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I was recently in a client’s home to provide therapy. The home was under-furnished with just the basics. There was a hole in the wall, and there were several holes in the floor. He has no income, and he carries the stigma of a felony which has made his employment search difficult. This client has spent years in prison, and experienced violence throughout his upbringing. I remember that as I sat there in this individual’s home, I felt overwhelmed considering all these aspects that have contributed to how the individual came to be where he is today. His road in recovery left him with a therapist and a diagnosis of PTSD. At that moment it seemed ridiculous for us to just meet and talk through his feelings when there are so many structural issues at play in his life and community. Macro MI gives me some ideas of how to move forward in community mental health as a therapist while attempting to disrupt systems of oppression.
I have served as a community-based mental health social worker for over a decade, and for most of my career I have used motivational interviewing (MI) as a key foundation supporting folks in mental health and substance use recovery. I chose to rely on MI in my work both because it fits with my core value of compassion, and because it has proven to be the most effective way of helping others create meaningful change in their lives. MI is effective, yet I have found that in the community mental health setting (and perhaps in other settings) it is not enough.
The concept of community mental health was solidified in the Community Mental Health Center Acts of 1963 and 1965 as “inclusive, multidisciplinary, systemic approach to publicly funded mental health services provided for all in need, residing in a given geographical locale (i.e., catchment area), without consideration of ability to pay” (Beck, 2008, pp. 917). Those using these services are often individuals who are living near or below the poverty line, those who have limited access to basic resources, and (perhaps due to the aforementioned factors) individuals who experience chronic mental health and or substance use problems. Issues such as housing instability, food insecurity, and limited access to medical care are common in the setting of community mental health. Folks seeking help from community mental health centers frequently have a history of complex trauma, and they often have a present reality of chronic daily stressors. Providers in the community mental health field are likely to find that those they serve have had many dehumanizing, traumatic, and even violent experiences with social institutions such as hospitals, jails and prisons, schools, childcare, and emergency residential facilities.
Community mental health centers can be resources of last resort, and it should be no surprise that folks who have been excluded and marginalized in a community tend be users of these services. For example the city in which I work (Milwaukee, WI in 2022) has a population of 27% black/African American residents, but 51% of our city’s community mental health consumers are made up of black/African American residents (CARS, 2022). This mental health disparity is especially stark given the fact that Black Americans tend to have low trust in mental healthcare systems (and for some valid reasons) (Ward, Wiltshire, Detry & Brown, 2013). Sexual orientation is another category where mental health disparities can be seen. Americans in the LGBTQIA+ community are also at much higher risk of substance use and mental health crisis (SAMHSA, 2023). In Wisconsin, 57% youth in the LGBTQIA+ community who wanted mental health support were not able to access it (TTP, 2022).
Similar statistics of increased need and decreased access to mental health services could be shown for individuals of other marginalized social identity groups related to income, race, sexual orientation, ability status, religion, and many others. This seems to make sense given that fact that being excluded due to social identity in the US seems to be a basic cause of stress, mental distress, and trauma (Alegría, et. al., 2018). The identities that we hold (or are assigned) can lead to being treated differently by providers, systems of service delivery, and society at large. Stigma, discrimination, institutions, systemic oppression, and other structural forces matter in mental health.
As a social worker and therapist serving individuals and communities in this field, how do I make sense of this? I can recognize some of the social determinants of mental health, yet I am trained to do “modalities” like motivational interviewing (MI), brainspotting (BSP), mindful self-compassion (MSC), or cognitive behavioral therapy (CBT). These traditional therapeutic approaches focus on helping or healing an individual. Therapists typically focus on emotions, thoughts, and other internal processes of the individual being served. The problems presented in the therapy room are seen as belonging to the individual, and the solutions to these problems are often individualistic in scope. Yet there is a larger structural cause to these issues.
In 2022 I was fortunate enough to attend the Chicago Motivational Interviewing Network of Trainers (MINT) International Form, where I was introduced to “macro MI.” The macro MI presentation and subsequent discussions shed some light on how a “micro worker” like a therapist could begin to think about and take action on issues of inequity, structurally engineered trauma, and mental health disorders (Avruch, 2022). His presentation opened the door to an exploration of how I might begin to bring the micro and macro practices together in my work. It starts with the aspiration of becoming a structurally competent provider.
Nef et. al. describe structural competency as “the capacity for health professionals to recognize and respond to health and illness as the downstream effects of broad social, political, and economic structures” (2020, p.2). A mental health provider who uses a structurally competent approach views mental health and substance use issues as existing within a larger context of structural inequity and oppression. This approach incorporates social context of power when assessing the issue at hand and when attempting to take action to address it. When helping others heal, a structurally competent practitioner dovetails the individual’s symptoms, experiences, and history with larger structural social factors such as stigma, marginalization, and institutional violence. A structurally competent approach to helping honors both the micro and the mezzo/macro in understanding the nature of the problem, in exploring ways to provide a helpful interventions, and in evaluating outcomes. An approach that honors structural factors can also be helpful in engagement and rapport building with those we serve.
For example, a client may come into a therapist’s office seeking treatment for PTSD. The therapist may first gather information about the individuals’ symptoms, specific events that contributed to these symptoms, and explore strengths that the individual has in their recovery. The structurally competent therapist will then also consider information pertaining to the individual’s culture, identities, and their interactions with institutions and social structures. On an individual level, the therapist finds that the consumer is experiencing ongoing symptoms of anxiety and worry related to past violent experiences of sexual abuse. But the bigger picture is outside of the therapy room and includes structures such as the foster system, child protective services, the legal system, and hospitals. If the therapist focused only on the individual’s symptoms and experiences with the typical view of “trauma,” they would be missing important parts of the bigger picture. Instead, the structurally competent therapist considers the cultural and structural impact on the issue. Avruch & Shaida proposed the idea of Macro MI as a way of practicing structural competency on the micro level (2022).
Avruch & Shaida highlight four rationales for taking a structurally competent approach when serving others: rapport building, increased contextual information, activating client engagement in social change, and activating helper engagement in social change. They note the MI has long been one of the leading approaches to supporting folks in community mental health and those experiencing the mental health impacts of oppression. Yet MI does not address structural issues and oppression explicitly. The authors propose combining MI with the more macro-focused approach of structural competency. By combining the micro and macro in this way, we can begin to look at the issue from the individual lens of trauma symptoms, and also zoom out with a wider lens of socially engineered trauma (2022).
MI skills such as the use of open-ended questions can be given a “structural flavor” by incorporating structural factors into how questions are asked. For example, one could ask an individual experiencing self-blame for housing insecurity “what larger factors, other than your personal choices, have contributed to your current housing situation?” Structural flavored reflections could be used in a similar way, “it makes sense that you are feeling unease as one of the only people of color in your class – in a larger educational institution that was initially created to serve exclusively wealthy white male landowners.” Naming structural factors that contribute to client’s situation can be a way to express accurate empathy, “The city has limited options to support individuals with low income in substance use recovery, it is not treated on an equal level of other medical and mental health issues and worse it is often stigmatized.” When a provider is collaborating with another to develop options for the conversational focus, structural issues can be added to the menu. “We could talk about your symptoms this week, how things have been going with your family relations, what efforts you might make to create some changes to how you are being treated at work, or something else – where would you like to start?” Providers can focus both on individual motivation for change of their own behaviors, and also help others build motivation to take actions to make changes in larger systems and structures. “It seems like you are hinting at a need that is not filled by the current policy at your living facility, I wonder what actions we could take to make some kind of change that would benefit you and other residents” (Avruch & Shaida, 2022).
Avruch & Shaia (among many others) posit that the mental health field focuses too narrowly on the individual. Trauma, addiction, and mental unwellness can often be a result of systemic inequalities, histories of violence and oppression, and exclusion. Trauma may initially appear to be a very individual issue, but an individual’s experience of trauma is directly connected to larger systems of power. For example, The War on Drugs has led to trauma caused by police violence and incarceration that disproportionately impacted black men and families. Homelessness is almost always a byproduct of low wealth/income status. Sexual assault can be seen as a result of the systemic subordination and devaluing of women. Our experiences in life, exposure to trauma, and mental health can be directly tied to our social and group identities; we are treated differently by systems and institutions of power based on these identities (2022).
Socially Engineered Trauma (SET) refers to the “traumatic events rooted in the forces of oppression and inequality,” and it is the manifestation of the “nonrandom distribution of trauma exposure within an unequal society” (Avruch & Shaida, 2022, p.3-4). In other words, socially engineered trauma is the result of systems of power that privilege some groups while disadvantaging others. I was recently told by one of my clients that he had experienced yet another gun battle outside his home. When I asked him if he had called the police, he reminded me “that might work in the neighborhood you live in. But when you have my skin color and live in this neighborhood, they won’t come and if they do it will take at least an hour.” This same person had previously shared with me stories of interactions with law enforcement that provide good evidence for his claim that law enforcement in his (largely black) neighborhood exists to police the community rather than to protect the community. These police practices take place within the setting of historical policies of redlining that created under resourced, isolated, and segregated neighborhoods.
The idea of a structurally competent approach can sometimes seem abstract or overwhelming – especially as you attempt to “do structural competence” in a one-on-one interaction. There have been several tools offered to support our understanding of how the structurally competent approach could be put into action. The social work profession has long held the Person in Environment approach to serving others (Richmond, 2017). Stern, Barbarin & Cassidy (2021) have provided us with an adaptation of the Bioecological Model applied to racial identity. Bourgois, Holmes, Sue & Quesada (2017) have created a Structural Vulnerability Tool. Liberation Psychology literature also offers tools related to stucutral competence such as the Triangulizing Model for assessing an issue in mental health (Kant, 2015). Most recently, Avruch & Shaia have presented the SHARP framework (2022).
The SHARP Framework was developed by Avruch & Shaia to incorporate the idea of addressing structurally engineered trauma in the context of a one-on-one helping interaction (2022). This framework is composed of 5 parts listed below.
Structural Oppression
Historical Context
Analysis of Role
Reciprocity and Mutuality
Power
Alegría M., NeMoyer A., Falgàs Bagué I., Wang Y., Alvarez K. (2018). Social Determinants of Mental Health: Where We Are and Where We Need to Go. Current Psychiatry, 20(11).
Ali, A., & Sichel, C. E. (2014). Structural Competency as a Framework for Training in Counseling Psychology. The Counseling Psychologist, 42(7), 901-918. https://doi.org/10.1177/0011000014550320
Avruch, DaD. & Shaia, W. (2022). Macro MI: Using Motivational Interviewing to Address Socially-engineered Trauma. Journal of Progressive Human Services, 33(2).
Avruch, D. (2022). Macro MI: Using Motivational Interviewing to Address Socially-engineered Trauma Presentation. Chicago: Motivational Interviewing Network of Trainers International Forum.
Ali, A., & Sichel, C. E. (2014). Structural Competency as a Framework for Training in Counseling Psychology. The Counseling Psychologist, 42(7), 901-918. https://doi.org/10.1177/0011000014550320
Beck, B (2008). Chapter 67 of Community Psychiatry. Editor(s): Stern, T., Rosenbaum, F., Fava, M., Biederman, J., Rauch, S., Massachusetts General Hospital Comprehensive Clinical Psychiatry. Pages 917-926
Bourgois, P., Holmes, S., Sue, K. & Quesada, J. (2017). Structural Vulnerability: Operationalizing the Concept to Address Health Disparities in Clinical Care. Academic Medicine 92(3):299-307.
Community Access to Recovery Services (CARS) (2022). CARS Quarterly Report. Milwaukee, WI: Behavioral Health Services. Retrieved from: https://county.milwaukee.gov/files/county/DHHS/BHD/CARS/Q3andQ42022.pdf
Gaztambide, D. J. (2019). Reconsidering culture, attachment, and inequality in the treatment of a Puerto Rican migrant: Toward structural competence in psychotherapy. Journal of Clinical Psychology, 75(11), 2022–2033. https://doi.org/10.1002/jclp.22861
Kant, J.D., (2015) Towards a socially just social work practice: the liberation health model. Critical and Racial Social Work, 3(2), 309-317.
Martinez, D.B. & Fleck-Henderson, A. (2014). Social Justice in Clinical Practice: A liberation health framework. NY: Routledge.
Neff J, Holmes SM, Knight KR, Strong S, Thompson-Lastad A, McGuinness C, Duncan L, Saxena N, Harvey MJ, Langford A, Carey-Simms KL, Minahan SN, Satterwhite S, Ruppel C, Lee S, Walkover L, De Avila J, Lewis B, Matthews J, Nelson N. (2020). Structural Competency: Curriculum for Medical Students, Residents, and Interprofessional Teams on the Structural Factors That Produce Health Disparities. MedEdPORTAL. 2020;16:10888. https://doi.org/10.15766/mep_2374-8265.10888
Richmond, M. (1917). Social Diagnosis. Russell Sage Foundation. Retrieved on 12/8/23 from: https://archive.org/details/socialdiagnosis00richiala
SAMHSA (2023). SAMHSA Releases New Data on Lesbian, Gay and Bisexual Behavioral Health. Rockville, MD: Substance Abuse and Mental Health Services Administration (SAMHSA). Retrieved from: https://www.samhsa.gov/newsroom/press-announcements/20230613/samhsa-releases-new-data-lesbian-gay-bisexual-behavioral-health
The Trevor Project (TTP) (2022). National Survey on LGBTQ Youth Mental Health Wisconsin. Retrieved from: https://www.thetrevorproject.org/wp-content/uploads/2022/12/The-Trevor-Project-2022-National-Survey-on-LGBTQ-Youth-Mental-Health-by-State-Wisconsin.pdf
Ward EC, Wiltshire JC, Detry MA, Brown RL (2013). African American men and women’s attitude toward mental illness, perceptions of stigma, and preferred coping behaviors. Nursing Research, 62(3):185-94
Jesse is a Licensed Clinical Social Worker (LCSW) with a focus on compassion, holistic mental health, and equity. He has over 15 years’ experience working with folks in community mental health settings. During his career as a community focused social worker, Jesse has served as a community support specialist, intake specialist, supervisor, manager, academic advisor, professor, trainer, and even executive director of a small nonprofit. Jesse has been trained and continues to grow in a variety of helping and therapy approaches. He is an active member of the Motivational Interviewing Network of Trainers (MINT), he is a Certified Self-Compassion in Psychotherapy (SCIP) therapist, and he is a candidate for Brainspotting (BSP) Certification. Jesse maintains the website www.intrinsicchange.com that features free learning resources for helpers, and he maintains an active blog Change Talk which provides in-depth discussion of compassion, equity, and other topics related to the helping professions. Jesse currently provides therapy to individuals in mental health and substance use recovery through Wisconsin Community Services (WCS) using brainspotting, motivational interviewing, and mindful self compassion. He regularly offers trainings in motivational interviewing, cultural humility, and mindful self-compassion to organizations in the Milwaukee area.
