The Why and the What
Meet Marcy, a social worker, treating Melanie, a 10-year-old child, whose father was recently imprisoned for domestic violence and child endangerment. Melanie came to the clinic with symptoms of PTSD and depression, including guilt. Melanie called the police, because she was so scared when her mother suffered abuse at home. Confusion, loss, shame, and embarrassment were all part of what she had to endure emotionally. What 10-year-old could bear such a thing? And Marcy, the social work therapist was determined to help Melanie make sense of it all, mourn her separation and loss, and forgive herself.
Seven months after intense family treatment, involving Melanie, her mother, Jane, and her siblings, Melanie has shown much progress but further therapy has now become challenging. Melanie had previously missed two consecutive appointments and this is now her third such no-show.
Important critical questions to consider:
Is this “resistance” on the part of the family, or
Is this no show secondary to the social worker asking Jane, Melanie’s mother, to challenge herself.
Is there something else Marcy may have missed?
Marcy decided to call Jane; “Jane, I have not heard from you; I wonder how you and Melanie are doing, and when I should expect to see you.” To this, Jane responds, “Ms. Marcy, I am very sorry; I was planning to call you. I am so sorry. I want to see you. I hope soon.” Marcy offered an acceptable appointment to Jane. However, on the appointment day, Jane failed to show up with Melanie. This was now the fourth no-show. Something was definitely wrong.
Marcy was worried about Melanie, her mother and family; she was concerned that seven months of intensive therapy had yet to be consolidated. Also, since suicidal ideation was part of Melanie’s initial presentation, Marcy reached out to her supervisor for help, eager to know what the next steps should be. After meeting with her supervisor, Marcy, felt armed with the right tools, and she now understood what questions to ask, and how and when to pose them. She then scheduled a billable 45-minute phone session to meet with Melanie and her mother.
Marcy’s findings and lessons learned:
With the right timing, questions, and communication skills, Marcy took her time to listen to Jane to get the full story;
"I am sorry, Ms. Marcy; so sorry. I did not know what to do. I just did not know. But, a lot has been happening. My husband was the only one working to provide an income for the family. And after he went to jail, things started to get tough. I needed to look for part-time work, but I also needed be sure I had enough time for Melanie and her four siblings. We don’t have anyone here to help with the kids, so I had to take time away from work to get the kids from school and take them to the doctor. Initially, my boss simply did not pay me for the days of missed work, but later on, he said he would have to fire me. It has now been two months since I lost my job, and I have been behind on my rent ever since.
Last month my landlord finally decided to evict me from the apartment. Thank God my pastor provided us a place in the basement of the church. But, Ms. Marcy, it is so far away from the clinic, two hours on the bus. And sometimes I don’t even have the money for bus fare to get Melanie’s younger sisters from school. (Jane was sobbing while she explained this).
Ms. Marcy, I am sorry, I am so sorry, but I could not get Melanie’s medications; I had no more money for co-pays. As a result, Melanie cannot sleep, and she wakes up screaming in the middle of the night. I don’t know what to do.”
Marcy allowed Jane the time to tell her story, empathized with her, provided some support, and vowed to work with her clinic team to help address the needs of both Melanie and her family. This process of family therapy and family support has been successful.
Similar to Part I of Social Determinants of Health, this continuing series article illustrates the story of Melanie and Jane, highlighting how important it is to address the needs of our clients and patients by paying attention to or addressing the social determinants of health. The above story touches upon several social determinants of health, in addition to the few mentioned in Part I. Below are the 15 most common social determinants that we all should consistently pay attention to in our daily practice. We will address each of them in subsequent articles, discuss how to best assess for them, and how to adequately address them. Lastly, before I present this list, it is worth asking:
Why should we pay attention to the social determinants of health?
Marcy was able to help Melanie, her mother and siblings make great progress in treatment. However, Melanie and her family sustained several no-show appointments. All were due to social factors that greatly influenced or “determined” Melanie’s treatment outcomes. The answer to the “why” of addressing the social determinants is related to understanding the factors concerning the client or patient, the clinician, the agency, and the whole healthcare system. In other words, it is a win-win for all, and failure to address these can be summarized in the following outcomes:
Clinical: Our patients and clients will hardly get better unless the social determinants are fully assessed and properly addressed.
Prognosis: Achieving full recovery will be difficult if the social determinants of health are not addressed.
Career and burn out: Our career goals of making a difference in the lives of others will fall short and burn out is likely to ensue.
Waste and cost: Waste in healthcare will continue and costs will only escalate.
The ability to name things is an important first step in establishing knowledge. Let me then name the 15 most common social determinants of health that require our attention.
Income and income distribution
Unemployment and job insecurity
Occupation, employment and working conditions
Social exclusion and lack of social support
Housing and neighborhood environment and safety
Early childhood development
Addiction, including smoking
Chronic stressors, including transportation
Difficulty accessing health services
I hope we have come to mutual understanding regarding the importance of paying attention to the social determinants of health. In subsequent series, we will be discussing further how the social determinants impact the health of our patients and clients, how to best assess them, and how to best address them. In the meantime, will you be bold enough to share your story, share your experiences with us and with others around social determinants?
Looking forward to hearing from you!
Mardoche Sidor, MD
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