The Critical Dialogue Cornerstone: Suggested Practices to Guide Implementation, Facilitation and Evaluation.

There has been an increased focus on utilizing critical consciousness-focused interventions to address complex, multidimensional socio-cultural problems, particularly health inequities. These interventions usually incorporate a critical dialogue component. However, there's little guidance on how to implement, facilitate and evaluate critical dialogue to develop critical consciousness (i.e., reflecting and acting on sociopolitical inequities). This conceptual paper: 1) introduces critical dialogue and the tools used to implement critical dialogue from the literature; 2) details the development of the Community Wise intervention to present how Community Wise incorporated a critical dialogue component; 3) provides a brief overview of a proposed framework of critical consciousness development that the critical dialogue component of Community Wise could support; 4) provides an anecdotal exploration of the critical dialogue sessions used in the first pilot test of the intervention through the proposed framework of Transformative Consciousness; and 5) suggests practice guidelines for group work that incorporates facilitated critical dialogue.

Work-in-progress: Focus groups evaluate and inform revisions of a socio-behavioral health intervention.

African American men and women are disproportionately impacted by HIV/STI risk. Particularly, African American women are more likely to be infected with HIV from heterosexual sex. Yet, much of the intervention research has focused on men who have sex with men. This article describes the development and feasibility study of a six-session socio-behavioral health intervention that utilized sociodrama to reduce substance use and HIV/STI risk among heterosexual, African American men and women who have multiple sex partners. The intervention was developed based on theories and models of critical consciousness, social scripts, and group work practice. Content and delivery were informed by qualitative data collection with a range of stakeholders including service providers and members of the target population. The resulting intervention was six group sessions, delivered by two licensed social workers, with one of the facilitators trained in sociodrama. The results of the qualitative study explored the feasibility of conducting this six-week intervention and evaluated a trial run of the intervention. The data was obtained through focus group interviews and observations. Findings revealed that the intervention could be delivered with fidelity and was acceptable to participants and indicated that the intervention's innovative components of sociodrama and critical consciousness resonated with the participants and has potential to reduce HIV/STI risk and substance use. Reported barriers and suggested revisions need to be examined further and addressed to develop and implement a sustainable program that can be delivered in community-based settings. A future randomized control trial of the revised intervention will evaluate the intervention's efficacy.

Linking critical consciousness and health: The utility of the critical reflection about social determinants of health scale (CR_SDH).

INTRODUCTION: Critical consciousness (CC) theory has been proposed as a framework to inform health interventions targeting a wide variety of health conditions. Unfortunately, methodological limitations have made it difficult to test CC as a mediator of health outcomes. Specifically, standardized and widely accepted measures of health-related CC are needed. The goal of this study was to develop and test a measure of critical reflection on social determinants of health (SDH). This measure focused on critical reflection, an essential dimension of CC. METHODS: Community-based participatory research principles and a mixed methods design were used with three samples: (1) experts in SDH and CC, (2) 502 individuals completing online surveys, and (3) 602 men with histories of substance use disorder and incarceration. All participants were over 18 years of age. Analysis included descriptive frequencies, exploratory factor analyses (EFA), confirmatory factor analysis (CFA), generalized linear regression models, correlations, and Cronbach's alpha calculations. RESULTS: The Critical Reflection about SDH scale (CR_SDH) is a short, unidimensional, and reliable scale (α = 0.914). Construct validity was supported and known-groups validity showed that the scale discriminated different levels of CR_SDH based on political views, educational level, knowledge of health inequities, and gender. CONCLUSION: The CR_SDH is a standardized measure that can assess critical reflection about the impact of SDH on health among providers and consumers of health care. The CR_SDH can be used to identify critical reflection related training needs and inform decisions about development and testing of critical reflection related health interventions and health care policy.

From Sculpting an Intervention to Healing in Action.

Blacks/African Americans have the most severe and disproportionate burden of HIV of all racial/ethnic groups in the United States. Oppression (i.e., socio-structural (macro), institutional (exo), community (meso), and interpersonal (micro)), operates as four interrelated prongs that perpetuate the HIV epidemic in Black/ African American communities. Oppressive (i.e., racist and sexist) cultural scripts transferred to individuals through community, family and interpersonal relationships may play a role in HIV/STI risk. However, socio-behavioral health interventions or behavioral risk reduction interventions have traditionally focused solely on individual-level health risk behaviors allowing invisible, inequitable socio-structural factors to continue unchallenged. A new intervention, Black Men and Women: Empowering Self, Relationships and Community, was sculpted from two existing interventions Community Wise and Men of African American Legacy Empowering Self (MAALES) to develop awareness of oppressive cultural scripts operating on interpersonal and intrapersonal levels and to take action against these oppressive messages to reclaim identity, restore relationships, and build community. This paper summarizes the theory and selected sociodramatic components of the intervention that promote healing in action to reduce HIV/STI risk among heterosexually identified, low-income African American men and women with multiple sex partners. Lessons learned in theory, research and practice are also discussed.

Transforming responses: Exploring the treatment of substance-using African American women.

This article explores how intrapersonal and structural oppression may impact treatment and the recovery process of 23 self-identified African American women with histories of incarceration and substance use. Using a critical consciousness (CC) framework and content-based thematic analysis, researchers systematically coded and extracted themes and patterns from focus group data to evaluate how marginalizing processes-such as race-based discrimination-impact treatment, the therapeutic relationship, and service provision. Results indicate that participants' health and treatment were negatively impacted by oppressive factors, specifically the oppressive process of silencing. The authors discuss research and practice implications.

Perceived Race as Variable: Moderating Relationship Between Perceived Discrimination in the Workplace and Mentally Unhealthy Days.

Since race is a social construct, the experience of racial discrimination occurs based on perceived race. This study explores the moderating effects of self-identified race and perceived racial identity on the relationship between perceived discrimination in the workplace and mentally unhealthy days using data derived from the four states (Arizona, Minnesota, Mississippi, and New Mexico) that responded to the 2014 Reactions to Race module of the Behavioral Risk Factor Surveillance System. The study hypothesized that self-identified White people, also perceived as White (WW), would have less perceived workplace discrimination and less mentally unhealthy days than self-identified non-White people perceived as White (NWW); NWW would have less perceived discrimination associated with mentally unhealthy days than self-identified White perceived as non-White (WNW); and, WNW would have less perceived discrimination associated with mentally unhealthy days than self-identified non-White perceived as non-White (NWNW). The study was conducted under the regulating body of the City University of New York in 2017. Findings suggest that being perceived as White is a protective factor as analysis determined that NWW experienced less discrimination in the workplace associated with mentally unhealthy days than NWNW.

"That's not me anymore": Resistance strategies for managing intersectional stigmas for women with substance use and incarceration histories.

Significant previous research has focused on how individuals experience stigma when interacting with the public sphere and service agencies; the purpose of this grounded theory study is to explore how formerly incarcerated mothers with histories of substance use experience stigmas from their intimate relationships with family and romantic partners. Using an intersectionality lens, this study reveals that the women perceived multiple stigmas due to their previous substance use, incarceration, and other addiction-related behaviors that challenged their roles as mothers and romantic partners. Compounding the behavioral-related stigmas were race and class-based stereotypes of black criminality that also challenged women's ability to embody key motherhood and womanhood roles. As a result, the women employed resistance strategies to safeguard against stigma and preserve their recovery. The implications for practice underscore the significance of addressing personal experiences of stigma, complex relational dynamics, and understanding the needs of support systems that are also shaped by the women's cycles of incarceration and illness.

Transformative Consciousness of Health Inequities: Oppression is a Virus and Critical Consciousness is the Antidote.

Oppression has been identified as a fundamental cause of disease. Like a self-replicating virus, it infects systems from the biological to the political, contributing to personal (e.g., substance use, low self-esteem) and social (e.g., community violence, mass incarceration) dysfunction. Paulo Freire's critical consciousness (CC) is a philosophical, theoretical and practice-based framework that has been identified as an antidote to oppression. Critical consciousness constitutes an awareness of, and action against, institutional, historical, and systemic forces that limit or promote opportunities for certain groups. Although CC theory has been used to address inequity, very few scholars have attempted to conceptualize, operationalize and describe the development process of CC. In response to the conceptual inconsistencies widely noted in the CC literature, this paper presents a new construct, Transformative Consciousness (TC), composed of three domains: Awareness, Behavioral-Response, and Consequence, for each level of the socio-ecosystem. The staged process of TC development is also described. The theoretical framework of TC can be applied to various social issues, such as violence, mass incarceration, homelessness, HIV/STI infection, and substance use - all of which have tremendous implications for health and well-being as a human right. With further research, Transformative Consciousness may prove necessary to move persons in the direction of anti-oppressive, individual and collective action to overcome and dismantle oppression, creating a healthier and more just and liberated society.

The Opposition.

Although social workers have an ethical and professional mandate to address inequity, theoretical and treatment approaches usually fail to address historical and structural contexts. In opposition, radical social work bridges individual and community practice by acknowledging that macro forces have micro consequences; micro practices are reflective of macro socio-political processes; and, by opposing the socio-structural forces underlying individual problems. By adopting transformative, anti-oppressive frameworks and practices, radical social workers make visible the invisible social-ecological factors that hurt people, including institutionalized white privilege; transform systems to help individuals rather than helping individuals cope with oppressive systems by reinforcing marginalized roles in accordance with inferior treatment; and develop transformative potential in self and others.

Critical Consciousness: A Critique and Critical Analysis of the Literature.

The education system has been heralded as a tool of liberation and simultaneously critiqued as a tool of social control to maintain the oppressive status quo. Critical consciousness (CC), developed by the Brazilian educator, Paulo Freire, advanced an educational pedagogy to liberate the masses from systemic inequity maintained and perpetuated by process, practices and outcomes of interdependent systems and institutions. If people are not aware of inequity and do not act to constantly resist oppressive norms and ways of being, then the result is residual inequity in perpetuity. If inequity is likened to a disease or poison, then CC has been deemed the antidote to inequity and the prescription needed to break the cycle. As such, CC is a construct that has important scholarly, practice and policy implications. Scholars, noting the relevance and application of CC to current social problems, have advanced CC theory and practice. However, these innovative advancements have left fissures in the CC theoretical base in need of resolution and consensus to advance a collective and organized body of CC theory. This paper explores the divergent CC scholarship within CC theory and practice articles, provides an in-depth review of the inconsistencies, and suggests ideas to resolve the discrepancies from the literature to support the need for a new, CC-based construct, transformative potential. Without such a review, moving toward conceptual clarity, the lack of a coherent CC knowledgebase will impede the reflection and action needed to transform systems and institutions that maintain and perpetuate systemic inequity that have dehumanizing consequences. If implemented within urban education, theoretical models, grounded in CC theory, could help achieve a system of education that is just, equitable and liberating.

Using Technology to Facilitate Collaboration in Community-Based Participatory Research (CBPR).

This study explores the use of Computer-Supported Collaborative Work (CSCW) technologies, by way of a computer-based system called iCohere. This system was used to facilitate collaboration conducting Community-Based Participatory Research (CBPR). Data was gathered from 13 members of a Community Collaborative Board (CCB). Analysis revealed that iCohere served the following functions: facilitating communication, providing a depository for information and resource sharing, and allowing for remote meeting attendance. Results indicated that while iCohere was useful in performing these functions, less expensive technologies had the potential to achieve similar goals if properly implemented. Implications for future research on CSCW systems and CBPR are discussed.

Addressing the Health of Formerly Imprisoned Persons in a Distressed Neighborhood Through a Community Collaborative Board.

This article provides a case study evaluating the structure and dynamic process of a Community Collaborative Board that had the goal of creating an evidence-based substance abuse/health intervention for previously incarcerated individuals. Meeting agendas, attendance, minutes, video recording of meetings, and in-depth interviews with 13 Community Collaborative Board members were used to conduct an independent process evaluation. Open coding identified quotes exemplifying specific themes and/or patterns across answers related to the desired domain. Several themes were identified regarding membership engagement, retention, and power distribution. Results showed member retention was due to strong personal commitment to the targeted problem. Analysis also revealed an unequal power distribution based on participants' background. Nevertheless, the development of an innovative, community-based health intervention manual was accomplished. Aspects of the process, such as incentives, subcommittees, and trainings, enhanced the Board's ability to integrate the community and scientific knowledge to accomplish its research agenda. Community-based participatory research was a useful framework in enhancing quality and efficiency in the development of an innovative, substance abuse/health intervention manual for distressed communities. Overall, this article sheds light on a process that illustrates the integration of community-based and scientific knowledge to address the health, economic, and societal marginalization of low-income, minority communities.

Cognitive behavioral therapy: a meta-analysis of race and substance use outcomes.

Cognitive behavioral therapy (CBT) is an effective intervention for reducing substance use. However, because CBT trials have included predominantly White samples caution must be used when generalizing these effects to Blacks and Hispanics. This meta-analysis compared the impact of CBT in reducing substance use between studies with a predominantly non-Hispanic White sample (hereafter NHW studies) and studies with a predominantly Black and/or Hispanic sample (hereafter BH studies). From 322 manuscripts identified in the literature, 16 met criteria for inclusion. Effect sizes between CBT and comparison group at posttest had similar effects on substance abuse across NHW and BH studies. However, when comparing pre-posttest effect sizes from groups receiving CBT between NHW and BH studies, CBT's impact was significantly stronger in NHW studies. T-test comparisons indicated reduced retention/engagement in BH studies, albeit failing to reach statistical significance. Results highlight the need for further research testing CBT's impact on substance use among Blacks and Hispanics.

Community Wise: paving the way for empowerment in community reentry.

Theoretical approaches traditionally applied in mental health and criminal justice interventions fail to address the historical and structural context that partially explains health disparities. Community Wise was developed to address this gap. It is a 12week group intervention informed by Critical Consciousness Theory and designed to prevent substance abuse, related health risk behaviors, psychological distress, and reoffending among individuals with a history of incarceration and substance abuse. This paper reports findings from the first implementation and pilot evaluation of Community Wise in two community-based organizations. This pre-posttest evaluation pilot-tested Community Wise and used findings to improve the intervention. Twenty-six participants completed a phone and clinical screening, baseline, 6- and 12-week follow-ups, and a focus group at the end of the intervention. Measures assessed participants' demographic information, psychological distress, substance use, criminal offending, HIV risk behaviors, community cohesion, community support, civic engagement, critical consciousness, ethnic identification, group cohesion, client satisfaction, and acquired treatment skills. Research methods were found to be feasible and useful in assessing the intervention. Results indicated that while Community Wise is a promising intervention, several changes need to be made in order to enhance the intervention. Community Wise is a new approach where oppressed individuals join in critical dialogue, tap into existing community resources, and devise, implement and evaluate their own community solutions to structural barriers.

Community Wise: Development of a Model to Address Oppression in Order to Promote Individual and Community Health.

Communities with histories of oppression have shown great resilience. Yet few health interventions focus on structural oppression as a contributor to health problems in these communities. This paper describes the development and active ingredients of Community Wise, a unique behavioral-health intervention designed to reduce substance use frequency, related health risk behaviors, and recidivism among individuals with a history of incarceration and substance abuse residing in distressed and predominantly African American communities. Community Wise, developed through the collaborative efforts of a board of service providers, researchers, consumers, and government officials, is a 12-week group intervention that aims to address behavioral-health problems by raising critical consciousness in distressed communities.