Social workers are mandated to challenge social injustice and pursue social change, particularly with and on behalf of vulnerable and oppressed individuals and groups of people. Social workers are trained to respect the inherent dignity and worth of the person. These are some of the core values of the National Association of Social Work (NASW (Ed.). (2018, January 1). Code of Ethics. Retrieved July 02, 2020, from https://www.socialworkers.org/
In the midst of a global pandemic, black people are most at-risk of infection apparently because of a higher incidence of comorbidity such as diabetes and high blood pressure, poor quality healthcare, and are most likely to hold ‘frontline’ jobs that increase their exposure to the virus. As if that isn’t bad enough, Black and brown people experience the ravages of systemic and structural racism that is embedded in programs and institutions ostensibly designed to be a resource. The sad truth is, despite our training, many social workers are gatekeepers to the very structures that oppress people of color.
Structural Racism Defined
To understand structural racism, the Aspen Institute Roundtable on Community Change, (Bitter, 2016) defined structural racism as a shorthand term for the many systemic factors that work to produce and maintain racial inequities in America today. These are aspects of our history and culture that allow the privileges associated with “whiteness” and the disadvantages associated with “color” to remain deeply embedded within the political economy.
Public policies, institutional practices, and cultural representations contribute to structural racism by reproducing outcomes that are racially inequitable.
So what are those structures, public policies, and institutional practices? These include poor housing, segregated housing, inadequate education, limited access to quality healthcare, discriminatory hiring practices, wage disparities, workplace microaggressions, poorly funded social programs, and dare I say, plain ole racism.
Consequently, these factors make black people more susceptible to psychosocial toxic stress, which can lead to lower immune function which in turn increases the vulnerability to COVID-19.
Two Global Pandemics Going On
Most of us would agree that this is an extraordinary time in our country with arguably two concurrent pandemics: COVID-19 and Racial Inequity. Both have far-reaching psychological implications. Most mental health professionals are charged by our code of ethics to be social justice advocates for our clients. Subsequently, one powerful way to fulfill this mission is to utilize supporting documentation beyond the DSM-5 to create a more appropriate clinical picture that demonstrates the multifaceted psychosocial stressors impacting our clients.
As social justice advocates, mental health professionals can and should collectively re-imagine Z-codes as descriptive resources instead of pathologizing people for the societal ills imposed upon them. Z-Codes should be looked upon as effective tools that do not require a diagnostic code as the primary reason for reimbursement.
We know that there are new ICD codes created for the medical profession for COVID-19 including U07 1.1 COVID-19, virus identified; U07.2 cOVID-19, virus not identified; Clinically-epidemiologically diagnosed COVID-19; Probable COVID-19; and Suspected COVID-19.
This makes sense that the medical field would have a diagnostic code for a deadly virus like COVID-19. The standard ‘medical model’ “focuses too heavily on disability and impairment rather than on an individual’s abilities and strengths. It suggests that disease is detected and identified through a systematic process of observation, description, and differentiation, in accordance with standard accepted procedures, such as medical examinations, tests, or a set of symptom description,” according to the Department of Clinical and Health Psychology University of Florida Gainesville, USA
Racism, The Other Pandemic
Subsequently, racism, the other ‘pandemic’ does not currently have an ICD diagnostic code. It is likely that other covert forms of racism such as microaggressions, civil unrest, discrimination, police brutality, etc. would not either. There needs to be a better way to document and validate the lived experiences of our clients. We need a way to non-judgmentally and compassionately name the cause, the system, or the circumstances that create psychosocial distress and suffering without criminalizing, vilifying, or blaming our clients for being victims.
In today’s social and racial climate, it is likely that many of our clients meet the diagnostic criteria for PTSD, Acute Stress Disorder, Depressive or Anxious Disorders, Adjustment Disorders, Substance-Related and Addictive Disorders. In those cases, assigning the proper diagnosis is advisable. However, many people are arguably experiencing a normal reaction to abnormal circumstances. Once the problem is removed, it is likely that they can return to normal functioning. It is incumbent upon mental health professionals to avoid perpetuating the pathologizing of our clients with diagnoses that stigmatize the victims of structural, systemic, and institutional racism.
Z Codes, Under-Utilized Clinical Resource
The systematic use of Z-Codes could have the potential to stand in the gap between significant psychosocial stressors and ICD-10 (soon to be 11) diagnostic codes. Although Z Codes are not the panacea to oppressive societal problems, it helps paint a clinical picture that elucidates the struggles that our clients face. It is worth repeating that Z-Codes are not mental disorders, they simply address issues that are the focus of clinical attention or affect the diagnosis, course, prognosis, or treatment of a patient’s mental disorder.
Z-Codes can be used to cover a wider variety of psychosocial problems. Z codes are usually accompanied by other diagnoses because most insurance companies do not reimburse for Z Codes and hence many practitioners choose not to use them. I believe that if we collectively and actively use Z codes, we can help magnify the importance of psychosocial and socioeconomic factors in mental wellness and recovery. My social work ‘spidey senses’ start to twitch with anticipation and excitement when I think of what we can do as a collective.
Social workers are change agents. All mental health practitioners are. Now is the time to impress upon insurance companies with our collective voice and power that they should recognize the validity of Z Codes as a primary or stand-alone psychosocial treatment focus area. Z Codes deserve legitimacy and reimbursement.
Barker, R. L. (2014). Social Justice. In The Social Work Dictionary (6th ed., pp. 398-399). Washington, DC, DC: NASW Press.
Bitter, M. C. (2016, April 11). Dismantling Structural Racism Through Community Building. Retrieved July 02, 2020, from https://www.aspeninstitute.org/blog-posts/dismantling-structural-racism-through-community-building/
Diangelo, R. (2018). White Fragility. In White Fragility: Why it’s’ so hard to talk to white people about racism. Boston, MA: Beacon.
Goar, E. S. (2017, May). Don’t Sleep On Z Codes. Retrieved July 02, 2020, from https://www.fortherecordmag.com/
Morrison, J. R. (2014). Diagnosis made easier: Principles and techniques for mental health clinicians. New York, NY: Guilford Press.
NASW (Ed.). (2018, January 1). Code of Ethics. Retrieved July 02, 2020, from https://www.socialworkers.org/
Narrow, W. E., MD, Peele, R., MD, Wulsin, L. R., MD, Zeanah, C. H., MD, & Fisher, P. W. (2013). Other Conditions That May Be a Focus of Clinical Attention. In Diagnostic and statistical manual of mental disorders (5TH ed., pp. 715-727). Arlington, VA: American Psychiatric Publishing.
Persons with potential health hazards related to socioeconomic and psychosocial circumstances. (n.d.). Retrieved July 02, 2020, from https://icd10coded.com/
Gena Golden, LCSW is a clinical social worker in private practice at Inner Coach Counseling, LLC. She can be contacted at