When one considers vision in schizophrenia at large, visual hallucinations (VH) are likely the first concept that comes to mind. However, a recent study estimated the weighted mean prevalence of VH in schizophrenia is only 27% (Waters et al., 2014). Comparatively, visual distortion prevalence is estimated at 60% (Silverstein & Lai, 2021). These distortions were first noted by Kraepelin’s (1903) reports of patients’ incomplete perception of briefly exposed objects. More recently, researchers have discovered that visual perception abnormalities in schizophrenia include deficits in perceptual organization, contrast sensitivity, perception of motion/colors/brightness, human figure and emotional expression perception, and distortion of shapes (Adamek et al., 2022). These demonstrated impairments in visual processes play a significant role in poorer community functioning for those with schizophrenia, thus further investigation and dissemination of information is crucial (Green et al., 2012). 

Visual perception abnormalities in schizophrenia are evident in the prodromal phase of the disorder, as well as during acute psychotic episodes and in patients who have achieved reasonable symptomatic remission (Chieffi, 2019). Advances in research have also led to the possibility of considering visual perception abnormalities as an endophenotype for schizophrenia. An endophenotype, also called an intermediate phenotype, is a heritable and generally state independent biological trait that appears in affected individuals and their nonaffected first-degree relatives with greater prevalence than the general population (Gottesman & Gould, 2003). A landmark 2004 study by Loughland and colleagues provided the first evidence that dysfunctional visual tracking is present in first-degree relatives and may indicate a trait marker in the familial transmission of the disorder. Longitudinal studies have made the connection between early childhood visual dysfunction and predictive development of schizophrenia spectrum disorders in adulthood, with visual distortions providing the highest predictive validity for later development of a psychotic spectrum disorder (Klosterkotter et al., 2001). 

Visual dysfunction in schizophrenia is complex and multilayered, with ties to abnormal brain activation in temporal, occipital, parietal, and prefrontal areas of the brain. Neuroimaging studies of schizophrenia show both abnormal structural and functional connectivity between brain regions, providing evidence that dysconnectivity between brain regions may play a significant role in issues with perceptual processing (Kaufman et al., 2015). Within the brain, there are two pathways that connect different brain regions with respect to visual information, the dorsal and the ventral streams (Kravitz et al., 2013). The dorsal stream is located in the parietal cortex and is dedicated to the processing of motion and spatial location, while the ventral stream is located in the lateral occipital and inferotemporal cortex and is dedicated to higher-level object recognition and detailed representation of stimuli (Kravitz et al., 2011). A 2019 study demonstrated abnormal connectivity in both the ventral and dorsal streams of individuals with schizophrenia, providing support for brain region dysconnectivity playing a role in visual perceptual impairments in schizophrenia (Deng et al., 2019). The ventral stream is also referred to as the “what” pathway, while the dorsal stream is referred to as the “where” pathway (Kravitz et al., 2011). Thus, if one is having difficulty with object recognition (“what”), disrupted connectivity will make it even more difficult to place the object in space (“where”) and evaluate it as a complete percept, and vice versa. 

Individuals with schizophrenia demonstrate disruptions in both bottom-up and top-down visual information processing. Bottom-up processing refers to the earliest stages of visual processing, with errors in pre-cortical areas disrupting higher visual cognition (Adamek et al., 2022). Pre-cortical areas of visual processing include the retina, optic nerve, and the thalamus. Dysfunction at the basal level of the visual system gives rise to impaired activation of cortical structures in both the dorsal and ventral visual stream pathways (Butler et al., 2007). This distortion of visual stimuli at the early stages leads the brain to ineffectively evaluate the information, making it more difficult to properly integrate it into consciousness (Javitt & Freedman, 2015) and thus disrupting the decision-making process (Shosina et al., 2020). Top-down processing involves drawing upon prior information and experiences to make a tentative hypothesis about visual stimuli by utilizing higher cognitive processes while integrating ongoing perceptual input (Schendan & Ganis, 2015). The top-down processing system influences all areas of the visual pathway, excluding the retina (Gilbert & Li, 2013). 

Regarding errors in pre-cortical areas of visual processing in schizophrenia, it is crucial to consider dysfunction of the retina—where sensory information enters our visual system and is subsequently modulated and converted into an electrochemical signal, eventually giving way to a visual percept (Roska & Meister, 2014). Retinal abnormalities in schizophrenia include morphological and related biochemical changes. Changes in retinal morphology in schizophrenia are confirmed by in-vivo studies using Ocular Coherence Tomography (Adamek et al., 2022) (OCT), which utilizes light waves to render a cross-sectional picture of the retina (Wojtkowski et al., 2004). Such studies have demonstrated reductions in the retinal nerve fiber layer (RNFL) in individuals with schizophrenia. The retinal nerve fiber layer (RNFL) is made up of ganglion cell axons, which then bundle together to form the optic nerve (Datta et al., 2020). It is still somewhat unclear the extent that retinal atrophy in schizophrenia directly relates to dysfunction in visual processes. However, specific visual disruptions such as contrast sensitivity and color perception that are observed in schizophrenia are similarly seen in other disorders with well-established retinal impairments such as Parkinson’s disease and retinal dystrophies (Archibald et al., 2009; Silverstein, Demmin, & Skodlar, 2017). Biochemical correlates of retinal pathology in schizophrenia include the neurotransmitters dopamine and glutamate (Adamek et al., 2022). On one hand, dysregulation in glutamate corresponds with retinal cell death, while excessive extracellular dopamine corresponds with photoreceptive cell hyperintensity (Adamek et al., 2022). The modulation of this retinal information is then transmitted further to pre-cortical and cortical areas of visual processing, indicating disruption at the biochemical level of the retina further impacts visual perceptual issues in schizophrenia (Adamek et al., 2022). 

Visual perceptual processes are the most influential in integrating external sensory stimuli into our inner world, and thus play a significant role in one’s perception of reality. This is especially crucial to investigate in schizophrenia, as distorted reality testing is a hallmark of the disease. Individuals with schizophrenia demonstrate a host of visual perception abnormalities that have been evident in the earliest descriptions of the disease yet have not been scientifically investigated until recently. This research has confirmed notable changes in the visual system of individuals with schizophrenia as early as the retina, where visual information first enters our brain. These early-stage abnormalities impacting the quality of visual perception lead to incorrect modulation of this information by higher cognitive functions, further disrupting one’s ability to appropriately integrate visual stimuli into consciousness. Recent models of the disorder posit that misinterpretation of visual information may lead to the development of an incorrect model of reality, due to errors in higher-order prediction based on aberrant visual information at the pre-cortical level. Further investigation into the visual system of schizophrenia is crucial, as well-demonstrated visual impairments lead to poorer real-world functioning and there may be novel clinical utility in understanding pre-cortical eye abnormalities in the disease. 

References 

• Adámek, P., Langová, V., & Horáček, J. (2022). Early-stage visual perception impairment in schizophrenia, bottom-up and back again. Schizophrenia (Heidelberg, Germany), 8(1), 27. https://doi.org/10.1038/s41537-022-00237-9
  
• Archibald, N. K., Clarke, M. P., Mosimann, U. P., & Burn, D. J. (2009). The retina in Parkinson's disease. Brain, 132(5), 1128-1145.
  
• Ascaso, F. J., Laura, C., Quintanilla, M. Á., Gutiérrez Galve, L., López-Antón, R., Cristóbal, J. A., & Lobo, A. (2010). Retinal nerve fiber layer thickness measured by optical coherence tomography in patients with schizophrenia: a short report. The European journal of psychiatry, 24(4), 227-235.
  
• Butler, P. D., Martinez, A., Foxe, J. J., Kim, D., Zemon, V., Silipo, G., ... & Javitt, D. C. (2007). Subcortical visual dysfunction in schizophrenia drives secondary cortical impairments. Brain, 130(2), 417-430.
  
• Chieffi, S. (2019). Dysfunction of magnocellular/dorsal processing stream in schizophrenia. Current Psychiatry Research and Reviews Formerly: Current Psychiatry Reviews, 15(1), 26-36.
  
• Datta, S., Baidya, K., Banerjee, M., Mahapatra, S., & Mukherjee, S. (2020). Retinal Nerve Fibre Layer Thinning in Patients with Thalassaemia, Iron Deficiency Anaemia, and Anaemia of Chronic Diseases. Journal of ophthalmology, 2020, 9268364. https://doi.org/10.1155/2020/9268364
  
• Deng, Y., Liu, K., Cheng, D., Zhang, J., Chen, H., Chen, B., Li, Y., Wang, W., Kong, Y., & Wen, G. (2019). Ventral and dorsal visual pathways exhibit abnormalities of static and dynamic connectivities, respectively, in patients with schizophrenia. Schizophrenia research, 206, 103–110. https://doi.org/10.1016/j.schres.2018.12.005
  
• Gilbert, C. D., & Li, W. (2013). Top-down influences on visual processing. Nature reviews. Neuroscience, 14(5), 350–363. https://doi.org/10.1038/nrn3476
  
• Gottesman, I. I., & Gould, T. D. (2003). The endophenotype concept in psychiatry: etymology and strategic intentions. American journal of psychiatry, 160(4), 636-645.
  
• Green, M. F., Hellemann, G., Horan, W. P., Lee, J., & Wynn, J. K. (2012). From perception to functional outcome in schizophrenia: modeling the role of ability and motivation. Archives of general psychiatry, 69(12), 1216-1224.
  
• Javitt, D. C., & Freedman, R. (2015). Sensory processing dysfunction in the personal experience and neuronal machinery of schizophrenia. American Journal of Psychiatry, 172(1), 17-31.
  
• Kaufmann, T., Skåtun, K. C., Alnæs, D., Doan, N. T., Duff, E. P., Tønnesen, S., ... & Westlye, L. T. (2015). Disintegration of sensorimotor brain networks in schizophrenia. Schizophrenia bulletin, 41(6), 1326-1335.
  
• Klosterkotter, J. Klosterko «tter, J., Hellmich, M., Steinmyer, EM, et al (2001) Diagnosing schizophrenia in the initial prodromal phase. Archives of General Psychiatry, 58-158.
  
• Kraepelin, E., 1903. Lehrbuch der Psychiatrie. Barth, Leipzig.
  
• Kravitz, D. J., Saleem, K. S., Baker, C. I., Ungerleider, L. G., & Mishkin, M. (2013). The ventral visual pathway: an expanded neural framework for the processing of object quality. Trends in cognitive sciences, 17(1), 26–49. https://doi.org/10.1016/j.tics.2012.10.011
  
• Kravitz, D. J., Saleem, K. S., Baker, C. I., & Mishkin, M. (2011). A new neural framework for visuospatial processing. Nature Reviews Neuroscience, 12(4), 217-230.
  
• Laprevote V, Oliva A, Ternois A-S, Schwan R, Thomas P and Boucart M (2013) Low spatial frequency bias in schizophrenia is not face specific: when the integration of coarse and fine information fails. Front. Psychol. 4:248. doi: 10.3389/fpsyg.2013.00248
  
• Loughland, C. M., Williams, L. M., & Harris, A. W. (2004). Visual scanpath dysfunction in first-degree relatives of schizophrenia probands: evidence for a vulnerability marker?. Schizophrenia research, 67(1), 11-21.
  
• Pamela D. Butler, Antigona Martinez, John J. Foxe, Dongsoo Kim, Vance Zemon, Gail Silipo, Jeannette Mahoney, Marina Shpaner, Maria Jalbrzikowski, Daniel C. Javitt, Subcortical visual dysfunction in schizophrenia drives secondary cortical impairments, Brain, Volume 130, Issue 2, February 2007, Pages 417–430, https://doi.org/10.1093/brain/awl233
  
• Roska, B. & Meister, M. The Retina Dissects the Visual Scene. The New Visual Neurosciences, 163–182 (2014).
  
• Schendan, H. E., & Ganis, G. (2015). Top-down modulation of visual processing and knowledge after 250 ms supports object constancy of category decisions. Frontiers in Psychology, 6, Article 1289. https://doi.org/10.3389/fpsyg.2015.01289
  
• Shoshina, I., Isajeva, E., Mukhitova, Y., Tregubenko, I., Khan’ko, A., Limankin, O., & Simon, Y. (2020). The internal noise of the visual system and cognitive functions in schizophrenia. Procedia Computer Science, 169, 813-820.
  
• Silverstein, S. M., Demmin, D., & Skodlar, B. (2017). Space and objects: on the phenomenology and cognitive neuroscience of anomalous perception in schizophrenia (ancillary article to EAWE domain 1). Psychopathology, 50(1), 60-67.
  
• Silverstein, S. M., & Lai, A. (2021). The Phenomenology and Neurobiology of Visual Distortions and Hallucinations in Schizophrenia: An Update. Frontiers in psychiatry, 12, 684720. https://doi.org/10.3389/fpsyt.2021.684720
  
• Waters, F., Collerton, D., Ffytche, D. H., Jardri, R., Pins, D., Dudley, R., ... & Larøi, F. (2014). Visual hallucinations in the psychosis spectrum and comparative information from neurodegenerative disorders and eye disease. Schizophrenia bulletin, 40(Suppl_4), S233-S245.
  
• Wojtkowski M et al. Ophthalmic imaging by spectral optical coherence tomography. Am J Ophthalmol. 2004 Sep;138(3):412-9.
  

History of 988
Did you know that 988 is in operation as of July 16, 2022? 988 is a number similar to 911 that can be used by someone experiencing a mental health or substance use crisis. Officially known as the 988 Suicide & Crisis Lifeline, the number was first designated in 2020 by the United States Congress after Congress recognized the mental health and addiction crises occurring in the country. The past two years have been spent preparing for the transition. According to the website for the Ohio Department of Mental Health and Addiction Services, 988 in Ohio will allow for calls and texts.

The National Suicide Prevention Lifeline (1-800-273-8255 or 1-800-273-TALK) was launched in 2005 by the United States Substance Abuse and Mental Health Services Administration (SAMHSA) and Vibrant Emotional Health as a number available for suicide and mental health crises. 988 is shorter and easier-to-remember, so individuals in crisis can reach the National Suicide Prevention Lifeline. The prior number (1-800-273-TALK) will still be in operation if you and/or your clients are already familiar with and utilize this number. The Ohio CareLine (1-800-720-9616) is a separate mental health call service offered through the Ohio Department of Mental Health and Addiction Services, and this number will remain active after 988 is introduced. If you have another mental health or substance use crisis line that you and/or your clients utilize, it is recommended you contact that agency to confirm that the line will remain active after the introduction of 988.

When to Call 988
If a person is experiencing a mental health or substance use issue that requires immediate intervention to maintain someone’s life or safety, that person should still call 911 for assistance. Examples of this would be someone who is actively suicidal, someone threatening to harm others, someone who is engaging in serious self-harming behaviors, and someone who appears to be overdosing. However, if someone is experiencing a mental health or substance use issue that is not life-threatening, the person should call 988. If the situation worsens or is determined to be life-threatening after the call is placed, the 988 professionals can transfer the call to 911 for immediate assistance.

988 Accessibility
The number is operational 24 hours a day, 7 days a week, 365 days a year. The services offered over the phone are free and confidential. According to the National Suicide Prevention Lifeline website, Spanish speakers can call 1-888-628-9454 for Spanish services. Individuals who speak other languages can utilize telephone interpreter services offered by the line, and SAMHSA noted that there are over 250 languages available when using this tele-interpreter service. Anyone can chat or text in English (using the National Suicide Prevention Lifeline website and 988, respectively), and those with hearing impairments can also utilize relay services to communicate with a professional. There are also plans for a video chat service to be made available, but it is unknown when this will be established.

Agencies Providing Services
Nineteen agencies in Ohio will be receiving calls made through 988. If you are curious which agencies are providing services in which counties, there is a detailed map available on the Ohio Department of Mental Health and Addiction Services’ 988 webpage, which is linked below.

Resources/References
National Suicide Prevention Lifeline: https://suicidepreventionlifeline.org/.
Ohio Department of Mental Health and Addiction Services: http://mha.ohio.gov/988.
Substance Abuse and Mental Health Services Administration (United States Department of Health and Human Services): https://www.samhsa.gov/find-help/988.

This holiday, celebrated by some humanists around the world, is one of many secular holidays. Secular holidays are holidays that are non-religious in nature. You are probably already familiar with and likely celebrate secular holidays, such as Martin Luther King Jr. Day, Juneteenth, Mother’s Day, Memorial Day, and Independence Day. There are also secular versions of some religious holidays, such as Christmas. 

Secular holiday celebrations are becoming more prevalent in the United States, thanks in large part to the growing number of religiously unaffiliated individuals. According to the Pew Research Center, approximately 22.8% of Americans are religiously unaffiliated and the Ohio population closely reflects that number with approximately 22% of Ohioans identifying as being religiously unaffiliated. Surveys have shown that younger generations are more likely to be religiously unaffiliated. In one study from 2016, 39% of individuals ages 18 to 29 were religiously unaffiliated compared to 13% of individuals over the age of 65. That same study showed that of people who were raised religious, 90% left religion before the age of 29. 

Surveys have shown that most Americans who have left religion did not have a specific experience or incident that resulted in them becoming religiously unaffiliated. A majority of religiously unaffiliated Americans (up to 60%) indicate that they stopped believing in the teachings of their religion. Other reasons cited in research include a dislike of organized religion, the belief that their prior place of worship was becoming overly focused on political issues, or dislike over their prior religion’s attitudes toward LGBTQ+ individuals. 

Religiously unaffiliated individuals may classify themselves using numerous different labels, including atheist, agnostic, skeptic, freethinker, secular, humanist, antitheist, nonreligious, and spiritual but not religious. Because many of these identities do not conflict or overlap with each other, you may see religiously unaffiliated individuals who combine some of these labels in order to best capture their particular identity, such as secular humanist or freethinking atheist. 

With a growing number of religiously unaffiliated individuals, it is unsurprising that some of these groups have started to establish their own holidays and days of celebration. World Humanist Day was established by humanists in the 1980s in order to spread awareness about the humanism and the beliefs held by humanists (namely, that humans can live ethical and fulfilling lives based on human reason and ethics without needing religion or a deity to guide them). According to Humanists International, there are no established rituals for celebrating World Humanist Day. Some ways their members have marked the occasion in the past include organizing a concert or a conference, displaying information about humanism on billboards and in libraries, hosting a film festival, and having a picnic. 

There are numerous other secular holidays that specifically celebrate the beliefs of religiously unaffiliated individuals, and these holidays often focus on science, human rights, and religious freedom. There are too many to list here, but here are a few if you are interested: National Religious Freedom Day (January 16), Darwin Day (February 12), Pi Day (March 14), National Freethought Day (October 12), and Festivus (December 23). It is important to note that not all religiously
unaffiliated individuals celebrate all of these holidays, and some may not celebrate any of them. When talking with religiously unaffiliated friends or clients, it is always best to ask about what holidays they celebrate and how they celebrate them. 

References: 

• Humanists International (2022). World humanist day. Retrieved from https://humanists.international/what-is-humanism/world-humanist-day/. 
  
• Jones, Robert P., Daniel Cox, Betsy Cooper, and Rachel Lienesch. “Exodus: Why Americans are leaving religion – and why they’re unlikely to come back.” PRRI. 2016. http://www.prri.org/research/prri-rns-poll-nones-atheist-leaving-religion/. 
  
• Lipka, M. (2016, August 24). Why America’s ‘nones’ left religion behind. Pew Research Center. Retrieved from https://www.pewresearch.org/fact-tank/2016/08/24/why-americas-nones-left-religion-behind/. 
  
• Pew Research Center (2014). Religious landscape study. Retrieved from https://www.pewforum.org/religious-landscape-study/. 
  

Did you know that Black History month was a concept that came to fruition in 1915 about fifty years after the 13th amendment resulted in the abolition of slavery in the United States?  Harvard-trained historian Carter G. Woodson and Jesse E Moorland, founder of the Association for the Study of Negro Life and History (ASNLH), collaborated to sponsor a national Negro History week in 1926 in the second week of February to coincide with the birthdays of Abraham Lincoln and Frederick Douglass. 

National Negro Week inspired schools and communities nationwide to organize and host local celebrations, history clubs, performances and lectures.

Today, the organization, now known as the Association for the Study of African American Life and History (ASALH), continues to promote, research, preserve, interpret and disseminate information about Black life, history and culture to the global community.

For decades to come, mayors of cities across the country began issuing yearly proclamations recognizing "Negro History Week.” As a result of the civil rights movement, this week had evolved into Black History Month on many college campuses.

In 1976, President Gerald Ford officially recognized Black History Month calling upon the public to “seize the opportunity to honor the too-often neglected accomplishments of Black Americans in every area of endeavor throughout our history.” 

In its evolution Black History Month has not only recognized the accomplishments of Black Americans but also it has promoted the study of the African diaspora.  The African diaspora is the study of Africa and the understanding of the dispersal of its peoples through the Trans-Atlantic slave trade.  This migration has influenced how descendants of enslaved Africans brought their cultures, ideas, and worldviews with them as they were coerced to integrate into new societies.

It is important that this resilience be recognized by descendants of enslaved Africans as well as the diversity of people belonging to the receiving societies, that this ethnic group created new cultures and recreated their old ways. Psychologically speaking, to gain understanding of who you were, promotes better understanding of who you are, and it encourages confidence in who you are likely to become.

References:
Defining and studying the modern African diaspora: Perspectives on history: AHA. Defining and Studying the Modern African Diaspora | Perspectives on History | AHA. (n.d.). Retrieved January 28, 2022, from https://www.historians.org/publications-and-directories/perspectives-on-history/september-1998/defining-and-studying-the-modern-african-diaspora#:~:text=The%20first%20African%20diaspora%20was%20a%20consequence%20of,of%20the%20dispersal%20and%20settlement%20of%20African%20peoples. 

History.com Editors. (2010, January 14). Black history month. History.com. Retrieved January 28, 2022, from https://www.history.com/topics/black-history/black-history-month 

SupertekSolutions. (n.d.). Superteksolutions. Diaspora African Forum. Retrieved January 28, 2022, from https://www.diasporaafricanforum.org/the-diaspora-african-forum-daf-welcomes-a-number-of-african-american-celebrities-to-ghana-for-the-full-circle-festival-in-commemorating-the-year-of-return-programme/ 

Photo of Anthony Anderson. Diaspora African Forum. (n.d.). Retrieved January 28, 2022, from http://www.diasporaafricanforum.org/ 

The suspension of non-essential medical services due to lockdowns and heightened safety precautions have made accessing mental healthcare more difficult for many during the COVID-19 pandemic (Banerjee, 2020; Benatti et al., 2020; Davide et al., 2020; Khosravani et al., 2021). Furthermore, even if medical facilities are open for non-essential services, some may avoid going to them for fear of potential COVID-19 infection (French et al., 2020). This may be especially true for those with obsessive compulsive disorder (OCD), given that an estimated 46% have contamination-related symptoms (Markarian et al., 2010). In one study, 59.1% of OCD patients reported that the COVID-19 pandemic has interfered with their treatment in some way (Wheaton & Ward et al., 2021). Given that the negative effect of the pandemic on OCD symptoms may be buffered by being in treatment (Baldi & Schreurs, 2021), it is important that those with OCD maintain some form of intervention during this time. 

Exposure and response prevention (ERP) is the first line therapeutic intervention for obsessive compulsive disorder. For those with contamination-related symptoms, ERP typically involves activities such as preventing compulsive handwashing after touching objects that are perceived to be potentially contaminated (Fontenelle & Miguel., 2020; Storch et al., 2020). This may include shaking hands with another person or eating food off of a table that was not cleaned beforehand (Storch et al., 2020). Clinicians and clients alike have concerns of an increased risk of COVID-19 infection from performing these types of activities given the inability to socially distance or adhere to other health guidelines (Aardema, 2020; Jassi et al., 2020). Furthermore, some argue that it is currently too difficult to tell the difference between reasonable responses to the pandemic and abnormal contamination-related fears (Aardema, 2020), which increases the risk of overpathologizing non-disordered behaviors.

Because of the confusion and potential safety risk, some experts have advised to modify ERP based psychotherapy for contamination OCD (Candelari et al., 2021; Sheu et al., 2020) such as through the use of imaginal instead of in vivo exposure (Fontenelle & Miguel., 2020; Storch et al., 2020). Others argue that ERP be paused altogether, and pharmacotherapy be used to prevent deterioration (Fineberg et al., 2020). Emerging research suggests adherence to SRI medication may be protective against impact of COVID-19 when CBT is more difficult to access (Sharma et al., 2021). 

Proponents of continuing ERP argue that the context of the pandemic may be useful for helping clients understand between rational fears and protective behaviors versus obsessional thoughts and compulsions (Aardema, 2020). Exposure activities should highlight the difference between rational and irrational contamination scenarios, such as doing an exposure to an irrationally feared contaminate, but also while observing guidelines for the justified fear of COVID-19 exposure. Additional recommendations for conducting ERP during the pandemic includes having conversations with clients about what is excessive in regard to protective health measures, as well as normalizing feelings of uncertainty and anxiety about COVID-19. Clinicians should also address the client’s exaggerated sense of responsibility, helping the client to understand that while they can take precautions that help protect others, they are not wholly responsible for the health and wellbeing of other people. These conversations about uncertainty and responsibility for harm act as exposure that may help to desensitize the client and allow them to better tolerate these feelings, something that is often difficult for those with OCD (Jassi et al., 2020; Wheaton et al., 2021). 

Clinicians should also be prepared to provide education on the most up-to-date health guidelines for COVID-19, as well as the level of risk associated with various settings and activities. When deciding what activities the client should engage in, the clinician can collaborate with the client on a cost-benefit analysis that is grounded in this research. Limiting exposure to news and other sources of information (or misinformation) is another suggestion for keeping the client from becoming overwhelmed. Several sources suggest engaging with news about the pandemic for a maximum of one hour per day (Davide et al., 2020; Fineberg et al., 2020; Tanir et al., 2020). Sources of information should also be properly vetted for reliability. Additionally, time spent engaging with the news should be balanced with spending time on pleasant activities that distract from intrusive thoughts. Even when in lockdown or unemployed due to the pandemic, clinicians should emphasize the importance of keeping a routine with a regular sleep schedule, physical activity, and a healthy diet (Davide et al., 2020; Fineberg et al., 2020; Pozza et al., 2020).

The use of telehealth has also emerged as a viable alternative to in-person psychotherapy for OCD (Candelari et al., 2021; Davide et al., 2020; Fineberg et al., 2020; Jassi et al., 2020; Ornell et al., 2021). For example, participants in one qualitative study of a group therapy for OCD that transitioned to a telehealth format reported that the treatment was still effective (Conrad et al., 2020). Telehealth can come in many forms including videoconference administered CBT (vCBT), telephone-delivered CBT (tCBT), computerized CBT (cCBT), internet-based CBT (iCBT), smartphone applications that provide psychoeducation and self-guided ERP, and vicarious exposure activities conducted through watching videos (Jalal et al., 2020). Besides increased safety during the pandemic, using telehealth comes with several other advantages including not requiring transportation, increased ease of conducting visual exposure using videos as well as the ability to do at-home in vivo exposures with the clinician present for support (Schiavonne et al., 2021).

Finally, it is important to note that both clinicians (McKay et al., 2020; Storch et al., 2020) and patients (Silva et al., 2021) may be less willing to engage in ERP as a result of the COVID-19 pandemic. These attitudes may extend beyond the duration of the pandemic itself, and there may be a need for trainings to help clinicians overcome negative beliefs and hesitation about conducting ERP during and after pandemic (McKay et al., 2020). Nevertheless, ERP is a viable option when modifications are made to account for pandemic-related safety concerns, and continued engagement in some sort of treatment may be important for the wellbeing of individuals with OCD during the COVID-19 pandemic.

References

• Aardema, F. (2020). COVID-19, obsessive-compulsive disorder and invisible life forms that threaten the self. Journal of Obsessive-Compulsive and Related Disorders, 26. https://doi.org/10.1016/j.jocrd.2020.100558 
  
• Baldi, S., & Schruers, K. (2021). Expert opinion in Obsessive-Compulsive Disorder: Could protective measures for COVID-19 contribute to the worsening of OCD symptoms? Personalized Medicine in Psychiatry, 27–28. https://doi.org/10.1016/j.pmip.2021.100076 
  
• Banerjee, D. (2020). The other side of COVID-19: Impact on obsessive compulsive disorder (OCD) and hoarding. Psychiatry Research, 288. https://doi.org/10.1016/j.psychres.2020.112966 
  
• Benatti, B., Albert, U., Maina, G., Fiorillo, A., Celebre, L., Girone, N., Fineberg, N., Bramante, S., Rigardetto, S., & Dell’Osso, B. (2020). What happened to patients with obsessive compulsive disorder during the COVID-19 pandemic? A multicentre report from tertiary clinics in northern Italy. Frontiers in Psychiatry, 11. https://doi.org/10.3389/fpsyt.2020.00720  
  
• Candelari, A. E., Wojcik, K. D., Wiese, A. D., Goodman, W. K., & Storch, E. A. (2021). Expert opinion in obsessive-compulsive disorder: Treating patients with obsessive-compulsive disorder during the COVID-19 pandemic. Personalized Medicine in Psychiatry, 27–28. https://doi.org/10.1016/j.pmip.2021.100079 
  
• Conrad, R., Bousleiman, S., Isberg, R., Hauptman, A., & Cardeli, E. (2020). Uncontrolled experiments: Treatment of contamination OCD during a pandemic. Psychological Trauma: Theory, Research, Practice, and Policy, 12(S1), S67–S68. https://doi.org/10.1037/tra0000806 
  
• Davide, P., Andrea, P., Martina, O., Andrea, E., Davide, D., & Mario, A. (2020). The impact of the COVID-19 pandemic on patients with OCD: Effects of contamination symptoms and remission state before the quarantine in a preliminary naturalistic study. Psychiatry Research, 291. https://doi.org/10.1016/j.psychres.2020.113213 
  
• Fineberg, N. A., Van Ameringen, M., Drummond, L., Hollander, E., Stein, D. J., Geller, D., Walitza, S., Pallanti, S., Pellegrini, L., Zohar, J., Rodriguez, C. I., Menchon, J. M., Morgado, P., Mpavaenda, D., Fontenelle, L. F., Feusner, J. D., Grassi, G., Lochner, C., Veltman, D. J., … Dell'Osso, B. (2020). How to manage obsessive-compulsive disorder (OCD) under COVID-19: A clinician's guide from the International College of Obsessive Compulsive Spectrum Disorders (ICOCS) and the Obsessive-Compulsive and Related Disorders Research Network (OCRN) of the European College of Neuropsychopharmacology. Comprehensive Psychiatry, 100, 152174. https://doi.org/10.1016/j.comppsych.2020.152174 
  
• Fontenelle, L. F., & Miguel, E. C. (2020). The impact of coronavirus (COVID‐19) in the diagnosis and treatment of obsessive‐compulsive disorder. Depression and Anxiety, 37(6), 510–511. https://doi.org/10.1002/da.23037 
  
• French, I., Lyne, J., Gavin, B., Lyne, J., & McNicholas, F. (2020). Acute exacerbation of OCD symptoms precipitated by media reports of COVID-19. Irish Journal of Psychological Medicine, 37(4), 291–294. https://doi.org/10.1017/ipm.2020.61 
  
• Jalal, B., Chamberlain, S. R., Robbins, T. W., & Sahakian, B. J. (2020). Obsessive-compulsive disorder-contamination fears, features, and treatment: novel smartphone therapies in light of global mental health and pandemics (COVID-19). CNS Spectrums, 1–9. https://doi.org/10.1017/S1092852920001947 
  
• Jassi, A., Shahriyarmolki, K., Taylor, T., Peile, L., Challacombe, F., Clark, B., & Veale, D. (2020). OCD and COVID-19: A new frontier. The Cognitive Behaviour Therapist, 13. https://doi.org/10.1017/S1754470X20000318 
  
• Khosravani, V., Aardema, F., Samimi Ardestani, S. M., & Sharifi Bastan, F. (2021). The impact of the coronavirus pandemic on specific symptom dimensions and severity in OCD: A comparison before and during COVID-19 in the context of stress responses. Journal of Obsessive-Compulsive and Related Disorders, 29. https://doi.org/10.1016/j.jocrd.2021.100626 
  
• Markarian, Y., Larson, M. J., Aldea, M. A., Baldwin, S. A., Good, D., Berkeljon, A., Murphy, T. K., Storch, E. A., & McKay, D. (2010). Multiple pathways to functional impairment in obsessive–compulsive disorder. Clinical Psychology Review, 30(1), 78–88. https://doi.org/10.1016/j.cpr.2009.09.005
  
• McKay, D., Minaya, C., & Storch, E. A. (2020). Conducting exposure and response prevention treatment for contamination fears during COVID-19: The behavioral immune system impact on clinician approaches to treatment. Journal of Anxiety Disorders, 74. https://doi.org/10.1016/j.janxdis.2020.102270 
  
• Ornell, F., Braga, D. T., Bavaresco, D. V., Francke, I. D., Scherer, J. N., von Diemen, L., & Kessler, F. H. P. (2021). Obsessive-compulsive disorder reinforcement during the COVID-19 pandemic. Trends in Psychiatry and Psychotherapy. https://doi.org/10.47626/2237-6089-2020-0054  
  
• Pozza, A., Mucci, F., Marazziti, D. (2020). Risk for pathological contamination fears at coronavirus time: Proposal of early intervention and prevention strategies. Clinical Neuropsychiatry, 17 (2), 100-102. https://doi.org/10.36131/CN20200214  
  
• Sharma, L. P., Balachander, S., Thamby, A., Bhattacharya, M., Kishore, C., Shanbhag, V., Sekharan, J. T., Narayanaswamy, J. C., Arumugham, S. S., & Reddy, J. Y. C. (2021). Impact of the COVID-19 pandemic on the short-term course of obsessive-compulsive disorder. Journal of Nervous and Mental Disease, 209(4), 256–264. https://doi.org/10.1097/NMD.0000000000001318   
  
• Sheu, J. C., McKay, D., & Storch, E. A. (2020). COVID-19 and OCD: Potential impact of exposure and response prevention therapy. Journal of Anxiety Disorders, 76. https://doi.org/10.1016/j.janxdis.2020.102314 
  
• Silva, R. M., Shavitt, R. G., & Costa, D. L. (2021). Obsessive-compulsive disorder during the COVID-19 pandemic. Revista Brasileira de Psiquiatria, 43(1), 108. https://doi.org/10.1590/1516-4446-2020-1189 
  
• Storch, E. A., Schneider, S. C., Guzick, A., McKay, D., & Goodman, W. K. (2020). Impact of COVID-19 on exposure and response prevention for obsessive-compulsive disorder: Present and post-pandemic considerations. Psychiatry Research, 292, 113310. https://doi.org/10.1016/j.psychres.2020.113310 
  
• Tanir, Y., Karayagmurlu, A., Kaya, İ., Kaynar, T. B., Türkmen, G., Dambasan, B. N., Meral, Y., & Coşkun, M. (2020). Exacerbation of obsessive compulsive disorder symptoms in children and adolescents during COVID-19 pandemic. Psychiatry Research, 293. https://doi.org/10.1016/j.psychres.2020.113363 
  
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• Wheaton, M. G., Ward, H. E., Silber, A., McIngvale, E., & Björgvinsson, T. (2021). How is the COVID-19 pandemic affecting individuals with obsessive-compulsive disorder (OCD) symptoms? Journal of Anxiety Disorders, 81. https://doi.org/10.1016/j.janxdis.2021.102410 

What are the warning signs?

• Withdrawal from friends or usual activities
  
• Changes in behavior 
  
  • Aggression
    
  • Anger
    
  • Hostility 
    
  • Hyperactivity
    
• Changes in school performance
  
• An apparent lack of supervision
  
• Reluctance to leave school activities, as if he or she doesn't want to go home
  
• Attempts at running away
  
• Self-harm or attempts at suicide

Protective Factors that reduce the likelihood of child maltreatment:

• Nurturing and attachment
  
• Knowledge of parenting and of child and youth development
  
• Parental resilience
  
• Social connections
  
• Concrete supports for parents
  
• Social and emotional competence of children

Resources 

National Child Abuse Hotline (1-800-4-A-Child or 1-800-422-4453)

https://www.cdc.gov/violenceprevention/childabuseandneglect/resources.html : Child abuse and neglect resources including data sources, publications and general resources. 

http://familysafetyandhealing.org/programs-and-services/child-and-family-counseling/: This center focuses on treating and preventing all aspects of family violence and provides comprehensive evaluation and management of child maltreatment, offering inpatient and outpatient services. Their website provides resources on how to obtain services and how to help as a mandated reporter.

References  

• Child abuse. (2018, October 5). https://www.mayoclinic.org/diseases-conditions/child-abuse/symptoms-causes/syc-20370864. 

• Protective Factors and ACEs - National Child Abuse Prevention Month - Child Welfare Information Gateway. Child Welfare Information Gateway website. (n.d.). https://www.childwelfare.gov/topics/preventing/preventionmonth/about/protective-factors-aces/. 
  

Given recent conflicting information about Critical Race Theory in the media, the aim of this article is to communicate what Critical Race Theory (CRT) is and what it is not, particularly in light of recent proposals across the country to ban the teaching of CRT in schools. CRT is an academic concept that uses science and theory to contextualize the current racial and ethnic disparities in the United States (Encyclopedia Britannica, 2021). This theory describes race as a social construct. It recognizes that racism is a normal feature of society and is embedded within systems and institutions, like the legal system. CRT posits that these embedded structures have led to inequity among different racial and ethnic groups and continue to perpetuate it. CRT recognizes the legacy of slavery, segregation, racism, and discrimination throughout U.S. history. It also acknowledges that the intersection between race and other identities, including ability status, gender, religion, and age, creates different experiences in the world. 

Arguments against CRT and teaching about structural racism in schools are often based on beliefs that racial discrimination has ended or that CRT presents an exaggerated or unrealistic perception of the historical legacy of racism in the United States. However, these arguments fail to explain the countless racial discrepancies the U.S. is currently facing and their direct connection to past systems. For example, nearly 75% of White families live in owner-occupied houses, while less than 50% of Black and Latinx families live in owner-occupied houses (Hamilton & Famighetti, 2019). Even among neighborhoods at the same poverty level, districts with more White students have more funding than districts with more Black students (Mosenkis, 2016). In fact, schools where a majority of students enrolled are students of color receive 32 billion dollars less in funding, despite serving the same number of students ("23 Billion," 2019). Children of color are also more susceptible to food insecurity, more likely to have to work a job after school, and less likely to have financial resources for study materials (Morales et al., 2020). Black and Hispanic students are underrepresented in colleges by 20% (Ashkenas et al., 2017). Black and Indigenous People of Color are almost twice as likely to be affected by police violence than White people (Edwards et al., 2019). Examples of racial and ethnic disparities are ubiquitous in the United States, propagated by racist policies and institutions. 

One example of how CRT can be used to understand current disparities can be seen in the area of housing through a process called Redlining. In the 1930s, the banking and real estate industry outlined neighborhoods that were primarily occupied by people of color in red ink, denoting these areas as “risky.” Subsequently, banking institutions denied mortgages to people living in “redlined” areas (Hanks et al., 2018). Two thirds of redlined areas continue to be inhabited primarily by minoritized groups, most frequently Black and Latinx individuals and families (Mitchell & Franco, 2018). Today, lending practices continue to be greater among neighborhoods that are predominately White. Further, individuals and families living in areas that were “redlined” have less wealth, greater poverty, lower life expectancy, and experience greater rates of chronic diseases. Additionally, homes of similar quality in neighborhoods with similar amenities are worth 23 percent less in majority Black neighborhoods, compared to those with very few or no Black residents (Perry et al., 2018). Understanding the historic underpinnings of current inequities as well as current systems and policies that maintain these inequities is critical to progress. 

Students already are not given the opportunity to learn about the history of structural racism in the US and its legacy. According to the Southern Poverty Law Center, only 8% of high school seniors identified slavery as the central cause of the Civil War (Shuster, 2018). Fewer than one-third (32 percent) correctly named the 13th Amendment as the formal end of U.S. slavery, and fewer than half (46 percent) identified the "Middle Passage" as the transport of enslaved Africans across the Atlantic Ocean to North America. Finally, fewer than 40% of students understood how slavery "shaped the fundamental beliefs of Americans about race and whiteness." Without an understanding of CRT, structural racism that harms people of color will continue to create racial and ethnic disparities. Ultimately, it is impossible to fix a problem that is not acknowledged and understood.  

Lack of knowledge about structural racism originates from school curricula focused on the history and perspective of white people (i.e., whitewashed curricula). One analysis found that 83% of books commonly used in New York City public school curriculum are written by white authors (Hester, 2018). A review from the Southern Poverty Law Center found that 46% percent of teachers do not discuss the continuing legacy of slavery in the United States today (Shuster, 2018). Additionally, nearly 60% of teachers do not believe their textbook’s coverage of slavery was adequate. Another review examined representations of Indigenous peoples in kindergarten through twelfth grade educational standards. This study found that nearly 90% of state history standards dictate teaching about Indigenous peoples in the context of pre-1900, representing the history of Indigenous peoples’ history as a small episode of this country’s development. Indigenous peoples’ history is largely presented alongside notions of Euro-American destiny, with limited recognition that the land west of Mississippi belonged to Indigenous peoples (Shear et al., 2015). 

As a result of these education standards, many adults are not aware of the history of racism in the U.S. institutions and policy (e.g., Redlining). Among adults, 70 percent of white people believe that individual discrimination is a bigger problem than discrimination built into the nation's laws and institutions ("On Views of Race and Inequality, Blacks and Whites are Worlds Apart," 2016). Only around half of the White population contend that Black individuals in this country are treated less fairly than white individuals when dealing with the police (50%) and in the courts (43%). These beliefs directly contradict the psychological literature regarding systemic racism, implicit and explicit bias, diversity, and inclusion (Feagan & Ducey, 2018). Incorporating CRT and diversity, equity, and inclusion material into curricula can lead to a more well-informed society. Without this awareness and acknowledgement of this problem, it will be impossible for us to fix current inequalities.

Without lessons drawing from CRT, our education system will also continue to alienate students of color (Purdie-Vaughns et al., 2008; Wilton et al., 2015). Currently, many schools operate under a "race-neutral" or color-blind approach, where race and racism are ignored (Revilla et al., 2004; Ullucci & Battey, 2011). Studies have consistently demonstrated that students who are exposed to color-blindness are less sensitive to racism and have less understanding of minoritized individuals' lived experiences (Apfelbaum et al., 2010; Neville et al., 2000; Offermann et al., 2014; Tynes & Markoe, 2010). It is important that students understand how structural racism affects minoritized groups, as upwards of 90% of children describe experiencing at least one instance of discrimination based on their race and/or ethnicity, which is associated with adverse mental health outcomes (Coker et al., 2009; Pachter et al., 2010). Teaching students about structural racism will allow students of color to access their complete histories and improve White students' ability to understand current inequities, creating greater awareness and empathy. 

Some individuals fear that a greater understanding of systemic racism will harm relations between racial groups; however, research has demonstrated that the inverse is true, such that color-blind approaches create greater social distance between racial groups (Apfelbaum et al., 2008; Holoien & Shelton, 2012; Madera & Hebl, 2013; Vorauer et al., 2009). By contrast, the inclusion of diverse perspectives in the teaching of social studies and history leads to increased student engagement, self-worth, and self-efficacy (Thomas, 2019). Students who learn from diverse perspectives in the classroom feel more confident in themselves and their ability to problem-solve and succeed (Sleeter & Zavala, 2020).

In conclusion, CRT uses theory and science to help us understand current racial and ethnic disparities in the U.S. Currently, students are underinformed about the complex history of racism in the United States and the ways in which it exists today, which exacerbates disparities. Understanding our history through CRT can increase students’ empathy and understanding about minoritized individuals lived experiences and allow students of color to access their full histories. Finally, CRT can help reduce social division between racial and ethnic groups and increase student’s engagement in the classroom as well as their confidence. 

References:

• 23 Billion. (2019). In (pp. 2-5). EdBuild.
• Apfelbaum, E. P., Pauker, K., Sommers, S. R., & Ambady, N. (2010). In Blind Pursuit of Racial Equality? Psychological Science, 21(11), 1587-1592. https://doi.org/10.1177/0956797610384741 
• Apfelbaum, E. P., Sommers, S. R., & Norton, M. I. (2008). Seeing race and seeming racist? Evaluating strategic colorblindness in social interaction. In (pp. 918-932): American Psychological Association.
• Ashkenas, J., Park, H., & Pearce, A. (2017). Even with Affirmative Action, Blacks and Hispanics Are More Underrepresented at Top Colleges Than 35 Years Ago. 
• Coker, T. R., Elliott, M. N., Kanouse, D. E., Grunbaum, J. A., Schwebel, D. C., Gilliland, M. J., . . . Schuster, M. A. (2009). Perceived racial/ethnic discrimination among fifth-grade students and its association with mental health. American journal of public health, 99(5), 878-884. https://doi.org/10.2105/AJPH.2008.144329
• Duignan, B., (2021) The Editors of Encyclopaedia Britannica “Critical Race Theory.” 
• Feagin, J.R., & Ducey, K. (2018). Racist America: Roots, Current Realities, and Future Reparations (4th ed.). Routledge. https://doi.org/10.4324/9781315143460
• Edwards, F., Lee, H., & Esposito, M. (2019). Risk of being killed by police use of force in the United States by age, race–ethnicity, and sex. Proceedings of the National Academy of Sciences, 116(34), 16793. https://doi.org/10.1073/pnas.1821204116 
• Hamilton, D., & Famighetti, C. (2019). State of the Union: Housing. 
• Hanks, A., Solomon, D., & Walker, C. (2018). Systematic InequalityHow America's Structural Racism Helped Create the Black-White Wealth Gap. In: Center for American Progress.
• Hester, M. (2018). Why Is Public School Curriculum Still Whites Only? In. Metropolitan Center for Research on Equity and the Transformation of Schools: NYU Steinhardt.
• Holoien, D. S., & Shelton, J. N. (2012). You deplete me: The cognitive costs of colorblindness on ethnic minorities. Journal of Experimental Social Psychology, 48(2), 562-565. https://doi.org/https://doi.org/10.1016/j.jesp.2011.09.010 
• Madera, J. M., & Hebl, M. R. (2013). "Don't stigmatize": The ironic effects of equal opportunity guidelines in interviews. Basic and Applied Social Psychology, 35(1), 123-130. https://doi.org/10.1080/01973533.2012.746601 
• Mitchell, B., & Franco, J. (2018). HOLC “Redlining” Maps: The Persistent Structure Of Segregation And Economic Inequality. In (pp. 4-18). NCRC RESEARCH.
• Morales, D. X., Morales, S. A., & Beltran, T. F. (2020). Racial/Ethnic Disparities in Household Food Insecurity During the COVID-19 Pandemic: a Nationally Representative Study. Journal of racial and ethnic health disparities, 1-15. https://doi.org/10.1007/s40615-020-00892-7 
• Mosenkis, D. (2016). Systemic Racial Bias in Latest Pennsylvania School Funding. In: Power.
• Neville, H. A., Lilly, R. L., Duran, G., Lee, R. M., & Browne, L. (2000). Construction and initial validation of the Color-Blind Racial Attitudes Scale (CoBRAS). Journal of Counseling Psychology, 47(1), 59-70. https://doi.org/10.1037/0022-0167.47.1.59 
• Offermann, L. R., Basford, T. E., Graebner, R., Jaffer, S., De Graaf, S. B., & Kaminsky, S. E. (2014). See no evil: color blindness and perceptions of subtle racial discrimination in the workplace. Cultur Divers Ethnic Minor Psychol, 20(4), 499-507. https://doi.org/10.1037/a0037237 
• On Views of Race and Inequality, Blacks and Whites are Worlds Apart. (2016). In: Pew Research Center.
• Pachter, L. M., Bernstein, B. A., Szalacha, L. A., & Coll, C. G. (2010). Perceived Racism and Discrimination in Children and Youths: An Exploratory Study. Health & Social Work, 35(1), 61-69. https://doi.org/10.1093/hsw/35.1.61 
• Perry, A., Rothwell, J., & Harshbarger, D. (2018). The Devaluation of Assets in Black Neighborhoods: The Case of Residential Property. In (pp. 2-22): Brookings Metropolitan Policy Program.
• Purdie-Vaughns, V., Steele, C. M., Davies, P. G., Ditlmann, R., & Crosby, J. R. (2008). Social identity contingencies: How diversity cues signal threat or safety for African Americans in mainstream institutions. In (pp. 615-630): American Psychological Association.
• Revilla, A. T., Wells, A. S., & Holme, J. J. (2004). We didn’t see color”: The salience of color blindness in desegregated schools. Off white: Readings on power, privilege, and resistance, 2, 284-301. 
• School Climate for LGBTQ Students in California. (2019). In 2019 State Snapshot: GLSEN.
• Shear, S. B., Knowles, R. T., Soden, G. J., & Castro, A. J. (2015). Manifesting Destiny: Re/Presentations of Indigenous Peoples in K-12 US History Standards. In (Vol. 43, pp. 68-101). Theory and Research in Social Education.
• Shuster, K. (2018). Teaching Hard History. 
• Sleeter, C., & Zavala, M. (2020). What the Research Says About Ethnic Studies. In. Transformative Ethnic Studies in Schools: Curriculum, Pedagogy, and Research: Teachers
• College, Columbia University.
• Thomas, R. (2019). The Boys in the Back: Using Culturally Responsive Teaching to Connect with Latino Male Students in Middle School. In: A Dissertation Presented in Partial Fulfillment of the Requirements for the Degree Doctor of Education.
• Tynes, B. M., & Markoe, S. L. (2010). The role of color-blind racial attitudes in reactions to racial discrimination on social network sites. In (pp. 1-13): Educational Publishing Foundation.
• Ullucci, K., & Battey, D. (2011). Exposing Color Blindness/Grounding Color Consciousness: Challenges for Teacher Education. Urban Education, 46(6), 1195-1225. https://doi.org/10.1177/0042085911413150 
• Vorauer, J. D., Gagnon, A., & Sasaki, S. J. (2009). Salient intergroup ideology and intergroup interaction. Psychol Sci, 20(7), 838-845. https://doi.org/10.1111/j.1467-9280.2009.02369.x 
• Wilton, L. S., Good, J. J., Moss-Racusin, C. A., & Sanchez, D. T. (2015). Communicating more than diversity: The effect of institutional diversity statements on expectations and performance as a function of race and gender. Cultur Divers Ethnic Minor Psychol, 21(3), 315-325. https://doi.org/10.1037/a0037883 

Written by: Stacey Henry PsyM | Wright State School of Professional Psychology 

Though chronic childhood illnesses (i.e., asthma, cancer, chronic fatigue syndrome [CFS], diabetes, etc.) impact 6.5% of children in the United States, there is relatively little research evaluating the impact these illnesses have on families as a whole (Barlow & Ellard, 2006). The available literature primarily focuses on the sick individual and parental adjustment but fails to address the impact on siblings. When this topic is evaluated, the research is often not grounded in theory. An emerging theory, known as Creating a Tenuous Balance (CTB), could be employed to address this lack. Below is a brief look into CTB theory and an outline of possible clinical implications.

Creating a Tenuous Balance (CTB) theory was first formulated by Long et al. (2015) when evaluating sibling's experiences of children with cancer. Havill et al. (2019) elaborated on the theory using a broader range of diagnoses, including siblings of individuals with diabetes, heart disease, and cystic fibrosis. The research identified several themes children experience in response to their sibling's illness. The responses were divided into two categories: Coping with the illness of their sibling and adapting to the illness such that "Coping is a function of how siblings appraise and try to change a situation… adaptation is the outcome of these coping efforts (e.g., psychosocial and physical functioning)" (Barlow & Ellard, 2006). Each category is further broken down into subcategories and themes of responses. 

Coping: Realizing the Seriousness 

• Knowing Something is Seriously Wrong – "This pattern of behavior describes how well siblings experience the time surrounding when the affected sibling became ill, a diagnosis was made, and then shared with the well sibling. Well siblings frequently experienced a prolonged period of uncertainty" (Havill et al., 2019).
  • Not knowing something is seriously wrong 
  • Enduring uncertainty 
  • Having the right information
• Figuring Out the Meaning of the Disease – "This pattern of behavior described processes well siblings engaged in to understand the medical and emotional aspects of the disease. In the original CTB study, findings related to this pattern focused on siblings' awareness that the ill child's cancer had life-altering or life-threatening consequences" (Havill et al., 2019).
  • Understanding what the disease means 
  • Coming to terms with the disease
  • Thinking about mortality
  • Losing a sense of security

• Adapting to Changes in Personal and Family Life – "This pattern of behavior describes the disruption of family normalcy and all-consuming nature of the disease. Well siblings respond by expanding their role within the family" (Havill et al., 2019). 
  • Losing family normalcy
  • Assuming a parent-like role
  • Being marginalized 
  • Evolving self 
  • Relying on others
• Handling Emotional Reactions to Disease – "Well siblings navigate emotionally laden information regarding the disease. They struggle to adapt and cope with frequent changes in their ill sibling and family environment" (Havill et al., 2019). 
  • Strong feelings 
  • Employing coping strategies 
  • Accepting social support  

Clinical Implications
How children cope and adapt to their sibling's chronic illness is likely unique and fluid to everyone. However, CTB theory suggests there are, in fact, common themes that children in this situation share to varying degrees. CTB theory can be used as a roadmap for adults to determine where well siblings may be in managing their experiences of the disease. The themes reviewed above can be used as conversation starters to identify barriers siblings may be experiencing in developing adaptive coping strategies. It can also be used to identify educational opportunities, create resources and interventions for siblings, and generate more theory-driven research questions. The research suggests that siblings often use avoidance strategies to manage their emotions (Barlow & Ellard, 2006). This maladaptive strategy likely maintains symptoms of anxiety, depression, and other externalizing/internalizing behaviors. CTB theory provides a framework for validating children's experiences and promoting a shift to positive coping strategies and healthy adaptation. 
 

References

• Barlow, J. H., & Ellard, D. R. (2006). The psychosocial wellbeing of children with chronic disease, their parents and siblings: An overview of the research evidence base. Child: Care, Health and Development, 32(1), 19–31. doi:10.1111/j.1365-2214.2006.00591.x
• Havill, N., Fleming, L. K., & Knafl, K. (2019). Well siblings of children with chronic illness: A synthesis research study. Research in Nursing & Health, 42(5), 334–348. doi:10.1002/nur.21978
• Hill, R. (1958). Social stresses on the family. J. Soc. J. Contemp. Soc. Serv. 39, 139–150. doi: 10.1177/1044389458039002-318
• Long, K. A., Lehmann, V., Gerhardt, C. A., Carpenter, A. L., Marsland, A. L., & Alderfer, M. A. (2018). Psychosocial functioning and risk factors among siblings of children with cancer: An updated systematic review. Psycho-Oncology, 27(6), 1467–1479. doi:10.1002/pon.4669
• Long, K. A., Marsland, A. L., Wright, A., & Hinds, P. (2015). Creating a tenuous balance: siblings' experience of a brother's or sister's childhood cancer diagnosis. Journal of Pediatric Oncology Nursing: Official Journal of the Association of Pediatric Oncology Nurses, 32(1), 21–31. 

Written by: Taylor Abounader, BS, psychology trainee at Wright State School of Professional Psychology 

Did you know July is Bebe Moore Campbell National Minority Mental Health Awareness Month?

In June of 2008 Bebe Moore Campbell National Minority Mental Health Awareness Month became formally recognized as a movement to highlight the struggles that minority groups experience regarding mental health in the United States. This year's campaign theme is strength in communities. The theme this year will promote the mental health supports developed by BIPOC for their communities.

Bebe Moore Campbell

National Minority Mental Health Awareness Month is named after the author, advocate, co-founder of NAMI Urban Los Angeles, Bebe Moore Campbell. Campbell’s novels often incorporated messages on the harmful impact of racism, often inspired by true events such as the murder of Emmett Till. Through her work, Campbell expressed the impact of mental illness on the family. Campbell and friend Linda Wharton-Boyd worked together to create National Minority Mental Health Awareness Month by holding a news conference in D.C encouraging mental health checkups, holding book signings, speaking to the masses, and creating a task force specifically to advance National Minority Mental Health. Although Bebe Moore Campbell passed away in 2006, her friends and family worked together to remain vigilant in their advocacy efforts. 


Minority Mental Health and Health Care Disparities 

Although racial and ethnic minorities have been shown to have an increased vulnerability to mental health problems compared to their White counterparts, they also demonstrate less utilization of mental health services (Lu et al.,2021). Several factors can affect the mental health of minorities, making it difficult for them to receive treatment (Lu et al., 2021).  Patients' symptom severity, fears, acculturation, social support, and therapist-patient ethnic match are among these factors (Lu et al., 2021). As a result of the pandemic, health care disparities are being uncovered and exacerbated not only on the medical front, but also on the mental health front, as ethnic minorities are experiencing a higher probability of developing mental illness (Smith et al., 2020).

Tips to Increase Engagement

• Make sure that information and psychoeducational material are available in English and a second language. Address concerns and fears in these materials (Smith et al., 2020).
• Maintain flexibility so that services are accessible and existing care can continue (Smith et al., 2020).
• Collaboration in the treatment process that encourages dialogue and allows the client's expertise to drive decision-making (Alegria et al., 2020).
• Practice humility and respect for the clients' perspective (Alegria et al., 2020).

References & Resources

Alegria, M., Falgas-Bague, I., & Fong, H. F. (2020). Engagement of ethnic minorities in mental health care. World psychiatry: official journal of the World Psychiatric Association (WPA), 19(1), 35–36. https://doi.org/10.1002/wps.20695

Bebe Moore Campbell National Minority Mental Health Awareness Month. NAMI. (n.d.). https://www.nami.org/Get-Involved/Awareness-Events/Bebe-Moore-Campbell-National-Minority-Mental-Health-Awareness-Month. 

BIPOC Mental Health Month. Mental Health America. (n.d.). https://www.mhanational.org/BIPOC-mental-health-month. 

Lu, W., Xu, L., & Hart, D. (2021). Editorial: Minority Adolescent Mental Health and Health Care Disparities. Frontiers in Public Health, 9. https://doi.org/10.3389/fpubh.2021.704765 

Smith, K., Bhui, K., & Cipriani, A. (2020). COVID-19, mental health and ethnic minorities. Evidence Based Mental Health, 23(3), 89–90. https://doi.org/10.1136/ebmental-2020-300174 

 Written by: Amanda Ross, PsyD

June is PRIDE month and is celebrated both nationally and globally! LGBTQ2+ Pride Month is celebrated every June as a tribute to those who were involved in the Stonewall Riots (also known as the Stonewall Uprising) that took place in 1969. What is the Stonewall Uprising? In New York on June 28, 1969, police raided the Stonewall Inn, a gay nightclub in Greenwich Village, which resulted in bar patrons, staff, and neighborhood residents protesting as police hauled employees and patrons outside. Among the many leaders of the Stonewall Uprising was a black, transgender, bisexual woman, Marsha P. Johnson, leading the movement that continued to over six days of protests and violent clashes with law enforcement. The Stonewall Riots served as a catalyst for the gay rights movement in the United States and around the world.

Pride Month is largely credited as being started by bisexual activist Brenda Howard. Known as ‘The Mother of Pride,’ Brenda organized Gay Pride Week and the Christopher Street Liberation Day Parade a year after the Stonewall Uprising. This eventually morphed into what we now know as the New York City Pride March and was the inspiration for the formation of similar parades and marches across the world. As a sub-holiday during Pride Month, Pride Day is celebrated on June 28. This day marks the date in history when the first pride march was held in New York City in 1970. 

Now that we understand the background of Pride Month, lets shift focus to the LGBTQ+ community and health. 

Understanding the acronym. As the gender and sexual minority community has expanded, it has become important to find ways to make terminology more inclusive. These terms are simultaneously descriptive, expressive, and political. 

LGBTTIPQQ2SAA:
Lesbian, Gay, Bisexual, Transgender, Transsexual, Intersex, Pansexual, Queer, Questioning, 2-Spirit, Asexual, and Allies

• Lesbian - This term refers to a woman who is sexually and/or romantically attracted to other women.
• Gay - This term refers to a man sexually and/or romantically attracted to other men. It’s also sometimes used as a blanket term to refer to any person who is interested in the same gender as their own.
• Bisexual - This term refers to a person attracted to two or more genders. This could be a person attracted to men and women, a person attracted to men and nonbinary genders, or a person attracted to their own gender and a few others. While “bi” does refer to two, as the community’s understanding of gender has grown, the term has expanded in its usage beyond the gender binary.
• Transgender – This term refers to a person whose experienced gender or gender identity is different than the one they were assigned at birth.
• Transexual – The term is often used to communicate that one’s experience of gender involves medical changes, such as hormones or surgery, that help alter their anatomy and appearance to more closely align with their gender identity. Transsexual isn’t an umbrella term. It should never be used to refer to the entire transgender community.
• Intersex – This term refers to someone whose sexual organs don’t fall within the sexual binary. 
• Pansexual - Similar to bisexual, a person attracted to many genders (usually more than two or any gender). Someone may consider themselves bisexual and pansexual, or just one or the other. 
• Queer – An umbrella term used to cover the entire/the broad range of LGBTQ2+ community; this is the first word of its kind to be reclaimed, as this term has historically been used to discriminate against the LGBTQ2+ community. 
• Questioning - A term used to refer to someone who is not sure what their gender identity or sexual orientation is, and who is in the process of figuring it out.
• 2-spirit – A gender identity, often associated with Native American culture, in which one person contains female and male spirits within them.
• Asexual – Asexuality is the term for people who don’t experience sexual attraction, and the spectrum refers to different ways in which people experience less sexual attraction than the norm. 
• Allies – A term used to define someone who confronts heterosexism, homophobia, biphobia, transphobia, heterosexual, and genderstraight privilege in themselves and others. 

Recognizing that the whole acronym changes regularly, more abbreviated versions of this acronym are acceptable in everyday language, such as LGBT, LGBTQ, and LGBTQIA+. 

However, in policy, the currently accepted version of the full acronym is to be preferred to ensure that policies do not exclude any sexual or gender minority. 

Speaking of policy… What’s going on in Ohio?

• Thanks to Obergefell v. Hodges, in 2016 same sex marriage has been legalized in Ohio and across the nation. Because of this…
  • All states recognize marriages performed in other states
  • Same-sex couples can file joint state tax returns
  • Employers must now offer same-sex couple spousal benefits
  • Couples have the same visitation and decision making rights as other couples
  • Now same-sex couples have the same rights upon the death of a partner
  • They also have a right to divorce
• Although same-sex adoption was made legal in Ohio in 2016, there are still several statutes that make adoption very difficult, including applying for shared parental rights in same sex couples. Prior to 2016, it was single adoption only. Additionally, in Ohio…
  • There are no parental leave laws for same-sex couples
  • Non-discrimination laws for same-sex couples looking to adopt are nonexistent, as well as same-sex couples looking to foster
• Conversion therapy is still legal in Ohio. Currently only about 15% of all LGBTQ+ are protected from conversion therapy in Ohio, with only 7 cities banning conversion therapy practices. These cities are…
  • Athens 
  • Cincinnati
  • Columbus 
  • Dayton 
  • Lakewood
  • Toledo 
• Ohio is only one of three states that do not allow trans individuals to change their gender on their birth certificates. The state does allow citizens to change their gender on the driver’s license, but must choose between only male or female.
• In terms of employment and housing laws and discrimination, there are no protections that extend statewide in Ohio for sexual orientation or gender identity, with only a handful of counties banning discrimination in housing or in the workplace. 
• In the counties that have passed laws for Ohio gay rights, you do have rights to fight back against discrimination. 

Why do gender and sexual identities matter in healthcare? 
1 in 8 – that is the number of LGBTQ2+   people who have experienced unequal treatment from healthcare staff RECENTLY... additionally, people of LGBTQ2+ community are less likely to engage in health care, are less likely to get preventive services, are less likely to report abuse in their relationships to health care providers, are more than twice as more likely to experience symptoms of a mental health condition, are 2-3x more likely to attempt suicide, and are 2.5x more likely to suffer from substance use disorders.
“There is a well-documented link between experiences of discrimination and marginalization and poor physical and mental health outcomes. Populations that face widespread stigma and discriminating are more likely to report poor overall health and are more vulnerable to a variety of physical and mental health conditions” (James et al 2015). 

10 things to focus on to create an inclusive health care environment for LGBTQ2+ people*:

1. Engagement from your leadership from both the board and senior management is critical, even if there is a great deal of support from throughout the organization. Leadership can set the tone an build LGBTQ2+ inclusiveness as part of a commitment to equitable care for all. 
2. Patient and employee non-discrimination policies should include “sexual orientation”, “gender identity”, and “gender expression”; these policies should be widely known in cases of questions of discrimination. 
3. Respectful communication and quality of care depend on all staff receiving training and expressed understanding on diverse LGBTQ2+  identities, terminology, and heath disparities. 
4. Processes and forms should reflect the diversity of the LGBTQ2+ community and their relationships: Use of language and preference is important in order to avoid gender-specific or assuming terms. 
5. The institute of medicine and the Joint Commission recommend data be collected on sexual orientation and gender identity of patients in order accurately measure quality of care and evaluate processes for eliminating LGBTQ2+ health disparities. 
6. Taking routine sexual health histories should be done regularly. Broadening the questioning and focus is of utmost importance in an inclusive health care environment. There are many widely used inclusive and comprehensive sexual health screeners available.  
7. Clinical care and services should offer and incorporate LGBTQ2+ health care needs in general physical and mental health services, including care for transgender individuals who may have more specific medical needs. This requires education on the part of the health care provider. 
8. The physical environment should welcome and include LGBT+ people. Adding affirmative imagery and content to education and marking materials, having single occupancy or gender neutral restrooms, asking about sexual and gender identities in health screens are just a couple of ways to do this. 
9. Having LGBTQ2+ Staff helps build a foundation for a respectful, inclusive health care environment. Be vocal about LGBT+ nondiscrimination policies in recruitment ads may aid in recruitment and retainment. 
10. Outreach efforts to engage LGBTQ2+ individuals in the community can help aid in LGBTQ2+ engagement in the healthcare field in which you work. 

*National LGBT Health Education Center

Eliminating LGBT health disparities and enhancing efforts to improve LGBT health are necessary to ensure that LGBT individuals can lead long, healthy lives. The many benefits of addressing health concerns and reducing disparities include: Reductions in disease transmission and progression; Increased mental and physical well-being; Reduced health care costs; Increased longevity.

To get more involved in the LGBTQ2+ activism as well as engage in PRIDE month events, please visit your local LGBT Center website – Cleveland LGBT Center webpage: Home - LGBT Community Center (lgbtcleveland.org)
 

By: Karissa Fogarty, Psy.D.

As psychologists, this may be something that you were already aware of.  However, because of our day to day interactions involving mental health, we may often forget about the need to bring awareness to those that are less informed.  Many patients continue to report stigma and judgement that they face not only from friends and family, but even from the media.  An important aspect of our profession is to utilize the knowledge that we have obtained in order to educate and inform the general population about the facts.  Additionally, this helps to reduce the burden of those struggling with mental illness to inform and educate the individuals in their own lives.  

The National Alliance on Mental Illness (NAMI)  on a main goal of educating and bring awareness through various outreach programs and events.  This month, NAMI continues to utilize the message of “You Are Not Alone” to help those struggling to connect with each other.  Some of the platforms they are using to help people connect include blogs, social media (#MHAM and #YouAreNotAlone), videos, and events such as NAMI Walks.  Below are some possible ways that we, as psychologists and mental health providers, can go beyond our day to day work to help bring awareness to the importance of prioritizing mental health and reducing stigma.

• Participate in awareness events and volunteer opportunities such NAMI Walks or the Diversity Walk Rock and Run
  • The Committee on Social Responsibility has created a team for the Virtual Diversity Walk Rock and Run this year—Please join us by using the link below to sign up!  The walk will be held from May 22nd to June 4th https://runsignup.com/RaceGroups/64628/Groups/928161
• Use the hashtags #YouAreNotAlone or #MHAM on social media to promote awareness and help spread your own knowledge and expertise
• Share information from OPA’s resource page to people in your life https://ohpsych.org/mpage/PublicResourceFamily
• Be open to starting conversations with friends, family, colleagues and even strangers about mental illness, prioritizing mental health, and self-care
• SPEAK UP when you hear others minimizing an individuals’ experience of mental illness, spreading myths and false information or using derogatory or judgmental language surrounding mental health 
• Engage in your own self-care to model prioritizing mental health
• Use NAMI’s Awareness Event guide for more tips on how you can get involved on a personal and individual level https://www.nami.org/getattachment/Get-Involved/Awareness-Events/Partners-and-Events/YANA2021-Partner-Guide.pdf

Written by: Allison Sylvia, MA 

My grandmother survived the Nazi occupation of France during the second World War. Afterwards, she married my grandfather, a US solider, and left France. She shouldered the emotional burden of a world-wide crisis as a teenager and tried to move on. Now, during the COVID-19 pandemic she feels the shadows of the War. Difficult memories and forgotten feelings triggered and increased social isolation and reduced coping strategies leave her more alone, with family unable to move in close to provide support. As warm weather comes with spring and more people across the US are vaccinated, it seems likely that we as a country will want to move on. We will likely want to forget the difficulties of the pandemic and enjoy a life free of its occupation of our spaces. However, for many of us the impact of the COVID-19 pandemic has been profound, triggering past trauma and adding new.

Potential sources of traumatic stress during this pandemic

• Sudden loss of family or community member(s) and prevention from engaging in typical forms of mourning, such as family gatherings and funerals in some countries
• High-stakes decision fatigue in healthcare professionals, and potential moral injury in cases of extremely limited access to care
• Vicarious traumatization of healthcare professionals 
• Sudden loss of financial stability 
• Sudden loss of previous social roles and identity (Masiero; 2020)

Certain populations face even greater loss and risk of traumatization
Although all people are at risk of the stressors described above, certain populations are at even greater risk of traumatization. The underlying health and economic disparities of the United States has had a profound impact on the way different groups have been required to handle the pandemic (Lund, 2020). Those who entered into this pandemic already at a disadvantage due to structural inequalities were less resourced to cope with the impact of the virus (Lund, 2020). Berkowitz and colleagues (2020) show evidence that the morbidity and mortality of the COVID-19 pandemic hit economically disadvantaged neighborhoods the hardest. This is, in part, because those who live in these neighborhoods have less space to socially distance and fewer accessible and acceptable health care resources (Berkowitz et al., 2020). Since such “neighborhoods are disproportionately populated by people of color” (Berkowitz et al., 2020, p. 1) it is clear that additional risks of being in these neighborhood disproportionality falls on people of color in the United States. Individuals in these communities are thus at greater risk of re-traumatization, experiences of grief and loss, and are less likely to access mental health services because of economic inequities and fears of racial bias when accessing services (Sneed & Key et al., 2020). 

Many individuals suffering from interpersonal victimization are also at increased risk. A recent study showed that for many of those with safety concerns due to interpersonal violence there has been a decrease in their level of safety. Loss of economic stability has been a major source of increased stress and potential victimization for this population (Wood et al., 2021). Another major barrier for this population is access to services and inconsistent experiences with virtual services (Wood et al., 2021). Also, children and youth who are at greater risk of abuse and neglect are likely experiencing even greater suffering due to the pandemic. According to recent data from the CDC “[d]uring the COVID-19 pandemic, the total number of emergency department visits related to child abuse and neglect decreased, but the percentage of such visits resulting in hospitalization increased, compared with 2019” (Swedo et al., 2020, p. 1).  This suggests that victims are less likely to receive care, perhaps because of the limited in-person social support that may have otherwise intervened (Swedo et al., 2020). 

Additionally, those with underlying mental health conditions, such as post-traumatic stress disorder, have been shown to be under greater distress during the pandemic (Holland et al., 2021; Venkateswaran & Hauser, 2020). Indeed, a recent article published in the Journal of the American Medical Association (JAMA) Psychiatry found that across the nation there was a significant increase in emergency room visits for suicide attempts and overdoses during the pandemic, when compared to the previous year (Holland et al., 2021). 

Many people have experienced this pandemic as a traumatizing or retraumatizing experience. As our society moves towards the summer and hopes that a vaccine will allow us to return to “normal,” it is important to bear in mind that many of us have been profoundly affected by this pandemic, in ways that may not appear readily apparent to others.  Thus, it is crucial that all of us, and especially psychologists, use a trauma-informed lens to approach our future work and social interactions (Collin- Vézina et al., 2020; Javakhishvili et al., 2020).

Using a Trauma-Informed Lens 

• Six trauma-informed principles to apply (Collin- Vézina et al., 2020):
  • Trustworthiness and transparency
  • Safety
  • Peer support
  • Collaboration and mutuality
  • Empowerment and choice
  • Use of a cultural, historical and gender lens
• Further education on a trauma-informed approach
  • Brief video explanation: https://www.youtube.com/watch?v=zg8ahtHIRxU
  • Longer trauma-informed care training: https://portal.ct.gov/LTCOP/Trainings/Trauma-Informed-Care

Other resources:
OPA Covid-19 resources page: https://ohpsych.org/page/PandemicResources

References:
Berkowitz, R. L., Gao, X., Michaels, E. K., & Mujahid, M. S. (2020). Structurally vulnerable neighbourhood environments and racial/ethnic COVID-19 inequities. Cities & Health, 1–4. https://doi.org/10.1080/23748834.2020.1792069

Collin-Vézina, D., Brend, D., & Beeman, I. (2020). When it counts the most: Trauma-informed care and the COVID-19 global pandemic. Developmental Child Welfare, 2(3), 172–179. https://doi.org/10.1177/2516103220942530

Holland, K. M., Jones, C., Vivolo-Kantor, A. M., Idaikkadar, N., Zwald, M., Hoots, B., Yard, E., D’Inverno, A., Swedo, E., Chen, M. S., Petrosky, E., Board, A., Martinez, P., Stone, D. M., Law, R., Coletta, M. A., Adjemian, J., Thomas, C., Puddy, R. W., … Houry, D. (2021). Trends in US Emergency Department Visits for Mental Health, Overdose, and Violence Outcomes Before and During the COVID-19 Pandemic. JAMA Psychiatry. https://doi.org/10.1001/jamapsychiatry.2020.4402

Javakhishvili, J. D., Ardino, V., Bragesjö, M., Kazlauskas, E., Olff, M., & Schäfer, I. (2020). Trauma-informed responses in addressing public mental health consequences of the COVID-19 pandemic: Position paper of the European Society for Traumatic Stress Studies (ESTSS). European Journal of Psychotraumatology, 11(1), 1780782. https://doi.org/10.1080/20008198.2020.1780782

Lund, E. M. (2020). Even more to handle: Additional sources of stress and trauma for clients from marginalized racial and ethnic groups in the United States during the COVID-19 pandemic. Counselling Psychology Quarterly, 1–10. https://doi.org/10.1080/09515070.2020.1766420

Masiero, M., Mazzocco, K., Harnois, C., Cropley, M., & Pravettoni, G. (2020). From Individual To Social Trauma: Sources Of Everyday Trauma In Italy, The US And UK During The Covid-19 Pandemic. Journal of Trauma & Dissociation, 21(5), 513–519. https://doi.org/10.1080/15299732.2020.1787296

Sneed, R. S., Key, K., Bailey, S., & Johnson-Lawrence, V. (20200611). Social and psychological consequences of the COVID-19 pandemic in African-American communities: Lessons from Michigan. Psychological Trauma: Theory, Research, Practice, and Policy, 12(5), 446. https://doi.org/10.1037/tra0000881

Swedo, E., Idaikkadar, N., Leemis, R., Dias, T., Radhakrishnan, L., Stein, Z., Chen, M., Agathis, N., & Holland, K. (2020). Trends in U.S. Emergency Department Visits Related to Suspected or Confirmed Child Abuse and Neglect Among Children and Adolescents Aged <18 Years Before and During the COVID-19 Pandemic—United States, January 2019–September 2020. MMWR. Morbidity and Mortality Weekly Report, 69(49), 1841–1847. https://doi.org/10.15585/mmwr.mm6949a1

Venkateswaran, K. D., & Hauser, C. T. (2020). Living with PTSD amid a global pandemic. Psychological Trauma: Theory, Research, Practice, and Policy, 12(S1), S71. https://doi.org/10.1037/tra0000857

Wood, L., Baumler, E., Schrag, R. V., Guillot-Wright, S., Hairston, D., Temple, J., & Torres, E. (2021). “Don’t Know where to Go for Help”: Safety and Economic Needs among Violence Survivors during the COVID-19 Pandemic. Journal of Family Violence. https://doi.org/10.1007/s10896-020-00240-7

Written by: Chiaothong Yong, PsyD  |  OPA Vice President-Diversity

Did you know that COVID-19 disproportionately impact the Black/African American population? 

When we look at the CDC data (last updated on February 2021) that contain race/ethnicity information, the data show that while 12.2% of the total COVID-19 cases identified as Black, 15.3% of the total deaths from COVID-19 were Black. In comparison, US Census Bureau estimated that 13.4% of the U.S. population identified as Black. See charts below for more compare and contrast. 

Data from 20,135,177 cases. Race/Ethnicity was available for 10,357,949 (51%) cases. 

Data from 327,166 deaths. Race/Ethnicity was available for 251,479 (76%) deaths.

Population estimates by race/ethnicity

(US Census Bureau, 2019)

Some of the factors that contributed to the numbers? 

• The long-standing health disparities (e.g., African Americans have a disproportionately high prevalence of comorbidities, such as diabetes, hypertension, obesity, and coronary artery disease) led to the disproportionate deaths among African Americans with COVID-19 (Tai, Shah, Doubeni, Sia, Wieland, 2020). 
• Blacks/African Americans tend to live in higher housing density, more multigenerational households, and face more housing insecurity. These make social distancing harder. (Tai, et al., 2020). 
• Compared with 8% of nonelderly White/Caucasian Americans, 12% of Blacks/African Americans are uninsured (Tai, et al., 2020).
• Blacks/African Americans tend to experience more financial struggles when compared to their White counterparts. The median wealth of White/Caucasian American households is ten times the wealth of Black/African American households (Tai, et al., 2020).
• Disproportionately lower number of COVID-19 testing sites and contract tracing in the Black/African American community (Chapman, 2020). 

Some of the things that we can do? 

• Check our implicit bias (Tai, et al., 2020)
  • Increase self-awareness on racial bias and stigma in clinical provision
  • Remove structural barriers by providing more support (e.g., empathy, cultural sensitivity) 
• Advocate within our institutions (Tai, et al., 2020)
  • Reexamine how clinical services may or may not adequately address equitable access to the underserved/vulnerable communities 
  • Build sustainable partnerships with the underserved or vulnerable communities
  • Attend continuing education seminars on equity, diversity, and inclusion 

For more reads/References: 

Centers for Disease Control and Prevention (2021, February). Demographic Trends of COVID-19 cases and deaths in the US reported to CDC. https://covid.cdc.gov/covid-data-tracker/#demographics 

Chapman, A. (2020). Ameliorating COVID-19’s Disproportionate Impact on Black and Hispanic Communities: Proposed Policy Initiatives for the United States. Health and Human Rights Journal,22(2), 329-332. https://cdn1.sph.harvard.edu/wp-content/uploads/sites/2469/2020/12/Chapman.pdf 

Tai, D.B.G, Shah, A., Doubeni, C.A., Sia, I.G., Wieland, M.L. (2020). The Disproportionate Impact of COVID-19 on Racial and Ethnic Minorities in the United States, Clinical Infectious Diseases, ciaa815, https://doi.org/10.1093/cid/ciaa815

US Census Bureau (2019). QuickFacts. United States. https://www.census.gov/quickfacts/fact/table/US/PST045219 

Written by: Amy Kerr, M.Ed., Clinical Psychology Trainee at Miami University

As the COVID-19 pandemic stretches on, individuals continue to experience additional stress and increased risk of mental health problems. The fear of infection, job insecurity or loss, increased financial strain, loss of loved ones, and disruption to daily routines associated with the pandemic have resulted in increased stress and uncertainty in the general population. Individuals identifying as LGBTQ+ face heightened risks of physical and mental health problems and financial insecurity.

LGBTQ+ individuals may face additional health risks leading to more negative disease outcomes.

Due to minority stress and discrimination, individuals identifying as LGBTQ+ experience higher rates of some health conditions associated with more negative outcomes from COVID-19 (National Center for Transgender Equality [NCTE], 2020). For example, individuals in the LGBTQ+ community face higher rates of HIV and cancer than cisgender, heterosexual individuals, and have more risk factors associated with respiratory illness (NCTE, 2020; Committee on Sexual Orientation and Gender Diversity, 2020). In addition to putting members of the LGBTQ+ community at risk for more negative health outcomes associated with COVID-19 infection, this increased risk could lead to greater fear of infection for these individuals.

Additionally, LGBTQ+ individuals may face barriers to accessing quality healthcare. These barriers may include lack of affirming healthcare providers, distrust of the medical system due to previous experiences with medical bias, and lower rates of insurance coverage (National Alliance on Mental Illness [NAMI], 2020). These barriers may prevent or delay individuals within this community from seeking care during COVID-19, potentially contributing to more serious illness or more negative outcomes long-term.

LGBTQ+ individuals may experience greater financial strain related to COVID-19.

Individuals in the LGBTQ+ community are more likely than non-LGBTQ+ individuals to work in industries that have been most impacted by the pandemic, such as food and beverage service, hospitals, or education (Whittington et al., 2020). They are also more likely to work gig or contract jobs, rather than salaried positions (Whittington et al., 2020). This could lead individuals in the LGBTQ+ community to experience greater job insecurity than non-LGBTQ+ individuals. Food service jobs and gig/contract jobs are also less likely to provide paid time off to employees (Whittington et al., 2020). Lack of paid time off can increase financial consequences if individuals must quarantine due to exposure or infection.
The stress associated with job or financial insecurity can contribute to mental health problems. 

LGBTQ+ individuals may be at risk for increased mental health problems during the pandemic.

Even prior to the COVID-19 pandemic, individuals in the LGBTQ+ community experienced depression, anxiety, suicidal ideation, and suicide attempts at higher rates than the general population (NCTE, 2020; NAMI, 2020). As the pandemic has resulted in higher rates of stress and mental health problems for the general population (Evans & Bufka, 2020), we might expect to see similar patterns in LGBTQ+ individuals. Research supports this, showing that individuals identifying as LGBTQ+ who were not experiencing significant depression or anxiety pre-pandemic saw increases in symptoms of anxiety and/or depression within the past nine months (Flentje et al., 2020). 

Additionally, individuals in the LGBTQ+ community may face stressors beyond those experienced by cisgender or heterosexual individuals. For example, as healthcare systems have been stretched trying to care for the influx of COVID-19 patients, many non-essential surgeries have been postponed. This includes postponement of gender-affirming surgeries for transgender individuals, which can lead to distress and increased gender dysphoria (NCTE, 2020). Around 45% of LGBTQ+ college students reported that their immediate families either were not aware of or were not affirming of their LGBTQ+ identity (Gonzales et al., 2020). Many college students moved back in with family as schools moved to a virtual learning model. For students whose families are not supportive of their LGBTQ+ identity, this could cause significant distress. 

Intersecting marginalized identities may place certain individuals at the highest risk. 

As LGBTQ+ individuals face heightened risk for physical and mental health problems and additional financial strain during the pandemic, so do individuals holding other marginalized identities. Those who hold multiple marginalized identities, such as Black transgender women, may be especially at risk for negative consequences related to the COVID-19 pandemic (Committee on Sexual Orientation and Gender Diversity, 2020). As always, psychologists should consider all aspects of their client’s identities when providing care and continue to advocate for a more equitable society.


How can psychologists support LGBTQ+ clients at this time? 

• Consider keeping a list of local healthcare providers that offer affirming care.
• Help connect clients with organizations providing financial or food assistance.
• Screen for mood and anxiety disorders in all clients, even those without a history of these issues.
• Encourage clients to connect with a supportive community, especially other LGBTQ+ individuals. 
• Continue to advocate for equal rights for members of the LGBTQ+ community. 

Resources:

• https://www.uclahealth.org/gender-health/covid-19-resources
• https://www.apa.org/topics/covid-19/sexual-gender-minorities

References:
Committee on Sexual Orientation and Gender Diversity. (2020, June 29). How COVID-19 impacts sexual and gender minorities. American Psychological Association. https://www.apa.org/topics/covid-19/sexual-gender-minorities 

Evans, A. C. & Bufka, L. F. (2020). The critical need for a population approach: Addressing the nation's behavioral health during the COVID-19 pandemic and beyond. Preventing Chronic Disease, 17. https://doi.org/10.5888/pcd17.200261

Flentje, A., Obedin-Maliver, J., Lubensky, M. E., Dastur, Z., Neilands, T., & Lunn, M. R. (2020). Depression and anxiety changes among sexual and gender minority people coinciding with onset of COVID-19 pandemic. Journal of General Internal Medicine, 35(9), 2788–2790. https://doi.org/10.1007/s11606-020-05970-4

Gonzales, G., Loret de Mola, E., Gavulic, K. A., McKay, T., & Purcell, C. (2020). Mental health needs among lesbian, gay, bisexual, and transgender college students during the COVID-19 pandemic. The Journal of Adolescent Health, 67(5), 645–648. https://doi.org/10.1016/j.jadohealth.2020.08.006

National Center for Transgender Equality. (2020, April 3). The coronavirus (COVID-19) guide. https://transequality.org/covid19

National Alliance on Mental Illness (2020). LGBTQI. https://www.nami.org/Your-Journey/Identity-and-Cultural-Dimensions/LGBTQI

Whittington, C., Hadfield, K., & Calderon, C. (2020). The lives & livelihoods of many in the LGBTQ community are at-risk amidst the COVID-19 crisis. Human Rights Campaign. https://assets2.hrc.org/files/assets/resources/COVID19-IssueBrief-032020-FINAL.pdf?_ga=2.213569809.467950166.1585537775-1752513918.1573502163

Written by: Elizabeth Harris, PhD

Did you know that December is Worldwide Food Service Safety month? 

In a time where our restaurant industry is struggling to keep its doors open during the pandemic we should give thanks to our food service workers who work hard to keep us safe.  For them, every day is food service safety day in the attempt to spare consumers from obtaining food-borne illnesses.  If you are able, continue to support your local restaurants so you can continue to enjoy the same food you've previously enjoyed. 

When you are home it is important to practice food safety.  Everyone has a role in keeping food safe. Here are some food hygiene tips for next time you’re cooking a meal at home.

1. Wash your hands with warm water and soap before handling food and make sure you thoroughly wash them again when you’re done.
   
2. If you have any cuts on your fingers, hands, or wrists, cover them with bandages before handling food.
   
3. Thoroughly wash your fruits and veggies with clean, warm water before use.
   
4. Make sure your cooked foods are separate from raw foods to avoid harmful bacteria cross-contamination.
   
5. Use fresh utensils when switching from raw meat to other foods during preparation.
   
6. Regularly wash your dishcloths and towels in the kitchen using hot water to keep as clean as possible.
   
7. Do not undercook your meat. Use a thermometer to make sure you get it right!

Written by: Karissa Fogarty, PsyD |  Chair, OPA Committee on Social Responsibility 

Food Insecurity

The week of November 14th through the 21st is Hunger and Homelessness Awareness Week. Although this week is about bringing awareness and support to these communities, it is important to raise awareness year round. Food insecurity can be defined as lack of access to nutritious foods that help maintain good health as well as inability to access affordable foods. Worldwide about 795 million people are said to be food insecure, while in the United States it is estimated that more than 35 million people are struggling with food insecurity. Within Ohio, the rate is about 14.5% of the population (Jones, 2017; Feeding America 2020). On the opposition, food security refers to the ability to access affordable and nutritious, unprocessed foods at all times (Red Nose Day 2019). Considering this definition, it is important to note that highly processed foods, foods high in refined-sugars and low in nutrients would not be considered adequate for food security. It is imperative for all people to have proper access to healthy and nutrient rich foods.

Many individuals believe that food insecurity only affects those living in poverty. Although there is a high percentage of homeless individuals and low-income households that struggle with food insecurity, hunger does not discriminate. Of the United States population, children and the elderly tend to be some of the most vulnerable. Of the 15.7% of households that struggle with food insecurity, 8% of these households have children. During the summer months, children tend to find themselves even more frequently food insecure as they are no longer receiving meals from school (Red Nose Day 2019). For the elderly population, food insecurity can go beyond finances. Mobility is often a barrier to obtaining adequate meals and some elderly individuals have reported that getting to the grocery store is too difficult. 

One final risk factor to consider when discussing food insecurity is household members with disabilities. In 2009, it was found that “one-third of households with a working-age adult who was unable to work due to a disability were food insecure” (USDA 2013). Although low-income can be a contributing factor for these households, income distribution among medical bills and other expenses is also an important factor. Individuals with disabilities may also be more significantly impacted by the negative effects on health caused by food insecurity (USDA 2013).

Food Insecurity and Health

When thinking about the impact of hunger on the body, we often focus to physical health. However, hunger and food insecurity can also significantly impact mental health. For example, hunger can severely impact learning and children need a balanced, healthy diet in order to maintain productivity and concentration (Ke & Ford-Jones, 2015; Waite, 2019). In recent studies, researchers have found that children from households that struggled with food security were two times more likely to experience symptoms related to hyperactivity and inattention when compared with children from food secure households. Furthermore, once these children were introduced to a balanced and healthy diet, some of these symptoms were no longer present. (Ke & Ford-Jones, 2015). 

Among adults, food insecurity can impact mental health in various ways. Although it is often difficult for adults in addition to children to concentrate when hungry, hunger can also impact mood and stress. When individuals are unable to obtain sufficient food necessary for good health, they often become overly stressed and may even experience shame and guilt. These emotions can be directly related to increased vulnerability to experience of depression (Jones, 2017). Additionally, some studies have found that mothers of children struggling with food security and severe hunger are 56.2% more likely to have posttraumatic stress disorder (PTSD) (Waite, 2019). 

What You Can Do

With America currently fighting through a global pandemic, food insecurity is on the rise. In 2020, it is estimated that more than 50 million Americans will experience food insecurity (Feeding America 2020). Please review some of the ways to get involved and help those in need during this difficult time. 

• Search for volunteer and donation opportunities within your community
• Help a neighbor by offering to purchase or pick-up groceries for them
• Choose non-WIC items if you are able so these items are available for families in need
• Donate to local food banks (both food and monetary donations are often accepted)
• Visit www.FeedingAmerica.org for more information on food insecurity and what you can do to help 

Please consider watching the following PSA for a brief overview of Food Insecurity created by OPA’s Committee on Social Responsibility:  https://youtu.be/Uf5YypCxRs4



References
Feeding America. (n.d.). Hunger in America. https://www.feedingamerica.org/hunger-in-america

Jones, A. D. (2017). Food insecurity and mental health status: a global analysis of 149 countries. American journal of preventive medicine, 53(2), 264-273.

Ke, J., & Ford-Jones, E. L. (2015). Food insecurity and hunger: A review of the effects on
children's health and behaviour. Paediatrics & child health, 20(2), 89-91.

Red Nose Day (2019, July 22). What is food insecurity and how does it impact kids. https://rednoseday.org/news/what-is-food-insecurity-and-how-does-it-impact-kids

United States Department of Agriculture (USDA). (2013, May 06). Disability is an important risk factor for food insecurity. https://www.ers.usda.gov/amber-waves/2013/may/disability-is-an-important-risk-factor-for-food-insecurity

Waite, Tori. (2019, February 6). 3 devastating effects of hunger on the body. https://www.feedingamerica.org/hunger-blog/3-ways-hunger-affects-your-body

Written by: Jack Baker |  Miami University 

Colleges and universities in the United States are charged with ensuring the on-campus safety of nearly 20 million students. One area of student safety and wellness that has received increased attention since the start of the new millennia has been campus-based sexual assault prevention.  The federal government has passed several laws mandating that publicly funded schools improve their violence prevention strategies, such as the Campus Sexual Violence Elimination Act in 2013. Meanwhile, academic research has pursued several paths for more effective prevention programs. 

 Unfortunately, evidence suggests that these efforts have not yet been successful. Prevalence rates of sexual assault on college campuses remain high, with some estimates being as much as 25% based in part upon how one defines sexual assault (Fedina, Holmes, & Backes, 2016). Survivors of sexual violence face multiple negative impacts, including an increased risk of being diagnosed with Posttraumatic Stress Disorder (PTSD), depression, anxiety, and substance abuse (Campbell, Dworkin, & Cabral, 2009; Jordan, Campbell, & Follingstad, 2010). As a result, sexual assault on college and university campuses in the United States remains a major public health concern. 

Lack of Success
There are several potential reasons for our lack of success in reducing rates of sexual violence on campuses. To begin with, while the federal government mandates some form of comprehensive sexual assault prevention for publicly funded schools, it is unclear what constitutes “comprehensive” prevention. This issue is compounded by the fact that most sexual assault prevention programs have demonstrated only mixed effectiveness in actually reducing rates of violence perpetration (Newlands & O’Donohue, 2016). In fact, the vast majority of such programs do not succeed in reducing the perpetration of sexual assault. Instead, programs are deemed “evidence-based” given their ability to achieve results in the form of increasing students’ knowledge of sexual assault and related topics (e.g., definitions of consent), as well as improving students’ prosocial attitudes (agreeing with statements such as “sexual assault is a problem” and “I intend to intervene when I see someone in trouble”; Jouriles et al., 2018). At times, some programs are even able to improve students’ skills related to being active bystanders and intervening in potentially dangerous situations that might precede sexual assault (Coker et al., 2014). It is thought that by increasing knowledge, improving attitudes, and increasing skills, we can inherently impact rates of sexual assault. This turns out not to be the case, however, resulting in “evidence-based” programs being only minimally successful (Austin et al., 2015; McMahon et al., 2015).

A New Approach: Improving University Capacity
Another potential reason for the lack of success with sexual assault prevention initiatives could be a deficiency in institutional infrastructure, or readiness, for providing comprehensive prevention. Readiness refers to an organization’s staff and administrators’ willingness and desire to provide successful prevention efforts, as well as the organization’s ability or capacity to support such efforts (Scaccia et al., 2015). The Readiness framework conceptualizes these components via the moniker R = MC2, wherein R (readiness) is a function of an organization’s momentum (willingness and motivation to provide prevention), general capacity (how well an organization functions on a regular basis), and innovation-specific capacity (how well an organization can implement a specific prevention activity with quality). If an organization lacks one or more of these components, its ability to provide effective comprehension decreases (Flaspohler, Meehan, Maras, & Keller, 2012). 

 Institutional readiness in the context of campus-based sexual assault prevention has not been well-researched. At this point in the lifespan of research on campus-based violence, most of the literature has focused on individual prevention programming without considering the overall context such programming occurs in. Successful prevention programming requires a sufficient level of readiness by the organization facilitating its implementation. This may help to explain why schools are not succeeding in reducing rates of sexual assault; if schools lack elements of readiness, positive programming outcomes may be difficult to achieve. Because of this, the field of campus-based sexual assault requires more research on the aspects of capacity and momentum that must be in place for a university to provide comprehensive sexual assault prevention (Wandersman et al., 2008). 

Components of Capacity that May Support Programming
There are four main areas of university infrastructure that can help to support sexual assault prevention on campuses. They include staff, leadership and institutional support, internal and external partnerships, and evaluation. By improving these areas, we can increase the likelihood of schools successfully implementing evidence-based practices.

• Staff. The motivation, knowledge, attitudes, and skills of the prevention staff can affect the implementation of prevention initiatives (Flaspohler et al., 2008). Having a sufficient number of well-trained and well-supported staff increases the likelihood of programs being implemented with fidelity.
• Leadership and Institutional Support. Support provided to staff beings with university leadership who are engaged in prevention planning and value evidence-based practice. Leadership also ensures that sufficient institutional support in the form of funding and physical resources is available to staff (Dills, Fowler, & Payne, 2016). 
• Internal and External Partnerships. There are many stakeholders on and off campus that can play a role in effective prevention. Partnerships within a university can facilitate collaboration between prevention staff and response staff, campus police, student health services, and students. Stakeholders can learn from one another and ensure that prevention efforts across campus are consistent in their messaging (Dills, Fowler, & Payne, 2016). Partnerships between prevention staff and community-based organizations such as hospitals, law enforcement, and advocacy groups can increase a university’s capacity to provide evidence-based prevention. This also ensures that prevention efforts are in line with efforts to respond to sexual assault. 
• Evaluation. Prevention programming must be thoroughly evaluated to ensure the implementation of evidence-based initiatives. In addition, rates of actual behavior, including perpetration rates, ideally should be measured (Casey & Lindhorst, 2009). Evaluation data should be used to inform further action, such as choosing to widely implement new programs and changing programs that are ineffective. 

Moving Forward
Ultimately, the world’s best prevention program can fail if an organization is not ready to implement it. It is possible that colleges and universities are not sufficiently ready or prepared to implement fully comprehensive programming. In addition to researching promising prevention initiatives, we should also invest in the infrastructure needed to support these initiatives when the time comes. This includes having better support for prevention staff, helpful administrators who understand the importance of this work, working partnerships with stakeholders both internal and external to universities, and thorough evaluation of implemented programs. Doing so can improve the chances that we can protect the millions of students on campuses across the country. 

References:
Austin, M. J., Dardis, C. M., Wilson, M. S., Gidycz, C. A., & Berkowitz, A. D. (2015). Predictors of Sexual Assault–Specific Prosocial Bystander Behavior and Intentions. Violence Against Women, 22(1), 90-111. 

Campbell, R., Dworkin, E., & Cabral, G. (2009). An Ecological Model of the Impact of Sexual Assault On Womens Mental Health. Trauma, Violence, & Abuse, 10(3), 225–246. doi: 10.1177/1524838009334456

Casey, E. A., & Lindhorst, T. P. (2009). Toward a Multi-Level, Ecological Approach to the Primary Prevention of Sexual Assault. Trauma, Violence, & Abuse, 10(2), 91–114. doi: 10.1177/1524838009334129

Coker, A. L., Fisher, B. S., Swan, S. S., Williams, C. M., Clear, E. R., & Bush, H. M. (2014). Multi-Year Evaluation of "Green Dot" Bystander intervention on College Campuses. Violence Against Women, 21(12), 1507-1527.

Dills, J., Fowler, D., & Payne, G. (2016). Sexual violence on campus: Strategies for prevention. National Center for Injury Prevention and Control, Centers for Disease Control and Prevention. Atlanta, GA.

Fedina, L., Holmes, J. L., & Backes, B. L. (2016). Campus Sexual Assault: A Systematic Review of Prevalence Research From 2000 to 2015. Trauma, Violence, & Abuse, 19(1), 76-93. 

Flaspohler, P., Duffy, J., Wandersman, A., Stillman, L., & Maras, M. A. (2008). Unpacking Prevention Capacity: An Intersection of Research-to-practice Models and Community-centered Models. American Journal of Community Psychology, 41(3-4), 182–196. doi: 10.1007/s10464-008-9162-3

Flaspohler, P. D., Meehan, C., Maras, M. A., & Keller, K. E. (2012). Ready, Willing, and Able: Developing a Support System to Promote Implementation of School-Based Prevention Programs. American Journal of Community Psychology, 50(3-4), 428–444. doi: 10.1007/s10464-012-9520-z

Jordan, C. E., Campbell, R., & Follingstad, D. (2010). Violence and Womens Mental Health: The Impact of Physical, Sexual, and Psychological Aggression. Annual Review of Clinical Psychology, 6(1), 607–628. doi: 10.1146/annurev-clinpsy-090209-151437

Jouriles, E. N., Krauss, A., Vu, N. L., Banyard, V. L., & Mcdonald, R. (2018). Bystander programs addressing sexual violence on college campuses: A systematic review and meta-analysis of program outcomes and delivery methods. Journal of American College Health, 66(6), 457-466. 

McMahon, S., Palmer, J. E., Banyard, V., Murphy, M., & Gidycz, C. A. (2015). Measuring Bystander Behavior in the Context of Sexual Violence Prevention: Lessons Learned and New Directions. Journal of Interpersonal Violence, 32(16), 2396-2418. 

Newlands, R., & O'Donohue, W. (2016). A Critical Review of Sexual Violence Prevention on College Campuses. Acta Psychopathologica, 02(02). 

Scaccia, J. P., Cook, B. S., Lamont, A., Wandersman, A., Castellow, J., Katz, J., & Beidas, R. S. (2015). A Practical Implementation Science Heuristic For Organizational Readiness: R = Mc2. Journal of Community Psychology, 43(4), 484–501.

Wandersman, A., Duffy, J., Flaspohler, P., Noonan, R., Lubell, K., Stillman, L., … Saul, J. (2008). Bridging the Gap Between Prevention Research and Practice: The Interactive Systems Framework for Dissemination and Implementation. American Journal of Community Psychology, 41(3-4), 171–181. doi: 10.1007/s10464-008-9174-z

Written by:Mercedes Pratt, M.A. |  Clinical Psychology Doctoral Student  |  Bowling Green State University 

Research and attention focused on Autism Spectrum Disorder (ASD) has drastically increased over the past 30 years due in part to a better understanding of the disorder, increased access to resources, including testing, and a broadening of the diagnostic criteria. Presently, the CDC estimates that 1 in 54 U.S. children meet diagnostic criteria for ASD with boys being 4x more likely than girls (APA 2020, CDC 2020). It is suggested that the ratio of boys to girls is 8:1 in high functioning individuals (Mandy et al., 2011). 

Most individuals with ASD have an Average or Above Average IQ, with 33% meeting criteria for an intellectual disability (CDC, 2020). They desire social and romantic relationships although the disorder often is marked by challenges with social interaction, leaving many individuals with ASD feeling anxious, lonely, and subject to peer difficulties (Rowley et al., 2012). 

While ASD is often diagnosed in childhood and adolescence, ASD is a lifelong disorder that impacts individuals in different ways throughout development. Over the past 20 years the rate of ASD diagnosis has substantially increased from 1 in 150 children to 1 in 54 children (CDC, 2020). This is due to various factors including a better understanding of the disorder, increased testing, and a greater inclusion of symptoms included in the “spectrum.”  It is expected that over time, clinicians will encounter clients with ASD. It is necessary for clinicians working with all populations to understand the key features of ASD and specifically how to identify ASD in a less researched population—girls. 

Autism in Girls

Autism Spectrum Disorder (ASD) is often undiagnosed, misdiagnosed, or diagnosed later in life in girls compared to boys. There are various factors that can lead to someone having ASD, largely genetic risk factors.  However, research has indicated that females often need a greater load of genetic factors/changes before they show signs of ASD. This is often referred to as the “female protective effect” (Happe, 2019). Therefore, it is possible that ASD does exist in fewer girls compared to boys, but the present extreme discrepancy between boy and girl diagnoses indicates that there are other factors contributing to a lower rate of diagnosis in girls.

ASD in girls often goes undetected until the social demands of middle school highlight their social differences. This is especially true for girls with an Average or Above Average IQ. The behavior of girls that mask ASD symptoms is called “camouflaging.” One way young girls may do this is by staying physically close to friends and “blending in” with fluid social groups. This is more challenging for boys, as boys tend to play more organized games with stable friend groups—leaving some boys with ASD to play alone (Dean, Harwood, Kasari, 2016). 

ASD is often overlooked in girls due to differences in symptom presentation as well as clinician and measurement bias—assuming girls are unlikely to have ASD or only identifying symptoms more often present in boys (Lundstrom et al., 2019). Additionally, while girls and boys may present similar levels of ASD symptoms, those diagnosing girls with ASD may not detect the presence of ASD unless the girl has significant behavior problems, specifically in the school setting, or the girl additionally has an intellectual disability (Dworzynski et al., 2012). Research also indicates that girls with a diagnosis of ASD have more severe symptoms (e.g., higher scores on ASD measures) and they also had higher scores on measures of AD/HD, ODD, and Learning Disorders. This suggests that girls with mild-moderate symptoms are often not recognized by clinicians as having ASD (Lundström et al., 2019). Autism has high comorbidity in adolescence with anxiety, depression, eating disorders, increased risk for suicide, and tic disorders (Rynkiewicz, Janas-Kozik, & Słopień, 2019). Thus, some clinicians may attribute girls’ challenges as symptoms of these disorders while missing the presence of ASD. 

The majority of research in the area of ASD has included boys and researchers suggest that girls may display a different phenotype of ASD compared to boys. Additionally, the research that exists that includes girls has some conflicting findings regarding intellectual abilities and emotional and behavioral problems (Pisula et al., 2017). Thus, more research is needed in this area focusing on girls with ASD in order to better understand the unique presentation in girls and help promote early diagnosis and intervention.

How might ASD look different in girls compared to boys?

• Girls have stronger motivation for social relationships
• Girls have an easier time understanding emotions of others
• Girls experience more difficulty integrating non-verbal and verbal communication and reciprocal interaction (Hiller et al., 2014)
• Girls may present with more internalizing symptoms (e.g., anxiety and depression) compared to boys with ASD (Solomon et al., 2012)
• Girls are less impaired with play and can be more abstract and imaginative
• Girls can imitate typical social behavior of others
• Girls have a greater number of friends
• Girls display less repetitive behaviors, restricted interests, and stereotyped behaviors (Bölte et al., 2011)
• Girls have different specialized interests compared to boys
• Girls are less hyperactive and inattentive compared to boys with ASD (Gould and Ashton-Smith, 2011; Hiller et al., 2014)

Below are some organizations and links for professionals to learn more about ASD and gain resources for parents and professional training:

Autism Speaks: https://www.autismspeaks.org/resource-guide 

Asperger Autism Network: https://www.aane.org/resources/professionals/

American Psychological Association (APA): 

• https://www.apa.org/topics/autism
  
• https://www.apa.org/pi/disability/resources/publications/newsletter/2016/09/autism-spectrum-disorder

Autism Society: https://www.autism-society.org/about-the-autism-society/publications/resource-materials/

UCLA Center for Autism Research and Training (CART): https://www.semel.ucla.edu/autism





References

Autism and developmental disabilities monitoring (ADDM) network. (2020, March 26). Center for Disease Control and Prevention. Retrieved September 8, 2020, from https://www.cdc.gov/ncbddd/autism/addm.html 

Bölte S, Duketis E, Poustka F, et al. (2011) Sex differences in cognitive domains and their clinical correlates in higher- functioning autism spectrum disorders. Autism 15: 497–511. 
Dean, M., Harwood, R., & Kasari, C. (2017). The Art of Camouflage: Gender Differences in the Social Behaviors of Girls and Boys with Autism Spectrum Disorder. Autism: The International Journal of Research and Practice, 21(6), 678–689. 

Dworzynski, K., Ronald, A., Bolton, P., & Happé, F. (2012). How different are girls and boys above and below the diagnostic threshold for autism spectrum disorders?. Journal of the American Academy of Child & Adolescent Psychiatry, 51(8), 788-797.

Gould, J., & Ashton-Smith, J. (2011). Missed diagnosis or misdiagnosis? Girls and women on the autism spectrum. Good Autism Practice (GAP), 12(1), 34-41.

Happé, F. (2019). What does research tell us about girls on the autism spectrum. Girls and autism: Educational, family and personal perspectives, 10-15.

Hiller, R. M., Young, R. L., & Weber, N. (2014). Sex differences in autism spectrum disorder based on DSM-5 criteria: evidence from clinician and teacher reporting. Journal of abnormal child psychology, 42(8), 1381-1393.

Lai, M. C. (2019). What do we know about the neuroscience of autism in girls and women?. Girls and Autism: Educational, Family and Personal Perspectives, 105.

Lundström, S., Mårland, C., Kuja-Halkola, R., Anckarsäter, H., Lichtenstein, P., Gillberg, C., & Nilsson, T. (2019). Assessing autism in females: The importance of a sex-specific comparison. Psychiatry Research, 282, 112566.

Pisula, E., Pudło, M., Słowińska, M., Kawa, R., Strząska, M., Banasiak, A., & Wolańczyk, T. (2017). Behavioral and emotional problems in high-functioning girls and boys with autism spectrum disorders: Parents’ reports and adolescents’ self-reports. Autism, 21(6), 738-748.

Rowley, E., Chandler, S., Baird, G., Simonoff, E., Pickles, A., Loucas, T., & Charman, T. (2012). The experience of friendship, victimization and bullying in children with an autism spectrum disorder: Associations with child characteristics and school placement. Research in Autism Spectrum Disorders, 6(3), 1126-1134.

Rynkiewicz, A., Janas-Kozik, M., & Słopień, A. (2019). Girls and women with autism. Psychiatr. Pol, 53(4), 737-752.

Solomon, M., Miller, M., Taylor, S. L., Hinshaw, S. P., & Carter, C. S. (2012). Autism symptoms and internalizing psychopathology in girls and boys with autism spectrum disorders. Journal of autism and developmental disorders, 42(1), 48-59.

Written by:Katelyn Wargel, MA - Doctoral Student at Miami University

National Health Center Week celebrates the work of America’s Health Centers who provide vital physical and mental healthcare and social services in communities where individuals are likely to experience high levels of oppression and discrimination. One issue impacting clients at these centers is stigma against mental illness. 

Stigma and Mental Health
Access to mental health care and progress in therapy are still significantly impacted by stigma. Stigma is one of the top reasons an individual may avoid asking for help or seeking mental health care. Among a large sample of individuals experiencing symptoms of depression or anxiety, 40% of individuals said that stigma or fears of others’ judgments kept them from seeking therapy (CAMH , 2020). While stigma involves attitudes and beliefs, it leads to many harmful behaviors. Stigma might show itself through an employer denying someone a job, lack of empathy from family and friends toward an individual’s symptoms, or when someone with a mental illness experiences bullying, physical violence, and harassment (CAMH, 2020; Greenstein, 2017; Mayo Clinic, 2017). Consequences of stigma and discrimination could lead a person to try to hide a mental illness, be reluctant to seek help, or feel shame and hopelessness because of their illness (impacting their recovery). 

Where does stigma come from?
Stigma arises primarily from fear, a lack of understanding, and prejudices held against individuals with a mental illness. These can be exacerbated when popular culture or the media portrays mental illness in a negative light or to fit certain story lines. Mental health stigma can overlap with other harmful discrimination and prejudices, making it an even more harmful factor for people of color, individuals experiencing economic marginalization, or LGBT groups. 

How can we work to reduce stigma?

References:

Centre for Addiction and Mental Health. (2020). Addressing stigma. https://www.camh.ca/en/driving-change/addressing-stigma

Committee on the Science of Changing Behavioral Health Social Norms; Board on Behavioral, Cognitive, and Sensory Sciences; Division of Behavioral and Social Sciences and Education; National Academies of Sciences, Engineering, and Medicine. Ending Discrimination Against People with Mental and Substance Use Disorders: The Evidence for Stigma Change. Washington (DC): National Academies Press (US); 2016 Aug 3. 4, Approaches to Reducing Stigma. Available from: https://www-ncbi-nlm-nih-gov.proxy.lib.miamioh.edu/books/NBK384914/ 

Greenstein, L. (2017). 9 ways to fight mental health stigma. National Alliance on Mental Illness. https://www.nami.org/blogs/nami-blog/october-2017/9-ways-to-fight-mental-health-stigma

Mayo Clinic Staff. (2017). Mental health: Overcoming the stigma of mental illness. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/mental-illness/in-depth/mental-health/art-20046477

Susman, D. (2019). 5 steps to reduce stigma about mental illness: How to change your attitudes and behaviors right now. Psychology Today. https://www.psychologytoday.com/us/blog/the-recovery-coach/201903/5-steps-reduce-stigma-about-mental-illness

Written by: Robert E. Fite, Miami University

Teletherapy has become a common treatment modality for mental health services since the COVID-19 pandemic. While much uncertainty remains about the future of COVID-19, and whether insurance companies will allow teletherapy to be a billable service, there may be substantial benefits to continuing to offer teletherapy services as an option for clients. Traditional barriers to in-person therapy include cost and travel time. For individuals with chronic health conditions these barriers are likely magnified, and additional barriers to using traditional face-to-face therapy may be present. 

There are a number of reasons why continuing to offer teletherapy may be beneficial, especially for those with chronic health conditions. First, individuals with chronic health conditions are especially vulnerable to the effects of COVID-19 or the flu. In the case of a resurgence of COVID-19, flu season, or if an unknown future pandemic hits, it will be important to limit the risk that these individuals are exposed to while seeking services. Second, individuals with chronic health conditions may be more likely to dropout from therapy if their condition prolongs their travel time to and from appointments (e.g., those who are visually impaired, have a mobility disability), or if they have symptoms that make them concerned about attending appointments (e.g., diarrhea). Teletherapy eliminates travel time, transportation needs, and has the potential to offer a more comfortable setting for the patient to attend therapy, while also being able to more easily manage symptoms of their underlying health condition at home. Finally, those with chronic health conditions may be more likely to have additional appointments for other health services (e.g., oncology appointments, appointments with a nutritionist, dialysis treatment). This can be a cumbersome cross to bear, including significant time and financial implications. Teletherapy has the potential to ease the time and travel costs of therapy. Importantly, those with chronic health conditions report an interest in using telehealth. Thus, it may be worth assessing interest in using teletherapy for treating psychological symptoms.

What can you do:

• Consider offering telehealth options even after the COVID-19 pandemic has ended
• Learn more about telehealth options and best practices (see resources below)
• Advocate for continued expansion of telehealth options for Medicaid/Medicare clients
• In the absence of being able to offer teletherapy services, consider how you can make your practice more accessible and welcoming to those with health conditions (e.g., having seating for different size bodies, having space for a wheelchair or service dog to get through)

Resources:

• APA is offering (temporarily) free webinars on best teletherapy practices 
• APA article reviewing different telehealth platforms that providers can use
• An introduction to telehealth available on ABCT’s website

References:

Andrade, L. H., Alonso, J., Mneimneh, Z., Wells, J. E., Al-Hamzawi, A., Borges, G., Bromet, E., Bruffaerts, R., de Girolamo, G., de Graaf, R., Florescu, S., Gureje, O., Hinkov, H. R., Hu, C., Huang, Y., Hwang, I., Jin, R., Karam, E. G., Kovess-Masfety, V., … Kessler, R. C. (2014). Barriers to mental health treatment: Results from the WHO World Mental Health surveys. Psychological Medicine, 44(6), 1303–1317. https://doi.org/10.1017/S0033291713001943

Dilworth, S., Higgins, I., Parker, V., Kelly, B., & Turner, J. (2014). Patient and health professional’s perceived barriers to the delivery of psychosocial care to adults with cancer: A systematic review. Psycho-Oncology, 23(6), 601–612. https://doi.org/10.1002/pon.3474

Edwards, L., Thomas, C., Gregory, A., Yardley, L., O’Cathain, A., Montgomery, A. A., & Salisbury, C. (2014). Are people with chronic diseases interested in using telehealth? A cross-sectional postal survey. Journal of Medical Internet Research, 16(5), 154–169. https://doi.org/10.2196/jmir.3257

Mohr, David. C., Hart, S. L., Howard, I., Julian, L., Vella, L., Catledge, C., & Feldman, M. D. (2006). Barriers to psychotherapy among depressed and nondepressed primary care patients. Annals of Behavioral Medicine, 32(3), 254–258. https://doi.org/10.1207/s15324796abm3203_12

Salinas, J. J., Heyman, J. M., & Brown, L. D. (2017). Financial barriers to health care among Mexican Americans with chronic disease and depression or anxiety in El Paso, Texas. Journal of Transcultural Nursing, 28(5), 488–495. https://doi.org/10.1177/1043659616660362

Wells, A. A., Palinkas, L. A., Shon, E.-J., & Ell, K. (2013). Low-income cancer patients in depression treatment: Dropouts and completers. The Journal of Behavioral Health Services & Research, 40(4), 427–441. https://doi.org/10.1007/s11414-013-9354-y

Written by: Alaina Miller, BA, psychology trainee at Wright State School of Professional Psychology 

Did you know over 437,000 children and youth are currently in foster care? About 20,500 youth are emancipated from foster care without ever being reunified with their families or ever being adopted. 
Did you know neglect is the #1 cause for removal of care and entrance into the foster care system? Other common reasons include abuse, domestic violence, exploitation, and adverse childhood experiences. 
Did you know the placement of the foster care system often creates an inconsistent atmosphere that may lead to various social-emotional, behavioral, and academic challenges for the child? 
Did you know ¼ of youth in foster care are incarcerated within 2 years of emancipation and only ½ graduate high school?

Foster care is a temporary placement service for children who can not be cared for by their biological parents and families. Children often come to the attention of the child welfare system because their parents cannot provide adequate care, in which these children have often experienced maltreatment such as neglect and trauma. The agency serves to provide a living space and stable upbringing for the child(ren) and seeks to find permanent homes for them, although 40% of children spend one to three years in foster care. Children are often placed with relatives, designated foster parents, group homes, or residential treatment centers. One of the biggest challenge’s children experience in foster care is constant instability of placement as well as limited opportunities to develop long-term skills and relationships necessary for success. This environment, in addition to experienced trauma, can have a long-lasting negative impact on the child and their development. 

Tips for professionals & caregivers when working with or caring for children in the foster care system that experienced maltreatment 

• Routine- establish a routine to enforce consistency and stability 
  
• Limit “triggers”- find out what their personal triggers are; or events that lead to dysregulation, hypervigilance, and avoidance. Try to limit them
  
• Give choices to enhance control and independence- throughout the day let the child pick between two activities/items to foster control 
  
• Time - The healing process is different for everyone. Each child will recover on their own timeline. Do not push them to overcome their trauma but allow them the time they need

Resources for Professionals
http://www.nctsn.org: The National Child Traumatic Stress Network (NCTSN) offers extensive resources for professionals, parents, and caregivers that include education, videos, and handouts. These target all types of trauma and victimization. In addition, resources are offered in multiple languages.

https://www.nctsn.org/resources/young-children-foster-care: NCTSN’s specific page for children in foster care

https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/healthy-foster-care-america/Pages/default.aspx: Resources such as listservs, conference videos, resource library, and tools for professionals. A good resource for professionals in the pediatric or primary care settings. 

References 

American Society for the Positive Care of Children. (2018). Get the facts-Foster care & adoption. Retrieved May 4, 2020, from https://americanspcc.org/get-the-facts-foster-care/

Annie E. Casey Foundation. (2020). What is foster care. Retreived May 4th, 2020, from https://www.aecf.org/blog/what-is-foster-care/?gclid=Cj0KCQjw-r71BRDuARIsAB7i_QPXQdK8xupcG72idboyBtTngXUE5jznpl60pDhD4n58EbFNRICx9TYaApVhEALw_wcB

Written by: Amy Kerr, MEd, Clinical Psychology Graduate Student, Miami University

As psychologists, we have a responsibility to advocate for health equity, as the health disparities that currently exist in the United States directly affect our clients and communities. These disparities exist for people belonging to various minority populations, including racial and ethnic minority groups, members of the LGBTQ+ community, people with disabilities, and people of low socioeconomic status. Though health outcomes and disparities differ among populations, people from minority populations are generally at higher risk for a variety of health problems such as heart disease, obesity, and pre-term infant birth (National Academies of Science, Engineering, and Medicine, 2017). These disparities have generally persisted despite efforts to increase health equity and improve health outcomes for people from minority groups. 

While a wide variety of factors impact health outcomes, evidence suggests that the stigma and stress of minority status may be driving these disparities. Stigma can be defined in sociological terms as concurrent labeling, stereotyping, separation, loss of status, and discrimination in a context involving power dynamics, and is related to a variety of factors that influence health outcomes, such as access to housing and healthcare, educational and employment opportunities, and level of social support (Hatzenbuehler, Phelan, & Link, 2013). Limited access to resources and supports leads to added stress for individuals in many minority populations. Additional stressors experienced by people holding minority identities include facing discrimination, macroaggressions, and internalized prejudice (e.g., internalized racism or homophobia) that influences their sense of self (Hatzenbuehler et al., 2013; American Psychological Association [APA], 2017). 

High levels of stress have been linked to a variety of negative health outcomes, including those listed above. Additionally, stress may lead to sleep difficulties, increases in maladaptive coping behaviors such as substance use, and difficulty self-regulating and recovering from stress, as well as exacerbating other mental health problems (APA, 2017). The serious consequences of stigma and related stress on the health of minority communities points to the  need for psychologists to promote greater health equity for their clients and communities. 

Psychologists are already doing a great deal to help people from minorities cope with the stigma and additional stressors they face and to reduce health disparities for minority populations. These efforts range from providing culturally adapted cognitive behavioral stress management interventions at the individual level to public policy advocacy and efforts to increase access to healthcare and other resources at the community level (APA, 2017). In addition to these efforts, psychologists must advocate for broad social change in order to help reduce the stigmas that are a fundamental cause of health disparities (Hatzenbuehler et al., 2013). See below for a list of suggestions on how you can continue these efforts. 

What can psychologists do?

• Conduct further research on how prejudice and discrimination influence health outcomes. Employ research methods that allow for members of minority populations to share their perspectives and serve as collaborators, such as community based participatory research. 
  
• Advocate for legislation and policies that promote health for minority populations, including policies aimed at increasing access to health and mental health care as well as  those aimed at reducing discrimination.
  
• Clinicians and trainees should continue to seek education and build cultural competence in working with individuals holding various minority identities. 
  
• Connect with local organizations and advocacy groups that aim to combat prejudice and discrimination.

Resources

• APA Advocacy – Health Disparities https://www.apa.org/advocacy/health-disparities/
  
• APA Public Interest Directorate – Health Disparities Office https://www.apa.org/pi/health-disparities/
  
• Multiethnic Advocates for Cultural Competence https://www.maccinc.net/
  
• National Institute on Minority Health and Health Disparities https://www.nimhd.nih.gov/

References:

American Psychological Association, APA Working Group on Stress and Health Disparities. 
(2017). Stress and health disparities: Contexts, mechanisms, and interventions among 
racial/ethnic minority and low-socioeconomic status populations. Retrieved from 
http://www.apa.org/pi/health-disparities/resources/stress-report.aspx

Hatzenbuehler, M. L., Phelan, J. C, & Link, B. G. (2013). Stigma as a fundamental cause of 
population health inequalities. American Journal of Public Health, 1(3), 813-821. 
https://doi.org/10.2105/AJPH.2012.301069. 

National Academies of Sciences, Engineering, and Medicine. 2017. Communities in action: 
Pathways to health equity. Washington, DC: The National Academies Press. https://doi.org/10.17226/24624 

Written by: Allison Sylvia, BS

Later this month, a nurse is starting on the front lines of the COVID-19 crisis, just hired on at a local hospital. He has asthma and his wife is expecting a child this year. Despite the precarious position of his health and family in this crisis, the hospital that hired him refuses to provide health insurance until months into his employment. This leaves him and his family at risk as he cares for his community. Although this story is set against the backdrop of the COVID-19 outbreak, unfair health insurance policies have long impacted Americans. Health insurance is often difficult to access, expensive, unequal and confusing. This is true of both medical and mental health coverage.

This article explains and examines parity laws, which are laws that require insurers to cover mental health treatment at a rate similar to medical and surgical care. Although parity laws help Americans access to mental health treatment, the laws are not always effective, leaving people without treatment. Indeed, according to the U.S. National Institute of Mental Health, 33.3% of the 11.2 million adults with severe mental illness went without mental health treatment and 52.7% of the 46.6 million adults diagnosed with any mental illness went without treatment in 2017 (National Institute of Mental Health, 2019). Children also have insufficient access to care. Approximately 60% of an estimated 3.5 million adolescents with depression did not receive treatment in 2016 (Lipari, 2018) and only half of the approximately 8 million children diagnosed with any mental disorder received treatment (Whitney & Peterson, 2019).These numbers are staggering. Many do not receive treatment because of inadequate mental health treatment coverage (Rowan et al., 2013). Strengthening parity law enforcement is a one of the best avenues available to address this disparity in access to treatment.

How do parity laws impact you?

• Parity laws impact your access to mental health treatment.
  
• Parity laws impact your patients’ access to mental health treatment.
  
• Parity laws impact reimbursement for the mental health treatment psychologists provide.
  

What are parity laws?

• Parity: State of being equal or equivalent.
  
• Parity law: Federal or state law that requires medical insurers to cover mental health and substance use treatment in a way that is equal to the coverage offered for medical/surgical appointments and procedures. For example, parity laws would make it illegal to charge a $100 copay for an individual therapy session and a $20 copay for a primary care appointment (American Psychological Association, 2014).
  
• The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA): 
  
  • Federal parity law that requires equal coverage in large group health plans across the nation (Department of Health and Human Services, 2016).
    
  • The Affordable Care Act (2010) extended MHPAEA parity protections to individual health insurance policies and Medicaid (Department of Health and Human Services, 2016).
    
  • Examples of quantitative and qualitative insurer policies that must be equivalent under MHPAEA: 
    
    • Copayments, limitations on number of visits, limitations on frequency of treatment, fail first policies with prescriptions, tiered coverage and requirements for evidence of medical necessity (Ohio Department of Insurance, 2019; Centers for Medicare & Medicaid Services, 2016).
      

What are the shortcomings of parity laws?

• Health insurance companies avoid meeting parity requirements in a number of ways. For example:
  
  • Create standards for what is “medically necessary” treatment that are stricter than physical illness standards (Abelson, 2019; Dangor, 2019).
    
  • Provide limited pool of in-network providers so patients are forced to go out of network, thus paying more out-of-pocket (Dangor, 2019; Diehl et al., 2017).
    
  • Deny coverage once a person’s mental health is “stable” rather than treating the underlying pathology (Abelson, 2019).
    

What are the parity laws in Ohio?

• Ohio’s state parity law only protects coverage for a limited list of “biologically-based” mental illnesses (e.g., bipolar disorder, schizophrenia) and allows insurers to create rules that limit access to mental health services (White, 2019).
  
• Senate Bill 254 is a bipartisan bill introduced in 2019 that, if passed, would require Ohio health insurance to comply with the MHPAEA and submit an annual report outlining their compliance with MHPAEA (The Ohio Senate, 2020).
  

What can you do?

• Being informed of your rights is the first step – awesome work!
  
• Look for red flags of parity violations. For example:
  
  • Higher costs for mental health treatment, fewer visits allowed for mental health, mental health treatment deemed medically unnecessary, difficulty findings in-network providers, no coverage for residential mental health when other physical illnesses provide residential care (National Alliance on Mental Illness, 2020).
    
• If you think there are is a parity law violation, consider filing an appeal or complaint with the insurance company.
  
• Consider filing a complaint with the Consumer Services Division at the Ohio Department of Insurance (ODI).
  
  • Link to file a complaint online: https://gateway.insurance.ohio.gov/UI/ODI.CS.Public.UI/Complaint.mvc/DisplayConsumerComplaintForm
    

References

Abelson, R. (2019). Mental Health Treatment Denied to Customers by Giant Insurer’s Policies, Judge Rules—The New York Times. https://www.nytimes.com/2019/03/05/health/unitedhealth-mental-health-parity.html

American Psychological Association. (2014). Does your insurance cover mental health services? https://www.apa.org/images/parity-guide_tcm7-171257.pdf

Centers for Medicare & Medicaid Services. (2016). The Mental Health Parity and Addiction Equity Act (MHPAEA). https://www.cms.gov/CCIIO/Programs-and-Initiatives/Other-Insurance-Protections/mhpaea_factsheet

Dangor, G. (2019). “Mental Health Parity” Is Still An Elusive Goal In U.S. Insurance Coverage. NPR.Org. https://www.npr.org/sections/health-shots/2019/06/07/730404539/mental-health-parity-is-still-an-elusive-goal-in-u-s-insurance-coverage

Department of Health and Human Services. (2016, May 23). Parity Policy and Implementation [Text]. https://www.hhs.gov/about/agencies/advisory-committees/mental-health-parity/task-force/resources/index.html

Diehl, S., Honberg, R., Kimball, A., & Douglas, D. (2017). Doctor Is Out   Sita Diehl, Ron Honberg, Angela Kimball and Dania Douglas. https://www.nami.org/About-NAMI/Publications-Reports/Public-Policy-Reports/The-Doctor-is-Out/DoctorIsOut.pdf

Ohio Department of Insurance. (2019). Ohio Mental Health Parity Report. https://insurance.ohio.gov/static/Consumer/Documents/MHP+Report+2019.pdf

Rowan, K., McAlpine, D. D., & Blewett, L. A. (2013). Access And Cost Barriers To Mental Health Care, By Insurance Status, 1999–2010. Health Affairs, 32(10), 1723–1730. https://doi.org/10.1377/hlthaff.2013.0133

The Ohio Senate. (2020). O’Brien Testifies on Bill to Increase Mental Health Coverage. https://www.ohiosenate.gov/senators/obrien/news/obrien-testifies-on-bill-to-increase-mental-health-coverage

What to Do If You’re Denied Care By Your Insurance | NAMI: National Alliance on Mental Illness. (n.d.). Retrieved March 28, 2020, from https://www.nami.org/Find-Support/Living-with-a-Mental-Health-Condition/Understanding-Health-Insurance/What-to-Do-If-You-re-Denied-Care-By-Your-Insurance

White, A. (2019). Pursuit of Parity: Where Ohio stands on insurance coverage of mental illness and substance use disorders. The Center for Community Solutions. https://www.communitysolutions.com/research/pursuit-parity-ohio-stands-insurance-coverage-mental-illness-substance-use-disorders/

Whitney, D. G., & Peterson, M. D. (2019). US National and State-Level Prevalence of Mental Health Disorders and Disparities of Mental Health Care Use in Children. JAMA Pediatrics, 173(4), 389. https://doi.org/10.1001/jamapediatrics.2018.5399

Written by: Annika Goldman- Miami University


As Psychologists, we are in a unique position to advocate for social justice. Not only do we have the privilege associated with higher education, but we are also made aware of discrimination and systemic inequality through our client’s personal accounts. Many in fact view advocacy for social justice as an ethical obligation, citing the APA’s Ethical Guidelines, Principle D, which encourages us to “recognize that fairness and justice entitle all persons to access to and benefit from the contributions of psychology and to equal quality in the processes, procedures, and services being conducted by psychologists.”

There are many ways to be an advocate outside of the political domain through education, volunteerism, interpersonal dialogue, and so much more. However, political advocacy is an especially impactful vessel for change that many psychologists remain hesitant to take part in due to time restraints, lack of awareness of political issues, or just not knowing where to start. Others may wary of being involved due to the dark history of psychologists’ influence in political movements and ideologies, such as the Nazi Party’s compulsatory sterilization of people with mental illness. While these hesitations should be considered seriously, they should not prevent us from participating in crucial activism on behalf of our client’s welfare. In addition to learning the historical bases for many of the ethical guidelines we have today, we should also consider the political victories that psychologists have made in our history. Here are some ways that psychologists of the past have made an impact on public policy, and how you can too.

Historical examples of political advocacy:

• Inez Beverly Prosser, Ph.D., was the first black female psychologist, receiving her doctorate in Psychology from the University of Cincinnati in 1933. Dr. Proosser’s work on how societal stressors affect the education of children was integral to the Supreme Court’s decision on Brown vs. Board of Education which integrated schools. Dr. Prosser’s work is still being cited to this day.
  
• Ted Strickland, Ph.D., received a doctorate in Counseling Psychology from the University of Kentucky in 1980. He represented Ohio in Congress for 5 terms and served as Ohio’s Governor for one term in 2006. Strickland sponsored a bill that passed in 2001 with overwhelming bipartisan support that created a national demonstration program for mental health courts. This law granted money to court programs in order to divert offenders with mental illness from prison sentences to voluntary treatment programs.  
  
• Relationship Psychologist, Letitia Anne Peplau, Ph.D. took to the stand in 2013 in a series of United States federal court cases that eventually legalized same-sex marriage in the State of California. 
  

How you can get involved:

• Educate yourself on issues related to inequality, mental health, healthcare, funding for the psychological sciences, etc.
  
• Volunteer and vote for local, state, and national political candidates that have a strong voting history and plans for serving marginalized communities.  
  
• Organize and attend rallies, sit-ins, and protests.
  
• Write op-eds for media outlets expressing support for a political issue. 
  
• Donate to political campaigns, think tanks, and action groups.
  
• Call or write messages to your legislators.
  
• Incentivize and support your students/trainees who are taking part in political action. 
  
• Sign up for the APA Federal Action Network newsletter to learn more about legislative issues impacting Psychology on Capitol Hill and respond to their calls to action: http://cqrcengage.com/apapolicy/apaactionalerts?1

Additional Resources:

• http://cqrcengage.com/apapolicy/apaactionalerts?1
  
• https://www.apa.org/pubs/journals/features/cap-53-3-151.pdf

References:

Ethical Principles of Psychologists and Code of Conduct. American Psychological Association, 2017, www.apa.org/ethics/code/.

Foxhall, K. (2001, January). Congress creates grants for mental health courts. Monitor on Psychology, 32(1). http://www.apa.org/monitor/jan01/congressgrants

Minter, Shannon. "Perry v. Schwarzenegger Proceedings, Day 3". Pam's House Blend. Archived from the original on July 27, 2011. Retrieved February 22, 2012.

Written by: Wesley R. Barnhart, BA, BS | Clinical Psychology Doctoral Student | Bowling Green State University

Eating disorders are serious disorders linked to biological, psychological, and sociocultural factors (Culbert, Racine, & Klump, 2015). According to the National Eating Disorders Association, nearly 30 million people in the United States will experience an eating disorder in their lifetime. Only recently have eating disorders moved from the top cause of mortality among psychological disorders in the United States, second to substance use disorder related to opioid use (Chesney, Goodwin, & Fazel, 2014). Eating disorders are non-discriminatory in that they can impact people of all genders and gender identity, age, race, and sexual orientation. Indeed, Gay, Bisexual, and Transgender (GBT) people may show disparate rates of eating disorders (Feldman & Meyer, 2007).
 
For example, compared to their cisgender counterparts, transgender individuals may be significantly more likely to experience an eating disorder in their lifetime (McClain & Peebles, 2016). Research on adolescent gay and bisexual boys identified that they were significantly more likely to engage in compensatory behaviors (e.g., vomiting or taking laxatives to lose/control weight) than their heterosexual counterparts (Austin et al., 2004). Critically, adult gay men are thought to make up approximately 5% of the total male population yet, according to some research, gay men make up approximately 42% of all men experiencing eating disorders (Carlat, Camargo, & Herzog, 1997; Mosher, Chandra, & Jones, 2002). Possible predictors of eating disorder risk among GBT populations are, but not limited to, comorbid depression, self-perceived stigma associated with sexuality, and self-compassion (Bell, Rieger, & Hirsch, 2018). We note that these data serve as a springboard for future research to understand and best assist GBT people with eating disorders.

Questions* to help understand eating disorders in your GBT patients:

• Do you worry about your weight and body shape more than other people your age?
  
• Are you afraid of gaining weight? How important is your weight to you?
  
• Are you currently on a diet? How many times in the past have you been on a diet?
  
• Does your sexual orientation play a role in how you view your body or weight?
  
• Have members in your community criticized your body or weight?
  
• Do you feel your body or weight are “incompatible” with people in your community (e.g., negatively impacting your ability to make friends, find romance, network, etc.)?
  

*These questions do not constitute formal evaluation of an eating disorder and should only be used as supplementary.

Tips for helping patients with eating disorders:

• Normalize and validate their experiences related to having an eating disorder, reassuring that this disorder is not a consequence of poor choices/poor self-regulatory behavior. Assess for comorbid psychopathology, including risk assessment for suicidal ideation (common in eating disorder populations). If needed, use this opportunity to implement psychoeducation informed by current biopsychosociocultural research on eating disorders. Support efforts to access inpatient treatment, if needed.
  
• Seek continued education and be sensitive to the added influence of being GBT on eating disorder development and maintenance. Discuss individual, interpersonal, and community influences on the development and maintenance of an eating disorder.
  
• Consider the important influence of intersectionality on eating disorder severity, including how added minority status (e.g., person of color, person with a disability, etc.) may compound eating pathology (e.g., dietary restriction, binge eating, etc.) among those who are also GBT. 
  
  

What you can do as a psychologist to support people with eating disorders in your community:

• Pursue continued education and sensitivity training on eating disorders and the influence of being GBT on eating disorder development and maintenance. If you do not have this education/sensitivity training, recommend this patient to a mental health professional who does. 
  
• Understand and make accessible current biopsychosociocultural research on eating disorders to patients and their loved ones.
  
• Advocate for legislation that supports accessible and inclusive prevention and treatment of eating disorders, including advocacy for increased research funding at local, state, and national levels.
  
• Be familiar with leading research and advocacy organizations such as the Academy for Eating Disorders and the National Eating Disorders Association to provide patients and their loved ones with continued, remote support.

Resources for information on eating disorders research, education, and advocacy:

• Academy for Eating Disorders: https://www.aedweb.org/home
  
• National Eating Disorders Association: https://www.nationaleatingdisorders.org/
• National Association of Anorexia Nervosa and Associated Disorders: https://anad.org/
  
• Binge Eating Disorder Association:  www.bedaonline.com
•  Eating Disorders Coalition: http://www.eatingdisorderscoalition.org/
  
  

References

Austin, S. B., Ziyadeh, N., Kahn, J. A., Camargo, C. A., Colditz, G. A., & Field, A. E. (2004). Sexual orientation, weight concerns, and eating-disordered behaviors in adolescent girls and boys. Journal of the American Academy of Child & Adolescent Psychiatry, 43(9), 1115-1123.

Bell, K., Rieger, E., & Hirsch, J. K. (2018). Eating disorder symptoms and proneness in gay men, lesbians, and transgender and gender non-conforming adults: Comparative levels and a proposed mediational model. Frontiers in Psychology, 9, 2692.

Carlat, D. J., Camargo, C. A., & Herzog, D. B. (1997). Eating disorders in males: A report on 135 patients. The American Journal of Psychiatry, 154(8), 1127-1132.

Chesney, E., Goodwin, G. M., & Fazel, S. (2014). Risks of all-cause and suicide mortality in mental disorders: A meta-review. World Psychiatry, 13(2), 153-160.

Culbert, K. M., Racine, S. E., & Klump, K. L. (2015). Research review: What we have learned about the causes of eating disorders - A synthesis of sociocultural, psychological, and biological research. Journal of Child Psychology and Psychiatry, 56(11), 1141-1164.

Feldman, M. B., & Meyer, I. H. (2007). Eating disorders in diverse lesbian, gay, bisexual populations. International Journal of Eating Disorders, 40(3), 218-226.

McClain, Z., & Peebles, R. (2016). Body image and eating disorders among lesbian, gay, bisexual, and transgender youth. Pediatric Clinics of North America, 63(6), 1079-1090.

Mosher, W. D., Chandra, A., & Jones, J. (2002). Sexual behavior and selected health measures: Men and women 15–44 years of age, United States. Hyattsville, MD: National Center for Health Statistics; 2005. Advance data from vital and health statistics; no 362