services that better address food insecurity, along with addressing housing, education and employment, we need to know about the access strategies: How and what are homeless young adults eating? Where are they finding food? What do they have to do to get it? And how does that affect other parts of their lives?”
For her qualitative study, Bowen conducted in-depth interviews with 30 young adults between the ages of 18-24 who were experiencing homelessness in Buffalo, New York.
“Working with this small group gives us insights into the lived experience,” says Bowen. “It’s a way of setting a knowledge foundation and understanding of the topic in the context of people’s lives, and what goes on with their health, housing, relationships, education and trying to get out of homelessness.”
In Bowen’s study, 70 percent of young adults were receiving SNAP benefits, also known as food stamps. But actually getting these benefits can be difficult.
SNAP covers dependent children under their parent’s benefits until the child’s 22nd birthday. But the program administers benefits based on the parents’ address and assumes that parents and children of a single family are living together.
“This is clearly a problem for young people experiencing homelessness since many of them are under 22 and obviously aren’t living at the same address as their parents,” says Bowen. “The young people in this case can’t get SNAP on their own because they’re already listed on their parents’ open application for those same benefits – and the burden of proof is on the young person to demonstrate they don’t live with their parents.”
Documentation is required as proof that the family is no longer together, according to Bowen, but in many cases getting the necessary paperwork is difficult because of strained family relationships.
“That’s one avenue for a policy change,” says Bowen.
But even with revised eligibility guidelines, food stamps sometimes are not enough, particularly for homeless young people who have no way to store or prepare food. Bowen notes that this problem would be greatly exacerbated by a change proposed in the 2019 federal budget to convert part of a household’s SNAP benefits from electronic benefits to a box of canned goods and other commodities.
Homeless young adults’ food access challenges are further compounded by the fact that young people are sometimes reluctant to use resources like soup kitchens, or have trouble accessing these places due to transportation barriers and limited hours. This finding mirrors prior research showing how young adults are not comfortable in places meant for the general homeless adult population, according to Bowen.
For instance, where shelter is concerned, an 18-year-old in the city of Buffalo is considered an adult and would go to an adult shelter, which can feel discouraging and unsafe.
“What I found in this study is that people were saying the same things about places to get food. They know about these soup kitchens, but the places feel institutional and stigmatized to young people,” says Bowen. “If we want to develop food programs to be engaging to young people we have to think about breaking down some barriers. For example, because of food insecurity among students, many college campuses are now offering food pantries. I would like to think about how to integrate food pantries and other services into places where young people are going anyway.”
How to Recognize and Help an Addict
It’s devastating to know a friend or a loved one suffers from an addiction. Before people get help, they often go down a long road of addiction prior to anyone, including themselves, noticing a problem. Consider the information and advice below if you know or suspect someone is an addict.
Addicts are excellent liars. It can seem disheartening to hear that you shouldn’t take them at face-value. However, listen to your gut. Your gut is telling you that something is wrong. Do not ignore this. They will tell you all the right things you’d like to hear. They will go into detail about where they were, why they did something and more. Everything will sound right to your mind. The very fact that you feel something isn’t right means more than likely something truly isn’t. Listen to what they say, and take notes because if they are addicts, they will slip up eventually. Don’t be the big-bad wolf that’s out to get them, but don’t be an enabler either. Enablers help them to stay stuck in their addiction by making excuses for them.
Addicts especially high-functioning addicts think that if they’re able to go to work, bring money home, do housework and other normal day-to-day life they do not have a problem with addiction. An addict is not just the junkie on the corner. Most addicts are high-functioning, which means they go under the radar for what passes as an addict to society. Because of this, and for reasons such as not wanting to face themselves, addicts will lie to themselves and the world. This is why most addicts are in denial. They might also reason that they don’t drink “enough” to be an addict. Make no mistake that alcoholism isn’t about the quantity of alcohol ingested. It’s about the mental obsession and physical craving of alcohol that makes someone an alcoholic. People who don’t drink for three of four months and suddenly “binge” can be alcoholics.
Things Don’t Add Up
It is often said that addicts lead double lives. This is true for anyone living in dysfunction. To the outside world, they have it together. Underneath that façade is a broken human being who uses alcohol, substances or anything else to get by. To make matters worse, this outward appearance can be further covered up, or justified, with a prescription medication. Abuse of a prescription medication is a serious concern. People often overdose on their pills or makeup excuses for why they need them even though they don’t have a legitimate need for them. This is why centers offer painkiller addiction treatment because it is a common phenomenon. It is also a growing phenomenon.
To the addict, you’re “mean,” “unreasonable,” and a few choice words when you confront them. Expect this upfront. It’s not a reflection of who you are as a person despite their best attempts to assassinate your character. What they say about you has everything to do with their dysfunction. More often than not, they will choose their addiction over you. Real help and real love mean saying, “I’m going to tell you the truth,” “I need to love myself before I can love you,” or “I don’t accept your excuse. You’re responsible for your behavior, and I refuse to be a part of your life until you take responsibility for yourself.”
You can’t force someone to get help, but you can stop enabling them. Don’t make excuses for their behaviors or addiction. Addicts have to want to get help before they do. Once you know there is a problem, stand your ground. Speak truthfully to the addict. Above all, love yourself because this has been and will continue to be incredibly hard on you. Understand that they have to learn to love themselves too.
Veterans: Take This Survey!
Learning about military-to-civilian reintegration requires asking the right questions of the right people. A novel, new study is seeking military veteran respondents to learn more about the way service impacts health, civic engagement, and socio-economic outcomes for military-connected men and women. The data collected through this survey are expected to help us answer questions such as:
• Do veterans feel welcome and interested in institutional service groups like the VA and informal groups like VSOs? Do those organizations serve their needs? How are prospective members welcomed and served?
• How does military service impact community involvement and political engagement?
• How does military service impact experiences on the job market (and is this effect conditioned by demographic factors?
• Does military service break the glass ceiling for service women?
The project was developed by an interdisciplinary research team with experience, training, and connections to the military community. Dr. Kyleanne Hunter is a Marine Corps Cobra pilot and political science researcher. Dr. Rebecca Best is an experienced security studies researcher with a focus on service women. Dr. Kate Hendricks Thomas is a public health researcher and Marine Corps veteran. Each has specific training in community-based, participatory research and is invested in filling current gaps in what we think we know about the transition from service member to civilian.
Access the survey online here: https://udenver.qualtrics.com/jfe/form/SV_572AiK5P3P75KQt
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