Bridges Out of Poverty.

Bridges Out of Poverty

The Bridges work is intended to be used at all of these levels: individual, institution, community, and policy. We call these the four lenses through which you can view and use the Bridges information as represented in the Community Sustainability Grid, Appendix H (and discussed on pp. 28–30) in Facilitator Notes for Getting Ahead in a Just-Gettin'-By World (DeVol, 2006). There are two objectives with the mental model on this page. The first is to have every participant view the material in all four ways. Every participant will have their “favorite” lens or way that they like to view the material. For example, some of us spend 98% of our job working with individuals, so when we go to training or receive new information like the Bridges material we are asking, “Now, how do I use this information when I am working directly with a person?” The Bridges individual track will give you specific tools that will assist you with this level. As a person gets promoted, their “favorite” lens often changes to the institution lens. Now when we receive new information we are not thinking about how we use this at an individual level but rather how do we use this to change the way our program is set up, to adjust how our institution operates. The institution track will give you concrete methods and ideas of how to use the Bridges information at this level. Still, some of us consider ourselves community advocates, and we want to know how we use this information at a community level. There are communities throughout the country and in other countries using the Bridges information. The community track will give examples and ideas of how to use this at a community level. If we use the Bridges material at the individual, institution, and community level, then often Policies begin to change. Policies include policies that run your program all the way up to the federal policies (program, institution, city, county, state, and federal are all included in policies). This is why it is a large arch over the other three. Copyright J. Pfarr Consulting. Reproduced with permission.

The Bridges Lens: Definition of Poverty
POVERTY: The extent to which an individual does without resources.

MODULE ONE MENTAL MODELS OF ECONOMIC CLASS OBJECTIVES Individual Lens
Explore the concrete experience of people in generational poverty. Create a mental model of poverty. Analyze elements of the model. Create a mental model of middle class. Understand the interlocking nature of the models and the demands of the environment. This module was originally designed for the Getting Ahead in a Just-Gettin’-By World group curriculum developed by Philip DeVol. The workbook curriculum is designed to allow adults in generational poverty to co-investigate the Bridges information, analyze their personal resources and those of the community, and create personal and community plans for building resources to achieve economic and other stability. It’s important to establish an accurate mental model of what poverty is like in your community. When we say “generational poverty,” if there are 50 of us, there are about 50 different mental models or paradigms of what that really looks like. This activity will lead us to more of a common understanding of what it is like for individuals and families in poverty, especially where resources are low. This module uses a co-investigative process, not a “telling” approach. Individual Lens

FYI: Use of Accurate Models
Bridges is not a program Bridges is a “lens” The lens defines economic class environments The mental models include poverty, middle class, and wealth Interventions do not work when models are inaccurate Other than the workgroup curriculum, “Getting Ahead in a Just-Gettin’-By World,“ by Philip DeVol (which is used with in a resource-building continuum with groups of individuals at some level of poverty), there is no “curriculum” for Bridges. Bridges is a set of principles, constructs, and strategies about addressing paradigms of economic class held by individuals, institutions, communities, and policy makers. Bridges Out of Poverty seeks to expand diversity programs to include specifics on economic class within environmental and collective efficacy. The Bridges lens is a common set of language and mental models that reflects the literature of poverty from a wide array of sources. The principles of Bridges Out of Poverty are reflected in the Bridges Constructs. See the Hard Differentiators in the manual for this module to identify what makes Bridges different from other models. The purpose of Bridges to Health and Healthcare is to expand understanding of the power of economic class environments on individual health behaviors, health outcomes, and health services designs.

At your table build a mental model of POVERTY How is time spent
At your table build a mental model of POVERTY How is time spent? What organizations are you involved in? How do you recreate? Where do you live? What businesses are near you? What is most important? Learning Exercise

At your table build a mental model of MIDDLE CLASS How is time spent
At your table build a mental model of MIDDLE CLASS How is time spent? What organizations are you involved in? How do you recreate? Where do you live? What businesses are near you? What is most important? Learning Exercise

Mental Model for Poverty
SCHOOLS POLICE SOCIAL SERVICES RELIGIOUS ORGANIZATIONS With this slide we expand our examination of the environment to include businesses and other community organizations. Have the group think about the relationship between people in poverty neighborhoods and the police, schools, etc. Is that the same as it is for middle class people? Analyze the model for stability, safety, and interactions with the dominant culture. Mental illness and chemical dependency exist in each class. The amount of time spent on them is dependent on resources. ANCHOR: If you think of a “pocket of poverty” in your community, you will often see certain organizations, services, and businesses. Are these present in your community? In order to understand poverty, we must also address the larger elements that coexist with poverty in our communities. Developed by Phil DeVol Businesses Pawn shop Liquor store Corner store Rent-to-own Laundromat Fast food Check cashing Temp services Used car lots Dollar store

Mental Model for Middle Class
SCHOOLS POLICE SOCIAL SERVICES RELIGIOUS ORGANIZATIONS Developed by Phil DeVol This slide continues the investigation into the middle class environment. The mental models of class show us where the hidden rules come from. Mental illness and chemical dependency exist in each class. The amount of time spent on them is dependent on resources. Businesses Shopping/strip malls Bookstores Banks Fitness centers Veterinary clinics Office complexes Coffee shops Restaurants/bars Golf courses

Mental Model for Wealth
This applies to the wealthiest 1% of households in the United States—those with a net worth of $7.8 million or more. This mental model is provided so that the audience can see where the hidden rules of class, including the wealthy class, come from. Analyze this mental model for stability, time horizon, problem-solving strategies, and power. The environment of poverty is unstable, so people have to focus on solving immediate, concrete problems. The environment of middle class is more stable; because people have today covered, they worry about the future and focus on planning. The environment of wealth is so stable that people don’t worry about today or tomorrow; they can make decisions based on family traditions. The time horizon in poverty is the present. The time horizon in middle class is 2–4 years; people can make plans 2–4 years in advance and reasonably expect to see them through. The time horizon in wealth is two decades. People in poverty have personal power, strength, and fighting ability, but they may not have the power to stop bad things from happening in the neighborhood or community. People in middle class have the power of the institutions because the institutions are run on middle class rules and norms. People in wealth have the power to influence and shape policy and the direction of the community. Mental illness and chemical dependency exist in each class. The amount of time spent on them is dependent on resources. REINFORCEMENT: These concepts will appear in the hidden rules and again in the module on poverty research. Our point is that to create sustainable communities, we must have all three classes at the table. It helps greatly if we understand one another’s environments and hidden rules. Developed by Ruby Payne

For a dialogue to occur, we must suspend our mental models.
Are internal pictures of how the world works Exist below awareness Are theories-in-use, often unexamined Determine how we act Can help or interfere with learning ADD: Introducing mental models as paradigms or “mindsets” allows participants to think about their own mental models of poverty and other economic classes. The mental models we carry may be below the surface. ANCHOR: How many of you have a family member who grew up in the Great Depression? What behaviors did they learn from that experience? Did they pass that learning along? What is the message or mental model of poverty from the Depression? How many of us could say, “Okay, Grandma, we’ve got enough rubber bands now!” because there was a sense of needing to save, to conserve during the Depression? How many of us have never bought a rubber band in our lives because we were taught to save each and every rubber band that crosses our path? The paradigm or mental model is passed along. Other mental models of poverty spring out of the experience of slavery and the African-American experience, the Native American experience, the immigrant experience, and many more. What mental models of poverty did you discuss at your table? REINFORCEMENT: Educators know that new learning is often anchored to what we already know. But authors and thinkers like Peter Senge suggest that at times our mental models actually impede new learning because we cannot let go of what is below the surface. We bounce new learning off our mental models. The new learning won’t stick! Suspending our mental models for a time (let them float in the air above your head) allows us to listen to one another and co-investigate new ideas. For a dialogue to occur, we must suspend our mental models. Source: The Fifth Discipline Fieldbook by Peter Senge.

MODULE TWO RESEARCH CONTINUUM OBJECTIVES Individual Lens
Understand the causes of poverty in order to build resources. Understand what is needed to build a sustainable community. Individual Lens

What might someone be in poverty?

Poverty – Caused By: Generational – Situational – Absence of Resources
(Key Points page 7 #4) Caused By: Explain that we all carry our own mental models based on our own life’s experiences. We must let go of what we THINK we know and learn what the truth really is as how people of poverty experience life. Absence of Resources Political/Economical Wrong Choices Exploitation

CAUSES OF POVERTY—RESEARCH CONTINUUM
INDIVIDUAL BEHAVIORS AND CIRCUMSTANCES COMMUNITY CONDITIONS EXPLOITATION POLITICAL/ECONOMIC STRUCTURES Definition: Research on the choices, behaviors, and circumstances of people in poverty Definition: Research on resources and human and social capital in the city or county Definition: Research on the impact of exploitation on individuals and communities Definition: Research on political, economic, and social policies and systems at the organizational, city/county, state, national, and international levels Sample topics: ~ Racism ~ Discrimination by age, gender, disability, race, sexual identity ~ Bad loans ~ Credit card debt ~ Lack of savings ~ Skill sets ~ Dropping out ~ Lack of education ~ Alcoholism ~ Job loss ~ Teen pregnancies ~ Early language experience ~ Street crime ~ Dependency ~ Work ethic ~ Lack of organizational skills ~ Layoffs ~ Middle class flight ~ Plant closings ~ Underfunded schools ~ Weak safety net ~ Criminalizing poverty ~ Charity that leads to dependency ~ Brain drain ~ City and regional planning ~ Mix of employment/wage opportunities ~ Loss of access to high-quality schools, childcare, and preschool ~ Downward pressure on wages ~ Payday lenders ~ Lease/purchase outlets ~ Subprime mortgages ~ Sweatshops ~ Human trafficking ~ Employment and labor law violations ~ Wage and benefits theft ~ Some landlords ~ Sex trade ~ Internet scams ~ Drug trade ~ Poverty premium (the poor pay more for goods and services) ~ Day labor ~ Return on political investment (ROPI) ~ Bursting “bubbles” ~ Free trade agreements ~ Lack of wealth-creating mechanisms ~ Stagnant wages ~ Insecure pensions ~ Deindustrialization ~ Increased productivity ~ Minimum wage, living wage, self-sufficient wage ~ Globalization ~ Declining middle class ~ Decline in unions ~ Taxation patterns Source: Getting Ahead in a Just-Getting’-By World Workbook Revised Edition by Philip E. DeVol (2013).

What are the housing costs in your community?
Item Grand Junction National avg. Home Price $204,700 $184,700.00 Avg. Mortgage Payment $1,467.50 $1,202.44 Apartment Rent (1 bed) $867 $949.00

Housing Nationally there are only 30 units affordable and available for every 100 extremely low income households. Federal Assistance serves only ¼ of those who qualify. National Low Income Housing Coalition Resource Libray 70% of people in poverty spent over 50% of their income on housing Safety is a factor QUOTE: There are no boundaries in generational poverty. Everybody knows about sex because there are no secrets. There are no boundaries about space. Picture of a family in Lamar. Living room serves as a sitting room in day and bed room at night. Pic of tub is their only “Shower” in the Martinez home in Lamar. Pictures: Think “If one has a cold – what is going to happen to the rest?” Look at the boys – are they happy? GJ Home from Denver Post = 27 people living in house and RV in yard. Includes 13 children. Lay offs from Energy Company. Middle Class = Avg 4 in 1 residence “Where are you living?” Implies Stability Dec 29, 2009 – Denver post.com - Childhood Poverty in CO

Colorado Monthly Rent Affordable to Selected Income with Two-Bedroom FMR example In Colorado, the Fair Market Rent (FMR) for a two-bedroom apartment is $916. In order to afford this level of rent and utilities – without paying more than 30% of income on housing – a household must earn $3,052 monthly or $36,623 annually. Assuming a 40-hour work week, 52 weeks per year, this level of income translates into a Housing Wage of: $17.61 In Colorado, a minimum wage worker earns an hourly wage of $8.00. In order to afford the FMR for a two-bedroom apartment, a minimum wage earner must work 88 hours per week, 52 weeks per year. Or a household must include 2.2 minimum wage earners working 40 hours per week year-round in order to make the two-bedroom FMR affordable. In Colorado, the estimated mean (average) wage for a renter is $ In order to afford the FMR for a two-bedroom apartment at this wage, a renter must work 47 hours per week, 52 weeks per year. Or, working 40 hours per week year-round, a household must include 1.2 workers earning the mean renter wage in order to make the two-bedroom Source:

What is the Living Wage in your County?
Grand Junction Adult - $10.20 minimum - $11.27 livable (?) Adult w/ 1 child - $24.75 Adult w/ 2 children - $28.77 Explain that we all carry our own mental models based on our own life’s experiences. We must let go of what we THINK we know and learn what the truth really is as how people of poverty experience life. $11.27 x 40hr = $ x 52 weeks = $23, % is $7032.3/12 = $586 affordable rent $16 x 40 = $640 x52 weeks = $33,280 30% is $9984/12 = $832 affordable rent

Research: Income, Race, and Health
Talk to your neighbors about how you have seen the health inequities linked to income and race. How do these inequities show up and impact the quality of work that you are called to do? Learning Exercise Take only a few minutes for this. Write as many as you can on a flip chart or have each group write an example on a sticky note and save them for a later discussion while mentioning/reading a few of them. Ask participants if race or income seems to matter equally.

Healthcare Research Areas
ACCESS AVAILABILITY COST QUALITY EFFICACY COMMUNICATION DEFINITION Ability to engage with a healthcare provider, system, resource Conditions and timeframe in which care can be received or allowed Actual cost, price charged, and amount paid for services offered or provided Extent to which services provided actually improve health outcomes Capacity to produce desired or optimal health outcome at the individual, institutional, community, and policy levels Verbal and nonverbal tools for reciprocal shared meaning and communication that positively impact health outcomes EXAMPLES Public transportation Insurance type Insurance co-pay Provider types, number, and location Appointment access Provider/agency policies Contact information Medication types Specialty care options Provider types, numbers, mix Hours of operation Location of providers Continuity of care Fragmentation in delivery system Payer source Insurance Reimbursement models Types of medication and cost Billing processes coding Legal/regulatory requirements Paperwork costs Non-coverage of complementary and alternative medicine Standards of practice Suboptimal management plans Knowledge of plans Level of continuity of delivery system Level of fragmentation of delivery system Knowledge bases and experience of providers’ staff Competitions among health systems Wraparound case management services Appropriate materials and expectations Individual resource analysis, 9 resources—financial, emotional, mental, spiritual, physical, support systems, relationships/role models, knowledge of hidden rules, formal register Community resource analysis Outcomes and disparities by subgroup (race, class, gender) Social cohesion (everyone represented) Social coherence (does it make sense?) Patient compliance Readmissions Change Model Hidden rules Formal register Abstract representational systems Impact of poverty on planning, thinking, and allostatic load Information gathering from story (plot versus character) Mental models for communication Role of one-on-one relationships in compliance Role of nonverbals in survival environment Quality care is achieved through the collective effort of those who train practitioners, institutions who serve the community, and communities willing to participate as informants in the services that they desire to create for the maintenance of a healthy community. The work that we do here today, while inviting participants from all three tables (and possibly some who make institutional or legislative policy), is focused on learning to enable, enrich, and enhance the effectiveness of outcomes and the costs of effort.

Population Health Disparities
Inequities in Health Two Bodies of Research At this point: Define population health as health inequities caused by larger influences that impact groups of people, and thereby, individuals. Define healthcare disparities as inequities in patient care at the individual level, thought to be linked to at risk populations. Formal definition is later in this module. Population Health Disparities Healthcare Disparities

Health Disparities Research Linked to Health Outcomes
Lower economic status Lower social status associated with racial/ethnic discrimination Individuals employed in stressful working conditions with low hierarchy and decision-making capacity Health disparities research focuses on how living conditions and environments influence health outcomes for groups with lower hierarchy: More specifically: How a person develops during the first few years of life (early-childhood development) How much education a person obtains Being able to get and keep a job What kind of work a person does Having food or being able to get food (food security) Having access to health services and the quality of those services Housing status How much money a person earns Discrimination and social support Access to healthcare

Population Health Disparities
Health disparities research focuses on how living conditions and environments influence health outcomes for groups with lower hierarchy.

What We Know POVERTY TAXES THE BRAIN Emily Badger writes:
“Poverty imposes such a massive cognitive load on the poor that they have little bandwidth … a mental burden akin to losing 13 IQ points … Coping not just with a shortfall of money, but also with a concurrent shortfall of cognitive resources.” How to frame this slide for your audience: Impact of lack of nutrition, homelessness, stress of poverty, etc. Often in healthcare—as in any service offered to the poor—we are tempted to confuse slow thinking (seemingly ‘flat’ affect or lack of responsiveness) with laziness or apathy. Could there be another possibility? Source: Based on a study by Shafir, Mani, Mullainathan, and Zhao. Reported by Emily Badger in Urban Work, 8/29/13. /6716/

Poverty and the Developing Brain: Insights from Neuro-imaging
Poverty is a significant social problem, affecting how individuals live and the resources available to them. For children, poverty represents a chronically suboptimal developmental environment as much as it reflects a state of economic stress. Brain imaging has contributed to the understanding of economic disparity by identifying changes in the brain’s structure and function associated with poverty. Due to the plasticity of neural pathways, some of the effects of poverty on the brain may be reversible. Noninvasive imaging of the developing human brain enables the testing of hypotheses about links between economic disadvantage and neural development. Neuroimaging techniques permit the noninvasive investigation of human brain development in adverse conditions such as poverty. Empirical research investigating the neural correlates of income disparity will continue to enable design of targeted interventions to prevent and ameliorate the effects of childhood poverty. Growing up in a low income household is associated with dietary and nutritional deficiencies, maternal malnutrition, environmental toxins, and insufficient early sensory stimulation (3,4,5). These differences may contribute to the achievement gap observed in academics and cognitive skills in low income and middle class children (6,7). Compared to children from middle class families, low income children are three times as likely to experience developmental delays. Living in poverty is associated with poorer overall physical health, and low income youths are also at higher risk of developing mental disorders affecting attention, anxiety, and mood (3,4,5). Socioeconomic status (SES) represents a combination of economic resources, as well as social aspects such as occupational prestige and social status (2,8). SES measurements typically include a combination of education, income, and occupation (9). Low SES families lack access to a wide range of resources to promote and support young children’s health and education, as well as resources. Source: Sheeva Azma, Synesis: A Journal of Science, Technology, Ethics, and Policy, 2013; 4: G40-46.

What We Know Costs of health and healthcare are increasing annually
The majority of baby boomers will be on Medicare by 2020 Health is directly related to education and socioeconomic status Lack of resources reduces individual, institutional, and community collective efficacy We know these things based on research. Please see your book and the Lesson Plan Grid for Sources. We know disparities exist based on socioeconomic status. The actions that contribute to these disparities can be found at the individual, institutional, community, and policy levels in varying degrees. At any level, things that may seem appropriate, when not considered within a global context, can result in unintended consequences. Case managers can give multiple examples about how one positive action—such as a 25-cent-per-hour raise, can make an individual ineligible for certain benefits, such as childcare, which actually supported the individual to keep a job. Trainers may also wish to use community-specific data.

What We Know POVERTY AND DEATH From Debra Watson:
A research team from Columbia University’s Mailman School of Public Health in New York City has estimated that 875,000 deaths in the U.S. in 2000 could be attributed to a cluster of social factors bound up with poverty and income inequality.… According to U.S. government statistics, some 2.45 million Americans died in Thus, the researcher’s estimate means that social deprivation was responsible for some 36 percent of total U.S. deaths that year, a staggering total. Watson quotes Dr. Galea, chair of Mailman’s Department of Epidemiology, as saying, “If you say that 291,000 deaths are due to poverty and income inequality, then those things matter, too.” These excess deaths represent a huge potential loss of intellectual, financial, and human social capital. Source: The dramatic effect of poverty on death rates in the U.S., Debra Watson, 7/13/2011

MODULE THREE BRIDGES CONSTRUCTS OBJECTIVE Individual Lens
Establish key concepts that underlie Bridges Out of Poverty and aha! Process knowledge. This module can be done in detail, taking hours, or it can be done very quickly, but it must be done. Key points and Bridges constructs that are unclear to audience members likely can be explained by their neighbor. It’s a good idea to focus on key points and Bridges constructs that have particular value to your audience. Option: Weave these constructs into your presentation and draw the attention of the audience to them as you go. For example: The first construct about using “the lens of economic class to understand … of others” can be illustrated while doing the mental models of class in Module 1, Section 2. It can be illustrated again in Section 2 of Module 4 (hidden rules) and Module 6 (resources), etc. Individual Lens

BRIDGES CONSTRUCTS Use the lens of economic class to understand and take responsibility for your own societal experience while being open to the experiences of others. At the intersections of poverty with other social disparities (racial, gender, physical ability, age, etc.), address inequalities in access to resources. Define poverty as the extent to which a person, institution, or community does without resources. Build relationships of mutual respect. Base plans on the premise that people in all classes, sectors, and political persuasions are problem solvers and need to be at the decision making table. Source: Bridges Out of Poverty Training Supplement, p. 25

BRIDGES CONSTRUCTS (continued)
Base plans on accurate mental models of poverty, middle class, and wealth. At the individual, institutional, and community/policy levels: Stabilize the environment, remove barriers to transition, and build resources. Address all causes of poverty (four areas of research). Build long-term support for individual, institutional, and community/policy transition. Build economically sustainable communities in which everyone can live well. Source: Bridges Out of Poverty Training Supplement, p. 25

Bridges Constructs Use the lens of economic class to understand and take responsibility for your own societal experience while being open to the experiences of others. Address inequalities in access to resources at the intersection of poverty with other social disparities (racial, gender, physical disability, etc.). Define poverty as the extent to which a person, institution, or community does without resources. Build relationships of mutual respect. Base plans on the premise that people in all classes, sectors, and political persuasions are problem solvers and need to be at the decision-making table. Application: Use the 10 constructs to test if programs and initiatives are truly “Bridges.”

Bridges Constructs (continued)
Base plans on accurate mental models of poverty, middle class, and wealth. Stabilize the environment, remove barriers to transition, and build resources at the individual, institutional, and community/policy levels. Address all causes of poverty (four areas of research). Note: BTHH uses six areas of research. Build long-term support for individual, institutional, and community/policy transition. Build sustainable communities in which everyone can live well. Read the paper “Introducing the Bridges Community of Practice Model: Supporting Innovation and Expansion of Bridges Out of Poverty Concepts,” developed by Jodi Pfarr, Terie Dreussi-Smith, and Philip DeVol.

BREAK TIME!!!

MODULE FOUR HIDDEN RULES OBJECTIVE Individual Lens
Understand and give examples of the hidden rules of the three economic class environments. Hidden rules are the unspoken cues and habits of a group. The hidden rules come from the environment in which one was raised or lives. Let’s go back to the mental models of poverty, middle class, and wealth. As noted above, hidden rules come from those environments. This reinforces the previous information and strengthens the hidden rule construct. Children will learn the rules of survival of their environment simply by breathing. No flip-chart lessons from Mom are needed. Hidden rules are easily broken because they are hidden. You know you’ve broken a rule when there’s an awkward silence, or perhaps you get “the look”—the look that says, “The wheel’s still spinning, but the hamster’s dead,” or the look you have when you see something moving in a wastebasket. We don’t criticize the rules of other classes because those rules are used for survival. (1) Hidden rules help people navigate different and difficult situations; (2) using them skillfully can help us build resources; (3) knowing them means we can design programs more skillfully and respectfully; (4) hidden rules can be used to resolve conflicts; (5) we can understand our own behaviors and values better; (6) we can understand the behaviors and points of view of others; and (7) knowing the hidden rules of all classes can help people in poverty gain power and influence—and move out of poverty if they so choose. The big problem with hidden rules is that they're seldom articulated. But, more importantly, they're equated with intelligence—or a lack thereof. Individual Lens

Could You Survive Quiz

Hidden Rules Situated-learning environments Are unspoken cues and habit of a group—are learned collectively Become deep rooted expectations Can be learned in new environments too Are critical to transitioning along the continuum from poverty to wealth Impact relationships (social capital) Impact health behaviors Refer to the chart of Hidden Rules Among Classes. And more importantly, in Health and Healthcare, they can spell the difference between creating or mitigating perceptions that influence service quality.

HIDDEN RULES OF CLASS Poverty Middle Class Wealth POSSESSIONS People. Things. One-of-a-kind objects, legacies, pedigrees. MONEY To be used, spent. To be managed. To be conserved, invested. PERSONALITY Is for entertainment. Sense of humor is highly valued. Is for acquisition and stability. Achievement is highly valued. Is for connections. Financial, political, social connections are highly valued. SOCIAL EMPHASIS Social inclusion of the people they like. Emphasis is on self-governance and self-sufficiency. Emphasis is on social exclusion. FOOD Key question: Did you have enough? Quantity important. Key question: Did you like it? Quality important. Key question: Was it presented well? Presentation important. CLOTHING Clothing valued for individual style and expression of personality. Clothing valued for its quality and acceptance into norm of middle class. Label important. Clothing valued for its artistic sense and expression. Designer important. TIME Present most important. Decisions made for moment based on feelings or survival. Future most important. Decisions made against future ramifications. Traditions and history most important. Decisions made partially on basis of tradition and decorum. EDUCATION Valued and revered as abstract but not as reality. Crucial for climbing success ladder and making money. Necessary tradition for making and maintaining connections. DESTINY Believes in fate. Cannot do much to mitigate chance. Believes in choice. Can change future with good choices now. Noblesse oblige. LANGUAGE Casual register. Language is about survival. Formal register. Language is about negotiation. Formal register. Language is about networking. HOUSEHOLD DYNAMICS Tends to be matriarchal. Tends to be patriarchal. Depends on who has money. WORLDVIEW Sees world in terms of local setting. Sees world in terms of national setting. Sees world in terms of international view. LOVE Love and acceptance conditional, based upon whether individual is liked. Love and acceptance conditional and based largely upon achievement. Love and acceptance conditional and related to social standing and connections. DRIVING FORCES Survival, relationships, entertainment. Work, achievement. Financial, political, social connections. HUMOR About people and sex. About situations. About social faux pas. Excerpted from Bridges Out of Poverty by Ruby Payne, Philip DeVol, and Terie Dreussi-Smith.

WHAT CAN YOU DO IN THE WORK AND AGENCY SETTING?
Hidden Rules Understand the hidden rules of your work/agency setting. Understand the hidden rules that customers and employees bring with them. Ensure that programs are not based on one set of hidden rules. Don’t try to discuss or reframe hidden rules unless there is a relationship of mutual respect. Use the understanding of hidden rules to create relationships of mutual respect. Hidden rules are best presented as a choice rather than a matter of identity. The more rules one knows, the more games one can play. The hidden rules can’t and shouldn’t be used to predict another person’s behavior or make assumptions about them. People tend to use (or have) rules from different classes. Knowing the hidden rules means you won’t be surprised by the rules people use. The wider the range of your responses, the more control you have over your situation—and the more opportunities become open to you. Institutional Lens

Review Health & Health Care Checklists
Page 52 BTHH

PBS Special PEOPLE LIKE US Do you see: Hidden Rules Language
Tammy Crabbtree - Matt Heid Waverly, Ohio Do you see: Hidden Rules Language Family Structure Resources Future Story Support for Transistion 2. What tools could you use to help? As you are listening to the story, what are some of the things you learned today that you see in the story? How can you use the tools you learned to make a difference? 4 children Small Ohio Town Son Matt attempting to rise to middle class Look for: Language “EH” Casual Relationship w/son based on need – little ones at home Don’t assume the marks on the neck are hickies. They could be twisties, a form of discipline. Possession/control Future story is limited – Never be Harvard/Identity Treatment from outside world – Won’t talk to her at work/ White Bitch Determination/Pride All I need is a little help. My dad worked. Hickies vs twisty marks from disciple. Hidden Rules Language Family Structure Resources Future Stories Support for Transition

Tammy’s Story Part 1

Tammy’s story part 2

LUNCH TIME!!!

MODULE FIVE LANGUAGE OBJECTIVES Individual Lens
Distinguish the different registers of language and assist people in the development of the formal register. Understand how language register, story structure, and language experience influence cognitive development. Our use of language can influence heavily how we are perceived, thus influencing our relationships with others. Knowing the registers of language, discourse patterns, and story structures can allow us to understand ourselves and others. This is crucial when developing relationships. Knowing the research on language experience by economic class can allow us to better understand the importance of language in a child’s cognitive development. This information is linked to future modules. Individual Lens

REGISTERS OF LANGUAGE REGISTER EXPLANATION FROZEN
Language that is always the same. For example: Lord’s Prayer, wedding vows, etc. FORMAL The standard sentence syntax and word choice of work and school. Has complete sentences and specific word choice. CONSULTATIVE Formal register when used in conversation. Discourse pattern not quite as direct as formal register. CASUAL Language between friends and is characterized by a 400- to 800-word vocabulary. Word choice general and not specific. Conversation dependent upon nonverbal assists. Sentence syntax often incomplete. INTIMATE Language between lovers or twins. Language of sexual harassment. The formal register of language is used to negotiate in organizations, businesses, courts, medical facilities, and schools. All registers have power. Speak formal register in a poverty neighborhood, and you will likely be in trouble. Formal register does not have power in that situation. Our organizations can use mental models, high-frequency words, videos, and stories to communicate. The first thing when someone enters our office: “Fill out the paperwork.” Using the formal register to negotiate nurtures one’s ability to think abstractly, to hold concepts inside the head. Middle class is all about paper. People in generational poverty tend to use the casual register of language to survive. Casual is more accurate for reading someone’s intent. In poverty, several people live in that house, so you have to know when it’s safe and when a fight is going to take place. That’s one reason for being able to read someone’s intent. In poverty, you must attend to sights and sounds to survive. In poverty, your world is often about processing the external environment. Because you are processing the external environment in poverty, nonverbals become crucial, and you become an expert at reading them. The language you have access to is often about survival. Thus often one will process more heavily in the concrete. Also, paper doesn’t have much value. Middle class sounds noisy to those in casual register. The key is to honor the register someone brings with them and yet also build bridges to formal register. Communication problems create an imbalance of power. It’s only when the balance of power is relatively equal that candid communication can take place. Adapted from work of Martin Joos

What the Data Show There is disparity in patient care between lower hierarchy groups and greater hierarchy groups Disparity is not necessarily associated with insurance or access Disparities are more likely associated with human interactions in healthcare settings This is also the case when the study cohorts included insured patients. The correlation is significant and not entirely due to insurance and access. This research suggests that healthcare disparities are more likely associated with human interactions in healthcare settings, rather than insurance or access.

How the patient perceives the staff is equally powerful.
Human Interactions How a patient is perceived— the perceptual lens of the clinic staff and the healthcare institution— influences the treatment the patient experiences. How the patient perceives the staff is equally powerful. THIS SLIDE CAN BE FOLLOWED BY CASE STUDY #2: It’s Only Human Interactions—Bill See Case Study Bank. Diagnosis and Treatment Race and ethnicity influence a patient's chance of receiving many specific procedures and treatments. Of nine hospital procedures investigated in one study, five were significantly less common among African American patients than among white patients; three of those five were also less common among Hispanics, and two were less common among Asian-Americans. Other AHRQ-supported studies have revealed additional disparities in patient care for various conditions and care settings including: Heart disease—African Americans are 13 percent less likely to undergo coronary angioplasty and one-third less likely to undergo bypass surgery than are whites. Asthma—Among preschool children hospitalized for asthma, only 7 percent of African-Americans and 2 percent of Hispanic children, compared with 21 percent of white children, are prescribed routine medications to prevent future asthma-related hospitalizations. Breast cancer—The length of time between an abnormal screening mammogram and the follow-up diagnostic test to determine whether a woman has breast cancer is more than twice as long in Asian-American, African-American, and Hispanic women as in white women. Human immunodeficiency virus (HIV) infection—African Americans with HIV infection are less likely to be on antiretroviral therapy, less likely to receive prophylaxis for Pneumocystis pneumonia, and less likely to be receiving protease inhibitors than other persons with HIV. An HIV infection data coordinating center, now under development, will allow researchers to compare contemporary data on HIV care to examine whether disparities in care among groups are being addressed and to identify any new patterns in treatment that arise. Nursing home care—Asian American, Hispanic, and African American residents of nursing homes are all far less likely than white residents to have sensory and communication aids, such as glasses and hearing aids. A new study of nursing home care is developing measures of disparities in this care setting and their relationship to quality of care. Identifying that disparities in care exist is important, but it is not enough. Now,—researchers are—beginning to focus on why these disparities exist, which disparities actually indicate poor-quality care, and how to develop strategies to address them.

Point of View in NICU “If the mother appears to be at least middle-class and is—it is assumed that “something happened” and that the mother had completed appropriate perinatal preventive treatment, did not smoke, drink, use drugs, or make other poor decisions that compromised the pregnancy. … There was a different discussion about the mother who appears to be from poverty. There was likely to be less generosity in assigning good choices to the mother and family. Staff tended to assume that this mother smoked or drank during the pregnancy.” Was this healthcare provider accurate in her perceptions about the different ways some staff members reacted to the economic class of the patient? Ask your audience to talk at their tables. What sorts of things are said about patients based on observations by clinical or other staff? Does the reaction range from pity to disdain? Might there be a connection between the way one perceives a patient and the care that patient is given—or not given? It is the premise of the authors of this book that there is a correlation between the lenses we use, the relationships we establish, and the care that ultimately is provided. —Excerpts from an interview with a prominent healthcare provider

Case Study Role Play page 64 BTHH

PATTERNS OF DISCOURSE FORMAL CASUAL
When you tell a story in formal register, it is very direct in nature. When a story is told in casual, it tends to be circular in nature. Not only do we often have organizations and customers in two different registers, how they tell stories is different as well. The formal story structure is expected at school, at work, and in other settings and organizations. It has a clear beginning, middle, and end. It gets to the point. You expect your attorney to use the formal story structure and register when representing you in court, and not to use a circular structure and a lot of nonverbals. Example: Kids may know the answers to an essay test question, but they need to put their answers in formal register—the register of that discipline. If the answer is in casual story structure, the student probably will not pass that course. Casual register is in some ways powerful, but it doesn’t let the teacher or employer or judge “know that you know.” In the healthcare setting, how do you know that the patient knows?

FORMAL B E PLOT CASUAL STORY STRUCTURES
The formal story structure has a clear-cut beginning, hence the B (for beginning). It moves through a sequence of events (a plot), then down to a definitive ending, hence the E (for ending). This story tends to move chronologically—past, present, and future in a sequence of events. This story is all about sharing information. Make a point and move on. Past, present, future: Make a point and move on. The casual story structure has no clear-cut beginning. The story may start with the present moment … or three months ago … or with an entirely different story. One person will start the story, often at the most dramatic moment, with openness to comments from listeners (this isn’t seen as interrupting). The triangular inserts represent where others will jump in with jokes or remarks. Especially if there’s a relationship between the storyteller and the listener(s), then “over-talking” is fine.

“I see you, but I can’t hear you …”
We almost always communicate with patients in formal and frozen registers. Patients/clients in generational poverty generally speak casual and intimate registers. In poverty, concrete communication is more powerful, including nonverbals. In the medical community, we almost always communicate in formal and frozen register! For the caregiver/clinician/health worker, the statement may be: “I see you, but I can’t hear you.” For the client/patient, the statement may be, “I can hear you, but I also see you, and they don’t match. Why is this so?” What you say becomes “blah, blah, blah” or “noise” if I can’t understand it. Define concrete vs. abstract communication.

Abstract vs Concrete Thinking
Abstract – can hold ideas and reason w/consequences inside the head. Teaching occurs outside the head. Learning occurs inside the head. Concrete – must touch to understand and think (Thinking inside the head) In poverty “When I tell my kids to do something, I need them to do it NOW. It is a safety factor. They are not to think, just react to what I say.” Is it because they are not intelligent enough to know/learn? NO, it is because they have not been taught to think abstract. Abstract – can hold ideas and reason w/consequences inside the head. Teaching occurs outside the head. Learning occurs inside the head. Concrete – must touch to understand and think (Thinking inside the head) In poverty “When I tell my kids to do something, I need them to do it NOW. It is a safety factor. They are not to think, just react to what I say.” Dancing w/Stars – young dancer from poverty “When we heard guns shots, we hit the floor” Is it because they are not intelligent enough to know/learn? NO, it is because they have not been taught to think abstract. How does that affect them? 4 stages of Concrete: Baby – Age 2 Sensory-motor stage: Touch it = know it. Babies – everything goes to the mouth. Toddlers throw toys to see what happens. Age 2 – 6 Language development/use symbols to represent different objects. Still think concrete and have difficulty understanding view pts dif from their own. The best way to teach children in this stage is to explain ideas in concrete terms and to demonstrate principles using materials that they can touch and handle. Story – Mom crossing the street w/daughter in poverty and daughter breaks away. Mom says “Don’t do that again!” /mom in middle class – same scenerio but mom explains the dangers. Age 7 – early adolescence More able to think abstractly and examine viewpoints. Begin to wonder what people are thinking. To teach them abstractly, they must be allowed to process info by repeating back to you in their own words so they can understand what you are saying. Adolescent + Dev ability to think ahead and to reason w/consequence. They consider moral delimmas and “what if” situations. Important to explain the reason for the rules and decisions and allow them input into issues. ---- Story – Mom crossing the street w/daughter in poverty and daughter breaks away. Mom says “Don’t do that again!” /mom in middle class – same situation but mom explains the dangers.

No Future Story Lack of Abstract Thinking Lack of ability to plan
No control of impulses or understanding of consequences No future story No Future Story No identity No Future Story = No Identity. Research shows that in poverty, where work is not consistent, your identity is dependent on your gender. Your identity is found in our role as parent. Thus young parents. (Story of WIC 14 yr old girl whose mom was taking pics of blood tests of the girl becuz they were so excited over being a grandparent)

YOUR Main Focus should be… RELATIONSHIP = MOST VITAL
“No Significant Learning occurs w/o a Significant Relationship.” -Dr. James Comer Your survival requires that you think of people as possessions. You must rely upon each other. Utlize stories of laundry day to exemplify. Car breaking down and nieghbor you hate fixing it because you “need” each other to survive. Relationship building w/your client doesn’t happen overnight. It can take time – years. It is on their timeline, NOT YOURS.

Build A Relationship Use your adult voice when you speak to me.
Your educational background can quickly become a barrier for me. Be more of a resource and less of an “expert”. Find out what is important to me, point it out and find ways for me to build on that. Help me to identify my strengths and resources. Show me how to use them. I don’t always see them myself. Emphasize relationship as the main key to everything else you will discuss today. Without Relationship, you cannot be as successful w/the other tools. It is vital. CAH To give example.

Tool #4: Use Visual Aides To Let Me “See It”
Now Your Plan Future Story I am a concrete thinker: Draw it out or use visual aides to help me see abstract ideas and paths. Use flash cards that I can take home with me so I can focus on one step or concept at a time. Can use example of What it takes to get funding for housing.

What Happens in Healthcare Settings?
Examples of lack of institutional efficacy: Delayed or inappropriate clinical interventions. Medical staff incentivized to use formal language. Abstract words make up formal register. Client/patient outcomes get compromised. Written communication without nonverbal assists can lead to lack of compliance. 1. Lack of adequate vocabulary, sentence structure, and syntax knowledge lead to delayed or inappropriate clinical interventions. 2. The doctor is incentivized to avoid litigation. The physician’s formal language is not limited to his/her written communications! 3. Use Ruby’s example from Haiti or one of your own. 4. and 5. Client/patient outcomes get compromised in the absence of adequate or appropriate translation of both verbal communication and nonverbals. This makes take-home instructions a challenge. Much of the meaning in casual register is derived from nonverbal assists, not from word choices. Explain the difference between abstract and concrete language. What might it mean to have a patient say something like the following to you? “I have sugar,” ”Something’s wrong with my nature,” “My piles are acting up,” or, “He gave me the claps.”

Mental Model for Disease Management
Use complete explanation Chapter 4. This mental model prepares patients to think through what needs to be done in several areas of their life to take care of themselves adequately. The age line has future orientation . The three sections for past, present, and future create space for mental models and notes below each. The Stability Scale (see Appendix F) appears at lower left in the chart in order to name the problem of stability if it comes up. The mental model of a support team is to be developed after making the mental model of the future. Explain that you will be working on a plan that patients can use from the moment they leave—something they can show to family members, along with the mental model of the disease. Patient should mark their age the on the line. Work on the “present”: Who will pick you up? ▪ Who is living with you? ▪ What do they know about your disease? Etc. (More questions–Chapter 4). Have the patient represent each person on the page with circles/initials or symbols; offer encouragement to place the people close to or far away, according to his/her feelings. Patient makes notes. Work on the “past” if necessary. ▪ What were things like earlier? ▪ Was it better or worse at some points? ▪ How have things changed for the people you mentioned? ▪ What was the stability factor like then? Have the patient make notes in the space. Work on the “future.” ▪ How do you need the future to look in order to be successful in the long term? (See questions–Chapter 4) ▪ Have the patient draw in the characters and discuss the realities. Develop the “support team” mental model by creating a set of circles with the patient in the center and adding supportive people and organizations around the patient. Again, ask patient to “teach forward”. Make copies of the mental models for your records, saying you will be checking back on this with the patient (only if this is true, of course).

Mental Model for Progression of Congestive Heart Failure
2 Heart Attacks High Blood Pressure Hospital: Trouble breathing Swollen legs  Heart Strength Salt/sodium Weight every day Pills 2 x day The purpose of the two mental models that follow is to prepare patients to take charge of their disease management from the moment they leave the facility. The first mental model of the patient’s condition is to be used by the patient to teach family members about the disease/condition and the importance of proper disease management. The second mental model helps patients anticipate the problems they will face when they are “under their own care” and have solutions and supports in hand, ready to be used. In this method the models are created by both patient and caregiver, working shoulder to shoulder. When the models are done well, the patient will not discard the paperwork but may ask for a copy to take home. The caregiver can give the original to the patient, make a copy for the facility’s records, and assure the patient that the caregivers are part of his/her support team. ▪ Is the disease progressive, chronic, and/or fatal? ▪ What are the stages /symptoms of the disease? ▪ (More questions-Chapter 4) In this example of congestive heart failure, the patient has marked her experience on a time line. The precipitating event was at age 63, but information from the past shows weakening heart strength. The disease management practices of salt/sodium, weight, and medication will stabilize the condition. If the disease isn’t managed well, the patient can expect to have trouble breathing, feel weak and tired, and will no doubt be coming back soon to the hospital. All of these things should be drawn by the patient as she talks through her understanding of her disease. As she talks through this with the caregiver she is “teaching back” to the professional. When she goes home she will be “teaching forward” to her friends and family. Some patients may indicate which events they want to experience in the next 15–30 years: the birth of grandchildren, annual family reunions, etc. The connection between relationship and future story may be the primary motivation for some individuals. The goal is for the patient, not the professional, to be making the argument for his/her own care and management. Features of the disease are included in this model. Models for other diseases and conditions should be created by staff. Trouble breathing Back in hospital Weak and tired Created by Sarah Garee and Philip DeVol

MODULE SIX RESOURCES OBJECTIVES Individual Lens
Analyze the eight resources of the customer/employee and make interventions based on those resources that are present. Understand that being stuck in poverty is often related to missing pieces; identify ways to build resources. Where do resources come from? From the unique qualities of each person; many resources are passed along from parents and family, as well as through friendships and connections. The community is also responsible for developing resources that create growth and a nurturing environment. There is significant research in the areas of resources and resiliency, both for adults and young people. For more information, go to: Search-Institute.org Resiliency.com It’s important to note that agencies, organizations, and schools create plans with individuals in poverty. The first question is: “Are the resources that the individual needs to achieve the plan present?” The next question is: “How do we build those resources?” The Getting Ahead in a Just-Gettin’-By World curriculum allows group participants to analyze their own resources in a safe and supportive environment, identify the strongest resources, and create a plan that uses those strongest resources to build other resources. The groups also identify community resources and partnerships that can support their plans. Individual Lens

DEFINITION OF RESOURCES
FINANCIAL Being able to purchase the goods and services of that class and sustain it. EMOTIONAL Being able to choose and control emotional responses, particularly to negative situations, without engaging in self-destructive behavior. Shows itself through choices. MENTAL Having the mental abilities and acquired skills (reading, writing, computing) to deal with daily life. SPIRITUAL Believing in (divine) purpose and guidance. PHYSICAL Having physical health and mobility. SUPPORT SYSTEMS Having friends, family, and backup resources available to access in times of need. These are external resources. RELATIONSHIPS/ROLE MODELS Having frequent access to adult(s) who are appropriate, nurturing, and who do not engage in destructive behavior. KNOWLEDGE OF HIDDEN RULES Knowing the unspoken cues and habits of a group. Resources are interconnected, and strengths in one area tend to lead to increased levels in another. Physical health can influence emotional health. Cognitive reasoning can influence emotional stability.

Hidden rules (Choice: two sets)
MENTAL MODEL OF RESOURCES Emotional Spiritual Mental Financial Physical BRIDGING This is another mental model (or two-dimensional drawing) of resources. Trace your hand, and label the parts of the hand. As you analyze the case study, write a rating of 1–5 or a question mark in each part of the hand that represents the different resources. Five is the highest score and represents an “above average” level of that resource. Write the names of the individual’s bonding and bridging social capital in the circles. Explanation of this mental model: Financial is on the little finger because it is only one of the resources that define poverty. Financial resources are important, but far from everything. Emotional is on the middle finger because that’s the finger we sometimes use when we get emotional.  Spiritual points the way—gives direction and purpose. The thumb helps us in grasping objects. It represents the physical resources. Support system (social capital) is on the palm of the hand. We use this part to shake hands or hold hands. Hidden rules (being able to use more than one set) are on the wrist, which guides the movement of the hand. Support Systems Role Models BONDING – ? Developed by Terie Dreussi-Smith Hidden rules (Choice: two sets)

Hidden rules (Choice: two sets)
HOW TO—RESOURCE HAND Sandy—Recently Separated: Current Resources BRIDGING BONDING Financial Mental Emotional Spiritual Physical Support Systems Role Models Hidden rules (Choice: two sets) Developed by Terie Dreussi-Smith – ? -Depression -Binge drinking -Angry outbursts -Good sense of humor -Empathetic/understanding -Annual income $120k -Financial assets 4 2.5 ? 5 Overall good health, but now… -Binge drinking -Cannot sleep -Under-eating -Stopped exercise -Smoking again -Ignoring preventive healthcare 3 Colleagues Therapists Professors -Working on Ph.D. This is how the team at one addiction recovery agency analyzed a female client aged 48. It is offered as a sample to show participants how to score resources using the resource hand. You might ask the audience to remember that a score of 5 is above average. You don’t have to be Einstein to get a 5 for mental, or Bill Gates to get a 5 for financial. It is not necessary to agree with every score. This is just a sample of one group’s thinking through the resource definitions and applying the resource lens to their clients. Here is the justification for their scores: FINANCIAL: A score of 5 is above average—currently $51,000/year is the median income. Sandy’s annual income of $120k puts her in the top 20%. She also has financial assets. Are there people who are wealthier? Yes. But Sandy is still a good example of a 5 in the U.S. Some participants will suggest a 4 is a better score. That is fine. All scores are subjective. The point is to think through the resource analysis and look for strengths whenever possible. MENTAL: This score is relative to Sandy’s cognitive ability and achievement in higher education and perhaps her profession. Please make sure your audience remembers that “stupid choices” belong in the emotional finger and may not actually have an affect on “IQ” or be driven by low cognitive abilities. This is how Bridges resources are defined, despite what Forrest Gump’s mother said (“Stupid is as stupid does”). EMOTIONAL: Audience will point out that it is difficult to rate emotional resources. We have shared some of Sandy’s strengths, as well as less-positive coping strategies. Note that there are some conflicts in all of us: Sandy is currently having unexpected angry outbursts, yet she exhibits considerable empathy and understanding of others. SPIRITUAL: We just don’t know yet. PHYSICAL: Sandy’s health is on a slow-paced, steady decline, but it is not emergent. For example, she hasn’t been diagnosed with a terminal cancer. She is putting her health “on hold” and engaging in some less-than-healthy lifestyle choices in her current situation. BONDING/BRIDGING SOCIAL CAPITAL – SOCIAL SUPPORT: We listed her significant bridging social network (her “get-ahead people,” as well as her supportive, bonding “get-by people”). KNOWLEDGE OF HIDDEN RULES: Sandy is familiar with and uses the Bridges Out of Poverty work. You can follow this slide by asking participants to trace their hand and work at their tables to analyze one of the resource case studies in the Bridges Out of Poverty book (Jerry, Oprah and Opie, et al.). Influential friends Familiar with and uses hidden rules of poverty and middle class 4

MENTAL MODEL OF RESOURCES
Getting Ahead participants helped create this mental model for analyzing their own resources. The mental model gives a picture of resource levels at a glance. The resource levels for this individual are comparatively high.

Life Focus = Getting Through TODAY
“Every day is just one crisis after another. I have no power over what will happen tomorrow so how can I think about change? Change doesn’t make sense to me. There is NO TIME for change!” Time Horizons for Planing Ahead: Poverty = TODAY Middle = 5 years Wealth = 20+ years People in poverty are solving concrete problems and usually don’t have the time or energy for the abstract, or new, learning. EXAMPLE: “It is easy for us to tell our clients that you need to check your blood sugar four times a day, count your carbohydrates and exercise. When you do, do you find that they shake their head, smile and say yes…then the next time you see them nothing has changed?” Now you know why. I’ll show you how to use this to develop a future story to help move them towards change in a minute.

Tool #1: Seeing Life through the Lens of a
Future Story Ask: “What would it feel like…what would it be like if....” Use both negative and positive examples to help me decide my own future story. Story: Grandma sees no reason to take her insulin. If she dies, the grandkids will go live Rosie down the hall. But only Grandma knows the family history, the roots to who they are. Who will teach them? Talk about someone you work with and how a future story would help move them forward. Allow 2 minutes to discuss.

Tool #2: Clarify for me that “If I Choose…
then I Have Chosen..” “If you choose” = You are in charge (power) and there is a choice. “Then you have chosen..” = builds future story Important: YOU MUST SAY THE SENTENCE TWICE Don’t just tell me what one behavior gets me. Talk to me about what 2 total different behaviors will get me. “If I choose not to pay my rent, then I have chosen not to live here. Or “If I don’t choose, then I have chosen to not to live here.”

Tool #7: Reflective Listening
Questions Can Be Roadblocks Instead, listen and reflect on what you have heard in order to guide the person through their thought process. What they are saying may not be the root of the problem but may lead to what really is. Try to guide them through the lens of their future story. Refer to handout on proper way to utilize this skill. Indicate that can be one of the most important tools that you use IF you use it correctly. Go over handout.

IT’S DUE TO SOCIAL COHERENCE
“Does a person have a sense of being linked to the mainstream of society, of being in the dominant subculture, of being in accord with society’s values?” “Can a person perceive society’s messages as information, rather than as noise? In this regard, the poor education that typically accompanies poverty biases toward the latter.” “Does a person have the resources to carry out plans?” “Does a person get meaningful feedback from society—do their messages make a difference?” ADD: When people in poverty try to get healthcare, they often get the message that it isn’t for them. Healthcare is for “us,” the middle class and wealthy. It isn’t for “them,” the people in poverty. That is social coherence. The middle class can do something about social coherence in the design of programs, the way language is used, and the role people can play in solving problems. Society’s messages to individuals who don’t identify with the dominant class sound like Charlie Brown’s teacher in a TV version of Peanuts: “Wahw wahw wahw wahw wawh!” The messages may be positive, but they aren’t effective if the people don’t think the message is meaningful for someone of their identity, situation (class), and resources. This theme will be picked up again when we talk about language issues. Programs designed for “problem solvers” (people in poverty) will look different from programs designed for people who have no “voice” and are considered needy, ill, or in some way deficient (again, people in poverty). We’ll discuss this in greater detail in the research module. REINFORCEMENT: “Doing agency time” is one of the elements that shows up on the mental model of poverty. When participants don’t have resources or a “voice,” the result is that they just “go through the motions” during the planning process. Sapolsky is describing another reason people in poverty distrust organizations. Robert Sapolsky, Aaron Antonovsky

Module Four Communication, Language, and Cognition Actions Steps for Health and Healthcare
A Four-Part Strategy: Use advocates or navigators Use language the patient is likely to know and tie it to pictures and drawings Procedures should be outlined two ways—with words and pictures For patient compliance to work, retelling by the patient is essential Draw mental models for impact

What Does It All Mean? Poverty is a concrete, sensory, reactive world
The medical community is verbal, abstract, representational, and proactive Without language, access, and bridging and bonding capital, one lacks the tools necessary to negotiate and manipulate his/her position in the world of healthcare services One of the reasons there's so much violence in poverty is that when you have only casual register, you don't have the words to resolve a conflict. What they tell you in conflict resolution is this: To resolve a conflict, you have to get away from the personal and get to the issue. To get to issues, you must have abstract words. On the other hand, the ability to ‘code switch’ in a healthcare setting can be an essential skill. Persistent use of formal register by a caregiver can create a perception of negative judgment or lack of respect and lead to noncompliance. This is often seen in Emergency Room settings and leads to turnover and issues of selectivity for staffing. Often the most effective nurse in the ED is the one who “appears” to have the worst bedside manner and style of communication. Who would you rather have as a Triage Nurse or Navigator 11 pm–7 am in the ED? All registers have power. Speak formal register in a poverty neighborhood and you will likely be in trouble. Formal register does not have power in that situation. Schools can use mental models, high-frequency words, videos, and stories to communicate and so can outpatient clinics with high traffic for generational poverty. Using formal register to negotiate nurtures one’s ability to think abstractly and hold concepts inside the head but often requires relationships of mutual respect having been built over time. People in generational poverty tend to utilize the casual register of language to survive. In poverty you must attend to sights and sounds to survive; your world is often about processing the external environment. Because you are processing the sensory environment in poverty, nonverbals become crucial, and you become an expert at reading them. This is why it can be often observed in patient care settings that certain caregivers are requested while others are avoided like the plague!

“If you have come to help me, you can go home again
“If you have come to help me, you can go home again. But if you see my struggles as a part of your own survival, then perhaps we can work together.” Lila Watson –Lila Watson, an Aboriginal Woman from Australia RMHP’s logo states “We understand CO, We understand you.” We understand that all 3 classes of society call CO their home. We serve all 3 classes. That is what RCCO is all about. The public sector says “We can do nothing until we have policy change. The private sector says “Lets start where we are now and do great things”. Good to be Great by Jim Collins It is our hope by presenting BOP, that you too will now have a better understanding of how to make a difference in lives of those you touch and from that, you too can do great things. On behalf of RMHP, CAH and myself, thank you for being such great listeners and we look forward to working with you in the future.

Courageously Crossing the Bridge
It takes a lot of courage to release the familiar and seemingly secure, to embrace the new. But there is no real security in what is no longer meaningful. There is more security in the adventurous and exciting, for in movement there is life, and in change there is power. –Alan Philip Cohen Alan Phillip Cohen (October 5, 1954) is an American businessman best known for his ownership of the Florida Panthers hockey team and his founding of several pharmaceutical companies. Cohen holds several degrees from the University of Florida. He and his wife, Karen, live in Weston, Florida.

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