Designed to help students advance their knowledge, values, and skills, the

Standards for Excellence Series assists students in associating CSHSEs National

Standards to all levels of human service practice.
FEATURES I NCLUDE
Standards for Excellence critical thinking questions tied to the Standards
appearing throughout the chapters
Chapter reviews with scenario-based multiple choice and essay questions
Links to correlated web-based assets
S TA NDA R D S F OR E X C E L L E NC E S E R I E S
STANDARD CHAPTER
Professional History
Understanding and Mastery
Historical roots of human services 2, 5, 8, 9, 10, 11, 12
Creation of human services profession 2, 5, 8, 9, 10, 11, 12
Historical and current legislation affecting services delivery 2, 5, 8, 9, 10, 11, 12
How public and private attitudes infuence legislation and the interpretation of policies related to
human services
2, 5, 8, 9, 14, 15
Differences between systems of governance and economics 2, 14, 15
Exposure to a spectrum of political ideologies 1, 2, 15
Skills to analyze and interpret historical data application in advocacy and social changes 1, 2, 15
Human Systems
Understanding and Mastery
Theories of human development 1, 2, 3, 4, 5, 6
How small groups are utilized, theories of group dynamics, and group facilitation skills 4
Changing family structures and roles 4, 5, 6, 7, 12
Organizational structures of communities 2, 4, 5, 6, 7, 13, 14, 15
An understanding of capacities, limitations, and resiliency of human systems 1, 4, 13, 14, 15
Emphasis on context and the role of diversity in determining and meeting human needs 1, 2, 3, 4, 5, 6, 7, 8, 9, 10,
11, 12, 13, 14, 15
Processes to effect social change through advocacy (e.g., community development, community and
grassroots organizing, local and global activism)
1, 2, 8, 9, 13, 14, 15
Processes to analyze, interpret, and effect policies and laws at local, state, and national levels 2, 4, 5, 6, 7, 13, 14, 15
Human Services Delivery Systems
Understanding and Mastery
Range and characteristics of human services delivery systems and organizations 1, 4, 5, 6, 7, 8, 9, 10, 11,
12, 13, 14,
Range of populations served and needs addressed by human services 1, 2, 5, 6, 7, 8, 9, 10, 11,
12, 13, 14, 15
Major models used to conceptualize and integrate prevention, maintenance, intervention, rehabilitation,
and healthy functioning
1, 2, 4, 5, 6, 7, 8, 10, 11,
12, 13, 14
Economic and social class systems including systemic causes of poverty 1, 2, 9, 14, 15
Political and ideological aspects of human services 2, 4, 5, 6, 7, 13, 14, 15
International and global infuences on services delivery 1, 2, 4, 5, 6, 7, 13, 14,
15
Skills to effect and infuence social policy 1, 2, 4, 5, 6, 7, 13, 14,
15
Adapted from the October 2010 Revised CSHSE National Standards
Council for Standards for Human Service Education (CSHSE) Standards Covered in this Text
STANDARD CHAPTER
Information Management
Understanding and Mastery
Obtain information through interviewing, active listening, consultation with others, library or other
research, and the observation of clients and systems
Recording, organizing, and assessing the relevance, adequacy, accuracy, and validity of information
provided by others
Compiling, synthesizing, and categorizing information
Disseminating routine and critical information to clients, colleagues or other members of the related
services system that is provided in written or oral form and in a timely manner
Maintaining client confdentiality and appropriate use of client data
Using technology for word processing, sending email, and locating and evaluating information
Performing elementary community-needs assessment
Conducting basic program evaluation
Utilizing research fndings and other information for community education and public relations and
using technology to create and manage spreadsheets and databases
Planning & Evaluating
Understanding and Mastery
Analysis and assessment of the needs of clients or client groups
Skills to develop goals, and design and implement a plan of action
Skills to evaluate the outcomes of the plan and the impact on the client or client group
Program design, implementation, and evaluation
Interventions & Direct Services
Understanding and Mastery
Theory and knowledge bases of prevention, intervention, and maintenance strategies to achieve
maximum autonomy and functioning
Skills to facilitate appropriate direct services and interventions related to specifc client or client group
goals
Knowledge and skill development in: case management, intake interviewing, individual counseling,
group facilitation and counseling, location and use of appropriate resources and referrals, use of
consultation
Council for Standards for Human Service Education (CSHSE) Standards Covered in this Text
STANDARD CHAPTER
Interpersonal Communication
Understanding and Mastery
Clarifying expectations
Dealing effectively with confict
Establishing rapport with clients
Developing and sustaining behaviors that are congruent with the values and ethics of the profession
Administration
Understanding and Mastery
Managing organizations through leadership and strategic planning
Supervision and human resource management
Planning and evaluating programs, services, and operational functions
Developing budgets and monitoring expenditures
Grant and contract negotiation
Legal/regulatory issues and risk management
Managing professional development of staff
Recruiting and managing volunteers
Constituency building and other advocacy techniques such as lobbying, grassroots movements, and
community development and organizing
Client-Related Values & Attitudes
Understanding and Mastery
The least intrusive intervention in the least restrictive environment
Client self-determination
Confdentiality of information
The worth and uniqueness of individuals including: ethnicity, culture, gender, sexual orientation, and
other expressions of diversity
Belief that individuals, services systems, and society change
Interdisciplinary team approaches to problem solving
Appropriate professional boundaries
Integration of the ethical standards outlined by the National Organization for Human Services and
Council for Standards in Human Service Education
Self-Development
Understanding and Mastery
Conscious use of self
Clarifcation of personal and professional values
Awareness of diversity
Strategies for self-care
Refection on professional self (e.g., journaling, development of a portfolio, project demonstrating
competency)
This page intentionally left blank
Introduction to Human
Services
Through the Eyes of Practice Settings
Michelle E. Martin
Dominican University
THIRD EDITION
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Library of Congress Cataloging-in-Publication Data
Martin, Michelle E.
Introduction to human services : through the eyes of practice settings / Michelle E.
Martin. 3rd ed.
p. cm.
Includes index.
ISBN 978-0-205-84805-8 ISBN 0-205-84805-2 1. Human servicesVocational
guidanceUnited States. I. Title.
HV10.5.M37 2013
362.973023dc23
2012034134
10 9 8 7 6 5 4 3 2 1
ISBN-10: 0-205-84805-2
ISBN-13: 978-0-205-84805-8
Credits and acknowledgments borrowed from other sources and reproduced, with permission, in this textbook appear on
appropriate page within text.
vii
Contents
Preface xvii
PART I: HUMAN SERVICES AS A PROFESSION 1
1. Introduction to the Human Services
Profession 1
Purpose, Preparation, Practice, and Theoretical Orientations
The Many Types of Human Service Professionals 1
Why Is Human Services Needed? 3
Human Service Professionals: Educational Requirements and
Professional Standards 5
Human Service Education and Licensure 6
Duties and Functions of a Human Service Professional 9
How Do Human Service Professionals Practice? 10
Theoretical Frameworks Used in Human Services 10
Understanding Human Services through a Look at Practice
Settings 15
PRACTICE TEST 17
2. History and Evolution of Social Welfare Policy 19
Effect on Human Services
The Feudal System of the Middle Ages 19
Poor Laws of England 20
The Elizabethan Poor Laws 21
The Protestant Reformation and Social Darwinism 23
Charity Organization Societies 26
Jane Addams and the Settlement House Movement 27
The New Deal and the Social Security Act of 1935 30
Influences of African American Social Workers 31
Gay Rights: From Marriage Equality to Dont Ask Dont Tell
Repeal 33
Welfare Reform and the Emergence of Neoliberal Economic
Policies 34
The Christian Right and Welfare Reform 37
The Tea Party Movement 39
viii Contents
A Time for Change: The Election of the First African American
President 39
Concluding Thoughts on the History of Social Welfare
Policy 41
PRACTICE TEST 43
3. Professional Ethics and Values in Human
Services 46
Moral, But by Whose Standards? 47
Ethical Values versus Emotional Desires: I Know It Was Wrong,
But We Were in Love! 47
When Our Values Collide: I Value Honesty, But What if Lives
Are at Stake? 48
The Development of Moral Reasoning 49
Developing a Professional Code of Ethics 50
Resolving Ethical Dilemmas 50
Cultural Influences on the Perception of Ethical
Behavior 51
Ethical Standards in Human Services 52
Concluding Thoughts on Professional Ethical Standards 53
PRACTICE TEST 55
PART II: GENERALIST PRACTICE AND THE ROLE OF
THE HUMAN SERVICE PROFESSIONAL 57
4. Skills and Intervention Strategies 57
Informed Consent and Confidentiality 58
The Limits of Confidentiality 59
Skills and Competencies 61
Sympathy and Empathy 61
Boundary Setting 63
The Hallmarks of Personal Growth 65
The Psychosocial Assessment 66
Patience 66
Active Listening Skills 67
Observation Skills 68
Family Genograms 68
Contents ix
Psychological Testing 70
Clinical Diagnoses 70
Criticisms of the DSM-IV-TR 71
Continuum of Mental Health 72
Case Management and Direct Practice 73
Direct Practice Techniques for Generalist Practice 74
Task-Centered Casework 75
Perceptual Reframing, Emotional Regulation, Networking,
and Advocacy 77
Cultural Competence and Diversity 78
Concluding Thoughts on Generalist Practice 79
PRACTICE TEST 80
5. Child Welfare Services 82
Overview and Purpose of Child and Family Services Agencies
The History of the Foster Care System in the United States 83
Historic Treatment of Children in Early America 83
Child Labor in Colonial America: Indentured Servitude and
Apprenticeships 84
Slavery and Child Labor 85
Child Labor during the Industrial Era: Children and
Factories 86
The U.S. Orphan Problem 86
The Orphan Asylum 87
The Seeds of Foster Care: The Orphan Trains 88
Jane Addams and the Fight for Child Labor Laws 90
Overview of the Current U.S. Child Welfare System 91
Getting into the System 93
Child Abuse Investigations 94
Mandated Reporters 94
Sequence of Events in the Reporting and Investigation of
Child Abuse 95
Types of Child Maltreatment 95
The Forensic Interview 96
To Intervene, or Not Intervene: Models for Decision
Making 97
Working with Children in Placement 99
Permanency Plans 99
Working with Biological Families 101
x Contents
Working with Foster Children: Common Clinical Issues 103
Separation 104
Loss, Grief, and Mourning 105
Identity Issues 106
Continuity of Family Ties 108
Crisis 109
Working with Foster Parents 109
Reunification 110
Family Preservation 111
Minority Populations and Multicultural Considerations 113
Placing Children of Color in Caucasian Homes 114
Native Americans and the U.S. Child Welfare
System 116
Concluding Thoughts on Child Protective Services 118
PRACTICE TEST 119
6. Adolescent Services 122
Adolescence: A New Stage of Development? 122
Developmental Perspectives 123
Common Psychosocial Issues and the Role of the Human Service
Professional 125
Abstract Reasoning: A Dangerous Weapon in the Hands of an
Adolescent 126
Adolescent Rebellion 126
Eating Disorders in the Adolescent Population 133
Other Clinical Issues Affecting the Adolescent
Population 134
Practice Settings Specific to Adolescent Treatment 135
Multicultural Considerations 137
Concluding Thoughts on Adolescents 138
PRACTICE TEST 139
7. Aging and Services for the Older Adult 142
The Aging of America: Changing Demographics 144
Old and Old-Old: A Developmental Perspective 145
Successful Aging 148
Contents xi
Current Issues Affecting Older Adults and the Role of the Human
Service Professional 149
Ageism 150
Housing 151
Homelessness and the Older Adult Population 152
Adjustment to Retirement 153
Grandparents Parenting 155
Depression 158
Dementia 159
Elder Abuse 159
Practice Settings Serving Older Adults 161
Special Populations 162
Concluding Thoughts on Services for Older Adults 163
PRACTICE TEST 164
8. Mental Health and Mental Illness 167
The History of Mental Illness: Perceptions and Treatment 168
The Deinstitutionalization of the Mentally Ill 169
Common Mental Illnesses and Clinical Issues 170
Serious Mental Disorders Diagnosed on Axis I 171
Serious Mental Disorders Diagnosed on Axis II 173
Mental Health Practice Settings and Counseling
Interventions 175
Intervention Strategies 175
Common Practice Settings 176
Mental Illness and Special Populations 178
Mental Illness and the Homeless Population 178
Mental Illness and the Prison Population: The
Criminalization of the Mentally Ill 180
Multicultural Considerations 182
Current Legislation Affecting Access to Mental Health
Services 183
Mental Health Parity 183
Other Federal Legislation 184
Ethical Considerations 186
Concluding Thoughts on Mental Health and
Mental Illness 187
PRACTICE TEST 188
xii Contents
9. Homelessness 191
The Nature of Homelessness: A Snapshot of Homelessness in
America 191
The Difficult Task of Defining Homelessness:
The HEARTH Act 192
The U.S. Homeless Population: Gauging the Extent of the
Problem 194
The Causes of Homelessness 195
History of Homelessness in the United States 198
The Contemporary Picture of Homelessness: The Rise of
Single-Parent Families 199
Homeless Shelter Living for Families with Children 201
Homeless Children: School Attendance and Academic
Performance 203
Runaway Youth 203
Single Men, the Mentally Ill, and Substance Abuse 205
Older Adult Homeless People 206
Current Policies and Legislation 207
The Role of the Human Service Professional: Working with the
Homeless Population: Common Clinical Issues 209
Common Practice Settings for Working with the Homeless
Population 213
Concluding Thoughts on Homelessness 215
PRACTICE TEST 217
10. Healthcare and Hospice 220
Human Services in Medical and Healthcare Settings 220
Crisis and Trauma Counseling 223
Single Visits and Rapid Assessment 224
Working with Patients with HIV/AIDS 225
HIV/AIDS and the Latino Population 227
Concluding Thoughts on Working with the HIV/AIDS
Population 228
The Hospice Movement 229
The History of Hospice: The Neglect of the Dying 229
The Hospice Philosophy 230
The Role of the Hospice Human Services Worker 231
The Psychosocial Assessment 231
Intervention Strategies 232
The Spiritual Component of Dying 235
Contents xiii
Death and Dying: Effective Bereavement Counseling 236
The Journey Through Grief: A Task-Centered Approach 236
Multicultural Issues 237
Concluding Thoughts on Human Services in Hospice
Settings 239
PRACTICE TEST 242
11. Substance Abuse and Treatment 244
History of Substance Abuse Practice Setting 245
History of Use and Early Treatment Efforts Within the United
States 245
The Prohibition Movement 246
The Rise of Modern Addiction Treatment in the United States 247
Demographics, Prevalence, and Usage Patterns 248
Defining Terms and Concepts 249
Theoretical Models of Use and Abuse 250
Types of Substances Abused 252
Abuse of Prescription Drugs 255
Common Psychosocial Issues and the Role of the Human Service
Professional 255
The Presence of Substance Abuse across All Practice
Settings 255
Acceptance of Problem 256
Hitting Bottom 257
Generalist Practice Interventions 257
Motivational Interviewing 258
Cultural Sensitivity 259
Defining Treatment Goals 260
Abstinence 260
Harm Reduction 260
Mode of Service Delivery 261
Availability of Treatment 261
Public Programs 261
Private Programs 261
Continuum of Care 262
Treatment Modalities 264
The Role of the Human Service Professional 264
Stages of Recovery 265
Relapse Prevention 265
xiv Contents
Common Treatment Settings 266
Detoxification Programs 266
Inpatient Treatment Programs 267
Partial Hospitalization Programs 267
Residential Treatment Programs 267
Outpatient Treatment 268
Pharmacological Treatments 269
Self-Help 269
Family Involvement 270
Concluding Thoughts on Substance Abuse 270
PRACTICE TEST 271
12. Human Services in the Schools 274
School Social Work 275
The School Social Work Model 277
School Social Work Roles, Functions, and Core
Competencies 277
School Counseling 281
Historical Roots of School Counseling 281
School Counselors: Professional Identity 281
Challenges Facing Urban Inner-city Schools 282
Common Roles and Functions of School Counselors 283
Common Ethical Dilemmas Facing School Counselors 284
Concluding Thoughts about School Counselors 285
School Psychologists 285
Common Issues and Effective Responses by Human Services
Personnel 286
Depression and Other Mental Health Concerns 286
Diversity and Race 288
Lesbian, Gay, Bisexual, Transgendered and Questioning
Youth 290
The Terrorism Threat and the Impact of 9/11 292
Substance Abuse 294
Child Abuse and Neglect 295
Teenage Pregnancy 296
Attention Deficit Disorder and Attention Deficit/
Hyperactivity Disorder 297
Concluding Thoughts on Human Services in the Schools 300
PRACTICE TEST 301
Contents xv
13. Faith-Based Agencies 305
Faith-Based Versus Secular Organizations 306
Federal Faith-Based Legislation 308
Methods of Practice in Faith-Based Agencies 310
The Benefits of Faith-Based Services 310
Religious Diversity in Faith-Based Organizations 311
Faith-Based Agencies: Services and Intervention Strategies 312
Jewish Human Services: Agencies and the Role of the Human
Service Professional 312
Christian Human Services: Agencies and the Role of the
Human Service Professional 319
Islamic Human Services: Agencies and the Role of the Human
Service Professional 327
Concluding Thoughts on Faith-Based Human Services
Agencies 332
PRACTICE TEST 333
14. Violence, Victim Advocacy, and
Corrections 336
Intimate Partner Violence 337
The Nature of Domestic Violence: The Cycle of Violence 338
Counseling Victims of Domestic Violence 339
Domestic Violence Practice Settings 342
The Prosecution of Domestic Violence 343
Batterers Programs 344
Sexual Assault 345
Why People Commit Rape 346
The Psychological Impact of Sexual Assault 347
Male-on-Male Sexual Assault 347
Common Practice Settings: Rape Crisis Centers 348
Victims of Violent Crime 348
The Victims Bill of Rights 349
VictimWitness Assistance 350
Surviving Victims of Homicide 351
Common Clinical Issues When Working with Victims of All
Violent Crime 352
Perpetrators of Crime 352
Gang Activity 352
Risk Factors of Gang Involvement 353
xvi Contents
Human Services Practice Settings Focusing on Gang
Involvement 354
Human Services in Prison Settings 354
The War on Drugs 355
Clinical Issues in the Prison Population: The Role of the
Human Service Professional 356
Barriers to Treatment 357
Concluding Thoughts on Forensic Human Services 358
PRACTICE TEST 360
PART III: MACRO PRACTICE, INTERNATIONAL
HUMAN SERVICES, AND FUTURE
CONSIDERATIONS 363
15. Macro Practice and International Human
Services 363
Why Macro Practice? 364
At-risk and Oppressed Populations 366
A Human Rights Framework: Inalienable Rights for All
Human Beings 367
Mobilizing for Change: Shared Goals of Effective Macro Practice
Techniques 368
Common Aspects of Macro Practice 368
The Global Community: International Human Services 371
HIV/AIDS Pandemic 373
Crimes Against Women and Children 374
Indigenous People 380
Refugees 381
Lesbian, Gay, Bisexual, and Transgendered Rights 382
Torture and Abuse 385
Genocide and Rape as a Weapon of War 387
Macro Practice in Action 388
Social Action Effecting Social Change 389
PRACTICE TEST 391
Epilogue 394
Index 399
xvii
Preface
The third edition of Introduction to Human Services: Through the Eyes of Practice Settings
includes many important additions. When I reflect back on all of the changes that
have occurred since I began writing the first edition, I am in awe. Never could I have
imagined the various tragedies that would unfold in the last decade! An agonizingly
long war in the Middle East; a globalized economic crisis as we have not seen in decades;
political and religious polarization that threatens to further fragment the social, politi-
cal, and economic landscape in the United States; and culture wars that have pitted
social conservatives, including those on the religious right against social progressives,
including many social advocates. But there were so many good things that happened
as wellthe first African American president was elected to office in the United States,
and sexual orientation was included in hate crimes legislation, followed by increasing
momentum gained in the marriage equity movement. Weve also seen a dramatic in-
crease in the effects of globalization fueled at least in part by the globalization of com-
munication technologies. Do you want to start a social movement? Create a Facebook
page and mobilize thousands of people globally, creating social awareness through the
posting of status updates, online news articles, blogs, and YouTube videos!
What youll notice throughout the third edition of this book is an exploration of
all of these events, their precursors, and some of their consequences. Youll also notice a
reflection of the effects of our ever-shrinking worldwhat we call globalization. I have
updated all chapters with regard to research, terminology, and applicable legislation. In
particular, I have made significant changes in Chapter 1 where Ive included some ex-
citing information about the continued growth of the human services profession, in-
cluding information on the new certification process for human service professionals.
Because of the continued professional development within the human services field,
I have reduced the material focusing on related fields, such as the social work profes-
sion, and increased the focus on the human services profession. In Chapter 2 I explored
numerous changes in social welfare legislation and policies that took effect under the
Obama administration, including discussions on increasing rights afforded to the
LGBTQ population, challenges facing migrant populations and the poor, and the most
recent information on the healthcare debate. In Chapters 3 and 4 I have enhanced the
focus on the human services profession. In Chapter 5 I included a section on the history
of child labor, making a connection between this dark part of U.S. history and current
patterns of abuse of vulnerable children in the United States, and around the world.
I also explored recent changes in child welfare legislation. In chapters 6 through 12 I have
updated the research and theories, and in chapter 13 I have increased interfaith content.
In Chapter 14 Ive added content on batterers intervention services, including informa-
tion on the efficacy of these programs. In Chapter 15 Ive added content on viewing
global social problems from a human rights framework, as well as very important con-
tent on refugees, genocide, and other at-risk populations. Overall I hope I have captured
the most recent trends, research, and contemporary issues on a local and global level that
are important to human service professionals.
xviii Preface
I would like to thank several people who helped make this edition possible. First,
and foremost, I would like to thank my familymy son Xander, who was only 9 when
I started writing this book, and is now 17. Id also like to thank my two surrogate
Rwandan daughters, Elodie Shami and Annabella Uwineza, who have shared my life,
my home, and my family for the last three years. My aunt Jeri Serpico has always been
my rock. My dear friend Karen Acevedo was a constant support for me throughout the
writing of this edition. I would like to thank my colleagues at Dominican Universitys
Graduate School of Social WorkKim Kick, Myrna McNitt, Leticia Villarreal Sosa,
and Charlie Stoopsfor their professional insights and perspectives; they helped to
sharpen my thinking. I would like to thank Asma Yousef with Islamic Relief USA for
her insights on the Muslim faith. Finally Id like to thank my social work students who
sharpen my mind, and give me new ways to think about this wonderful profession.
1
Learning Objectives
Identify and describe the varied
reasons why people may need
human services intervention
Describe the various ways one
can enter the feld of human
services, and the various types
of careers within the human
services profession
Identify the most common de-
gree and licensure requirements
associated with the human ser-
vices profession
Describe the new human
services certifcation process
developed by the Council for
Standards in Human Service
Education
Identify and describe the most
common theoretical frame-
works used in the human
services discipline
Introduction to the
Human Services
Profession
Purpose, Preparation, Practice,
and Theoretical Orientations
CHAPTER 1
The Many Types of Human Service Professionals
Sara works for a hospice agency and spends one hour twice a week with
Steven, who has been diagnosed with terminal cancer of the liver. He has
been told he has approximately six months to live. He has been estranged
from his adult daughter for four years, and Sara is helping him develop
a plan for reunifcation. Sara helps Steve deal with his terminal diagno-
sis by helping him talk through his feelings about being sick and dying.
Steve talks a lot about his fear of being in pain and his overwhelming
feeling of regret for many of the choices he has made in his life. Sara lis-
tens and also helps Steve develop a plan for saying all the things he needs
to say before he dies. During their last meeting, Sara helped Steve write
a list of what he would like to say to his daughter, his ex-wife, and other
family members. Sara is also helping Steve make important end-of-life
decisions, including planning his own funeral. Sara and Steve will con-
tinue to meet until his death, and if possible, she will be with him and his
family when he passes away.
Gary works for a public middle school and meets with six seventh
graders every Monday to talk about their feelings. Gary helps them learn
better ways to explore feelings of anger and frustration. During their
meetings, they sometimes do fun things like play basketball, and some-
times they play a board game where they each take turns picking a self-
disclosure card and answering a personal question. Gary uses the game
to enter into discussions about healthy ways of coping with feelings,
Courtesy of Michelle Martin
2 Part I / Human Services as a Profession
particularly anger. He also uses the game to get to know the students in a more personal
manner, so that they will open up to him more. Gary spends one session per month to
discuss their progress in their classes. Te goal for the group is to help the students learn
how to better control their anger and to develop more prosocial behavior, such as empa-
thy and respect for others.
Cynthia works for her countys district attorneys ofce and has spent every day this
past week in criminal court with Kelly, a victim of felony home invasion, aggravated kid-
napping, and aggravated battery. Cynthia provides Kelly with both counseling and advo-
cacy. Kelly was in her kitchen one morning feeding her baby when a man charged through
her back door. Te ofender was recently released from state prison, had just robbed a gas
station, and was running from the police in a stolen car. He ran from home to home un-
til he found an unlocked door and entered it, surprising Kelly. Kelly immediately started
screaming but stopped when he pulled a gun out and held it to her babys head. During
the next hour the defendant threatened both Kelly and her infant sons life and at one point
even threatened to sexually assault Kelly. Te ofender became enraged and hit Kelly several
times when she couldnt fnd any cash in her home. Te police arrested him when he was
attempting to force Kelly to drive him to an ATM to obtain money. Cynthia keeps Kelly
apprised of all court proceedings and accompanies her to court, if Kelly chooses to assert
her right to attend the proceedings. She also accompanies Kelly during all police interviews
and helps her prepare for testifying. During these hearings, as well as during numerous
telephone conversations, Cynthia helps Kelly understand and deal with her feelings, includ-
ing her recent experience of imagining the violent incident again and again, her intense fear
of being alone, and her guilt that she had not locked her door. Lately, Kelly has been expe-
riencing an increasing amount of crying and unrelenting sadness, so Cynthia has referred
her to a licensed counselor, as well as to a support group for Kelly and her husband.
Frank works for county social services, child welfare division, and is working with
Lisa, who recently had her three young children removed from her home for physical
and emotional neglect. Frank has arranged for Lisa to have parenting classes and indi-
vidual counseling so that she can learn how to better manage her frustrations with her
children. He has also arranged to have her admitted to a drug rehabilitation program to
help her with her addictions to alcohol and cocaine. Frank and Lisa meet once a week to
talk about her progress. He also monitors her weekly visitation with her children. Frank
is required to attend court once per month to update the judge of Lisas progress on her
parenting plan. Successful completion of this plan will enable Lisa to regain custody of
her children. Frank will continue to monitor her progress, as well as the progress of the
children, who are in foster care placement.
Allison is currently lobbying several legislators in support of a bill that would in-
crease funding for child abuse prevention and treatment. As the social policy advocate
for a local grassroots organization, Allison is responsible for writing position statements
and contacting local lawmakers to educate them on the importance of legislation aimed
at reducing child abuse. Allison also writes grants for federal and private funding of the
organizations various child advocacy programs.
What do all these professionals have in common? Tey are all human service pro-
fessionals working within the interdisciplinary feld of human or social services, each
Introduction to the Human Services Profession 3
possessing a broad range of skills and having a wide range of responsibilities related
to their roles in helping people overcome a variety of social problems. Te National
Organization for Human Services (NOHS) defnes the human services profession as
follows: Te Human Services profession is one which promotes improved service de-
livery systems by addressing not only the quality of direct services, but by also seek-
ing to improve accessibility, accountability, and coordination among professionals and
agencies in service delivery. Human services is a broad term covering a number of ca-
reers, but all have one thing in commonhelping people meet their basic physical and
emotional needs that for whatever reason cannot be met without outside assistance.
Te human services feld can include a variety of job titles, including social worker,
caseworker, program coordinator, outreach counselor, crisis counselor, and victim ad-
vocate, to name just a few.
Why Is Human Services Needed?
All human beings have basic needs, such as the need for food, health, shelter, and safety.
People also have social needs, such as the need for interpersonal connectedness and love,
and psychological needs, such as the need to deal with the trauma of past abuse, or even
the psychological ramifcations of disasters such as a hurricane or house fre. People who
are fortunate have several ways to get their needs met. Social and psychological needs can
be met by family, friends, and places of worship. Needs related to food, shelter, and other
more complicated needs such as healthcare can be met through employment, education,
and family.
But some people in society are unable to meet even their most basic needs either
because they do not have a supportive family or because they have no family at all. Tey
may have no friends or have friends who are either unsupportive or unable to provide
help. Tey may have no social support network of any kind, having no faith community,
and no supportive neighbors, perhaps due to apartment living or the fact that many
communities within the United States tend to be far more transient now than in prior
generations. Tey may lack the skills or education to gain sufcient employment; thus,
they may not have health insurance or earn a good wage. Perhaps theyve spent the ma-
jority of their lives dealing with an abusive and chaotic childhood and are now sufering
from the manifestation of that experience in the form of psychological problems and
substance abuse and, thus, cannot focus on meeting their basic needs until they are able
to deal with the trauma they had been forced to endure.
Some people, particularly those who have good support systems, may falsely be-
lieve that anyone who cannot meet their most basic needs of shelter, food, healthcare,
and emotional needs must be doing something wrong. Tis belief is incorrect because
numerous barriers exist that keep people from meeting their own needs, some of which
might be related to their own behavior, but more ofen, the reasons why people cannot
meet their needs are quite complicated and ofen lie in dynamics beyond their control.
Tus while some people who are fortunate enough to have great families, wonderfully
supportive friends, the beneft of a good education, not faced racial oppression or social
exclusion, and no signifcant history of abuse or loss may be self-sufcient in meeting
4 Part I / Human Services as a Profession
their own needs. This does not mean that others who find themselves in situations
where they cannot meet their own needs are doing something wrong. Human service
agencies come into the picture when people fnd themselves confronting barriers to get-
ting their needs met and their own resources for overcoming these obstacles are insuf-
fcient. Some of these barriers include the following:
Lack of family (or supportive family)
Lack of a healthy support system of friends
Mental illness
Poverty
Social exclusion (due to racial discrimination for instance)
Racism
Oppression (e.g., racial, gender, age)
Trauma
Natural disasters
Lack of education
Lack of employment skills
Unemployment
Economic recession
Physical and/or intellectual disability
A tremendous amount of controversy surrounds how best to help people meet
their basic needs, and various philosophies exist regarding what types of services truly
help those in need and which services may seem to help initially but may actually cre-
ate more problems down the road, such as the theory that public assistance creates
dependence. For instance, most people have heard the old proverb, Give a man a fsh
and he will eat for a day. Teach a man to fsh and he will eat for
a lifetime. One goal of the human services profession is to teach
people to fish. This means that human service professionals are
committed to helping people develop the necessary skills to be-
come self- sufcient and function at their optimal levels, personally
and within society. Tus although an agency may pay a familys
rent for a few months when they are in a crisis, human service pro-
fessionals will then work with the family members to remove any
barriers that may be keeping them from meeting their housing needs in the future,
such as substance abuse disorders, a lack of education or vocational skills, health prob-
lems, mental illness, or gaining self-advocacy skills necessary for combating prejudice
and discrimination in the workplace.
In addition to a commitment to working with a broad range of populations, includ-
ing high-needs and disenfranchised populations, and providing them with the necessary
resources to get their basic needs met, human service professionals are also committed
to working on a macro or societal level to remove barriers to optimal functioning that
afect large groups of people. By advocating for changes in laws and various policies, hu-
man service professionals contributed to making great strides in reducing prejudice and
discrimination related to ones race, gender, sexual orientation, socioeconomic status
Human service professionals are
committed to helping people develop
the necessary skills to become
self-suffcient and function at their
optimal levels, personally and within
society.
Introduction to the Human Services Profession 5
(SES), or any one of a number of characterizations that might mar-
ginalize someone within society.
Human service professionals continue to work on all social
fronts so that every member of society has an equivalent opportu-
nity for happiness and self-sufciency. Te chief goal of the human
service professional is to support individuals as well as communities
function at their maximum potential, overcoming personal and so-
cial barriers as efectively as possible in the major domains of living.
Human Service Professionals: Educational
Requirements and Professional Standards
Each year numerous caring individuals will decide to enter the feld
of human services and will embark on the confusing journey of
trying to determine what level of education is required for specifc
employment positions, when and where a license is required, and
even what degree is required. Tere are no easy answers to these questions, because the
human services profession is a broad one encompassing many diferent professions, in-
cluding human service generalist, mental health counselor, psychologist, social worker,
and perhaps even psychiatrist, all of whom are considered human service professionals
if they work in a human service agency working in some manner with marginalized,
disenfranchised, or other individuals who are in some way experiencing problems re-
lated to various social or systemic issues within society.
Another area of confusion relates to the educational and licensing requirements
needed to work in the human services feld. Determining what educational degree to
earn, the level of education required, and what professional license is needed depends in
large part on variables such as specifc state and federal legislation (particularly for highly
regulated fields, such as in the educational and healthcare sectors), industry- specific
standards, and even agency preference or need. To make matters even more confusing,
these variables can vary dramatically from one state to the next; thus, a job that one can
do in one state with an Associate of Arts (AA) degree may require a Master of Social
Work (MSW) degree and a clinical license in another state. In addition, many individu-
als may work in the same capacity at a human service agency with two diferent degrees.
According to the NOHS website, a human service professional is
[a] generic term for people who hold professional and paraprofessional jobs in
such diverse settings as group homes and halfway houses; correctional, mental re-
tardation, and community mental health centers; family, child, and youth service
agencies, and programs concerned with alcoholism, drug abuse, family violence,
and aging. Depending on the employment setting and the kinds of clients served
there, job titles and duties vary a great deal. (National Organization for Human
Services, 2009, para.11)
Within this text, I use the title human service professional to refer to all profes-
sionals working within the human services feld, but if I use the term social worker,
Human Services
Delivery Systems
Understanding and Mastery of Human
Services Delivery Systems: Range of
populations served and needs addressed
by human services
Critical Thinking Question: Human
service professionals oftenbut not
alwayswork with the most disadvan-
taged members of society. What are
some roles in which they serve the most
vulnerable populations? What are some
roles in which they might serve more
affluent clients?
6 Part I / Human Services as a Profession
then I am referring to the legal defnition and professional distinction of a licensed
social worker, indicating either a Bachelor of Social Work (BSW) or an MSW level of
education. Also, I use the term human service agency, but this term is ofen used syn-
onymously in other literature with social service agency. One reason for the dramatic
variation in educational and licensing requirements is that the human services feld is
a growing profession, and with the evolution of professionalization comes increasing
practice regulations. Yet, issues such as the stance of legislators in a particular state
regarding practice requirements, the need for human service professionals within the
community, or even whether the community is rural or urban can afect educational
and licensing requirements for a particular position within the human services profes-
sion (Gumpert& Saltman, 1998).
Some human service agencies are subject to federal or state governmental licensing
requirements, such as the healthcare industry (hospitals, hospices, home healthcare),
government child welfare agencies, and public schools, and as such may be required
to hire a professional with an advanced degree in any of the social science felds, or a
particular professional education requirement might be specifed. For instance, in many
states, school social workers must have an MSW degree and educational credentials in
school social work, and school counselors must have a masters degree in educational
counseling.
Tere is still considerable variability among state licensing bodies in terms of how
professional terms such as counselor, social worker, and related feld are defned. For in-
stance, most states require hospice social workers to be licensed social workers, thus
requiring either a BSW or an MSW degree. But in Illinois, for instance, the Hospice
Program Licensing Act provides that a hospice agency can also employ bereavement
counselors who have a bachelors degree in counseling, psychology, or social work with
one year of counseling experience. Some states require child welfare workers to be li-
censed social workers with an MSW, whereas other states require child welfare workers
to have a masters degree in any related feld (i.e., psychology, human services, sociol-
ogy). In states where there is a signifcant need for bilingual social workers, such as
California, educational requirements may be lowered if the individual is bilingual and
has commensurate counseling and/or case management experience.
Keeping such variability within specifc human services felds in mind, as well as dif-
ferences among state licensing requirements, Table 1.1 shows a very general breakdown
of degrees in the mental health feld, their possible corresponding licenses, as well as
what careers these professionals might be able to pursue, depending on individual state
licensing requirements.
Human Service Education and Licensure
Te Council for Standards in Human Service Education (CSHSE) was established in
1979 for the purposes of guiding and directing human service education and training
programs. Tis organization has developed national standards for the curriculum and
subject area competencies in human service degree programs and serves as the accredi-
tation body for colleges and universities ofering degrees in the growing human services
discipline at the associates, bachelors, and masters levels.
Introduction to the Human Services Profession 7
Multiple Discipline Degree Requirements Table 1.1
Degree Academic Area/Major License/Credential Possible Careers
BA/BS Human Services BS-BCP Caseworker, youth worker, resi-
dential counselor, behavioral
management aide, case man-
agement aide, alcohol coun-
selor, adult day care worker,
drug abuse counselor, life skills
instructor, social service aide,
probation offcer, child advo-
cate, gerontology aide, juvenile
court liaison, group home
worker, child abuse worker,
crisis intervention counselor,
community organizer, social
work assistant, psychological
aide
BA/BS Psychology, Sociology N/A Same as above, depends on state
requirements
BSW Social Work (program ac-
credited by CSWE)
Basic licensing (LSW)
depends on state
Same as above, depends on state
requirements
MA/MS Counseling Psychology LCP (Licensed Clinical
Professionalon
graduation)
Private practice, some governmen-
tal and social service agencies
3060 credit
hours
LCPC (Licensed Clinical
Professional
Counselor~3,000
postgrad supervised
hours)
MSW Social Work (program
accredited by CSWE)
LSW (on graduation) Private practice, all governmental
and social service agencies
(some requiring licensure)
60 credit
hours
LCSW (Licensed
Clinical Social
Worker~3,200
postgrad supervised
hours)
PsyD 120
credit
hours
Doctor of Psychology PSY# (Licensed
ClinicalPsycholo-
gist~3,500 post-
grad supervised
hours)
Private practice, many
governmental and social
service agencies, teaching
in some higher education
institutions
PhD
(Psychol-
ogy)
Doctor of Philosophy in
Psychology
PSY# (~3,500 post-
gradsupervised
hours)
Private practice, many governmen-
tal and social service agencies,
teaching in higher education
institutions
120 credit
hours
8 Part I / Human Services as a Profession
Te CSHSE requires that curriculum in a human services program cover the follow-
ing standard content areas: knowledge of the human services feld through the under-
standing of relevant theory, skills, and values of the profession; history of the profession;
human systems; scope of the human services profession; standard clinical interventions;
common planning and evaluation methods; and information on self-development. Te
curriculum must also meet the minimum requirements for feld experience in a human
service agency, as well as appropriate supervision.
Te term human services is new compared to the title social work or mental health
counselor, and grew in popularity partly in response to the narrowing of the defnition
and increasing professionalization of the social work profession. For instance, in the
early 1900s many of those who worked in the social work feld were called social work-
ers; yet, as the social work feld continued to professionalize, the title of social worker
eventually became reserved for those professionals who had either an undergraduate or
a graduate degree in social work from a program accredited by the Council on Social
Work Education (CSWE), the accrediting body responsible for the accreditation of so-
cial work educational programs in the United States.
Tere is a wide variation between states with regard to what types of degrees are
required; education levels required; what careers require licensing, certifcations, or
credentials as well as the variation in titles used to identify social
workers, human service professionals, and counselors (Rittner &
Wodarski, 1999). In many states, the human services profession is
still largely unregulated, but this is quickly changing for several rea-
sons, including the fact that many third-payer insurance companies
will not reimburse for services unless rendered by a licensed mental health provider
(Beaucar, 2000).
In 2010, the CSHSE and the NOHS in collaboration with Center for Credentialing &
Education took a significant step toward the continuing professionalization of the
human services profession by developing a voluntary professional certifcation called
the Human Services Board Certifed Practitioner (HS-BCP) (2009 was a grandfather
year that allowed human service practitioners to apply for the certifcate without taking
the national exam). In order to take the national certifcation exam, applicants must
have earned at least a technical certifcate in the human services discipline from a re-
gionally accredited college or university and completed the required amount of post-
graduate supervised hours in the human services feld. Te number of required hours
worked in the human services feld ranges based upon the level of education earned,
from 7,500 hours required for those applicants with a technical certifcate, 4,500 hours
required for those applicants with an associate degree, 3,000 hours for those applicants
with a bachelors degree, and 1,500 hours for those applicants with a masters degree.
Applicants who have earned degrees in other than a CSHSE-approved program, such as
in counseling, social work, psychology, marriage and family therapy, or criminal justice,
must complete coursework in several diferent content areas related to human services,
such as ethics in the helping professions, interviewing and intervention skills, so-
cial problems, social welfare/public policy, and case management. Te implementa-
tion of the HS-BCP certifcation has moved both the discipline and the profession of
In many states the human services
profession is still largely unregulated,
but this is quickly changing.
Introduction to the Human Services Profession 9
human services toward increased professional identity and recognition within the larger
area of helping professions (for more information on the HS-BCP certifcation, go to
http://www.nationalhumanservices.org/certifcation).
Duties and Functions of a Human Service Professional
Despite the broad range of skills and responsibilities involved in human services, most
human services positions have certain work-related activities in common. Te NOHS
describes the general functions and competencies of the human service professional
on its website located at www.nationalhumanservices.org. Tese include the following:
1. Understanding the nature of human systems: individual, group, organization, com-
munity and society, and their major interactions. All workers will have preparation
which helps them to understand human development, group dynamics, organiza-
tional structure, how communities are organized, how national policy is set, and
how social systems interact in producing human problems.
2. Understanding the conditions which promote or limit optimal functioning and
classes of deviations from desired functioning in the major human systems. Work-
ers will have understanding of the major models of causation that are concerned
with both the promotion of healthy functioning and with treatment rehabilitation.
Tis includes medically oriented, socially oriented, psychologically-behavioral ori-
ented, and educationally oriented models.
3. Skill in identifying and selecting interventions which promote growth and goal at-
tainment. Te worker will be able to conduct a competent problem analysis and
to select those strategies, services, or interventions that are appropriate to helping
clients attain a desired outcome. Interventions may include assistance, referral, ad-
vocacy, or direct counseling.
4. Skill in planning, implementing, and evaluating interventions. Te worker will be
able to design a plan of action for an identifed problem and implement the plan in
a systematic way. Tis requires an understanding of problems analysis, decision-
analysis, and design of work plans. Tis generic skill can be used with all social sys-
tems and adapted for use with individual clients or organizations. Skill in evaluating
the interventions is essential.
5. Consistent behavior in selecting interventions which are congruent with the values of
ones self, clients, the employing organization, and the human services profession. Tis
cluster requires awareness of ones own value orientation, an understanding of organi-
zational values as expressed in the mandate or goal statement of the organization, hu-
man service ethics, and an appreciation of the clients values, life style and goals.
6. Process skills which are required to plan and implement services. Tis cluster is
based on the assumption that the worker uses himself as the main tool for respond-
ing to service needs. Te worker must be skillful in verbal and oral communication,
interpersonal relationships, and other related personal skills, such as self-discipline
and time management. It requires that the worker be interested in and motivated
to conduct the role that he has agreed to fulfll and to apply himself to all aspects of
the work that the role requires.
10 Part I / Human Services as a Profession
How Do Human Service Professionals Practice?
Since human beings have walked this planet, people have been trying to fgure out what
makes them tick. If we were to construct a historical time line, we would see that each
era tends to embrace a particular philosophy regarding the psychological nature of hu-
mans. Were we created in the image of God? Are we inherently good? Are personal
problems a product of social oppression, or are individuals responsible for their lot in
life? Do we have various levels of consciousness with feelings outside our awareness,
motivating us to behave in certain ways? What will make us happy? What leads to our
emotional demise? Tese questions are ofen lef to philosophers and more recently to
psychologists, but they also relate very much to human services practice because the
view of humankind held by human service professionals will undoubtedly infuence
how they both view and help their clients.
One of the most common questions human service professionals are asked in a
job interview is about their theoretical orientation. I recall having a professor in my
graduate program who cautioned that when we were asked that question to make sure
we never said we were eclectic because this was a clear indication to any employer
that we had no idea what theoretical orientation we embraced. Essentially what this
question is addressing is what theoretical orientation the human service professional
operates from as a foundation. In any mental health clinic, one practitioner might
counsel from a psychoanalytic perspective, another from a humanistic perspective,
and yet another from a cognitive-behavioral perspective. Te theoretical orientation
of mental health professionals will serve as a sort of lens through which they view
their clients. Depending on the theory, a human service professionals theoretical
orientation may include certain underlying assumptions about human behavior (e.g.,
what motivates humans to behave in certain ways), descriptive aspects (e.g., common
experiences of women in middle adulthood), as well as prescriptive aspects, defning
adaptive versus maladaptive behaviors (e.g., is it normal for children to experience
separation anxiety in the toddler years? Is adolescent rebellion a normal developmen-
tal stage?).
Most theoretical orientations will also extend into the clinical realm by outlining
ways to help people become emotionally healthy, based on some presumption of what
caused them to become emotionally unhealthy in the frst place. For instance, if a prac-
titioner embraces a psychoanalytic perspective that holds to the assumption that early
childhood experiences infuence adult motivation to behave in certain manners, then
the counseling will likely focus on the clients childhood. If the practitioner embraces a
cognitive-behavioral approach, the focus of counseling will likely be on how the client
frames and interprets the various occurrences in his or her life.
Theoretical Frameworks Used in Human Services
When considering all the various theories of human behavior, it is essential to remem-
ber that culture and history afect what is considered healthy thinking and behavior.
Common criticism of many major psychological theories is that they are ofen based
on mores common in Western cultures in developed countries and are not necessarily
Introduction to the Human Services Profession 11
representative or refective of individuals living in developing or non-Western cultures.
For instance, is it appropriate to apply Freuds psychoanalytic theory of human behav-
ior, which was developed from his work with higher society women in the Victorian
era, to individuals of the Masai tribe in Africa? Or, is it appropriate to use a theory of
human behavior developed during peacetime when working with
those who grew up in a time of war? Any theory of human behavior
one considers using in relation to understanding the behavior of cli-
ents should include a framework addressing many systems, such as
culture, historical era, ethnicity, and gender, as well as other systems
within which the individual operates. In other words, it is impera-
tive that the human service professional consider environmental el-
ements that may be a part of the clients life as a part of any evaluation and assessment.
Consider this example:
A woman in her forties is feeling rather depressed. She spends her frst counseling
session describing her fears of her children being killed. She explains how she is
so afraid of bullets coming through her walls that she doesnt allow her children
to watch television in the living room. She never allows her children to play out-
side and worries incessantly when they are at school. She admits that she has not
slept well in weeks, and she has difculty feeling anything other than sadness and
despair.
Would you consider this woman paranoid? Correctly assessing her does not de-
pend solely on her thinking patterns and behavior, but on the context of her think-
ing patterns and behavior, including the various elements of her environment. If this
woman lived in an extremely safe, gate-guarded community where no crimes had
been reported in 20 years, then an assessment of some form of paranoia might be
appropriate. But what if she lived in a high-crime neighborhood, where drive-by
shootings were a daily event? What if you learned that her neighbors children were re-
cently shot and killed while watching television in the living room?
Her thinking patterns and behavior do not seem as bizarre when
considered within the context or systems in which she is operating.
Human service professionals are ofen referred to as general-
ists, implying that their knowledge base is broad and varied. Tis
does not mean that they do not have areas of specialization; in fact,
in the last 100 years human service professionals have increasingly
ventured into practice areas previously reserved for social work-
ers, psychologists, and professional counselors (Rullo, 2001). But
many believe that in order to be most effective, human service
professionals must be competent in working with a broad range
of individuals and a broad range of issues, using a wide range of
interventions. A conceptual framework that is most commonly as-
sociated with human service generalist practice is one that views
clients in the context of their environment, specifcally focusing on
the transaction or relationship between the two.
It is imperative that the human
service professional consider
environmental elements that may
be a part of the clients life as a part
of any evaluation and assessment.
Human Systems
Understanding and Mastery of Human
Systems: Emphasis on context and the
role of diversity in determining and meet-
ing human needs.
Critical Thinking Question: Human ser-
vice professionals are generalists, drawing
on a wide range of knowledge, skills,
and theoretical perspectives in order
to best serve their clients. How might
this broad array of tools help a profes-
sional to effectively serve clients from
diverse cultural and/or socioeconomic
backgrounds?
12 Part I / Human Services as a Profession
Several theories capture this conceptual framework, and virtually all are derived
from general systems theory, which is based on the premise that various elements in
an environment interact with each other, and this interaction (or transaction) has an
impact on all elements involved. Tis has certain implications for the hard sciences such
as ecology and physics, but when applied to the social environment, its implications
involve the dynamic and interactive relationship between environmental elements, such
as ones family, friends, neighborhood, church, culture, ethnicity, and gender, on the
thoughts, attitudes, and behavior of the individual. Tus, if someone asked you who
you were, you might describe yourself as a female, who is a college student, married,
with two high schoolaged children, who attends church on a regular basis. You might
further describe yourself as having come from an Italian family with nine brothers and
sisters and as a Catholic.
On further questioning you might explain that your parents are older and you have
been attempting to help them fnd alternate housing that can help them with their ex-
tensive medical needs. You might describe the current problems youre having with
your teenage daughter, who was recently caught ditching school by the truancy of-
fcer. Whether you realize it or not, you have shared that you are interacting with the
following environments (ofen called ecosystems): family, friendships, neighborhood,
Italian-American culture, church, gender, marriage covenant, adolescence, the medical
community, the school system, and the criminal justice system.
Your interaction with each of these systems is infuenced by both your expectations
of these systems and their expectations of you. For instance, what is expected of you as
a college student? What is expected of you as a woman? As a wife? As a Catholic? What
about the expectations of you as a married woman who is Catholic? What about the
expectations of your family? As you attempt to focus on your academic studies, do these
various systems ofer stress or support? If you went to counseling, would it be helpful for
the practitioner to understand what it means to be one of nine children from a Catholic,
Italian-American family?
Tis focus on transactional exchange is what distinguishes the feld of human services
from other felds such as psychology and psychiatry, although recently, systems theory
has gained increasing attention in these latter disciplines as well. Several theories have
been developed to describe the reciprocal relationship between individuals and their
environment. Te most common are Ecological Systems Teory, Person-in-Environment
(PIE), and Eco-Systems Teory.
BRONFENBRENNERS ECOLOGICAL SYSTEMS THEORY Urie Bronfenbrenner
(1979) developed the Ecological Systems Teory. In his theory, Bronfenbrenner catego-
rized an individuals environment into four expanding spheres, all with increasing levels
of intimate interaction with the individual. Te Microsystem includes the individual and
his family, the Mesosystem (or Mezzosystem) includes entities such as ones neighbor-
hood and school, the Exosystem includes entities such as the state government, and the
Macrosystem would include the culture at large. Figure 1.1 illustrates the various sys-
tems and describes the nature of interaction with the individual. Again, it is important
to remember that the primary principle of Bronfenbrenners theory is that individuals
Introduction to the Human Services Profession 13
can best be understood when seen in the context of their relationship with the various
systems in their lives. Understanding the nature of these reciprocal relationships will aid
in understanding the individual.
PERSON-IN-ENVIRONMENT Another theory that is similar in nature to Ecological
Systems Teory is referred to as Person-in-Environment, or PIE. Te premise of this
theory is quite similar to Bronfenbrenners theory, as it encourages seeing individuals
within the context of their environment, both on a micro and macro levels (i.e., intra
and interpersonal relationships and family dynamics) and on a macro (or societal) level
(i.e., the individual is an African American, who lives in an urban community with sig-
nifcant cultural oppression).
ECO-SYSTEMS THEORY Similar to Bronfenbrenners theory, in
Eco-Systems Teory, the various environmental systems are repre-
sented by overlapping concentric circles indicating the reciprocal
exchange between a person and environmental system. Although
there is no ofcial recognition of varying levels of systems (from
micro to macro), the basic concept is very similar, and most who
embrace this theory understand that there are varying levels of sys-
tems, all interacting and thus impacting the person in various ways.
It is up to the human service professional to strive to understand
the transactional and reciprocal nature of these various systems
(Meyer, 1988).
It is important to note that these theories do not presume that
individuals are necessarily aware of the various systems they oper-
ate within, even if they are actively interacting with them. In fact,
Dan
Family
Faith
Community
Gender
Ethnicity Employer
FIGURE 1.1
Example of Common
Eco-Systems with the
Person in the Middle
Human Systems
Understanding and Mastery of Human
Systems: Theories of human development
Critical Thinking Question: The field
of human services focuses on the indi-
vidual within the context of her envi-
ronment. How might this perspective
lead a human service professional to
respond to a client differently than
would, say, a psychiatrist who focuses
on childhood trauma as the root of
adult dysfunction?
14 Part I / Human Services as a Profession
SELF-ACTUALIZATION
NEEDS
ESTEEM NEEDS
LOVE NEEDS
SAFETY NEEDS
PHYSIOLOGICAL NEEDS
efective human service professionals will help their clients increase their personal aware-
ness of the existence of these systems and how they are currently operating within them
(i.e., nature of reciprocity). It is through this awareness that clients increase their level of
empowerment within their environment and consequently in all aspects of their life.
MASLOWS HIERARCHY OF NEEDS Another effective model for understand-
ing how many people are motivated to get their needs met was developed by
Abraham Maslow. Maslow (1954) created a model focusing on needs motivation. As
Figure 1.2 illustrates, Maslow believed that people are motivated to get their most
basic physiological needs met first (such as the need for food and oxygen) before
they attempt to meet their safety needs (such as the security we find in the stability
of our relationships with family and friends). According to Maslow, most people
would find it difficult to focus on higher-level needs related to self-esteem or self-
actualization when their most basic needs are not being met. Consider people you
may know who suffer from low self-esteem and then consider how they might react
if a war suddenly broke out and their community was under siege. Maslows theory
suggests that thoughts of low self-esteem would quickly take a back seat as worries
about mere survival took hold. Maslows Hierarchy of Needs can assist human ser-
vice professionals in helping clients by recognizing a clients need to prioritize more
pressing needs over others.
FIGURE 1.2
Maslows Hierarchy of
Needs
Maslow, Abraham H.; Frager, Robert D.; Fadiman, James, Motivation and Personality, 3rd Ed., 1987.
Reprinted and Electronically reproduced by permission of Pearson Education, Upper Saddle River,
New Jersey
Introduction to the Human Services Profession 15
Understanding Human Services through a
Look at Practice Settings
It is important to remember that the nature of intervention is completely dependent on
the specifc practice setting where the human service professional is providing direct
service. Tus, how clients are helped to improve their personal and social functioning
will look very diferently depending on whether services are provided in a school set-
ting, a hospice, or a county social service agency. Human service professionals practice
in numerous settings, some of which include schools, hospitals, advocacy organizations,
faith-based agencies, government agencies, hospices, prisons, and police departments,
as well as in private practice.
It would be difcult to present an exhaustive list of categories of
practice settings due to the broad and ofen very general nature of
this career. Practice settings could be categorized based on the so-
cial issue (i.e., domestic violence, homelessness), target population
(i.e., older adults, the chronically mentally ill), or the area of spe-
cialty (i.e., grief and loss, marriage and family). Regardless of how
we choose to categorize the various felds within human services,
it is imperative that the nature of this career be examined and ex-
plored through the lens of practice settings in some respect to truly
understand both the career opportunities available to human ser-
vice professionals and the functions they perform within these various settings.
Some of these practice settings include (but are not necessarily limited to) medi-
cal facilities, including hospitals and hospices; schools; geriatric facilities, including
assisted-living facilities; victim advocacy agencies, including domestic violence, sexual
assault, and victimwitness assistance departments; child and family service agen-
cies, including adoption agencies and child protective service agencies; services for the
homeless, including shelters and the government housing authority; mental health cen-
ters; faith-based agencies; and social advocacy organizations, such as
human rights agencies and policy groups.
Regardless of the manner in which practice settings are catego-
rized, there is bound to be some overlap because one area of prac-
tice could conceivably be included within another feld, and some
practice settings could also be considered an area of specialization.
For instance, there are Christian hospices (medical social work and
faith-based practice), some human service professionals work with
both victims of domestic violence (victim advocacy) and batterers
(forensic human services), and adoption is sometimes considered a
practice setting unto itself and sometimes included under the um-
brella of child welfare.
For the purposes of this text, the roles, skills, and functions of
human service professionals will be explored in the context of par-
ticular practice settings, as well as areas of specialization within the
human services feldgeneral enough to cover as many functions
Human service professionals
practice in numerous settings, some
of which include schools, hospitals,
advocacy organizations, faith-based
agencies, government agencies,
hospices, prisons, and police
departments, as well as in private
practice.
Human Services
Delivery Systems
Understanding and Mastery of Human
Services Delivery Systems: Range and
characteristics of human services delivery
systems and organizations
Critical Thinking Question: Human ser-
vice professionals work in a wide variety
of settings, including hospitals, schools,
the legal system, child advocacy agencies,
and mental health clinics, to name just a
few. In what settings have you come into
contact with human service professionals
so far in your life?
16 Part I / Human Services as a Profession
and settings as possible within the feld of human services, but narrow enough to be
descriptively meaningful. Te role of the human service professional will be examined
by exploring the history of the practice setting, the range of clients, the clinical issues
most commonly encountered, mode of service delivery, case management, and most
common generalist intervention strategies within the following practice settings and
areas of specializations: child welfare, adolescents, geriatric and aging, mental health,
housing, healthcare and hospice, substance abuse, schools, faith-based agencies, vio-
lence, victim advocacy and corrections, and macro practice, including international
human rights work.
17
1. The following are reasons why people may need to
utilize human services:
a. Mental Illness
b. Racism
c. Trauma
d. All of the above
2. According to the chapter, someone is considered
to be working in the human services feld if he is
working
a. in the occupational and/or speech therapy felds
b. with marginalized, disenfranchised, or other indi-
viduals who are in some way experiencing prob-
lems related to various social or systemic issues
within society
c. with marginalized, disenfranchised, or other indi-
viduals who are in some way experiencing prob-
lems related to various personal or pathological
issues within oneself
d. None of the above
3. According to the National Organization for Human
Services, the human services profession is one which
promotes ______________ not only by addressing
the quality of direct services, but by also seeking to
improve _________________ among professionals
and agencies in service delivery.
a. a healthy lifestyle/collaboration
b. societal structures/accessibility and collaboration
c. improved service delivery systems/accessibility,
accountability, and coordination
d. None of the above
4. The Human Services Board Certifed Practitioner
(HS-BCP) is a
a. voluntary national professional certifcation
b. license that allows paraprofessionals to work in
schools and hospitals
c. name for the accreditation of human services
educational programs
d. national professional certifcation required by in-
surance companies for payment reimbursement
5. The foundational theoretical approaches to the hu-
man services discipline include
a. Person-in-Environment
b. Bronfenbrenners Ecological Systems Theory
c. Eco-systems Theory
d. All of the above
6. In Maslows Hierarchy of Needs, a person would frst
need to meet her _____ needs, before meeting her
_____ needs.
a. higher level/lower level
b. central level/lower level
c. internal/external
d. lower level/higher level
The following questions will test your knowledge of the content found within this chapter.
CHAPTER 1 PRACTICE TEST
7. Compare and constrast the human services feld with the social work and psychology disciplines.
8. Describe the basic tenets of Bronfenbrenners Ecological Sytems Theory and provide an example of how this
theory applies in the human services discipline.
18 Part I / Human Services as a Profession
Internet Resources
American Counseling Association: http://www.counseling.org
Council for Accreditation of Counseling & Related
Educational Programs: http://www.cacrep.org
Council for Standards in Human Service Education:
http://www.cshse.org
Human Services Career Network: http://www.hscareers.com
National Organization for Human Services: http://www.
nationalhumanservices.org
References
Beaucar, K. O. (2000). Licensing a mixed bag in 99. NASW News,
45(2), 9.
Bronfenbrenner, U. (1979). The ecology of human development:
Experiments by nature and design. Cambridge, MA: Harvard
University Press.
Gumpert, J., & Saltman, J. E. (1998). Social group work practice in
rural areas: The practitioners speak. Social Work with Groups,
21(3), 1934.
Maslow, A. (1954). Motivation and personality. New York: Harper.
Meyer, C. H. (1988). The eco-systems perspective. In R. A. Dorf-
man (Ed.), Paradigms of clinical social work (pp. 275294).
Philadelphia: Brunner/Mazel, Inc.
National Organization for Human Services. (n.d.). What
is human services? Retrieved from http://www.
nationalhumanservices.org/what-is-human-services
Rullo, D. (2001). The profession of social work. Research on Social
Work Practice, 11(2), 210216.
Rittner, B., & Wodarski, J. S. (1999). Differential uses for BSW and
MSW educated social workers in child welfare services. Children
& Youth Services Review, 21(3), 217238.
19
Learning Objectives
Recognize how economic,
religious, and social policies
influence societys perception
of the poor
Recognize the historic role of
people of color in the develop-
ment of the human services
profession
Understand the impact of the
Great Depression and the con-
text in which New Deal social
welfare programs were created
Compare and contrast con-
temporary socio-political
perspectives
Identify and develop methods of
identifying and addressing bias in
perceptions of disenfranchised
populations, including bias based
on race, socioeconomic status
(SES), gender, sexual orientation,
and age
History and Evolution of
Social Welfare Policy
Effect on Human Services
CHAPTER 2
The practice of helping others in need can be traced back to ancient
times, but the human services profession in its current context has his-
toric roots dating back to at least the late 1800s. Te development of the
social welfare system in the United States was very much infuenced by
Englands social welfare system; therefore, it is important to understand
the evolution of how the poor were treated in England to truly under-
stand how social welfare policy has developed within the United States.
The Feudal System of the Middle Ages
A good place to begin this examination would be in Englands Middle
Ages (the 11th century), where a system called feudalism prevailed as
Englands primary manner of caring for the poor. Under this elitist sys-
tem, privileged and wealthy landowners would parcel of small sections
of their land, which would then be farmed by peasants or serfs. Many
policy experts frame the feudal system not only as an efective method
for controlling poverty, but also as a governmentally imposed form of
slavery or servitude, because individuals became serfs through both
racial and economic discrimination and were commonly born into serf-
dom with little hope of ever escaping. Serfs were considered the legal
property of their landowner, or lord; thus although lords were required
to provide for the care and support of serfs in exchange for farming their
land, the lords had complete control over their serfs and could sell them
or give them away as they deemed ft (Stephenson, 1943; Trattner, 1998).
Despite the seeming harshness of this system, it did provide insur-
ance against many of the social hazards associated with being poor, and
it was complemented by the prevailing attitude toward the poor during
this time period, which was based on the notion that there was no shame
in poverty. In fact, the commonly held societal more during medieval
Everett Collection/SuperStock
20 Part I / Human Services as a Profession
times was that poverty within society was unavoidable, and the poor were a necessary
component of society, in that it gave an opportunity for the rich to show their grace and
goodwill through the giving of alms to those less fortunate than themselves. Te poor
were also necessary because without them there would be no servants.
Tis attitude was infuenced by religious teachings, particularly teachings within the
Judeo-Christian tradition, and was reinforced by church authorities, who shouldered
the primary responsibility, within a governmental capacity, of administering relief to
those unable to support themselves. Tus, caring for the poor was perceived as a noble
duty that rested on the shoulders of all those who were able-bodied. Almost in the same
way that evil was required to highlight good, poverty was likewise necessary to highlight
charity and goodwill as required by God.
A policy of charity is not limited to Judeo-Christian faiths though; in fact, most
religions include charity as requirements of faith. For instance, in Islam followers are
required to contribute a ffh of their income to the poor (Quran 8:41), and believers
also practice regular charity (Quran 2:43) and care for the orphans (Quran 2:177). In
the tradition of Buddhism (more correctly referred to as a philosophy than a religion
because of the lack of deity) sufering and giving are foundational to understanding the
meaning of life.
Te Middle Ages was a time when there was no separation of church and state;
therefore, the church and government were one and the same. Poor relief was han-
dled on a local level, with Catholic bishops administering aid through local parishes,
which were supported by mandatory taxes or compulsory tithing. Much of the rea-
son for the relative success of this system was due to the absence of many of the
issues with which contemporary society must contend. Populations were not nearly
as transient as they are now; in fact, residency requirements were strictly enforced,
thus many of the poor were known within the community and had perhaps been
former contributing members who had fallen on hard times. Te concept of commu-
nity as family was easier to envision when communities were small and completely
governed by the church (Trattner, 1998).
Poor Laws of England
Many economic and environmental conditions led to the eventual phasing out of
the traditional feudal system in the mid-14th century to the mid-16th century (1350
through 1550), including several natural disasters such as massive crop failures as well
as the bubonic plague; mass urbanization spawned by the wool industry; as well as the
Industrial Revolution in general. Te increased demand for factory wage labor in the
cities ultimately led to droves of individuals moving to the city to work in factories, and
this trend, coupled with the decline of the feudal system as well as the diminishing in-
fuence of the church with its complex and efective framework of charitable provision,
led to the need for a complete overhaul of the social welfare system in England. Tus,
although this vast wave of urbanization led to freedom of serfdom for the poorest in
England, it also generated a vacuum in how poverty was managed, creating the neces-
sity for the development of Englands earliest poor laws (Trattner, 1998).
History and Evolution of Social Welfare Policy 21
Although these social changes were gradual, they led to a dramatic shif in not only
how poverty was managed, but also how poverty was perceived. It is always easier to
have a gracious attitude and extend a helping hand to someone we know, but such gra-
ciousness becomes more challenging when the poor are no longer extended family and
longtime neighbors, whose personal circumstances are well known, but rather are name-
less, faceless strangers living en masse, ofen from diferent countries, speaking diferent
languages, and behaving in very diferent manners (Martin, 2010; Trattner, 1998).
Te increasingly impersonal nature of poor care as well as the complexity of life in
the city ultimately led to the belief that the incorporation of punitive measures into relief
policy was needed to control what was becoming a true social ill: begging, vagrancy, and
increased crime in the cities. In response, England passed several relief laws during the
mid-1500s through the early 1600s, which set forth guidelines for dealing with the poor.
Englands relief act of 1536 placed responsibility for dealing with the poor at the local
level and refected a complete intolerance of idleness. Local law enforcement scoured
the cities in search of beggars and vagrants, and once found, a determination was made
as to whether they were true victims of poverty (the worthy poor) or legally defned
vagrants (the unworthy poor). Legislative guidelines typically stipulated that only preg-
nant women, individuals who were extremely ill and unable to work, or any person over
the age of 60 were considered justifably poor, and thus they were treated more leniently,
including given governmental authorization to beg (typically in the form of a letter of
authorization), or they were given other forms of sustenance. If a person was found to
be able-bodied and unemployed, they were determined to be vagrant, punishable by
whippings, naked parading through the streets, being returned to the town of birth, or
incarceration. Repeat ofenders were ofen subjected to having an ear cut of or even
death (Beier, 1974; Birtles, 1999).
Clearly, there was no sympathy to be had for individuals, male or female, who were
deemed capable of working but found themselves without a job or any means of support,
and little consideration was given to economic difculties or what is now termed the
cycle of poverty. Also, little sympathy was extended to children, particularly adolescents
who were found begging, and district ofcials ofen took these children into custody,
placing them into an apprenticeship program, which was later considered to be little dif-
ferent from child slavery. Tus, vagrancy was handled as a criminal matter, and the local
authorities provided sustenance only for those truly unable to work (Trattner, 1998).
The Elizabethan Poor Laws***
Te earlier English poor laws laid the foundation for the Elizabethan Poor Laws of 1601,
which in turn acted as a foundation for American social welfare policy. Tus, rather
than viewing the Elizabethan Poor Laws of 1601 as a single act, it is more appropriate to
view it as an evolution, and the more fnal in a series of previous acts. Te Elizabethan
Poor Laws of 1601 served to set the stage for poor relief for several centuries and is
still considered foundational in contemporary social welfare policy in both England and
America. Tis act established three driving principles as the foundation for social leg-
islation, including the belief that the primary responsibility for provision lay with ones
22 Part I / Human Services as a Profession
family, that poor relief should be handled at the local level, and fnally, that individuals
should not be allowed to move to a new community if unable to provide for themselves
fnancially.
Charity included both indoor and outdoor relief, with the former referring to assis-
tance provided in almshouses and other institutionalized settings and the latter refer-
ring to services provided in the home environment of the person in need and might
involve the delivery of food baskets or medicine.
It was quite common for community members to bring charges against others if it
could be proven that they had moved into the district within the last 40 days and had
no means to support themselves. Such individuals would be charged as vagrants by the
local ofcials and returned to their home districts. Te underlying notion was that local
parishes didnt mind supporting those individuals who had fallen on hard times afer
years of paying taxes, but they didnt want to be forced to support strangers who came to
their district for the sole purpose of receiving aid. Elements of these residency require-
ments can be found among current U.S. welfare policy; in fact, most welfare reform bills
today contain residency requirement language.
Te Elizabethan Poor Laws of 1601 were then an organized merging of Englands
earlier, sometimes conflicting and erratic, social welfare legislation, which not only
brought order and organization to Englands poor laws, but also served as the foun-
dation for such legislation in colonial America. Life in colonial America not only
ofered tremendous opportunity, but also presented signifcant hardship related to life
on the frontier. Many immigrants were quite poor to begin with, and the long and dif-
fcult ocean voyage to the New World ofen lef them unprepared for the rigors of life in
America. Tus, even though colonial America ofered many opportunities not available
in the Old World, such as land ownership and numerous employment opportunities,
many of the social ills plaguing new immigrants in their homeland followed them to
America.
English colonization of North America began around the 16th century and contin-
ued throughout the 17th century. Because there was no existing infrastructure in the
original 13 colonies (such as religious monasteries or other social welfare programs),
poor relief consisted primarily of mutual kindness, family support, and distant help
from the motherland. Self-sufciency was a must, and life was not easy on the frontier.
But as the population increased within the colonies, the need arose for a more orga-
nized form of relief, and it makes sense that the colonies would rely on the English
Poor Laws.
Although the prevailing assumption among many is that the United States was
founded based on a desire to be completely diferent than England, in reality, the over-
riding reasons for the American Revolution, although certainly complex, were based
more on the desire for independence, rather than solely on the desire for a completely
diferent governmental structure. Tis presumption is evident in the development of
many of the social customs, governmental infrastructures, and legislation, including the
social welfare policy of the American colonies. Tus, the colonies adopted not only the
social welfare legislation of England, but much of the perceptions of and attitudes about
the poor and indigent as well.
History and Evolution of Social Welfare Policy 23
Te practice of human services is wholly infuenced by social welfare policy, and to
be truly efective in helping the poor and indigent, it is essential that all human service
providers gain a level of social and cultural objectivity so that they can
more fully understand both how social welfare policy and legislation
has evolved over the years and how the complex relationship between
such social welfare policy and legislation and the current prevailing at-
titudes toward the poor infuence one another. It would be nave to as-
sume that any current trends in how the poor are perceived and treated
developed in a vacuum; thus, a general understanding of the roots
of current social welfare legislation, policy, and attitudinal trends is essential to any
practicing human service professional.
The Protestant Reformation and Social Darwinism
Despite popular contention that economic policy practice is evidence-based, objective, and
free of ideological bias, signifcant evidence exists indicating that both historic and current
economic policy practice is solidly interwoven with moral philosophy, refecting the cultural
mores of the times as well as of the particular society (Hausman & McPherson, 2006). Social
policy, particularly policy addressing the social welfare of its citizenry, commonly refects
particular philosophical movements and themes. In the mid-19th century several philo-
sophical movements existed that attempted to address problems in the social world, particu-
larly problems of social inequity and poverty.
In his book Te Protestant Ethic and the Spirit of Capitalism, Max Weber described
in detail the vast infuence of John Calvins theory of Predestination, an integral aspect of
the Protestant Reformation and Puritan theology in the mid-16th century, on European
and American society. According to Weber, Calvin asserted that God perceived all
humans as sinful and wholly undeserving of salvation, yet God in his infnite wisdom
and providence determined who would go to heaven and who would be condemned to
hell, based solely upon his all-knowing determination of what action would best glorify
himself. Human action in an attempt to secure salvation thus was futile since ones eternal
fate rested not upon human goodness (which according to Calvin would always fall short
of the perfection of God), but solely upon Gods mysterious desire (Weber, 1905/1958).
Although Calvin rejected the notion that one could determine the state of ones sal-
vation from any outward signs, Weber notes that determining the state of grace of
oneself and others became an integral part of Reformed doctrine in part because a con-
siderable amount of social functioning depended upon societys ability to separate the
elect from the condemned. For instance, only Gods faithful were allowed to become
members of the church, receive communion, and enjoy other benefts of salvation (such
as societal respect).
In time particular behaviors and conditions became certain indicatorsor signs
of ones eternal fate. Most notably among these behaviors were hard work and good
moral conduct. The high value placed upon hard work, what Weber referred to as
the Protestant ethic, is refective of Calvins belief that one was called to a particular
vocation and should work tirelessly as a sign of faithfulness. Tus, according to Weber,
A general understanding of the
roots of current social welfare
legislation, policy, and attitudinal
trends is essential to any practicing
human service professional.
24 Part I / Human Services as a Profession
individuals did not need to endure a lifetime of questioning their salvation; rather, the
commitment to a strong work ethic was the best possible means of attaining this self-
assurance. Tis and this alone would drive away religious doubt and give assurance of
ones state of grace (Weber, 1905/1958, pp. 7778).
A life lived in pursuit of purity and denial of worldly pleasures, what Weber referred
to as Puritan asceticism, also became an indicator of ones state of grace because, ac-
cording to Calvin and Reformed theology, only members of the elect were capable of
manifesting such a state of sanctifed holiness. Tus, material success in response to
hard work and high moral conduct became the universally accepted signs among main-
stream (i.e., respectable) society of those predestined for eternal salvation (Hudson &
Coukos, 2005; Weber, 1905/1958).
The influence of the Protestant ethic and Calvins doctrine of predestination on
society as a whole, and specifically upon societys cultural mores related to poverty,
and the poor were signifcant, extending beyond that of the religious community (Kim,
1977). With hard work, good moral conduct, and material success serving as the best
signs of election to salvation, it did not take long for poverty and presumed immoral
behavior (because it was presumed that only the elect had the spiritual fortitude to behave
morally) to become a clear indication of ones condemnation (Chunn & Gavigan, 2004;
Gettleman, 1963; Hudson & Coukos, 2005; Kim, 1977; Schram, Fordingy, & Sossz, 2008;
Tropman, 1986; Weber, 1905/1958).
Social Darwinism was another social philosophy that signifcantly infuenced how
poverty and disadvantage were perceived and treated within the American social welfare
system. Social Darwinism involved the application of Charles Darwins theory of natural
selection to the human social world. Darwins theory, developed in the mid-19th century,
was based upon the belief that environmental competitiona process called natural
selection, ensured that only the strongest and most ft organisms would survive ( allowing
the biologically fragile to perish), thus guaranteeing successful survival of a species
(Darwin, 1859/2009). Darwins theory was focused primarily upon the biological ftness
of animals and plant life; yet, he did apply his theory to humans as well, providing natural-
istic explanations for various phenomena in human social life. Weikart (1998) describes
written discussions with contemporaries where Darwin espoused a belief that humans
were subject to natural law and that economic competition was a necessary component
of natural selection in the human species. In fact, Darwin even went so far as to argue
that socioeconomic inequality was primarily due to biological inequality, thus it could
not be avoided intimating that those in society who sufered poverty and other forms
of misfortune were merely victims of their own biological inferiority; therefore, their
demise was necessary in order for the survival of society as a whole (Weikart, 1998).
Tiel, another social Darwinist, argued that not only was the struggle for survival
within society unavoidable, it was desirable, asserting that competition for economic
resources should be maximized in order to weed out the weaker members of society,
thus allowing the biologically (and mentally) superior to prevail. Tiel (1868, as cited
in Weikart, 1998) cautioned against most forms of government intervention designed
to lif individuals out of poverty and misfortune, or create social equality, asserting that
giving the weak an opportunity to survive could actually pose a threat to society. In
History and Evolution of Social Welfare Policy 25
defending inequality within human society, Darwin and his colleague Tomas Henry
Huxley advocated social structures that allowed the more talented to advance and the
less competent to sink. Tey advocated economic inequality and the accumulation of
wealth as necessary for the progress of humanity (Weikart, 1998, p. 27).
One of the most infuential social Darwinists was Herbert Spencer, an English phi-
losopher who actually preceded Darwin in applying concepts of natural selection to the
social world. Spencer coined the term survival of the fttest (a term ofen incorrectly
attributed to Darwin) in reference to the importance of human competitiveness for lim-
ited resources in securing the survival of the fttest members of society. Spencer was a
ferce opponent of any form of government intervention or charity on behalf of the poor
and disadvantaged, arguing that such interventions would interfere with the natural or-
der, thus threatening society as a whole (Hofstadter, 1992). Although Spencers theory
of social superiority was developed in advance of Darwins theory, his followers relied
upon Darwins theory of natural selection for scientifc validity of social Darwinism.
Te fatalistic nature of social Darwinism and the Protestant ethic became deeply
imbedded in both American religious and secular culture and were used to justify a
laissez-faire approach to charity and social welfare throughout most of the 19th and
20th centuries (Duncan & Moore, 2003; Hofstadter, 1992). Although the specifc te-
nets of these ideologies may have sofened over the years, the signifcance of hard work,
good fortune, material success, and living a socially acceptable life have remained asso-
ciated with a collective sense of entitlement to special favor and privilege in life, whereas
poverty and disadvantage have remained associated with weak character, laziness, and
questionable behavior. Standing back then and leaving the poor and disadvantaged to
their own devices was perceived as nothing more than complying with Gods (or na-
tures) grand plan (Duncan & Moore, 2003).
The popularity of social Darwinism and the Protestant ethic in
American culture was related, at least in part, to the American cultural
more of rugged individualism and self-sufciency. Whereas traditional
Catholicism focused on the transformation of the community and the
giver by being blessed through the act of giving, the Protestant ethic
and social Darwinism focused on the individual who was transformed
(behaviorally) by the act of receiving (Duncan & Moore, 2003). With
the focus of charity placed upon the one in need, the dilemma faced
by the state and charity providers was determining who deserved help
and who did not (Chunn & Gavigan, 2004; Duncan & Moore, 2003;
Gettleman, 1963; Hudson & Coukos, 2005; Kim, 1977; Schram et al.,
2008; Tropman, 1986; Weber, 1905/1958). Tis dilemma led to the prac-
tice of categorizing the poor as worthy or unworthy based upon the
perceived cause of their impoverishment and misfortune and presumed
likelihood of behavioral change in response to charity. Yet, with many
asserting that providing charity to the poor would only serve to increase
their immorality and dependence, even the worthy poor experienced
difficulty in obtaining material assistance (Chunn & Gavigan, 2004;
Gettleman, 1963; Weber, 1905/1958).
Professional History
Understanding and Mastery of
Professional History: How public and
private attitudes influence legislation and
the interpretation of policies related to
human services
Critical Thinking Question: The influ-
ences of the Protestant ethic and
social Darwinism are unmistakable
in the history of U.S. social welfare
policy. In what ways are the concepts
of work and morality, survival of the
fittest, and the wor thy and unwor-
thy poor reflected in current policies
and in the attitudes of the U.S. public
today?
26 Part I / Human Services as a Profession
Tese ideological themes of moral defciency of the poor and the belief that giving
material support to the poor would only serve to increase their immoral nature, lazi-
ness, and dependency have been refected in the policy perspectives of the American
social welfare system at some level throughout U.S. history (Chunn & Gavigan, 2004;
Duncan & Moore, 2003; Gettleman, 1963; Hudson & Coukos, 2005; Kim, 1977; Schram
et al., 2008; Tropman, 1986).
Charity Organization Societies
Te Charity Organization Society (COS), ofen considered the genesis of the social ser-
vices, marked one of the frst organized eforts within the United States to provide char-
ity to the poor. Te COS movement started in about 1870 in response to frustration
with the current welfare system that was less of a system and more of a disorganized and
ofen chaotic practice of almsgiving. Te COS movement itself was started by a pastor,
Rev. S. Humphreys Gurteen, who believed that it was the duty of good Christians every-
where to provide an organized and systematic way of addressing the plight of the poor.
Gurteen and his colleagues strongly believed that the indiscriminate giving of alms by
many of the relief agencies of that time encouraged fraud and abuse, which in turn en-
couraged laziness on the part of those who were benefciaries of relief.
Te COS philosophy was built on the concept of voluntary coordination, in which
various charities worked within a larger network-coordinating services delivered to
the local community. Te frst COS was created in New York in 1877, and the concept
quickly spread to large cities across the nation. Soon, most large cities had at least one
COS serving the community, acting as an umbrella organization for smaller agencies
and churches ofering charity services to the community. Te COSs practiced what was
called scientifc charity, which embraced social Darwinist philosophies of intelligent
giving and embraced the notion that charity should work with natural selection, not
against it (Gettleman, 1963). A primary motivation of the COS movement was to coor-
dinate charity eforts by serving as an umbrella organization for the myriad of indepen-
dent and private charities, thus maximizing the best use of material relief (Schlabach,
1969). Outdoor relief, such as cash assistance or indiscriminate giving, was highly dis-
couraged and actually considered evil based upon the long-standing belief that such
assistance encouraged dependence and laziness, while discouraging self-sufciency,
which ultimately led to increased poverty (Gettleman, 1963; Kusmer, 1973).
In this respect, those involved in the COS movement embraced the concepts of the
unworthy and worthy poor, and it was their goal to determine which category aid re-
cipients fell into and then prescribe what each recipient actually neededmaterial aid
for those who would not abuse it and other services for those who would. To accom-
plish this goal, the COSs employed friendly visitors, an early version of caseworkers,
who visited the homes of aid applicants and attempted to diagnose the reason for their
poverty and, if possible, develop a case plan to authentically alleviate their sufering
(Trattner, 1998).
A social hierarchy was refected in the philosophical motivation of the COS leaders,
ofen the communitys most wealthy members, who agreed to provide charity to the poor
History and Evolution of Social Welfare Policy 27
dependent upon the poor remembering his place of inferiority (Gettleman, 1963, p. 319).
Yet, even the deserving poor did not escape the demands of the Protestant ethic or the
fatalism of social Darwinism, both of which were deeply imbedded in COS culture. Tese
philosophical values were clearly refected in a speech given by Josephine Shaw Lowell, a
leader in the COS movement, at a charity conference held in 1895, where she stated Even
the widow with little children, if she fnds that everything is made easy for her, may lose
her energy, may even, by being relieved of anxiety for them, lose her love for the children
(1895 as cited in Gettleman, 1963, p. 323). Te unworthy poor were ofen provided with
indoor relief almshouses only and, according to COS leaders, should be allowed to perish
according to natural selection. Many in the COS movement argued that to provide charity
to those destined to perish was immoral and unkind because it just served to prolong their
sufering to no good end for either the poor or society (Gettleman, 1963).
Mary Richmond, the general secretary of the Baltimore COS, is ofen associated
with the COS movement because of her passion for social advocacy and social reform.
Richmond believed that charities could employ both good economics and compassion-
ate giving at the same time. Richmond became well known for increasing public aware-
ness of the COS movement and for her fund-raising eforts. Richmonds compassion
for the poor was the likely result of her own experience with poverty. Orphaned at the
age of 2 and later lef by an aunt to fend for herself in New York when she was only
17 years old, Richmond no doubt understood the social components of poverty, and
how devastating it could be to ones life.
Richmond was responsible for developing the early conception of casework, having
written several books and articles on the service delivery model. As a result, the concept
of the friendly visitor grew, as did the debate about material relief continued, with many
arguing that the best opportunity to truly efect change in those sufering from poverty
was through the services of the friendly visitor who could help identify and address any
barriers to self-sufciency (Kusmer, 1973).
Despite the general success of the COS movement and the difcult task of basically
cleaning up the social welfare system in the postCivil War climate, the COS philosophy
was tinged by the Reformation theology that anyone who worked hard enough would be
blessed and could rise from the depths of poverty. Tis sentiment added to the general
sense of rugged individualism ofen worn as a badge of strength by many U.S. citizens.
But it was nave to presume that poverty was primarily caused by individual failure and
that material relief would lead to moral decline. Te country was about to learn a very
hard lesson during the Depression era, one that immigrants and ethnic minorities had
known for yearsthat sometimes conditions exist that are beyond an individuals control
and that create immovable barriers to self-sufciency, leading to poverty and complete
destitution.
Jane Addams and the Settlement House Movement
Not all social welfare movements within the United States refected these harsh philo-
sophical approaches though. Jane Addams, an advocate for social reform, was respon-
sible for beginning the U.S. settlement house movement in the late 1800s. Addamss
28 Part I / Human Services as a Profession
social action eforts refected a far more compassionate approach to poverty alleviation
and social inequity. Addams started the Hull-House Settlement house in Chicago
as an alternative to the more religiously oriented charity organizations, which she
perceived as heartless and overly concerned with efciency and rooting out of fraud
( Schneiderhan, 2008, p. 3). Addams used a relational model of poverty alleviation based
upon the belief that the problems of poverty and disadvantage resulted from problems
within society, not idleness and moral defciency (Lundblad, 1995). Addamss social
action eforts refected a far more compassionate approach to poverty alleviation and
social inequity. Addams advocated for changes within the social structure of society that
created barriers to lateral contribution of all members of society, which she viewed as an
essential aspect of a democracy (Hamington, 2005; Martin, 2012). In fact, the opening
of the frst settlement house in the United States was considered the beginning of one
of the most signifcant social movements in U.S. history (Commager, 1961, as cited in
Lundblad, 1995).
Addams was born in Cedarville, Illinois, in 1860. She was raised in an upper-class
home where higher education and philanthropy were highly valued. Addams greatly
admired her father, who encouraged her to pursue an education at a time when women
were primarily encouraged to pursue only marriage and motherhood. She graduated
from Rockford Female Seminary in 1881, the same year her father died. Afer her fa-
thers death, Addams entered Womans Medical College in Pennsylvania, but dropped
out because of chronic illness. Addams had become quite passionate about the plight
of immigrants in the United States, but due to her poor health and the societal lim-
its placed on women during that era, she did not believe that she had a role in social
advocacy.
Te United States experienced another signifcant wave of immigration in the 19th
and early 20th centuries (between 1860 and 1910), with 23 million people emigrating
from Europe, including Eastern Europe. Many of these immigrants were from non-
English-speaking countries, such as Italy, Poland, Russia, and Serbia, and thus did not
speak English, and were very poor. Unable to obtain work in the skilled labor force,
many immigrants were forced to live in subhuman conditions, crammed together with
several other families in deplorable tenements in large urban areas. New Yorks Lower
East Side had 330,000 inhabitants per square mile (Trattner, 1998). With no labor laws
for protection, racial discrimination and a variety of employment abuses were common,
including extremely low wages, unsafe working conditions, and child labor. Poor fami-
lies, particularly non-English-speaking families, had little recourse, and their mere sur-
vival depended on their coerced cooperation.
Addams was aware of these conditions because of her fathers political involvement,
but she was not sure how to respond. Despondent afer her fathers death and her fail-
ure in medical school, as well as over her chronic medical problems, Addams took an
extended trip with friends to Europe, where among other activities she visited Toynbee
Hall, Englands response to poverty and other social problems. Toynbee Hall was a
settlement house, which was essentially a neighborhood welfare institution in an urban
slum area, where trained workers endeavored to improve social conditions, particularly
by providing community services and promoting neighborly cooperation.
History and Evolution of Social Welfare Policy 29
This concept was revolutionary, in that in its attempt to improve conditions
through the promotion of social and economic reform, it actually called for the
settlement house workers to reside in the home alongside the im-
migrant families they helped. In addition to providing a safe, clean
home, settlement houses also provided comprehensive care, such as
assistance with food, healthcare, English language lessons, child care,
and general advocacy. Te settlement house movement was diferent
from the traditional charity organizations, in that it had as its goal
the mission of no longer distinguishing between the worthy and un-
worthy poor.
Addams returned home convinced that it was her duty to do something similar
in the States, and with the donation of a building in Chicago, the Hull House became
Americas frst settlement house in 1889. Addams and her colleagues lived in the settle-
ment house, in the middle of what was considered a bad neighborhood in Chicago,
ofering services targeting the underlying causes of poverty such as unfair labor practices,
the exploitation of non-English-speaking immigrants, and child labor. Services ranged
from child care to education classes. The Hull House became
the social center for all activities in the neighborhood and even
ofered residents an opportunity to socialize in the residents caf.
Addamss infuence of American social policy was signifcant,
in that it represented a shif away from the fatalistic and metaphys-
ical philosophies of Calvinism and social Darwinism, marking
recognition of the need for social change within society in order
to remove barriers to upward mobility and optimal functioning
(Martin, 2012). Addams and her counterparts were committed to
viewing all individuals equally, to be treated with respect and dig-
nity. Addams clearly saw societal conditions and the hardship of
immigration as the primary cause of poverty, not necessarily ones
own moral failing. Focus was placed on making changes in the
community, and social inequality was perceived as the manifesta-
tion of exploitation, with social egalitarianism perceived as not just
desirable but achievable (Lundblad, 1995, Martin, 2012).
Te settlement house movement radically transformed not
only how the poor were cared for, but also how they were per-
ceived by the majority population. Now, immigrants had a safe
place to live, a voice to advocate for them, and a way to better
integrate into American society, so that their dream of obtaining
a better life for themselves and their children could actually be
realized. Addams also lobbied tirelessly for the passage of child
labor laws and other legislation that would protect the working-
class poor, who were ofen exploited in factories with sweatshop
conditions. She also worked alongside Ida B. Wells, an African
American reformer, confronting racial inequality in the United
States, such as the extrajudicial lynching of black men.
The settlement house movement
was different from the traditional
charity organizations, in that it had
as its goal the mission of no longer
distinguishing between the worthy
and unworthy poor.
Abolishing the Sweating System poster.
Jane Addams Memorial Collection, Hull House
Association records, HHA negative 33, Special
Collections, University Library, University of Illinois
at Chicago
30 Part I / Human Services as a Profession
Although there are no working settlement houses today, the prevailing concept
espoused by this model involves recognition of the need for a holistic approach to pov-
erty alleviation that encompasses challenges to social structures, and not just a focus
on individual behavioral management. Elements of this concept can still be seen in the
current U.S. social welfare system, as well as its current mental healthcare system (see
Chapter 6); yet, unfortunately there would be far more future challenges to any philo-
sophical approach to poverty alleviation that considers social inequality as a core rea-
son for poverty, rather than personal moral failing. Tus, despite the overall success of
the settlement house movement and the particular success of Addams with regard to
achieving social reform in a variety of arenas, the infuences of Calvinism, particularly
the Protestant Ethic and social Darwinism remained strong, experiencing cyclical de-
cline only during difcult economic times or civil unrest (as experienced in the 1960s).
The New Deal and the Social Security Act of 1935
In 1929 the stock market crashed, leading to a series of economic crises such as the
United States had never before experienced. For the frst time in modern U.S. history,
large segments of the middle-class population were unemployed, and within a very
short time thousands of people who had once enjoyed secure lives were without jobs
and soon without homes and food as well. Tis served as a wake-up call for social re-
formers, many of whom had abandoned their earlier commitment to social activism.
In response, many within the human service felds started pushing President Hoover to
develop the countrys frst federal system of social welfare.
Hoover was resistant, though, fearing that federal social welfare would create depen-
dency and displace private and local charities. He wanted to allow time for democracy
and capitalism to self-correct before intervening with broad entitlement programs. But
much of the country, many of whom were literally starving, apparently did not agree,
and in 1933, Hoover lost his bid for reelection, and Franklin D. Roosevelt was elected as
president. Roosevelt immediately set about to create dramatic changes in federal policy
with regard to social welfare, promising a New Deal to the country, where a minimum
standard of living was seen as a right, not a privilege.
Within his first 100 days in office, Roosevelt passed 13 acts including the Civil
Works Administration (sometimes referred to as the CWA), which provided over a
million temporary jobs to the unemployed; the Federal Emergency Relief Act, which
provided direct aid and food to the unemployed; and the Civilian Conservation Core
(CCC), which put thousands of young men aged 18 to 25 to work in reforestation and
other conservation programs. Yet, as progressive as Roosevelt was, and as compassion-
ate as the country had become due to the realization that poverty could strike anyone,
racism was still rampant, as illustrated by Roosevelt placing a 10 percent limit on the
enrollment of black men in the CCC program (Trattner, 1998).
By far the most famous of all programs in the New Deal and Great Society programs
were those created in response to the Social Security Act of 1935, which among other
things created old age assistance, unemployment compensation, aid to dependent moth-
ers and children, and aid to the blind and disabled. In total Roosevelt created 15 federal
History and Evolution of Social Welfare Policy 31
programs as a part of the New Deal, some of which remain and some
of which were dismantled once the crisis of the Depression subsided.
Although some claim that the New Deal was not good for the coun-
try in the long run, it did pull the country out of the Depression, and
it provided relief for millions of Americans who may have literally
starved had the federal government not stepped in when it did. Pro-
grams such as the Federal Deposit Insurance Corporation (FDIC),
which provided insurance for deposits, helped to instill a sense of
confdence in the banking system once again, and the development
of the Securities and Exchange Committee (SEC), which regulates
the stock market, helped to ensure that a crash similar to the one
in 1929 would be unlikely to occur again. In later times though, the
dismantling of some post-Depression fnancial regulations would
contribute to yet another devastating economic downturnperhaps
not as severe as the Great Depression, but more serious and long-lasting than any other
recession experienced in the U.S. post-Depression era, particularly because of its global
consequences.
Infuences of African American Social Workers
A review of the historical elements infuencing the development of the human services
feld would be remiss if the infuences of African Americans reformers, particularly
African American women in the last part of the 19th century, werent explored. Black
activists had a signifcant infuence on the development of social justice and human ser-
vices, particularly in the South, flling the vacuum lef by a racist society that ofen cre-
ated barriers to service in the black community in earlier eras.
Ida B. Wells was an African American reformer and social activist whose campaign
against racial oppression and inequity laid the foundation for the civil rights movement
of the 1960s. Wells was born in 1862 to parents who were slaves in rural Mississippi, and
although her parents were ultimately freed, Wellss life was never free from the crushing
efects of severe racial prejudice and discrimination. Wells as orphaned at the age of 16,
and went on to raise her fve younger siblings. Tis experience not only forced Wells to
grow up quickly, but also seemed to serve as a springboard for her subsequent advocacy
against racial injustice. In Wellss early advocacy career, she was the owner of a black
newspaper (the only one of its kind) called Free Speech, where she consistently wrote
about matters of racial oppression and inequity, including the vast amount of socially
sanctioned crimes committed against blacks (Hamington, 2005).
Te indiscriminate lynching of black men was prevalent in the South during Wellss
lifetime, and was an issue that Wells became quite passionate about. Black men were
commonly perceived as a threat on many levels, and there was virtually no protection
of their personal, political, or social rights. Te black mans reputation of an angry rap-
ist was endemic in white society, and many speeches were given and articles written by
white community members (including clergy) about this growing problem. Davidson
(2008) references an article published in the mainstream newspaper in the South, the
Professional History
Understanding and Mastery of
Professional History: Historical and current
legislation affecting services delivery
Critical Thinking Question: The New
Deal created a number of social wel-
fare programs, many of which are still
in place. Who benefits from these pro-
grams? How have they contributed to
a shift in societal attitudes about basic
economic rights?
32 Part I / Human Services as a Profession
Commercial, entitled More Rapes More Lynchings, which cites the black mans penchant
for raping white women, stating:
Te generation of Negroes which have grown up since the war have lost in large
measure the traditional and wholesome awe of the white race which kept the
Negroes in subjection . . . Tere is no longer a restraint upon the brute passion of
the Negro . . . Te facts of the crime appear to appeal more to the Negros lustful
imagination than the facts of the punishment do to his fears. He sets aside all fear
of death in any form when opportunity is found for the gratifcation of his bestial
desires. (p. 154)
Wells wrote extensively on the subject of the myth of the angry black man, and
the myth that all black men raped white women (a common excuse used to justify the
lynching of black men) (Hamington, 2005). She challenged the growing sentiment in
white communities that black men, as a race, were growing more aggressive and lust-
ful, raping white women, accusations ofen used as a justifcation for lynching, and
prompted in part by the increasing number of biracial couples. Te response to Wellss
articles was swif and harsh. A group of white men surrounded her newspaper building
with the intention of lynching her, but when they could not fnd her they burned down
her business (Davidson, 2008).
Although this act essentially stopped her newspaper career, what this act of revenge
really did was to motivate Wells even further. Afer the burning of her newspaper Wells
lef the South and moved to Chicago where she continued to wage a ferce anti-lynching
campaign, ofen coordinating eforts with Jane Addams. She wrote numerous books and
articles on racial inequality, challenging socially entrenched notions that all black men
were angry and violent sexual predators (Hamington, 2005). Wells and Addams worked
as colleagues, coordinating their social justice advocacy eforts fghting for civil rights.
Together, they ran the Chicago Association for the Advancement of Colored People, and
worked collectively on a variety of projects, including fghting against racial segregation
in schools (Martin, 2012).
Many other key African American social welfare reformers made signifcant ad-
vances in the human services feld, particularly with regard to confronting the disen-
franchisement and marginalization of African Americans within U.S. society. In this
absence of mainstream human services within this population, African American social
welfare reformers operated as a tight community, developing close relationships with
each other, even though many of these women were spread across the United States. Be-
cause racism excluded African Americans from receiving many services, including edu-
cational opportunities and health services, many early social welfare reformers focused
on these two areas, developing Negro schools and healthcare facilities. One such re-
former was Modjeska Simkins, who developed healthcare programs for the black com-
munity focusing on everything from infant mortality to tuberculosis. Another creative
example of human services in the face of extreme opposition was the work of the black
sorority Alpha Kappa Alpha, whose members were determined to provide healthcare
services to sharecroppers in Mississippi. When the white community refused to rent
them ofce space, they ofered the health services from cars (Gordon, 1991).
History and Evolution of Social Welfare Policy 33
Other black women who signifcantly infuenced social welfare reform include Anna
Cooper, who pushed for increased educational opportunities for blacks; and Jane Hunter,
who formed the frst black Young Womens Christian Association (YWCA) (Gordon,
1991). Although ofen unreported and undervalued, African American social welfare
reformers not only assisted their own communities but helped the broader community as
well by modeling the power of networking and relentlessly pursuing social justice for all,
particularly for those who are the subject of social oppression and discrimination.
Gay Rights: From Marriage Equality to
Dont Ask Dont Tell Repeal
Ethnic minorities, women, and immigrants are not the only groups in U.S. society to be
used as scapegoats. Te gay community, typically referred to as the LGBTQ (lesbian, gay,
bisexual, transgendered, and questioning and/or queer), has long been a marginalized
group in the United States (as well as in most countries in the world). Members of the
gay community are ofen victims of horrifc hate crimes, ofen solely because of their
sexual orientation. For years this community has been excluded from many of the social
welfare laws designed to protect disenfranchised and socially excluded groups. Yet, in the
last three decades, several LGBTQ advocacy organizations, such as the Gay & Lesbian
Alliance Against Defamation (GLAAD), have become increasingly vocal about the right
of the LGBTQ community to live openly, and enjoy the same rights and protections as
heterosexuals without fear of reprisal. Specifc issues GLAAD has advocated for include
the right to be included as a specially protected group in hate crimes legislation, the right
to legal marriage (ofen referred to as marriage equality), and the right to serve openly in
the military.
Despite strong opposition from social conservative groups, the LGBTQ community
has experienced recent success in response to their eforts. In 2009 President Obama
signed into law the Matthew Shepard and James Byrd, Jr. Hate Crimes Prevention Act,
which expanded existing hate crime legislation to include crimes committed against in-
dividuals based upon perceived gender, sexual orientation, and gender identity. Mar-
riage equalitythe right of same-sex couples to get legally marriedis currently a battle
fought on both a federal and state level. In 1996 the Defense of Marriage Act was passed,
which defnes marriage on a federal level as a union between one man and one woman.
Yet, some states have passed laws legalizing same-sex marriage, including Massachusetts
and Iowa. Arguments for same-sex marriage are typically based upon rights of equality.
Te GLAAD website lists several protections that marriage ofers that are currently un-
available to the LGBTQ population in same-sex partnerships. Tese include
automatic inheritance
child custody/parenting/adoption rights
hospital visitation
medical decision-making power
standing to sue for wrongful death of a spouse
divorce protections
34 Part I / Human Services as a Profession
spousal/child support
access to family insurance policies
exemption from property tax upon death of a spouse
immunity from being forced to testify against ones spouse
domestic violence protections, and more (GLAAD, 2010, p. 7).
Arguments against same-sex marriages are ofen based upon religious values that
hold homosexuality as sinful and unnatural, and defne traditional marriage as being
between a man and a woman. Tere also appears to be a general fear that the normaliza-
tion of homosexuality will lead to the lowering of moral standards in a variety of respects
throughout society. Yet, advocates of same-sex marriage confront religious arguments
by citing research that disputes allegation that same-sex marriage will somehow dilute
traditional marriage or harm children. Tey also cite the increasing acceptance among
U.S. citizens of same-sex marriage and of homosexuality in general (according to a se-
ries of Gallup polls, in 2009, 63 percent of the U.S. population surveyed stated that they
believed that same-sex couples should be able to marry or have a legal civil union, com-
pared to 55 percent in 2004).
Another area of success for the LGBTQ population involves the right to serve in
the U.S. military openly. Historically, gays and lesbians were systematically discharged
from the military if their homosexuality was discovered. In December 1993, in
response to mounting pressure to change this policy, the Clinton administration com-
promised by implementing Dont Ask Dont Tell (DADT), an ofcial policy of the U.S.
government that prohibited the military from discriminating against homosexual
military personnel as long as they kept their sexual orientation as secret. In other
words, military personnel could no longer investigate ones sexual orientation, but if
a member of the military admitted to being a homosexual, he or she could legally be
discharged from the military. DADT was repealed by Congress in December 2010
pending review by military leadership who were to determine the efect on military
readiness, but in July 2011 a federal court of appeals ruling barred further enforce-
ment of the policy, and it was ofcially repealed by President Obama in September
2011. In May 2012 President Obama officially declared his support for marriage
equality, citing his daughters friends with same-sex parents, and his recognition that
he could not defend a position that would prohibit them from having the same right
to legally marry as heterosexual parents.
Tese achievements by the LGBTQ population seem to illustrate a movement to-
ward greater acceptance of what some call alternative lifestyles; yet, there remains
considerable resistance to the inclusion of homosexuality into mainstream America,
particularly among social and religious conservatives.
Welfare Reform and the Emergence of Neoliberal
Economic Policies
A resurgence of earlier negative sentiments toward the poor and their plight began in
the mid-1970s, peaking in the 1990s, perhaps in response to increased economic pros-
perity within mainstream America. Tis increased negative attitude toward the poor is
History and Evolution of Social Welfare Policy 35
refected in several studies and national public opinion surveys that refected the general
belief that the poor were to blame for their lot in life. For instance, a
national survey conducted in 1975 found that the majority of those liv-
ing in the United States attributed poverty to personal failures, such as
having a poor work ethic, poor money management skills, a lack of any
special talent that might translate into a positive contribution to society,
and low personal moral values. Tose questioned ranked social forces,
such as racism, poor schools, and the lack of sufcient employment, the
lowest of all possible causes of poverty (Feagin, 1975).
Ronald Reagan capitalized on this negative sentiment toward the
poor during the 1976 presidential campaign when he based his platform in large part
on welfare reform. In several of Reagans speeches he cited the story of the woman from
the South Side of Chicago who was fnally arrested afer committing egregious welfare
fraud:
She has eighty names, thirty addresses, twelve Social Security cards and is collecting
veterans benefits on four non-existing deceased husbands. And she is collecting
Social Security on her cards. Shes got Medicaid, getting food stamps, and she is
collecting welfare under each of her names. (Zucchino, 1999, p. 65)
While Reagan never mentioned the womans race, the context of the story as well as
the reference to the South Side of Chicago (a primarily black community) made it clear
that he was referring to an African American woman on welfarethus matching the
common stereotype of welfare users (and abusers) (Krugman, 2007). And with that, the
enduring myth of the Welfare Queen was born.
Journalist David Zucchino attempted to debunk the myth of the welfare queen in his
expose on the reality of being a mother on welfare, but stated in his book Te Myth of
the Welfare Queen that the image of the African American woman who drove a Cadillac
while collecting welfare illegally from numerous false identities was so imbedded in
American culture it was impossible to debunk the myth, even though the facts do not
back up the myth (Zucchino, 1999). Krugman (2007) also cites how politicians have
used the myth of the welfare queen in order to reduce sympathy for the poor and gain
public support for welfare cuts ever since, arguing that while covert, such images clearly
play on negative racial stereotypes. Tey also play on the common belief in the United
States that those who receive welfare benefts are poor due to immoral behavior and a
lack of motivation to work.
More recent surveys conducted in the mid-1990s revealed an increase in the tendency
to blame the poor for their poverty (Weaver, Shapiro, & Jacobs, 1995), even though a
considerable body of research points to social and structural issues as the primary cause
of poverty, such as shortages in affordable housing, recent shifts to a technologically
based society requiring a signifcant increase in educational requirements, longstanding
institutionalized oppression and discrimination against certain racial and ethnic groups,
and a general increase in the complexity of life (Martin, 2012; Wright, 2000).
Te general publics perception of social welfare programs seems to be based in
large part on this negative bias against the poor, and the misguided belief that the
A national survey conducted in 1975
found that the majority of those
living in the United States attributed
poverty to personal failures, such
as having a poor work ethic, poor
money management skills . . . and low
personal moral values.
36 Part I / Human Services as a Profession
poor were lazy, immoral, and dependent. In several studies during the 1980s and
1990s those surveyed claimed support for the general idea of helping the poor, but
when asked about specific programs or policies, most became critical of govern-
mental policies, specifc welfare programs, and welfare recipients in general. In fact,
a 1987 national study found that 74 percent of those surveyed believed that most
welfare recipients were dishonest and collected more benefts than they deserved
(Kluegal, 1987).
A new conservative political movement during this time period was born at least
in part out of this increasingly negative attitude toward the poor and social programs
designed to alleviate poverty, beginning during the Reagan administration in the 1980s
and ultimately leading to both Republican and Democratic support for drastic welfare
reform. Focus once again shifed from social and structural causes of poverty to per-
sonal ones with a renewal of punitive social welfare policies refecting the paternalistic
ideologies of the past (Schram et al., 2008).
Political discourse in the mid-1990s refected what are ofen referred to as economic
neoliberal philosophies, a political movement embraced by most political conservatives,
espousing a belief that capitalism and the free market economy were far better solu-
tions to many social conditions, including poverty, than government programs. Advo-
cates of neoliberalism pushed for social programs to be privatized based upon the belief
that getting social welfare out of the hands of government and into the hands of private
enterprise, where market forces could work their magic, would increase efciency and
lower costs. Yet, research consistently showed that social welfare services did not lend
themselves well to free market theory due to the complexity of client issues, as well as
unknown outcomes, lack of competition, and other dynamics that makes social welfare
services so unique (Nelson, 1992; Van Slyke, 2003).
In 1994, during the U.S. Congressional campaign, the Republican Party released
a document entitled Te New Contract with America, which represented a plan that
would reform welfare and, along with it, the behavior of the poor (Hudson & Coukos,
2005, p. 2). Te New Contract with America, introduced just a few weeks prior to the
1994 Congressional election, Clintons frst mid-term election, was signed by all but
two of the Republican members of the House of Representatives, as well as all of the
partys Congressional candidates. In addition to a renewed commitment to smaller
government and lower taxes, the contract also pledged a complete overhaul of the wel-
fare system to root out fraud and increase the poors commitment to employment and
self-sufciency.
Hudson and Coukos (2005) note the similarities between this political movement in
the mid-1990s and the one just 100 years before, arguing that Protestant ethic theology
served as the driving force behind both. Take for instance the common arguments for
welfare reform (policies that reduce and restrict social welfare programs and services),
which have ofen been predicated upon the beliefs that (1) hardship is ofen the result
of laziness; (2) providing assistance will increase laziness (and thus dependence), hence
increasing hardship, not decreasing it; and (3) those in need ofen receive services at the
expense of the working population (all of which were sentiments cited during the COS
era). A 1995 article in Time Magazine entitled 100 Days of Attitude captured this us
History and Evolution of Social Welfare Policy 37
versus them dynamic fostered in the debate on welfare reform in the mid-1990s. In his
article, Stacks (1995) described how the country was up-in-arms over public assistance
program, and this outrage spread quickly through the country. Te House held hearings
on the state of public welfare in the country in response to the uproar. One of the most
infammatory speeches heard on the House foor was when John Mica compared public
assistance users to alligators, arguing that if you treat the alligator like a pet or a child, it
will become dependent.
Such perspectives negate the complexity of economic disadvantage ofen experi-
enced by vulnerable and marginalized populations, and categorize the poor as a ho-
mogenous group that is in some signifcant way diferent with regard to character than
mainstream working society.
Te debate about public welfare also refected the genderized and racialized nature
of welfare contributing to institutionalized gender bias and racism. Whether veiled or
overt (such as Reagans welfare queen), negative bias bestowed upon female public wel-
fare recipients of color negates the disparity in social problems experienced by African
American women, including increased incidences of poverty, violence, and untreated
child sexual victimization, and their associated psychological and social problems
(El-Bassel, Caldeira, Ruglass, & Gilbert, 2009; Martin, 2012; Siegel & Williams, 2003).
Although welfare reform was initiated by a Republican Congress, it was passed
by the Democratic Clinton administration, in the form of the Personal Responsibility
and Work Opportunity Act (PRWORA) of 1996, illustrating wide support not only for
welfare reform but also for the underlying philosophical beliefs about the causes of pov-
erty and efective poverty alleviation methods. PRWORA of 1996 refected a marked
shif away from its predecessor, the Aid to Families with Dependent Children (AFDC),
an entitlement program created under the New Deal. Many social welfare advocates
believe that the new program, Temporary Assistance for Needy Families (TANF), is
very punitive in nature, with strict time limits for lifetime benefts (ranging between
three and five years depending upon the state), stringent work requirements (often
regardless of circumstances), and other punitive measures designed to control the
behavior of recipients. Supporters of welfare reform and the passage of PRWORA relied
on old arguments of Calvinism and social Darwinism, citing the need to control welfare
fraud and welfare dependency, among a host of other behaviors exhibited by welfare
recipients, such as sexual promiscuity and having children out of wedlock (Hudson &
Coukos, 2005).
The Christian Right and Welfare Reform
A powerful voice within the Republican Party that was a big backer of welfare reform is
ofen called the Christian Righta group of individuals, ofen Evangelical Christians,
who espouse conservative family values. Conservative Christian organizations, such
as the Christian Coalition, the Eagle Forum, and Focus on the Family have wielded
considerable infuence within the Republican Party beginning in the 1980s, becoming
a fringe core of the party in the 1990s (Green, Rozell, & Wilcox, 2003; Guth & Green,
1986; Knuckey, 2005). Tese groups were instrumental in the call for welfare reform,
38 Part I / Human Services as a Profession
voicing significant concerns about moral decline in society and citing the need to
defend and uphold traditional family values (Reese, 2007; Uluorta, 2008).
Uluorta (2008) points out that far too ofen morality within the United States is a
highly circumscribed concept that ofen confnes itself to select individual behaviors
such as those pertaining to sex and sexuality (e.g., abortion, abstinence), marriage (e.g.,
gay marriage) and social standing (e.g., welfare reform) (pp. 253254). Many within
the Christian Right were fervent supporters of welfare reform, and specifically the
PRWOA of 1996 because of its focus on behavioral reform, including the promotion of
marriage and sexual abstinence (Reese, 2007). As an example of the Christian Rights
focus on individualism, morality, and social responsibility, Uluorta (2008) references
Evangelical pastor Rick Warrens book Te Purpose Driven Life: What on Earth Am I
Here For?, where Warren states that the only way to fnd true purpose in ones life is
through individual responsibility, discipline and being born-again (p. 254). While in-
dividual responsibility is certainly a trait worth achieving, it also can be a code word
for philosophies that scapegoat the poor, and minimize long-standing social inequality.
Te ability of the conservative Christian movement to mobilize its members into
political action is notable. For instance, Uluorta (2008) points out the political lobbying
success of Focus on the Family, a conservative Evangelical Christian organization that
broadcasts its messages on over 1,600 radio stations and 16 television stations nation-
wide, has a frequently used website, and disseminates newsletters and political action
alerts via email and physical mail to millions of members who are ofen asked to strongly
advocate for the organizations policy positions refecting its socially conservative values
(focusing primarily on the support of traditionally moral behavior). Tis level and
type of mobilization is of great concern to many within the human services felds and
others who advocate for a more compassionate approach to helping the poor and dis-
advantaged, and who recognize the wide range of ways to frame social problems (and
their causes), rather than focusing solely upon perceived behavioral patterns of those
who are struggling. Te rhetoric of the Christian Right and other socially conservative
groups ofen frame their arguments in terms of tradition, yet their version of American
tradition, and patriotism ofen refects the experiences of the majority population, the
majority of whom have had the cumulative beneft of white privilege (Martin, 2012).
White privilege is a social phenomenon where Caucasian members of society enjoy a distinct advantage
over members of other ethnic groups. White privilege is defned as unearned advantages of being white
in a racially stratifed society and an expression of institutionalized power (Pinterits, Poteat, & Spanier-
man, 2009, p. 417). It is something that most Caucasians do not acknowledge leading many of those who
beneft from this advantage to take personal credit for whatever they gain through white privilege (Neville,
Worthington, & Spanierman, 2001). Unfortunately, this also means that many Caucasians also blame those
from non-Caucasian groups for not being as successful. Yet, due to various forms of racial discrimination, it
has typically been the white man who has benefted most from the best that life has to offergaining ac-
cess into the best educational systems (or being the only ones to obtain an education at all), the best jobs,
and the best neighborhoods. Even if white privilege were to end, the cumulative beneft of years of advan-
tage would continue well into the future, just as the negative consequences of years of social exclusion will
continue to negatively affect diverse groups who have not benefted from white privilege.
Box 2-1
History and Evolution of Social Welfare Policy 39
The Tea Party Movement
Another conservative social movement, which appears to overlap at least to some
extent with the Christian Right, is the American Tea Party Movement, a social move-
ment and a part of the Republican base that advocates for smaller government, lower
taxes (the name of the group is a reference to the Boston Tea Party), state rights, and
the literal interpretation of the U.S. Constitution. The Tea Party
movement has quickly gained a reputation for advocating on be-
half of very conservative policies, similar in many ways to the
Christian Right. Michele Bachmann, a 2012 presidential candidate,
was criticized for her alleged position on gay and lesbian rights,
in relation to her and her husbands Christian counseling prac-
tice, which, according to a former gay client, claimed endorsed a
pray the gay away approach to counseling homosexual clients
(Bachmann denies this) (Ross, Schwartz, Mosk & Chuchman,
2011). Tere have also been allegations made against some mem-
bers of the Tea Party movement for their stance on immigration
and racial issues in general, which appear to be based upon nega-
tive racial stereotypes. Te media has consistently highlighted the
racially charged tone at some Tea Party political rallies, pointing
out racial slurs on posters, many of which are directed at President
Obamas ethnic background, although proponents of the Tea Party complain that
the media is exaggerating racist elements at the protests and rallies by seeking out
and over-focusing on the more extremist elements of the movement. Although tea
partiers ofen deny racist or homophobic values, a recent study showed that about
60 percent of tea party opponents believed that the movement had strong racist
and homophobic overtones (Gardner & Tompson, 2010). Currently the Tea Party
is considered a part of the Republican base, but it appears to be creating some
controversy within the party, particularly among the more moderate base. Whether
the Tea Party remains a part of the Republican Party or braches of to its own party
will depend upon many factors, including whether it can maintain its current
momentum and increase the number of supporters.
A Time for Change: The Election of the First
African American President
Te 2008 presidential election was unprecedented in many respects. Te United States
had its frst African American presidential candidate and its frst female presidential
candidate of a major party. Many people who have historically been relatively apathetic
about politics were suddenly passionate about this election for a variety of reasons.
Growing discontentment with the leadership of the preceding eight years coupled with
a lengthy war in the Persian Gulf region and a struggling economy created a climate
where signifcant social change could take root. Barack Obamas campaign slogans based
upon hope and change (e.g., Yes We Can! and Change We Can Believe In) seemed to
capture this growing discontent. Many human service professionals and other advocates
Human Services
Delivery Systems
Understanding and Mastery of Human
Services Delivery Systems Political and
ideological aspects of human services
Critical Thinking Question: Issues such
as abortion, same-sex marriage, and
immigration are hotly contested in the
United States today. What factors should
human service professionals take into
account in deciding whether, and how,
to advocate for policies congruent with
their political and/or religious beliefs?
40 Part I / Human Services as a Profession
hope that the election of President Obama has signaled a move to-
ward a more compassionate treatment of social problems, including
poverty.
Te fedgling economy of 2007 evolved into an economic melt-
down toward the end of the Bush presidency and extended into the
Obama administration, evidenced by a plummeting stock market, the
near-collapse of the banking industry, and the real estate bubble at
a level not experienced since the Great Depression (Geithner, 2009).
Whereas some economists have argued that this economic crisis is a
result of the combination of many forces and trends, including globalization, technologi-
cal innovation, and a changing workforce Kevin Doogan (2009), Jean Monnet Professor
of European Policy Studies at the University of Bristol and author of New Capitalism? Te
Transformation of Work, discusses the efect of a primarily unregulated free market and
unrestrained CEO compensation, resulting in federal fnancial bailouts of banks and a
changing corporate structure. Doogan suggests that much of this most recent fnancial
crisis is a result of manufactured insecurities and unrestrained exposure to market forces.
Doogans critique of neoliberal policies might seem anticapitalist to some political con-
servative advocates, but upon further analysis it seems clear that some balance must be
achieved between free market forces, which can stimulate the economy by creating a
spirit of competition, thus theoretically keeping prices low and quality high, with support
for a strong nation-state that provides a safety net for all of its constituents.
President Obama and the 111th Congress responded to the economic crisis with
several policy and legislative actions, including the passage of the American Recovery
and Reinvestment Act of 2009 (ofen referred to as the Stimulus bill [Pub. L. No. 111-5]).
Tis economic stimulus package, worth over $787 billion, includes a combination of
federal tax cuts, various social welfare provisions, and increases in domestic spending,
designed to stimulate the economy and assist Americans who were sufering economi-
cally. It will be some time before economists and the American public comes to a con-
sensus on whether the stimulus package was successful in turning the economy around.
In the meantime, the lead-up to the 2012 presidential elections revealed the same
debate about the causes of poverty and efective poverty alleviation strategies. Afer a
brief display of compassion toward the poor at the height of the 2008 economic crisis,
harsh sentiments refecting historic stigmatization of the poor were strongly espoused,
particularly among potential Republican primary candidates who continued their cam-
paign against big government, social welfare programs, and civil liberties in general.
One Republican presidential hopeful, Newt Gingrich, even went so far as to challenge
current child labor laws, calling them stupid (see Chapter 4 for a discussion on the his-
tory of child labor in the United States where African American and immigrant children
faced life-threatening conditions working 12-plus hours a day in dangerous factories).
In a campaign speech in Iowa in the fall of 2011, Gingrich scapegoated the poor, playing
on negative racial stereotypes by characterizing poor ethnically diverse children living
in poor neighborhoods as lazy and having no work ethic. In two diferent speeches (his
initial speech and a subsequent speech where he was asked to clarify his earlier com-
ments), Gingrich suggested that poor children in poor neighborhoods could start work
Some balance must be achieved
between free market forces, which
can stimulate the economy by
creating a spirit of competition, . . .
[and] support for a strong nation-
state that provides a safety net for
all of its constituents.
History and Evolution of Social Welfare Policy 41
early, perhaps as janitorial staf in their own schools. Characterizing most poor children
in economically challenged neighborhoods Gingrich stated that these children have:
No habits of working and nobody around them who works . . . they have no habit
of showing up on Monday and staying all day or the concept of I do this and you
give me cash, unless its illegal.
In his follow-up statements, he clarifed his earlier comments by stating:
You have a very poor neighborhood. You have students that are required to go to
school. Tey have no money, no habit of work . . . What if you paid them in the
afernoon to work in the clerical ofce or as the assistant librarian? And let me get
into the janitor thing. What if they became assistant janitors, and their job was to
mop the foor and clean the bathroom?
Framing his comments in religious terms, Gingrich concluded by stating:
If we are all endowed by our creator with the right to pursue
happiness, that has to apply to the poorest neighborhoods in
the poorest counties, and I am prepared to fnd something that
works, that breaks us out of the cycles we have now to fnd a way
for poor children to work and earn honest money. (Dover, 2011,
para 35)
Gingrichs comments clearly refect the same rhetoric rooted in
Calvinism and the Protestant Ethic theology, social Darwinism, and
even Scientifc Charity practiced through the centuriesthe very
philosophies that Jane Addams and other social reformers worked
so hard to challenge. Such sentiments presume a level playing feld
in society, negating current and historic social forces, such as ra-
cial oppression and white privilege that have consistently given one
group an unfair advantage for centuries.
Concluding Thoughts on the History of Social welfare policy
As often happens in broad-based economic downturns, this most recent recession
seems to have led to a sofening of antipoverty rhetoric and a political discourse that
recognizes the importance of an efective social welfare system for all Americans. Dis-
cussions of the need for universal healthcare, a federal living wage, and other policies
designed to address the dire fnancial situation that so many in the United States found
themselves facing, including employment lay-ofs and home foreclosures at a rate not
seen since the Great Depression, will be ongoing. Te debate regarding how capitalism
and a free market economy can be balanced with a social safety net for all members of
U.S. society continues to rage among politicians and the public alike and will no doubt
continue to continue for many years into the future. Unfortunately this sentiment ap-
pears to be short-lived, as anti-poor rhetoric and calls for cut backs in social welfare
programs, including Medicare and Social Security, are increasing, alongside modest
Professional History
Understanding and Mastery of
Professional History: Exposure to a
spectrum of political ideologies
Critical Thinking Question: The rel-
atively liberal ideology of President
Obama and his supporters contrasts
sharply with the conservatism of the
Christian Right and the Tea Party move-
ment. How have these competing views
influenced the development of policies
related to social welfare?
42 Part I / Human Services as a Profession
improvements in the U.S. economy. Only time will tell where U.S. society ultimately will
fall in the philosophical spectrum of individual responsibility and social equity.
Social movements appear to be on the rise, with passionate supporters of both lib-
eral causes, such as the Marriage Equality, and more conservative social movements,
such as Pro-Life and anti-immigration movements dominating political rhetoric, and
leading to increased polarization within U.S. society. Human service professionals can
positively engage in a variety of social movements by advocating for social equality in
productive ways that does not necessarily contribute to existing polarization. Many of
these advocacy techniques will be discussed in subsequent chapters focusing on specifc
social problems.
43 CHAPTER 2 PRACTICE TEST
1. The feudal system was:
a. Englands primary manner of caring for the poor
prior to the Middle Ages
b. a system of care based upon feuds between
rival communities where prevailing villages were
compelled to provide care for those communities
they conquered
c. an elistist system where privileged and wealthy land-
owners would parcel off small sections of their land,
which would then be farmed by peasants or serfs
d. Both A and C
2. The theory that competition over resources was
necessary in life in order to weed out those who
were ill-equipped to manage lifes challenges and
complexities is called
a. predestination
b. evolutionary Darwinism
c. social Darwinism
d. None of the above
3. The English Poor Laws of 1601 established three
driving principles as the foundation for social legisla-
tion, including the belief that:
a. the primary responsibility for provision lay with
ones family
b. poor relief should be handled at the local level
c. no individual should be allowed to move to a new
community if he or she was unable to provide for
themselves fnancially
d. All of the above
4. In what way was the settlement house movement dif-
ferent from the traditional charity organizations?
a. Its goal was to no longer distinguish between the
worthy and unworthy
b. It provided only counseling rather than focusing
on comprehensive care
c. It focused on providing services to adults only
rather than providing services to the entire family
d. It worked diligently to prohibit immigrants from
receiving the same benefts as U.S. citizens
5. Modjeska Simkins, Ida Wells, and Jane Hunter are ex-
amples of:
a. former settlement house residents who went on
to infuence social policy by engaging in advocacy
efforts on a policy level
b. leaders in the American suffrage movement that
gave the women the right to vote
c. African American social workers who developed
social programs for black communities since most
social welfare programs often excluded African
Americans
d. Both A and B
6. Civil Works Administration (CWA), the Federal
Emergency Relief Act (FERA), the Civilian Conserva-
tion Core (CCC), and the Social Security Act of 1935
are examples of:
a. programs created by President Lyndon B. Johnson
in response to the Great Depression
b. programs created by President Roosevelt in
response to the Great Depression
c. programs created by President Hoover in
response to the ongoing effects of World War II
d. programs created in response to legislation
passed by Jane Addams and Dorthea Dix
The following questions will test your knowledge of the content found within this chapter.
7. Describe the concept of the Myth of the Welfare Queen, including the roots of this myth, and the short- and
long-term effect of its existence.
8. Compare and contrast AFDC and TANF. What are the pros and cons of 1996 welfare reform?
44 Part I / Human Services as a Profession
Suggested Readings
Carlton-LaNey, I. B. (2001). African American leadership: An em-
powerment tradition in social welfare history. Washington, DC:
NASW Press.
Katz, M. B. (1990). Undeserving poor. New York: Pantheon.
Katz, M. B. (1996). In the shadow of the poorhouse: A social history
of welfare in America. New York: Basic Books.
Linn, J. W., & Scott, A. F. (2000). Jane Addams: A biography. Chi-
cago: University of Illinois Press.
Martin, J. M., & Martin, E. P. (1985). The helping tradition in the
black family and community. Washington, DC: NASW Press.
Reisch, M., & Andrews, J. (2002). The road not taken: A history of
radical social work in the U.S. Washington, DC: Taylor & Francis.
Internet Resources
Jane Addams Hull House: http://www.hullhouse.org
Jane Addams Hull-House Museum: http://www.uic.edu/jaddams/
hull/hull_house.html
The Social Work History Online Timeline: http://www.gnofn.
org/~jill/swhistory
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46
CHAPTER 3
Learning Objectives
Defne ethics and morality
within a professional context,
identifying the nature of moral
relativism
Identify Kohlbergs stages of
moral development, and apply
these stages to a professional
ethical code of conduct
Describe the purpose of pro-
fessional ethical standards in
general and in human services in
particular in relation to resolving
ethical dilemmas
Identify multicultural consider-
ations in relation to professional
ethical standards and resolving
ethical dilemmas, analyzing how
cultural diversity affects ethical
perceptions and decision-making
Describe the ethical standards
for human services, and apply
these standards to various types
of ethical dilemmas common to
the human services feld
Ethics can be defned in many diferent ways, with most defnitions in-
cluding references to a set of guiding principles or moral values. In a
professional context, ethics ofen refers to a set of standards that provide
guidance to individuals within a particular discipline with the goal of as-
sisting them in resolving ethical dilemmas they are likely to face. Regard-
less of how ethics per se is defned, ethical standards, within virtually all
contexts, are by defnition based on a foundational value system designed
to tell us what good behavior is and what bad behavior is. Or, another
more basic way of putting it is that ethical standards and principles tell us
what we ought to do in any given situation.
Now you might be asking yourselfIm a good person, so why do I
need a detailed set of ethical values to tell me what to do? Dont good people
behave good naturally? Te answer may surprise you! Although it may be
true that very few people wake up in the morning and say to themselves,
Hey! I think Im going to lie, cheat, and steal today!, it is true that many
people become hysterical or enraged, or are biased, selfsh, nave, or igno-
rant, and in the process of being so very human, they may very well behave
quite unethically as they make decisions based on their urges, desires, pas-
sions, personal biases, negative stereotypes, or uninformed opinions.
Ethical values and principles are a very necessary part of life, both
personally and professionally, and although some may argue that their
personal ethical values are not necessarily tied to their professional eth-
ics, a strong argument can be made that they are in fact very much a re-
fection of one another. Most of you probably remember former president
Bill Clintons impeachment hearings, which centered on his perjury in
a sexual harassment claim fled against him, as well as his inappropriate
relationship with a young White House intern. Many of his supporters
argued fervently that what he did in his personal life had no bearing on
Professional Ethics
and Values in
Human Services
Tom Herzberg/Images.com
Professional Ethics and Values in Human Services 47
his ability to be a good president. Yet others argued that poor character
demonstrated in ones personal life will most defnitely play out in ones
professional life, and one cannot draw a line between these two domains.
Moral, But by Whose Standards?
It would be very convenient if there were one long list of rules and all situations could be
perceived in the same manner by everyone. But of course that is not how life works. Most
people will argue that there are universal moral principles, particularly relating to issues
such as murder, robbery, child abuse, and sexual assault. But even with these seemingly
black-and-white moral issues, the gray seems to abound. Such is the case when someone
kills in self-defense, or someone steals bread for a starving child. So, is morality absolute
or relative? What I mean by this is, is there an absolute right and wrong in this world? Or,
is the rightness and wrongness of a decision or action dependent on perspective, culture,
or ones own truth? Tis is an age-old question and not one that I will answer defnitively
here. In fact, many moral theorists deal with this very issue, and although some argue
for either extreme position, most will argue that both are truethere are ultimate moral
principles that are universal (e.g., sexually abusing a child is always wrong) and there
are many occasions when one must consider the appropriateness of a certain behavior
within the context of ones culture (e.g., burping in public).
I want to address some of the issues that have the greatest potential of muddying
the waters a bit when it comes to determining how we know whether an action is moral
or immoral, which in turn will help us determine how we can ensure were making
moral decisions. We will then apply what weve learned to the professional arena, spe-
cifcally the human services profession.
Ethical Values versus Emotional Desires: I Know It Was Wrong,
But We Were in Love!
Other than the most rigid people, most people will find themselves caught in a tug-
of-war between their ethical standards and their emotional desires, or feelings, with
the latter often leading to breaking down of moral behavior at some point in their
lives. I have a counseling practice, and I often tell my clients that feelings and emo-
tions are like the interior design of a housemoving and poignant, even beauti-
ful at timesbut truly useful only if protected by the exterior and structure of the
housethe walls and roof, which are the framework, like our ethical standards,
values, and principles. Thus, although human beings are certainly emotional, indi-
viduals with high character are not driven to act solely on the basis of their desires
and passions.
In fact, individuals who are motivated primarily by emotions are ofen emotionally
unstable, not because their emotions are wrong, but because their values and principles
are not well-enough defned and/or developed to contain or regulate their emotions,
ofentimes leading to the inability to control their impulses. For instance, an employee
might become angry with the boss and feel like striking the boss, but doesnt because
Ethical standards and principles tell
us what we ought to do in any given
situation.
48 Part I / Human Services as a Profession
the employee values nonviolence. A persons ethical values should then be the rudder of
behavior, and although there are certainly times when people will be driven by passion,
or will need to follow their hunches, emotions and desires serve people best when they
arent chief in the decision-making process.
Another reason why it is important to understand the relationship between our
ethical values and our emotions is because we ofen use our emotions to justify our un-
ethical behavior. Cheating on a test is wrong, unless the test is too hard and we hate our
teacher; adultery is wrong, unless were in a loveless marriage, are extremely lonely, and
fall hopelessly in love with someone else; lying is wrong, unless we need the day of and
will get paid only if we say were sick, even though were not; violence is wrong, unless
were provoked; and drinking too much alcohol is wrong, unless weve gone two weeks
without and just had a very bad day. Tus, one of the primary functions of ethical values
is to keep us on a good moral track, particularly when we fnd our ethical values at odds
with our emotional desires and urges. Certainly there are times when emotions should
lead, and we certainly do not want to become heartless in our application of rules.
When someone is driven to act solely on the basis of their values or rules, they are ofen
deemed rigid legalists. But when someone behaves in a manner that is solely driven by
their feelings and desires, they are ofen deemed immature, volatile, and impulsive.
When Our Values Collide: I Value Honesty,
But What if Lives Are at Stake?
Ethical behavior is not just made difcult because of competing emotions and desires,
but ofentimes we fnd ourselves in situations where our values are competing with one
another. We value family dinners with our kids, but what if that conficts with our value
of their extracurricular involvement? We value our friendships, but what if they are in-
terfering in our marriage that we also value? Many times people act in a way that is
later perceived to be unethical, when at the time they were committing the act they may
have believed that they were acting in a very ethical manner, but were forced to choose
among competing values. Employees who shred documents to protect their employers
may very well believe they were acting ethically based on their ethical value of loyalty to
their employer. Yet, they may later be charged with obstruction of justice because some-
one else perceived their behavior to be immoral. Perhaps in retrospect these employees
will realize that their values were misguided, or they may forever believe as though they
were behaving morally and the government was not.
In 1945 when Corrie ten Boom was hiding Jews in her attic, she chose to lie to the
Nazi ofcers who came to her door questioning her, even though she believed lying
to be wrong (ten Boom, Sherrill, & Sherrill, 1974). Corrie was put in a position where
she had to choose the higher value. What did she value more? Complete honesty at all
costs? Obedience to authority? Personal safety? Or interceding in matters of inhumane
cruelty and injustice at all costs? In light of what we now know about Nazi Germany
and the Holocaust, Corrie and her family are lauded as heroes, behaving in the highest
moral fashion, refusing to stand by and do nothing as an evil government slaughtered
millions of innocent people. Yet, does this mean that those who did not hide Jews acted
Professional Ethics and Values in Human Services 49
immorally? What if you had the opportunity to interview a family
who refused to hide a Jewish neighbor? What if this family told you
that Nazis used the practice of dressing as Jews and going door-to-
door asking for refuge and that the punishment for harboring a Jew
was imprisonment in a concentration camp, and likely death? What
if this family explained that they believed they behaved morally be-
cause their frst responsibility was to protect their children? Would
you still consider their behavior immoral? Or, what about the rul-
ing authorities perspective? Corrie ten Boom and her family broke
the law. From the authorities perspective, then, their behavior was
immoral. What makes the ten Boom familys behavior moral now?
Our belief that the Nazis were evil? So does this mean that if you or I
believe that a particular law, or even our entire government, is evil
that wed be justifed in disobeying its laws? Many protective parents kidnap their chil-
dren because they strongly believe that the family courts will not protect the children
from the other abusive parent. If this is true, is their behavior justifed? Many African
American men believe that if they are pulled over by the police, it is because they are be-
ing racially profled, and they may be arrested for no reason. Does this justify an attempt
to fee? Would their behavior be any more or less moral than a slave who escaped prior
to the Civil War?
I hope you are beginning to see that evaluating ethical behavior in retrospect, when
we have the beneft of perspective and outcome, is a far easier task than determining
what is truly ethical in the moment. And the lens that we use to evaluate
the moral rightness of a behavior is ofen determined by the outcome
something that the person involved doesnt have the beneft of knowing
or any control over, in many circumstances, when making decisions.
This explains why some people who are initially perceived as highly
immoral are later considered heroes, and some people who authenti-
cally believe they are behaving morally, end up in prison.
The Development of Moral Reasoning
Before developing a set of ethical values, it is important to under-
stand the nature of moral development, and there is no shortage of
theorists who have attempted to do just that. Obviously what people
base their values on can vary dramatically. Value systems can be
based on the values of ones family of origin, on ones culture, or on
ones religious beliefs. Lawrence Kohlberg (Gibbs, 2003) believed
that the capacity to reason morally developed along with cognitive
development. Kohlberg conducted interviews with people of all ages
and discovered that children (or immature adults) cited something
as being immoral because they would get into trouble, thus rely-
ing on external references of right and wrong, whereas more ma-
ture adults could understand and grasp the various shades of gray
Human Systems
Understanding and Mastery of Human
Systems: Emphasis on context and the
role of diversity in determining and
meeting human needs
Critical Thinking Question: We all face
situations in which two or more of our
values are at odds with each other. What
factors should we take into account as
we determine how to behave in such
situations?
Human Systems
Understanding and Mastery of Human
Systems: Theories of human development
Critical Thinking Question: According
to Kohlbergs theory of moral develop-
ment, the capacity for moral reasoning is
connected with cognitive development
and with the ability to think abstractly.
How might this theory be used to in-
form the treatment of juveniles who
break the law?
Evaluating ethical behavior in
retrospect, when we have the
beneft of perspective and outcome,
is a far easier task than determining
what is truly ethical in the moment.
50 Part I / Human Services as a Profession
involved in a moral dilemma and cited the moral nature of a situation relying on inter-
nal references. Kohlberg theorized that the type of moral reasoning that adults use to
evaluate the moral dilemmas in their lives is dependent on abstract reasoning ability,
a cognitive function that children lack. And although the capacity for moral reasoning
does not necessarily mean that someone will behave morally, it is important to consider
someones cognitive ability to apply moral reasoning before judging them.
Developing a Professional Code of Ethics
It is because of the difcult nature of determining what constitutes moral behavior
including the balancing of our ethical values and emotional urges, of knowing which
competing values to choose in any given situation, of having the beneft of perspective
when making moral decisionsthat many professions have elected to develop founda-
tional ethical standards and professional values to safeguard from emotion, bias, and
misguided commitments being the primary motivators in ethical decision making.
Many professions begin with some stated set of values or underlying guiding assump-
tions, ofentimes found refected in their mission statement, and sometimes ethical
standards are developed from some form of abuse. Te ethical standard prohibiting
human service professionals from dating a client was likely developed in response to
some human service professionals use of poor judgment in dating clients who later
fled complaints because they felt exploited or abused.
Regardless of how standards are developed, virtually all professions rely on some
form of ethical standards to maintain integrity and trust within their profession. Nu-
merous professions espouse basic ethical principles, which serve as a foundation for
their business practices and standards, but in addition to such values of choice, an in-
creasing number of professions are bound by legally enforced ethical standards, which if
violated can result in quite punitive consequences, ranging from professional or fnan-
cial sanctions (such as license suspension or fnes), to a wide range of criminal penalties
(including incarceration).
Virtually every professional group operates under a professional organization or
licensing entity that enforces ethical codes in some form. Attorneys operate within
certain legal ethical standards administrated by the American Bar Association. Psychol-
ogists must abide by particular professional standards that are set forth by the American
Psychological Association (APA). Even stockbrokers must not only abide by the ethical
standards and values of their companies, which may include putting the clients needs
frst and not overcharging for services, but they must also abide by the legally binding
ethical standards set forth by the Securities and Exchange Commission (SEC), which if
violated can include both professional and fnancial sanctions, or in extreme cases, even
a criminal indictment.
Resolving Ethical Dilemmas
It is very important that any professional code of ethics be considered an ever-growing
and changing entity, never in fnal form, and always open for evaluation and debate.
Professional Ethics and Values in Human Services 51
West (2002) discussed the importance of ethical mindfulness, citing several real-world
examples of questionable ethical practices in the counseling and human services feld,
including issues related to informed consent (informing clients of their rights and mak-
ing sure they know all that is involved in engaging in the counseling process), the use of
real clients in therapist educational videotapes, and other ethical issues appropriate for
discussion and evaluation.
But even if everyone agrees that having ethical standards is a good thing, and that
constant evaluation is necessary, the next challenge is to determine how to respond
when an ethical breach may have occurred. Kitcheners (1984) model of ethical decision
making was designed to guide professionals in navigating the sometimes-murky waters
of decision making in difcult situations. Kitcheners model is based on four assump-
tions that he maintains need to be at the heart of any ethical evaluation and can, in a
sense, be used as a litmus test when attempting to determine whether a certain act was
in fact unethical. Tese assumptions include: (1) autonomy, (2) benefcence, (3) nonma-
lefcence, and (4) justice.
In Kitcheners model, when a certain act is being evaluated to determine its ethical
nature, the model would have the evaluators ask whether the professional acted with
free will (autonomy); whether the professionals actions were intended to beneft the
client (benefcence); whether the professionals actions involved evil, illegal, or harmful
intentions (nonmalefcence); and whether these acts were carried out in a manner that
respected the rights and dignity of all involved parties (justice).
Let us use Corrie ten Booms actions as an example. Te ruling government cer-
tainly considered her behavior unethical, and although we have the beneft of perspec-
tive and outcome in evaluating her behavior, as I mentioned before, rarely does one
have this luxury when in the midst of a moral dilemma. If one were to use Kitcheners
model in determining the ethical nature of ten Booms behavior, it could be argued
that she was not acting in a manner that was based on her free will (i.e., would she
normally oppose government ofcials?), because although she was acting in auton-
omy, the Nazi regime forced her to hide her activities. Her behavior was benefcent
in the sense that it involved acts of kindness toward her fellow human beings, she
refused to do harm by standing by and allowing atrocities against her Jewish neigh-
bors and friends, and she was motivated by her hatred for injustice. Tus ten Booms
behavior should be considered ethical regardless of the fact that history deems the
Nazi Party an evil regime.
Cultural Infuences on the Perception of Ethical Behavior
Cultural context is another very important variable to consider when evaluat-
ing the rightness or wrongness of behavior. Garcia, Cartwright, Winston, and
Borzuchowska (2003) discussed a model of ethical decision making that stresses
the importance of being culturally sensitive when evaluating any ethical decision-
making process. Garcia et al. challenged the notion that all cultures value autonomy
equally, arguing that many cultures operate on a very interdependent basis. They
also cautioned that what one culture considers abnormal, another culture considers
52 Part I / Human Services as a Profession
perfectly normal. But regardless of how one goes about determin-
ing what is ethical and how ethical decisions are made (or how
unethical decisions are made), it is very important to remember
to be sensitive to differences between cultures, genders, and ages
(across the generations).
Again, it is also very important to remember that ofentimes
what appears blatantly unethical in retrospect may have seemed
quite ethical, or at the very least somewhat muddy, in the midst.
Thus, taking the time to truly understand the behavior from
the professionals perspective, keeping issues related to encul-
turation in mind, is absolutely imperative and undoubtedly very
challenging.
Ethical Standards in Human Services
Te ethical standards that govern the human services profession depend on many vari-
ables, including human service professionals level of education, professional license,
and even the state in which they practice. With the increasing popularity of the hu-
man services discipline, the National Organization for Human Services (NOHS) was
founded in 1975. Te NOHS website states that its purpose is to unite educators, stu-
dents, practitioners, and clients within the feld of human services. Although it has no
enforcement powers, its members not only agree to abide by a code of ethics that is very
similar to the one put forth by the NASW, but include a focus on the ethical standards
as they apply to educators as well (NOHS, 1999). According to the NOHS its Ethical
Standards of Human Service Professionals can be used as guidelines for human service
professionals and educators in resolving ethical dilemmas they face both with clients
and within the community-at-large.
The preamble of the NOHS ethical standards explain that the purpose of the
standards is to provide human service professionals and educators with guidelines to
help them manage ethical dilemmas efectively. Tus, while these standards are not
legally binding they were established as guiding principles for ethical human service
practice.
Te guidelines are broken down into two sections, with section one focusing on
standards for human service professionals, and section two focusing on standards for
human service educators. In the section on human service professionals, the standards
are broken down into categories pertaining to responsibilities to clients, responsibilities
to community and society, responsibilities to colleagues, responsibilities to the profes-
sion, and responsibilities to employers.
The ethical standards for human service eductors include a reference to being
accountable to other related professional disciplines, such as the American Association
of University Professors (AAUP), American Counseling Association (ACA),
Academy of Criminal Justice (ACJS), American Psychological Association (APA),
American Sociological Association (ASA), National Association of Social Workers
Human Systems
Understanding and Mastery of Human
Systems: Emphasis on context and the
role of diversity in determining and
meeting human needs
Critical Thinking Question: Ethical per-
spectives are subjective, varying across
cultures, socioeconomic classes, and
generations. How can an understanding
of this fact help a human service profes-
sional to better serve her clients?
Professional Ethics and Values in Human Services 53
(NASW), National Board of Certified Counselors (NBCC), National Education
Association (NEA), and the National Organization for Human Services (NOHS)
(NOHS, 2009).
Overall, the general theme of all of these ethical standards centers on respect for
the dignity of others, doing no harm, honoring the integrity of others,
and recognizing power diferentials and avoiding exploitation of others,
particularly clients and students. Tis is accomplished through main-
taining self-awareness, engaging in all aspects of ones professional and
personal life honestly and ethically, and by developing an awareness of
past and current global dynamics, particularly those involving the mar-
ginalization and oppression of others. In fact, the NOHS human service
ethical standards can be summed up in large part with Statement 28:
Human service professionals act with integrity, honesty, genuineness,
and objectivity (NOHS, 2009, para 31).
Ethical principles are an integral part of everyday life, enabling us to conduct busi-
ness, both personal and professional, in a respectful and safe manner, striving to re-
spect the dignity of all persons, regardless of age, gender, race, and socioeconomic status
(SES). Without ethical guidelines to help us navigate through various situations, were
all at risk for allowing emotions to rule, leaving each person open to the infuence of
personal biases. Ethical principles in the human services profession are foundational
to the continued development of a helping profession that strives to objectively, profes-
sionally, and compassionately meet the complex needs of the most vulnerable members
of our society, and without such guidelines, we are at risk of exposing clients to potential
revictimization.
Concluding Thoughts on Professional Ethical Standards
I began this chapter by discussing how many professional felds have adopted ethical
codes of conduct. Virtually all the helping professions have such ethical codes man-
dating how practitioners must conduct themselves professionally. Tere are signifcant
similarities among the various counseling professional organizations,
such as the NOHS, the APA, the ACA, and the NASW, but a review of
each disciplines ethical standards reveals how the disciplines focusing
on the human services (NOHS and NASW) tend to focus as much
on macro responsibilities (communities and the broader society) as
much as on the individual client. For instance, neither counselors,
family therapists, clinical psychologists, nor licensed social workers
can have a romantic relationship with clients, but one signifcant dif-
ference that sets the human services and social work felds apart from
the other helping professions is the added responsibility to advocate
for social justiceboth on behalf of clients and on behavior of society
as a whole, whereas the APA (2002), for instance, refers to justice in individual terms
as it relates to every individuals right to beneft from the contributions of psychology.
The NOHS human service ethical
standards can be summed up in large
part with Statement 28: Human
service professionals act with
integrity, honesty, genuineness, and
objectivity (NOHS, 2009, para 31).
The focus on social justice in a
broader context is important
because it highlights the macro
focus of the human services feld,
with the recognition that society
and its social structures play a
signifcant role in the relative
mental and physical health of its
members.
54 Part I / Human Services as a Profession
Te focus on social justice in a broader context is important be-
cause it highlights the macro focus of the human services feld, with
the recognition that society and its social structures play a signif-
cant role in the relative mental and physical health of its members.
Human service professionals may have a greater likelihood of
confronting complex ethical dilemmas than professionals working
in other helping professions due to the broad range of human ser-
vice practice settings and the broad range of clients with whom they
work (many of whom may have quite complex individual and social
problems). Tus it is imperative that anyone considering a career in
human services become familiar with relevant laws and professional
ethical standards of not only their specific discipline (pertaining
to their academic degree and their licensing bodies) but of related
felds as well.
Human Services
Delivery Systems
Understanding and Mastery of Human
Services Delivery Systems: Political and
ideological aspects of human services
Critical Thinking Question: The macro-
level, social justice orientation of the human
services profession sets it apart from other
helping professions such as psychology.
How might a human service professionals
personal values support his work for social
justice? In what ways might such personal
values impede his work?
55
1. Most people will fnd themselves caught in a tug-
of-war between their ethical standards and their
______.
a. religious beliefs
b. emotional desires
c. professional ethics
d. personal experiences
2. Many times individuals act in ways that are later per-
ceived to be unethical, when at the time they were
committing the act they may have believed that they
were acting in a very ethical manner, but were forced
to choose among:
a. competing values
b. their emotions and their ethics
c. being accepted or standing in isolation
d. their friends and their job
3. According to Kohlberg, it is important to consider
someone's ______ ability to apply moral reasoning
to their behavior before judging them able to make
moral decisions.
a. cognitive
b. cultural
c. structural
d. social
4. Numerous professions espouse basic ethical prin-
ciples, which serve as a foundation for their business
______.
a. negotiations
b. practices and standards
c. marketing strategies
d. intervention and strategies
5. Violations of legally enforced ethical standards can
result in
a. professional sanctions, including license
suspensions
b. fnancial sanctions
c. criminal penalties
d. All of the above
6. Human service professionals face the increased likeli-
hood of confronting ethical dilemmas of greater com-
plexity because
a. they work in settings lacking a formal set of pro-
fessional standards
b. education levels for human service professionals
have declined in the past decade
c. they work in a broad range of practice settings
with a broad range of clients
d. of emotional regulation
The following questions will test your knowledge of the content found within this chapter.
CHAPTER 3 PRACTICE TEST
7. Describe Kitchener's model of ethical decision making and explore how it can help human service professionals
successfully manage common ethical dilemmas.
8. Cite an NOHS ethical standard that you may have diffculty abiding by, and explain why.
Suggested Readings
Dolgoff, R., Lowenberg, F. M., & Harrington, D. (2004). Ethi-
cal decisions for social work practice. Belmont, CA: Wad-
sworth Publishing.
Kenyon, P. (1998). What would you do? An ethical case work-
book for human service professionals. Belmont, CA: Wad-
sworth Publishing.
Nash, R. J. (1996). Real world ethics: Frameworks for educa-
tors and human service professionals. New York: Teacher's
College Press.
Reamer, F. G. (1998). Ethical standards in social work: A criti-
cal review of the NASW code of ethics. Washington, DC:
NASW Press.
56 Part I / Human Services as a Profession
Internet Resources
Josephson Institute of Ethics: http://www.josephsoninstitute.org
National Organization for Human Services Ethical Standards:
http://www.nationalhumanservices.org/mc/page.do?sitePageI
d=89927&orgId=nohs
National Association of Social Workers Code of Ethics: http://
www.naswdc.org/pubs/code/code.asp
References
American Psychological Association. (2002). Ethical principles of
psychologists and code of conduct. Washington, DC: Author.
Garcia, J. G., Cartwright, B., Winston, S. M., & Borzuchowska, B.
(2003). A transcultural integrative model for ethical decision
making in counseling. Journal of Counseling & Development,
81(3), 268277.
Gibbs, J. (2003). Moral development and reality: Beyond the theories
of Kohlberg and Hoffman. London: Sage Publications Ltd.
Kitchener, K. S. (1984). Intuition, critical evaluation, and ethical
principles: The foundation for ethical decisions in counseling
psychology. The Counseling Psychologist, 12, 4355.
National Association of Social Workers. (1999). Code of ethics of the
National Association of Social Workers. Washington, DC: Author.
National Organization for Human Services. (1999). Ethical
standards of human service professionals. Washington, DC:
Author. Available online at: http://www.nationalhumanservices.
org/ethical-standards-for-hs-professionals
ten Boom, C., Sherrill, J., & Sherrill, S. (1974). The hiding place.
New York: Bantam Books.
West, W. (2002). Some ethical dilemmas in counseling and counsel-
ing research. British Journal of Guidance & Counseling, 30(3),
261268.
57
CHAPTER 4
Learning Objectives
Understand the nature and im-
portance of informed consent
and confdentiality, including the
limits of confdentiality in the
counseling relationship
Recognize skills and competen-
cies within oneself, such as em-
pathy and active listening skills,
which are important in human
service generalist practice
Develop an understanding of
the concept of psychological
boundaries and recognize situa-
tions when boundary setting is
important
Develop an understanding of the
importance of client empower-
ment and self-determination
germane to human services
practice
Understand the basic elements
of a psychosocial assessment
and common intervention
strategies
All professionals use tools to accomplish their job duties. A professional
baseball player uses a bat, a ball, and a mitt. An accountant uses a cal-
culator; an airline pilot uses an airplane. What is unique about the hu-
man services feld is that the professional is the tool. Most people who
enter this feld do so because they possess some basic inclination toward
counseling, advocacy, and caregiving. One might question, then, why
someone who is a natural counselor needs a professional education to
become a human service professional. Even the most naturally talented
counselor needs training and refnement; needs to be taught useful tech-
niques; and will be able to beneft from the results of broad-based re-
search, the knowledge of others concerning professional issues, such as
multicultural considerations, and collaboration with other professionals
with years of practice experience.
Because the human service professional is the primary tool for inter-
vention, it is very important for all human service professionals to gain
insight into their own values and belief systems so that they can better
understand how they infuence their impressions of the clients they work
with and the problems their clients face. Gaining personal insights into
ones own life experiences, whether one was raised with privilege, or was
a victim of oppression, for instance, will help the human service profes-
sional to consistently address and confront any personal biases toward or
against certain groups of people, and social problems.
It is important to note though that human service professionals who
do not have a license to counsel (such as licensed counselors, social work-
ers, and psychologists) will not engage in counseling per se, and bach-
elors level human service education does not train students to counsel
clients in the traditional and legal sense of the word. Since human service
professionals work on a variety of degree levels, I use the words counsel
and counseling in this chapter in a general sense in reference to engaging
Skills and Intervention
Strategies
Michael Newman/PhotoEdit
58 Part II / Generalist Practice and the Role of the Human Service Professional
in any type of direct practice with clients. Tis may involve the facilitation of support
groups, providing general case management, or discussing a persons problems on the
telephone as a crisis hotline worker. Direct practice may also include therapeutic coun-
seling if the human service professional has a license to provide professional counseling
services. Since the human services profession includes such a wide range of activities
at so many levels (from paraprofessional helpers to professional licensed counselors),
the term counseling within this chapter should be interpreted broadly.
Informed Consent and Confdentiality
Prior to any discussion on counseling, competencies and generalist skills, the important
topics of informed consent, confdentiality, and the limits of confdentiality must frst
be discussed. Informed consent refers to disclosing to clients the nature and risks of
the counseling relationship prior to their engaging in these services. According to the
National Organization of Human Services (NOHS), human service professionals ne-
gotiate with clients the purpose, goals, and nature of the helping relationship prior to its
onset as well as inform clients of the limitations of the proposed relationship. Accord-
ing to the NOHS the client also has the right to terminate the counseling relationship at
any time he sees ft (NOHS, 1996).
Te NOHS also mandates the clients right to privacy and confdentiality (NOHS,
1996). Other professional organizations ethical codes address confidentiality as
well (National Association of Social Workers [NASW], 2002; American Counseling
Association, 2005; American Psychological Association [APA], 2002). Confdentiality
is an important aspect of the counselorclient relationship, where clients are assured
that whatever they share with their counselor will not be shared with others. Tis
commitment to keep whatever clients share within the counseling relationship
private is not merely a clinical issue practiced by most in the mental health feldit
is considered so vital to mental health treatment that confdentiality is a legal man-
date in every state in the nation. Tus, any professional ofering counseling services
must by law maintain confdentiality or face losing their professional license or other
sanction.
Te importance of confdentiality is based on the belief that for trust to develop in
the counseling relationship, clients must be assured that they have a safe place to discuss
their most private thoughts, fears, and experiences. Without such a guarantee, clients
might not be willing to discuss their fears that they are not good par-
ents, their intermittent desire to abandon their families because they
are so overwhelmed in life, or their histories of child sexual abuse.
Knowing that they have a safe place to talk about their most private
thoughts with someone who is not personally afected by their feel-
ings, experiences, or choices makes this exploration possible for thou-
sands of individuals, enabling them to become better parents, less
overwhelmed in their lives, and learn how to turn childhood victim-
ization into a survivor mentality.
The importance of confdentiality
is based on the belief that for
trust todevelop in the counseling
relationship, clients must be assured
that they have a safe place to discuss
their most private thoughts, fears,
and experiences.
Skills and Intervention Strategies 59
The Limits of Confidentiality
Tere are limits to confdentiality, though, designed to ensure the safety of the client and
the general public. Although there are no national standards for the limits of confdenti-
ality in mental health services, each state has laws that establish exceptions of confden-
tiality related to both voluntary and involuntary disclosures. Tese laws determine how
and when client information can be disclosed to other treatment providers, insurance
companies, and caregivers, and typically require that the client sign an authorization to
release information, a legal document that provides all relevant information about what
information will be released and for what purpose. Statements 3 and 4 of the NOHS
ethical standards stipulate the limits of confdentiality, as shown here:
STATEMENT 3: Human service professionals protect the clients right to privacy
and confdentiality except when such confdentiality would cause harm to the cli-
ent or others, when agency guidelines state otherwise, or under other stated condi-
tions (e.g., local, state, or federal laws). Professionals inform clients of the limits of
confdentiality prior to the onset of the helping relationship.
STATEMENT 4: If it is suspected that danger or harm may occur to the client or
to others as a result of a clients behavior, the human service professional acts in
an appropriate and professional manner to protect the safety of those individuals.
Tis may involve seeking consultation, supervision, and/or breaking the confden-
tiality of the relationship. (NOHS, 1996)
In general, the limits of confdentiality involve the counselors duty-to-warn and duty-
to-protect and relate to situations where through direct disclosure clients share that they are
a threat to themselves (suicidal) or others (homicidal). For instance, if a client shares with
a human service professional that he plans on leaving the ofce and committing suicide,
the practitioner has the legal obligation to disclose this information to the clients family
or even the police to ensure the clients safety. If a minor child client discloses during the
counseling session that she is being sexually abused by her uncle, the practitioner is legally
obligated to report this information to child protective services to ensure the childs safety.
Disclosures are not always so clear-cut or direct, though, and there are many occa-
sions where human service professionals fnd themselves needing to use their clinical
skills to determine whether violating confdentiality is the appropriate course of action.
For instance, consider the client who may be suicidal and who discloses a level of de-
spair that may indicate suicidal ideation. Couple this with a disclosure that the client
attempted suicide four months before and told no one; that he uses alcohol to make the
pain go away; and that although he wont admit to a suicide plan, he doesnt always feel
safe. A client who shares this type of disclosuredenying any outright plan to commit
suicide, but appearing to manifest many signs of suicidal behaviormay very well be at
real risk for committing suicide, but might be resistant to sharing this clearly either be-
cause of confusion about how he feels (wants to end life one moment and wants to live
the next) or because he may have already planned to commit suicide and does not want
anything or anyone to get in the way.
60 Part II / Generalist Practice and the Role of the Human Service Professional
Tis scenario requires the practitioner to take a clinical riskif the practitioner
takes no action, the client may indeed commit suicide, but if the practitioner violates
confdentiality and the client was not really at risk for suicide, then the counselorclient
relationship might be seriously damaged. Because confdentiality does not bar profes-
sional discussions among practitioners within the same agency, clinical dilemmas are
most appropriately explored in clinical supervision, where a team of counselors dis-
cusses the risks involved and as a group attempts to make the best decision possible.
Another challenging scenario involves a minor child client who discloses possible
abusea spanking that seems to the practitioner to go beyond mere discipline, verbal
abuse that might meet the criteria of child maltreatment, or some other indication that
the child may be experiencing abuse at home. Determining when that line has been
crossed is a clinical issue, best explored within clinical supervision, but it is important to
note that legally, it is the practitioner who is responsible for complying with disclosure
laws, and it is the practitioners professional license that will be at risk if the appropriate
actions are not taken. In some states a failure to report suspected child abuse can result
in criminal misdemeanor charges; thus, although clinical supervision can be of signif-
cant assistance in making these types of clinical decisions, the practitioner must make
the fnal decision on whether to violate confdentiality to protect the clients welfare.
Another limit to confdentiality involves a client who discloses during the coun-
seling relationship that he or she has a plan to cause serious and immediate harm to
another person. Laws in most states dictate specifcally how, when, and to whom this
information is to be disclosed. Duty-to-warn laws have been infuenced greatly by a
tragic incident that occurred on the University of California, Berkeley, campus when a
student disclosed to a campus psychologist his intent to kill his girlfriend. Although the
psychologist informed various individuals, including his supervisor and campus police,
he did not inform the intended victim or her family. Te girlfriend was later killed by
the client. Te family of the victim sued the university for the psychologists failure to
warn the victim. Te case Tarasof v. Te Regents of University of California resulted in
two decisions by the California Supreme Court in 1974 and 1976 (Tarasoff I and II,
respectively). Tarasof I found that a therapist has a duty to use reasonable care to give
threatened persons a warning to prevent foreseeable danger. Tarasof II was more spe-
cifc in referencing the therapists duty and obligation to warn intended victims if neces-
sary to protect them from serious danger of violence. Virtually every state in the nation
now uses the Tarasof decisions as a foundation for the development of duty-to-warn
laws (Fulero, 1988).
Although clients are told about the limits of confdentiality by the written informed
consent, they may forget or be confused about what would warrant violation of the con-
fdentiality privilege. Clients who share deeply personal information with their coun-
selors may feel betrayed by the counselor who informs them that a disclosure is going
to be shared with someone to protect the client or others. It is vital that this topic be
fully discussed during the frst counseling session so the client knows what disclosures
do and do not limit confdentiality. For instance, disclosures of shoplifing, cheating on
ones taxes, lying to an employer, having an afair, or feeling like attacking a coworker do
not limit confdentiality, but admissions of plans to kill oneself or someone else, to set
Skills and Intervention Strategies 61
someones house on fre, or admissions of child maltreatment (as defned in Chapter 5)
do limit confdentiality requiring disclosure. Child and adolescent clients in particular
may be taken by surprise when their confdentiality is violated; thus, it is ofen a good
idea for the counselor to remind clients of these limits intermittently throughout the
counseling relationship.
Skills and Competencies
Generalist practice has been defned as a perspective focusing on the interface between
systems with equal emphasis on the goals of social justice, humanizing systems, and im-
proving the well-being of people (Schatz, Jenkins, & Sheafor, 1990, p. 220). Generalist
practice is also characterized as having a wide range of skills that are used with a diverse
population. Terefore, the skills and intervention strategies referenced in this chapter
will be general enough to be applied to a variety of situations and clients. More specifc
skills and intervention strategies will be discussed in successive chapters as they apply
to clients seeking services in particular practice settings. Despite the generalist nature
of the human services profession, and the fact that in most (if not all) states human
services professionals working on a bachelors level will not be permitted to work in
the capacity of a professional licensed mental health provider, some direct practice with
clients will occur in various contexts, as many who work in the helping felds will attest;
thus, it is important for human service workers on all professional levels to become fa-
miliar with some basic theoretical modalities and counseling techniques.
Many of the skills included in this chapter could almost be considered personal-
ity characteristics. Empathy and compassion are powerful and necessary skills and ofen
appear naturally engrained in someones personality or character. Nevertheless, even if
someone is naturally empathetic and a naturally good listener, it is imperative that these
skills be sharpened and more fully developed to be truly useful in the human services
feld. Other skills are less natural and must be taught. For instance, although some peo-
ple might be a good judge of character, they need to be taught various clinical assess-
ment skills and techniques.
Sympathy and Empathy
Escalas and Stern (2003) discussed the traditional defnition of both sympathy and em-
pathy (commonly confused responses). Tey defne sympathy as sorrow or concern for
anothers welfare, whereas empathy is defned as a persons absorption in the feelings
of another. Te diference between these two responses, although seemingly subtle, is
signifcant when one considers that the response of empathy goes one step further, al-
lowing oneself to actually feel what another feels.
In a counseling setting, empathy involves the willingness and ability to truly under-
stand a clients beliefs, thoughts, feelings, and experiences from the clients own per-
spective. Sympathy is not a difcult emotional response to muster for the true victims
of this world (Greenberg, Elliot, Watson, & Bohart, 2001). Imagine watching the news
and hearing about the plight of a young couple whose fve-year-old child was recently
abducted. Your immediate response would likely be to express feelings of sorrow for
62 Part II / Generalist Practice and the Role of the Human Service Professional
them, and you might express concern for their welfare, wondering what will become
of the little girl and her family as they search for her. You might stop short, though, of
allowing yourself to feel the actual feelings of grief and fear that this couple is no doubt
feeling. Allowing yourself to immerse so deeply in what you imagine their feelings to be
might hit too close to home, particularly if you have children. You might feel compelled
to distance yourself emotionallyto resist putting yourself in their place. You shiver as
you watch your own fve-year-old playing on the swing set in your backyard and will
yourself not to give this situation another thought, lest you fnd it impossible to sleep
tonight.
Efective practitioners cannot limit their emotional responses to sympathy alone,
and to be efective counselors and advocates they must be willing to go on the emo-
tional roller coaster ride with the client. Tis requires emotional maturity, the ability
to be honest with oneself, the capacity for immersing oneself in anothers emotional
crisis without getting lost in the experience, and being able to keep the focus on the cli-
ent, not on themselves. I have ofen referred to the empathetic response in counseling
as having the emotional capacity to not only see the clients world through the clients
eyes, but also be willing to walk alongside the client through a difcult time. Tis can
be emotionally exhausting, but if I am working with a victim of rape, and if I want to be
truly efective in helping my client navigate through this crisis, then I need to be will-
ing to understand what it feels like to be sexually violated as best I can without having
gone through this experience myself, what it feels like to be humiliated, and what it feels
like to be flled with shame and embarrassment. Tus, although the concept of empa-
thy might seem appealing, many practitioners resist truly empathizing with their clients
because it requires them to search their own minds and hearts, to refect on past hurts,
and in this case, past times in their lives where they have been humiliated, shamed, and
embarrassedexperiences many are not particularly inclined to revisit.
Another challenge in responding empathetically to clients is when one is working
with clients who do not appear to deserve sympathy or empathy. How do counselors
empathize with pedophiles, with parents who abuse their children, or with the drunk
driver who drove into a family of fve, killing a child? Unlike therapists in private prac-
tice who typically have complete control over their caseloads, human service profession-
als rarely have such control and are ofen given a caseload, depending on the practice
setting, with clients who the general public might deem undeserving of anything other
than a prison sentence.
Looking at the world through the eyes of a serial rapist, a domestic batterer, or a
raging drunk might be the last thing any sane human being would want to do, but the
willingness to do so is a requirement for human service professionals, who will likely
fnd themselves working with mandated clients, individuals who are required by some
governmental agency (e.g., the courts, department of probation, child welfare) to seek
treatment.
So how does one accomplish this feat, when the behavior of such a client is ofen
morally incomprehensible, or at the least abusive? Te frst step is in understanding
that to empathize does not mean to condone. Consider the last motion picture that you
watched. It is the directors job to help the viewer see the world through each of the
Skills and Intervention Strategies 63
characters eyes. Considering the role of the director, although not
a direct parallel, illustrates the concept of the human service profes-
sional essentially sitting alongside those in counseling and seeing the
world through their eyes. You do not have to agree with their per-
spective, and you certainly do not have to agree with their actions,
but to be a truly efective human service professional you must be
willing and able to understand what it feels like to be them.
Although it might not make sense that a victim of abuse
goes on to become the batterer, this dynamic is quite common.
Teboywhowas sexually abused may grow up to be a pedophile,
the child who was beaten may grow up to beat her own children,
and the boy who witnessed his father beat his mother may grow up
to beat his own wife. Te nature of this dynamic will be discussed
in later chapters, but understanding that most abusive behavior is
borne out of pain might help to see mandated clients not as monsters, but as broken hu-
man beings who have sufered greatly themselves, yet rather than remaining vulnerable
so healing could occur, their hearts were hardened and sometimes they become like
those who hurt them.
Boundary Setting
Any discussion of empathy and the need for emotional immersion in anothers prob-
lems must be considered in the context of boundary setting. Although human services
certainly is not the sort of career one can leave at the ofce, it would be imprudent to
become so immersed in a clients problems that practitioners cannot distinguish the dif-
ference between their problems and the problems of their clients. It is probably easier
to discuss good boundary setting by giving examples of poor boundary setting. Te
practitioner who counsels a victim of domestic violence and spends the majority of the
session talking about her own abusive relationships has poor boundaries. Te practi-
tioner who becomes so upset about a mother abusing her child that he takes the child
home with him is not setting good boundaries. Te practitioner who becomes so upset
at a client who projects anger in the counseling session that she cries and tells the cli-
ent how she is having a horrible day and that the client just made it worse is not setting
good boundaries. Finally, the practitioner who gets so immersed in his clients problems
that he becomes convinced his clients cannot survive without him is not setting good
boundaries.
Personal boundaries are sometimes compared to physical boundaries such as the
property line around ones house, porous enough that someone can en-
ter the property, but solid enough that a neighbor knows not to set a
shed up in another neighbors yard (Cloud & Townsend, 1992). So too
must human service professionals establish boundaries in their mental,
physical, and emotional lives to determine what falls within their do-
main and responsibility and what does not.
In the human services field, some boundaries are determined
by the ethical standards of the field. For instance, having a sexual
Human Systems
Understanding and Mastery of Human
Systems: An understanding of capacities,
limitations, and resiliency of human
systems
Critical Thinking Question: Most human
service professionals will, at some point,
work with clients whose values and ac-
tions they find difficult to accept, or even
reprehensible. How might a professional
increase her capacity to empathize with
these individuals?
n een-
set a
o too
enttal,
r ddo-
mined
exu ual
Human service professionals [must]
establish boundaries in their mental,
physical, and emotional lives to
determine what falls within their
domain and responsibility and what
does not.
64 Part II / Generalist Practice and the Role of the Human Service Professional
relationship with a client violates an ethical boundary because this type of intimacy
can exploit the practitionerclient relationship that grants the practitioner a signifcant
measure of control even authorityover the client. Violating the prohibition against
having sexual relations with a client is so serious that it can result in suspension of ones
professional license. Violating this ethical boundary might seem like an obviously bad
idea to most people, but it occurs more ofen than many suspect. Counseling some-
one of the opposite sex creates a sense of intimacy that can sometimes foster romantic
feelings, particularly on the part of the client.
Much like the child who develops a crush on a teacher, a client who is depressed
and lonely may experience the practitioners comfort, nurturing, and guidance as inti-
mate love. But a sexual relationship when one party possesses power and control and
the other is vulnerable and broken will always result in emotional and physical exploi-
tation. A practitioner who respects this boundary will recognize the clinical nature of
the clients feelings and will help the client see that experiencing intimacy can be a very
positive experience, but developing a romantic relationship should only occur when it
can be truly reciprocal. Tis is an example of a clearly marked boundary, and it is dif-
fcult to step over this boundary line without knowing one is in dangerous territory.
However, other boundaries are not so clear and are frequently violated by human ser-
vice professionals.
My frst job in human services was as an adolescent counselor at a locked residential
facility. I was 23 years old, fresh out of college, and excited to fnally be making a dif-
ference in peoples lives. I became too involved in my clients lives, though, and quickly
began to overidentify with the teens on my caseload. I was so fattered by my clients
expressed need for me that I was willing to work any hours necessary to make sure they
knew how much I cared. If I worked a 3:00 pm to midnight shif, and one of the girls
on my caseload told me that she needed me there in the morning, I would make sure I
was there at 8:00 am, even if it meant getting little sleep. If another counselor called me
at home because a teen on my caseload was insisting that she would only talk to me, I
dropped whatever I was doing and rushed down to the facility, feeling good that I was
so needed.
Tis sort of behavior on my part indicated several problems. First, it led to a situa-
tion where I almost lef the feld of human services all together because afer three years
I was so burned out that I was no longer sure I wanted to be a human service profes-
sional in any respect. It also encouraged a sense of dependency among the girls on my
caseload. Because it felt good to be needed, I neglected one of the fundamental values
of human service professionals: empowering clients to be more self-sufcient. Setting
boundaries would have encouraged my clients to develop relationships with other coun-
selors and to rely on themselves and newly developed skills to cope with their struggles.
Since that point in my career I have developed some rules for the road for de-
termining necessary boundaries and for making sure that I consistently enforce them.
One rule is that I never work harder than my client. Tis does not mean that I do not
advocate for clients, or that I do not assist clients in performing various tasks, but what
it does mean is that I recognize that I am not truly helping clients who are not motivated
to change because a counselor who overfunctions in a counseling relationship helps no
Skills and Intervention Strategies 65
one. Tus, when I begin to feel exhausted in my work with clients, I recognize this as a
potential sign that I may be doing too much work, perhaps out of impatience and a need
to see progress, and recognize that it is time to step back a bit and give my clients room
to decide the best course of action for themselves.
I have also come to see my clients lives as their journey, not mine. Tis conceptu-
alization allows me to view myself as one of many individuals who will come alongside
clients and help them at some point along their journeys, just as various people have
helped and infuenced me along my own life journey. Tis conceptual framework helps
to remind me that my clients have free will to make whatever choices they deem ft. Tis
self-determination means that they can accept my help and suggestions, or they can
reject them.
A fnal conceptualization that can help establish and maintain healthy boundaries in
a counseling relationship is to recognize that people grow and change at varying rates
and in their own unique way. Tus, when I am working with someone and it appears as
though nothing I am doing or saying is making a diference, I remember that I might
be the seed planter. Seed planters do just as it soundsthey plant the seeds of future
growth, but ofentimes they do not have the beneft of seeing these changes come to fru-
ition. It is ofen this way when working with adolescents. I rarely witnessed the results
of my work with my teen clients, but I had to trust that in fve or ten years, something
I said, some kindness I showed, some reframing I did would result in healthy personal
growth.
The Hallmarks of Personal Growth
It is equally important to recognize the role of the fertilizer and the harvester in counsel-
ing relationships. Tese are the counselors who come into the lives of clients afer the
seeds have already been planted. Te fertilizer is the practitioner who helps the client
do productive workthis is no easy task, but the counselor has the beneft of seeing the
results of the counseling and intervention strategies. Te harvester is probably the most
gratifying role a human service professional can have. Tis practitioner comes along
when everything seems to align for the client. Te client is ready to make the necessary
changes for a healthy life, recognizes past negative patterns in relationships and choices,
and has the necessary insight and motivation to efect true change.
I recently had a client who was at this point in her life. Fortunately, I was able to rec-
ognize that I could not take full credit for helping her to make the signifcant realizations
and changes she was making in counseling. Shed had several prior counseling experi-
ences, and my role was to help her to merge all that she had previously learned so that
she could fnally make the necessary, permanent changes in her attitude and approach
to life, so that she could be a healthy and happy productive individual, recognizing her
own right to self-determination and dignity and her responsibilities to herself, her fam-
ily, and her community. If you are working productively with a client but see little to no
progress, you may very well be the seed planter. If you are working productively with
a client but it seems as though change is still a long way of, then you are probably the
fertilizer, and if you are reaping changes lef and right with a client, then you may very
well be the harvester. Seeing yourself operating as a part of a team, even though you will
66 Part II / Generalist Practice and the Role of the Human Service Professional
likely never meet the practitioners who came before you or those who may come afer,
helps to ease the burden of feeling so responsible for a clients growth, as well as helping
to resist the temptation to take full credit for the clients progress.
The Psychosocial Assessment
Te process of assessing the psychosocial issues of a client utilizes a combination of nu-
merous skills, such as patience, active listening skills, and good observation skills, as well
as more tangible skills, such as being familiar with how to administer various psycho-
logical tests and assessments. Te tools for conducting an efective assessment are nu-
merous. Te frst session is ofen spent conducting an intake interview, which includes
collecting basic demographic information about the client (e.g., age, marital status,
number of children, and ethnicity). Other pertinent information includes the nature
of the identifed problem(s), employment status, housing situation, physical health sta-
tus, medications taken, history of substance abuse, criminal history, history of trauma,
any history of mental health problems (including depression, suicidal thoughts, or other
mental illness), and any history of mental health services.
When I was in graduate school I recall being taught that the frst fve sessions with a
client should be focused almost exclusively on assessment, but I quickly realized that if
some intervention does not occur during those frst few sessions, clients are not likely to
return. Unlike many clients who come to see a clinical psychologist in private practice,
many human service clients are in crisis, and they ofen need immediate intervention.
Tus, human service professionals ofen fnd themselves jumping in with both feet, siz-
ing up the client and the situation rather quickly so that some intervention strategies
can be employed.
Tis by no means indicates that the assessment process should be shortchanged due
to the frequent crisis nature of many human services agencies. Quite the opposite in
factalthough it is true that the practitioner will be focusing more on assessment the
frst few sessions, the process of assessing the mental health functioning, as well as the
clients situation, is ongoing and should continue throughout the counseling process.
Tis is important for two reasons. First, before efective intervention strategies can be
identifed and used, the practitioner needs to know what the clients issues are. In addi-
tion, more ofen than not, new information will continue to emerge long afer the for-
mal assessment period is over, and if practitioners assume the assessment is complete,
they might overlook important information about the client that emerges later in the
counseling relationship.
Patience
Patience, therefore, is imperative in conducting an efective assessment. One reason why
people enter the feld of human services is because they love to fgure other people out,
but a seasoned professional will not allow this passion to result in a rush to judgment. It
is important to hold at bay the intense desire to exclaim Ah ha! too quickly. I used to
work with victims of domestic violencea practice setting that I am passionate about
because I am an advocate for those who are vulnerable. I recall one female client who
Skills and Intervention Strategies 67
shared stories of her controlling and abusive husband. Her stories seemed valid, and
there was nothing in particular that would cause me to believe that she was not telling
me the truth. In fact, what she shared about her husbands behavior met many of the
hallmark signs of domestic violence relationshipsher husband controlled the fnances,
and she had little or no access to the bank accounts; her husband appeared jealous and
possessive, consistently demanding to know her constant whereabouts; and many of the
arguments she reiterated to me refected what appeared to be her husbands critical re-
sponse to her in all respects, ranging from her housekeeping ability to the way she man-
aged their children.
I quickly began to view her low self-esteem and depression as being the result of his
abusive behavior and counseled her accordingly. Yet, several sessions into our counsel-
ing relationship she retold a story, which she apparently did not recall telling me before.
Tis version, though, was considerably diferent. I knew she was reciting the same story,
but this time the events illustrating her husbands abusive behavior were diferent. I was
not sure whether she was simply merging stories accidentally or whether this was an in-
dication that she was not being completely honest with me. I made a note to explore this
area further and to be more diligent in determining the veracity of her stories.
After interviewing her husband and children and spending more time assessing
my client, I discovered that she was actually the abusive member of the family! She
feared her husband leaving her and seeking custody, and thus, she hoped to enter into
a counseling relationship and manipulate the counselor, so that she was perceived as
the victim, and the counselor would therefore support her version of events in court. If
practitioners are not diligent in thoroughly assessing their clients, they will be far like-
lier to be manipulated by some of their clients, thus doing more harm than good.
Human service professionals should always approach clients with the understanding
that the clients perspective is just thatthe clients perspective. Moreover, I was once
told that truth comes in three parts: what you said happened, what the other person
said happened, and what really happened. Understanding this does not detract from the
counselors advocacy role of their clients, but rather supports the counselors ability to
help clients reframe various incidences and situations in their lives to help clients gain a
healthier and more balanced perspective.
Tus, although a clinical assessment is a broad and ongoing process, it is also spe-
cifc, where the human service professional is both assessing the mental health of clients
and conducting a needs assessment to determine the quality and level of functioning in
the various domains of their lives (interpersonal, work, family, social, spiritual, com-
munity). An afective clinical assessment depends on many skills, some of which have
already been discussed earlier in this chapter. But two of the most important skills nec-
essary for an efective clinical assessment relate to the practitioners ability to listen well
and be sufciently observant.
Active Listening Skills
Active listening skills involve the ability to attend to the speaker fully, without distrac-
tion, without preconceived notions of what the speaker is saying, and without being
distracted by thoughts of what one wants to say in response. Active listening in the
68 Part II / Generalist Practice and the Role of the Human Service Professional
counseling relationship also includes behaviors such as maintaining direct eye contact
and observing the clients body language. It also involves considering virtually every-
thing that the client says as relevant. It is ofen the subtle, ofand comment that yields
the most information about the clients interpersonal dynamics.
I recall working with one female client for depression and parenting issues, who
in response to my questions regarding her perception of the origin of her problems,
spent a considerable amount of time discussing her troubled marriage and her dif-
ficulty making friends. In the midst of sharing a particularly painful story about
her difcult college years, she made a casual comment about how one of her college
roommates said something to her once that reminded her of something her mother
always said. If I had not been actively listening, I could have missed the signifcance
of that seemingly unimportant comment. It was stated as a joking aside, but I also no-
ticed her brief pause and a quick, almost imperceptible, sadness in her eyes. Te entire
exchange lasted no more than a few seconds, but it completely turned the course of
my assessment. I made a mental note to revisit the issue of her mother during a later
session when we knew each other better and she knew she could trust me. Eventually
it became clear that her core emotional issues resided in her tumultuous relationship
with her mother, but she had previously been so protective of this relationship that
it felt far too unsafe for her to recognize that her primary issues revolved around her
relationship with a controlling, shaming mother. Over the course of the next several
months I continued to revisit the issue, slowly at frst and then more boldly once we
were on solid ground in our own relationship, and she was fnally able to recognize
the hold her mother had on her all these years. Had I not been as attentive, respond-
ing instead to only what the client wanted to focus on, we would have spent our time
together focusing on residual issues.
Observation Skills
Good observation skills are also an important part of the assessment process because
individuals communicate as much through their bodies as they do through their
words. Practitioners should observe their clients eye contact, whether they are shifing
uncomfortably in their seats when talking about certain subjects, crossing their arms
self-protectively, or tapping their feet anxiously. All these behaviors can be clues or
indicators of deeper dynamics. Employing good observation skills can also yield infor-
mation about whether a client is being direct or evasive, genuine or masked, sincere or
manipulative, open or guarded.
Family Genograms
A more comprehensive assessment tool involves constructing a genogram of the clients
family. Murray Bowen (1978) developed Family Systems Teory, which is based on the
premise that inter- and intrarelational patterns are transmitted from one generation to
the next. Tus, one way to grasp the big picture of the clients life is to study this inter-
generational transmission as it relates to issues such as communication style, emotional
regulation, and various other rules for living (e.g., it is good to express emotions, it is
Skills and Intervention Strategies 69
bad to express emotions). Bowen believes that the goal for achieving positive well-being
is to fnd the balance between achieving personal autonomy and individuation while
maintaining appropriate closeness with ones family system. Tose who are so close to
their family system that they cannot make decisions without family approval without
the fear of being considered betrayers of the family are considered enmeshed, and those
who fnd it necessary to emotionally distance themselves to the point of estrangement
to achieve independence are considered cut of.
Most people have some information about their parents, limited information about
their grandparents, and ofentimes no information whatsoever about their great-grand-
parents. Tey may have grown up hearing one-sided (and unquestioned) versions of
family feuds or odd distant relatives, but to gain accurate and valuable information
about ones family system, information seeking must be intentional. Tis can be uncom-
fortable and may rufe some feathers, because it is ofen the family members who have
been cut of, or are considered the black sheep, who hold the family secrets that will
unlock the true underlying dynamics of a family system. Poking around the skeleton
closet can ofen threaten families, particularly in closed family systems, but this infor-
mation may also hold the key to truly unlocking hidden dynamics that have been in
place sometimes for numerous generations.
Genograms use a variety of symbols designed to indicate gender, the type of rela-
tionship (married, divorced, etc.), and the nature of the relationships (cut of or en-
meshed). Traumatic events, such as deaths, divorces, and miscarriages, are noted, as are
the familys responses to these events (e.g., losses are openly talked about, never dis-
cussed, or denied). Typically, shameful events are also relevant, such as out-of-wedlock
births (particularly relevant in earlier generations), abortions, extramarital afairs, do-
mestic violence, alcohol abuse, sexual abuse and assault, and job losses. Such events are
ofen kept secret but can afect family members for generations to come. Te shame of
an extramarital afair and an out-of-wedlock birth that was hushed up several genera-
tions back can have a profound efect on how emotions are handled and how feelings
are communicated.
I once worked with a woman who struggled to understand why her mother never
seemed to accept or approve of her. She had spent years in counseling attempting to
understand her mothers and her own intense perfectionism and refusal to accept even
the smallest of mistakes. My client was convinced that her mother was ashamed of her,
and this belief afected every area of her functioning. A genogram revealed that my cli-
ents grandmother was raped, and my clients mother was the product of that rape. Both
the grandmother and my clients mother lived their lives in constant shame, and their
high expectations of my client were really a refection of their desire to protect her from
the shame they were forced to endure, not some statement of their disapproval of her.
It was through the development of a genogram that my client was enabled to take a few
emotional steps back and see her family system with more clarity.
A family genogram provides a structured way to obtain a comprehensive family
history so that the practitioner and client can develop a more complete understand-
ing of the family dynamics that are afecting the client in ways perhaps never before
recognized or acknowledged. It also provides for an objective and nonshaming way
70 Part II / Generalist Practice and the Role of the Human Service Professional
to gain a level of objective understanding of various issues within
ones family system that can potentially pave the way for the client
to view relationships and various events without personalizing
hurtful experiences, including gaining an objective understand-
ing of the nature of conflict-filled family relationships (Prest &
Protinsky, 1993).
No longer is the client blaming himself for his fathers seeming
disapproval or feeling hurt because his mother seemed emotionally
distant and rejecting. Instead clients can develop a greater under-
standing of the broader picture and can see their family members
as individual people who are as much a victim of circumstances as
the client. Tus, a family genogram is not merely an efective assess-
ment tool, but also a very efective intervention tool that can be used
to address long-standing issues that have potentially kept clients in
emotional bondage for years.
Psychological Testing
Counselors have numerous other tools at their disposal as well,
including various objective assessments tools, such as inventories
designed to assess levels of depression, anxiety, social functioning,
and personality style. Less objective measures, such as interpretive drawing exercises,
free choice drawing, clay manipulation, and structured play therapy, can also be useful.
Tese assessments work particularly well when working with clients who are either less
verbal or dealing with particularly painful emotional issues.
When working with traumatized children, I would ofen ask them to draw a pic-
ture of their families. Although the results always need to be considered cautiously, and
in the context of all other information gleaned during sessions, it is always interesting
to see how children conceptualize themselves and their various family members. For
instance, drawing a picture where the father is signifcantly larger than the rest of the
family might indicate a perception that the father is overbearing. A child who draws
himself foating away or standing separately from the rest of the family might indicate a
feeling of being disconnected from the rest of the family members. Again, it is essential
that practitioners use great caution when interpreting subjective techniques, and all as-
sessment material should be considered as a whole, rather than giving too much weight
to any one particular measure.
Clinical Diagnoses
Most licensed human service professionals use the Diagnostic and Statistical Manual
of Mental Disorders, fourth edition, text revision (DSM-IV-TR), to diagnose the men-
tal and emotional disorders of their clients. Te DSM-IV-TR is a classifcation system
developed by the APA (2000). It includes criteria for mental and emotional disorders,
such as schizophrenia, depressive disorders, and anxiety disorders, and personality
Human Systems
Understanding and Mastery of Human
Systems: Changing family structures
and roles
Critical Thinking Question: Family struc-
tures and roles in the United States have
evolved markedly over the past 50 years:
Women have entered the workforce in
large numbers, altering the balance of
economic power in households; lifespans
have increased, changing the roles of
elders and their adult children; single-
parent households have become more
common; and gay and lesbian individuals
and couples have come out of the closet.
How can a deep exploration of family
dynamics across several generations
(e.g., the construction of a genogram)
assist a client in developing insight into
her current situation?
Skills and Intervention Strategies 71
disorders such as narcissistic personality disorder and antisocial personality disorder
(sociopathy). Te DSM-IV-TR is a multiaxial diagnostic system, which means that indi-
viduals are diagnosed on fve axes, or fve diferent areas of functioning.
Clinical disorders requiring clinical attention, such as schizophrenia or depres-
sion, are diagnosed on Axis I. Personality disorders, such as borderline personality
disorder and mental retardation, are diagnosed on Axis II. General medical condi-
tions that might have an impact on ones mental health are diagnosed on Axis III.
Psychosocial and environmental problems, such as problems with housing and em-
ployment, are diagnosed on Axis IV. Axis V is reserved for the clients global assess-
ment of functioning (GAF). The GAF scale ranges from 0 to 100, with 0 indicating
someone at a homicidal or suicidal level and 100 indicating a functioning level far
higher than any of us will likely ever achieve. Although the assessment of ones GAF
is somewhat subjective and arbitrary, the DSM-IV-TR contains a guide that assists
practitioners in determining where their clients might fall in their overall function-
ing level. In general, individuals who are struggling in most areas of their lives and
are in need of clinical intervention will be functioning somewhere in the range of
0 to 50.
Criticisms of the DSM-IV-TR
Although the diagnostic criteria of the DSM-IV-TR relies signifcantly on professional
peer consensus and review and is backed by a large body of research, many profession-
als in the human services feld have concerns about the DSM-IV-TR because it applies
the medical model to emotional disorders. Tis paradigm in many respects pathologizes
what might just be a broader range of human thoughts and behaviors, which in turn
tends to create a stigma for those who are sufering from emotional problems. Consider
someone who has recently been the victim of a violent crime. If he experiences mental
fashbacks of the traumatic event, is he exhibiting behaviors that are adaptive and ex-
pected? Or, in the alternative, is he sufering from post-traumatic stress disorder? Is the
angry adolescent whose parents were just divorced exhibiting a normal grief response
to this loss? Or does he have oppositional defant disorder? Even if human service pro-
fessionals do not naturally view human behavior from a disease perspective, using the
DSM-IV-TR can infuence practitioners to view their clients from a pathological per-
spective (Dufy, Gillig, Tureen, & Ybarra, 2002).
Yet, even if one believes that the medical or disease model is appropriate to use
when evaluating psychological disorders, an important distinction between the diag-
nostic system used to diagnose medical conditions and the system used to diagnose
mental disorders is that the DSM-IV-TR uses criteria based on symptoms, whereas
medical conditions are diagnosed based on the etiology (cause or origin) of the dis-
order. Tus rather than diagnosing a patient with a stomachache, which could poten-
tially have many causes, the medical diagnosis would be a virus, an ulcer, or cancer.
Yet, when considering mental disorders, one is not diagnosed with a neurotrans-
mitter disorder, negative thinking, or an abusive childhood, but diagnosed with ma-
jor depressive disorder based on the symptoms the client is experiencing, not on
etiology.
72 Part II / Generalist Practice and the Role of the Human Service Professional
Other criticisms of the DSM-IV-TR include questioning the process that determines
what behaviors are deemed abnormal enough to be included in the DSM-IV-TR and
which behaviors are not, and whether it is appropriate to categorize
human behavior, pathologizing alternative understandings of hu-
man behavior (Dufy et al., 2002).
Many practitioners have also expressed concerns about health
insurance companies reliance on the DSM-IV-TR for the diagno-
ses of mental disorders required for reimbursement, which can put
both practitioner and client in a precarious positionthe practitio-
ner might feel compelled to diagnose a client to get paid and the
client may have difculty obtaining insurance coverage in the future
if diagnosed with a serious mental health disorder. Yet, despite the
criticisms of the DSM-IV-TR, it remains the most well-researched,
collaborative classifcation system for mental pathology currently
in existence and does provide a means for organizing various emo-
tional problems and mental disorders.
Many human service professionals use the DSM-IV-TR but
in general rely on it less than other mental health disciplines, be-
cause the human services profession is based on empowerment
theory, where clients are encouraged to recognize that they have
more control over their lives than they may have previously thought.
Self-determination is a related concept and refers to the rights of
all individuals to make choices that they believe are in their own best interest. Self-
determination can be empowering as clients realize that they have learned to have good
judgment, which increases their sense of competency and self-reliance.
Continuum of Mental Health
Another important consideration when evaluating someones level of functioning and
mental health status is to recognize that virtually all behaviors occur on a continuum.
It is only when a particular behavior occurs frequently enough, and at an intensity level
high enough to interfere with normal daily functioning for a signifcant amount of time,
that it becomes the subject of clinical attention. All of us feel sad at times, but if we are
so intensely sad that we stop eating and want to stay in bed all day, then we may be suf-
fering from clinical depression. Similarly, many of us become concerned from time to
time that our friends might be talking behind our backs or that one of our coworkers is
trying to get us fred, but if were convinced that everyone is out to get us, even people
weve never met, then we may be sufering from some form of paranoia.
The DSM-IV-TR accounts for this continuum by including criteria relating to
frequency and intensity of psychological experiences. For instance, to meet the criteria
for major depressive disorder, an individual does not just have to be depressed, but must
have a depressed mood nearly every day for at least a two-week period. An individ-
ual who meets the criteria for generalized anxiety disorder isnt someone who worries
from time to time, but someone who worries excessively, more days than not, for at least
six months.
Human Services
Delivery Systems
Understanding and Mastery of Human
Services Delivery Systems: Major models
used to conceptualize and integrate pre-
vention, maintenance, intervention, reha-
bilitation, and healthy functioning
Critical Thinking Question: The DSM-
IV-TR is commonly used by mental health
professionals to diagnose emotional
and mental disorders by examining five
specific areas of functioning. In what
ways does the five-axis system of the
DSM-IV-TR parallel the human service
professionals focus on the person within
her environment? In what ways might it
limit the professionals understanding of
a clients situation?
Skills and Intervention Strategies 73
In summary, the value of services provided depends on the efec-
tiveness of the assessment. A good assessment defnes the problem or
problems the client is experiencing, develops a needs assessment to de-
termine where the clients strengths and defcits lie, ascertains the cli-
ents social support system, and develops an appropriate treatment plan.
It is also important to reassess the client at various points in the coun-
seling process to monitor new or previously masked issues, and to make
sure that treatment goals are consistent with the assessment.
Case Management and Direct Practice
It is important to understand the qualitative diferences between case management and
direct counseling services. Although both encompass a broad range of activities, they
are distinctly diferent. Direct practice with clients is focused more on an individuals
psychological growth and the development of emotional insight and personal growth,
whereas case management involves coordinating services with other systems impacting
the life of the client. A case manager might coordinate services with a clients school
social worker, the housing authority, the local rape crisis center, or even a court liaison,
all in an attempt to meet the needs of the client who is interacting in some manner with
each of these systems. Te goal of the case manager is to assist the client in plugging
in to necessary and supportive social services within the community and to learn how
to improve the reciprocal relationship or transaction with each of these social systems.
Tese eforts have many purposes and goals, but chief among them is the caseworkers
proactive attempt to strengthen and broaden the clients social support network.
In the Human Services Board-Certifed Practitioner Exam Handbook that is pro-
vided to human service professionals in preparation for the HSE-BCP examination, a
description of case management includes the following tasks:
Collaborate with professionals from other disciplines
Identify community resources
Utilizes a social services directory
Coordinate delivery of services
Participate as a member of a multidisciplinary team
Determine local access to services
Maintain a social services directory
Participate in case conferences
Serve as a liaison to other agencies
Coordinate service plan with other service providers (Center for Credentialing and
Education [CCE], 2011).
Te NASW also provides a relatively comprehensive defnition of case management:
Social work case management is a method of providing services whereby a
professional social worker assesses the needs of the client and the clients
family, when appropriate, and arranges, coordinates, monitors, evaluates,
The value of services provided
depends on the effectiveness of the
assessment.
74 Part II / Generalist Practice and the Role of the Human Service Professional
and advocates for a package of multiple services to meet the specific clients
complex needs. A professional social worker is the primary provider of so-
cial work case management. Distinct from other forms of case management,
social work case management addresses both the individual clients biopsy-
chosocial status as well as the state of the social system in which case man-
agement operates. Social work case management is both micro and macro in
nature: intervention occurs at both the client and system levels. It requires the
social worker to develop and maintain a therapeutic relationship with the cli-
ent, which may include linking the client with systems that provide him or her
with needed services, resources, and opportunities. Services provided under
the rubric of social work case management practice may be located in a single
agency or may be spread across numerous agencies or organizations. (2002)
Direct Practice Techniques for Generalist Practice
Although the assessment process is ongoing, once the initial assessment is complete a
treatment plan is developed that is designed to address the clients identifed issues. I
will cover direct practice and counseling techniques appropriate for clients served in
particular practice settings in more detail in subsequent chapters, but there are basic
techniques involved in generalist practice that apply in a broad way to most counseling
and intervention situations.
Many individuals seeking services at a human services agency will need assistance
with developing better coping skills. Regardless of whether the problems experienced
by the client are pervasive or more limited, most clients can beneft from learning to
manage high levels of stress, learning to prioritize the various problems in their lives,
and learning how to manage the current crisis in a way that diminishes the possibility
of a domino efect of crises. A crisis with ones child requiring a signifcant amount of
time and attention can quickly result in a job loss, which can in turn result in the loss of
housing. Confronting crises efectively, though, can have a positive impact on ones life,
including an increase in self-esteem, the development of new and more efective coping
skills, the gaining of wisdom and the development of new social skills, and the develop-
ment of a better overall support system.
Most mental health experts recognize that one of the best opportunities for personal
growth is a crisis, due to the possibility of shaking up long-standing and entrenched
maladaptive patterns of behavior. Park and Fenster (2004) studied stress-related growth
in a group of college students who experienced a stressful event and found that the
struggle involved in a life crisis produced personal growth. Tis is true, though, only
for those who expend the necessary energy to work through their struggles in a positive
way. Tose in the study who remain negative and avoided dealing with the problems
borne out of the crisis did not take advantage of the growth-producing opportunities
and thus did not experience any signifcant personal growth. Tose who worked hard
to manage the stress resulting from their crisis and were able to see the crisis as an op-
portunity for growth ofen developed better personal mastery skills and developed a
changed and healthier perspective. Recognizing this potential for personal growth
Skills and Intervention Strategies 75
provides the practitioner with a framework for assisting clients in developing better
coping skills that not only can better assist them in the management of concrete prob-
lems, but can also help them to shif their entire perspective of life struggles in general.
For instance, clients who once saw themselves as powerless victims can begin to see
themselves as empowered survivors.
Task-Centered Casework
When most individuals are confronted with a crisis, panic sets in, and it becomes dif-
fcult to address the problem in a healthy or meaningful way. Most of us can relate to
feeling completely overwhelmed when facing a life crisis. We know there are things we
need to do to manage the crisis, but all we see is a gigantic mountain looming before us.
For some, this has a motivating efect, and they attack the mountain until every issue is
resolved. But for some, particularly those with a long history of crises, those with poor
coping skills, or those sufering from emotional or psychological problems with dimin-
ished personal management skills, the mountain can seem virtually insurmountable,
and their response is to shrink away with a feeling of despair and defeat.
A counseling technique called the Task-Centered Approach, an intervention strategy
developed by the School of Social Services at the University of Chicago (Reid, 1975),
works well with clients who feel paralyzed in response to the challenges of various psy-
chosocial problems. Treatment is typically short, lasting anywhere between two and
four months, and is focused on problem solving. Te client and counselor or caseworker
defne the problems together and develop mutually agreed-upon goals. Each problem is
broken down into smaller and more easily manageable tasks. Goals can be as tangible
as fnding a new job or as intangible as more efectively managing frustration and anger.
Rather than having one broad goal of obtaining a job, a client might have a week-one
goal of doing nothing more than looking at the want ads in the local newspaper and a
week-two goal of making one phone call to a prospective employer. Dividing large goals
into smaller, specifc, stepping-stone goals diminishes the possibility that clients will
allow their anxiety to overwhelm them. By focusing on specifc problems and break-
ing them into bite-sized, manageable pieces, clients not only learn efective problem-
solving skills, but also gain insight into the nature of their problems, develop increased
self-esteem as they experience success rather than failure in response to meeting goal
expectations, and learn to manage their emotions, such as anxiety and depression, with-
out allowing such states to overtake and overwhelm them.
Te counselor or caseworker assists clients in meeting goal expectations through a
variety of intervention strategies specifc to the actual problem, but can include plan-
ning for obstacles, role-playing (where the client can actually act out difcult situations
in the safety of the counselors ofce as a way of practicing communication, etc.), and
mental rehearsal (similar to role-playing but involves the client thinking or fantasizing
about some specifc situationsuch as an upcoming job interview or a difcult con-
frontation) (Reid, 1975). Revisiting original goals and evaluating client progress are also
powerful tools in helping clients experience a sense of personal mastery and empower-
ment as they are helped to recognize their progress.
Consider the following case study.
76 Part II / Generalist Practice and the Role of the Human Service Professional
CASE STUDY 4.1
Case Example of Task-Centered Approach
Mary is the 34-year-old single parent of a 5-year-old boy. She has been living with her
mother since her own divorce three years ago. Tis is a negative situation because her
mother is verbally abusive of Mary and her son, abuses alcohol, and smokes inside the
home. In addition, their living space is small, and Mary and her son share a bedroom.
Marys original goal was to live with her mother for only six months, but whenever she
considers moving out she becomes overwhelmed with the prospect of not only fnding an
appropriate apartment, but fnding child care as well, because despite her mothers abusive
behavior, Mary has been relying on her mother for before- and afer-school child care
while she works. Mary feels trapped but completely powerless to do anything about her
situation. During Marys intake interview she described her prior counseling experiences,
sharing that she quit counseling because whenever she was faced with the prospect of
fnding an apartment, her fears would snowball into so many fears that she simply couldnt
even bring herself to make the frst phone call in search of housing. She ended up feeling
embarrassed, as if she were letting the counselor down, and just decided she could not deal
with any more failures, so she stopped going to counseling. Mary explained that through-
out the past several years her mother has consistently reminded her that she would never
make it on her own, that she would surely fail, and that she would end up destroying her
life and the life of her son. Her mother also told Mary that if she moved out, and ran out of
money, she would not bail Mary out again and would instead force Mary and her son to go
to a shelter. Opening the newspaper to look for a rental advertisement resulted in a food
of worries and concernssome specifc and some she could not even put into words. She
worried about everything from whether she would know what to say when calling on an
apartment, to whether she would be able to support herself and her son. What if she was
laid of from her job and could no longer aford her apartment and had to live in a shelter?
What if she couldnt fnd a babysitter she could aford? What if she found an apartment
and got a babysitter, but the babysitter ended up abusing her son worse than her mother
did? She read about such things all the time in the newspaper, she reasoned. Or what
if she found an apartment, but she had a fnancial emergency such as her car breaking
down, and she started falling behind in her rent and was evicted? She couldnt fathom the
thought of moving out and then having to move back in with her mother again, or worse
what if her mother made good on her threat and refused to allow them to move back in
with her? Once confronted with this slippery slope of catastrophizing, she would resist
even taking the frst step toward independence and could not bring herself to even look
at rental ads. Marys mood became increasingly melancholy over the years, and afer years
of verbal abuse from her mother, her ex-husband, and now her mother again, she had no
confdence in her ability to fnancially support her own son or even to manage her own life
without her mothers assistance. Marys caseworker reassured her that there was absolutely
no rush in fnding an apartment. In fact, she reminded Mary that she was in charge of her
own life and could make the choices she thought were best for her and her son. During
the frst two sessions, Mary and her caseworker developed realistic goals for her, including
securing an apartment when Mary had the funds to ensure fnancial security. Mary and
her caseworker developed a detailed budget and determined that she would need three
Skills and Intervention Strategies 77
months salary put away in a savings account to ensure against any realistic fnancial emer-
gencies. By identifying possible obstacles to Mary achieving independence, decisions were
made based on facts and realistic risks, not on undefned and generalized fear. Once goals
were developed and obstacles identifed, Mary and her caseworker agreed on tasks to be
accomplished by the following week. Marys task for the frst week was to look through the
newspaper and circle rental advertisements within her price range. She was not to call any
of them though, even if she found one that seemed ideal. Mary came in the second week
with the newspaper flled with circled apartment ads. Mary and her caseworker spent the
frst portion of the session discussing how Mary felt while circling these ads. Mary ex-
plained that her initial excitement was quickly followed by intense anxiety, but that when
she realized she could not call the apartments even if she had wanted to, she calmed down
almost immediately. Te next portion of the session was spent on determining tasks for
the following week. Te frst task included circling all appropriate ads and calling on two
apartments for informational purposes only. Because Mary had a signifcant amount of
anxiety about calling and talking to a stranger, Mary and her caseworker wrote a script
and rehearsed it by doing a role-play with her caseworker playing the part of the potential
landlord. Marys additional task for the week was to talk to her boss seeking reassurance
that her employment was secure. Mary returned the following week excited. She called on
two apartments and followed the script on the frst one, but the second call went so well
she did not even need the script. Her discussion with her boss also went well, and he reas-
sured her that her job was secure. Mary shared excitedly that her boss was pleased that
Mary showed assertiveness in approaching him and ofered her an opportunity to attend
some training courses so that she could be promoted. For the next three months Marys
counseling proceeded in a similar fashion with weekly tasks that inched her along slowly
enough that she did not become overwhelmed by unreasonable fears, but quickly enough
that she gained confdence and courage with each successive step. Mary rented an apart-
ment during her fourth month of counseling with three months income safely tucked
away in a savings account, a promotion with a raise, and reputable and afordable day care.
Perceptual Reframing, Emotional Regulation,
Networking, and Advocacy
Another general counseling method includes the reframing of a clients perception of
a situation, emphasizing the importance of viewing various events, relationships, and
occurrences from a variety of possible perspectives. For some reason it seems easier
for human beings to assume the negative in many situations. Whether considering
the intentions of a boyfriend or the prospects of getting a better job, most of us seem
to gravitate toward negative assumptions. Many people in the midst of a physical or
emotional crisis of any proportion will ofen resort to taking a somewhat polarized
negative stance on an issue and would beneft from assistance in seeing situations and
relationships from a diferent perspective. A clients perception that life is unfair and
nothing good ever happens to her can be encouraged to see life struggles as normal
and even good because they promote positive personal growth. Clients who feel shame
because they were recently fred from a job they despised can be encouraged to see this
78 Part II / Generalist Practice and the Role of the Human Service Professional
incident as a disguised blessing opening the door to fnd a career for which they are far
better suited.
Additional intervention goals include assisting clients with emotional regulation,
teaching them how to sit with their emotions rather than immediately acting on them;
developing a better social support network so that they can become emotionally in-
dependent and self-reliant; and advocating for clients who are being oppressed, either
within their family systems or in society in general.
Cultural Competence and Diversity
Because human service professionals work with such a wide range of people, across vari-
ous cultures, socioeconomic levels, coming from varying backgrounds, it is vital that hu-
man service education and training be presented in a context of cultural competence
and cultural sensitivity. Cultural competence is refective of a counselors ability to work
effectively with people of color and minority populations by being sensitive to their
needs and recognizing their unique experiences and is a required
component of working in the human services feld. For instance,
the NOHS ethical standards specify the requirements and compe-
tencies human service professionals are required to maintain. Spe-
cifcally, standards 17 through 21 deal with issues related to cultural
competence, focusing in particular on anti-discrimination, cultural
awareness, self-awareness relating to personal cultural bias, and re-
quirements for ongoing training in the feld of cultural competence:
STATEMENT 17 Human service professionals provide services without discrimi-
nation or preference based on age, ethnicity, culture, race, disability, gender, reli-
gion, sexual orientation or socioeconomic status.
STATEMENT 18 Human service professionals are knowledgeable about the
cultures and communities within which they practice. Tey are aware of multicul-
turalism in society and its impact on the community as well as individuals within
the community. Tey respect individuals and groups, their cultures and beliefs.
STATEMENT 19 Human service professionals are aware of their own cultural
backgrounds, beliefs, and values, recognizing the potential for impact on their re-
lationships with others.
STATEMENT 20 Human service professionals are aware of sociopolitical is-
sues that diferentially afect clients from diverse backgrounds.
STATEMENT 21 Human service professionals seek the training, experience,
education and supervision necessary to ensure their efectiveness in working with
culturally diverse client. (NOHS, 1996)
Te human services feld is not the only discipline to require cultural training. Rather,
most professional organizations require that their mental health professionals obtain cul-
tural competency training based upon a foundation of respect for and sensitivity to cul-
tural diferences and diversity (Conner & Grote, 2008). Yet, cultural competency extends
beyond that of ethnic diferences. For instance, counselors who undergo cultural com-
petency training will learn the importance of remaining sensitive to populations from
diferent income levels, religions, physical and mental capacities, genders, and sexual
Cultural competence is refective
of a counselors ability to work
effectively with people of color
and minority populations by
being sensitive to their needs and
recognizing their unique experiences.
Skills and Intervention Strategies 79
orientations, as well as races, and as such, will learn the importance of avoiding what
is commonly referred to as ethnocentrismthe tendency to perceive ones own back-
ground and associated values as being superior, or more normal than others. In recent
years, the issue of cultural or multicultural competence has become so important that
training protocols have been developed with recommendations that all those who work
in the helping felds engage in some form of cultural competency training.
Cultural competence is somewhat of a general term though and is ofen used syn-
onymously with other terms such as cultural sensitivity. Despite the relatively universal
belief among human service and mental health experts that cultural
competence is a vital aspect of practice, very little consensus exists as
to what constitutes cultural competency on a practice level (Fortier &
Shaw-Taylor, 2000). Although broad themes of respect and sen-
sitivity tend to be universally accepted as foundational to cultural
competent practice, the concept of cultural competency has tended
to remain as an idea or general philosophy that has not yet been op-
erationalized in a concrete way. For instance, Cunningham, Foster,
and Henggeler (2002) surveyed counselors who considered them-
selves culturally competent and found that there was a vast difer-
ence in terms of which counseling methods they believed were most
efective with culturally diverse clients. Tis last of consensus among
experts on which specifc counseling approaches and counselor re-
sponses constituted cultural competence makes it difcult, if not
impossible, to determine what methods will have the greatest likeli-
hood of having a positive outcome in counseling a particular ethni-
cally diverse client group. Although recent research has attempted
to develop what is called evidence-based practice with regard to cultural competence, to
date there remains very little research on what constitutes cultural competent practice.
Concluding Thoughts on Generalist Practice
Although human service professionals work with a very wide range of clients present-
ing with an equally diverse range of psychosocial problems, these skills and interven-
tion techniques can be broadly applied in generalist practice. Understanding that people
are not pathological by nature, but ofen are responding to real traumas, tragedies, and
crises in a natural way (e.g., it is normal to become depressed afer experiencing a loss)
helps the human service professional look for a clients strengths, rather than solely
assessing a clients perceived defcits.
Te unique nature of the human services profession encourages practitioners to view
the individual as a part of a greater whole; thus, a clients social world is assessed and eval-
uated, which enables human service professionals to help their clients better navigate their
world. Essentially, it is the human service professionals commitment to working with dis-
placed populations, assessing not only clients but the worlds in which they live, and then
applying various culturally competent intervention techniques designed to encourage,
empower, and integrate some of societys most broken and marginalized members helping
them to become whole and functional, perhaps for the frst time in their lives.
Human Systems
Understanding and Mastery of Human
Systems: Emphasis on context and the
role of diversity in determining and
meeting human needs
Critical Thinking Question: The text
describes ethnocentrism as the
tendency to perceive ones own back-
ground and associated values as being
superior, or more normal than others.
In what ways might ethnocentrism affect
a human service professionals ability to
effectively serve clients? How might he
take steps to reduce his ethnocentrism?
80
1. Disclosing the nature and risks of the counseling
relationship to clients prior to their engaging in these
services is called:
a. the limits of confdentiality
b. a duty-to-warn
c. informed consent
d. confdentiality
2. Keeping information shared by clients in the counsel-
ing relationship confdential is:
a. mandated by law
b. voluntary
c. optional
d. dependent upon the nature of the counseling
relationship
3. Limits of confdentiality refers to:
a. the counselors legal right to share information
disclosed by clients with colleagues for the pur-
poses of clinical supervision
b. the nature and purpose of counseling services
c. the laws that determine how and when client
information can be disclosed to other treatment
providers, insurance companies, and governmental
agencies
d. Both A and B
4. A counselors duty-to-warn and duty-to-protect
relate to situations where through direct disclosure
clients share:
a. their intention to terminate counseling despite
being ordered by the court to receive mental
health services
b. that they are a threat to themselves (suicidal) or
others (homicidal)
c. that they could potentially be a threat to them-
selves or others in the future, under certain
theoretical conditions
d. All of the above
5. Setting boundaries with clients encourages clients to
a. develop relationships with other counselors
b. rely on themselves and newly developed skills to
cope with their struggles
c. become self-destructive due to feelings of
abandonment
d. Both A and B
6. Patience, active listening, and observational skills are
all aspects of:
a. the psychological evaluation
b. the psychosocial evaluation
c. the clinical assessment
d. emotional regulation
The following questions will test your knowledge of the content found within this chapter.
CHAPTER 4 PRACTICE TEST
7. Describe the nature and purpose of creating a family genogram, including ways in which genograms aid clients in
gaining a more objective perspective of family dynamics.
8. Compare and contrast direct practice and case management, including their respective techniques and goals.
Suggested Readings
Bowen, M. (1985). Family therapy in clinical practice. New
York: Jason Aronson.
Epstein, L., & Brown, L. B. (2001). Brief treatment and a new
look at the task-centered approach. Boston: Allyn & Bacon.
Fulero, S. M. (1988). Tarasoff: 10 years later. Professional Psy-
chology: Research and Practice, 19, 184190.
Nash, K. A., & Velazquez, J. (2003). Cultural competence: A guide
for human service agencies. Atlanta, GA: CWLA Press.
Reamer, F. G. (2005). Pocket guide to essential human services.
Washington, DC: NASW Press.
Russo, J. R. (2000). Serving and surviving as a human-service
worker. Long Grove, IL: Waveland Press.
Skills and Intervention Strategies 81
Internet Resources
American Counseling Association: http://www.counseling.org
Center for Credentialing & Education, Human Services
Board Certified Practitioner: http://www.cce-global.org/
credentials-offered/hsbcp.
Genograms: http://www.genopro.com/genogram
National Organization for Human Services: http://www.national-
humanservices.org
References
American Counseling Association. (2005). ACA code of ethics.
Alexandria, VA: Author.
American Psychiatric Association. (2000). Diagnostic and statistical
manual of mental disorders (4th ed., Text Revision). Washington,
DC: Author.
American Psychological Association. (2002). Ethical principles of
psychologists and code of conduct. Washington, DC: Author.
Bowen, M. (1978). Family therapy in clinical practice. New York:
Jason Aronson.
Center for Credentialing & Education. (2011). Human Services-
Board Certified Practitioner Exam Candidate Handbook.
Retrieved January 1, 2011, from: http://www.cce-global.org/
Downloads/HS-BCPHandbook.pdf.
Cloud, H. C., & Townsend, J. (1992). Boundaries. Grand Rapids,
MI: Zondervan.
Conner, K., & Grote, N. (2008, October). Enhancing the cultural
relevance of empirically-supported mental health interventions.
Families in Society, 89(4), 587595. Retrieved September 14,
2009, from Academic Search Premier database.
Cunningham, P., Foster, S., & Henggeler, S. (2002, July). The elusive
concept of cultural competence. Childrens Services: Social Policy,
Research & Practice, 5(3), 231243. Retrieved September 14,
2009, from Academic Search Premier database.
Duffy, M., Gillig, S. E., Tureen, R. M., & Ybarra, M. A. (2002). A
critical look at the DSM-IV-TR. The Journal of Individual Psy-
chology, 58(4), 362373.
Escalas, J. E., & Stern, B. B. (2003). Sympathy and empathy:
Emotional responses to advertising dramas. Journal of Consumer
Research, 29, 566578.
Fortier, J. P., & Shaw-Taylor, Y. (2000). Assuring cultural competence
in healthcare: Recommendations for national standards and an
outcomes-focused research agenda. Resources for Cross-Cultural
HealthCare and the Center for the Advancement of Health.
Rockville, MD: U.S. Department of Health and Human Services,
Office of Minority Health.
Fulero, S. M. (1988). Tarasoff: 10 years later. Professional Psychology:
Research and Practice, 19, 184190.
Greenberg, L. S., Elliot, R., Watson, J. C., & Bohart, A. C. (2001).
Empathy. Psychotherapy: Theory, Research, Practice, Training,
38(4), 380384.
National Association of Social Workers. (2000). Cultural com-
petence in the social work profession. In Social work speaks:
NASW policy statements (pp. 5962). Washington, DC: NASW
Press.
National Association of Social Workers. (2002). NASW standards
for social work case management. Retrieved May 25, 2004, from
http://www.naswdc.org/practice/standards/sw_case_mgmt.
asp#intro
National Organization for Human Services. (1996). Ethical stan-
dards of human service professionals. Washington, DC: Author.
Park, C. L., & Fenster, J. R. (2004). Stress-related growth: Predic-
tors of occurrence and correlates with psychological adjustment.
Journal of Social and Clinical Psychology, 23(2), 195215.
Prest, L. A., & Protinsky, H. (1993). Family systems theory: A uni-
fying framework for codependency. American Journal of Family
Therapy, 21(4), 352360.
Reid, W. J. (1975). A test of a task-centered approach. Social Work,
20(1), 39.
Schatz, M., Jenkins, L., & Sheafor, B. (1990, Fall). Milford redefined:
A model of initial and advanced generalist social work. Journal of
Social Work Education, 26(3), 217231. Retrieved June 24, 2009,
from Professional Development Collection database.
Tarasoff v. Regents of the University of California, 118 Cal. Rptr. 129,
529 P.2d.533 (Cal. 1974).
Tarasoff v. Regents of the University of California, 113 Cal. Rptr. 14,
551 P.2d.334 (Cal. 1976).
Wodarksi, J. S., Rapp-Paglicci, L. A., Dulmus, C. N., & Jongsma, A.
E. (2001). The social work and human services treatment planner.
Hoboken, NJ: John Wiley & Sons.
82
CHAPTER 5
Learning Objectives
Develop an understanding of the
history of the child welfare sys-
tem, recognizing the impact of
historic policies and practices on
the current child welfare system
Develop an understanding of the
demographic makeup of children
currently in care of the child wel-
fare system, understanding the
reasons for overrepresentation
of certain racial ethnic groups
Understand how children enter
the child welfare system, includ-
ing having a basic understanding
of the federal and state laws that
govern child placement policies
Develop an understanding of
the nature of working with
biological parents, children in
placement, and foster parents,
recognizing the complementary
and confictual roles of each
Recognize the historic and cur-
rent trends of bias and abuse of
certain ethnic minority groups
within the child welfare system,
as well as understanding ways
of avoiding such abuse through
cultural competent practice
Te feld of child and family services generally involves the care and pro-
vision of children who cannot be appropriately cared for by their biologi-
cal parents, as well as providing assistance for those who need support
and assistance in the management and provision of their families. Tis
practice setting is primarily concerned with children in foster care place-
ment, but may also involve family preservation services and adoption
services. A human service professional working in a child and family ser-
vices setting may be involved in the following activities:
Child abuse investigations
Child abuse assessments
Case management and counseling of the child in placement, foster
families, and biological parents
Case management and counseling of families in crisis
Case management and counseling of potential adoptive parents,
adult adoptees, and birth parents
Te clinical issues involved in this feld are quite broad but involve
issues related to abandonment and loss, post-traumatic stress disorder
(PTSD), cultural sensitivity, child development, parenting issues, sub-
stance abuse, anger management, and the ability to work with a broad
range of life stressors and maladaptive responses that might lead to
breakdowns within the family.
In addition to the wide range of activities in which a human service
professional might engage within a child and family services agency,
there is also a wide range of practice settings where the human service
professional might work, the largest being a states child protective ser-
vices (CPS) agency. Human service professionals also work at not-for-
profit agencies, some of which are contracted by the state to provide
mandated services to children in substitute care and some of which
Child Welfare Services
Overview and Purpose of Child
and Family Services Agencies
Kyodo/Newscom
Child Welfare Services 83
provide voluntary services to any family in crisis. Within these agencies a human service
professional may be involved in a number of activities, including counseling, case man-
agement, and writing grants for increased funding. Many human service professionals
working in the feld of child welfare may do so on a volunteer basis, and although these
individuals are not paid professionals, the work they do is so vital that their role in the
welfare of children must be mentioned. For instance, CASA (court-appointed special
advocates) volunteers are court-appointed advocates for children who are placed into
state care, working to protect the best interest of the children by being their voice in all
court proceedings.
The History of the Foster Care System in the United States
Te child welfare system in the United States has undergone signifcant changes in the
last several hundred years due to numerous factors such as urbanization, industrial-
ization, immigration, mass life-threatening illness, changes within the family system,
changing social mores (including the reduction of shame associated with divorce, out-
of-wedlock births, and single parenting by choice), and the eventual availability of gov-
ernment fnancial assistance for those in need. Tus, to truly understand the current
child welfare system it is vital to understand its past.
In 2001, ABCs news show Nightline aired a documentary featuring the horrible
plight of the street children of Romania (Belzberg, 2001). Afer the show, U.S. citizens
fooded the network with telephone calls, expressing outrage and horror at the images
that fashed across their television screens for almost two hours. Te documentary re-
vealed children as young as six years old living on the streets, with no food to eat, with
only slightly older children and liquid glue to keep them warm at night. Te reporter
explained how political events in Romania created a situation where impoverished fam-
ilies could no longer care for their ofspring, leading to the streets becoming fooded
with marauding children, in desperate search of money and food. Tese children, who
ofen resorted to pickpocketing and other petty crimes, were considered by most main-
stream Romanians to be the scourge of society, pests to be avoided.
Te U.S. response was one of literal horror, not only at the conditions in which the
children were forced to live but also at the apparent apathy of most Romanians, par-
ticularly those in government, including the Romanian police force. Te documentary
showed numerous incidences of police mistreatment, including one young boy whose
leg was broken in a scufe with a police ofcer. Tis seeming indiference shocked view-
ers, who expressed outrage at the heartlessness necessary to not only accept orphans liv-
ing on the street, but actually perceive these orphans as social pariahs. Tese concerned
and outraged Americans are apparently unaware that our own recent past includes
alarmingly similar conditions and attitudes toward orphans, with only 150 to 200 years
separating the United States from Romania in this regard.
Historic Treatment of Children in Early America
There were many ways in which children were mistreated in Colonial America, but
in this section I will be exploring primarily two areas of mistreatment of children in
84 Part II / Generalist Practice and the Role of the Human Service Professional
contemporary America and Great Britain, which in many respect served as the founda-
tion for child welfare laws in the United States, including child labor laws. Tese two
areas include the use of children in the labor market, otherwise known as child labor,
and the treatment of children who were, for whatever reason, without parents, most of-
ten referred to as orphans or street children. Of course there are many other ways in
which children were mistreated as wellwithout federal laws protecting children, there
was rampant sexual abuse, physical abuse, and various other forms of maltreatment such
as neglect (physical and emotional). By exploring primarily child labor and the treatment
of orphans and street children, readers should not presume that other forms of maltreat-
ment did not exist in Americas history. Te rationale for exploring these two areas of
maltreatment (child labor and the treatment of orphans and street children) is based
upon the fact that they represent a signifcant departure from how children are treated
today, and also highlight key areas within child welfare, with regard to early child welfare
advocacy and development of laws, policies, and programs intended to protect children.
Child Labor in Colonial America: Indentured Servitude and
Apprenticeships
During Colonial America, all children were expected to work, whether bonded or not.
In fact, children as young as 6 years old worked alongside their parents, and children as
young as 12 years old were expected to work in adult-like capacities, ofen working in
apprenticed positions outside of their homes, and away from their families. Children of
poor families, particularly immigrants, were ofen forced to work alongside their par-
ents either in indentured servitude or as slaves. During the many waves of early immi-
gration, individuals, families, and minor children as young as 10 or 11 years old ofen
paid for their passage to the United States through a process called indentured service.
Indentured service contracts required that the servantmost ofen a poor individual,
or families hoping for a better life in Americawork of the cost of their travel by work-
ing for a master in some capacity once they arrived in America. If a family immigrated
to the United States in this manner, then their children, regardless of age, were required
to work as well.
Te economic system of indentured servitude was extremely exploitative. Research
indicates that it was the ship owners who would ofen recruit unsuspecting, yet desper-
ate, individuals from other countries, with stories of abundant life in America. Many
individuals and entire families accepted the call, believing that they could make a better
life for themselves in Colonial America. Tey were told that the terms of their service
would last for three years, and then they would be freefree to buy land and to make a
life for themselves that was not possible in many European countries (Alderman, 1975).
In reality, the cost of their passage would be paid of in only one year, and the remaining
years of service were considered free work. Further, masters ofen treated their bonded
labor quite poorly. Servants received no cash wages, but were supposed to be provided
with basic necessities, which depending upon the nature and means of the master,
might include anything from sufcient sustenance to meager sustenance and substan-
dard shelter. Tus, while indentured servants were not considered slaves, the treatment
of them was quite similar (Martin, in press).
Child Welfare Services 85
Although most indentured servants were in their early 20s, Green (1995) notes that
children who immigrated with their families on bonded contracts were expected to
work as well, and were ofen treated no diferently than their parents. Children were not
allowed to enter into bonded labor contracts without the permission of their parents,
but very poor and orphaned children, particularly in London, were ofen kidnapped
and sold to ship captains, who then brought them to America and sold them as in-
dentured servants, most ofen to masters who used them as house servants. Also, local
governments that were responsible for the poor, would bind out poor and orphaned
children in early America as a form of poor relief (Katz, 1996). Most local laws favored
masters (since virtually all judges were in fact masters themselves), and stipulated that
child bonded servants could often be kept until the age of 24, and if they ran away,
their treatment became even more abusive and their time in bonded servitude was ofen
doubled (Green, 1995).
Slavery and Child Labor
Indentured servitude eventually waned during the 17th century in favor of slavery, but
the binding out of children who were poor and orphaned continued well into the 19th
century. During the 300 years of the Atlantic slave trade over 15 million Africans were
brought to the United States through the West Indies, or directly from Africa. Among
these Africans were many children who were either forced or born into slavery along with
their parents. In time masters realized that slaves who had once experienced freedom
were far more difcult to control than those born into captivity; thus, a market developed
for children who could work for a slave owner and essentially grow up as captive slaves,
and be trained to be a submissive servant. According to Green (1995) children under the
age of about seven were more ofen sold with their mothers, but once the children were
between the ages of 7 and 10, they could and ofen were sold of and separated from their
families, particularly to fll this growing need for young negro slave children born into
captivity. Slavery was outlawed in 1865 with the passage of the Tirteenth Amendment
to the U.S. Constitution, but the plight of African children did not improve signifcantly
(and most human service professionals would argue that the legacy of slavery creates
signifcant challenges for African American children to this day).
Tere were not as many African slave children born into captivity as one might ex-
pect, due in large part to extremely high rates of infant mortality of African slave chil-
dren due to disease and poor nutrition. In fact, the infant mortality of African slave
children under the age of four was double that of white children during the time when
slavery was legal. Ironically, not only has this trend continued well into the 21st century,
but it has gotten far worse with infant mortality among African American infants being
about three times that of Caucasian infants (CDC, 2002).
Troughout early American history children worked within their own households
and farms working alongside their families. Te hope of parents was that their chil-
dren would be able to aford to buy farms of their own when they grew to adulthood.
Another form of work that children engaged in early America was apprenticeship.
Apprenticeship involved the training of children in a craft. Some children went to
live with the artisan who trained them and others did not. Essentially apprenticeship
86 Part II / Generalist Practice and the Role of the Human Service Professional
involved an artisan taking on an apprentice in early adolescence and teaching him a
trade. Te apprentice would serve as an assistant to the artisan (Schultz, 1985). Appren-
ticeships might involve learning to become a barber, making shoes, or woodworking.
Children were not paid, and in fact parents ofen had to pay to have their children ap-
prenticed. While most apprenticeships did not involve overt exploitation, the practice
did refect the focus on working children, rather than education. Apprenticeships even-
tually became less popular as Industrialization began in the late 18th century, as ma-
chines were developed replacing the need for many crafsmen.
Child Labor during the Industrial Era: Children and Factories
By the mid-19th century, virtually all apprenticeships and indentured contracts had
disappeared, and most families could no longer support themselves through farming
alone. Te primary form of labor, particularly child labor, was factory work (Bender,
1975). Children were ofen recruited to work in factories, particularly orphans or those
from poor families. By the early to mid-19th century, it is estimated that hundreds of
thousands of childrensome as young as sixwere employed in the textile industry,
including cotton mills. In fact, some scholars estimated that children were the bulk of
the workforce in many factories throughout the 19th century, with some children work-
ing six days a week, 14 hours a day (Green, 1985). Excerpts of autobiographies written
by individuals who worked in factories throughout their childhoods reference dismal
conditions, with poor sanitation and air quality, repetitive work on machinery that lef
small hands bleeding, and very long days on their feet, which in many cases signifcantly
shortened the life spans of these child workers (Green, 1985).
Garment industry sweatshops began to spring up throughout New York and other
large cities in the mid- to late-19th century. Although sweatshops eventually occurred
in factory-like settings, their origin involved what was called outwork, where workers
sewed garments and other textiles in their homes. Women and children were primarily
hired for these tasks since they could be paid a lower wage. Since they were paid by the
piece, they ofen worked 14 or more hours per day, seven days a week. Children worked
alongside their mothers, because their small fngers enabled them to engage in detail
work, such as sewing on buttons that was challenging for adults.
The U.S. Orphan Problem
Te United States also experienced several waves of political, economic, and environ-
mental tragedies that resulted in strikingly similar conditions as those experienced in
Romania today. During the 1700s and 1800s in particular, attitudes toward children
were harsh, and many orphaned or uncared for children roamed the streets, particu-
larly in growing urban areas such as New York. Tese street children were ofen treated
harshly and punitively. If children were on the streets because their parents were desti-
tute, they were ofen sent to almshouses, regardless of their harsh conditions, to work
alongside their homeless parents. Many homeless and orphaned children were forced
into a form of indentured servitude called apprenticeships, which taught them a trade
and provided cheap labor during an era that saw many economic depressions and a
shortage of available workers (Katz, 1996).
Child Welfare Services 87
The plight of the orphan did not appear to tug at the heartstrings of the average
U.S. citizen during that era, not only because of the vast amount of abandoned and
orphaned children (which appears to have a desensitizing efect on the human psyche),
but also because during the 17th through the mid-19th century, children were not
perceived to be in need of special nurturing, because childhood was not considered
a distinct stage of development until years later. Te infuence of Puritanical religious
thought as well as the general mores of the times led to the common belief that children
needed to be treated with harsh discipline or they would fall victim to
sinful behaviors such as laziness and vice (Trattner, 1998).
A significant shift in child welfare policy occurred in the mid-
1800s, though, when the Civil War left thousands of children or-
phaned, making tragedy a visitor in some respect to virtually every
U.S. family. Coinciding with this increase in concern over the plight
of disadvantaged children was a dramatic shif in the way children on
the whole were viewed. Te development of the feld of psychology in
the frst quarter of the 20th century, as well as a transition in religious thought toward
a more compassionate and loving God, led to the emerging belief that children were
essentially good by nature and needed to be treated with kindness, love, and nurtur-
ing to enhance their development and ultimate potential as adults (Trattner, 1998).
In addition to these changes, the Industrial Revolution reduced the need for
apprenticeship, and at the same time, stories of abhorrent conditions and mass abuse in
almshouses (particularly involving abuses against children) were being widely reported.
Settlement house workers, Charity Organization Societies (COSs), and government of-
fcials alike were eager to address the problem of orphaned and abused children in the
latter part of the 19th century, and the most commonly suggested solution was the cre-
ation of institutions designed solely for the care of orphaned and needy children.
The Orphan Asylum
Although some orphanages existed in the 1700s, they did not become the primary
means for handling needy and orphaned children until the middle to late 1800s, and
by the 1890s there were more than 600 orphanages in existence in the United States
(Trattner, 1998). Orphanages, or orphan asylums as they were often called, did not
house just children who lost both parents to death, but also became the solution for
many of the economic and environmental conditions of the time. Even though mor-
tality rates were down in both the United States and Europe during the Industrial age
(Condran & Cheney, 1982), several factors existed that resulted in the increasing need
for orphanages.
Poor safety conditions in factories resulted in a relatively high prevalence of work-
related injuries and death among the poorest members of society, leaving many children
orphaned or fatherless. Coupled with this was a signifcant infux of poor immigrants
in the late 1800s and early 1900s, resulting in a vulnerable segment of society ofen not
having an extended family on which to rely in cases of parental death or disability. Tis
was ofen true of recently emigrated families, who lef their extended families behind in
their venture to the New World.
During the 17th through the mid-
19th century, children were not
perceived to be in need of special
nurturing, because childhood was
not considered a distinct stage of
development until years later.
88 Part II / Generalist Practice and the Role of the Human Service Professional
Families who were for whatever reason suddenly unable to support their children
could leave them in the temporary care of an orphanage for a small fee, but if they
missed some monthly payments, the children would become wards of the state, and the
parents would lose all legal rights to them (Trattner, 1998). In addition, although infec-
tious disease was nothing new to Colonial America, several infectious disease epidem-
ics spread through urban United States between the mid-1800s and the early part of the
1900s, including smallpox, infuenza, yellow fever, cholera, typhoid, and scarlet fever,
leaving many children orphaned (Condran & Cheney, 1982).
Although the orphanage system was originally perceived as a signifcant improve-
ment over placing children in almshouses or forcing them into indentured servitude,
these institutions were not without their share of trouble, and in time, reports of harsh
treatment and abuses were common in orphanages as well. Although some orphanages
were government run, most were privately run with governmental funding, but had lit-
tle if any oversight or accountability. Because the government paid on a per child basis,
there was a fnancial incentive to run large operations, with some orphanages housing
as many as 2,000 children under one roof. Obedience was highly valued in these institu-
tions out of sheer necessity, whereas individuality, play, and creativity were discouraged
through strict discipline and harsh punishment (Trattner, 1998).
Te next wave of child welfare reform involved the gradual shif from institution-
alized care to the substitute family foster care system, or the placing-out of children
into private homes prompted by the development of compulsory public education,
which meant that the education of an orphan was no longer linked with the provision
of housing.
The Seeds of Foster Care: The Orphan Trains
Have you ever wondered where the expression farming kids out came from? Te origin
of this term is rooted in what is called the Orphan Train movement, a program devel-
oped by the frst agency to utilize in-home placement rather than institutionalized care.
Te New York Childrens Aid Society was founded by Rev. Charles Loring Brace, who
recognized the serious problem of children growing up on the streets of New York due to
several tragic events from the mid-19th century. Brace estimated that as many as 5,000
children were homeless and forced to roam the streets in search of money, food, and shel-
ter. Brace was shocked at the cruel indiference of most New Yorkers, who called these
children Street Arabs with bad blood. He was also appalled at reports of children as
young as fve years old being arrested for vagrancy (Bellingham, 1984; Brace, 1967).
Many factors contributed to the serious orphan problem in New York. Historians
estimate that approximately 1,000 immigrants fooded New York on a daily basis in the
mid-1800s (Von Hartz, 1978). Mass urbanization remained the trend with poor rural
families focking to the cities looking for factory work. Industry safety standards were
essentially nonexistent; thus, factory-related deaths were at an all-time high. An out-
break of typhoid fever also lef many children orphaned or half-orphaned with new
widows who had virtually no way to support their children because government aid was
not yet available. Tese harsh social conditions, coupled with the absence of any orga-
nized governmental subsidy, lef many children to fend for themselves on the streets of
New York, resorting to any means for survival.
Child Welfare Services 89
Brace feared that the temptations of street life would preclude any pos-
sibility that these children would grow up to be God-fearing, responsible
adults, and he reasoned that children who had no parents, or whose parents
could no longer care for them, would be far better of living in the clean open
spaces of the farming communities out west, where fresh air and the need
for workers were plentiful. Because the rail lines were rapidly opening up
the West, Brace developed an innovative program where children would be
loaded onto trains and taken west to good Christian farming families. Notices
were sent in advance of train arrivals, and communities along the train line
would come out and meet the train, so that families who had expressed an
interest in taking one or more children could examine the children and take
them right then, if they desired. Brace convened committees who would in-
terview families to ensure that they met the standards for qualifed adoptive
or foster families.
Survivors of these Orphan Trains have talked about how they felt like cat-
tle, being paraded across a stage. Interested foster parents would ofen feel the
childrens muscles and check their teeth before deciding what child they would
take. Few parents would take more than one child, thus siblings were most
ofen split up, sometimes without even a passing comment made by the child
care agents or the new parents (Patrick, Sheets, & Trickel, 1990). It was almost
as if the breaking of lifelong family bonds was considered trivial compared
to the gif these children were receiving by being rescued from their hopeless
existence on the streets.
Most children were not legally adopted, but were placed with a family
under an indentured contract, which served two purposes. First, this type of
contract allowed the placement agency to take the children back if something
went wrong with the placement. Second, children placed under an indentured
contract could not inherit property; thus, farming families could adopt boys
to work on the farm or girls to assist with the housework, but didnt have to
worry about them inheriting the family assets (Trattner, 1998; Warren, 1995).
The Orphan Trains ran from 1854 to 1929, delivering approximately
150,000 children to new homes across the west, from the midwestern states to
Texas, and even as far west as California. Whether this social experiment was
a glowing success or a miserable failure (or somewhere in between) depends
on whom one asks. Some children were placed in wonderful, loving homes
and grew up to be happy and responsible adults, who feel strongly that the
Orphan Trains were a true blessing. But other survivors of the Orphan Trains
shared stories of heartache and abuse. Some tell stories of lives no better than
that of slaves, where they were taken in by families for no other reason than to
provide hard labor for the cost of bed and board. Others tell stories of having
siblings torn from their sides as families chose one child, leaving brothers and
sisters on the train. And still others tell stories of failed adoptions, where farm-
ing families exercised their one-year return option, sending the children back
to the orphanage or allowing the children to drif from farm to farm to earn
their keep (Holt, 1992).
Typical wanted advertisement
posted throughout the Midwest
by the Childrens Home and Aid
Society between 1854 and 1929.
Nemaha County Herald/nebraska
State Historical Society
90 Part II / Generalist Practice and the Role of the Human Service Professional
Eventually new child welfare practices caught up with new
child development theories, leading to a general focus shifing
from one of work virtue to one of valuing childhood play. By
the early 20th century the practice of farming out children re-
ceived increasing criticism, and the last trainload of children was
delivered to its many destinations in 1929. Despite the contro-
versy surrounding the Orphan Train movement and the many
similar outplacement programs that followed across the country,
even its harshest critics agreed that it was a far better alternative
than allowing children to fend for themselves on the streets of
New York. Also, despite the programs many shortcomings, in-
cluding poor oversight and insufcient screening of the families,
it is considered the forerunner of the current foster care system
in the United States, where children are placed in available pri-
vate homes, rather than in institutions (Trattner, 1998).
Jane Addams and the Fight for Child Labor Laws
At around the same time that Charles Loring Brace was sending New
York orphans out west, Jane Addams and her friend Ellen Gates Starr
were busy founding Hull-House of Chicago, the frst U.S. settlement
house providing residential and what we would now call wrap around services, as well as
advocacy to marginalized populations working in sweatshop conditions in Chicago. Addams
was appalled by the conditions of those living in poverty in urban communities, particularly
the plight of recently arrived immigrants, who were forced to live in substandard tenement
housing and work long hours in factories, ofen in very dangerous working conditions.
Hull-House ofered several services for children and their widowed mothers, includ-
ing afer-school care for those children whose mothers worked long hours in factories.
Providing comprehensive services to those in need, and living among them in their own
community were some of the ways in which Addams became aware of the plight of chil-
dren forced to work in the factories. In her autobiography Twenty Years at Hull-House,
Addams wrote of her frst encounter with child labor:
Our very frst Christmas at Hull-House, when we as yet knew nothing of child la-
bor, a number of little girls refused the candy which was ofered them as part of
the Christmas good cheer, saying simply that they worked in a candy factory and
could not bear the sight of it. We discovered that for six weeks they had from seven
in the morning until nine at night, and they were exhausted as well as satiated
during the same winter from a Hull-House club were injured at one machine in a
neighboring factory for a lack of a guard which would have cost but a few dollars.
When the injury of one of these boys resulted in his death, we felt quite sure that
the owners of the factory would share our horror and remorse, and that they would
do everything possible to prevent the recurrence of such a tragedy. To our surprise
they did nothing whatever, and I made my frst acquaintance then with those pa-
thetic documents signed by the parents of working children, that they will make no
claim for damages resulting from carelessness. (Addams, 1911, pp. 198199)
Children on the Orphan Train.
Riis, Jacob A. (Jacob August), 18491914/Library
of Congress Prints and Photographs Division
[LC-USZ62-17233]
Child Welfare Services 91
Addams and her colleagues began an advocacy campaign against sweatshop
conditions in Chicago factories early in the Hull-Houses existence, advocating
in particular for the women and children who were most often hired to work in
them. Their activism seemed to pay off quickly when the Illinois legislature passed
a law limiting the word day to just eight hours (from the typical 12- to 14-hour
day). Their excitement though was soon tempered when the law was quickly over-
turned by the Illinois Supreme Court as unconstitutional. In her autobiography
Addams discussed how the greatest opposition to child labor laws came from busi-
ness sector business men from large corporations (such as Chicago glass compa-
nies), who considered such legislation as radicalism, arguing that their companies
would not be able to survive without the labor of children (Addams, 2011; Martin,
in press).
Addams and the Hull-House networked quite extensively joining eforts with trade
unions and even the Democratic Party, which in 1892 adopted into its platform union
recommendations to prohibit children under the age of 15 years old from working in
factories. Addams and her Hull-House colleagues increased the focus
of their activism to the federal level with their support for the Sulzer
Bill, which when passed allowed for the creation of the Department
of Labor. In 1904 the National Child Labor Committee was formed,
and Addams served as chairman for one term. In 1912, one of
Addamss Hull-House colleagues, Julia Lathrop was appointed chief
of a new federal agency by President William Taf, focusing on child
welfare, including child labor. As chief of the Childrens Bureau Lath-
rop was responsible for investigating and reporting on all relevant is-
sues pertaining to the welfare of children from all classes, and spent
a considerable amount of time extensively researching the dangers of
child labor (Martin, in press).
After several failed attempts federal legislation barring
child labor was finally passed in 1938, and signed into law by
President Franklin D. Roosevelt, three years afer Addamss death.
Te Fair Labor Standards Act is a comprehensive bill regulating
various aspects of labor in the United States, including child labor.
Te act defned oppressive child labor and set minimum ages
of employment and the number of hours children were allowed
to work. Tis act is still in existence today and has been amended several times to
address such issues as equal pay (Equal Pay Act of 1963), age discrimination (Age
Discrimination in Employment Act of 1967), and low wages (federal minimum wage
increases) (Martin, in press).
Overview of the Current U.S. Child Welfare System
Children living in contemporary western societies face very diferent challenges than
children living 100 years ago. Child labor laws preclude child exploitation in the work-
force, and federal and state social welfare programs now exist, which have helped not
Professional History
Understanding and Mastery of Profes-
sional History: Historical roots of human
services
Critical Thinking Question: It is clear
that the treatment of children through-
out the history of the United States (as
in all cultures across time) is shaped by
religious and philosophical beliefs, soci-
etal structures, and economic systems.
How is current child welfare policy and
practice shaped by these same factors?
In 50 or 100 years, what will historians
find laudable about our current policies?
What will they find short-sighted or
harmful to children?
92 Part II / Generalist Practice and the Role of the Human Service Professional
only to alleviate poverty but also have helped protect families from the efect of various
catastrophes, such as natural disasters and pandemics. Also, vulnerable groups of chil-
dren are far better protected from disparity in treatment through the passage of such
federal legislation as the Civil Rights Act of 1964 and the Americans with Disabilities
Act; yet, there remains disparity in treatment of children from certain ethnic groups,
such as African Americans, Latinos, and Native Americans.
Tere also remain serious issues with how some children are treated within U.S.
society. For instance, few truly effective systems are in place to assist runaway and
homeless youth. Far too ofen adolescents who experienced physical and sexual abuse
in their homes are typically not served well by child protective custody services, and
often choose to live on the streets rather than remain in their homes, or trust the
system to provide for their care. Far too many children are charged as adults for
crimes they committed as children, and most of these are children of colorprimarily
African American boys. African American girls also experience disparity in treatment
by organizations charged with the responsibility for their protection. For instance,
there is a growing recognition that African American girls are far more likely to be vic-
tims of domestic sex trafcking; yet, if they are apprehended, rather than being treated
as victims, they are far more likely to be charged as prostitutes and sent back to the
streets (Martin, in press).
With regard to child protection and the care of orphaned and abused children, care
has slowly transitioned from institutionalized care, to primarily substitute family care
or foster care over the past 100 years. By 1980, virtually no children remained in insti-
tutionalized care in the United States, excluding group homes, treatment centers, and
homes for developmentally disabled children (Shughart & Chappell, 1999). Govern-
ment public assistance programs, which developed in the 1960s, reduced the necessity
for the removal of children from their homes due to poverty, because single mothers
now had someplace to go for fnancial help in raising their children (Trattner, 1998).
Te demographic makeup of children currently in the foster care system difers con-
siderably from the children institutionalized in orphanages in the 1800s, as well as the
children of the Orphan Train era. Tus, gone are the days where the majority of children
being placed into substitute care were orphaned due to industrial accidents, war, or ill-
ness. Instead, the majority of children currently in child protective custody have been
removed from their homes due to serious maltreatment. Also, unlike earlier eras when
orphanage placements were most ofen permanent, almost half of all children currently
in foster care have the goal of reunifying with their biological parents (U.S. Department
of Health and Human Services, 2008).
As of September 1, 2010 (the most recent statistics available), there were approx-
imately 408,325 children in the U.S. foster care system. Tis represents a decrease of
almost 105,000 children since 2006, and it also represents a continued pattern of re-
duction of children in out-of-home placement since 1998 (U.S. Department of Health
and Human Services, 2010). Approximately 41 percent of all children in foster care are
Caucasian, followed by 29 percent African American children, and 21 percent Hispanic
children. Tese demographics indicate an overrepresentation of African American chil-
dren in the foster care system in particular because African Americans constitute only
Child Welfare Services 93
15 percent of the general population, whereas Caucasians constitute 61 percent of the
general population.
Te average age of children in care is about nine years old, with the greatest num-
ber of children in foster care placement between the ages of 11 and 15 years, followed
by children ages one through fve years. About half of all children in placement are in
nonrelative foster care placement, followed by about a quarter of all children placed in
relative care. Te median length of stay in foster care is about 18 months, but it appears
that if children arent placed in the frst 18 months of placement, chances increase that
children will remain in placement for several years. Te greatest
number of children who lef the child welfare system in 2010 were
infants under 3 years of age, and those exiting the system ages 17
and above (U.S. Department of Health and Human Services, 2010).
Te U.S. child welfare system exists to provide a safety net for
children and families in crisis. A primary goal of the foster care
system is to reunite foster care children with their biological par-
ents whenever possible (Sanchirico & Jablonka, 2000). Federal and state laws have
established three basic goals for children in the U.S. child welfare system:
Safety from abuse and neglect
Permanency in a stable, loving home (preferably with the biological parents)
Well-being of the child with regard to their physical health, mental health, and de-
velopmental and educational needs
How these goals are met depends on the specifc issues involved in each case, but before
these various alternatives are considered, it is important to understand how a child en-
ters the child welfare system in the frst place.
Getting into the System
So, how does a child end up in foster care? Made-for-television movies might have the
public thinking that child welfare workers have the power to remove children from
homes with minimal evidence of abuse. Yet, in reality, several criteria must be met to
place a child into protective custody, and a child cannot be removed from a family home
without a judges approval. Te U.S. Constitution guarantees certain liberties to parents
by giving them the right to parent their child in the manner they see ft. But such liber-
ties are balanced by the parents duty to protect their childs safety and ensure their well-
being. If parents cannot or will not protect their children from signifcant harm, the state
has the legal obligation to intervene (Goldman & Salus, 2003).
The U.S. Congress has passed several pieces of legislation that support the states
obligation to protect its youngest residents, including the Child Abuse Prevention and
Treatment Act (CAPTA) of 1974, which was established to ensure that children of mal-
treatment are reported to the appropriate authorities. Tis act (which was most recently
amended in 2010) also provides minimum standards for defnitions of the diferent types of
child maltreatment. Te Adoption Assistance and Child Welfare Act of 1980 requires that
states develop supportive programs and procedures enabling maltreated children to remain
in their own homes and to assist family reunifcation following out-of-home placements.
A primary goal of the foster care
system is to reunite foster care
children with their biological parents
whenever possible.
94 Part II / Generalist Practice and the Role of the Human Service Professional
Other legislation is aimed at (1) improving court efciency so that child abuse cases
will not languish in the court system for years, (2) providing assistance to foster care
children approaching their eighteenth birthday, and (3) bolstering family preservation
programs designed as an early intervention program in the hopes of circumventing out-
of-home placement (Goldman & Salus, 2003).
In 1997 the president signed into law the Adoption and Safe Families Act, which
amended and made improvements to the Adoption Assistance and Child Welfare Act
of 1980. Among the amendments the act provides are incentives for families adopting
children in the foster care system and mandates that states provide evidence of adop-
tion eforts. Amendments also set a new accelerated time line for terminating the rights
of parents whose children are in foster care placement. As we will see in subsequent
sections of this chapter, there are both positive and negative aspects of this legislation.
Certainly no one wants abused and neglected children to languish in temporary place-
ment, but expediting the fnding of permanent homes should not be at the expense of
biological parents rights to have an appropriate amount of time to meet the states cri-
teria for regaining the custody of their children. Balancing the rights of the biological
parents with the best interest of their child is challenging, particularly in light of the
complexity involved in many foster care cases.
In 2006, the Safe and Timely Interstate Placement of Foster Children Act (Pub. L. No.
109-239) was passed, which made it easier to place children in another state, if neces-
sary. Tis legislation holds states accountable for the orderly, safe and timely placement
of children across state lines by requiring that home studies be completed in less than
60 days, and that the children be accepted within 14 days of completion. Te legislation
also provides grants for interstate placement and requires caseworkers to make inter-
state visits, when necessary.
Quite likely, the most signifcant federal legislation passed recently is the Foster-
ing Connections to Success and Increasing Adoptions Act of 2008 (Pub. L. No. 110-
351), which former president Bush signed into law in October 2008. Tis law amends
the Social Security Act by enhancing incentives, particularly in regard to kinship care,
including providing kinship guardian fnancial assistance as well as providing family
connection grants designed to facilitate and support kinship care. Tis legislation also
includes provisions related to education and healthcare particularly for children in kin-
ship care, many of whom were not eligible for special assistance programs unless they
were in nonrelative care.
Child Abuse Investigations
Mandated Reporters
Tere are several ways that a child abuse investigation may be initiated, but all have their
origin in a concern that a child is being mistreated in some manner. Many professionals,
such as counselors, teachers, physicians, and even Sunday school teachers, are required
by law to call their states child abuse hotline immediately if they suspect that a child is
being abused or neglected. Mandated reporters typically fall into one of several catego-
ries and include professionals who work with children as a part of their normal work
Child Welfare Services 95
duties. Mandated reporters include personnel in the following felds: medical, schools,
social service, mental health, law enforcement, child care, and members of the clergy.
Most states have strict laws that defne the parameters of child abuse reporting, in-
cluding delineating what constitutes a reportable concern, the time frame in which a
mandated reporter must report the suspected abuse, and the consequences of failing to
report suspected abuse, such as the suspension of ones professional license. In fact, in
most states, the failure to comply with mandated reporting requirements is a crime (a
misdemeanor or even a felony for repeated failures). In many states, the majority of calls
made to the child abuse hotline are from mandated reporters, but this does not preclude
anyone from calling the child abuse hotline if they suspect that a child is being abused
or neglected by a parent or caregiver. Tus, it is not uncommon for neighbors, friends,
or even relatives to report suspected child abuse, and those who are not mandated re-
porters are allowed to call anonymously.
Sequence of Events in the Reporting
and Investigation of Child Abuse
A child abuse investigation is initiated when someone, either a concerned individual or
a mandated reporter, places a call to the state child abuse hotline. Due to the intrusive
nature of an abuse investigation, federal and state laws exist to protect the privacy of
family life. Tus, hotline workers must adhere to strict guidelines regarding what re-
ports can and cannot be accepted. If the report of alleged abuse meets the stated criteria,
then the report will be accepted and investigated in a timely manner.
For state CPS agencies to receive federal funding, the federal law mandates that
all child abuse reports be screened immediately and investigated in a timely manner
(CAPTA, 2010). Although federal law does not specify a particular time frame, most
states have compliance laws stipulating specifc guidelines mandating that reports of
abuse be investigated anywhere from immediately afer receiving a report for cases in-
volving imminent risk, to 10 days in some states for reports with moderate to minimal
risk to the child (Kopel, Charlton, & Well, 2003).
Once a hotline worker makes the decision to accept a child abuse report, the case is
sent to the appropriate regional agency and assigned to an abuse investigator, who is a
licensed social worker or other licensed human service professional. Te actual inves-
tigation will vary depending on the specifc circumstances of the allegations, but most
investigations will involve interviewing the child, the nonofending parent(s), and the
alleged perpetrator. Although the sequence of the interviews might alter depending on
the specifc circumstances of the case, most investigators prefer to interview the child
before the parents or caregivers to avoid the potential for infuencing or intimidating
the child.
Types of Child Maltreatment
Child maltreatment is a crime regardless of who the perpetrator is and should always
be reported to authorities, but a states CPS agency becomes involved when the abuse is
perpetrated by someone who is acting in a caregiving role to the child. Tis includes a
parent, a relative, a parents boyfriend or girlfriend, a teacher, or even a babysitter.
96 Part II / Generalist Practice and the Role of the Human Service Professional
Although each state is charged with the responsibility for defning child abuse and
neglect according to state statute, the federal government has developed a defnition of
what constitutes the minimum standard for child abuse and neglect and has created four
general categories of child maltreatment, including neglect, physical abuse, sexual abuse,
and emotional abuse. Te following is the U.S. Health and Human Services defnition of
each type of abuse, but again it is important to remember that each state, although bound
to this minimum standard, will likely have additional criteria and scenarios that qualify
as abuse (National Clearinghouse on Child Abuse and Neglect, 2005).
Neglect is failure to provide for a childs basic needs. Neglect may be
Physical (e.g., failure to provide necessary food or shelter or lack of appropriate
supervision)
Medical (e.g., failure to provide necessary medical or mental health treatment)
Educational (e.g., failure to educate a child or attend to the childs special education
needs)
Emotional (e.g., inattention to a childs emotional needs, failure to provide psycho-
logical care, or permitting the child to use alcohol or other drugs)
Because cultural values, standards of care in the community, and poverty may be
contributing factors related to caregiving challenges, the existence of some of these prob-
lems does not necessarily indicate that the legal abuse of a child is occurring. Rather, the
manifestation of certain problems within a family system, such as not sending a child to
school, may indicate an overwhelmed familys need for information and general assis-
tance. Yet, if a family fails to utilize the information, assistance, and resources provided
and the childs health or safety is determined to be at risk, then CPS intervention may
be required.
Physical abuse includes physical injury (ranging from minor bruises to severe frac-
tures or death) as a result of punching, beating, kicking, biting, shaking, throwing, stab-
bing, choking, hitting (with a hand, stick, strap, or other object), burning, or otherwise
harming a child. An injury is considered abuse regardless of whether the caretaker in-
tended to hurt the child.
Sexual abuse includes activities by a parent or caretaker that include fondling a
childs genitals, penetration, incest, rape, sodomy, indecent exposure, and exploitation
through prostitution or the production of pornographic materials.
Emotional abuse involves a pattern of behavior that impairs a childs emotional de-
velopment or sense of self-worth. Tis may include constant criticism, threats, or rejec-
tion, as well as withholding love, support, or guidance. Emotional abuse is ofen difcult
to prove, and therefore, CPS may not be able to intervene without evidence of signif-
cant harm to the child. Emotional abuse is almost always present when other forms of
abuse are identifed.
The Forensic Interview
In the past 25 years, allegations of child abuse, particularly child sexual abuse, have
skyrocketed. Reasons for this include increased public awareness, mandatory report-
ing requirements, and a signifcant change in attitudes regarding child abuse, with an
Child Welfare Services 97
increasing sentiment that abuse is no longer a private family matter. Yet, as the pendu-
lum swung, the 1970s witnessed a sort of frenzy in child sexual abuse reporting, and
a popular contention among mental health experts was that children were incapable
of making false allegations. Tis belief fostered a sense of overeagerness on the part of
some therapists, who sometimes used inappropriate interviewing techniques, with lead-
ing questions: Did he touch you on your privates?, forced choice: Did he touch you
under your clothing, or over your clothing?, option posing: I heard that your uncle has
been bothering you, or suggestive questions: Many kids at your school have said that
your teacher has touched them, did he touch you too?.
Eventually this method of questioning was met with overwhelming criticism, par-
ticularly by members of the legal community, who were charged with defending those
individuals falsely accused of sexually abusing children in their charge. Tese types of
questions signifcantly increased the likelihood of erroneous disclosures, particularly
with preschool-aged children (Hewitt, 1999; Peterson & Biggs, 1997; Poole & Lindsay,
1998).
In response to such criticism, CPS agencies across the country developed pilot pro-
grams that combined the resources from several investigative branches, including CPS
agencies, police departments, and district attorneys ofces. Tis coordinated approach
not only prevents the trauma of duplicative interviews by separate enforcement agen-
cies, but also allows for the highly specialized training of investigators on forensic inter-
viewing techniques that avoid any type of suggestive or leading questions.
Although there is a general understanding among investigators of what constitutes
a forensic interview, there was still concern that many interviewers used types of ques-
tions that were somewhat leading in nature, including an interviewers inadvertent reac-
tion to a childs response that either encouraged or discouraged an honest disclosure.
For instance, an investigator who strongly believes that a child has been abused may
inadvertently respond with frustration if a child denies the abuse, which may infuence
the child, who wants to please the investigator, to give a false disclosure of abuse. Even
an expression of sympathy on the part of the interviewer, in response to disclosures of
abuse, can inadvertently encourage a child to embellish somewhat to receive more of
the interviewers compassion.
Te National Institute of Child Health and Human Development (NICHD) devel-
oped a forensic interviewing protocol that teaches interviewers how to ask open-ended
questions, using retrieval cues that rely on free recall. Tell me everything you can re-
member is an example of an open-ended question. Tell me more about the room you
were in is an example of a retrieval cue (Bourg, Broderick, & Flagor, 1999; Sternberg,
Lamb, & Orbach, 2001).
To Intervene, or Not Intervene: Models for Decision Making
Many variables infuence the outcome of an investigation, including the criteria with
which a CPS agency uses to determine (1) whether abuse is occurring and (2) whether
the abuse rises to the level of warranting intervention. In other words, it is possible for
some abuse reports to be determined as unfounded, even though the investigator may
strongly suspect that an unhealthy home environment does exist. But another reason
98 Part II / Generalist Practice and the Role of the Human Service Professional
for not substantiating an incident of child abuse relates more to poor or inconsistent
decision-making policies within a CPS agency due to human errors in decision mak-
ing. DePanflis and Scannapieco (1994) discussed the vital importance of CPS agen-
cies developing and adhering to a consistent and realistic decision-making model when
determining whether family intervention is warranted in order to avoid the inherent
problems in making bias-free and fact-based decisions. Child abuse investigators are
responsible for:
1. assessing the safety of children who are at risk of maltreatment,
2. deciding what types and levels of services may be immediately needed to keep chil-
dren safe, and
3. determining under what conditions children must be placed in out-of-home care
for their protection. (p. 229)
According to the Child Welfare League of American (CWLA) there are several ap-
proaches to making risk assessments of child maltreatment in child protection. Te ap-
proaches are either statistically based or based upon consensus of experts in the feld,
as well as research on the area of child maltreatment. Actuarial models of risk assess-
ment and decision making assess families based upon factors and characteristics that
are statistically associated with the recurrence of maltreatment. Because the inventory
is based upon a statistical calculation, the validity of the inventory may be considered
higher than the consensus-based model risk assessments; yet, many within the child
welfare felds express concern that actuarial models do not allow enough for clinical
assessment. An example of an actuarial model for risk assessment and decision making
includes the CRC Actuarial Models for Risk Assessment (Austin, DAndrade, Lemon,
Benton, Chow & Reyes, 2005).
Consensus-based approaches include the theoretically-empirically guided ap-
proach that ranks a series of factors that have empirical support for their association
with child maltreatment, and Family Assessment Scales (CWLA, 2005). Some exam-
ples of consensus-based models for risk assessment and decision making include the
Washington Risk Assessment Matrix (WRAM), the California Family Assessment and
Factor Analysis (CFAFA, or the Fresno Model), and the Child Emergency Response
Assessment Protocol (CERAP) (Austin, DAndrade, Lemon, Benton, Chow, & Reyes,
2005).
The Child at Risk Field System (CARF) is an example of a consensus-based risk-
assessment model that has been tested in the feld. Te CARF provides the following
guidelines for abuse investigators making a determination about abuse:
Where children were determined to be maltreated and unsafe, the ofending parents
1. were out of control,
2. were frequently violent,
3. showed no remorse,
4. may actually request placement,
5. did not respond to previous attempts to intervene, and/or
6. location was unknown.
Child Welfare Services 99
And the caseworker believed that
1. the parents were a fight risk,
2. the child had special needs the parents could not meet,
3. the conditions in the home are life-threatening, and/or
4. the nonofending parent could not protect the children.
Where children were determined to be maltreated and safe, the
parents
1. possessed a sufcient amount of impulse control,
2. accepted responsibility for the situation in their home,
3. had appropriate understanding of the child, showed concern for
the child and remorse for the maltreatment,
4. had a history of accessing help and services, and
5. exhibited knowledge of good parenting skills.
Thus, although definitions of child maltreatment are statutorily
defned, there is a tremendous amount of latitude that an investiga-
tor has in determining whether child maltreatment is occurring and
whether the extent of the abuse warrants intervention. Primarily, it is
through the use of an efective and well-tested decision-making model
that an abuse investigator will have the greatest likelihood of making an appropriate
determination in a child abuse investigation.
Working with Children in Placement
Permanency Plans
When an abuse investigator determines that a child must be placed into protective cus-
tody, the child is removed from the home and placed in one of many environments,
including relative foster care, nonrelative foster care, or an emergency shelter pend-
ing more permanent placement. Te case is then transferred to a family caseworker,
who evaluates all the relevant dynamics of the case (i.e., reason for placement, nature
of abuse, attitude of the parents), as well as assesses the strengths and weaknesses of the
biological parents and the family structure. A permanency goal for the child must then
be determined and can include:
1. Reunifcation with the biological parents
2. Living with relatives
3. Guardianship with close friends
4. Short-term or long-term foster care
5. Emancipation (with older adolescents)
6. Adoption with termination of parental rights
Although reunifcation with the biological parents remains the most common per-
manency plan, recent changes in many state and federal laws have shifted the focus
from protecting the biological family unit to considering the best interest of the child.
Human Services
Delivery Systems
Understanding and Mastery of Human
Services Delivery Systems: Major models
used to conceptualize and integrate pre-
vention, maintenance, intervention, reha-
bilitation, and healthy functioning
Critical Thinking Question: A number
of tools exist for assessing the occur-
rence of child abuse or maltreatment
and for gauging the likelihood of a reoc-
currence of the abuse. Yet, these tools
are not perfect, and critics argue that
they should not be used as a substitute
for the professional experience and
expertise of human service workers.
How might human service professionals
balance the use of these tools with their
own practice wisdom?
100 Part II / Generalist Practice and the Role of the Human Service Professional
Te reason for this shif can be traced to several high-profle cases in the mid-1990s
where children were either seriously abused or killed afer being reunifed with their
biological parents. Well-meaning child advocates launched campaigns in Washington,
DC, appealing to Congress to do something about the horrible plight of children who
were returned to their biological families only to face further abuse and sometimes their
deaths in a failed efort to save troubled families.
Although there was no documented increase of child maltreatment during this time
period, newspaper and magazine articles highlighting tragic (but rare) cases of contin-
ued abuse or deaths when children were reunited with their families were passed around
Congress, and articles such as Te Little Boy Who Didnt Have to Die were utilized in
an efort to make an emotional appeal to legislators to shif priorities from family reuni-
fcation to parental termination and subsequent adoption (Spake, 1994). Te result of
this campaign was the passage of the American Adoption and Safe Family Act of 1997,
which marked a clear departure away from abuse prevention and family preservation
and toward paving the way for termination of biological parents rights, clearing the way
for adoption of children in foster care placement.
Te best interest of the child standard may sound great on the surface, but it has been
the subject of signifcant scrutiny, with critics questioning just how this standard is be-
ing applied. In other words, best interest of the child according to whom? According
to the foster parents? Te courts? Te caseworker? It doesnt take much analysis to see
how easily this standard can be abused. For instance, what if the caseworker determines
that it is in the best interest of the child to be placed permanently with a two-parent
fnancially secure home rather than to be returned to the childs poor single mother,
regardless of how diligently this parent works to regain custody? Te potential to make
permanency plans that discriminate against biological parents who are marginalized
members of society, such as parents who are poor, single, of a minority race, homo-
sexual, and perhaps even undocumented immigrants, is signifcant.
Dorothy Roberts, author of Shattered Bonds: Te Color of Child Welfare (2002), cau-
tions that the new federal law creates many problems, including a confict created when
caseworkers are required to pursue two permanency plans at the same time to comply
with the new permanency plan time framesreunifcation with the family and possible
adoption. What many caseworkers do to accomplish this task is to place foster chil-
dren in preadoptive homes while at the same time planning for reunifcation with the
biological parents. Tis creates a situation where the biological parents rights are ofen
in confict with the childrens rights, and where foster care families, who are by defni-
tion charged with the responsibility of fostering a relationship between the children and
their biological parents, are now competing for the children.
Another possible confict according to Roberts includes the acts adoption incen-
tive program, where states are given fnancial incentives of $4,000 for each child placed
for adoption (above a baseline) and $6,000 for a special needs adoption. Te poten-
tial for agency abuse is evident as states scramble to replace lost revenue due to the
poor economy. Roberts warns that this new legislation was not directed at efecting
faster termination of parental rights in cases with severe abuse because these cases
were always relatively open-and-shut. Rather, it is the cases involving poverty-related
Child Welfare Services 101
maltreatment, most ofen in African American and Native American homes, that have
been most afected by this new federal law, which Roberts fears has led to increased so-
cial injustice in many CPS agencies.
For this reason as well as many others, the caseworker must be careful in determin-
ing what criteria to use in making permanency determination recommendations. For
instance, some experts have suggested using attachment ties as a guide in deciding a per-
manent placement plan (Gauthier, Fortin, & Jliu, 2004). Tese researchers suggest that
a child should remain with the family who they appear to have the greatest attachment
with to avoid further emotional ruptures. Yet, the potential for foster parent bias is great,
particularly in light of the fact that the foster parents will have a greater advantage over
the biological parents because children will, of course, have a greater likelihood of devel-
oping a stronger attachment to the family they are living with, particularly if biological
parents are restricted from participating regularly in their childrens lives through regular
visitation. U.S. history is flled with reports of abuses of this sort, where parents consid-
ered unworthy have experienced unfair treatment by CPS agencies (see discussion on
Native Americans), and this legislation risks escorting in a new dawn of similar abuses.
Working with Biological Families
A caseworker works with the biological parents most closely when it is determined that
the most appropriate permanency plan is parent reunifcation. Once a child has been
placed into foster care, the caseworker must prepare a detailed service plan, typically
within 30 days, outlining goals that the biological parents must accomplish before re-
gaining custody of their child. Te specifc goals must be related to the identifed par-
enting defcits, but can include goals such as:
1. Counseling
2. Parenting classes
3. Treatment for substance abuse
4. Anger management
5. Securing employment
6. Securing housing
7. Maintaining regular contact with children
It is then the responsibility of the caseworker to facilitate the biological parents
achieving these goals. Tis might involve giving referrals to the parents or securing
services for them, as well as monitoring their ongoing progress.
It is also important for caseworkers to be aware that biological parents who have
had their children removed may be enduring emotional trauma in response to this loss,
which may result in them behaving in ways that could be uncharacteristic for them. Te
strain of having to be accountable to external forces exerting control over their lives
makes many biological parents vulnerable to feeling overwhelming shame, which may
manifest in defensiveness that could be misinterpreted as indiference or a lack of re-
morse. An efective caseworker will understand this possible dynamic and will create an
environment where biological parents will be able to overcome the barrier of defensive-
ness and shame and work on the issues identifed in their service plan.
102 Part II / Generalist Practice and the Role of the Human Service Professional
Te intergenerational nature of child abuse has been well documented in research
(Bentovim, 2002, 2004; Ehrensaf, Cohen, & Brown, 2003; Newcomb, Locke, & Tomas,
2001; Pears & Capaldi, 2001), and although the majority of individuals
who have been abused in childhood do not go on to abuse their own
children, parents who are abusive to their children have likely been
abused in their own childhoods. Homes marked by violence, drug
abuse, neglect, and sexual abuse create patterns that can be passed
down to the next generation. Although it might not initially make
sense that someone who endured the pain of abuse would infict this
same abuse on their own child, the complex nature of child abuse of-
tentimes renders abuse patterns beyond the control of the batterer without some form
of intervention. For instance, consider Case Study 5.1 about Rick.
CASE STUDY 5.1
Case Example of the Intergenerational Cycle of Child Abuse
Rick grew up in a home marked with domestic violence, which ofentimes extended to
the children. Ricks mother was chronically depressed and ofen resorted to using al-
cohol to avoid dealing with her feelings. Rick recalls days and sometimes weeks where
she refused to get out of bed, and he was responsible for caring for his younger siblings.
His father also had an alcohol problem and would fy into nightly rages where he would
physically abuse his mother. When Rick got older, he attempted to intervene and pro-
tect his mother, which only resulted in his father physically abusing him. In addition to
physical abuse, Rick was also the victim of emotional abuse and neglect. Ricks father
would ofen call him derogatory names and humiliate him by telling him that he would
amount to nothing in life. It seemed as though Rick could do nothing right, and when he
was about 12 years old, he promised himself that he would never allow anyone to hurt or
humiliate him again. Rick married when he was 21 and was hopeful that his life of being
victimized was over. He loved his wife very much and was determined to be the best hus-
band and father he could possibly be. He vowed not to repeat the mistakes of his parents.
But deep inside he was plagued with fears that he wasnt good enough for his wife and
that she would eventually leave him. He became increasingly jealous and accused his wife
of wanting to leave him. If she tried to convince him otherwise, he accused her of lying.
When she became pregnant he was thrilled, but afer the baby was born he became upset
because his wife seemed to want to spend all her time with the baby, leaving him to fend
for himself. One day Ricks boss called him into his ofce and pointed out a mistake that
Rick made. All Rick could think of was the promise he had made to himself years ago
to never allow anyone to hurt or ridicule him again. Even though his bosss comments
would have seemed reasonable to most people, to Rick it was a recreation of the abuse he
endured as a child. He lost control of his temper, slammed his fst into the wall, and quit
his job. When he got home he told his wife and fully expected her to sympathize with
him and support his decision to not tolerate such abuse, but instead she complained that
his act was selfsh, particularly in light of his responsibilities as a father. Rick completely
lost his temper and in a blinding rage accused his wife of betraying him. In the blur
Although the majority of individuals
who have been abused in childhood
do not go on to abuse their own
children, parents who are abusive to
their children have likely been abused
in their own childhoods.
Child Welfare Services 103
that followed, Rick accused her of cheating on him, of caring about the baby more than
him, and of even getting pregnant by another man. In the midst of his angry outburst
he shoved his wife against the wall. All he could think of was how this woman who he
thought was his savior was really his enemy, and at that moment he hated her for allow-
ing him to lower his guard and trust her. All the pain of his childhood, with all the hurt
and humiliation, came rushing back, and he began to choke her. When his baby inter-
rupted his rage, he screamed at his son to shut up. When his babys crying got louder, he
picked him up and shook him violently.
Te case study about Rick illustrates some of the dynamics at play with the intergen-
erational transmission of abuse, and why it is so important for caseworkers to under-
stand what may occur in the mind of someone who has endured physical, emotional,
and sexual abuse at the hands of parents and other caregivers. Individuals who have suf-
fered signifcant childhood abuse ofen sufer from low frustration tolerance, displaced
anger, inability to delay gratifcation, impulse control problems, problems with emo-
tional regulation, difculty attaching to others, and an unstable self-identity (Bentovim,
2002, 2004). Issues such as poor parental modeling, lack of understanding about normal
child development, and an individuals level of residual anger and frustration tolerance
afect a persons ability to positively parent their children.
BIOLOGICAL PARENTS AND THEIR CHILDREN: MAINTAINING THE
CONNECTION A part of any good reunifcation plan will involve a visitation sched-
ule that supports and encourages the childs relationship with the biological parents and
provides them with applying new parenting techniques that theyve learned in parent-
ing classes and counseling (Sanchirico & Jablonka, 2000).
An efective caseworker will give consistent feedback to the biological parents about
their progress toward meeting service plan goals, will balance constructive feedback
with encouragement, will protect the parentchild relationship, and will do whatever
possible to remove barriers to complying with their service plan, such as fnding alter-
nate mental health providers when waiting lists would cause unreasonable delays and
resolving conficts between goals, such as not scheduling visitation during the parents
working hours when maintaining stable employment is a service plan goal.
Working with Foster Children: Common Clinical Issues
Foster children obviously come in all shapes and sizes, so it is difcult to summarize
the issues and experiences of the majority of children in foster care in a page or two.
But certain generalizations can be made, particularly with regard to the types of ex-
periences that bring a child into substitute care, as well as the range of short-term and
long-term emotional and psychological manifestations many children in foster care
may experience. Te clinical issues that a caseworker may deal with will vary depend-
ing on variables such as the age of the child, the length of time in placement, the rea-
sons for placement, and the plan for permanency (i.e., adoption or family reunifcation).
104 Part II / Generalist Practice and the Role of the Human Service Professional
Younger children are typically easier to place and may display less oppositional behavior
than adolescents, who are ofen placed in group homes.
Children who have been sexually abused often manifest emotional problems that
require sophisticated handling on the part of the caseworkers, therapists, and foster par-
ents. Sexually abused children may act out sexually with their foster parents as well as
other children, which can create an uncomfortable situation, particularly for those who are
unfamiliar with such acting out behavior. In addition, most children who have been mis-
treated in some manner may behave well during the honeymoon period of placement, but
then act out once they begin to feel more secure. Tis phenomenon can lead to disrupted
placements if the foster parents are unaware of the dynamics behind this shif in behavior.
A recent national survey of approximately 4,000 foster care children, aged 2 through
14, who had been removed from their homes due to maltreatment, revealed that nearly
half of these children had clinically signifcant psychological and/or behavioral problems.
Alarmingly though, only about half of these children had received any counseling in the
past year. Te children who were the most likely to receive mental health services were
younger children who had been victims of sexual abuse. African American children were
the least likely to receive mental health services, as were children who remained living in
their biological homes (Burns et al., 2004). Siu and Hogan (1989) identifed fve clinical
themes experienced by most children in foster care and made recommendations for how
child welfare caseworkers should respond. Tese include issues related to (1) separation;
(2) loss, grief, and mourning; (3) identity issues; (4) continuity of family ties; and (5) crisis.
Separation
Children involved in the child welfare system are contending with either issues related
to separation from their biological family members or the threat of separation. Siu and
Hogan (1989) recommended that caseworkers be familiar with the psychological dy-
namics involved in such separations as they relate to each developmental stage. It is im-
portant for caseworkers to acknowledge that these children are not just being separated
from their biological parents, but are experiencing multiple separations, such as separa-
tion from their extended family, perhaps their siblings and their familiar surroundings,
including their bedroom, house, neighborhood, and even their family pets. Casework-
ers need to confront these separation issues head on with the children, resisting the
temptation to avoid them in response to their own separation anxiety.
Children ofen go through diferent stages when confronted with signifcant sepa-
ration, beginning with the preprotest stage, where children accept removal from their
home with little protest. But this stage is ultimately followed by the protest stage,
where children can respond with outright combative and oppositional behavior
or with a more subtle uncooperative attitude. The third stage is marked by despair,
where the child ofen submits to the placement with a sense of brokenness and hope-
lessness. Te fnal stage involves adjustment to the placement, but involves a sense of
detachment to that which the child had been attachednamely, their biological families
(Rutter, 1978).
Caseworkers can respond to children dealing with separation issues by being hon-
est with them (in an age-appropriate manner) regarding what is happening with their
Child Welfare Services 105
families and by helping to prepare them for the upcoming changes in order to reduce
the anxiety associated with anticipating the unknown. Younger children are far more
likely to be operating in the here and now; thus, it is important for the caseworker to
reassure the child that the separation is only temporary (if the goal is family reunifca-
tion) and that the feelings of sadness and discomfort experienced afer being separated
will not last forever.
Children who have been removed from their homes also need to be reassured that
they are not the cause of the family disruption. It is quite common for foster care chil-
dren to feel responsible for their parents getting into trouble, and they may even be
tempted to recant their disclosures of abuse in the hope that they can return home.
Such children ofen reason that enduring the abuse is better than having their family
torn apart and their parents in trouble. In fact, many abused children have been told
for years that if they ever did disclose the abuse that the parents would go to jail and the
children would be taken away. Tus, it is important that the caseworker anticipate the
possibility of such prior conversations between children and parents and address this
by encouraging the children and reassuring them that the current course of action will
actually beneft and strengthen the entire family.
Loss, Grief, and Mourning
Coming alongside children who have experienced a loss and permitting them to grieve
involves having a high tolerance for a wide range of emotions. Lee and Whiting (2007)
discuss the concept of ambiguous loss with regard to children in foster care. Ambiguous
loss is defned as loss that is unclear, undefned, and in many instances, unresolvable.
Ambiguous loss in foster care situations can involve losses that are confusing for the
child, such as the loss of an abusive parent. Children who are removed from an abusive
home and placed in a foster home with caring, nonabusive parents may feel conficted
about the loss of the parent and entry into the child welfare system. Feelings may in-
clude confusion, ambivalence, and guilt, for instance.
Earlier research studies have found that people who endure ambivalent loss tend to
experience similar feelings, such as:
Frozen (unresolved) grief, including outrage and inability to move on
Confusion, distress, and ambivalence
Uncertainly leading to immobilization
Blocked coping processes
Experience of helplessness, and therefore, depression, anxiety, and relationship
conficts
Response with absolutes, namely, denial of change or loss, denial of facts
Rigidity of family roles (maintaining that the lost person will return as before) and
outrage at the lost person being excluded
Confusion in boundaries and roles (e.g., who the parent fgures are)
Guilt, if hope has been given up
Refusal to talk about the individuals and the situation (Boss, 2004 as cited in Lee &
Whiting, 2007, p. 419).
106 Part II / Generalist Practice and the Role of the Human Service Professional
With these feelings in mind Lee and Whiting (2007) interviewed 182 foster chil-
dren, ages two through 10. Children were asked about each of the feelings identifed
in Boss study as typical responses to ambiguous loss. Te study showed that virtually
all of the children interviewed exhibited these typical feelings, particularly feelings as-
sociated with confusion, ambiguity, and outrage about their situation. Several children
noted confusion about their futurenot knowing when they would see their parent(s)
again, or how long they would be in foster care. Te children also expressed feelings of
uncertainty, guilt, and immobility.
Lee and Whiting (2007) recommend using the model of ambiguous loss when work-
ing with children in foster care, cautioning against pathologizing their feelings (and the
consequential behaviors). In describing the application of this model of loss, Lee and
Whiting state:
Terapists, case managers, ofcers of the court, and foster family members need
not see these externalizing and internalizing behaviors as pathology, but as active
coping strategies appropriate to the childrens circumstances. Attempts to squelch
these behaviors in the interest of tranquil foster placements are unrealistic and
may exacerbate underlying psychosocial conditions. (p. 426)
In referencing therapy goals they continue:
Te immediate goal is to make understandable those things that are disruptive
to the foster placement. Te diverse stakeholders, including the children, need to
appreciate how unresolved grief leads to ambivalence about and fears of interde-
pendency, relationship testing, and self-fulflling prophecies of non-lovableness. In
short, all invested members must move from defcit detecting to appreciating that
many of these otherwise disturbing behaviors are signs of ego strength. (p. 426)
Siu and Hogan (1989) also cite the importance of caseworkers understanding the
nature of grieving and thereby assisting foster care children to grieve the loss of their
families. It is vital for caseworkers to be familiar with the possible expressions of depres-
sion among grieving children, which ofen manifest as irritability and can easily be mis-
taken for misbehavior. It is also quite common for children to express heartfelt grief for
parents who have horribly abused them. Even children who have been sexually abused
ofen express missing their abusive parent. Caseworkers must be careful to allow these
children to grieve their parents, despite the fact that the parents have hurt them.
Identity Issues
Identity is a multifaceted concept referring primarily to ones self-knowledge, self-
appraisal, and self-assessment. Developmental theorist Erik Erikson (1963, 1968, 1975)
believed that identity formation involves the integration of numerous and sometimes
conficting childhood identities. Erikson believed that this convergence of identities
took place during the adolescent stage of development, when the adolescent developed
an internal continuity and consistency that integrated all diferent aspects of the self,
allowing ones real identity to emerge. Our individual identities are based on several
factors, some involving internal traits and some involving external traits. As individuals
Child Welfare Services 107
mature, their basis for identity becomes more internally based. But children, particu-
larly younger children, will typically base their identity more on external, rather than
internal attributes. For instance, if someone were to ask you to describe yourself, you
might begin by saying that you are a college student (external). You might then share
that you are a soccer player (external) and on student counsel (external). But, you might
then describe yourself as an extrovert (internal), who is courageous (internal), loyal (in-
ternal), and kind (internal). Te more internally based ones identity is, the more resil-
ient a person will be in times of crisis and transition.
Children tend to be far more external in their self-identity, and their self-appraisal
can be quite fragile, varying dramatically if their external structure is removed. Siu and
Hogan (1989) suggested that caseworkers become familiar with the process of identity
development and how the removal of children from their family of origin can signif-
cantly afect their sense of personal identity. Te nature of this impact will depend, of
course, on the age of the children and their stage of development, but can also be afected
by several other variables. Some of the factors involved in identity formation include
ones gender, ethnic and cultural identity, extracurricular activities, talents, socioeco-
nomic status, and relationships with others. Children are ofen unaware of how they are
afected by things such as their socioeconomic status, but it afects them nonetheless.
Ones positive identity is dependent on an afrming reciprocal exchange between
the various aspects of identity and ones environment. Consider this reciprocity as
a mirror refecting back either a positive or negative image of how one is perceived
and valued by others. Essentially, the positive or negative nature of ones identity is
based at least in part on how these various aspects of ones self are valued by others.
Individuals who are extremely talented musically may only perceive this talent as a
positive part of their identity if their family and community perceive musical talent
as valuable. Children who are intelligent but are raised in families that value athletic
prowess may not perceive their intellectual ability as a positive and
valuable trait. Children who are removed from their home for mal-
treatment and are placed in a new environment will struggle with
identity issues because despite being in a more positive environ-
ment, they are no longer the youngest sibling, no longer the owner
of a small dog, no longer the funniest student in the class, and no
longer the best bike rider in the neighborhood. Now they are foster
children, diferent and set apart, perhaps living in a home much
nicer than their own, leaving their feelings somewhat defcient and
less than; they are no longer funny because they know no one in
class, and they are not the youngest kids because they are only fos-
ter children in new homes.
Because so much of childrens identities reside outside the self
and are dependent on external validation and encouragement, an ef-
fective caseworker must understand the various dynamics of iden-
tity development, understanding how removing children from their
homes, even abusive homes, can undermine childrens identity de-
velopment. Any acting out behavior on the part of the child should
Human Systems
Understanding and Mastery of Human
Systems: Theories of human development
Critical Thinking Question: Removing a
child from his biological parents can con-
tribute to difficulties in the childs identity
development. On the other hand, abuse,
neglect, and maltreatment can also
erode a childs development of a strong,
internally focused sense of identity. How
might these effects be exacerbated by
placement with a foster or adoptive
family, which is significantly different (in
terms of ethnicity, religious beliefs, or
socioeconomic status) from the childs
family of origin?
108 Part II / Generalist Practice and the Role of the Human Service Professional
be viewed through this lens of identity disruption, and the caseworker can then respond
by providing comfort and encouragement to the child during this transition. Children
who have only received praise for their ability to play good basketball are going to strug-
gle immensely with their identity if placed in homes that value academic performance
or musical ability. A caseworker can assist these children in recognizing that their worth
is internal and should not be based solely on the approval and afrmation of others.
Continuity of Family Ties
Picture yourself in a boat moored to a dock on the shore of a large lake. Being
anchoredhere provides you with a connection to the mainland and a sense of security,
without fearing becoming adrif at sea. But what if you need to get to the other side
of the lake? You would have to pull up your anchor and drif across the water, and it
wouldnt be until you reached the other side and safely anchored yourself against that
shore that you would feel secure and stable again. Many signifcant life transitions are
like this time adrif at seacaught between two shores, where continuity and stability
are temporarily lost. Children who have been removed from their biological homes
will undoubtedly lose their sense of continuity with their biological families and will
feel adrif at sea during the time period when they have not yet established new bonds
with their foster family.
Siu and Hogan (1989) strongly recommend that caseworkers consider the impor-
tance of continuity and stability when considering where to place a child. Ready access
to the biological family and even close friends should always be a priority in placement
decisions, and although this can become challenging, particularly in low-income areas
where there may be a limited number of available foster families, consideration should
still be given to a placement that will facilitate ongoing parental involvement.
At times siblings must be placed in separate foster homes, and consideration to con-
tinuity issues needs to be extended to this situation as well. Far too ofen, siblings in fos-
ter families do not visit with each other regularly because of the geographic constraints
placed on foster families, who are ofen responsible for providing transportation.
Caseworkers may fnd themselves in double-bind situations, though, where they
must make difcult choices regarding keeping siblings together by placing them in a
foster home that is a signifcant distance away from a parent who does not have trans-
portation, or placing the children in diferent foster homes that are closer to their bio-
logical parents, but precludes family visitation due to the difculty in coordinating visits
among various foster families. Caseworkers must rely on their clinical skills in deciding
on the right course of action and should then recognize and acknowledge how this in-
terruption of family continuity and stability will afect the children, particularly early in
the placement.
Far too ofen the foster care system, with all its complications, does not do an ef-
fective job of fostering a relationship between children in placement and their biologi-
cal families, because if children do not have ready access to their biological families,
they will most likely search for continuity and connectedness with their foster families,
which, although necessary and important, can pose a risk to the continuing bond with
their biological parents.
Child Welfare Services 109
Research has clearly shown that children who visit their biological parents more
frequently have a stronger bond with them and have fewer behavioral problems, are
less apt to take psychiatric medication, such as antidepressant medication, and are less
likely to be developmentally delayed, which underscores the importance of strengthen-
ing the attachment between foster children and their biological parents through reg-
ular and consistent visitation (McWey & Mullis, 2004). Restricting visitation for any
reason other than the safety of the child will have a negative efect on this attachment
and might even be subsequently used against the biological parents when it comes time
to make reunifcation plans.
Crisis
Removing children from their biological homes and placing them into foster care con-
stitutes a crisis. Siu and Hogan (1989) referred to this crisis as a critical transition, which
throws an already fragile family into complete disequilibrium. In fact, most child wel-
fare experts put foster care placement in the category of a catastrophic crisis. Crises are
not always bad though, and a popular contention among mental health experts dis-
cussed in Chapter 4 is that a crisis provides the best opportunity for personal growth
and authentic change.
Ordinary coping skills are typically not going to be enough to help a child deal with
the trauma associated with being placed in foster care. But an efective and seasoned case-
worker can help a child develop more efective coping skills that can help them respond
to the multiple crises of being removed from their home and placed with strangers.
Working with Foster Parents
Foster care can refer to many placement settings, including kinship care, an emergency
shelter, a residential treatment center, a group home, or even an independent living situ-
ation (with older adolescents), but most frequently foster care involves placing a child
with a licensed foster family (two-parent or single-parent family). Every state has cer-
tain guidelines and standards that prospective foster parents must meet to qualify to
become licensed (Barth, 2001). Licensure typically requires that families participate in
up to 10 training sessions focusing on topics such as the developmental needs of at-risk
children, issues related to child sexual abuse, appropriate disciplining techniques for
at-risk children, ways that foster parents can support the relationship between the fos-
ter children and their biological parents, and ways to manage the stress of adding new
members to their family. In addition, individuals who will be foster parenting children
of a diferent ethnicity will undergo training focusing on transcultural parenting issues.
Foster parents provide an invaluable service by accepting troubled children into
their homes and providing love, nurturing, and security, even though they know the
children may be in their homes for only a short time. In addition to good training, fos-
ter parents beneft from caseworkers who are consistently supportive and available to
them, particularly during high stress times when foster children are acting out. Foster
placement will be far less likely to fail if the foster parents feel sufciently well prepared
and supported by their caseworker.
110 Part II / Generalist Practice and the Role of the Human Service Professional
Because the majority of foster children return to their biological parents, foster par-
ents must be supported in their role in the reunifcation process. Te success of a reuni-
fcation plan depends largely on the cooperation of the foster parents. A foster parent
who eagerly facilitates visitation and the sharing of vital information with the biological
parents will help protect and maintain the continuity between the foster children and
their biological parents. Te caseworker plays a pivotal role in providing support and as-
sistance to foster parents. A foster parent who feels unsupported will be far more likely
to either purposely or inadvertently undermine the relationship between the foster child
and the biological parents. Much of the time this action comes in the form of advocacy
for the child. Unfortunately, though, this advocacy, as well meaning as it may be, has the
potential of disrupting the necessary process of reunifcation. Tus, although it is cer-
tainly understandable that the process of emotional bonding with the foster child makes
foster parents vulnerable to advocating for the best interest of their foster children, fos-
ter parents who take it upon themselves to protect their foster child by discouraging the
relationship with the biological parents in any way are violating their designated roles,
and their efectiveness as foster parents will most likely be seriously compromised.
Te Public Broadcasting Service (PBS) documentary entitled Failure to Protect: Te
Taking of Logan Marr documents the removal of fve-year-old Logan and her baby sis-
ter, Baily, from their young biological mother, Christie Marr. Te documentary reveals
how Maines child welfare system, the Department of Human Services (DHS), removed
Logan from her mothers care on the presumption that the child might be abused at
some future time based on some dynamics in the home. Afer years of jumping through
hoops and getting Logan back, Christie had another child, but ultimately lost both of
her girls afer marrying someone whom DHS did not approve. Regardless of Christies
compliance with her parenting plan, the caseworker placed her girls with another DHS
worker who was also a licensed foster parent. Te foster mother wanted to adopt the
Marr girls and actively hindered the relationship between the girls and their mother. In
this situation, as well as many others, the foster mother was responsible for providing
transportation for visitation, as well as for keeping Christie comprised of major events
in the girls lives. Tus, she had tremendous power to limit visitation if she so desired or
to be begrudging with vital information about the girls.
Logan ultimately died in this foster mothers care, and her death led to an uproar
over the treatment of Christie, the apparent cozy relationship between the fos-
ter mother and the DHS caseworker, as well as the caseworkers refusal to investigate
Logans earlier complaints that her foster mother had abused her. Tis tragic case il-
lustrates how vital it is for foster parents to be well trained and sufciently supported by
their caseworker. An efective caseworker will be able to sense when a foster parent is
either burning out or overstepping appropriate boundaries and will respond with
support and limit setting as necessary.
Reunifcation
Te decision of whether or when to reunify foster children with their biological parents
is based on many factors, including the biological parents success in meeting their ser-
vice plan goals. Even if these goals are sufciently met, the timing of reunifcation may
Child Welfare Services 111
depend on minimizing disruptions in the childs life, such as switching schools in the
middle of the school year. If reunifcation is the plan from the beginning of placement,
then the caseworker should be planning for this event from the initial stages of the case.
Problems arise when issues such as court postponements, additional service plan goals,
changes in caseworker assignments, and other factors lead to delays in reunifcation.
A judge may deem it perfectly reasonable to postpone a reunifcation hearing so that
a child can complete the fnal four months of school without disruption, but such a
decision can be devastating for the biological parents who have worked diligently to
reach all service plan goals and go to court expecting to leave with their biological child,
only to be told they must wait an additional four months to avoid their child changing
schools in the middle of the school year. Te potential for a biological parent to give up
attempting to regain custody and to relapse into unhealthy behaviors out of discourage-
ment and frustration is great, and caseworkers must be sensitive to the possibility of
such frustrations leading to despair or relapse.
Terefore, even though reunifcation with biological parents is associated with sev-
eral changes in the childs life, many of which may be negative in nature (Lau, Litrownik,
Newton, & Landsverk, 2003), an efective caseworker will begin preparing the child for
these transitions from the beginning of placement in foster care. Simply verbalizing what
is going to happen, telling the child what to expect in the future, and giving such chil-
dren a voice in expressing their fears and frustrations, even if they do not have decision-
making power, will go a long way in minimizing the negative effect of reunification,
particularly for children who have been in placement for a signifcant amount of time.
Reunifcation is not just stressful for the child, it is stressful for the biological parents
as well, and many biological parents are the most vulnerable to stress-related relapse in
the weeks following reunifcation. Te combination of increased stress and the acting
out of the child due to yet another transition can create a potentially volatile situation
where negative behavior patterns resurface. Any good reunifcation plan involves ongo-
ing monitoring and provision of in-home services to prevent any such problems during
the reunifcation transition. Tese services can be provided by the county child wel-
fare ofce directly or by a contracted agency-based practice that specializes in providing
services such as in-home case management and support. With good support services,
many reunifcations go quite smoothly, and in time the children and parents settle in to
a regular routine where healthier communication patterns and positive parenting styles
will lead to a positive response from the children.
Family Preservation
Because the number of children placed in substitute care rose consistently since the
1980s, particularly in most urban communities, there has been an increasing focus on
early intervention and prevention programs since the early 1990s. Family preservation
programs are designed to reduce the need for out-of-home placement by intervening in
a family process before the dynamics deteriorate to the point of requiring the removal of
the children. Tese programs are comprised of a variety of short-term, intensive services
designed to immediately reduce stress and teach important skills that will reduce the
likelihood of out-of-home placement. Services can include family counseling, parenting
112 Part II / Generalist Practice and the Role of the Human Service Professional
training, assistance with household budgeting, stress management, child development,
respite care for caregivers, and in some cases, cash assistance (Child Welfare League of
America, n.d.).
Although there has been some controversy surrounding the success of these pro-
grams in reducing foster care placements, the federal government remains committed
to early intervention programs, and many counties report that approximately 80 percent
of families who have participated in family preservation programs remained intact in
the year following the suspension of services (Child Welfare League of America, n.d.).
Relevant to any discussion on family preservation is the importance of human
rights as they relate to children, particularly those who are living in environments that
are fragile, thus increasing the already vulnerable nature of dependence. Te United
Nations Convention on the Rights of the Child (UNCRC), adopted in
1989 and enacted in 1990, is considered by most in child welfare to be
one of the most signifcant international treaties establishing and en-
forcing human rights for all children. Every country in the world has
signed and ratifed the UNCRC except the United States and Somalia,
both of which have signed but not ratifed the treaty. Te UNCRC con-
sists of 41 articles setting forth basic rights of children (as well as the
means for ensuring the enforcement of these rights) based upon the
best interest of the child principle, which places the needs of children, particularly in
decisions relating to their care, as a primary concern above all other interests. Te ulti-
mate goal of the UNCRC is to protect the survival, health, education, and development
of children securing their well-being (UNCRC, 1989).
Te UNCRC guarantees children the most basic rights, including the right to live,
to develop in a healthy manner (including the right to play and enjoy a wide range of
child-appropriate activities), to have a legal name and identity that is registered with
the government (such as a birth certifcate), to reside with parents (as long as this is in
the childs best interest), to have access to appropriate healthcare, to have an education,
and to have an adequate standard of living free from profound poverty. Several articles
also guarantee a childs freedom of expression including having a voice in choices that
afect them (as is deemed developmentally appropriate), appropriate freedom of expres-
sion, privacy, and access to information, with indigenous children even having the right
to practice their own cultural traditions. Children are guaranteed the right to protec-
tion, including protection from violence, child labor, exposure to the drug trade, drug
abuse, sexual exploitation, abduction, trafcking, excessive detention, and punishment.
Relevant to the discussion on family preservation, several articles of the UNCRC set
forth the rights of children who for whatever reason cannot reside with their families,
including the right to be cared for in a manner that respects their religion, ethnic group,
and cultural traditions, and the right to have all aspects of the UNCRC applied to them
regardless of their residential or family status (UNCRC, 1989).
Clearly, the international community recognizes the value of the biological family
unit and supports all governmental eforts designed to support families maintain their
bonds, particularly with their children. Such support can be in the form of family-
friendly policies, fnancial and case management support for kinship care (increased
The ultimate goal of the United
Nations Convention on the Rights of
the Child is to protect the survival,
health, education, and development
of children and to secure their
well-being.
Child Welfare Services 113
since the passage of the Fostering Connections to Success and Increasing Adoptions
Act of 2008), as well as other measures that focus on prevention and preservation rather
than solely intervention.
Minority Populations and Multicultural Considerations
Children of color are overrepresented in the foster care system, comprising nearly 60
percent of all placements in the year 2004. Tis is nearly twice their representation in
the general population. Of all children requiring child welfare intervention, the ma-
jority of African American children requiring care are placed in foster care, whereas
the majority of Caucasian children receive in-home services (Child Welfare League of
America, 2002). In addition, African American children remain in foster care far longer
and are reunited with their families far less ofen. Tis overrepresentation of children
of color in the foster care system, particularly African American children, is fueled by
other long-standing factors such as social oppression, negative social conditions, racial
discrimination, and economic injustice. For instance, African American children were
initially excluded from the child welfare system, but are now the most overrepresented
of all racial groups (Smith & Devore, 2004).
Some reasons for this overrepresentation relate to complex social issues such as in-
stitutionalized racism, intergenerational poverty, and culturally based drug abuse. But
other possible causes include racism within the child welfare system.
Types of racial discrimination include:
1. Racial bias in referring families for family preservation programs versus out-of-home
placement. Certain special populations, including African American families, are
not consistently targeted for family preservation programs. Reasons for this include
caseworker bias based on the belief that the needs of the African American com-
munity may be too great to be appropriately handled by this program (Denby &
Curtis, 2003).
2. Racial partiality in assessing parentchild attachment leading to delays in returning
children to their biological parents. A 2003 study of approximately 250 black and
white children in foster care placement found that racial partiality existed in assess-
ing the parentchild attachment when the caseworker was of a diferent race than
the biological parent. Although this result was reciprocal (i.e., black caseworkers
showed partiality to black families and white caseworkers show partiality to white
families), the effect of this trend has particular relevance to the African
American community because the majority of caseworkers are Caucasian, and
African American children are disproportionately represented among children in
foster care. Te results of this study revealed that Caucasian caseworkers might have
erred when they concluded that African American mothers were poorly attached to
their children because of the caseworkers lack of understanding of cultural difer-
ences between Caucasian and African American customs (Surbeck, 2003).
3. Caseworkers who are poorly trained in cultural competencies. For a caseworker to ac-
curately assess many of the factors necessary in determining whether out-of-home
114 Part II / Generalist Practice and the Role of the Human Service Professional
placement is warranted, such as the level of violence in the home, the ability of par-
ents to protect their children, or the level of parental remorse, a caseworker must
be aware of commonly held negative stereotypes of various racial groups. It is unac-
ceptable for a member of the majority culture to claim not to hold any negative ste-
reotypes, and it is only through the honest admission of overt and subtle negative
biases toward other cultures that a caseworker can begin to work efectively with a
variety of ethnic groups.
Placing Children of Color in Caucasian Homes
Considerable controversy exists surrounding the placement of children of color in
Caucasian homes. Many advocacy organizations do not support this practice, whereas
others claim that it is not in the best interest of children to experience placement delays
simply because there are no foster families available that are the same race as the child.
From a micro perspective, this latter argument makes sense. If an African American
child is in desperate need of a long-term foster home, how much sense would it make to
have a policy in place that prevents placement in a suitable home only because the foster
family is Caucasian? Afer all, all children deserve loving homes, and the color of their
skin should not keep them from being placed in one. Right?
Yet, from a macro perspective, a diferent viewpoint is revealed. Consider the eq-
uity of a majority culture systematically destroying an entire race, as the United States
has done to the African American population during the slavery and postCivil War
era or to the Native American population during colonial times and the era of early oc-
cupation of the United States. How do you think these racial groups would perceive this
same majority culture then rushing in to rescue the children who were maltreated in
great part because of this cultural genocide and the resultant social breakdown?
Advocates of placing children of color in homes of the same race cite such cultural
genocide in their arguments. Alternatives to transracial placement include the develop-
ment of kinship care programs, where members of a childs extended family act as foster
parents, ofen made possible through fnancial assistance. Te National Association of
Black Social Workers (NABSW) cites the long-standing tradition of informal kinship
care within the African American community extending back to the Middle Ages and
solidifed during the slavery era, when many African Americans acted in the informal
capacity of parents for children whose biological parents were sold and sent away. Such
cultural traditions can serve as a precursor for federally funded programs that promote
kinship care foster programs, which respect cultural identity and tradition (NABSW,
2003).
Recent studies support the concerns expressed by the NABSW and others about the
difculties faced by even the most well-meaning white adoptive parents to appropri-
ately and accurately teach their black adopted children lessons about race in a culturally
appropriate manner. A recent study by Smith, Juarez, and Jacobson (2011) found that
the majority of adoptive families of black adoptees were white, middle to upper-class
families from primarily white communities, and despite their attempts to teach their
children about matters of race and instill in them a sense of cultural pride, most of the
Child Welfare Services 115
black adoptees were ofen lef to struggle with racial discrimination and racial encultur-
ation on their own. Te primary reason for this dynamic was that their white adoptive
families more ofen than not experienced race quite diferently than their black adopted
children, viewing racial dynamics through a white Eurocentric lens (Smith, Juarez &
Jacobson, 2011).
In their study on the attempts of white parents to teach their black adopted children
about race and racism in America, Smith, Juarez, and Jacobson (2011) state:
As members of U.S. societys dominant mainstream, White adoptive parents are
positioned to transmit collective understandings, interpretations, knowledge, and
memories about Whiteness, not Blackness. Tey are well positioned to teach les-
sons about race that refect and give privilege to the interests, values, experiences,
and perspectives of Whites. (p. 1198)
Teir study revealed that while a majority of white transracial adoptive parents cited
the importance of their children developing a sense of pride in their cultural heritage,
they framed cultural pride as an individual process, not a collective one. Since the ma-
jority of transracial families interviewed in the study lived in primarily white communi-
ties, their black children did not participate or engage in communities of color; thus,
any development of cultural pride was done in collective isolation.
Most of the white parents in this study taught their children about African American
culture, including the nature of race relations in America, through books, flms, and
cultural events, such as attending black camps. For instance, several white adoptive
parents shared that they taught their black adoptive children about overcoming racism
through the telling of stories of famous black individuals who became successful despite
racial barriers through personal fortitude and a lot of hard work. Yet Smith, Juarez, and
Jacobson (2011) point out how this type of racial framing illustrates Western notions
of individualism, rather than community eforts more refective of African American
culture and history, and did not teach black adoptees about racial inequality involved in
structural relations within society that enable the hard work of some to pay of more
than that of (racialized) others (p. 1214).
Tis study revealed just how committed the white adoptive parents who were inter-
viewed were in their attempts to appropriately validate their black adoptive childrens
racial heritage and culture pride, but they did so in ways that were distinctly white. For
instance, the white adoptive parents taught their black children to:
Afrm and feel positively about racial diferences,
Subvert personal needs and responses to racial discrimination to help Whites learn
about race and racism, and
Develop a thick skin to defect the consequences of race-based discrimination
in a way that avoids confict and does not disrupt harmony with Whites. (pp.
12211222)
Framing racial and cultural dynamics in such a White Eurocentric individualist way
contradicted sharply with how most African American parents handled matters of race
with their children. Although the white parents in this study clearly loved their black
116 Part II / Generalist Practice and the Role of the Human Service Professional
adopted children and appeared very committed to addressing matters of race, with re-
gard to cultural pride and dealing with racial prejudice, by presuming that racism was
the result of white ignorance that could be overcome only through education and hard
work, the white parents were inadvertently drawing from historic white cultural nar-
ratives of racial inequality, not black ones, which are far more likely to emphasize the
purposeful agenda of racial oppression and inequality within American society, and the
collective struggle of African Americans to fght against it.
Although Smith, Juarez, and Jacobson (2011) do not specifcally advocate against
transracial adoption, they do caution white parents to be very careful about the ways
in which they choose to teach lessons about race to their adopted children, in order
to avoid even the inadvertent inculcation of white racist framing of the black experi-
ence in America. Tey suggest doing this through the reframing of race and racial issues
through the experiences of the black community, and not through the lens of White
America. Whether this is possible, is difcult to say, but further research on ways in
which race lessons can be taught to black adoptees will inform this growing area of re-
search, particularly if informed by black adoptees themselves.
Native Americans and the U.S. Child Welfare System
Te British colonization of North America involved an organized and methodical cam-
paign to decimate the Native American population through invasion, trickery (such as
trading land for alcohol), and ultimately the forced relocation of all Native Americans
onto government-designated reservations, where the assimilation into the majority
culture became a primary goal of the U.S. government (Brown, 2001). Te few Native
Americans who survived this genocide were broken physically, emotionally, and spiritu-
ally, sufering from alcoholism, rampant unemployment, and debilitating depression.
In the early part of the 19th century the U.S. government assumed full responsibil-
ity for educating Native American children. It is estimated that from the early 1800s
through the early part of the 20th century,
virtually all Native American children were
forcibly removed from their homes on the
reservations and placed in Indian boarding
schools, where they were not allowed to speak
in their native tongues, practice their cultural
religion, or wear their traditional dress. Dur-
ing school breaks many of these children were
placed as servants in Caucasian homes rather
than being allowed to return home for visits.
Te result of this forced assimilation amounted
to cultural genocide where an entire genera-
tion of Native Americans was institutionalized,
deprived of a relationship with their biological
families, and robbed of their cultural heritage.
This ongoing campaign to assimilate the
Native Americans into European American
Student body assembled on the Carlisle Indian School Grounds.
Buyenlarge/Archive Photos/Getty Images
Child Welfare Services 117
culture became even more aggressive between
1950 and 1970, when social workers with gov-
ernmental backing removed thousands of
Native American children from their homes
on the reservations for alleged maltreatment,
placing them in adoptive Caucasian homes. In
reality, many of the problems on the reserva-
tions were the product of years of governmen-
tal oppression resulting in extreme poverty and
other commonly associated social ills, and the
U.S. government response to this was to tear
Native American families apart rather than in-
tervene with mental health services.
Between 1941 and 1978, approximately 70
percent of all Native American children were
removed from their homes and placed either
in orphanages or with Caucasian families,
many of whom later adopted them (Marr, C. 2002). In truth, few of these children
were removed from their homes due to maltreatment as it is currently defned. Rather,
approximately 99 percent of these children were removed because social workers be-
lieved that the children were victims of social deprivation due to the extreme poverty
common on most Indian reservations (U.S. Senate, 1974). Te result of this govern-
ment action has been nothing short of devastating. Native Americans have one of the
highest suicide rates in the nation, with Native American youth, particularly those who
have spent time in U.S. boarding schools, having on average fve to six times the rate of
suicide compared to the non-Native American population. When these children grad-
uated from high school, they were adults without a cultureno longer feeling com-
fortable on the reservation afer years of being negatively indoctrinated against their
cultural heritage, yet not being accepted by the white population either. Te response
of many of these individuals was to turn to alcohol in an attempt to drown out the pain.
In 1978, the Indian Child Welfare Act (Pub. L. No. 95-608) was passed, which pre-
vented the unjustifed removal of Native American children from their homes. Te act
specifes that if removal is necessary, then the children must be placed in a home that re-
fects their culture and preserves tribal tradition. Tribal approval must be obtained prior
to placement, even when the placement is a result of a voluntary adoption proceeding
(Kreisher, 2002). Tis act has for the most part successfully stemmed the tide of mass re-
moval of thousands of Native American children from their homes on the reservations,
but unfortunately many caseworkers still do not understand the reason why such a bill
was passed in the frst place, or why it is necessary, and mistakenly believe that this act
hampers placing needy children in loving homes.
Gaining a fuller understanding of the history between people of color and the U.S.
child welfare system will make it easier to understand why some minority groups may
not trust human service professionals in issues regarding allegations of abuse. Te social
worker might not be aware of the long-standing negative history between government
Old Sun Residential School.
Library of Congress
118 Part II / Generalist Practice and the Role of the Human Service Professional
child welfare agencies and a particular racial group, but members of that particular
group are most likely aware of this history. It is vital that human service profession-
als develop cultural competencies, regardless of whether they are actively working with
ethnic minority populations. It is only through a comprehensive understanding of the
history of child welfare policies and abuses of power that the U.S. child welfare system
will truly achieve its goal of respecting the autonomy and dignity of all people, regard-
less of race, gender, age, nationality, and sexual orientation.
Concluding Thoughts on Child Protective Services
Human service professionals who work with troubled families have the opportunity to
efect change that positively afects not only the present families, but all future genera-
tions within that family system as well. CPS caseworkers ofen experience high caseloads
and can feel overwhelmed and burned out in the face of such immensely complicated
dynamics commonly involved in child welfare cases.
An increased focus on family preservation programs and other early intervention
programs ofer the best opportunity for reducing out-of-home placements, but these
programs must be ofered to all potentially appropriate families without bias. Tis can
occur through sufcient federal and state funding of child welfare programs and the
efective recruitment and training of human service professionals willing to work with
a variety of families, from various cultures dealing with a wide range of life challenges.
119
7. Explore some of the psychological dynamics experienced by many biological children removed from their biologi-
cal homes and placed into nonrelative foster care, and some ways human service professionals can assist foster
care children with this transition.
8. Explore the advantages of family preservation programs, including ways in which human service professionals can
ensure that all families can beneft from this program equitably.
CHAPTER 5 PRACTICE TEST
1. Prior to the Civil War, the common belief about
children was that they needed
a. dedicated play time in order to develop
psychosocially
b. to be treated with harsh discipline or they would
fall victim to laziness and vice
c. to be in school at least six hours a day
d. to be treated with tenderness and understanding
2. Prior to the Industrial Revolution, orphans were
often
a. forced to live on the streets
b. sold into apprenticeships that were sometimes no
better than slavery
c. sent to almshouses to work alongside adults
d. All of the above
3. One signifcant difference between child welfare
programs of 100 years ago and those of today is
that
a. alcohol was the chief cause of child removal
100 years ago and today it is drug abuse
b. the majority of children in substitute care
today are not orphans but are victims of child
maltreatment
c. caring for orphaned and abused children has
slowly transitioned from institutionalized care
to primarily substitute family care, or foster care
over the past 100 years
d. Both B and C
4. The Child Abuse Prevention and Treatment Act
(CAPTA) of 1974 was established to ensure that
a. children of maltreatment are reported to the
appropriate authorities
b. parental rights are terminated on a timely basis
c. Both A and C
d. None of the above
5. Children of color are not just disproportionately
represented in the foster care system in the United
States, but
a. far fewer children of color are reunited with their
families
b. far more children of color are placed into institu-
tionalized care
c. far more children of color are emancipated prior
to their 17th birthday
d. far fewer of these children receive regular visita-
tion with their biological parent(s)
6. In 1978 the Indian Child Welfare Act (PL 95-608) was
passed, which
a. prevented the unjustifed removal of Native
American children from their homes
b. required that Native American children be placed
in Native American homes
c. required tribal approval prior to adoptive place-
ment, even when the placement was a result of a
voluntary adoption proceeding
d. All of the above
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122
CHAPTER 6
Learning Objectives
Understand the stage of ado-
lescent development from both
a historical and contemporary
perspective, recognizing how
structural events have affected the
course of adolescent development
Compare and contrast concrete
and abstract reasoning, recogniz-
ing how abstract reasoning in
adolescence affects both think-
ing and behavior
Identify major psychosocial
dynamics experienced within
the adolescent population and
ways in which human services
professionals can intervene
Describe key social problems
experienced by adolescents in
mainstream United States, and ex-
plain the role and function of hu-
man service professionals working
a variety of practice settings
Describe ways in which culture
affects the experience of adoles-
cence, identifying the nature and
dynamics associated with at-risk
groups
One second shes curled up in my lap asking me to stroke her hair as she
cries about a fght she had with one of her girlfriends, and the next sec-
ond shes screaming at me, telling me she doesnt need a mother, and that
her father and I are ruining her life. She is so dramatic and her moods
shif from moment to moment. Shes driving us crazy, and Im wonder-
ing where my sweet little girl went. So complains one of my neighbors
about her 15-year-old daughter. Te stage of adolescence is as confusing
for adults as it is for the adolescents. Tis stage of development serves as
the bridge from childhood to adulthood, and crossing this bridge ofen
involves several circuitous routes that sometimes appear to parents
as though no progress toward maturity is being made.
Adolescence is an interesting stage of development for many reasons.
Te concept of this stage is rather new as there was little acknowledg-
ment or understanding of adolescence as a separate stage of development
until the latter part of the 19th century. But even now, when adolescence
is accepted as a distinct stage of development, there are signifcant dif-
ferences in how the stage of adolescence is perceived among various
cultures, both within the United States and internationally. In addition,
many societal changes have occurred in the last 150 years that have had a
dramatic impact on adolescents themselves, creating new dynamics and
issues refected in developmental theories.
Adolescence: A New Stage of Development?
It has been widely reported among psychologists, sociologists, and histo-
rians that the stage of adolescence is relatively new, not having been for-
mally acknowledged until psychologist G. Stanley Hall began his study
of adolescence in 1882, culminating in his groundbreaking book on ado-
lescence published in 1904. Yet, it would be misleading to assume that
Adolescent Services
ZUMA Wire Service/Alamy Limited
Adolescent Services 123
because society did not formally acknowledge the stage of adolescence that it did not
exist. Tere was little acknowledgment of childhood being a distinct stage of develop-
ment prior to the late 1800s, but that does not mean that children did not throw tan-
trums, play, and essentially act and feel like children. Halls earliest writing on the study
of adolescence sounds strikingly similar to contemporary descriptions of adolescent be-
havior. Hall described adolescents as possessing a lack of emotional steadiness, violent
impulses, unreasonable conduct, lack of enthusiasm and sympathy (as cited in Demos &
Demos, 1969, p. 635).
But even if adolescents have always behaved as adolescents, there have been sig-
nifcant shifs in child and adolescent developmental theories, infuenced by the soci-
etal changes that have occurred over the past few hundred years. Tese changes have
infuenced not only how the stages of childhood and adolescence are perceived, but
also the course of development itself. Lifestyles were quite diferent 200 years ago when
the United States was a new country. Te U.S. economy was diferent, livelihoods were
different, neighborhoods were different, and families were different. An important
question to consider is what kind of impact these changes have had on adolescent devel-
opment and whether adolescent behavior has changed or whether societys expectations
and perception of adolescents have changed.
Tere is no question that the mass urbanization of the past 200 years has had an
impact on individual and family lives, including the lives of adolescents, who at one
point in history worked alongside family members on the family farm, but who in con-
temporary times have far less vocational responsibility, as an increasing amount of focus
is placed on the academic education of adolescents. Even the way in which many ado-
lescents are educated has changed, likely infuencing adolescent development, as teens
spend signifcantly more time with their peers in large school environments, with in-
creasing exposure to violence (Larsen, 2003; National Center for Education Statistics,
1999; Raywid, 1996).
Tus, although adolescents of the past acted in ways that are strikingly similar to the
ways in which they act today, the many profound changes within U.S. society, including
changes in family structure, the public educational system, and expectations of adoles-
cents within these systems, have infuenced the ways in which many contemporary ado-
lescents both develop and behave.
Developmental Perspectives
To understand the behavior of adolescents, it is important to understand the develop-
mental stages that children and adolescents progress through on their way to adulthood.
Development occurs within various domains, including the intellectual, emotional, psy-
chosocial, moral, and even spiritual spheres. Many theories of development propose
that individuals progress through distinct stages of growth with earlier stages acting as
foundations for successive stages. Because the course of development is infuenced by
many factors, both on an individual and on a broader societal level, it is important to
consider both developmental theories and the course of developmental growth and ma-
turity of children and adolescents within various contexts. For instance, in the previous
124 Part II / Generalist Practice and the Role of the Human Service Professional
section we discussed changes that have occurred in families in the United States since
the mid-19th century. It is likely that what was considered normal behavior for ado-
lescents in 1900 would not necessarily be considered normal in contemporary society.
In other words, it is important to consider the normative aspects of adolescent de-
velopment within a historical context. What is expected of an adolescent, and what is
considered adaptive and healthy behavior, depends on what is occurring in the world
during the time in which the adolescent lives. A world war with a mandatory draft
forces adolescents to grow up quickly, just as the Great Depression shortened child-
hoods across the country as adolescents were looked upon to help support their fami-
lies. Yet, in contemporary society childhoods are ofen considered lengthened by a good
economy, which reduces the need for adolescent employment, an increase in educa-
tional requirements required for professional employment, and the cessation of a man-
datory draft, all of which have led to many believing that contemporary society has
lower expectations of adolescents than in past eras. Adolescents who did not work dur-
ing the Great Depression would likely have been considered irresponsible for not being
willing to assist in the support of their families, but adolescents who do not work in
contemporary society are likely presumed to be focused solely on their academic studies
in preparation for college.
It is also important to consider developmental issues within a cultural context. What
is considered normative and emotionally healthy within one culture may be considered
maladaptive in another, and what is considered respectful and honorable behavior in
one culture may be a sign of an emotional disorder in another. For instance, in many
cultures, remaining in the family home until marriage is considered the norm. It is com-
mon in collectivist cultures, such as Asian, Latino, and even some European cultures,
for single adult children as old as 30 years to live at home with their parents. In many
of these cultures it would be considered a sign of disrespect for a single adult to move
from the family home to gain independence prior to getting married. Te United States
is, for the most part, an individualistic society that values independence and autonomy;
thus, many within the U.S. culture may perceive the 30-year-old male still living with his
parents as a sign of unhealthy emotional enmeshment, where the boundaries between
parents and adult child are blurred.
Finally, it is important to consider development within a regional context. Although
urbanization over the last 200 years within the United States has resulted in the majority
of people living in urban or suburban communities, rural life still exists in the United
States and some research suggests that there are signifcant diferences between ado-
lescent life in rural communities and adolescent life in urban communities. Although
there is not a wide body of research comparing urban and rural adolescents, a study
conducted in 2001 found that rural adolescents felt less pressure to become involved in
gang activities, were confronted with less violence both on and of campus, and felt less
academic pressure, from both their school and their parents, compared with adoles-
cents residing in urban areas (Gandara, Gutierrez, & OHara, 2001).
Understanding the natural course of development will assist the human service
professional to correctly evaluate an adolescents behavior, framing it as either adaptive
or maladaptive, depending on the context within which the behavior is exhibited. For
Adolescent Services 125
instance, understanding that it is normal for an adolescent to act in a self-centered and
dramatic manner will aid the human service professional in framing behavior that, in
an adult, would be indicative of a personality disorder.
Keeping historical, cultural, and regional contexts in mind will
assist the human service practitioner in not mischaracterizing cer-
tain behaviors because their origin is either misunderstood or not
valued by the majority culture. Adolescents in contemporary culture
may act in a different manner than adolescents in past generations;
yet, this does not necessarily mean that adolescents today are any
less respectful than those of the past. It is also important for those
in human services to understand that adolescents who immigrated
to the United States from a Latin American country might act in a
different manner than adolescents who have lived in the United States their entire
lives, or that adolescents who recently moved from a farming community to a large
city school might act differently than adolescents who grew up in
an urban community.
Having a competent grasp of normative development can be a
guide for human service professionals who work with adolescents
and must evaluate and assess their behavior before determining
the appropriate level of intervention or whether intervention is
warranted at all. Most of the developmental theorists agree that
adolescence is a time of searching for ones own identity and de-
veloping a sense of autonomy. Trying on different selves is a
common mental and behavioral activity of adolescents who are
in the process of developing an internally anchored sense of who
they are, rather than defning themselves by what others think or
expect of them (including their parents) (Erikson, 1968; Kerpel-
man & Pittman, 2001). Many normal and healthy adolescents can
be quite dramatic and egocentric in their behavior, and although
this might give many parents cause for concern, most adolescents
grow out of this stage to become giving and compassionate adults.
Common Psychosocial Issues and the Role of the
Human Service Professional
Te common stereotype of adolescents being generally rebellious and out of control
is both true and untrue. Many adolescents are quite responsible and do not have
mental health problems. But adolescence is a time of stress; of trying on diferent
selves; and of exploring undiscovered issues, attitudes, and behaviors. Tere are
many reasons for these dynamics. Most developmental theorists consider this time
in ones life to be transitional, and typically all transitions can be stormy. But there
are other relevant issues that make adolescence unique among the various develop-
mental stages of life, which has an impact on providing counseling services to those
adolescents who are troubled.
Keeping historical, cultural, and
regional contexts in mind will assist
the human service practitioner in not
mischaracterizing certain behaviors
because their origin is either
misunderstood or not valued by the
majority culture.
Human Systems
Understanding and Mastery of Human
Systems: Theories of human development
Critical Thinking Question: Chapter 5
noted that, in terms of identity develop-
ment, younger children tend to focus
on their relationship to others (external
identity), while mature adults tend to
identify themselves by internal charac-
teristics. How might the egocentrism,
drama, and changeability that character-
ize adolescence fit into this framework
of identity development?
126 Part II / Generalist Practice and the Role of the Human Service Professional
Abstract Reasoning: A Dangerous Weapon in the
Hands of an Adolescent
Jean Piaget (1950), a Swiss-born biologist turned psychologist, developed a theory of
cognitive development that is still the dominant theory of intellectual development to-
day. Among Piagets many fndings is his discovery that children, adolescents, and adults
each think diferently. Most notably, Piaget discovered that younger children think con-
cretely, meaning that they lack the ability to understand many adult concepts such as
parables and analogies, as well as other abstract concepts. If a group of adults were asked
what it meant to let the chips fall where they may, they will most likely explain that
this is an idiom meaning to let things happen naturally. But if a group of children were
asked what this statement meant, they will most likely reply that it means that if chips
fall on the ground, one should not pick them up.
Piaget (1950) believed that as children approached adolescence, they began to de-
velop the ability for logical reasoning involved in abstract thought. Abstract thought
or reasoning enables us to have empathy by putting ourselves in someone elses shoes.
It allows us to think metaphorically, to understand sarcasm, to deduce, to analyze, to
synthesize, and to rationalize. It also allows us to understand, and thus internalize,
moral standards: to not just know that something is wrong, but to understand why it is
wrong. If children of the age of fve are asked why it is wrong to hit another child on the
playground, they might state that it is wrong because they will get in trouble. But most
adults would be able to explain that this act is wrong because it violates another persons
personal rights, that violence does not resolve confict, and that they would not want
to be hit, even if someone else was angry with them. Tis type of reasoning requires
empathy, the ability to see situations from multiple perspectives, the ability to draw on
other experiences, and the ability to connect the immediacy of hitting someone to the
generalized concept of violenceall of which require abstract reasoning ability.
It is through the development of abstract reasoning ability that adolescents discover
that their parents might not always be right, that lying can be rationalized, that break-
ing the rules can sometimes be fun, and that authority can be questioned. When a child
asks, Why? the question usually relates to why the sky is blue and the grass is green.
But when adolescents ask, Why? it ofen relates to asking why sex before marriage is
wrong, why education must occur in a 20 * 20 classroom, why drinking alcohol is bad,
and perhaps even existential questions such as whether God is real or why they were put
on this earth.
Abstract reasoning is a useful and powerful intellectual tool and can be a lethal
weapon in the hands of an unstable and angry adolescent. Existential questions about
the meaning of life can quickly spiral into questioning why one should exist at all, and
questions about the concept of authority can quickly evolve into abandoning the con-
cept of obeying authority altogether. Te necessary skill of logical or abstract reasoning
ofen enables a troubled adolescent to rationalize away reasons not to rebel.
Adolescent Rebellion
As long as there have been adolescents, one can be assured that there has been adolescent
rebellion. Casually defned, adolescent rebellion can include any behavior on the part of
Adolescent Services 127
an adolescent that is in marked opposition to standard rules, either within the family or
within society in general. Determining what specifcally constitutes rebellious behavior,
though, can be a bit more challenging and ofen depends on current social mores, as well
as ones own personal value system. Behaviors that involve outright destruction and the
breaking of laws are easily characterized as rebellious. But whether the more subtle chal-
lenging of rules is considered rebellious is certainly in the eye of the beholder, where one
persons rebellion is another persons sign of autonomy and individuation. For instance,
most would agree that behaviors such as taking illegal drugs, habitual lying, and engag-
ing in chronic truancy are rebellious, but what about the occasional drinking of alcohol
or the intermittent breaking of a curfew? Many mental health experts and even some
parents might normalize this behavior as being typical of the majority of adolescents who
are striving for increased independence and testing limits along the way.
In general, though, any behavior in adolescents should be considered maladaptive if it
is interfering with normal functioning and causing problems in the adolescents everyday
life. For instance, adolescents who skip one day of school in an entire year would not be
considered rebellious, but adolescents who are truant several times per week, thereby
afecting their ability to pass their classes, would likely be characterized as rebellious.
EXTERNALIZING BEHAVIORS Conduct disorder and oppositional defant disor-
der are disorders included in the Diagnostic and Statistical Manual of Mental Disorders,
fourth edition, text revision (DSM-IV-TR) that are diagnosed during adolescence to
describe behavioral problems in children and adolescents. Conduct disorder, the more
serious of these two disorders, involves a consistent pattern of behaviors in which social
mores and rules are habitually broken and the rights of others are consistently violated
without regard for the other persons feelings. To avoid a child being diagnosed with
conduct disorder in response to uncharacteristic or minor rebellion, children cannot
receive this diagnosis unless they meet at least three of the following four criteria in the
preceding 12-month period:
1. Exhibiting aggression to people and animals, such as bullying, threatening or intim-
idating others, initiating fghts, using weapons, exhibiting physical cruelness toward
people or animals, stealing from a victim (e.g., armed robbery), or forced sexual
activity.
2. Destroying property, such as destructively setting a fre, or deliberately destroying
another persons property, such as fre setting with the intention of causing serious
damage.
3. Deceitfulness or thef, such as breaking into someones home or car; lying to obtain
something desired; or nonviolent stealing such as shoplifing.
4. Serious violations of rules, such as frequently staying out at night despite parental
curfew, running away from home, and frequent truancies from school (American
Psychiatric Association, 2000).
Again, what most often determines the difference between the adolescents who
are harmlessly spreading their wings and adolescents with conduct disorder is the fre-
quency, persistence, and seriousness of the maladaptive behaviors. A 12-year-old who
128 Part II / Generalist Practice and the Role of the Human Service Professional
runs away to the next-door neighbors house or a 16-year-old who breaks curfew by
30 minutes on just a few occasions would certainly not be diagnosed with this disorder.
But a 12-year-old who runs away for weeks at a time or a 16-year-old who comes home
whenever he pleases certainly might.
Oppositional defance disorder is another emotional disorder commonly diagnosed
in adolescents and is characterized by a milder set of behavioral problems, including
negative, hostile, and defant behavior such as losing ones temper, arguing with adults,
and consistently refusing to obey rules. Other criteria include blaming others for per-
sonal mistakes, being easily annoyed, frequent feelings of anger and resentment, spite,
and vindictiveness.
Because human service professionals always evaluate the mental health of individ-
uals within the context of their environment, it is vital to examine any potential envi-
ronmental causes or infuences of an adolescents maladaptive behavior. For instance,
socioeconomic status, gender, parenting styles, environment, genetic
infuences, cognitive defcits, and temperament have all been associ-
ated with juvenile delinquency (Lahey, Moftt, & Caspi, 2003). It is
important to note that although such research indicates some type
of a relationship between conduct disorders and these various in-
fuences, they do not specify whether any of these variables actually
cause conduct disorders in adolescents. Tus, it would be incorrect to assume that be-
cause a child is from a lower socioeconomic background that she will engage in juvenile
delinquency. More likely, families that are chaotic, perhaps even abusive, are likely to be
from a lower socioeconomic level because such behaviors are ofen not amenable to the
skill sets required to be a high wage earner.
I have worked with adolescents for yearsfirst in a residential setting, then
in a school setting, and now in my private practice, and I have found that adoles-
cents typically act out for specifc reasons. Clinically evaluating the entire picture
is extremely important as many children and adolescents who meet the criteria for
conduct disorder or oppositional defance disorder come from homes where mal-
adaptive behavior abounds (Frick, 2004). Such behaviors are ofen a manifestation
of earlier abuse, neglect, and general chaos in the home environment. In general, if
children and adolescents cannot talk out their feelings, they will likely act them out,
ofen in a negative manner. Tus, if adolescents have neither the opportunity nor the
maturity to connect behaviors with feelings, they will be at greater risk of expressing
negative feelings in a destructive way.
INTERNALIZING BEHAVIORS Adolescents, like children and adults, do not always
manifest their emotional problems in outward ways. In fact, some of the most emotion-
ally disturbed adolescents turn their anxiety, anger, and sadness inward with behaviors
that refect forms of depression. Tese adolescents are ofen overlooked, particularly
within a school system, because they are not disruptive, ofen sitting in the back of the
class quietly, disturbing no one. Yet, emotional disturbances turned inward can ofen be
the most serious of all, putting these adolescents at higher risk of depression, self-abuse,
and suicide.
It is vital to examine any potential
environmental causes or
infuences of an adolescent's
maladaptive behavior.
Adolescent Services 129
Depression and Anxiety. Everyone experiences depression from time to
time, but when feelings of sadness become so pronounced and long-standing that
these emotions become barriers to normal functioning, the individual may be suf-
fering from clinical depression, also referred to as major depressive disorder. Te
DSM-IV-TR lists several criteria for major depressive disorder, including abnormally
depressed mood; loss of interest and pleasure; inappropriate guilt; disturbances in
sleep, appetite, energy level, memory, and concentration; and, in serious cases, fre-
quent thoughts of suicide. In children and adolescents the melancholy can often
appear as irritability, which can lead to confusion in diagnosing the appropriate dis-
order because an irritable teenager can look far more oppositional than a sad or mel-
ancholy one.
Te term used to indicate the existence of two emotional disorders simultaneously
is comorbidity, and the comorbidity of depression and anxiety is quite high, with ap-
proximately 80 percent of those with depression also sufering from anxiety of some
type (Gorwood, 2004). Although anxiety has a completely diferent set of diagnostic cri-
teria (see the DSM-IV-TR), if one examines the possible origin of mood disorders, then
it makes sense that the emotional issues that can make someone feel depressed could
likely lead to feelings of anxiety as well.
Tere are many treatments for depression and anxiety, ranging from counseling to
drug therapy, including antidepressants and antianxiety medication. However, working
with adolescents is a special challenge because adolescents can be impulsive, dramatic,
and narcissistic as a normal part of development, but a depressed adolescent who is im-
pulsive, dramatic, and narcissistic can be dangerous.
I discussed earlier how some adolescents express their negative, uncomfortable
emotions by acting out in aggressive and destructive ways toward others, but another
way that adolescents deal with their problems is by turning all their emotions inward.
Adolescents sufering from depression and anxiety ofen manifest many self-destructive
behaviors, the most serious being suicide. But there are many other self-abusive behav-
iors that emotionally disturbed adolescents may engage in that, although certainly not
as serious as suicide, still warrant serious clinical intervention.
Deliberate Self-Harm. Deliberate self-harm (DSH), also sometimes called self-
injury, self-abuse, or self-mutilation, is defned in various ways in research studies. One
defnition of self-injury includes any deliberate, repetitive attempt to harm ones own
bodily tissue without a conscious desire to commit suicide (Nock & Prinstein, 2005).
Hicks and Hinck (2009) use a more narrow defnition for DSH, which they defne as
the intentional act of tissue destruction with the purpose of shifing overwhelming
emotional pain to a more acceptable physical pain (p. 409). Tey describe the purpose
of DSH stating that the [t]issue damage is a visual demonstration of extreme emotional
distress, and the physical act of mutilation seems to reconcile this emotion (p. 409).
DSH most often includes cutting the arms and legs with a razor blade or any sharp
object (such as a paper clip), but can also include burning, picking at wounds, and
even head-banging. People who self-mutilate using a sharp object are commonly called
cutters.
130 Part II / Generalist Practice and the Role of the Human Service Professional
Although self-injury occurs in the adult population (occurring in about 4 percent
of the general population), adolescents are at increased risk for self-injury, with 39 per-
cent of the adolescent population admitting to having self-injured at some point in their
lives and 61 percent of adolescents in a psychiatric in-patient setting having self-injured
(Nock & Prinstein, 2005). Approximately 40 percent of college students have admitted
to engaging in self-injury (Whitlock, Purington, Gershkovich, 2009).
DSH can be a difcult issue to treat because so little is known about its causes. In
addition, this type of behavior tends to be resistant to treatment. What is known is that
females tend to engage in DSH far more than males, with some studies indicating that
of all those who self-abuse, 97 percent are women (Nock & Prinstein, 2005). One rea-
son for this may be due at least in part to how females are socialized to internalize their
negative feelings, whereas males are socialized to externalize their negative feelings.
Te precise reasons why adolescents engage in DSH behaviors is unknown, but DSH
has been associated with a host of emotional and psychological problems, including sui-
cidal thoughts, eating disorders, chronic feelings of hopelessness and despair, depres-
sion and anxiety, sexual abuse, physical abuse, severe emotional abuse, perfectionism,
and a pervasive sense of loneliness (Nock & Prinstein, 2005). Te National Institute of
Mental Health estimates that approximately 50 to 60 percent of cutters were sexually
abused as children (Crowe & Bunclark, 2000). Many adolescents who engage in DSH
cite many reasons for physically harming themselves, including the belief that the cut-
ting or burning allows them to feel something in the midst of emotional numbness.
In fact, in order for self-mutilation to be considered DSH the pain and/or the sight of
blood caused by the self-mutilation must result in some relief of emotional pain, and
psychological reintegrationin other words, not in pleasure as is the case with masoch-
ism. Additionally, the self-mutilation of tissue must not refect a suicide attempt or a
desire to adorn oneself, such as the case of tattooing or piercing (Clarke & Whittaker,
1998; Favazza, 1996).
Other reasons for self-injury relate to the internal expression of rage and relieving
intolerable tension resulting from deep feelings of anger, frustration, despair, and loneli-
ness. Adolescents who are survivors of sexual molestation ofen claim that they cut in
response to the shame.
A human service professional will likely encounter adolescent clients who engage in
DSH in a variety of practice settings, including adolescent residential facilities, group
homes, foster homes, schools, and any other settings where adolescents are served. It
is important that clinicians always be on the lookout for common warning signs of
self-injury, even if the adolescent or the parents deny the behavior. Adolescents who
self-mutilate for attention will ofen faunt their work by showing of what frequently
amounts to superfcial cuts on the forearm or thighs. But as mentioned earlier, serious
self-mutilators will ofen hide their wounds; thus, a human service professional would
be wise to note suspicious behaviors, such as consistently wearing long sleeves and
pants, even on warm days. More obvious signs of self-injury may include parallel scars
on the forearm or thighs, burn marks in these same places or even on the fngertips, or
any unexplained or suspicious wound, particularly wounds that tend not to heal (due to
chronic reinjury).
Adolescent Services 131
The most successful treatment programs include a combination of individual,
group, and family therapy with the goal of increasing the adolescents personal insight
and awareness of the dynamics underlying the compulsion to self-injure. Issues such
as impulse control and emotional regulation are paramount in any successful treatment
plan, as is assisting the adolescent client in learning how to understand and efectively
manage intense or uncomfortable emotions in a direct manner. Tis approach will allow
self-abusive adolescents to own their emotions, rather than deny or suppress them.
Suicide. Te ultimate internalizing behavior is, of course, the killing of ones self,
and although people have been committing suicide for centuries, understanding the dy-
namics of suicidal behavior, or suicidal ideation, remains a relatively new area of study.
Of particular interest to social scientists and mental health practitioners is discovering
how to most efectively prevent suicide attempts. As with self-injury, adolescents are at
particularly high risk of suicide and suicidal ideation for several reasons, including their
propensity for impulsivity, as well as their frequent feelings of omnipotence.
Between 1999 and 2006 (the most recent data available), 11 percent of all deaths
of adolescents between the ages of 12 and 19 were caused by suicide, making suicide
the third leading cause of death, behind unintentional accidents and homicide (Minio,
2010). Adolescent suicidal behavior can include suicidal gestures, suicide attempts, and
serious suicide attempts and suicide completions. Each of these behaviors can result in
a completed suicide, even if that is not the intention of the adolescent, but it is impor-
tant to distinguish between each of these types of suicidal behavior for the purposes of
intervention, as well as developing an understanding of what goes on in the mind of an
adolescent who engages in any type of suicidal behavior.
Suicidal Gestures. A suicidal gesture typically involves behavior on the part of
an adolescent that is unlikely to result in a completed suicide, but is more ofen a cry for
help or attention. Even if a practitioner does not believe that her adolescent clients truly
wish to kill themselves, these gestures should not be taken lightly, because it is always
possible that adolescents will kill themselves even if death wasnt the intended outcome.
Suicide Attempts and Complete Suicide. Certainly the most serious of all
suicidal behavior involves actions that are intended to end ones life. As with the adult
population, it is not necessarily the adolescents who scream their suicidal intentions
from the roofop who clinicians need to be the most concerned about, but the sad, hope-
less, and depressed adolescents who quietly slink away, without drawing any attention,
determined to kill themselves in a manner that precludes intervention. Fortunately, not
all serious attempts are successful. Some adolescents experience a last-minute change
of heart and call a family member or friend, reach out to a suicide hotline, or call 9-1-1.
Te types of adolescents who attempt suicide are diferent than those who complete
suicide. For instance, research indicates that about 85 percent of attempters are fe-
male (Andrus et al., 1991), whereas about 80 percent of suicide completers are typi-
cally male (Arias, Anderson, Kung, Murphy, & Kochanek, 2003). Reasons for this might
be related to the social acceptance of males completing suicide rather than making an
attempt (Moskos, Achilles, & Gray, 2004). Other reasons may relate to gender-related
132 Part II / Generalist Practice and the Role of the Human Service Professional
methods for committed suicide, such as the male tendency to elect for far more lethal
methods such as the use of frearms, whereas women tend to use less lethal methods,
such as drug overdoses (Vrs, Osvth, Fekete, 2004). Among adolescent populations,
those who admitted having attempted suicide were up to 30 percent more likely to be
addicted to drugs and alcohol (Vrs, Fekete, Hewitt, & Osvth, 2005).
Assessment, Intervention, and Treatment of Suicidal Behavior. Recog-
nizing whether an adolescent is at real risk of attempting suicide is an important clinical
skill that develops with education and experience. One of the most
intimidating issues facing any human service professional is knowing
how to predict suicidal behavior. Te answer to that question is that it
is virtually impossible to defnitively predict when anyone will make
an attempt to end her life, but there are indicators and precursors that
practitioners can look for, such as the psychosocial risk factors dis-
cussed in the previous section.
Although any human service professional should have a safety
first approach to treatment, there are valid concerns for not calling 9-1-1 each time
an adolescent client sounds hopeless or immersed in despair, including not wanting to
destroy the counseling relationship by overreacting. When adolescent clients share that
they sometimes wonder what it might feel like to die, and an anxious practitioner responds
by having the adolescent involuntarily hospitalized, trust can certainly be destroyed. But
in light of the alarming increase in adolescent suicides since the mid-1990s, particularly
within the adolescent male population, safety is of paramount importance. Tus, some
sort of balance must be struck between honoring the privacy and safety of the counseling
relationship and making sure that the adolescent remains safe.
Before any successful intervention strategy can be developed, the questions of why
so many teenagers are killing themselves and who is most at risk must be addressed.
Suicide rates of African American males is increasing dramatically, particularly among
those in higher socioeconomic status, and suicide rates in the adolescent Native
American population are exceedingly high (Moskos et al., 2004).
Rutter and Behrendt (2004) conducted a study of 100 at-risk adolescents, focusing
on psychosocial risk factors. Teir research revealed that those adolescents who were
plagued by feelings of hopelessness, had little to no social support, had feelings of hostil-
ity, and had a negative self-concept were at the greatest risk for committing suicide. Tis
research is consistent with the research on self-injury, which revealed that self- mutilation
was often the manifestation of rage and hostility turned inward, and as previously
mentioned, suicide is the most injurious of all self-abusive behaviors.
Other risk factors for suicide include having a friend commit suicide (Hazell &
Lewin, 1999), and for males having a gun available was a significant risk factor and
for girls low self-esteem. Research also showed that deep involvement in school activi-
ties markedly decreased the potential for suicidal behavior (Bearman & Moody, 2004).
Treatment will then emanate directly from any defcits found in these areas of function-
ing and will include the development of emotional insight and better coping skills to
deal with all these emotions and insights.
It is virtually impossible to
defnitively predict when anyone
will make an attempt to end her
life, but there are indicators
and precursors that
practitioners can look for.
Adolescent Services 133
If an adolescent is assessed to be a suicide risk, a safety plan must be developed with
the parents or primary caregivers, because the desire to commit suicide can only come
to fruition if there is opportunity. Tus, it is important for the adolescents environment
to be as free of risk as possible. For instance, a good home safety plan will include the
removal of all pharmaceutical drugs, guns, kitchen knives, and loose razor blades. A
depressed and socially isolated adolescent who is not actively suicidal but who thinks
about dying from time to time may not need to be hospitalized, but should be moni-
tored at all times so that any escalation in depressive symptoms can be addressed imme-
diately. At any time that adolescent clients acknowledge suicidal intent, admit to feeling
frightened of their desire to harm themselves, or disclose having a suicide plan, the hu-
man service professional may decide hospitalization is warranted, and in that case, the
family will be directed to either call 9-1-1 or take their teen to their local emergency
room.
Spirito and his colleagues found that the single most powerful predictors of contin-
ued suicidal behavior are the existence of depression and family dysfunction. Terefore,
any treatment plan designed to address suicidal behavior must seriously address what is
most likely the interplay between negative family relations and the adolescents feelings
of depression (Spirito, Valeri, Boergers, & Donaldson, 2003).
Current treatment intervention focuses on school-based suicide
prevention education programs, crisis centers including teen suicide
hotlines, screening programs aimed at identifying high-risk adoles-
cents within their community, peer support programs, and public
awareness campaigns, including pleas to remove guns from homes
with at-risk adolescents. Suggestions for future programs include
recommendations that the juvenile justice system coordinate eforts
with the school-based programs and other youth outreach agencies,
because over 60 percent of adolescents who committed suicide also
had a history of involvement with the justice system (Moskos et al.,
2004).
Human service professionals must be prepared to deal with the
growing trend of suicidal behaviors in the adolescent population.
Trough education, prevention, and intervention strategies, includ-
ing a multidisciplinary approach that addresses depression from an
emotional and social, as well as a medical, perspective, mental health
experts are optimistic that adolescent suicide can be successfully
addressed.
Eating Disorders in the Adolescent Population
Another set of disorders common to adolescents is eating disorders, including an-
orexia nervosa and bulimia nervosa. Although individuals of all ages sufer from eating
disorders, the primary onset of eating disorders occurs during adolescence (Ray, 2004).
Females tend to sufer from eating disorders far more ofen than males, comprising
approximately 85 to 90 percent of all documented cases of eating disorders, but the
Human Services
Delivery Systems
Understanding and Mastery of Human
Services Delivery Systems: Range of
populations served and needs addressed
by human services
Critical Thinking Question: The text
cites a range of clinical issues that dis-
proportionately affect adolescents; it also
notes that adolescence is often a time
of turbulence, drama, and trying on new
roles and behaviors. What are some
ways in which a human service profes-
sional can walk the tightrope between
protecting an adolescent client from
harm and allowing the client to navigate
normal adolescent changes?
134 Part II / Generalist Practice and the Role of the Human Service Professional
incidence of eating disorders in males is increasing, particularly among male athletes
(Walcott, Pratt, & Patel, 2003). Additionally, men who have eating disorders tend to
overeat, whereas women tend to under-eat (Striegel-Moore, Rosselli, Perrin, DeBar,
Wilson, May, & Kraemer, 2009).
Anorexia involves the intentional starving of oneself and the refusal to maintain ex-
pected body weight. Te DSM-IV-TR criteria for anorexia includes a body weight of less
than 85 percent of normal body weight, an intense fear of gaining weight, distortion
of how ones body is perceived, and the absence of a menstrual cycle for at least three
months (American Psychiatric Association, 2000).
Among the various theories of the causes of anorexia, the most popular tend to
focus on maladaptive family patterns where the adolescents anorexia is presumed to
help protect unhealthy family dynamics. Tese maladaptive patterns can include con-
fict avoidance, rigidity, and family enmeshment (Lock & le Grange, 2005). It is for this
reason that family counseling is the most common recommended treatment for adoles-
cents sufering from anorexia, in addition to in-patient treatment for adolescents who
are at risk of serious health complications (Fairburn, 2005).
Bulimia involves a pattern of binge eating, indicating a lack of control followed
by purging in the form of self-induced vomiting, use of laxatives, or excessive exercise
in an attempt to rid oneself of the abundance of food (American Psychiatric Associa-
tion, 2000). Bulimia is far more prevalent than anorexia in the
adolescent population (van Hoeken, Seidell, & Hoek, 2003).
Common risk factors of adolescents sufering from bulimia in-
clude perfectionism, body dissatisfaction, and low self-esteem (Vohs
et al., 2001). Adolescents who engage in binging behavior ofen ex-
perience signifcant shame once the binging phase is over. Tese
feelings of shame are ofen dealt with by purging to rid the body of
the excess food. Tis binging-purging cycle ofen becomes a com-
pulsion, robbing the adolescent of the ability to stop the behavior.
Treatment for bulimia ofen includes insight therapy, family
therapy, and cognitive behavioral therapy (CBT), which focuses
on the negative self-statements the adolescent thinks in response
to life events, as well as negative self-appraisals (Gowers & Bryant-
Waugh, 2004). Depression and anxiety are ofen associated with
both anorexia and bulimia; thus, a course of antidepressant or
antianxiety medication is ofen considered appropriate.
Other Clinical Issues Affecting the
Adolescent Population
Other issues that are commonly diagnosed in adolescents in-
clude substance abuse, discussed in detail in Chapters 11 and 12.
Attention defcit issues, such as attention defcit disorder (ADD)
and attention defcit/hyperactivity disorder (ADHD), are also a
growing concern in the adolescent population, particularly in
school settings, and thus are discussed in detail in Chapter 12.
A suferer of anorexia nervosa who is clearly
below her ideal body weight.
Prisma/SuperStock
Adolescent Services 135
Adolescence is a time of sexual discovery and experimentation and thus is an is-
sue that must be acknowledged and addressed in a counseling setting. Issues related to
sexual behavior and teen pregnancy are explored in Chapter 12. Adolescents are also at
increased risk for homelessness and for academic failure and sexual exploitation once
homeless. Te problem of homelessness among the adolescent population is explored
in Chapter 9.
Practice Settings Specifc to Adolescent Treatment
Tere are many practice settings where adolescents receive clinical services, as well as
many ways in which these services are provided. Some adolescents may receive indi-
vidual counseling from therapists who are in private practice. Tese counseling services
can be provided by anyone who has a license to provide independent counseling ser-
vices such as psychiatrists, psychologists, marriage and family therapists (MFTs), licensed
clinical professional counselors (LCPCs), and licensed clinical social workers (LCSWs).
Counseling typically occurs in the counselors ofce as ofen as the practitioner and par-
ents deem necessary, but once a week is the most common schedule.
Counseling also occurs in many other settings, such as in schools by school social
workers, counselors, and psychologists (see Chapter 12); human service agencies that
specialize in adolescent issues; outreach organizations such as afer-school programs;
religious organizations such as Jewish Community Centers (JCC) (see Chapter 13); or-
ganizations that provide therapeutic foster care; and the juvenile justice system.
Residential care is a practice setting ofen utilized for adolescents who are severely
behaviorally disordered and at high risk of self-harm and destructive behaviors. Al-
though institutionalized care has steadily decreased for most segments of the popula-
tion, this institutionalized care for the adolescent population has literally skyrocketed
since the 1980s (Wells, 1991). Tese institutions can be locked or open, private or gov-
ernmental, short or long term, therapeutic or more punitive in nature, but all provide
some level of mental health services in relatively large, dormitory-like settings, where
the adolescent residents sleep and attend school.
Residential treatment programs vary widely in type and nature, with some residen-
tial programs ofering services making them sound more like a boarding school than a
treatment facility, boasting equine programs, river rafing, and therapeutic skiing pro-
grams, whereas others are far more sterile ofering few extracurricular activities. One
reason for this diference can be directly related to the range of populations served. For
instance, behavior on the part of an adolescent that results in court intervention and
juvenile detention in a residential facility would not necessarily be conducive to a thera-
peutic ski trip to Vail, Colorado.
Placement times can also vary, with some adolescents being placed in a residen-
tial facility for a few months to some who require several years, again depending on
the severity of their problems. One popular short-term residential program is Outward
Bound, a wilderness therapy program that uses physical challenges to help adolescents
deal more efectively with their emotional problems. Tese programs are ofered in vari-
ous locations within the United States and range from 21 to 28 days in length.
136 Part II / Generalist Practice and the Role of the Human Service Professional
Group homes (or therapeutic foster homes) ofer less-structured residential care,
where various community services are ofen accessed and where adolescents attend the
local public high school and are not isolated from the general community.
More structured residential treatment programs are a bit more sterile in nature, ofer-
ing services to adolescents whose conduct problems or self-destructive behaviors require
a more long-term, in-depth, and controlled environment. Adolescents in these programs
are isolated from the general population and even attend school within the facility where
they are housed. Treatment modalities in these facilities ofen include a combination of
behavior modifcation where desirable behaviors are rewarded and undesirable behav-
iors are punished, individual therapy, group therapy, and family therapy. Referrals to
such programs can be made by parents, public schools, or the juvenile court system.
Te most structured and most serious of all residential treatment programs include
correctional institutions for adolescents, most commonly referred to as juvenile hall or
juvenile detention centers. Tese facilities are reserved for adolescents who have been
convicted of breaking some law, and although there is far more of an emphasis on reha-
bilitation than in adult correctional facilities, there is a far greater emphasis on correc-
tions and punishment than in a therapeutic treatment center.
A creative version of the juvenile correctional institution that has received mixed
reviews is boot camp programs, which ofer rehabilitation (as well as restraint) in the
form of a military-like, highly structured environment. Te philosophy behind these
boot camps is that adolescents or young adults who sufer from poor impulse control,
low self-esteem, and high rates of acting out behavior can benefit from a military-
like structured setting that pushes them to their limit (both physical and emotional).
Te high emphasis on structure and self-discipline, coupled with the push to achieve,
is believed to have a positive impact on both self-esteem and self-
respect, which is hoped to generalize into more respectful behavior
in society. Many parents and participants commonly claim dramatic
changes in the behavior of participants afer a boot camp experience,
but research appears to indicate that boot camps do not necessar-
ily reduce recidivism rates in young ofenders (Peters, Tomas, &
Zamberlan, 1997).
Another type of treatment facility for adolescents experienc-
ing mental health problems is in-patient psychiatric hospitals.
Tese programs tend to be acute (short term), focusing on stabiliz-
ing the adolescents high-risk behaviors, such as suicidal behavior,
self-abuse, substance abuse, and eating disorders. Some in-patient
programs specialize in one or more of these disorders or are more
general in nature, ofering short-term acute services to any adoles-
cent who cannot be maintained safely outside a hospital setting.
Many of the same type of therapies are available in an in-patient
setting as in a residential treatment center, with the exception that
drug therapies may be more prevalent in a psychiatric hospital. In-
patient hospitals also rely heavily on discharge planning, a task that
typically falls to a hospital social worker or other human service
Human Services
Delivery Systems
Understanding and Mastery of Human
Services Delivery Systems: Range and
characteristics of human services delivery
systems and organizations
Critical Thinking Question: A wide vari-
ety of therapeutic interventions exist for
adolescents, ranging from weekly outpa-
tient sessions with a counselor, through
programs such as Outward Bound, to
inpatient facilities with a range of pro-
grams and supports. Ideally, adolescent
clients would receive the level of treat-
ment most appropriate to their situation;
in reality, what other factors play a role
in the type and level of treatment which
adolescents receive?
Adolescent Services 137
professional who works with the family and community resources to ensure that the
adolescent will transition back to home and school with enough outpatient support to
minimize the need for rehospitalization.
Multicultural Considerations
It would be nave to assume that race and ethnicity did not have a signifcant efect
on adolescent development, including the types of problems adolescents of various
races experience as well as the various responses to those problems, both within the
family and within the community. Human service professionals must be aware of
the way in which race and ethnicity afect adolescent development and behavior, as
well as any negative stereotypes that might afect the types of diagnoses adolescents
receive.
A 2001 study found that African American adolescents were more commonly di-
agnosed with conduct disorders, whereas Caucasian adolescents more ofen received a
diagnosis of depression (DelBello, Lopez-Larson, & Soutullo, 2001). But is this because
more African American adolescents actually have conduct disorders? Or is it because
the negative stereotype that African American males are typically more violent infu-
enced the practitioner rendering the diagnosis? DelBello et al. (2001) doubted that the
diference in diagnosing refected any real variation in disorders among adolescents
of diferent races, but was more likely attributable to variables such as misdiagnosing
based on cultural diferences and misperceptions.
Other research indicates that Latino adolescents, specifcally Mexican Americans,
are at higher risk for delinquency, depression, and suicide than Caucasians ( Roberts,
2000). African American youth tend to show the greatest need for mental health
services, yet were severely underserved, and although most mentally ill African
American adolescents had a long history of diagnosable mental health problems, ofen
their frst exposure to treatment was within the juvenile justice system. One reason for
this might be that there is a negative stigma associated with mental health disorders
in certain ethnic minority groups. But another equally signifcant reason is likely the
lack of afordable mental health services in ethnically diverse neighborhoods, as well
as issues such as poor or no insurance coverage for mental health services in ethnically
diverse populations. In fact, a recent study showed that very little has changed in this
trend in the last few decades, despite considerable research in this area and policy
recommendations. For instance, a 2011 study revealed that African
American, Latino, and Asian adolescents with major depression were
signifcantly less likely to receive mental health treatment, including
prescription medication, than non-Hispanic white adolescents,
regardless of income levels and health insurance (Cummings & Druss,
2011). It is interesting to note that Latino adolescents were rated as
the most underserved of all racial groups, despite the fact that they
had signifcant needs, and Caucasians were reported to have the high-
est rate of mental health utilization, although they have less serious
mental health diagnoses compared to other racially diverse groups
(Rawal, Romansky, & Jenuwine, 2004).
A 2011 study revealed that African
American, Latino, and Asian
adolescents with major depression
were signifcantly less likely to
receive mental health treatment,
including prescription medication,
than non-Hispanic white adolescents,
regardless of income levels and health
insurance.
138 Part II / Generalist Practice and the Role of the Human Service Professional
Certainly not all diferences in adolescent diagnoses can be attributed to cultural
misperceptions, misdiagnoses, and underutilization of services. Social conditions, such
as poverty, high crime neighborhoods, and unemployment likely contribute to a signif-
cant proportion of mental health problems in racially ethnic youth. Rawal et al. (2004)
noted that African American adolescents are far more likely to be raised in single- parent
households, be placed in foster care, and experience signifcantly higher rates of famil-
ial abuse and neglect, all of which can be expected to have a negative impact on their
mental health. Latino adolescents also exhibited higher incidences of acting out and an-
tisocial behaviors, such as juvenile delinquency, compared to Caucasians; yet, they also
had greater familial support, with their caregivers exhibiting greater
understanding and involvement in their mental health issues, which
might act as an intervention negating the necessity of more serious
intervention.
Regardless of the reasons for the differences in mental health
issues among adolescents of diferent ethnic groups, it is impera-
tive that human service professionals be trained to deliver cultur-
ally competent counseling. Education that addresses all these issues,
including institutionalized racism, both within the community and
within the juvenile justice system; culturally based stigmas associ-
ated with mental health issues; social conditions afecting adoles-
cents of all races; and the relevant histories of various racially ethic
minority groups within the United States (e.g., the history of slavery
among African Americans or the history of forced institutionalized
care among Native American youth) will assist the human service
professional render a bias-free mental health evaluation and provide
the most appropriate treatment for the adolescent client.
Concluding Thoughts on Adolescents
Clearly, our society will continue to change and evolve, afecting all its members, in-
cluding adolescents. As our society becomes more technologically based, it will become
more complex as well, which will no doubt mandate increasing levels of educationa
trend that the United States has seen steadily increase in the last 50 years at least. Tis
does not mean that juvenile violence will continue to rise. Most mental health experts
refuse to adopt such a fatalistic attitude. History reveals that adolescence has always
been a difcult stage to navigate, long before it was even recognized as an ofcial stage
of development. Te greatest hope one can ofer parents and educators alike is that ad-
olescents who ofen seem destined for a lifetime of narcissistic obsession most ofen
evolve into loving, caring, and responsible adults. Human service professionals can help
families ensure that this is the path for as many adolescents as possible through efective
program development and supportive services on all levels.
Human Systems
Understanding and Mastery of Human
Systems: Changing family structures and
roles
Critical Thinking Question: In some
cases, and particularly among certain
ethnic and cultural groups, the family can
serve as a strong source of support for
troubled adolescents; on the other hand,
families may sometimes stand in the way
of a teens accessing professional help.
How might a human service professional
build on the strengths that clients fami-
lies have to offer, and break down barri-
ers to cooperation?
139
1. One of the frst theorists to study the stage of ado-
lescence and who in 1904 described adolescents as
possessing a "lack of emotional steadiness, violent
impulses, unreasonable conduct, lack of enthusiasm
and sympathy" was
a. Erik Erikson
b. Sigmund Freud
c. G. Stanley Hall
d. Jean Piaget
2. When considering the normative nature of adoles-
cent behavior, what contexts must one keep in mind?
a. Historical, cultural, and regional
b. Historical, cultural, and contemporary
c. Cultural, regional, and socioeconomic
d. Cultural, socioeconomic, and contemporary
3. Oppositional defance disorder is an emotional dis-
order commonly diagnosed in adolescence and is
characterized by
a. negative, hostile, and defant behavior
b. angry, rebellious, and rage-flled behavior
c. depressed, anxious, and socially phobic behavior
d. melanchology, stoicism, and apathetic behavior
4. Human service professionals working with the
adolescent population should look for signs of self-
mutilation, which may include
a. wearing long sleeves and pants on warm days
b. parallel scars on the forearm or thighs
c. wounds that tend not to heal
d. All of the above
5. A majority of adolescents who committed suicide
also had a history of involvement with
a. drugs and alcohol
b. a negative peer group
c. the mental health system
d. the juvenile justice system
6. A 2001 study found that African American adoles-
cents were more commonly diagnosed with ______
whereas Caucasian adolescents were more often
diagnosed with ___________.
a. depression/conduct disorder
b. conduct disorder/depression
c. conduct disorder/anxiety
d. oppositional defance disorder/conduct
disorder
The following questions will test your knowledge of the content found within this chapter.
CHAPTER 6 PRACTICE TEST
7. Describe some of the reasons why many adolescents within ethnic minority populations do not receive necessary
mental healthcare services compared to their Caucasian counterparts. Explore some of the vulnerabilities experi-
enced by ethnic minority youth and ways that human services professionals can address these unmet needs.
8. What are some common ways that rebelliousness manifests in the adolescent population? Make sure to frame
your response within appropriate context. As a human service professional what are some evidence-based ways
that you might consider responding to an adolescent client experiencing psychosocial problems?
Suggested Readings
Cloud, H., & Townsend, J. (2001). Boundaries with kids.
Grand Rapids, MI: Zondervan.
Mattaini, M. A. (2001). Peace power for adolescents strategies
for a culture of nonviolence. Washington, DC: NASW Press.
Roles, P. (2005). Facing teenage pregnancy: A handbook for the
pregnant teen. Atlanta, GA: CWLA Press.
Ungar, M. (2002). Playing at being bad: The hidden resilience
of troubled teens. Washington, DC: NASW Press.
Ungar, M. (2003). Nurturing hidden resilience in troubled
youth. Washington, DC: NASW Press.
140 Part II / Generalist Practice and the Role of the Human Service Professional
Internet Resources
Adolescence and Peer Pressure: http://ianrpubs.unl.edu/family/
nf211.htm
Child and Adolescent Mental Health: http://www.nimh.nih.
gov/health/topics/child-and-adolescent-mental-health/index.
shtml
Mental Health Risk Factors for Adolescents: http://education.indi-
ana.edu/cas/adol/mental.html
Outward Bound: http://www.outwardbound.org
WHO Adolescent Health: http://www.who.int/child-adolescent-
health/OVERVIEW/AHD/adh_over.htm
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suicide among adolescents in Oregon, 1988. American Journal of
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142
CHAPTER 7
Learning Objectives
Understand the changing demo-
graphics of the U.S. population,
often referred to as the Aging
of America
Identify the impact that the aging
baby boomers are having and
will likely continue to have on
various aspects of U.S. society
and culture
Recognize various elements of
successful aging and be able to
describe lifestyles that lead to a
successful aging lifestyle
Become familiar with the nature
of ageism in a variety of con-
texts and describe ways in which
human service professionals can
work to combat discrimination
based upon age
Identify trends associated with
grandparents parenting, including
developing a basic awareness of
current demographic patterns,
common causes of these pat-
terns, and the various issues fac-
ing custodial grandparents
Carrie looked at the sea of faces before her. Tey looked emptyalmost
as if they had no souls. Te only sounds in the camp were the incessant,
never ceasing buzzing of hungry flies. Even the children were quiet.
Carrie reasoned that the calm was due to hungerpeople were often
subdued when they hadnt eaten well in days, but she knew this calm was
related to something far removed from hunger.
Just three days ago the people in this camp were victims of an Arab
militia known as the Janjaweed. These bands of marauding fighters
combed the countryside, indiscriminately killing black Africans. As the
villagers looked on in horror, Janjaweed militia began to systematically
slaughter the innocent villagers one by one. Not even infants were spared;
some militia tossed babies and toddlers into the air, calling them future
enemies, as they shot them with machine guns. Te few villagers who
managed to escape joined other escaping villagers running through the
desert and were eventually picked up by the American Red Cross.
Carrie is a missionary with an organization that specializes in send-
ing retirees abroad. When Carrie became a widow at the age of 71, she
thought her life was over. However, the pastor at her church approached
her, and afer months of talking, he fnally convinced her that her years
of nursing experience need not go to waste. Carrie was initially skeptical
when her pastor shared the stories of other retirees, many of whom were
widows, who served in clinics and refugee camps overseas in countries
like Guatemala, Burma, and Sudan, but it wasnt until she met some older
adult missionaries at home on sabbatical that she fnally realized that this
was something she could do.
Of course, Carries adult children thought shed lost her mind, they
even questioned whether her decision to become a missionary was a sign
of early Alzheimers, but they eventually grew to understand her decision
and even respect it, although she was certain that they never felt truly
Aging and Services for
the Older Adult
Ariel Skelley/Corbis
Aging and Services for the Older Adult 143
comfortable with the thought of their old mother living in a refugee camp in the middle
of a war-torn country. Carries contemplative thoughts were interrupted with the an-
nouncement of the most recent infux of shell-shocked and injured refugees, and she
ventured out of the makeshif hospital to meet the new arrivals.
Dan was shocked as he walked down La Salle Avenue, in the heart of the business
district in Chicago. He was used to seeing homeless people, either standing or sitting
along the side of the road with signs asking for money, but he had never seen an old
couple begging for money before. What was unique about this couple was that they
looked as though they could be his own mother and father.
He began to walk by them, avoiding their stare as he usually did when people begged
for money, but this time was diferent, and he could not resist approaching this couple.
Hi, my name is Dan, and Id love to give you some money. Te couple looked at him
sheepishly, and he noticed the shame in their eyes. Tank you, the woman said quietly,
diverting her glance downward. Dan handed them a $10 bill and started to walk away,
but curiosity got the better of him. He turned around and asked them if he could talk to
them about their situation. Te husband and wife looked at each other, and Dan did not
know if it was with suspicion or simple caution, but they eventually agreed once Dan
ofered to buy them lunch.
Over their meals of hot soup and sandwiches, Rosemary and Donald shared about
their all-American lives. They raised two children in a suburb of Chicago, owned a
home, and even had a family dog. Tey were like anyone else in the neighborhood or
their church, until Donald was laid of two years before his scheduled retirement when
the company he had worked for for 40 years downsized. Donald was unable to fnd a job
due to his age, and eventually they had to let their health insurance lapse because they
could no longer fnancially handle the extremely high monthly premiums.
Unfortunately, Rosemary became ill the following month with a bout of infuenza
that ultimately developed into pneumonia. Te hospital bill for her two-week stay was
almost $10,000. With no retirement and only Social Security benefts to count on, and
with their two adult children serving overseas in the military, Donald and Rosemary
began a downhill fnancial descent that didnt stop until they depleted their life savings
and ultimately lost their house. Tus, although most couples like Donald and Rosemary
spend their golden years playing golf in Florida, Donald and Rosemary spend their days
sitting outside the train station, begging for money.
Tese two vignettes highlight the vast range of experiences Americans living in the
United States can have in the last decades of their liveswhat is normally called old age.
And although there are some similarities between the older adults of today and the
older adults of 100 years ago, there are also signifcant diferences brought on by many
of the societal changes referenced in earlier chapters, particularly in relation to social
welfare policy explored in Chapter 2, including ongoing urbanization, changes in the
family structure, and the dawning of the technological era. However, there have also
been transitions in culture and society that have afected the older adult community in
a unique way. Tese include issues such as increasing longevity, the global community
and economy, other economic shifs, the advent of long-distance travel enabling family
members to move further and further away from one another, the healthcare crisis,
144 Part II / Generalist Practice and the Role of the Human Service Professional
signifcant demographic shifs, as well as the increasing complexity of society in general.
Each of these issues and their impact on the older adult population afects the human
services feld as it attempts to meet the complex needs of this growing population.
The Aging of America: Changing Demographics
Te opening vignette illustrates the vast range of experiences of those considered old
in the United States. Todays older adults in the United States experi-
ence a broader range of lifestyles than ever before, but they experi-
ence a greater range of challenges as well. Tere are several reasons
for this vast array of lifestyle choices and options, including the in-
crease in the human life span, changes in the perception of old age
in general, changes in the economy, and fnally changes in the nature
and defnition of the American family in the United States, including
a dramatic increase in divorce and two-parent working families.
Read just about any scholarly article relating to the older adult population, and you
will likely read about the Graying of America. Tis term relates to the increase in the
older adult population in the United States (as well as in most parts of the world). Tis
dramatic increase, as well as the projected increase in the U.S. older adult population
between now and 2050, is directly related to the aging of a cohort of individuals re-
ferred to as the baby boomers. Te baby boomers are popularly defned as those having
been born between 1946 and 1964. Te name refers to the boom of births afer World
War II, which caused an unusual spike in the U.S. population. Approximately 76 mil-
lion individuals (roughly 29 percent of the U.S. population) fall into the cohort of baby
boomers. It is obvious why this cohort has been the focus of particular interest to social
scientists, the media, politicians, and others. For one thing, despite the somewhat broad
range of ages within this cohort, similarities between members are numerous, including
their socioeconomic status, which tends to be higher than earlier cohorts, consumer
habits, and political concerns. As the boomers age, their tastes and concerns transition,
and in recent years their collective focus has included discussions regarding the conse-
quences of this large cohort heading into their retirement years. Te graying of America,
then, refers to the projected increase in the older adult population because of the aging
boomers.
Te aging of the baby boomers is not the only variable leading to the increase in the
older adult population. Other factors include the 50 percent increase in the human life
span the United States has experienced during the 20th century. In 1900 the average
human life span in the United States was about 47 years. But by 1999 it had increased
to about 77 years, which is where it stands today, although it is expected to increase at
least another 15 years by the year 2100 (Arias, 2004). Tis life expectancy increase is due
to many variables, including improved medical technology, medical discoveries such as
antibiotics and immunizations for various life-threatening diseases, and generally safer
lifestyles.
Currently there are approximately 40 million people over the age of 65 living in the
United States (NHSTA, 2009), but that number is projected to double by the year 2050,
Todays older adults in the United
States experience a broader range
of lifestyles than ever before, but
they experience a greater range of
challenges as well.
Aging and Services for the Older Adult 145
growing to more than 88 million (Passel & Cohn, 2008). Additionally, the U.S. Census
Bureau projects that the population of those aged 85 and older is expected grow from
5.8 million in 2009 to approximately 20 million by the year 2050 (Department of Health
and Human Services, 2010). When one considers that from 1900 to 2050 the over-65
population in the United States will grow from about 3 million to almost 90 million, it is
not difcult to understand why the feld of gerontology has received so much attention
in recent years!
So far this all sounds pretty goodwere living longer, and in the next 10 or 20 years
a third of the population will be classifed as older adults, which will no doubt increase
the attention paid to social and political issues important to those in their retirement
years. However, the landscape for older adults in the United States is not completely
rosy; quite the opposite, in fact. Some will no doubt enjoy their longer life span, but
for many, their extra years on this earth may be spent in a long-term care facility with
chronic health problems far too complex to make remaining in their home a possibil-
ity. Increases in rates of dementia, depression, and alcohol abuse are valid concerns for
older adults and their family members, as they face a multitude of challenges in a rap-
idly changing world.
Te most recent economic crisis starting in 2008, also called the Global Financial
Crisis, resulted in the forced retirement and unanticipated layof of many aging indi-
viduals within the workforce. In addition, changes in the U.S. and global economies
risk leaving many individuals approaching retirement in economically vulnerable posi-
tions as companies shif away from ofering employees lifelong careers with permanent
and secure retirement plans. Sharp increases in the cost of medical care and possible
changes in Social Security benefts are also putting some older adults at risk of fnan-
cial vulnerability. Tus, an increasingly older population will no doubt have an impact
on the fnancial, housing, medical, mental health, and even transportation needs of the
older adult population. Add to that, changes in the U.S. family structure, such as the
signifcant increase in divorce rates, have put some older adults in the position of hav-
ing to provide day care for their grandchildren and, in some cases, even parenting their
grandchildren. Tus, although some older adults will be able to take advantage of the
many medical advances, healthier lifestyles, and increased opportunities for enjoying
life, many others will not.
Tis chapter will explore the wide range of issues confronting the older adult popu-
lation in the United States, as well as exploring some issues projected to be relevant in
the future. Te role of the human service professional will be explored as well, with a
special focus on how the feld of gerontology has changed in recent years, expanding the
role of the human service professional in various practice settings.
Old and Old-Old: A Developmental Perspective
Before beginning any real discussion about clinical issues afecting older adults or the
role of the human service professional, it is important to understand the various aspects
of physical, social, and emotional development common to individuals in the last quar-
ter or so of their lives. Although there is no specifc age limit marking the end of middle
146 Part II / Generalist Practice and the Role of the Human Service Professional
age and the beginning of older adult years, most contemporary developmental theorists
consider old age to begin at around the age of retirement.
Many theorists have argued that adults do not go through systematic and uniform
developmental stages in the same way that children do; thus, earlier developmental the-
ories typically stop at early adulthood or lump all adult development into one category
stretching from post-adolescence and beyond. One reason for this approach is that if
development consists of the combined impact of physical, cognitive, and emotional ma-
turity, then certainly one can see that children who are spurred on to extend their social
boundaries will be motivated to push themselves from a crawl to a walk in their quest to
explore their social worlds. Yet, once one has reached physical and cognitive maturity,
this interplay between physical ability and emotional desire (where one dynamic acts
as the incentive for the other) subsides, and the motivation to pursue a particular life
course becomes based more on personal choice and internal motivation, making adult
maturity anything but systematic or universal.
Nevertheless, should we assume that adults do not continue to develop in any sort of
consistent or predictable way? Would it be correct to assume that once individuals have
reached all physical developmental milestones (somewhere afer puberty) their emo-
tional development occurs in a completely unique and individualistic manner? Most
of us have heard about the infamous midlife crisis marking the entry into middle age,
or empty nesting, the universal life crisis some women experience in response to their
adult children leaving home, and regardless of the validity of the universality of such life
events, it does seem reasonable to assume that individuals within a particular society
will respond and adapt to both internal and external demands and expectations placed
on them by cultural mores and norms and that there would be some interplay between
their physical development (or physical decline), their emotional and cognitive devel-
opment, infuenced by their social worlds, which give meaning to their experiences.
Cultural expectations in the United States, such as marriage, child rearing, employ-
ment, and home ownership, certainly have an impact on those in early and middle
adulthood, just as retirement, increased physical problems, and widowhood will have
an impact on those in later adulthood. Yet, because the options and choices available to
adults are so broad, any developmental theory must be considered in somewhat broad
and descriptive terms, rather than the narrower and more prescriptive terms ofen used
to evaluate and consider child developmental theories.
Erik Erikson (1959, 1966), a psychodynamic theorist who studied under Sigmund
Freud (the father of psychoanalysis), developed a theory of psychosocial development,
beginning with birth and ending with death. According to Erikson, each stage of devel-
opment presented a unique challenge or crisis brought about by the combining forces
of both physiological changes and psychosocial need. Successfully resolving the devel-
opmental crisis resulted in being better prepared for the next stage. Te eighth stage
of Eriksons model is integrity versus despair and spans from age 65 to death. Erikson
believed that individuals in this age range needed to refect back on their lives, taking
stock of their choices and the value of their various achievements. If this refection
resulted in a sense of contentment with ones choices and life experiences, then the
individual will be able to accept death with a sense of integrity, but if he does not like
Aging and Services for the Older Adult 147
the choices made, the relationships developed, and the wisdom gained, then he will
face death with a sense of despair.
Because the successful navigation of each stage is dependent on the successful navi-
gation of the preceding stages, Erikson believed that individuals who did not develop a
sense of basic trust in others or in the world (Stage 1), struggled developing a sense of
personal autonomy (Stage 2), had difculty developing any personal initiative (Stage 3)
or a sense of accomplishment (Stage 4), faced challenges in adolescence when attempt-
ing to discover a personal identity (Stage 5), making it difcult to develop truly intimate
relationships with others (Stage 6), leaving them incapable of ofering true guidance and
generativity to the younger generations (Stage 7), which would likely mean that they
would not refect back on their life with any sense of contentment and satisfaction, and
would then likely face impending death with a true and deep sense of despair.
Daniel Levinson (1978, 1996) is probably one of the most well-known adult devel-
opmental theorists, having developed a life span theory extending from birth through
death. Levinson wrote two books explaining his theory, The Seasons of a Mans Life
(1978) and Te Seasons of a Womans Life (1996), where he focused on middle adult-
hood, but what was revolutionary about his theory was his argument that adults do con-
tinue to grow and develop on an age-related timetable. Levinson noticed that adults
in the latter half of their lives are more refective, and as they approached a point in
their lives where they had more time behind them than ahead of them, this refection
intensifed. Levinson also believed that individuals progress through periods of stability
that are followed by shorter stages of transition. Te themes in his theory most relevant
to human service professionals include this notion of life refectionthe taking stock
of ones life choices and accomplishments, the need to be able to give back to society,
which encompasses an acknowledgment that at some point the goal in life is not solely
to focus on ones own driving needs, but to give back to others and community through
the sharing of gained wisdom and mentoring.
Finally, Levinsons belief that as people age they need to become more intrinsically
focused rather than externally based is equally relevant. Consider the man who in
his 30s gains self-esteem and a sense of identity through working 80 hours per week
and running marathons. How will this same man defne himself when he is 70 and
no longer has the physical stamina or agility to perform these activities? Levinson
believed that a developmental task for aging adults was to become more internally
anchored, more intrinsic in their self-identify, lest they develop a sense of despair and
depression later in life when they are no longer able to live up to their own youthful
expectations.
Another theory that purports to describe the changes individuals experience from
middle to older adulthood on emotional, cognitive, and physical levels is called gero-
transcendence (Tornstam, 1994). Tis theory explores how an individual moves from a
strong connection to the material world to transcendending above the material aspects
of the world into a more existential approach to the world. In a similar way as Levinson,
Tornstam describes how individuals progressing from midlife onward transition from
an externalizing perspective, where they are focusing outward toward the world, to a
more internally focused approach in life.
148 Part II / Generalist Practice and the Role of the Human Service Professional
Tornstam (2003) describes three dimensions of transcendence, including the cos-
mic level where individuals change their notions of time and space, such as reorient-
ing themselves in regard to how they view life and death, ultimately accepting death
with a sense of peace. Te second realm relates to the self where individuals increas-
ingly move away from self-centeredness, transcendending above a focus on the physical
and move toward more altruism. Te third level of transcendence is a realm involving
social and individual relationships, where the relationships are viewed in a new light
with new meaning, including developing new insights into the diferences between the
self (who they really are), and the roles they play in life (mother/father, son/daughter,
friend, etc.), and the ability to rise above black-and-white thinking, embracing the gray
in life (Degges-White, 2005).
Degges-White (2005) discusses implications of Tornstams theory of gerotranscen-
dence for counselors working with the older adult population, highlighting key issues
involved in the process of personal transcendence across the three dimensions (cosmic,
self, and relationships with others). For instance, Degges-White cites the importance of
counselors becoming comfortable with the concept of death within
themselves, so that they can help their aging clients accept the inevi-
tability of death without fear and anxiety. With regard to transcen-
dence in the self domain, Degges-White describes how counselors
can help their older clients conduct a life review where they seek to
better understand and accept their life choices, thus fnding a level
of peace and self-acceptance about their choices and experiences,
particularly the challenging and painful ones. The ultimate focus
of counseling older adults using a gerotranscence model is to assist
older adults move toward increased self- and other-acceptance and
wisdom in various dimensions and domains in life, and in a sense,
giving them permission to drawn intrinsically inward as they let go
of the more transitory dimensions of life, and toward a more existen-
tial framework.
Successful Aging
A relatively recent concept that has become popular in relation to the study of geriatrics
is the concept of successful aging, which is used to describe the process of getting the most
out of ones life in later years. Successful aging literally means to add years to ones life and
to get the most out of living (Havighurst, 1961). Researchers have examined individuals
who age better than others to determine what diferences might account for their suc-
cess, and some of the variables at play include maintaining a moderately high physical
and social activity level, including keeping active with hobbies, social events, and regu-
lar exercise (Warr, Butcher, & Robertson, 2004). A study in 2007 found that when older
adults participated in some type of social activity, such as paid or unpaid work, religious
activities, and political involvement, mortality and cognitive function impairment were
reduced, yet disparity in opportunities for meaningful social activities lef some older
adult groups more vulnerable to physical and cognitive decline (Hsu, 2007).
Human Services
Delivery Systems
Understanding and Mastery of Human
Services Delivery Systems: Theories of
human development
Critical Thinking Question: Theorists
such as Erikson, Levinson, and Tornstam
produced models describing stages of
development among older adults. How
might human service professionals utilize
these models in their work with the
aging population?
Aging and Services for the Older Adult 149
Te natural aging process, though, seems to discourage high activ-
ity levels in virtually all domains. Employment provides most people
with one of the greatest opportunities for social interaction, and when
individuals retire, a signifcant portion of their social life is lost along
with their career. Physical limitations also encourage disengagement.
Few older adults play on intramural sofball teams, and even something
like poor night vision can keep an older adult from being able to hop in
the car and visit family. Tus, many older people naturally begin with-
drawing from the world, both physically and socially, in response to
diminished capability and opportunity, and with such disengagement
comes an increase in physical and emotional problems, such as depression and even
alcohol abuse to combat loneliness.
A very recent study seems to indicate that good psychological health is the most
important factor of all in ensuring good quality of life in later years (Bowling, & Ilife,
2011). For instance, the ability of older adults to rely on their psychological resources,
such as a good self-efcacy (ones perception of personal competency) and resilience
were more strongly linked to successful aging than were biological and social factors.
Tis does not mean that good physical health and an active social life arent important,
but as Tornstam (2005) and Degges-White (2005) suggest, older adults who can men-
tally and emotionally transcend beyond the physical and social limitations inherent
in the aging process seem to age more successfully and have a better quality of life
compared to older adults who lack these psychological resources.
Consider an individuals level of psychological resilience, which encompasses ones
coping strategies that can be relied upon during challenging times. For instance, many
older adults must not only face increased health problems and physical limitations,
but also deal with multiple losses as they begin to lose friends, siblings, and even their
spouse to death. Many older adults must move from their longtime home into residen-
tial care or the home of a family member, and even the loss of independence can create a
situation where their mental health is determined by the veracity of their coping mecha-
nisms. Psychological resilience enables older adults to manage these multiple losses in a
healthier manner, even perhaps fnding some existential meaning in facing these losses
with a sense of wisdom and acceptance, despite the deep pain and sense of powerless-
ness many older adults may feel.
Current Issues Affecting Older Adults and the Role of the
Human Service Professional
In anticipation of the increase in the older adult population as well as an increase in the
needs and complex nature of the issues facing many older adults, the Older Americans
Act was signed into federal law in 1965. Tis act led to the creation of the Administra-
tion on Aging, and it funded grants to the states for various community and human
service programs and provided money for age-related research and the development
of human service agencies called Area Agencies on Aging (AAA) operating on the
local level. Te Administration on Aging also acts as a clearinghouse, disseminating
Many older people naturally begin
withdrawing from the world,
both physically and socially, in
response to diminished capability
and opportunity, and with such
disengagement comes an increase
in physical and emotional problems,
such as depression and even alcohol
abuse to combat loneliness.
150 Part II / Generalist Practice and the Role of the Human Service Professional
information about a number of issues affecting the older adult population in the
United States.
Numerous issues afect todays older adult population, including elder abuse, age-
based discrimination, housing needs, biopsychological problems (such as depression,
anxiety, and alcoholism), adjustment to retirement, and grandparenting. Tose in the
human services feld are ofen included in the group of professionals most likely to come
into contact with the older adult population, either through direct service or through
providing counseling services to a family member of an older adult, and therefore they
must be familiar with these key issues, knowing how they afect older adults and their
family.
Ageism
Ask some typical young Americans what they think it is like to be a man of 70, and they
may well tell you that an average 70-year-old man is in poor health, drifs of to sleep
at a moments notice, talks of nothing but the distant past, and unproductively sits in a
rocker, rocking back and forth all day long. Tey might even throw in a comment or two
about his general grouchy disposition. Ask if older adults still have the desire for sexual
intimacy, and you might get a good hearty laugh in response. However, this description
of older adults is a myth based on deeply entrenched negative stereotypes and can serve
as a foundation of a form of prejudice and discrimination of older adults called ageism.
Te term ageism was frst coined by Robert Butler (1969), chairman of a congressio-
nal committee on aging in 1968. He defned ageism as a systematic stereotyping of and
discrimination against people simply because they are old, just as racism and sexism ac-
complish this with skin color and gender. Butler theorized that the basis of this negative
stereotype is a fear of growing old. Tis fear and the resultant negative stereotyping can
ofen result in the discrimination of the older adult population in all areas of life and is
the basis of many forms of elder abuse.
Ageism typically involves any attitude or behavior that negatively categorizes older
adults based either on partial truth (ofen taken out of context) or on outright myths
of the aging process. Such myths ofen describe old age as involving (1) poor health,
illness, and disability; (2) lack of mental sharpness and acuity, senility, and dementia;
(3) sadness, depression, and loneliness; (4) an irritable demeanor; (5) a sexless life;
(6) routine boredom; (7) a lack of vitality and continual decline; (8) an inability to learn
new things; and (9) loss of productivity (Tornton, 2002).
Gerontologists caution that the promotion of such negative stereotypes of old age and
older adults not only trivializes older individuals, but also risks displacing the older adult
population as communities undervalue them based on the perception that older adults
are nothing more than a drain on society. A further risk of ageism is that older adults may
internalize this negative stereotype, creating a self-fulflling prophecy of sorts (Tornton,
2002). Tis is similar to what happens with other vulnerable populations, such as minority
groups, who internalize the negative perceptions of them held by the majority population
(Snyder, 2001).
Old age has not always been something those in the United States have viewed nega-
tively. In fact, earlier in the 20th century, societal attitudes refected a relatively positive
Aging and Services for the Older Adult 151
view of older adults and of the aging experience. Older adults were respected for their
wisdom and valued for their experience. Tey were not typically perceived as being a
drain on society or as a burden to the community. Yet, sometime around the mid-1900s,
as life expectancy began to grow and medical technology improved dramatically, pro-
fessionals such as physicians, psychologists, and gerontologists began discussing older
adults in terms of the problems they posed (Hirshbein, 2001).
Many social psychologists and gerontologists cite the media as a major source of
negative stereotypes of older adults. Tese critics claim that the consistent negative
portrayal of older adults in both television shows and commercials, for example, por-
traying them as dimwitted, foolish individuals living in the past, has a dehumanizing
efect on the entire older adult population and has a negative efect on the self-concept
of older adults. Yet, the results of a study conducted in 2004, which reviewed televi-
sion commercials from the 1950s to the 1990s, did not support this critical view of the
media (Miller, Leyell, & Mazacheck, 2004). In fact, Miller and his colleagues found
that the media depiction of older adults has been relatively positive, particularly in
the latter two decades.
It is vital that human service professionals make certain that they do not hold any
of these misconceptions of old age. For instance, assuming that someone over the age
of 70 is incapable of being productive and of learning something new, of gaining a new
insight, whether in the counseling ofce or in life in general, would undoubtedly afect
the dynamic between the counselor and the older adult client. In fact, research shows
that negative stereotypes about aging are ofen internalized by older adults and can ac-
tually increase feelings of loneliness and dependency (Coudin & Alexopoulos, 2010).
Practitioners then must address any misconceptions they have of old age and of the
older adult population in general. Practices such as talking down to older adult clients
and not directly addressing difcult issues for fear that they lack the capacity to under-
stand will undoubtedly afect the level of investment the client makes in the counseling
relationship. Tis type of behavior on the part of the practitioner can also encourage a
self-fulflling prophecy within older adult clients, where they begin to act the part of the
incapable, unproductive, and cognitively dull individual. Making positive assumptions
about older adult clients will increase the possibility of bringing out the most authentic
and dynamic aspects of older adult clients.
Housing
Contrary to the common belief of many in the United States, most older adults remain
in their homes until death and are cared for by family members (Bergeron & Gray,
2003). But as medical technology allows people to live longer albeit not necessarily
healthier lives, coupled with the fact that more women than ever are in the workforce
and therefore unavailable to care for their older and chronically ill relatives, many older
adults fnd themselves needing to move out of their homes once they reach a certain
level of physical and/or cognitive decline. Tey might move into the home of a family
member, which was far more prevalent when the United States was an agricultural soci-
ety, and both men and women were home based in their work, or they might move into
a retirement community, where they can still enjoy their independence while enjoying
152 Part II / Generalist Practice and the Role of the Human Service Professional
many facility-ofered services to meet their needs, such as shuttle service, handicapped-
accessible facilities, and child-free living.
Government-subsidized older adult housing can make housing costs more afordable
for the older adult population, whether in the form of a subsidy provided directly to
older adults in the form of tax credits, loans, or rental vouchers or subsidies provided to
the housing community, which then passes on this discount to the renter. One problem
with many of these programs, though, is that they require older adults to fnd their own
housing in the community, much of which is older and not appropriate for older adult
residents who ofen need special age-related accommodations. Another concern relates
to government-subsidized communities that are designed for older adult populations
but tend to be wrought with problems related to safety, including problems with poor
physical upkeep of the property.
A 2003 longitudinal study that followed 1,200 older adults in their transition from
independent living to age-restricted housing in 1995 found that those older adults who
transitioned to more expensive communities fared the best with regard to physical
health and overall life satisfaction and those who transitioned to government-subsidized
housing programs fared the worse. Although the study investigators acknowledged that
levels of life satisfaction might be related to a cumulative efect of a lifetime of poverty,
they concluded that overall quality of housing has a direct relation-
ship to life satisfaction (Krout, 2003).
Older adults needing more consistent care with their activities
of daily living (ADL) sometimes enter assisted-living facilities. Tese
facilities ofer apartment-like living in a more structured environ-
ment. In many respects assisted-living facilities act as a bridge be-
tween independent living and nursing home care. Assisted-living
facilities ofer assistance with eating, bathing, dressing, housekeep-
ing, and medication, and some even have fully functioning medical
centers. Many assisted-living apartments have alarm systems in ev-
ery unit, ofer a restaurant-style cafeteria, a club for social activities,
a hairdresser, a medical staf, home healthcare, and a relatively full
array of human services. Te services are far more intensive than
in a retirement community, as residents in assisted-living facilities
are there because they cannot manage their ADL without daily as-
sistance. Human service professionals provide many of the same
services as provided in retirement communities, but at a more com-
prehensive level.
Homelessness and the Older Adult Population
One of the opening vignettes of this chapter highlighted the issue of homelessness in
the older adult community. Although older adults are at a lower risk for homelessness
than other age groups, homelessness in the older adult population is a growing con-
cern because the percentage is expected to grow as the baby boomer generation ages
(Gonyea, Mills-Dick, & Bachman, 2010). Additionally, for years the problem of home-
lessness among the older population has been essentially ignored by policy makers and
Human Services
Delivery Systems
Understanding and Mastery of Human
Services Delivery Systems: Range of
populations served and needs addressed
by human services
Critical Thinking Question: Many older
adults need to change their living accom-
modations at some point, for a variety
of reasons including affordability, physi-
cal challenges, proximity to other family
members, or a need for specialized care.
What additional factors should a human
service professional take into account
while working with older adult clients
who are making such a transition?
Aging and Services for the Older Adult 153
legislators, rendering this population relatively
invisible (Gonyea, Mills-Dick, & Bachman,
2010).
The common causes of homelessness in
the general population apply to older adult
subgroups as well, such as a lack of afordable
housing, too few jobs for unskilled workers,
and a reduction in human services support
(Hecht & Coyle, 2001; Kutza & Keigher, 1991),
but the older adult population in general has
additional risk factors such as being too old
to sufciently recover from a job loss, enter a
new career, or reenter the workforce, as well as
experiencing chronic illnesses that either are
costly or bar older adults from being self-supporting (Kutza & Keigher, 1991).
For statistical purposes, individuals above the age of 50 to 55 are usually considered
in the older adult category, but generally the lower threshold for what is considered
elderly is increasing. Homeless older adults are a particularly vulnerable subgroup
because of age-related physical vulnerability, which is ofen exacerbated by poor nutri-
tion and difcult living conditions either on the streets or in a homeless shelter. Tey
are also at a much higher risk of becoming a victim of crime while living on the streets
(Hecht & Coyle, 2001).
A research study based in Los Angeles found that unlike the homeless in the general
population, 85 percent of the older adult population was white (versus 61 percent in
the younger homeless population) and 59 percent were veterans (versus 27 percent in
the younger homeless population). Older homeless adults were far more likely to be so-
cially isolated and sufer from a physical illness, but less likely to sufer from substance
abuse, mental illness, or domestic violence (Linn & Mayer-Oakes, 1990). Older home-
less adults between the ages of 50 and 65 are ofen the most vulnerable group because
they are frequently the target of ageism when attempting to reenter the workforce, but
too young to qualify for Medicare and Social Security benefts (Hecht & Coyle, 2001).
Te diferences between younger homeless and older homeless populations become
important when considering programs designed to assist the older adult homeless pop-
ulation. Many human services homeless assistance programs focus on root causes of
homelessness more common in younger populations, such as providing assistance with
substance abuse and domestic violence. Any human services programs designed to as-
sist the older adult subgroups with housing issues need to focus more on issues related
to insufcient income, health concerns, and low-income housing, ofering supportive
services to the older adult population with declining health.
Adjustment to Retirement
Te concept of retirement is so common to the 21st century that it rarely needs explana-
tion. When an individual comments on his or her upcoming retirement, others seem
to instinctually understand that what is being discussed is the practice of leaving ones
An aged homeless
woman with all of her
belongings in two gar-
bage bags.
Joseph Sohm/Visions of
America/Corbis
154 Part II / Generalist Practice and the Role of the Human Service Professional
employment to permanently enter a phase of chosen nonemployment, and even though
some might choose to dabble in part-time employment from time to time, the most
common conceptualization of retirement involves an employee permanently surrender-
ing his or her position, at approximately age 65, and drawing on a pension or retirement
account that has likely been accruing for years. Of course, there are numerous variations
on this themesome people dont ever formally retire, and some people work in felds
that have mandatory retirement ages, such as the airline industry, which requires that
all pilots retire at the age of 60, and for some, retirement is a luxury they cannot aford.
Also, it would be incorrect to assume that everyone in the workforce has accrued a pen-
sion sizeable enough to permit them to live on for years. But despite the range of retire-
ment experiences, certain generalizations can be made about the retirement experience
for the majority of those living in the United States during the 21st century.
Robert Atchley (1976) was one of the frst researchers who attempted to describe the
retirement experience for men and women. He identifed fve distinct, yet overlapping,
stages that most retirees progress through on formal retirement. Tese stages are as follows:
1. Te Honeymoon Phase: Retirees embrace retirement and all their newfound free-
dom in an optimistic but unrealistic manner.
2. Disenchantment: Retirees become disillusioned with what they thought retirement
was going to be like and get discouraged with what ofen feels as though is too
much time on their hands.
3. Reorientation: Retirees develop a more realistic view of retirement, with regard to
both increased opportunities and increased constraints.
4. Stability: Retirees adjust to retirement.
5. Termination: Retirees eventually lose independence due to physical and cognitive
decline.
Tere has been some controversy about whether retirees actually progress through
such distinct phases or whether there is just too much of a range of experiences among
retirees in the United States to categorize experiences in a stage theory. A study by Reitzes
and Mutran (2004) appears to support Atchleys stage theory, finding that retirees
experience a temporary lif right afer retiring (for about 6 months), but then develop an
increasingly negative attitude afer about the 12-month mark, with some retirees start-
ing to experience increased optimism afer about two years. Te study also found that
an individuals level of self-esteem preretirement seemed to have an efect on their over-
all mental health afer retirement, with those who had higher levels of self-esteem far-
ing better. A more recent study on postretirement dynamics seems to support some of
Atchley, and Reitzes and Mutrans fndings, while refuting others. Te study, which was
funded by the National Institute on Aging, found that men and women who continued
to work for a period of time afer retirement, on a part-time or temporary basis (called
bridge employment) had much better physical and psychological quality during their
elder years, indicating that sudden and complete retirement, without any transition, may
have negative side efects for an older adults physical and mental health. Interestingly,
the positive efects gained from bridge employment existed regardless of the retirees
preretirement mental and physical health (Zhan, Wang, Liu, & Shultz, 2009).
Aging and Services for the Older Adult 155
Because nearly 50 percent of the U.S. population is now over the
age of 50, the implications of retirement preparation and adjustment
to retirement for the human services feld obviously cannot be ignored.
Human service professionals will likely come into contact with retired
or retiring adults in many diferent settings, thus it is important to real-
ize that impending retirement can become an issue for someone even in
middle adulthood.
Finally, race and gender have a significant effect on retirement experiences. Re-
search has shown that women and minority workers ofen have diferent attitudes and
experiences surrounding retirement issues due to disparity in income and education
levels (McNamara & Williamson, 2004). Tus, the human service professional must un-
derstand that most factors afecting a clients retirement experience are going to be in-
fuenced by the clients gender and racial background.
Grandparents Parenting
Te practice of grandparents raising grandchildren has increased dramatically over the
past several years, signaling many problems within U.S. society that have emerged since
the 1970s. Te U.S. Congress became interested in this issue in the mid-1990s, and in
1996, it passed legislation that required the 2000 U.S. Census to include questions re-
garding whether grandparents were residing with grandchildren, whether they had pri-
mary responsibility for them, and what length of time they had acted in a parental role
(i.e., revealing whether the situation was temporary or permanent).
Current (as of 2009, the most recent statistics available) fgures estimate that ap-
proximately 6.6 million U.S. households (about 5 percent of the population) are com-
prised of grandparents coresiding with grandchildren under the age of 18; 64 percent
of these are female grandparent-headed households. Approximately 2.7 million of
these families involved grandparents who were primarily responsible for their grand-
children (U.S. Census Bureau, 2012). Tis represents a signifcant increase over past
years, and means that 28 percent of grandparents in the United States are responsible
for raising their grandchildren. About two-thirds of these grandparents are between
the ages of 50 and 59, and about a third are over 60. Some of these households included
at least one of the parents, but many of them included one or both grandparents acting
in the role of surrogate parent(s).
Alt hough t he demographi cs of grandparent-headed househol ds var y
considerably, such households are far likelier to be an ethnic minority, sufer from
poverty, and have low education levels. Households led by only a grandmother
are far more likely to face economic hardship. Grandparent caregivers in the
Southeast and in urban areas have the highest levels of poverty and the lowest levels
of education ( Simmons & Dye, 2003; Whitely & Kelley, 2007). Even though older
African American grandmothers are disproportionately represented in custodial
grandparent arrangements, a recent research study indicates that older grandparents
may experience less emotional strain related to their primary parenting role than do
younger grandparents, likely related to their increased ability to manage stressful life
situations (Conway, Jones, & Speakes-Lewis, 2011).
Because nearly 50 percent of the
U.S. population is now over the age
of 50, the implications of retirement
preparation and adjustment on the
human services feld obviously cannot
be ignored.
1
5
6

Grandparents Living with Grandchildren, by Race TABLE 7.1
Race Hispanic origin
Characteristic Total
White
Alone
Black or
African
American
Alone
American
Indian
and
Alaska
Native
Alone
Asian
Alone
Native
Hawaiian
and
Other
Pacifc
Islander
Alone
Some
Other
Race
Alone
Two or
More
Races
Non-Hispanic
or Latino
Hispanic
or
Latino
(of any
race) Total
White
Alone,
Non-
Hispanic
or Latino
Population 30 years
old and over
158,881,037 125,715,472 16,484,644 1,127,455 5,631,301 169,331 5,890,748 2,862,086 14,618,891 144,262,146 119,063,492
Grandparents living
with grandchildren
5,771,671 3,219,409 1,358,699 90,524 359,709 17,014 567,486 158,830 1,221,661 4,550,010 2,654,788
Percent of
population 30
years old and over
3.6 2.5 8.2 8.0 6.4 10.0 9.6 5.5 8.4 8.2 2.2
Responsible for
grandchildren
2,426,730 1,340,809 702,595 50,765 71,791 6,587 191,107 63,076 424,304 2,002,426 1,142,006
Percent of coresi-
dent grandparents
42.0 41.6 51.7 56.1 20.0 38.7 33.7 39.7 34.7 44.0 43.0
By duration of care
(percent)
a
Total
100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0
Less than 6 months 12.1 12.6 9.8 13.0 13.6 12.7 15.6 13.5 14.6 11.5 12.4
6 to 11 months 10.8 11.6 9.3 10.5 11.0 8.4 11.4 11.2 11.2 10.7 11.6
1 to 2 years. 23.2 23.8 21.2 22.5 25.2 23.8 26.1 23.4 25.1 22.8 23.6
2 to 4 years 15.4 15.8 14.6 13.9 17.6 11.7 15.7 16.0 15.8 15.3 15.7
5 years or more 38.5 36.3 45.2 40.0 32.7 43.3 31.1 35.9 33.3 39.6 36.6
Data based on sample. For information on confdentiality protection, sampling error, nonsampling error, and defnitions, see www.census.gov/prod/cen2000/doc/st3.pdf.
a
percent duration based on grandparents responsible for grandchildren. Percent distribution may not sum to 100 percent because of rounding.
Source: U.S. Census Bureau, Census 2000, Summary File 4.
Source: U.S. Census Bureau, American Community Survey 2009, Subject Table S1002, Grandparents, <http://factfnder.census.gov/>, accessed February 2011
Aging and Services for the Older Adult 157
Ethnic minority children are far more likely to be raised by a grandparent than
Caucasian children, with African American children in the Southeast states having
a significantly higher rate of living with custodial grandparents than children in
other regions in the United States. African American grandparents are far likelier to
experience poverty, despite the fact that the majority are in the labor force. Tey are also
far likelier to not have health insurance, and experience greater physical and emotional
stressors (Whitely & Kelley, 2007).
Tere are several reasons why grandparents become surrogate parents, but the chief
reasons include the following:
1. Te high divorce rate, leaving many women facing potential poverty, resulting in
them returning home to live with parents
2. Te sharp rise in teen pregnancies, resulting in the mother residing with her par-
ents for economic (and ofentimes emotional) reasons
3. Te increase in relative foster care in response to a sharp increase in child welfare
intervention due to child abuse
4. Te increase in parents serving time in prison, primarily for drug and drug-related
ofenses punishable by high prison sentences due to the U.S. governments War on
Drugs
5. Te sharp increase of drug use, particularly among women of color whose use of
crack cocaine has literally exploded over the past 10 years
6. Te AIDS crisis, which has devastated many communities, leaving children or-
phaned and in need of permanent homes. Tese cases are complicated when the
children have contracted HIV, particularly when one considers their complex medi-
cal needs (de Toledo & Brown, 1995).
Te issues facing grandparents raising grandchildren are complex involving emo-
tional as well as fnancial, legal, and physical challenges. Many grandparent caregivers
are ofen forced to live in a type of limbo not knowing how long they will remain re-
sponsible for their grandchildren, particularly when the biological parents are either in
jail or sufering from drug addiction that prevents them from resuming their primary
parenting role.
The choice to act as a surrogate parent is in many instances made in a time of
crisis; thus, older adults who may have been planning their retirement for years ofen
fnd themselves in a position where they either take on this parenting role in the face
of the situation that rendered the biological parents unable to continue parenting or
allow their grandchildren to enter the county foster care system. Parenting younger
children has its unique challenges, but ofen comes with some level of social support,
at least within the elementary school system, but this is ofen not the case with older
children, particularly adolescents.
Parenting adolescents can ofen present signifcant challenges for grandparents, par-
ticularly those who are very old. Parenting adolescents can be an exhausting endeavor
for the young or middle-aged parent, but imagine the demands placed on someone
who is an older adult, has limited physical capacity, and even more limited fnancial
means. Adolescents who have endured signifcant loss through death or abandonment,
158 Part II / Generalist Practice and the Role of the Human Service Professional
have been raised in abusive homes, or have been raised by parents
who abuse drugs or are serving time in prison are likely to act out
emotionally and even physically, putting even greater stress on an
already vulnerable family system.
Human service professionals may enter a grandparent-led family
system in numerous waysthey could be the school social worker
working with the children, they might be the child welfare case-
worker assigned to assist the grandparents who are serving as relative
foster care parents, or they might work for a human services agency
ofering outreach services to grandparent caregivers.
Depression
Another significant concern affecting the older adult population is
the increased incidence of depression. In fact, the National Institute of
Mental Health (NIMH) estimates that approximately 2 million indi-
viduals over the age of 65 sufer from some form of depression, and
as many as 5 million more sufer from some form of depressive symp-
toms, although they may not meet all the criteria for clinical depression. Although preva-
lence rates can vary rather widely within the population, due in part to how depression is
defned, these statistics indicate that at any given time anywhere from 5 to 30 percent of the
older adult population may sufer from some form of depression, compared to a 1 percent
prevalence rate in the general population (Birrer & Vemuri, 2004).
Depression rates in nursing homes are even higher, with some studies fnding up to
50 percent of the residents meeting the criteria for clinical depression. Older adults are
also disproportionately at risk for suicide. Although individuals aged 65 years and older
make up about 12 percent of the U.S. population, they account for nearly 16 percent of
all those who committed suicide in the year 2004, which is the highest rates of all age
groups. Surprisingly, older adults at the highest risk for suicide are white males over the
age of 85, many of whom are widowed (Birrer & Vemuri, 2004; Kraaij & de Wilde, 2001;
McIntosh, 2004; NIMH, 2007).
Many believe that depression is just a normal part of the aging process caused by the
natural course of cognitive and physical decline and the multiple losses associated with
growing old. But depression is not a natural part of growing older and can be avoided.
Unfortunately, many in the medical and mental health felds, even older adults them-
selves, believe that it is, and thus many in the older adult population who are sufer-
ing from depression remain undiagnosed and untreated. Misdiagnosis is also relatively
common, with depression ofen being mistaken for dementia or some other form of
cognitive impairment (Birrer & Vemuri, 2004).
Human service professionals working with the older adult community must be ob-
servant of the signs of depression. Tey must also be aware of the many risk factors for
depression, including anxiety; chronic medical conditions such as heart disease, stroke,
and diabetes; dementia; being unmarried; alcohol abuse; stressful life events; and mini-
mal social support (Birrer & Vemuri, 2004; Lynch, Compton, Mendelson, Robins, &
Krishnan, 2000; Waite, Bebbington, Skelton-Robinson, & Orrell, 2004).
Human Systems
Understanding and Mastery of Human
Systems: Changing family structures and
roles
Critical Thinking Question: The phe-
nomenon of grandparents parenting
occurs disproportionately among fami-
lies of lower socioeconomic status and
places a variety of additional strains on
the aging grandparent. How might a hu-
man services professional work at the
micro (individual/family), mezzo (com-
munity), and macro (larger policy) levels
to build support for these grandparents
and the children they are raising?
Aging and Services for the Older Adult 159
Dementia
Te American Psychiatric Association defnes dementia as progressive, degenerative ill-
nesses experienced during old age that impair brain function and cognitive ability. De-
mentia is an umbrella term encompassing most likely numerous disorders. Two of the
most common forms of dementia are Alzheimers disease and multi-infarct dementia
(small strokes in the brain).
Te general symptoms of dementia include a comprehensive shutting down of all
bodily systems indicative by progressive memory loss, increased difculty concentrat-
ing, a steady decrease in problem-solving skills and judgment capability, confusion, hal-
lucinations and delusions, altered sensations or perceptions, impaired recognition of
everyday objects and familiar people, altered sleep patterns, motor system impairment,
inability to maintain ADL (such as dressing oneself), agitation, anxiety, and depression.
Ultimately, the dementia suferer enters a complete vegetative state prior to death.
According to the NIMH, multi-infarct dementia accounts for nearly 20 percent of
all dementias, afecting about 4 in 10,000 people. Even more individuals sufer from
some form of mild cognitive impairment, but do not yet meet the criteria for full-blown
dementia (Palmer, Fratiglioni, & Winblad, 2003). Alzheimers disease afects approxi-
mately 4.5 million Americans, or about 5 percent of the population between the ages of
65 and 74 years, and the incident rate increases to 50 percent for those over 85 years of
age. Diagnosis is based on symptoms, and it is only through an autopsy that a defnitive
diagnosis is made. Te United States has experienced a dramatic increase in the inci-
dence of dementia in the latter part of the 20th century, primarily due to the increased
human life span. It is theorized that dementia did not have an opportunity to develop
prior to the 1900s, when the average life span was about 47 years. Tere is no known
cure for dementia, thus treatment is focused on delaying and relieving symptoms.
Human service professionals may work directly with the suferer of dementia or
with the caregiver (typically a spouse or adult child) if they work in a practice setting
that serves the older adult community. However, dealing with dementia as a clinical
issue can occur in any practice setting because any client may have a relative sufer-
ing from one of these disorders and will therefore need counsel and perhaps even case
management. Consider the practitioner who assists clients in managing an ailing par-
ent, questioning whether their parent is sufering from cognitive impairment, grieving
the slow loss of the parent they love, and needing support in making difcult decisions
such as determining when their parent can no longer live alone. Or, consider the school
social worker who is counseling a student whose grandfather was recently diagnosed
with Alzheimers disease. Te pressure on the entire family system will afect the stu-
dent in numerous waysacademically, emotionally, perhaps even physicallyand will
frequently magnify any existing issues with which the student is currently struggling.
Elder Abuse
Older adults are a vulnerable population due to factors such as their physical frailty, de-
pendence, social isolation, and the existence of cognitive impairment, and as such are
at risk of various forms of abuse and exploitation. Te National Center on Elder Abuse
(NCEA) defnes elder abuse as any knowing, intentional, or negligent act by a caregiver
160 Part II / Generalist Practice and the Role of the Human Service Professional
or any other person that causes harm or a serious risk of harm to a vulnerable adult.
Te specifc defnition of elder abuse varies from state to state, but in general can include
physical, emotional, or sexual abuse; neglect and abandonment; or fnancial exploitation.
Although elder abuse is presumed to have always occurred, just as other forms of
abuse such as child abuse and spousal abuse, it was not legally defned until addressed
within a 1987 amendment of the Older Americans Act. Reports of elder abuse have in-
creased signifcantly over the last several years not only due to an increase in reporting
requirements, but also due to societal changes that are putting more older adults at risk.
In 1986 there were 117,000 reports of elder abuse nationwide, and by 1996 the number
of abuse reports increased to 293,000 (Tatara, 1997). By the year 2000 (the most re-
cent reported data) the number of elder abuse reports had risen to an alarming 472,813
among all 50 states, Guam, and Washington, DC. One reason for the rise in abuse re-
ports is that the newest fgures include not only abuse in domestic settings, but abuse in
institutional settings as well, but despite the more comprehensive data collection meth-
ods, there is no escaping the fact that elder abuse is increasing within the United States
(Teaster, 2000). Elder abuse is projected to continue to rise in the coming years due to
the increased life span and the resultant increase in chronic illnesses, changing family
patterns, and the complexity involved with contemporary caregiving.
Sixty percent of all reported abuse victims are women, 65 percent of all abuse vic-
tims are white, more than 60 percent of abuse incidences occurred in domestic settings,
and about 8 percent of abuse incidences occurred in institutionalized settings. Family
members were the most commonly cited perpetrators, including both spouses and
adult children (Teaster, 2000). Afer years of failed attempts, in March 2010, the Elder
Justice Act of 2009 (EJA) was passed and signed into law by President Obama as part of
the Patient Protection and Afordable Care Act (PPACA). Te act sets forth numerous
provisions for addressing the abuse, neglect, and exploitation of older adults, both in
the form of preventative and responsive measures. For instance, the legislation provides
grants for a number of training programs focusing on prevention of abuse and exploita-
tion of older adults; provides measures for expanding long-term care services, including
a long-term care ombudsman program; establishes mandatory reporting requirements
for abuse against older adults occurring in long-term care facilities; and includes provi-
sions for creating national advisory councils (National Health Policy Forum, 2010).
Despite the fact that there remain relatively limited mechanisms on a national level
regulating how elder abuse is to be handled (primarily due to a lack of funding), every
state in the United States has an adult protective services (APS) agency. Tere is signifcant
variation between states, particularly related to reporting laws and investigation methods
and policies. Some states have separate agencies handling elder abuse, and some combine
the protection of older adults with the protection of disabled adults of all ages. One sig-
nifcant diference between state policies involves who is considered a mandated reporter.
Sixteen states require anyone who is aware of elder abuse to report it. About half the states
require medical personnel, the clergy, and mental health personnel, including all human
service professionals, to report elder abuse. Some states specify that only medical person-
nel are mandated reporters. Yet fve statesColorado, Delaware, New York, South Dakota,
and Wisconsindo not mandate that anyone report elder abuse (Teaster, 2000).
Aging and Services for the Older Adult 161
Elder abuse tends to be grossly underreported for several reasons, but many cite the
lack of uniform reporting requirements as a primary reason. Because of the wide range
of elder abuse reporting requirements, as well as diferences in adult protective services
investigation policies and enforcement powers, it is essential that those working in the
human services feld be aware of the elder abuse reporting laws and requirements in
their state. Many human service professionals may be in a position to protect an older
adult client but may not be aware that their state has an elder abuse hotline.
Caregiver burnout is one of the primary risk factors of elder abuse. Te most common
scenario involves a loving family member who becomes intensely frustrated by the seem-
ingly impossible task of caring for a spouse or parent with a chronic illness such as demen-
tia. Providing the continuous care of someone with Alzheimers disease, for example, can
be frustrating, provoking an abusive response from someone with no history of abusive
behavior.
One of the most efective intervention strategies is caregiver support groups. Tese
groups are typically facilitated by a social worker or other human services practitioner
and focus on providing caregivers, many of whom are older adults themselves, a safe
place to express their frustrations, sadness, and other feelings related to caring for their
dependent older adult loved one.
Practice Settings Serving Older Adults
Unfortunately working with older adults remains a rather unpopular career pursuit for
human service professionals across the globe (Weiss, 2005). Yet, a commitment on the
part of several educational accreditation agencies is to increase infusion of gerontology
issues in educational curriculum, as well as fnancial incentives such as scholarships and
stipends for students in gerontological feld placements, is believed to be making a dif-
ference in the number of students who select gerontology as their career focus.
For human service professionals wishing to provide direct service to the older adult
population, a wide array of choices in practice settings awaits them. Virtually all prac-
tice settings delivering services to older adults have certain treatment and intervention
goals, including the promotion of the health and well-being of older adults, special at-
tention to the needs of special populations such as women and ethnic minority groups,
providing efective services at an afordable price, identifying the common needs of all
elders, and removing existing social barriers so that elders can be empowered to seek
assistance in meeting those needs.
AAAs, discussed earlier in this chapter, ofen serve as human service agencies ofer-
ing direct service to the older adult community on a local level. Generally these agen-
cies ofer a multitude of services for older adults, such as nutrition programs, services
for homebound older adults, low-income minority older adults, and other programs
focusing on the needs of older adults within the local community. Many AAAs also act
as a referral source for other services in the area. For instance, the Mid-Florida AAAs
ofer programs for those sufering from Alzheimers (including caregiver respite), a toll-
free elder hotline that links older adults in the area with resources, an emergency home
energy assistance program, paralegal services, home care for older adults, Medicaid
162 Part II / Generalist Practice and the Role of the Human Service Professional
waivers, and practitioners who work with older adults in helping them make informed
decisions. Most AAAs ofer both in-house services, many of which are facilitated by hu-
man service professionals, and of-site programs. Human service professionals working
at an AAAs-funded center might facilitate caregiver respite programs, or they might
provide case management services for an agency that provides employment services for
clients over 60 years old. Even at centers where services are primar-
ily medical in nature, human service professionals ofen provide ad-
junct counseling and case management as a support service.
Other practice settings include adult day cares, geriatric assessment
units, nursing home facilities, veterans services, elder abuse programs,
adult protective services, bereavement services, senior centers, and
hospices. A human service professional will likely perform similar types
of direct service, consultation, and educational services focused on as-
sisting older clients maintain or improve their quality of life, indepen-
dence, and level of self-determination. Tasks are typically performed
using a multidisciplinary team approach and can include conducting
psychosocial assessments, providing case management, developing
treatment plans, providing referrals for appropriate services, and pro-
viding counseling to older adult clients and their families. Services are
also provided to family caregivers ofering support and respite care.
Special Populations
As the frail older adult population has increased in numbers, the government has shifed
its priorities and began developing programs aimed at long-term healthcare needs, with a
particular focus on vulnerable populations such as women, ethnic minorities, and older
adults living in rural communities. It is difcult to defne who is special or particularly
vulnerable within the older adult population because in many senses all older adults could
conceivably be considered special in that they are vulnerable to social, economic, physi-
cal, and psychological harm or exploitation simply by virtue of their advancing age and
corresponding dependency needs. But many gerontologists classify various subpopula-
tions as more vulnerable for various reasons. For instance, successful ag-
ing has been linked to good economic status, good healthcare, relatively
low stress levels, and high levels of social connections. A 2004 study also
showed a link between good health and fnancial stability, fnding that
Caucasians tend to have greater economic wealth and better health than
African American and Latino populations (Lum, 2004).
Women are ofen considered a special population because as a
group they are more prone to depression and typically have a worse response to an-
tidepressant medication (Kessler, 2003). Women ofen experience greater fnancial
vulnerability, particularly if divorced or widowed, and are ofen in lower-wage jobs,
undereducated, and underinsured. Widowhood is a common occurrence for women
because they live an average of seven years longer than men, and although the majority
of women in the United States marry, 75 percent of women are unmarried by the age
Human Services
Delivery Systems
Understanding and Mastery of Human
Services Delivery Systems: Range and
characteristics of human services delivery
systems and organizations
Critical Thinking Question: What are
some of the major ways in which the
needs of the older adult population are
different from those of other groups of
human service clients? In what ways are
older adults needs similar to those of
other groups?
Successful aging has been linked
to good economic status, good
healthcare, relatively low stress levels,
and high levels of social connections.
Aging and Services for the Older Adult 163
of 65. Widowhood puts women at increased risk for lower morale and other mental
health problems, even though these symptoms abate with time and intervention
( Bennett, 1997).
Research has also shown a link between stress and racism that afects quality of life.
A study conducted in 2002 found that racism, and particularly institutionalized racism
(such as government-sanctioned racism through discrimination in housing, employ-
ment, and healthcare), had a detrimental efect on older African Americans, particu-
larly men, who tend to experience worse racial discrimination than women (Utsey,
Payne, Jackson, & Jones, 2002). Other research has shown how institutionalized racism
can lead to feelings of invisibility, stress, depression, and ultimately despair as the per-
son experiences a sense of futility in combating a lifetime of discrimination and White
privilege (Franklin, Boyd-Franklin, & Kelly, 2006).
Other special populations could conceivably include any subgroup that is vulnerable
at any point across the life span because of physical or mental disability, veterans sta-
tus, and those individuals living in isolated rural areas. Identifying special populations
within the older adult population will allow the human service professional to explore
issues that can potentially render older adult clients at increased risk and vulnerability
during old age. For example, research has shown that veterans are at special risk for
depression, post-traumatic stress disorder (PTSD), and alcohol abuse. Tus, older adult
veterans will be at particular risk for these conditions. An older adult client who is de-
velopmentally disabled will also face increased vulnerability compared to those in the
older adult population who have intelligence in the normal range. A human service pro-
fessional who is well versed on typical risk factors for older adults in the United States,
as well as for the increased risk factors facing special populations, will be far more efec-
tive in protecting and advocating for their older adult clients.
Concluding Thoughts on Services for Older Adults
Te older adult population is increasing at a dramatic rate in the United States, rendering
this one of the fastest growing target populations of human service agencies. As the baby
boomers continue to age and as life continues to become more complex, many within
the older adult population will rely on human service professionals to meet many of their
basic needs. Many human service educational programs are adding the feld of older adult
care, or social gerontology, as an area of specialization in response to the growing need for
practitioners committed to work with this population in a variety of capacities.
Future considerations include the continued efort to identify vulnerable popula-
tions, as well as addressing ongoing concerns such as the shortage of available afordable
housing, the availability of long-term care and healthcare services directed to the older
adult population, and the increased role of parenting responsibilities placed on the older
adult population. Human service professionals can make a signifcant positive impact
on the lives of older adults and their family members by addressing both ongoing and
anticipated needs of this population.
164
The following questions will test your knowledge of the content found within this chapter.
1. The term that relates to the increase in the elderly
population in the United States is
a. the Aging Increase
b. the Baby Boomers Blast
c. the Graying of America
d. the Elderly Explosion
2. The baby boomers is a cohort of people born
a. before World War II
b. after World War II
c. between 1946 and 1964
d. Both b and c
3. In 1900 the average human life span in the United
States was about _____ years but by 1999 it had
increased to about _____ years.
a. 47/77
b. 47/86
c. 62/77
d. 62/86
4. The eighth stage of Eriksons model spanning from
age 65 to death is called
a. integrity versus despair
b. intimacy versus isolation
c. generativity versus stagnation
d. industry versus inferiority
5. Researchers have examined individuals who age bet-
ter than others to determine what differences might
account for their "success," and some of the variables
at play include
a. having hobbies and attending social events
b. maintaining a moderately high physical and social
activity level
c. exercising regularly
d. All of the above
6. Robert Atchleys study of the stages of retirement
found that directly after the honeymoon phase many
retirees experienced
a. reorientation, where retirees developed a more
realistic view of retirement, both with regard to
increased opportunities, but also with regard to
increased constraints
b. disenchantment, where retirees became disil-
lusioned with what they thought retirement was
going to be like
c. stability, where retires adjusted to retirement
d. All of the above
CHAPTER 7 PRACTICE TEST
7. Describe the recent trend in grandparents parenting, including reasons for the increase in custodial grandparents,
demographics, and effect on grandparent(s) and children.
8. Describe the dynamic of elder abuse, its characteristics, associated dynamics, common demographics, and causes
and consequences.
Suggested Readings
Bergling, T. (2004). Reeling in the years: Gay mens perspec-
tives on age and ageism. Binghamton, NY: Southern Tier
Editions.
Davis, R. (1989). My journey into Alzheimers disease. Whea-
ton, IL: Tyndale House.
de Toledo, S., & Brown, D. E. (1995). Grandparents as parents:
A survival guide for raising a second family. New York: The
Guildford Press.
Kaye, L. W. (2005). Perspectives on productive aging: Social
work with the new aged. Washington, DC: NASW Press.
McGowin, D. F. (1994). Living in the labyrinth: A personal jour-
ney through the maze of Alzheimers. New York: Delta Books.
Osborne, H. (2002). Ticklebelly hill: Grandparents raising
grandchildren. Bloomington, IN: Authorhouse.
Rosenthal, E. R. (1990). Women, aging and ageism. Bingham-
ton, NY: Huntington Park Press.
Aging and Services for the Older Adult 165
Internet Resources
Alzheimers Disease Education & Referral Center: http://www.nia.
nih.gov/alzheimers
AARP: http://aarp.org
Arthritis Foundation: http://www.arthritis.org
Elder Hostel: http://www.elderhostel.org
The Grandparent Foundation: http://www.grandparenting.org
National Indian Council on Aging: http://www.nicoa.org
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167
Every society has its mentally illthose members whose behavior is con-
sidered outside what is normal and appropriate. Each society has also
developed ways in which to handle or manage such individuals so that
healthy societal function is not disrupted. But because the criteria for
what is considered normal behavior changes from era to era, as well as
from culture to culture, it is important to keep cultural mores and gen-
erational issues in mind when characterizing someones behavior as ab-
normal or unhealthy.
It would be difcult to imagine human service professionals who do
not at some point in their career come into contact with clients sufer-
ing from some form of mental illness. Mental illness is a term that, in its
broadest sense, refers to a wide range of mental and emotional disorders,
such as depression and anxiety disorders and, in its most narrow sense,
refers to those individuals who sufer from severe and chronic mental ill-
ness, requiring at least intermittent custodial care. Because of the broad-
ness of this term, it can be challenging to reach a consensus on just how
many people sufer from mental illness at any one time within the United
States.
A recently published report found that close to 27 percent of the U.S.
adult population sufer from some diagnosable mental disorder, about
40 percent suffered from a mental illness of a moderate severity, and
about 25 percent sufered from mental illness that was considered severe
(SAMHSA, 2010). Te term severely mentally ill typically refers to those
individuals who sufer from schizophrenia, bipolar disorder, severe and
recurrent depression, and other mental disorders that prevent normal
functioning such as maintaining employment or performing activities of
daily living. Individuals sufering from severe mental illness are ofen un-
able to consistently provide self-care, think clearly, reason, relate to oth-
ers, and cope with the demands of daily life. Research has also shown
Learning Objectives
Understand the reasons for de-
institutionalization and its impact
on the mentally ill population
Become familiar with the com-
munity mental health model
currently in place in the United
States, and identify its key
strengths and defcits
Develop a basic understanding
of the basic criteria of serious
mental illness that a human ser-
vice professional may encounter,
becoming familiar with practice
settings where human service
professionals will most likely
encounter individuals suffering
from mental illness
Become familiar with special
populations suffering from men-
tal illness such as the homeless,
prisoners, and ethnic minority
populations
Understand the current state
of mental health legislation, and
become familiar with how such
legislation impact the funding
and treatment of current mental
health programs
Mental Health and
Mental Illness
CHAPTER 8
cloki/2010/Used under license
from Shutterstock.com
168 Part II / Generalist Practice and the Role of the Human Service Professional
that there is a correlation between poverty and mental illness (as cited in SAMHSA,
2010), which is important to remember when considering the complexity of mental
illness, and how the mentally ill are treated within the United States and other places
around the globe.
The History of Mental Illness: Perceptions and Treatment
To understand the current climate with regard to perceptions of mental illness as well
as treatment paradigms commonly used in the United States, it is important to have
some understanding of the historic treatment of the severely mentally ill. It has been
said that the measure of a truly civil, ethical, and compassionate society is refected in
how it treats its most vulnerable members. Te mentally ill, particularly the severely
and chronically mentally ill, certainly fall into this category, and if this statement is in
fact true, then the U.S. society has undoubtedly gone through some periods that were
uncivilized, unethical, and compassionless.
Early in human history, mental illness, or madness as it was ofen called, was com-
monly believed to be caused by demonic possession. Skulls dating back to at least 5000
BCE were found with small holes drilled throughout, presumably to allow the indwell-
ing demons to escape. Demonic possession and witchcraf were still thought to be the
cause of insanity and lunacy throughout the Middle Ages and well into the 17th and
18th centuries. A common cure for madness in the Middle Ages involved tying up
those suspected being witches or demon-possessed with a rope and lowering them
into freezing cold water. If they foated, they were believed to be witches and were then
killed in some horrible way. If they sunk, they were not witches, but the cold water was
believed to be a cure for madness, so either way the problem of insanity was resolved
( Porter, 2002).
During colonial times the problem of the insane and feebleminded was considered
a family matter, but as populations in the cities grew, those sufering from some form of
mental illness increasingly became a problem for the community. Almshouses, typically
used as poorhouses or workhouses for those unable or unwilling to fnd work on their
own, were often used to house the insane as well. By the mid-1700s many towns in
Colonial America were following the trend in Europe of building separate almshouses
and even specialized hospitals for the insane (Torrey & Miller, 2002). Yet, reports of
mistreatment were common. In fact, the trend of abuse noted in the Middle Ages
continued throughout the 19th century, where members of society whose behavior was
not in line with social mores and the general expectations of society were subjected
to public beatings, incarceration, and sometimes death, particularly if their strange
behavior was perceived as threatening. Typical treatment in asylums, in almshouses,
and even in the new state hospital system included, among other things, beatings with
chains and rods. Chains were also used to contain patients in insane asylumssome for
most of their lives (Torrey & Miller, 2002).
By early 18th century, mental health reform had begun, led in part by Philippe Pinel
of France, who when appointed chief physician at a hospital for the incurably men-
tally insane was appalled at the barbaric conditions of the hospital. He found patients
Mental Health and Mental Illness 169
chained to walls, some for up to 40 years, and a system where community residents
could pay an admission fee to see the insane patients as if they were animals in a zoo. In
1792 Pinel was memorialized for his decision to unchain up to 5,000 patients. Tis event
marked the beginning of the era of Moral Treatment of the mentally ill. Pinel later
became chief of another hospital in Paris, where he consistently pushed for reform for
more compassionate care.
Dorothea Dix, a U.S. social activist, was a leader in advocating for more compas-
sionate treatment of the mentally ill in insane asylums. Her plea to the Massachusetts
state legislature in 1843 poignantly described the deplorable conditions those with
mental illness were forced to endure, including being held in cages by chains, of-
ten naked, beaten with rods, and whipped to ensure obedience. Dix pleaded for the
legislators to intercede on behalf of societys most vulnerable members. Dixs eforts
resulted in an improvement in the conditions of both hospitals and asylums (Torrey
& Miller, 2002).
By the beginning of the 20th century most of the almshouses and insane asylums
had closed, and state mental institutions became the primary facilities housing the
mentally ill. Yet although institutionalized care was considered revolutionary, com-
passionate, and far better than the plight of the mentally ill in
former generations, rampant abuses involving cruel treatment,
neglect, and physical and emotional abuse were increasingly
reported throughout the early 1900s.
The Deinstitutionalization of the Mentally Ill
Although horrible abuses in state and private mental hospitals
were well documented through the mid-1900s, institutionalized
care remained the primary method of treatment for the seriously
mentally ill for another 50 years. Te U.S. governments frst leg-
islative involvement in the care of the mentally ill occurred in
1946, when former president Harry Truman signed the National
Mental Health Act. Te signing of this act allowed for the creation
of National Institute of Mental Health (NIMH) (one of the frst
four institutes under the National Institutes of Health) in 1949.
In 1955 the Mental Health Study Act was passed, which di-
rected the convening of the Joint Commission on Mental Health
and Illness (under the auspices of the NIMH), charged with
the responsibility of analyzing and assessing the needs of the
countrys mentally ill, as well as making recommendations for
a more efective and comprehensive national approach to their
treatment. Te committee was comprised of professionals in the
mental health feld, such as psychiatrists, psychologists, thera-
pists, educators, and representatives from various professional agencies, including
the American Academy of Neurology, American Academy of Pediatrics, American
Psychological Association, National Association of Social Workers (NASW), and
National Association for Mental Health.
Te mentally ill were of-
ten housed in inhumane
conditions, sometimes
restrained for extended
periods of time.
Peter Turnley/Corbis
170 Part II / Generalist Practice and the Role of the Human Service Professional
In general, in addition to making recommendations for increasing funding for both
research and training of professionals, the committee recommended transitioning from
an institutionalized treatment model to an outpatient community mental health model,
where patients were treated in the least restricted environment within the community.
Tis report led to the creation of the Community Mental Health Centers (CMHC) Act
of 1963, which was passed under the Kennedy administration. Tis act enabled funding
of a new national mental healthcare system focusing on prevention and community-
based care, rather than on institutionalized custodial care (Feldman,
2003). Te passage of the CMHC Act set the deinstitutionalization
movement into motion, prompted by an overall dissatisfaction with
public mental hospitals in general, the development of new psycho-
tropic medications, and a new focus on the brainbehavior connec-
tion that fostered a sense of hope and optimism among those in the
mental health feld (Mowbray & Holter, 2002).
Several decades afer President Kennedy described the CMHC program as a bold
new approach to dealing with mental illness, many in the mental health feld cite frus-
tration and discouragement with what many perceive as numerous failures of the pro-
gram. Te replacement of hope with discouragement is in part due
to the reality that mental illness has been a far more worthy oppo-
nent than early advocates for change suspected. Early proponents
of deinstitutionalization had hoped that through early detection,
increased research, psychotropic medication, and better interven-
tion strategies, mental illness could be greatly reduced and perhaps
even eliminated. Yet, mental illness remains a pervasive problem in
todays society regardless of signifcant eforts to curb its devastating
impact on individuals, families, and society. Te most serious criti-
cisms are leveled at the federal government, which many claim fell
short of funding commitments, resulting in far fewer community
mental health centers being opened across the United States, which
in turn resulted in the burden of care for the countrys mentally ill
shifing from the public mental hospital system to nursing homes,
the streets, and the prison system (Sullivan, 1992).
Common Mental Illnesses and Clinical Issues
Human service professionals may encounter mental illness directly when clients seek
therapy for previously diagnosed disorders, or they may encounter mental illness indi-
rectly when clients seek services from a human services agency for reasons unrelated to
their mental health and symptoms of mental illness begin to surface in the midst of the
counseling relationship. Whether clients present with prior diagnoses or have no previ-
ously identifed mental health issues, practitioners must be able to recognize the com-
mon signs and symptoms of mental illness in their clients.
In the United States individuals are diagnosed using the Diagnostic and Statisti-
cal Manual of Mental Disorders, fourth edition, text revision (DSM-IV-TR), which
Professional History
Understanding and Mastery of Profes-
sional History: Historical roots of human
services
Critical Thinking Question: We have
seen that societal attitudes about
vulnerable populations have a marked
impact on policies and practices. This
is clearly illustrated by the historical
treatment of the mentally ill. How do
current stereotypes and attitudes about
individuals with mental illnesses affect
the treatment options available to them?
Mental illness remains a pervasive
problem in todays society
regardless of signifcant efforts
to curb its devastating impact on
individuals, families, and society.
Mental Health and Mental Illness 171
categorizes mental disorders in a manner similar to physical disorders. Certain criteria
must be met to diagnose someone with a particular mental or emotional disorder. It
is important to remember, though, that mental and emotional disorders are diagnosed
based on symptoms, not causes or etiology, as with medical illness. Tere is some con-
troversy surrounding the possibility that the DSM-IV-TR contributes to pathologizing
people rather than focusing on their strengths, but it is to date the most efective system
available for assessing individuals in a systematic, organized, and universal manner.
Te frst two axes of the DSM-IV-TR are the ones most commonly used by clinicians
in diagnosing clients. Clinical or mental disorders are diagnosed on Axis I, in 14 difer-
ent categories. Disorders such as anxiety disorders, eating disorders, mood disorders
(depression and bipolar disorder), and substance-related disorders are all diagnosed on
Axis I. Many clinical disorders are amenable to treatment through psychotherapy and
psychotropic medication, but they are diagnosed on the frst axis because they are seri-
ous enough to warrant clinical attention.
Axis II is reserved for personality disorders and mental retardation. Personality dis-
orders difer from clinical disorders in many respects, but most notably, many clini-
cians believe that personality disorders can be resistant to treatment because most of
the problems that individuals with personality disorders experience are by defnition
ingrained in their personalities, thus authentic change is challenging because changing
ones personality requires pervasive transformation. Examples of personality disorders
include antisocial personality disorder (sociopathy), borderline personality disorder,
and narcissistic personality disorder.
Serious Mental Disorders Diagnosed on Axis I
Te following section includes some of the more serious mental illnesses that human
service professionals ofen encounter in clients who are functionally impaired and in
need of extensive case management and counseling services. Depending on the severity
of their illness, these individuals might be in and out of inpatient psychiatric facilities,
referred through the court system, or even living on the streets. It is important, then,
that even entry-level human service professionals be generally familiar with these dis-
orders so that their cases can be as efectively managed as possible and referred for ap-
propriate services.
PSYCHOTIC DISORDERS Psychotic disorders include a number of illnesses where
contact with reality is severely impaired. Common symptoms of a psychotic disorder
include hallucinations, delusions, and generally bizarre and eccentric behavior.
Te most common psychotic disorder is schizophrenia, which is actually an um-
brella term referencing what is theorized to be a number of disorders with similar
symptoms, but with many diferent causes, such as genetic anomalies, brain chemistry
disturbances, and brain damage. Recent research has even suggested that some forms
of schizophrenia may be caused by exposure to the Borna virus (Terayama et al., 2003).
Schizophrenia usually manifests during the teen and early adulthood years. Schizo-
phrenia is not a split personality, and a diagnosis of schizophrenia does not automati-
cally mean that someone will become violent (despite sensationalized media reports).
172 Part II / Generalist Practice and the Role of the Human Service Professional
Schizophrenia is not caused by a bad childhood, although stress and trauma can trigger
a psychotic episode.
According to the DSM-IV-TR (APA, 2000), symptoms of schizophrenia can include
the following:
1. Delusions: False beliefs or misperceptions, many of which could not possibly be
true, such as believing that the government is monitoring ones activities through
the television set or that one has special powers, such as speaking to others through
mental telepathy.
2. Hallucinations: Sensations that are experienced but do not exist, such as hearing
voices, seeing things that are not there, smelling smells that do not exist, or feeling
sensations when nothing is present.
3. Disorganized thinking and speech: Te frequent trailing of into incoherent talk of-
ten referred to as word salad. Speech ofen refects thinking that makes no sense.
Some people with schizophrenia may even make up their own words, and some will
stop speaking all together (as is the case with catatonia).
4. Negative symptoms: Te absence of normal behavior such as the lack of emotion
(ofen referred to as afective fattening), alogia (complete lack of any speech), and
extreme apathy (complete lack of interest or drive).
Treatment used to consist solely of custodial care and heavy tranquilizers to mini-
mize symptoms, particularly destructive ones. Antipsychotic medication has been avail-
able since the mid-1950s, but negative side efects of the medication, such as sexual
impotence, tardive dyskinesia (involuntary jerking spasms of the muscles), and tran-
quilizing efects, kept many individuals with schizophrenia from taking their medi-
cation consistently. Yet new atypical antipsychotic drugs, such as risperidone, have
shown great promise in signifcantly reducing schizophrenic symptoms such as halluci-
nations and delusion without nearly the number of side efects.
AFFECTIVE DISORDERS Afective disorders include disorders of ones mood and
emotions and include depression and bipolar disorder. People who sufer from clini-
cal depression, referred to in the DSM-IV-TR as major depressive disorder, ofen feel
sad, anxious, empty, hopeless, irritable, guilty, worthless, helpless, and feeling tired all
the time. Major depression also ofen involves sleep and eating disturbances, difculty
concentrating and remembering things, various somatic symptoms such as head and
body aches, and may also include thoughts of suicide. Someone with clinical depres-
sion may experience all of these feelings or a combination of them (e.g., they may be
feeling sad and guilty but not anxious, or they may be eating relatively normally but
they cant sleep at night). In order for a diagnosis of clinical depression to be given, the
DSM-IV-TR stipulates that the individual experience fve or more of these symptoms
for at least a two-week period (APA, 2000). Depression is quickly becoming one of the
most profound disorders afecting the population, and it tends to co-occur with many
other disorders and conditions, including poverty (SAMHSA, 2010). In fact, the World
Health Organization has projected that depression will continue to be widespread glob-
ally, becoming a leading cause of disability by 2020 (Michaud, Murray, & Bloom, 2001).
Mental Health and Mental Illness 173
References to depression date back to the beginning of recorded time. Hippocrates
wrote about melancholy in the 4th century, citing an imbalance in the bodys humors
or liquids (blood, bile, phlegm, and black bile) as the cause of melancholy. Everyone
feels sad at times, and grieving over a loss is perfectly normal and in fact healthy, de-
spite the pain and discomfort involved. A productive depression can motivate people to
change both themselves and their circumstances, where complacency might otherwise
keep someone in an unhealthy situation. But debilitating depression is rarely productive
and can leave people feeling ashamed, particularly in a productivity-oriented society
such as the United States. Such shame and guilt just serves to add an increased bur-
den to the depressed person, exacerbating depressive symptoms and ofen leading to a
downward emotional spiral.
A popular theory of depression is the cognitive-behavioral theory, which is some-
what of a hybrid model (incorporating aspects of Aaron Becks cognitive theory of de-
pression and the theory of behaviorism). Tis theory hypothesizes that depression is
related to negative or irrational thinking. Toughts such as Im a horrible person or
Nothing good will ever happen to me, I will always fail if thought consistently enough
can ultimately lead to feelings of sadness, despair, and hopelessness (Beck, 1964).
Another popular theory, particularly with human service professionals and social
workers, is a social-contextual model of depression in which environmental conditions
such as negative life events, racial discrimination, and poverty impacting an individual
is believed to contribute to depression, particularly if the depressed individual does not
have the coping skills to deal with them in a positive manner (Swindle, Cronkite, &
Moos, 1989).
In the last several decades a biological model of depression has emerged in which
a predisposition to depression is believed to be genetically related, and depressive
symptoms are believed to be caused by neurohormonal irregularities, such as prob-
lems with neurotransmitter functioning. Most human service professionals embrace
a biopsychosocial model of depression that recognizes the biological basis of many
depressions, the emotional nature of depression, and the impact that ones environ-
ment, including factors such as an abusive childhood, and even social oppression can
have on depression.
Because depression ofen co-occurs with other disorders, such as anxiety, eating dis-
orders, substance abuse disorders, and even psychotic disorders, it is essential that all
human service professionals involved in direct service be able to screen for depression,
even if a client is not seeking services for this purpose.
Serious Mental Disorders Diagnosed on Axis II
Personality disorders include generally rigid and infexible patterns of inner experience
and outward behavior. Personality disorders ofen involve unhealthy and maladaptive
patterns of perceiving things, difculty controlling or regulating emotions, and dif-
culty controlling emotional impulses. Someone with a personality disorder will ofen
perceive things diferently than others and ofen misperceive anothers behavior and in-
tentions. Up to 30 percent of all individuals seeking mental healthcare services have at
least one personality disorder (Dingfelder, 2004).
174 Part II / Generalist Practice and the Role of the Human Service Professional
But just because someone has personality traits that are irritating or somewhat ec-
centric, it does not mean that they have a personality disorder. One of my best friends
can be defensive if someone is criticizing her children. She ofen misperceives innocent
comments as slights or criticism of her parenting. But does this mean that she has a
personality disorder? Of course not. But what if her defensiveness was so intense that
she started arguments constantly with friends and family members? What if she could
not enjoy going out socially because all she could think about was protecting her chil-
dren? What if she perceived insults everywhere and could not get along with anyone,
including her childrens teachers? Tis behavior might then push her in the direction of
a personality disordera collection of maladaptive and rigid personality traits that are
exhibited across diferent contexts and interfere with ones ability to function efectively
in life, including interfering with ones ability to enjoy reasonably healthy relationships
with others.
For instance, it might be perfectly normal for a woman to feel emotionally attacked
whenever she gets into an argument with her husband if he has an attacking way of
expressing his needs and frustrations. But it is not necessarily healthy or normative for
a woman to feel emotionally attacked whenever she receives constructive feedback that
she perceives as criticism from her husband, friends, family, coworkers, supervisor,
teachers, and children. It also might be perfectly healthy for a man to consistently focus
on himself in certain situations where perhaps he feels somewhat insecure, such as in
large social environments. But it might not be considered healthy if this person exces-
sively focused on himself in virtually all areas of his lifeat home, at work, with family,
in social situations large and small, ofen at the expense of others.
Te relative level of health or adaptive aspects of ones personality traits are judged
on a continuum, like so many other mental and emotional conditions. If someone is
a bit on the rigid side with certain issues, it wouldnt necessarily be appropriate to di-
agnose this person with a personality disorder. Yet, if someone gets far enough out on
the continuum with regard to rigidity, for example, so that it interferes with an ability
to function at work, with family, or with social situations, then this person might have
what is considered a disordered personality. Te key diference according to the DSM-
IV-TR (American Psychiatric Association, 2000) is that a personality disorder must
cause distress and impairment of functioning in several important areas of functioning.
The DSM-IV-TR categorizes personality disorders into three groups or clusters
with three to four personality disorders in each cluster. Although all personalities share
some factors in common, such as misperception, rigidity, pervasive problems in inter-
personal relationships, and emotional regulation, each cluster of personality disorders
varies considerably with both symptoms and cause. For instance, many of the Cluster
A personality disorders, such as schizoid personality disorder, are strongly believed
to be precursors of psychotic disorders. Obsessive compulsive personality disorder is
also theorized to be obsessive compulsive disorder in the early stages. Yet the Cluster
B and C personality disorders such as borderline personality disorder and dependent
personality disorder are theorized to have some biological infuences, but are believed
to be related to abuse in childhood, particularly sexual and physical abuse (Bandelow
et al., 2005).
Mental Health and Mental Illness 175
Counseling individuals with personality disorders is ofen frustrating for practitio-
ners because progress is slow, and clients are ofen resistant to change. Yet many new
counseling techniques are being developed, some with signifcant success, but progress
is always slow because authentic change requires that clients actually change the entire
way they perceive the world, and themselves within it. Tey must also learn how to sit
with their emotions rather than act on them and to control their impulses rather than
indulging them. Tus, teaching self-discipline is a signifcant component of counseling
most individuals with personality disorders. Antidepressant and antianxiety medication
can help with the co-occurring depression and anxiety common with many personality
disorders.
Mental Health Practice Settings and Counseling Interventions
Human service professionals involved in the practice of caring for the mentally ill was
formally marked by involvement in the afercare movement of the late 1800s and early
1900s. Afercare, a social reform issue of the time, involved the short-term care of the
formerly insane and lunatics (Vourlekis, Edinburg, & Knee, 1998). Afercare was
typically managed by private charitable societies who ofered temporary assistance and
housing for those coming out of the state asylum system. Social workers were on the
forefront of this helping model, which was really before its time because this type of
continuum of care was not a part of the psychological mainstream during that era. It
wasnt long before afercare programs were considered the sole domain of social work-
ers, who were paid by the state, and ultimately by public or private hospitals. Tis pro-
gram set the foundation for the contemporary role of those in the human services feld
who provide both advocacy and direct service to those who sufer from mental illness.
Intervention Strategies
A chief complaint of many in the human services feld is the mental health communitys
general tendency to approach mental illness from a pathological perspective. This
inclination to see human behavior in what ofen amounts to polarized terms of good
and bad, acceptable and unacceptable, desirable and undesirable has
only served to promote the social stigma of mental illness. Viewing
mental illness through the lens of biology can also contribute to the
tendency to pathologize the mentally ill where individuals are seen
as sick and broken. So although the discovery that many forms of
mental illness have biological roots can relieve the mentally ill and their
family of unnecessary guilt, it also suggests limited potential on the part
of the mentally ill, increasing both social stigma and social rejection
(Sullivan, 1992).
An alternative approach to viewing mental illness is to use a strengths perspective, a
model commonly used in the human services feld. Tis theoretical perspective encour-
ages the practitioner to recognize and promote a clients strengths, rather than focus-
ing on defcits. A strengths perspective also presumes clients ability to solve their own
problems through the development of self-sufciency and self-determination. Although
A chief complaint of many in the
human services feld is the mental
health communitys general tendency
to approach mental illness from a
pathological perspective.
176 Part II / Generalist Practice and the Role of the Human Service Professional
there are several contributors to strengths-perspective research in the human services
feld, Saleebey (1996) has developed several principles for practitioners to follow that
can help clients experience a sense of empowerment in their lives. Saleebey encourages
practitioners to recognize that all clients:
1. have resources available to them, both within themselves and their communities;
2. are members of the community and as such are entitled to respect and dignity;
3. are resilient by nature and have the potential to grow and heal in the face of crisis
and adversity;
4. need to be in relationship with others in order to self-actualize; and
5. have the right to their own perception of their problems, even if this perception
isnt held by the practitioner.
Sullivan (1992) was one of the frst theorists to apply the strengths perspective to the
area of chronic mental illness where clients sufering from mental illness are encouraged
to recognize and develop their own personal strengths and abilities. Sullivan compared
this approach to one ofen used when working with the physically challenged, where fo-
cusing on physical disabilities is replaced with focusing on and developing ones physi-
cal abilities. Sullivan claimed that by redefning the problem (rather than continuing to
search for new solutions), by fully integrating the mentally challenged into society, and
by focusing on strengths and abilities rather than solely on defcits, an environment can
then be created that is truly consistent with the early goals of mental health reforms who
sought to remove treatment barriers promoting respectful, compassionate, and com-
prehensive care of the mentally ill. Operating from a strengths perspective is important
regardless of what intervention strategies a human service professional uses in direct
practice.
Human service professionals utilize many tools and interventions when working
with mentally ill clients. Some of these intervention strategies include insight counseling,
where clients develop self-awareness skills intended to help them cope more efectively
with their various mental healthrelated challenges. Group counseling assists mentally
ill individuals gain strength and support from others in similar situationssome a few
steps ahead of them and some a few steps behind. Psychotropic medication based on re-
cent brain research ofers many clients hope of controlling the ofen debilitating symp-
toms common to many serious mental illnesses.
Common Practice Settings
Human service professionals working with the mentally ill population do so in a vari-
ety of practice settings, including outpatient mental health clinics, not-for-proft agen-
cies, outreach programs, job training agencies, housing assistance programs, prisoner
assistance programs, government agencies, such as departments of mental health and
human services, and probation programs. Human service professionals might be case
managers responsible for conducting needs assessments and coordinating the mental
healthcare of clients, they might be providing psychotherapy services on an individual
and/or group basis, or they may provide more concrete services such as job training.
In truth, a human service professional will likely encounter clients with serious mental
Mental Health and Mental Illness 177
illnesses in just about any practice setting, but in this section I will focus on those set-
tings where the seriously and persistently mentally ill is the target population.
Community mental health centers provide direct services to the seriously and
chronically mentally ill population. Tey are typically licensed by the state and desig-
nated to serve a certain catchment area within the community. Services ofered ofen
include outpatient services for adults and children, 24-hour crisis intervention, case
management services, community support, psychiatric services, alcohol and drug treat-
ment, psychological evaluations, and various educational workshops. Tey might also
ofer partial hospitalization and day treatment programs. Although most community
mental health centers operate on a sliding scale, they cannot turn away clients who have
no ability to pay, thus they are highly reliant on public funding.
Another practice setting that ofen encounters the seriously mentally ill is the full-
service human service agency. It is difcult to defne human service agencies because they
come in all shapes, sizes, and colors, but essentially a full-service human or social ser-
vice agency is a not-for-proft organization, meaning that any fnancial profts must be
reinvested in the agency. Tis distinction also means that the agency is exempt from
paying state and federal taxes, allowing more money to be directed back into the agency.
Human services agencies typically ofer an array of services aimed at various target pop-
ulations, including the seriously mentally ill. Te agency might provide general counsel-
ing services or might target more specifc services, such as providing job skills training,
housing assistance, or substance abuse counseling.
A human service professional might work in a number of capacities within a human
services agency, depending in large part on what types of programs the agency ofers.
For instance, a human services worker might ofer general case management services
coordinating all the care the client is receiving and act as the point person for the psy-
chologist, psychiatrist, and any other service providers involved. Tey might provide
direct counseling services or run support groups focusing on a number of psychosocial
and daily life issues. If the agency provides outreach services, the human services worker
might be out in the community providing emergency crisis intervention services for the
local police department or other emergency personnel. Obviously the list of program
services is almost endless, particularly because a part of the role of the human services
worker and agency is to identify needs within a community and fulfll those needs if not
otherwise met.
An alternative to inpatient hospitalization is partial hospitalization or day treatment
programs. Tese programs, ofen operated within a hospital setting, are intensive and
ofer services for individuals who are having difculty coping in their daily lives, but
are not at a point where inpatient hospitalization is a necessity. Clients attend the pro-
gram fve days a week, for approximately seven hours a day, and typically work with a
multidisciplinary team of professionals, including a psychiatrist, psychologist, and so-
cial worker. Family involvement is highly encouraged. Certain partial hospitalization
programs narrowly focus on specifc issues, such as eating disorders, self-abuse, or sub-
stance abuse, whereas others focus on a wider range of clinical issues such as severe
depression, anger management, and past abuse issues. Te nature of the program will
also vary depending on whether the target population is adults, adolescents, or children.
178 Part II / Generalist Practice and the Role of the Human Service Professional
Tese structured programs can either serve as an alternative inter-
vention to inpatient hospitalization or they can be utilized in the
transition from inpatient hospitalization.
Although deinstitutionalization of the mentally ill has resulted
in a dramatic reduction in long-term hospitalization of the severely
mentally ill, some individuals who are acutely disturbed or suicidal
are hospitalized on a short-term basis for diagnostic assessment
and stabilizing in inpatient or acute psychiatric hospitals. Psychiatric
units are typically locked for the safety of the patients who are ofen
either actively psychotic or a danger to themselves or others. Again,
services are focused on assessment and stabilizing with focus on dis-
charge planning. Human service professionals and paraprofession-
als, such as licensed social workers, counselors, and psychologists
ofen provide case management and discharge planning services in
inpatient settings providing adult services and will likely provide
more intensive counseling services such as facilitating individual
and group counseling, as well as behavioral management if the program is focused on
children and adolescents.
Mental Illness and Special Populations
Mental Illness and the Homeless Population
One unanticipated consequence of deinstitutionalization was the shifing of literally
thousands of mentally ill patients from institutions to the streets. In fact, a 2005 study
found that nearly one in six mentally ill individuals are homeless (Folsom, Hawthorne, &
Lindamer, 2005). Such individuals would have previously been hospitalized, but with
the closing of the majority of public mental hospitals and the transitioning of most
psychiatric units to a focus on short-term stays, the severely mentally ill who do not
have a network of supportive and able family members are ofen lef with no place to
live. Even individuals who do have supportive families will ofen live on the streets
due to the nature of psychosis, which clouds judgment and impairs the ability to
think without distortion, leading some individuals to disappear for literally years at
a time.
Tis link between homelessness and mental illness is not solely related to deinstitu-
tionalization. Certainly warehousing the mentally ill kept them of the streets, but the
nature of this link is far more complex and likely reciprocal in nature, meaning that
severe mental illness leaves many incapable of providing for their basic needs, and the
stressful nature of living on the streets, not knowing where one will lay their head at
night, dealing with exposure to violence as well as inclement weather, and not knowing
where their next meal will come from would put the healthiest of individuals at risk for
developing some mental illness.
Government sources estimate that approximately 26 percent of the homeless popu-
lation is severely mentally ill (U.S. Conference of Mayors, 2011), and if mental illness
is broadened to include clinical depression and substance abuse disorders (ofen used
Human Services
Delivery Systems
Understanding and Mastery of Human
Services Delivery Systems: Range of
populations served and needs addressed
by human services
Critical Thinking Question: Mental
illnesses cover a broad spectrum of
symptoms, and their severity can range
from minimal to completely debilitating.
What steps can a human service
professional take to ensure that clients
with mental illnesses receive the level
and nature of treatment they need?
Mental Health and Mental Illness 179
to self-medicate), that percentage jumps to an astounding 50 to 80 percent, and this
number is continuing to rise (North, Eyrich, Pollio, & Spitznagel, 2004; Shern et al.,
2000). Te mentally ill homeless population is a somewhat diverse group, but African
American single men and veterans are most likely to be homeless and sufering from
mental illness (Folsom et al., 2005; Koerber, 2005; Shern et al., 2000). Although deinsti-
tutionalization is credited for being the primary cause of this increase in the homeless
population, the increase in homelessness did not occur until the 1980s, thus other issues
are at play as well, including a shortage in afordable housing and again a lack of funding
of housing assistance programs targeted to middle-aged men and veterans.
One of the biggest challenges in getting individuals with severe mental illness of the
streets is engaging them in treatment. One of the problems noted afer deinstitutional-
ization was the common difculty of mentally ill individuals exercising their newly won
right to refuse treatment. But a deeper look into this issue reveals that it may not be as
simple as individuals in need not wanting help, but rather may be far more related to the
difculty and complexity of accessing needed services (Shern et al., 2000).
Barriers to accessing services ofen include difculties in applying for government
assistance such as Medicaid and Medicare to pay for both treatment and medication.
Another barrier involves the actual service delivery model most popular in counseling
and mental health centers, where the client comes to the psychologist. History clearly
reveals that this model simply does not work with seriously mentally ill individuals, par-
ticularly those living on the streets. Such individuals are ofen confused, disoriented,
and frequently distrusting of others, particularly if they are sufering from some sort of
paranoid disorder. To expect a person who is homeless and sufering from some mental
illness to remember a weekly appointment and somehow fgure out how to navigate
transportation is clearly unrealistic.
Another barrier to seeking treatment involves the many stipulations and require-
ments common in standard treatment models used by many community mental
health centers. Most standard mental health programs have strict participation re-
quirements, particularly related to behavioral issues such as maintaining sobriety to
remain in a housing assistance program, or program requirements such as requiring
clients to participate in weekly counseling support groups to receive other services.
In fact, most standard programs are directive with seriously mentally ill clients, ofen
determining treatment goals and interventions for the client, rather than empow-
ering clients to assist in determining their own treatment goals and interventions
(Shern et al., 2000).
The problem of homelessness among the mentally ill population will not be re-
solved until sufcient long-term housing assistance can be provided. Housing assistance
programs typically have long waiting lists and ofen allow only women with children
accelerated access to the program. Because African American men and veterans are
overrepresented in the mentally ill homeless population, more programs need to be
developed that target these populations most at risk for homelessness. Such programs
must also be designed to address issues related to alcohol and substance abuse problems
as well because many within the mentally ill homeless population have co-occurring
substance abuse problems.
180 Part II / Generalist Practice and the Role of the Human Service Professional
Mental Illness and the Prison Population: The Criminalization of
theMentally Ill
Another unintended by-product of deinstitutionalization is what has efectively amounted
to the inadvertent shifing of chronically mentally ill patients from public hospitals to jails
and prisons. In fact, many mental health advocates have argued that
prisons have now become one of the primary institutions warehous-
ing the United States most severely mentally ill individuals (Palermo,
Smith, & Liska, 1991; Torrey, 1995). Tus, although this was never the
intention of policy changers and proponents of deinstitutionalization,
it appears that the United States has in many respects returned to the
era where the mentally ill were locked away in almshouses.
Human Rights Watch reports that the number of mentally ill has
quadrupled in the last six years, from 283,000 prisoners in 1998 to over 1.25 million in
2006. In fact, it has recently been reported that there are more mentally ill individuals
in prisons and jails than in hospitals. Further, approximately 40 percent of the mentally
ill population will come into contact with the criminal justice system at some point in
their lives (Torrey, Kennard, Eslinger, Lamb, & Pavle, 2010).
Women are particularly overrepresented in the prison population with approximately
31 percent of women in state prisons sufering from some form of serious mental illness
(compared to about 14 percent for men) (Torrey, Kennard, Eslinger, Lamb, & Pavle, 2010).
Most mentally ill prisoners are poor and were either undiagnosed prior to their incarcera-
tion or untreated in the months prior to entering the prison system. Mentally ill inmates
were twice as likely to have a history of physical abuse and four times as likely to have been
the victim of sexual abuse. In fact, almost 65 percent of mentally ill female inmates reported
having been physically and/or sexually abused prior to going to prison (Ditton, 1999).
But what does this really mean? Could it simply mean that some mentally ill indi-
viduals break the law more than mentally healthy individuals? Couldnt it be argued that
one must certainly be mentally ill to kill a string of women or ones entire family? Afer
all, what sane person sexually abuses children? Depending on how mental illness is de-
fned, it could be argued that those who commit heinous crimes are by defnition men-
tally ill, and their mental illness does not and should not negate the appropriateness of
sending them to prison for their crimes. But even in situations where ofenders clearly
should be incarcerated, a retrospective look at their mental health histories might reveal
a history of poor service utilization, treatment refusal, or an outright inability to access
much needed mental health treatment.
While prisons have always held mentally ill prisoners, the number of incarcerated
mentally ill has increased sharply, in large part because of a decrease in treatment options
available for the mentally ill population in the general population. Te reasons for this
decrease include a reduction in funding of community mental health centers, barriers
to access treatment for certain segments of the population, and increasing difculty in
involuntary hospitalization of the severely mentally ill (Te Sentencing Project, 2008).
Te majority of those mentally ill who are incarcerated have been convicted of
nonviolent petty crimes, related to the mentally ill. In fact mentally ill individuals in
prisons and jail are targets for violence, such as assault, robbery, and sexual assault
Prisons have now become one
of the primary institutions
warehousing the United States
most severely mentally ill
individuals.
Mental Health and Mental Illness 181
(Marley & Buila, 2001). Far too ofen mentally ill prisoners, particularly those in the
general prison population, are consistent targets of victimization, particularly sex-
related crimes, many of which go unreported.
Te incarceration of the mentally ill is not a simple problem, thus it has no simple
answers. Mental health and prison advocates cite barriers to accessing mental health
services and problems with early intervention as direct causes of seriously mentally ill
individuals ending up in the penal system, rather than in psychiatric facilities. Once
again the controversial issue of an individuals right to refuse treatment is relevant in
this matter as well evidenced by the many family members of the mentally ill who con-
sistently complain that the courts have refused to order involuntary treatment, only to
have their mentally ill family member commit a violent crime some time later. What
is so unfortunate in these incidences is that the majority of mentally ill defendants are
amenable to treatment, but many were not receiving any treatment at the time of their
incarceration (Marley & Buila, 2001).
MENTAL HEALTH COURTS Many steps are currently being taken by those in the
criminal justice system and mental health and human services felds to address the issue
of the incarceration of the mentally ill as the many factors that create this complex cycle
of re-incarceration. Te development of mental health courts program is an example of
a signifcant step in the right direction. Te Mental Health Courts Program was devel-
oped pursuant to the Americas Law Enforcement and Mental Health Project (Pub. L.
No. 106-515 passed in November 2000) and is administered under the Bureau of Justice
Assistance (BJA), a component of the U.S. Department of Justice, in cooperation with
the Substance Abuse & Mental Health Services Administration (SAMHSA).
Te goal of the BJA is to encourage, lead, and fund the development of comprehen-
sive programs run by criminal justice systems across the country that ofer alternatives
to incarceration as well as helping to avoid future court involvement.
Mental health court program goals include the following:
Increased public safety for communitiesby reducing criminal activity and
lowering the high recidivism rates for people with mental illnesses who become
involved in the criminal justice system
Increased treatment engagement by participantsby brokering comprehensive
services and supports, rewarding adherence to treatment plans, and sanctioning
nonadherence
Improved quality of life for participantsby ensuring that program participants
are connected to needed community-based treatments, housing, and other services
that encourage recovery
More efective use of resources for sponsoring jurisdictionsby reducing repeated
contacts between people with mental illnesses and the criminal justice system
and by providing treatment in the community when appropriate, where it is more
efective and less costly than in correctional institutions
Even though the goal is for all court jurisdictions to have a mental health court, as of
2007, only 175 mental health courts were in existence across the United States (Council
182 Part II / Generalist Practice and the Role of the Human Service Professional
of State Governments, 2008). But their numbers are growing, from only a handful in
the 1990s, and preliminary research indicates that they are successfully diverting the
mentally ill from jail to programs ofering much needed services. One study researching
one of the frst mental health courts (located in Broward County, Florida) found that
participants spent 75 percent less time in jail, received needed mental health services
on a more frequent basis, and were no more likely to commit a new crime, compared to
mentally ill defendants who proceeded through the traditional court process (Christy,
Poythress, Boothroyd, Petrila, & Mehra, 2005).
Multicultural Considerations
Early studies have shown that ethnic minority populations are ofen poorly served in
mental health centers because of a lack of culturally competent counselors and bilingual
counselors (Sue, 1977). Other early studies showed that whereas those in the Latino and
Asian populations were underrepresented in community mental health center settings,
those within the African American and Native American populations were overrepre-
sented (Sue & McKinney, 1975; Diala, Muntaner, Walrath, Nickerson, LaVeist, & Leaf,
2001). Tis pattern may be partly due to cultural acceptance or rejection of psychother-
apy within diferent cultural groups, and it might also be related to the relative complexity
of issues facing the populations served, particularly Native Americans, who traditionally
have high rates of substance abuse and depression and ofen reside in remote areas.
A 1997 study found that African American caregivers of mentally ill individuals face
a number of barriers, making it difcult for them to be involved in their family mem-
bers treatment, including a failure on the part of practitioners to recognize them as an
integral part of the treatment team. Mental health clinicians need to partner with the
family members of mentally ill clients and keep an open line of communication so that
family caregivers do not feel marginalized in the treatment process. Te authors of the
study suggested that by working hard to engage family caregivers in treatment, common
negative assumptions of family members of African American clients can be countered
and overcome (Biegel, Johnsen, & Shafran, 1997).
Mental health providers and social justice advocates have increasingly expressed
concerns about the impact of anti-immigration policies on the Latino community, par-
ticularly with regard to the additional stress such legislation and the associated xeno-
phobia (an irrational fear of immigrants or those presumed to be foreigners) can cause
the immigrant community (Ayon, Marsiglia & Bermudez-Parsai, 2010). A recent study
of Latino youth and their families in the Southwest, which has the greatest number of
anti-immigrant policies and attitudes, showed that the majority of the Latino youth
and parents surveyed had experienced signifcant discrimination related to their ethnic
backgrounds, and immigrant status, even if they were born in the United States. Yet,
their strong ties to family (immediate and extended) and their communities (referred
to as familismo) seemed to counter the efects of discrimination (Ayon, Marsiglia &
Bermudez-Parsai, 2010). Mental health providers, including human service profession-
als who embrace Euro-American values of individualism, could potentially view the
cultural tradition of familismo as something negative rather than as a cultural strength
that can serve as protection from the negative efects of discrimination and xenophobia.
Mental Health and Mental Illness 183
It is important that human service professionals be aware of their negative biases,
whether they are toward people of color, sexual orientation, or socioeconomic status.
Most people, particularly within the majority culture, deny having negative or stereo-
typical biases toward cultures diferent than their own, because few want to be charac-
terized as racist, homophobic, or elitist, but all individuals possess some negative biases,
and if not directly confronted both through personal awareness and in clinical super-
vision within their agency, even subtle biases will unfold within the counseling rela-
tionship. Racial bias can infuence many factors associated with mental healthcare and
counseling. For instance, a relatively recent study found that African Americans were
far more likely to be diagnosed with disruptive behavioral disorders in mental health
counseling, compared to Caucasians who were far more likely to be diagnosed with less
serious clinical disorders, such as adjustment disorder (Feisthamel & Schwartz, 2009).
Racially disproportionate clinical diagnostic assessment may be due to personal racial
biases on the part of human service professionals, but may also be due to counselors not
taking into consideration the disproportionate challenges facing many ethnic minori-
ties, such as increased levels of poverty, racial oppression, and higher rates of unemploy-
ment compared to Caucasians in America (Feisthamel & Schwartz, 2009).
Other types of bias can enter the counseling relationship as well. Consider the bias
that many in the United States (particularly Euro-Americans) have about time. Te U.S.
culture tends to highly value time and promptness. When someone is timely, they are
ofen considered to be respectful, considerate of others, and organized. Conversely, those
who are consistently late are ofen presumed to be disrespectful, inconsiderate of others,
disorganized, and perhaps even lazy. Yet not all cultures value time in the same manner,
and a stereotyped bias is that individuals from these cultures (e.g., Latino and East Indian
cultures) are lazy, disrespectful, and disorganized. Human service professionals who have
been enculturated in U.S. values might not even realize that they hold this stereotype and
might unconsciously attribute negative traits to clients who consistently show up late to
their appointments. Tus, although it might be worth exploring whether this pattern is
related to lacking motivation, it may be racist to make negative assumptions about a cli-
ents character based solely on the fact that the client is from an ethnic culture that does
not value time in the same manner as those embracing U.S. values.
Hence, although rarely is someone eager to admit holding negative stereotypes
about certain races, cultures, or lifestyles, it is imperative, particularly when work-
ing with the seriously mentally ill population, that these negative stereotypes are ex-
plored, challenged, and discarded. Otherwise they will remain powerful forces in how
human service professionals subtly or overtly evaluate and assess client actions and
motivations, strengths, and defcits, including assessing accountability and causation
for their life circumstances.
Current Legislation Affecting Access to Mental Health Services
Mental Health Parity
Some mental illnesses take a lifetime to develop. Others seem to hit out of nowhere,
such as schizophrenia. Mental illness cuts across all socioeconomic, racial, and gender
184 Part II / Generalist Practice and the Role of the Human Service Professional
lines; in fact, one could say that mental illness is an equal opportunity afiction. I
have worked with both the lower-income and undereducated population and the upper-
income and highly educated population, and my only observation about the diference
regarding these two groups is that ofentimes those on the upper end of the income/
education continuums do a better job at hiding their mental illnesses and emotional
disorders, at least for a time. For this reason, as well as the increasing evidence of the
biological basis of many mental illnesses formerly believed to be solely psychological
in nature, most mental health advocates argued the importance of
requiring health insurance companies to cover mental health condi-
tions in the same manner as they cover general medical conditions.
Yet in the 1980s, when managed care became the norm in health in-
surance coverage, many advocates complained that managing costs
became synonymous with limiting much-needed benefts, particu-
larly in the area of mental health coverage.
Trough bipartisan eforts, the Mental Health Parity Act was passed in 1996. It bars
employee-sponsored group health insurance plans from limiting coverage for mental
health benefts on a greater basis than for general medical or surgical benefts. Tis ini-
tial bill removed annual and lifetime dollar limits commonly used by
insurance companies to limit mental health benefts. Unfortunately,
the majority of health insurance companies have found loopholes,
allowing them to avoid complying with this legislation.
The Mental Health Parity and Addiction Equity Act of 2008
(sponsored by President Obama when he was a senator), which was
attached to the 2008 federal bail-out legislation, promises signifcant
reform of mental health parity in the United States. Te act went into
efect January 1, 2010, and requires group health plans (covering 50
or more employees) that already provide medical and mental health
coverage to provide mental health and substance abuse benefts at
the same level as provided medical benefts (i.e., it does not require
employers to provide mental health and substance abuse coverage).
Tus, if an employer-sponsored insurance plan ofers mental health
benefts, the benefts must be consistent with what is ofered in the
medical plan with regard to deductibles, co-pays, number of visits
allowable per year, and so on. Although some exemptions do exist
in this act, it goes a long way in securing parity of mental health and
substance abuse beneft coverage.
Other Federal Legislation
Former president George W. Bush announced the establishment of the New Freedom
Initiative designed to identify and remove barriers to community living for all indi-
viduals with mental disabilities and long-term mental illness. Tis initiative led to the
formation of the Commission on Mental Health on April 29, 2002. Te commission
was charged with the responsibility of studying the mental health delivery system and
making recommendations on ways for adults and children with serious mental illnesses
Human Services
Delivery Systems
Understanding and Mastery of Human
Services Delivery Systems: Range and
characteristics of human services delivery
systems and organizations
Critical Thinking Question: There is a
disturbing correlation between mental
illness and incarceration in contempo-
rary U.S. society. Mental health courts
appear to be one promising alternative
to incarcerating individuals with mental
illnesses who have committed certain
crimes. What strategies might human
service professionals use in reaching out
to incarcerated and recently released in-
dividuals who have mental illnesses?
Mental illness cuts across all
socioeconomic, racial, and gender
lines; in fact, one could say
that mental illness is an equal
opportunity affiction.
Mental Health and Mental Illness 185
to integrate into their communities as fully and as efectively as possible. Referring to
the current system as ofering a piecemeal approach to mental healthcare, the com-
mission made recommendations for change based on the contention that people can
recover from mental illness and are not destined to accept a life of long-term disability.
Te commission promised to transform mental healthcare in America by promoting
access to educational and employment opportunities to individuals with mental dis-
abilities, as well as promoting full access to community life (Presidents New Freedom
Commission on Mental Health, 2003).
One of the chief complaints of the commissions report was that the current system
did not ofer much hope of recovery to those sufering from a mental illness. In addi-
tion, the commission noted that it took sometimes years for new treatment strategies
discovered at research institutes to be used in clinical settings. Tus, although thou-
sands of government dollars were being spent identifying new treatment modalities,
those sufering from mental illness ofen did not beneft from these discoveries, due to
many factors, including poor communication between research facilities and clinical
settings. Te commission then made several recommendations for removing barriers to
treatment and lifing the stigma ofen associated with mental illness.
Ironically, the fnal report for the committee studying the CMHC program in 1963
had goals that were very similar in nature and just as admirable as the commissions
goals, yet clearly the implementation of those goals did not unfold as anyone had hoped
or planned. Former president Bushs administration did move forward on some of the
commissions goals, including providing some assistance to states in developing a more
efective mental health delivery system, as well as increasing the number of screening
programs designed to increase early detection and treatment of serious mental illness.
Yet, in the midst of these ambitious goals and promises of sweeping reforms, federal
funding for mental health programs under former president Bush was signifcantly cut
by billions of dollars over several years.
Perhaps one of the most signifcant federal laws to be passed in years is the Patient
Protection and Affordable Care Act of 2010 (PPACA) signed into law by President
Obama in March of 2010 afer a ferce public relations war waged by Republicans and
health insurance companies designed to prevent its passage. Te PPACA, taking efect
incrementally from 2010 to 2014, is a comprehensive healthcare reform bill. It will have
an impact on behavioral and mental healthcare coverage as well, thus while I will be
exploring this legislation in more detail in Chapter 10, I will touch on its relevance to
mental healthcare here. Overall this legislation is designed to make it easier for individ-
uals and families to obtain quality health insurance, despite pre-existing conditions, and
will make it more difcult for health insurance companies to deny coverage. It also ex-
pands Medicare in a variety of ways, including bolstering community and home-based
services, and provides incentives for preventative, holistic, and wellness care. With re-
spect to behavioral and mental healthcare, the PPACA provides increased incentives for
coordinated care, school-based care including mental healthcare and substance abuse
treatment, and it includes provisions that will require the inclusion of mental health and
substance abuse coverage in benefts packages, including prescription drug coverage,
and wellness and prevention services.
186 Part II / Generalist Practice and the Role of the Human Service Professional
One of the most powerful ways that the federal government can infuence policy
and program development is through sufcient funding and a chief complaint about the
many failures of community-based mental healthcare programs is the lack of sufcient
federal funding. Tus, the success or failure of any new federal legislation or program
focusing on mental healthcare reform is dependent on broad-based government fnan-
cial commitment. Some of the funding that was cut under the George W. Bush admin-
istration was reinstated under President Obama, and the success of the PPACA remains
to be seen, but advocates are hopeful that it will address many of the challenges faced
by those struggling with mental illness, as they face signifcant chal-
lenges in attempting to get their holistic needs met.
Some human service professionals might question the impor-
tance of understanding federal trends in funding programs designed
to meet the needs of the mentally ill, yet virtually all human service
professionals will be afected one way or another if state and federal
budget cuts continue to be implemented. Attempting to facilitate
much-needed mental healthrelated programs without proper fund-
ing can involve everything from understafng and high caseloads to
inadequate ofce space and the general inability to meet the compre-
hensive needs of the chronically mentally ill. Tus, although human
service professionals involved in direct practice may prefer to steer
clear from administrative and policy concerns, such involvement
particularly on an advocacy level is important because the efective
facilitation of vital mental health programs is dependent on efective
legislation and appropriate funding.
Ethical Considerations
Human service professionals working with the chronic and seriously mentally ill must
manage several ethical considerations. Although most human service workers will not
be formally diagnosing clients using the DSM-IV-TR, unless they are licensed to engage
in professional counseling, it is still important to be aware of the ethical challenges fac-
ing those counselors who do, since ofen human service professionals will be working
within multidisciplinary team, as well as with clients who have received one or more
DSM-IV-TR diagnoses. Challenges in diagnosing clients abound, but many relate to
conducting a thorough assessment of clients and diagnosing them accurately without
upcoding (rendering a more serious diagnosis for insurance reimbursement pur-
poses) (Kress, Hofman & Eriksen, 2010), diagnosing based upon the trendy disorders
(e.g., not allowing pharmaceutical companies to drive diagnoses), or diagnosing based
upon a clients ability to pay. For instance, a recent research study found that counselors
were more likely to render a DSM-IV-TR diagnosis to managed care clients than those
who pay out of pocket (Lowe, Pomerantz, & Pettibone, 2007). Other ethical consider-
ations include avoiding reductionist approaches to clients based upon a clients diagno-
ses (e.g., my borderline client, my OCD client), and avoiding assessing, diagnosing,
Professional History
Understanding and Mastery of Professional
History: Historical and current legislation
affecting services delivery
Critical Thinking Question: The Mental
Health Parity Act of 1996 and the
Mental Health Parity and Addiction
Equity Act of 2008 expanded access to
mental health services for individuals and
families who had employer-sponsored
health insurance. In general, which
populations benefited most from these
pieces of legislation? Which populations
did not benefit?
Mental Health and Mental Illness 187
and treating clients in ways that emanate from personal bias related to gender, income
level, education level, ethnicity, or immigration status.
Concluding Thoughts on Mental Health and Mental Illness
Te feld of mental health is a dynamic practice area for the human service professional
for many reasons. Human service professionals have the ability to truly make an impact
while working with some of societys most vulnerable members. Because mental illness
is such a broad term, encompassing such a wide array of psychological, emotional, and
behavioral issues, the human service professional works as a true generalist whether
in a direct service capacity or whether providing advocacy within the community. Te
United States has experienced dramatic shifs in its mental health delivery system dur-
ing the past 50 years and will no doubt continue to experience future changes, some
intended and some unintended. Human services workers are on the front lines of these
intended changes lobbying for increased funding, developing new programs to meet the
complex needs of the severely and chronically mentally ill population.
188
1. Approximately 26 percent of the U.S. adult population
suffers from some diagnosable mental disorder, most
of which
a. are relatively serious, requiring formal psychological
intervention
b. are relatively minor, not requiring formal
psychological intervention
c. are serious enough to require at least short-term
hospitalization
d. affect primarily Caucasian women
2. Early in human history mental illness was commonly
believed to be caused by
a. alcoholism
b. remaining unmarried
c. demonic possession
d. rebellion
3. The passage of the Community Mental Health
Centers (CMHC) Act
a. increased the amount of time patients remained
in psychiatric hospitals
b. started what is often called the era of
"deinstitutionalization"
c. started the HMO phenomenon
d. None of the above
4. Believing that the government is monitoring ones
activities through the television set is an example of
a. delusion
b. splitting
c. dissociation
d. hallucination
5. Saleebey encourages human service professionals to
recognize that the chronically mentally ill are
a. dangerous and should be treated with caution
b. members of the community and are entitled to
respect and dignity
c. resilient by nature and have the potential to grow
and heal in the face of crisis adversity
d. Both B and C
6. The group most likely to be homeless and to suffer
from some mental illness is
a. African American single men
b. veterans
c. older adults in residential care
d. Both A and B
The following questions will test your knowledge of the content found within this chapter.
CHAPTER 8 PRACTICE TEST
7. Describe the process of the deinstitutionalization of the mental ill, citing the reasons, goals, and short- and long-
term effects of the transition from an institutional model to a community mental health model.
8. Discuss the reciprocal relationship between mental illness, homelessness, and incarceration.
Suggested Readings
Kreisman, J. J., & Straus, H. (1991). I hate you, dont leave me.
New York: Avon.
Lachenmeyer, N. (2001). The outsider: A journey into my
fathers struggle with madness. New York: Broadway.
Mason, P. T., & Kreger, R. (1998). Stop walking on eggshells:
Taking your life back when someone you care about has bor-
derline personality disorder. Oakland, CA: New Harbinger
Publishing.
Porter, R. (2002). Madness: A brief history. New York: Uni-
versity Press.
Torrey, E. F., & Miller, J. (2001). The invisible plague: The rise
of mental illness from 1750 to the present. New Brunswick,
NJ: Rutgers University Press.
Mental Health and Mental Illness 189
Internet Resources
Affective disorders: http://www.pendulum.org
Anxiety Disorders Association of America: http://www.adaa.org
Borderline personality disorder: http://www.bpdcentral.com
Children and adults with attention deficit/hyperactivity disorder:
http://www.chadd.org
Depression central: http://www.psycom.net/depression.central.html
Eating disorders: http://www.something-fishy.org
Internet mental health: http://www.mentalhealth.com
National Alliance on Mental Illness: http://nami.org
Personality disorders: http://personalitydisorders.mentalhelp.net
PsyWeb mental health site: www.psyweb.com
Schizophrenia: http://www.schizophrenia.com
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family mental health: Exploring the role of discrimination and
familismo. Journal of Community Psychology, 38(6), 742756.
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personality disorder and healthy controls. Psychiatry Research,
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191
Learning Objectives
Become familiar with the current
demographics of the homeless,
including the various ways in which
the homeless population is counted
Understand the root causes
of homelessness, including the
changing demographics of the
homeless population and how
this is impacting treatment in-
terventions and practice setting
structure and policies
Become aware of the existence
and nature of the stigma of home-
lessness, including what variables
increase this stigma and negative
stereotypes of the homeless popu-
lation in general, and with particu-
larly vulnerable populations
Develop an understanding of
the current challenges facing
homeless single mothers, both
in gaining self-suffciency as well
as in contending with policies
and practices employed by most
homeless shelters
Become familiar with current
legislation designed to address
the homeless problem in the
United States, and the strengths
and defcits of the legislation and
associated policies
Homelessness
CHAPTER 9
The Nature of Homelessness: A Snapshot
of Homelessness in America
For as long as there have been established residential settlements, there have
been those within the population who have either by choice or by life cir-
cumstances been homeless. To address the problem of homelessness, it is
important to frst understand the nature of this social condition, including
developing an understanding of the extent of the homeless problem, deter-
mining who is most vulnerable to becoming homeless, as well as discovering
the root causes of homelessness. It is only through understanding the demo-
graphic nature and common reasons for homelessness that social programs
can be developed to assist members of society in obtaining permanent, stable
housing, as well as developing preventative measures to protect against home-
lessness in the future. Many homeless advocates believe that signifcantly re-
ducing the homeless population is a reasonable goal, and in fact it truly does
seem plausible to assume that one of the wealthiest countries in the world
would have enough resources to wipe out homelessness all together.
Homelessness is increasing in the United States, particularly among
families with children. Most urban cities have reported that they have
experienced a marked increase in the number of families seeking assis-
tance, and some cities have cited the need to turn away homeless indi-
viduals and families due to a lack of resources. In fact, in the most recent
annual U.S. Conference of Mayors report (2011), 42 percent of cities
reported an annual increase of almost 20 percent in the homeless pop-
ulation. Te rate of homelessness began to increase between 1970 and
1980 due to a decrease in afordable housing and an increase in poverty
( National Coalition for the Homeless, 2006), but the 2007 global fnan-
cial crisis has exacerbated this trend of fnancial vulnerability, as indi-
cated by most cities in the United States, which have reported a marked
increase in requests for emergency shelter and food assistance from 2008
through 2011. In fact, for the frst time in years, unemployment leads the
Bruce Ayres/Getty Images
192 Part II / Generalist Practice and the Role of the Human Service Professional
list of causes of homelessness, ahead of a lack of housing and poverty (U.S. Conference
of Mayors, 2011). Te majority of U.S. city mayors expect the trend of homelessness to
continue to increase, and yet do not expect funding for services to keep pace.
Most scholars and homeless advocates agree though that the problems of homeless-
ness are multifaceted and are not caused by one or two factors (i.e., unafordable hous-
ing, lack of employment). Homelessness is caused by many factors, including economic,
social, and psychological dynamics, and yet one problem in addressing the problem of
homelessness is that federal defnitions of homelessness ofen focus on only one vari-
able: housing (Gonyea, Mills-Dick & Bachman, 2010).
The Difficult Task of Defining Homelessness: The HEARTH Act
To confront the problem of homelessness, it must frst be determined who is homeless. Tis
is a challenge due to the difculty in defning homelessness as well as the transient nature of
the homeless population. Tere is currently no universally agreed-upon defnition of home-
lessness, although the 1994 reauthorization of the Stewart B. McKinney Homeless Assistance
Act of 1987 (now referred to as the McKinney-Vento Act) defnes homelessness as
1. an individual or family who lacks a fxed, regular, and adequate nighttime residence;
2. an individual or family with a primary nighttime residence that is a public or pri-
vate place not designed for or ordinarily used as a regular sleeping accommodation
for human beings, including a car, park, abandoned building, bus or train station,
airport, or camping ground;
3. an individual or family living in a supervised, publicly or privately operated shelter
designated to provide temporary living arrangements (including hotels and motels
paid for by federal, state, or local government programs for low-income individuals
or by charitable organizations, congregate shelters, and transitional housing);
4. an individual residing in a shelter or place not meant for human habitation and who is
exiting an institution where he temporarily resided. (42 U.S.C. 11302, et seq., 1994)
When homelessness is defned using the federal defnition, there were on average
636,017 individuals who experienced homelessness (sheltered and unsheltered) on
any given night in 2007 in the United States (U.S. Department of Housing and Urban
Development, 2011). Although this represents a slight decline from prior years, this
defnition is ofen criticized because its narrow parameters omit the
majority of the homeless population who are difcult to count either
because they are not living in traditional emergency shelters or be-
cause they do not want to be counted. Te hidden homeless may
include those living in motels, automobiles, and abandoned build-
ings; those who frequently double up with friends or relatives on a
temporary basis; and those who for whatever reason do not want to
be counted. When homelessness is defned in a more inclusive man-
ner, estimates jump signifcantly, to between 2.5 and 3.5 million in-
dividuals nationally (National Alliance to End Homelessness, 2009).
Another problem in determining the scope of the homeless problem relates to the
transient nature of the homeless population, which the McKinney-Vento Act defnition
The hidden homeless may
include those living in motels,
automobiles, and abandoned
buildings; those who frequently
double up with friends or relatives
on a temporary basis; and those
who for whatever reason do not
want to be counted.
Homelessness 193
did not address. Most individuals who have experienced homelessness have done so on
an intermittent basis, where homelessness occurs in an ongoing cycle of temporary or
tenuous housing, leading to eventual homelessness due to economic instability. Tus, as
aggressive as any count might be, the number of homeless individuals will range dra-
matically on any given day.
In response to criticism as well as the quick pace at which the nature of homeless-
ness is changing, the McKinney-Vento Act was signifcantly amended under the Obama
administration in 2009. Te reauthorization of the McKinney-Vento Act was signed
into legislation as Homeless Emergency Assistance and Rapid Transition to Housing
(HEARTH) Act. Among many signifcant changes to the act, the defnition of homeless
underwent a much-needed expansion to include those previously considered homeless
as well as:
5. an individual or family who
A. will imminently lose their housing, including housing they own, rent, or live in
without paying rent, are sharing with others, and rooms in hotels or motels not
paid for by Federal, State, or local government programs for low-income indi-
viduals or by charitable organizations, as evidenced by
i. a court order resulting from an eviction action that notifes the individual or
family that they must leave within 14 days;
ii. the individual or family having a primary nighttime residence that is a room
in a hotel or motel and where they lack the resources necessary to reside
there for more than 14 days; or
iii. credible evidence indicating that the owner or renter of the housing will not
allow the individual or family to stay for more than 14 days, and any oral
statement from an individual or family seeking homeless assistance that is
found to be credible shall be considered credible evidence for purposes of
this clause;
B. has no subsequent residence identifed; and
C. lacks the resources or support networks needed to obtain other permanent
housing; and
6. unaccompanied youth and homeless families with children and youth defned as
homeless under other Federal statutes who
A. have experienced a long-term period without living independently in permanent
housing,
B. have experienced persistent instability as measured by frequent moves over such
period, and
C. can be expected to continue in such status for an extended period of time be-
cause of chronic disabilities, chronic physical health or mental health conditions,
substance addiction, histories of domestic violence or childhood abuse.
(42 U.S.C. 11302, et seq., 2009)
Te HEARTH Act goes a long way in addressing defcits in the previous act by now
including many of the hidden homeless previously excluded under the former legisla-
tion, such as those who have a long history of housing instability living in motels and
194 Part II / Generalist Practice and the Role of the Human Service Professional
on others couches, and specifcally addresses the growing issue of
homelessness among families with children and unaccompanied
youth. It also increases the focus on prevention of homelessness, by
identifying risk factors that ofen lead to housing insecurity such as
domestic violence and child abuse. For instance, a report summariz-
ing several studies across the United States found that about half of
all homeless single mothers surveyed (across the country) had expe-
rienced child abuse, including child sexual abuse, during their child-
hoods, and almost all had experienced domestic violence at some
point in their lives (National Law Center, 2006).
The U.S. Homeless Population: Gauging the
Extent of the Problem
Because of the methodological challenges involved in attempting
to accurately count the homeless population, most recent demo-
graphic studies now use homeless estimates based on indirect counts obtained by sur-
veying professionals working with the homeless population. Tis reporting method
is wrought with problems, though, including underreporting since this method, as
other reporting methods, omits those who are not seeking housing or shelter assis-
tance. One of the most signifcant concerns with the underreporting of the homeless
population due to these methodological challenges relates to the fact that government
grant money is ofen directly linked to census numbers; thus, underreporting leads to
less money, which in turn leads to fewer services. For this reason as well as others, in
2004 Congress directed the Department of Housing and Urban Development (HUD)
to collect comprehensive data on the homeless population in the United States. Tis
mandate represents the frst federal attempt to conduct a direct count of the homeless
population. HUD responded to this mandate by developing the Housing Management
Information System (HMIS), which provides a computerized method for collecting
data on the use of shelter and transitional housing programs within each state. Te
most recent report published in 2010 (reflecting 2009 data) included a point-in-
time count of homeless persons and the number and demographic characteristics of
homeless individuals and homeless families (U.S. Department of Housing and Urban
Development, 2010).
Te report revealed that on a single night in 2009, 643,037 people were homeless
nationwide (living both in shelters and on the streets). Tis number refects relative sta-
bility in the number of homeless in recent years, with a decrease in the people living on
the streets (about 37 percent of all homeless people) compared to those living in shel-
ters (about 60 percent). Te authors note that this increase may be due more to better
head counts of people living on the streets versus an increase in the unsheltered home-
less population. Te report also revealed that approximately two-thirds of the homeless
population consisted of individuals, and about one-third consisted of families, which
is consistent with prior years. About 50 percent of solitary individuals were sheltered
and about 47 percent were unsheltered, while most families were living in some type
Professional History
Understanding and Mastery of Professional
History: Historical and current legislation
affecting services delivery
Critical Thinking Question: The McKinney-
Vento Act and the HEARTH Act made
great strides toward defining who is
homeless and gaining an accurate count
of how many homeless persons there are
in the United States. Why are a definition
and a count important steps toward ad-
dressing the issue of homelessness? What
else is needed to facilitate the next steps
toward eradicating homelessness?
Homelessness 195
of shelter (78 percent) on any given night. One disconcerting trend is the increase in
homeless families, which has risen in the past two years.
Te typical homeless person in 2009 was a middle-aged man who was a member of
an ethnic minority group, who was alone. Over two-thirds of the homeless population
has some type of disability. Tere has also been a consistent increase in the overall age
of the homeless population, which the authors attribute to the aging cohort of homeless
individuals who became vulnerable to homelessness when they were younger.
At any given night in 2009 there were approximately 124,135 chronically homeless
individuals living in shelter. Of these, about 13 percent were veterans (down from 15.5
percent in 2006), 4 percent were persons living with HIV/AIDS, 1.5 percent were unac-
companied youth (down from 4.8 percent in 2006), 12 percent were victims of domestic
violence (down slightly from 13 percent in 2007), 25 percent were sufering from severe
mental illness (down from 27.6 percent in 2007), and 34 percent had a chronic substance
abuse problem (down from 39 percent in 2007). Te average length of stay in emergency
shelter was anywhere from a week to a month, with most staying about two weeks. Te
average length of stay in a transitional housing program was just under 100 days. Of home-
less families, the majority are younger single mothers with two children. Most tend to enter
transitional housing programs, are members of minority groups (African American, Latin
American, and Native American), and became homeless afer leaving someone elses home.
It must be noted that these statistics do not capture the full picture of what most
experts are predicting will be a signifcant increase in fnancial and subsequent housing
insecurity brought on by the 2007 global fnancial crisis. With a dramatic increase in
housing foreclosures, the tightening of the credit market, and mass layofs, the picture of
homelessness in the United States will most assuredly change for the worse. Although it
is still too soon to capture specifc statistics refecting these changes, a 2009 study con-
ducted by the Urban Institute exploring the impact of the foreclosure crisis on U.S. fam-
ilies showed that many families who experienced foreclosure found it difcult to rent
due to damaged credit ratings and instead were forced to live with family members or
friends. Tis trend is troublesome because the typical path toward homelessness ofen
involves a pattern of moving from self-sufciency, to living in someone elses housing
unit, to ultimately moving into emergency shelter. States with the highest foreclosure
rates, such as Nevada, Arizona, California, and Florida, also experienced the highest
jump in request for social services such as food assistance. Older adults appear to be
particularly vulnerable due to the risk of physical health problems that create barriers to
fnding employment in a very tight job market (Kingsley, Smith, & Price, 2009).
The Causes of Homelessness
Determining the root causes of homelessness is not only as challenging as determining who
is homeless, but also essential, particularly for human service professionals who are com-
mitted to advocating for and assisting those who experience poverty and homelessness.
Equally important is the task of identifying common biases against and negative stereo-
types of the poor and homeless population that dramatically infuence the general percep-
tion of the poor and homeless, which in turn infuences the types of assistance programs
that will be supported by state and federal policy makers as well as the voting public.
196 Part II / Generalist Practice and the Role of the Human Service Professional
In general, most peoples attitudes toward the poor and the homeless are negative,
and the stigma that has always been associated with poverty seems to increase when the
poor become homeless. Te reasons for this negative bias are likely related to the public
nature of homelessness, where those without permanent homes are forced to live out in
the open, such as on the streets or alleyways, or in parks or automobiles, where good
hygiene is virtually impossible and begging for money and food is ofen the only means
of survival (Phelan, Link, Moore, & Stueve, 1997).
Te common association of mental illness and substance abuse with poverty and
homelessness also contributes to the negative stigma associated with being homeless,
and many experts suspect that the general public assumes that virtually all homeless
individuals abuse drugs and alcohol, do not shower, live on the streets, and aggressively
beg for money (to buy drugs and alcohol), adding to a sense of perceived dangerousness
of the homeless population, particularly those believed to be mentally ill.
Tis increased negative attitude toward those who are poor and homeless is refected
in several studies and national public opinion surveys. Generally, it appears as though
most people blame the poor for their bad lot in life. For instance, one older national sur-
vey conducted in 1975 found that the majority of those in the United States attributed
poverty and homelessness to personal failures, such as having a poor work ethic, poor
money management skills, a lack of any special talent that might translate into a positive
contribution to society, and low personal moral values. Tose questioned ranked social
causes, such as poverty, racism, poor schools, and the lack of sufcient employment, the
lowest of all possible causes (Feagin, 1975).
More recent surveys conducted in the mid-1990s reveal an increase in the ten-
dency to blame the poor for their poverty (Weaver, Shapiro, & Jacobs, 1995), even
though a considerable body of research points to social and structural issues as the
primary cause of poverty, such as shortages in afordable housing, recent shifs to a
technologically based society requiring a signifcant increase in educational require-
ments, long-standing institutionalized oppression and discrimination against certain
racial and ethnic groups, and a general increase in the complexity of life (Wright,
2000). A 2007 study comparing attitudes toward homelessness among respondents
in seven countriesthe United States, the United Kingdom, Belgium, Germany, and
Italyfound that the respondents in the United States and the United Kingdom, the
only two English-speaking countries, reported higher rates of lifetime homelessness
and fewer social programs, yet had lower levels of compassion for the homeless popu-
lation (Toro et al., 2007).
In general, though, compassion for poverty-related homelessness tends to be
greater during difcult economic times and lower during economic booms, and general
compassion for homeless individuals such as families, who are unlike the stereotypical
skid row alcoholic, tends to be greater as well. Recent studies refecting attitudes about
poverty during the most recent economic crisis, increasingly referred to as the Great
Recession or the Global Crisis reveal this sense of increased compassion, but they also
show an increase in class confict, where lower income individuals express resentment
toward the wealthy. Nowhere was this more apparent than in the Occupy Wall Street
movement, a series of staged demonstrations across the United States, which began on
September 17, 2011, in Manhattans Financial District, and spread to over 100 cities
Homelessness 197
nationwide. Te Occupy Wall Street movement website (www.occupywallst.org) states
that it
is a people-powered movement that . . . is fghting back against the corrosive power
of major banks and multinational corporations over the democratic process, and
the role of Wall Street in creating an economic collapse that has caused the great-
est recession in generations. Te movement is inspired by popular uprisings in
Egypt and Tunisia, and aims to fght back against the richest 1% of people that
are writing the rules of an unfair global economy that is foreclosing on our future.
(Occupy Wall Street, 2011)
This popular social movement reflects the findings of a 2012 study conducted by
the Pew Center, which found that negative perceptions of each classthe poor of the
rich and the rich of the poorcommonly referred to as class confict has signifcantly
increased in recent years. In fact, an interesting shif in attitude is that more white people
than ever before are noticing this confict, whereas the majority of African Americans
and Latinos have always perceived a confict between the rich and the poor. Attitudes
toward the wealthy, something not explored in earlier attitudinal surveys about income
levels, reveal that almost half of all respondents (about 46 percent) believe that most rich
people are wealthy mainly because they know the right people or were born into wealthy
families whereas 43 percent say wealthy people became rich mainly because of their
own hard work, ambition or education (Taylor, Parker, Morin, & Motel, 2012, p. 3).
Based on these studies it appears as though their remains at the least confusion
about the causes of poverty and wealth, whether poverty and homelessness are caused
by behavioral factors or social conditions, and whether wealth is a result of privi-
lege and inheritance or hard work. Despite intermittent increases in compassion to-
ward the poor and homeless, the general public does not appear to understand the
underlying causes of poverty and homelessness, which may make it easier to jump
to incorrect conclusions based upon negative stigmas. Although perceptions of indi-
vidual homeless individuals are not as negative as perceptions of specifc subgroups
within the homeless population (e.g., single men, certain racial groups, alcoholics,
undocumented immigrants), possible reasons for the overall negative perception of
the homeless population may relate to the fundamental attribution error, where people
tend to attribute their own personal failures or the failures of people they know well
and like to situational factors, but attribute the failures of those they do not know or
do not like to personal or dispositional factors. Tus, according to the fundamen-
tal attribution error, the average person would assume that those whom they did not
know were homeless due to their own personal shortcomings. Yet, if someone they
knew became homeless, they would attribute the homelessness to situational causes,
such as being laid of or abruptly leaving an abusive marriage.
Human service professionals must understand the stigma associated with homeless-
ness because unless these negative attitudes are acknowledged and challenged, human
service professionals may even embrace them, signifcantly infuencing their perceptions
of their clients sufering from poverty and poverty-related homelessness. Understanding
homelessness from a historical perspective is also useful in understanding the nature of
this long-standing social problem so that situational forces can be acknowledged.
198 Part II / Generalist Practice and the Role of the Human Service Professional
History of Homelessness in the United States
Te types of people who have experienced homelessness and the reasons for their mis-
fortune have changed signifcantly throughout the years. Prior to the Middle Ages (from
about the 14th to the 17th century), the early church was responsible for the care of the
poor, including those without homes. Te monasteries embraced this responsibility as one
given by God. Tus, at least the deserving poor (those who were poor through no fault
of their own) were considered blessed, and it was considered a blessing to care for them.
Troughout the Middle Ages, the homeless population consisted primarily of the
wandering poorthose individuals, most commonly men, who migrated for employ-
ment, either working someones land or selling goods. Te English poor laws (discussed
in Chapter 2), which were adopted by many of the American colonies, included harsh
measures for dealing with the poor and destitute, adding to the overall negative social
stigma associated with poverty. For example, most communities enforced strict resi-
dency requirements designed to discourage the wandering poor from settling in more
afuent districts to collect social welfare intended to serve longtime residents who had
contributed to the community before falling on hard times. Tis policy, as well as others
against vagrancy and even unemployment, is refective of the overall negative sentiment
held of the homeless population in general, particularly when it could be assumed that
one was homeless either through choice or some personal failing.
Distinguishing the deserving from the undeserving poor was
practiced throughout the Middle Ages (in fact many argue that
U.S. policy continues this practice even today). Under English
poor laws many of the undeserving poor and homeless were sent
to work camps or almshouses, where they were forced to perform
demeaning work for excessively long hours in what amounted to
slave labor. Tis practice continued to play into the overall stigma
of poverty and homelessness by stripping the poor and destitute
of their self-determination, their family, and their freedom. Even
the deserving poor who received public assistance were ofen
forced to wear badges or some marking signifying that they were
receiving public assistance (Phelan et al., 1997).
Throughout the 19th and early 20th centuries the homeless
population still consisted of primarily men, either vagrants (men
who were unemployed for a variety of reasons, including men-
tal illness or alcoholism) or migrant workers, such as men who
were making their way out West to work in the gold mines, the
railroads, or the felds. Hobos, for instance, were ofen counted
among the homeless population. Hobos were men of European
descent, typically Germany or Scandinavian countries, who were
migrating laborers and were ofen treated with mistrust and con-
tempt despite the fact that they were an integral part of the labor
force throughout the 19th century (Axelson & Dail, 1988).
It was not until the Great Depression in the mid-1930s that
families began to appear on the homeless scene in significant
Te Great Depression resulted in extremely high
unemployment and homelessness
Getty Images
Homelessness 199
numbers. Te failure of the fnancial markets, the closings of many banks, and rampant
unemployment resulted in many families losing their homes and wandering the streets
in search of sustenance and shelter. Because the Great Depression hit just about everyone
in the United States, there was increased compassion for the homeless population and for
those sufering from poverty in general. Te Great Depression brought most people back
to a pre-Protestant ethic time, where people recognized and acknowledged that poverty
and homelessness could be caused by circumstances beyond ones control. Tus, although
the Protestant ethic and Social Darwinism might have had many people believing that
falling on hard times was a result of laziness, the Great Depression reminded everyone
that sometimes, no matter how hard one works or is willing to work, circumstances oc-
cur that render someone destitute and impoverished. Unfortunately, this spirit of empathy
and compassion for societys poor and homeless did not last much past the next economic
boom. Apparently, a by-product of personal good fortune may just be a reduction in ones
ability to empathize with those less fortunate.
The Contemporary Picture of Homelessness: The Rise
of Single-Parent Families
Afer the Depression, the homeless landscape returned to its former de-
mographic picture, with the majority of the homeless population consist-
ing primarily of single, white men. Yet another signifcant change was on
the horizon. Te 1970s and 1980s saw a dramatic increase in the home-
lessness of families. Yet the diference between the homeless families of
the Great Depression era and homeless families of late is that the latter consists primarily
of single parents with children. An increase in homelessness families has occurred in the
past two consecutive years of available data (2008 and 2009). Te typical family consists
of a single mother and two children, about 80 percent of whom reside in a shelter of
some sort, and 20 percent of whom are unsheltered (U.S. Conference of Mayors, 2010).
There is a tendency among policy mak-
ers to oversimplify the causes of homelessness,
perhaps because a simple cause would warrant
a simple solution, and multifactor causes ofen
call for overwhelmingly complex responses. But
most single-parent families become homeless
as a result of a complex set of circumstances,
as illustrated in Case Study 9.1 (p. 211). Tere
are some common themes among single-
parent homeless families. The great majority
of homeless single mothers are approximately
25 years of age, with two to three children in
the preschool to 6 years of age range. Te ma-
jority of these single mothers are U.S. citizens,
native born, and fuent English speakers. Even
states that border Mexico have a relatively low
Most single-parent families
become homeless as a result of a
complex set of circumstances.
Children are at increasing risk of becoming homeless
Bushnell/Soifer/Getty Images
200 Part II / Generalist Practice and the Role of the Human Service Professional
percentage of homeless immigrants. Families of color are at greatest risk of becoming
homeless, although single-parent homelessness among Caucasians is signifcant as well.
Most homeless single mothers have never been married, and although many are
high school graduates, a signifcant majority of single mothers never established a solid
work history for many reasons. Most cite either never having had stability in their hous-
ing situations or having experienced unstable housing for several years prior to be-
coming homeless. Most have experienced homelessness chronically on a cyclical basis,
securing housing for a short time only to experience a fnancial crisis, such as a job loss,
which results in a domino efect of negative life events and ultimately another incident
of homelessness. Many homeless single mothers are either underemployed or unem-
ployed, with the majority citing the inability to pay for child care as the primary barrier
to fnding employment, but others cited being undereducated and an inability to secure
employment that would pay for market rent. Te Great Recession of 20072009 has re-
sulted in an increase in single-mother unemployment. For instance, the percentage of
single mothers employed in an average month between 2000 and 2009 decreased by
about 8 percent, from 76 percent in 2000 to only 68 percent in 2009 (U.S. Department
of Labor, 2010). Tis trend has led to increases in food and housing insecurity among
single-mother households as well (Legal Momentum, 2010).
Unfortunately, the safety net in the form of public assistance programs has signif-
cantly shrunk since the passage of federal welfare reform legislation in 1996. Welfare re-
form efectively ended the Aid to Families with Dependent Children (AFDC) program
and initiated the Temporary Assistance for Needy Families (TANF), a program that pro-
vides assistance at about one-third of the federal poverty level (Nickelson, 2004).
Historically, only about 20 percent of homeless individuals have been on any form
of public assistance, even though the majority of these individuals would have qualifed
for some form of assistance (Shlay & Rossi, 1992). Although single mothers qualify for
more aid than single homeless men and single homeless women, as a group they still
tend to underutilize public assistance programs. In fact, according to a report evaluat-
ing how single mothers and their children have fared between 2000 and 2009, unem-
ployment has increased and welfare utilization has decreased, which has resulted in an
increase in extreme poverty among single mothers. What may surprise many is that de-
spite the increases in single-mother unemployment and overall poverty levels in single-
mother families between 2007 through 2009, the percentage of these families receiving
welfare benefts decreased from 16 percent in 2001 to only 10 percent in 2010 (Womens
Legal Defense and Education Fund, 2010). To add to the dilemma of shrinking public
assistance programs, aid that is provided in the form of block grants or aid packages
may have long waiting lists for certain types of assistance, such as child care.
Another contributing factor to homelessness of single-mother families may relate to
the bad childhoods many homeless women experienced. Many single mothers report
unstable childhoods flled with physical and sexual abuse. In fact, it appears as though
many of these women proceeded to recreate these patterns of abuse in their adult lives
because approximately three-quarters of all homeless single mothers who were married
prior to becoming homeless cited domestic violence as the primary reason for leaving
Homelessness 201
their marital home and moving into a shelter with their children. Other reasons include
having a child early, either during adolescence or early adulthood, which interrupts the
development of educational and career goals (Nunez & Fox, 1999). Other personal vul-
nerabilities include having a substance abuse disorder or mental illness (although some
research suggests that the trauma of homelessness is actually a risk factor for substance
abuse and mental disorders, such as depression, and not typically the cause of homeless-
ness in single-mother families), having grown up in the state foster care system, and
having a poor or absent social support system.
Some structural causes of the recent dramatic increase in homeless single-parent
families include the failure of many courts to enforce child support orders, dramatic
cutbacks in federal housing programs in the 1980s, and the failure of public welfare to
keep pace with infation and increases in the cost of living. Further increases in home-
less families are expected particularly now that welfare benefts are limited to only two
to fve years (depending on the state), rather than providing long-term benefts on a
case-by-case basis.
It is important to discuss the strengths that many of these single mothers exhibit as
well, particularly because human service professionals will need to identify such strengths
and work with the single-parent client to enhance and build on existing strengths. A 1994
study found that single mothers living in shelters had an amazing amount of determina-
tion, a sense of personal pride, and an ability to confront their problems directly. Many
of the single mothers interviewed exhibited a strong commitment to the welfare of their
children (particularly those who chose homelessness over remaining in an abusive rela-
tionship), had strong moral values that acted as a guide in decision making, and had deep
religious convictions that provided them with a sense of purpose and meaning. Despite
being homeless, many of these single mothers maintained a commit-
ment to helping others in need (Montgomery, 1994). Many also over-
came what seemed to be insurmountable odds to keep their children
with them rather than have them placed within the state foster care
system, despite harsh living conditions. A more recent study evaluat-
ing the resiliency of single mothers in general (not homeless) found
that respondents were quite resilient, despite all of the challenges they
faced. Most stated that they disagreed with the negative stereotypes
of single mothers as inadequate, and believed that they had person-
ally grown through the challenges they faced in raising their children
alone, many of whom had disabilities. Many found the experience
of single parenting transformative and confdence-building (Levine,
2009). Human service professionals can tap into these strengths
when assisting single parents access resources in order to gain self-
sufciency in the face of multiple challenges.
Homeless Shelter Living for Families with Children
Te increase in single-mother family homelessness has resulted in the need for signif-
cant changes in social welfare policy regarding how homelessness is managed on local,
Human Services
Delivery Systems
Understanding and Mastery of Human
Services Delivery Systems: Economic and
social class systems including systemic
causes of poverty
Critical Thinking Question: A substantial
number of the homeless are single-
mother families with young children.
What systemic factors contribute to
poverty and homelessness among this
population? What changes in policy and/
or practice might help to alleviate this?
202 Part II / Generalist Practice and the Role of the Human Service Professional
state, and federal levels. When the homeless population was more homogeneous, con-
sisting primarily of single men living in single-room occupancy (SRO) or on skid row,
the community response was less complex focusing on low-cost housing and substance
abuse counseling. But this new homeless population presents more complex problems
requiring a more multifaceted approach. For instance, the traditional homeless person
typically resided on the streets, whereas families ofen avoid street dwelling opting for
shelter living instead. Yet, many emergency shelters are not equipped to serve families.
Elizabeth Lindsey (1998) interviewed single mothers who had lived in homeless shel-
ters with their children and asked them about their experiences in shelters and the impact
it had on their family life. Many shelters would not allow boys as young as eight years to
sleep in the same area as their mothers, requiring them to stay on the mens side of the
shelter alone, stay with relatives, or in some cases, even enter the foster care system.
Other shelters applied the same rules to families as they did to singles, forcing single
mothers to leave the shelter at 7:00 a.m., even if they had infants or preschool-aged chil-
dren, and not allowing them to return to the shelter until 5:00 or 6:00 p.m., regardless of
weather conditions or the safety of the community where the shelter was located. Many
single mothers complained that there was no way to look for a job when they had to stay
out of the shelter with their kids for hours a day. Other complaints included staf who
seemed insensitive to childrens needs, such as enforcing rules against children running
around and playing, which created difcult situations for parents who were mandated
to keep their children quiet at all times, with no distractions, such as television or toys,
to assist them.
But by far the most difcult aspect of shelter life according to these women involved
staf who would override their parenting decisions, such as correcting a parent in front of
the child and other shelter residents for how she was disciplining her child. Mothers com-
plained that their authority was ofen diminished by shelter rules and interfering shelter
staf. Other shelter rules that make parenting difcult include rules prohibiting anyone
from eating in the shelter at any time other than during designated meal times, including
prohibiting mothers from even bringing snacks into the shelter for their young children.
Research studies have shown that such shelter rules and policies, not necessarily
created with families in mind, have a powerfully devastating efect on the parentchild
relationship, as mothers fnd themselves no longer the head of household with the
power to make parenting decisions in the best interest of their childreneven basic
decisions such as when to bathe and feed their children. Instead, their children are cared
for on the shelters time frame. Tese issues might seem like minor inconveniences and
relatively innocuous in light of the other major crises going on in the lives of homeless
mothers, but researchers noted that the disintegration of the motherchild relationship
is not just temporarily disruptive, but this disruption essentially further degrades and
disempowers parents who are already feeling shamed and powerless by their homeless
status leading to an increase in parental distress and depression, which in turn ofen
leads to an increase in child misbehavior and acting out (Lindsey, 1998).
More recent research on single mothers living in homeless shelters with their chil-
dren showed similar dynamics. In a 2009 study of single mothers attitudes about the
efect of living in a shelter on child-rearing, the mothers cited several challenges to their
Homelessness 203
parenting such as the loss of privacy and the lack of fnancial resources. Tey also cited
several strengths, such as their ability to persevere through these various challenges,
and their faith and optimism. Tey also recommended that those working with single-
mother homeless families maintain a humble attitude and avoid acting like an expert,
and avoid negative stereotypes of single mothers (Swick & Williams, 2010).
Homeless Children: School Attendance and Academic Performance
Children are the fastest-growing segment of the homeless population, which cre-
ates new challenges for shelters and other social welfare responses, particularly when
these children are school-aged. Developing effective programs designed to keep
homeless children in school and succeeding academically is essential, otherwise all
these homeless children will be at risk for continuing the cycle of homelessness in
the next generation, having never experienced physical or emotional security in their
own childhoods.
Between the chronic and cyclical nature of homelessness and the fact that most
emergency shelters limit the amount of time residents can stay, ranging anywhere from
1 to 30 days, a signifcant problem for school-aged children was switching schools every
time their families were forced to move to a new shelter. I recall when I was working
as a school human service professional in the inner city of Los Angeles having several
school-aged children who were homeless on my caseload. No sooner did these children
get settled and acclimated to their classroom and start the long process of building a
trusting relationship with me than they would literally disappear one day. I would typi-
cally learn at some point later that the family was forced to move to a diferent shelter,
and even if remaining at their school of origin was a legal possibility, it was not a realis-
tic one because there was no guarantee that the next shelter would be anywhere close to
the childrens current school.
A 2000 report to Congress stated that only 87 percent of homeless children were en-
rolled in school, and of these only 77 percent attended school regularly (U.S. Department
of Education, 2001). Many school districts attempted to resolve this issue by creating
special schools or programs for homeless children, but these programs have been criti-
cized by many because it segregated homeless children, increasing their social stigma
and sense of rejection they no doubt already experienced. Federal legislation, discussed
later in this chapter, was designed to address this issue and put a stop to poor attendance
and student retention and poor academic performance related to homelessness.
Runaway Youth
No one is certain just how many adolescents are homeless and living on the streets, but
some estimates put that number as high as 2 million in the United States alone. Tis is a
unique population among the entire homeless population because the reasons, risk fac-
tors, and intervention needs are considerably diferent. Adolescents are far more likely
to be living on the streets than in a shelter. Tey are also far more likely to participate in
dangerous behaviors such as drug abuse (including needle sharing), panhandling, thef,
and survival sex (sex for food, money, and shelter). Tese risky behaviors put homeless
204 Part II / Generalist Practice and the Role of the Human Service Professional
adolescents at risk for HIV, hepatitis B, hepatitis C, and sexually transmitted diseases
(Beech, Meyers, & Beech, 2002). Tese teens are also at high risk for physical and sexual
violence, both by other teens and by adults.
Most homeless adolescents are living on the streets because they have run away from
an abusive home, have been kicked out of their homes by parents who no longer wish
to take care of them (throw-away youth), or have aged out of the foster care system.
Te majority of homeless adolescents interviewed in various research studies reported a
history of both physical and sexual abuse, which served as a primer for being similarly
victimized on the streets (Whitbeck, Hoyt, & Ackley, 1997). Another study of over 600
runaway youth found that sexual abuse was the chief reason adolescents chose to live on
the streets rather than remaining in their homes (Yoder, Whitbeck, & Hoyt, 2001). Te
fact that many of these teens will continue to experience sexual exploitation while living
on the streets, whether through outright attacks or through survival sex, is certainly a
tragedy, and one that can be addressed by those in the human services feld.
One study that involved the surveying of homeless youth found that in most ur-
ban cities homeless adolescents often operate as a somewhat cohesive group on the
streets, protecting each other and helping one another survive. In fact, this study found
that the more seasoned adolescents would ofen take new homeless teens under their
wings, teaching them survival tactics and welcoming them into the fold. Newer home-
less youth who were interviewed talked about what a relief it was to have someone es-
sentially mentor them into the ways of surviving street life. But without glamorizing
this life, most teens, both boys and girls, talked of the horrors of having to participate
in prostitution to survive. In fact, the adolescents who were interviewed talked about
many ways in which they felt exploited, both by older teens and by adults who forced
them into drug dealing and prostitution (Auerswalk & Eyre, 2002).
Ironically, many teens reported having a strong belief in God, who they believed
watched out for them and kept them alive. One teen stated that when they were not re-
ally in need, they would ofen get no ofer of food and little money while panhandling.
Yet when they were really in need, having gone without food for a few days, then what-
ever they needed would just come to them. He attributed this to God knowing what
they needed and providing for them when they needed it the most (Auerswalk & Eyre,
2002). In fact, in one study researchers found that over half of all homeless youth inter-
viewed cited faith in God as the primary motivation for survival (Lindsey, Kurtz, Jarvis,
Williams, & Nackerud, 2000).
Yet even with this surprisingly high percentage of faith-seeking homeless teens,
an estimated 40 percent of homeless youth attempt suicide (Auerswalk & Eyre, 2002).
Tey are also at high risk for post-traumatic stress disorder (PTSD), anxiety disorders,
depression, substance abuse, and delinquency (Trane, Chen, Johnson, & Whitbeck,
2008). Many runway and homeless youth report losing all contact with people in their
former lives, even siblings, extended family, and those who had been supportive of them
in the past. Most also talked of feeling extremely lonely and distrustful but in desperate
need of love and afection. Because the majority of homeless adolescents have run away
from abusive homes, it seems likely that many were sufering from some form of emo-
tional disturbance even prior to entering street life (Kidd, 2003).
Homelessness 205
Unfortunately, many of the adolescents interviewed were highly suspicious of all
adults, including outreach workers with human services agencies providing assistance to
the homeless adolescent population. Te overall perspective of these outreach agencies
were negative, and adolescents who accepted assistance from these agencies were consid-
ered sellouts and foolish. Te prevailing belief was that human services organizations
would force the teens to return to an abusive home environment, or theyd be turned over
to the police. Knowing these attitudes, though, can aid human services agencies in devel-
oping outreach eforts and other services designed to overcome these negative perceptions.
Any successful intervention program is going to have to address the issue of the
teens feeling like outsiders. In fact, research studies have found that homeless adoles-
cents are acutely aware of their outsider status, and many of them manage this through
incorporating this outsider status into their identity. By embracing being an outsider,
through multiple piercings, for example, they take control of something that could
potentially make them vulnerable (Auerswalk & Eyre, 2002).
Many human service experts strongly recommend that any intervention program be
targeted at identifying the adolescents strengths. But this is challenging when most inter-
vention systems view homeless youth in a deviant manner; frst, because they are run-
aways, and second, because many of the behaviors they engage in while living on the
streets are criminal. Even the classifcation of their behavior is in pathological terms, such
as diagnosing them with conduct disorder. Tis can be humiliating and shaming to an
adolescent who is likely acting out in response to being victimized in her family of origin.
Most homeless youth have been both physically and verbally abused and degraded in their
homes; thus, in many respects they are living up to their parents negative expectations of
them by dropping out of high school and living on the streets. To then enter into the juve-
nile justice system that continues to pathologize their behavior and responds in punitive
measures rather than supportive ones only adds to their feelings of victimization.
Human service professionals working with this population must provide consistent
encouragement, compassionate care, and understanding that promote both self-esteem
and self-efcacy (a sense of competence) in these emotionally broken and bruised teens.
Tis can be accomplished while focusing on basic needs such as providing food, shelter,
and good healthcare. Yet again the barrier that human services agencies must overcome
is signifcant because so many homeless youth have been so horribly rejected and aban-
doned by their families, and then further exploited and abused by adults on the streets,
that to trust any adult seems foolish and risky.
Developing one-on-one relationships where trust can grow slowly is one method of
intervention that may be more successful than more traditional outreach eforts, but the
ratio of outreach workers to homeless youth renders this approach challenging. Regard-
less, any intervention must allow the teen to feel safe and empowered in seeking services.
Single Men, the Mentally Ill, and Substance Abuse
Although single-parent families now comprise a large proportion of the homeless popu-
lation, just less than 50 percent of the homeless population consists of men, many of
whom are single, some of whom are mentally ill, some of whom have substance abuse
206 Part II / Generalist Practice and the Role of the Human Service Professional
issues, and most of whom are veterans. Of course these are overlapping categories in
many instances. Reasons for homelessness ofen vary, and some are similar to the causes
noted in single-parent familieschildhood histories of abuse, grow-
ing up in the foster care system, having little or no family or social
support, being undereducated and stuck in minimum wage jobs,
substance abuse, and mental illness. Social causes include institu-
tionalized racism and oppression, sufering from PTSD afer having
served in the military during wartime, and changes in the economic
infrastructure resulting in fewer well-paying jobs.
Veterans services address many of these issues in programs de-
signed to meet the complex needs of the homeless population who
were enrolled in the armed services. Human service professionals working for the
Department of Veterans Afairs (VA) provide both in-house and outreach services and
are trained on PTSD recovery and the unique needs of this special population.
Older Adult Homeless Population
Chapter 7 touched briefy on the issue of older adults and homelessness, but it will be
explored again somewhat briefy in this chapter because although rates of homelessness
among older adults are signifcantly lower than younger individuals, it is still an impor-
tant issue worth exploring in some depth, particularly because the number of homeless
older adults is expected to increase as the baby-boomer generation ages.
Diferences exist between homelessness among younger and older persons, both in
terms of the root causes of homelessness and efective responses. Younger homeless in-
dividuals report domestic violence and previous incarceration as reasons for becoming
homeless far more frequently than older populations. Both groups report equal dif-
culty in fnding afordable housing, and both groups report equivalent rates of alcohol
and substance abuse as reasons for homelessness, with 4 percent of younger individuals
reporting this as a reason and just over 6 percent of older adults reporting substance
abuse as the primary reason for their homelessness. Yet in light of the nature of sub-
stance abuse and the tendency for alcoholics and drug addicts to minimize or deny the
impact of their addiction, these percentages might be underreported.
Older adult homeless persons report being without shelter for far longer periods
than younger individuals, with older adult men reporting an average homeless episode
lasting over 60 days, and younger homeless men averaging about 14 days. Older men
also reported far longer episodes without a permanent shelter, some reporting homeless
episodes of over two years, whereas younger men reported being homeless an average
of 11 months (Hecht & Coyle, 2001). Tis is likely due to fewer social supports and the
difculty in either moving in with a roommate or living with family, ofen due to care-
taking issues related to common age-related physical problems.
Even though there are more similarities than diferences between older and younger
homeless persons, the response to older adults who are homeless must be vastly difer-
ent due to all of the variables associated with their advanced age. One variable men-
tioned in the previous paragraph relates to the diminished capacity of older people
in getting back on their feet by fnding new employment opportunities or entering a
Just less than 50 percent of the
homeless population consists of
men, many of whom are single,
some of whom are mentally ill,
some of whom have substance
abuse issues, and most of whom
are veterans.
Homelessness 207
reeducation program to enter a new career; thus, the possibility of
regaining fnancial independence is greatly diminished in the older
adult population.
Other issues affecting older adults include their increased
vulnerabilityboth physically and psychologically, leaving them
open to physical and fnancial victimization. Physical disability and
illness are also complicating factors in meeting the needs of the older
adult homeless population.
Although there is increased funding for services for older adults,
most economic support is not available until the age of 65. Self-suf-
ciency models designed for the general homeless population do not
work with the older adult population for the reasons mentioned ear-
lier; thus, some experts suggest responding to the older adult home-
less population by developing aid-assisted low-cost housing with
social services to assist with fnancial, physical, and psychological
support to deal with the trauma of becoming homeless. As referenced earlier, home-
less advocates and policy experts have expressed concern that the recent fnancial cri-
sis involving the crash of the stock market, loss of retirement funds, mass layofs, and
dramatic increases in foreclosures will have a signifcantly negative impact on the older
adult population due to decreased possibilities to rebound fnancially.
Current Policies and Legislation
Governmental policies designed to meet the needs of the homeless population are ofen
targeted to subgroups, such as single-parent families and veterans, or toward particular
issues that make one more vulnerable to homelessness, such as substance abuse and
mental illness. But some legislation has been passed intended to address the homeless
problem directly. Te McKinney-Vento Homeless Assistance Act of 1987 is probably
one of the most important pieces of legislation passed for those sufering from home-
lessness or who are at risk for homelessness, and prior to the passage of this act, the
majority of homeless services were facilitated at the grassroots level. Tis act guarantees
government assistance for the homeless and homeless services and increases in federal
funding from passage to the mid-1990s has been signifcant, from its original appro-
priation of $180 million in 1987 to $1.8 billion in 1994.
As mentioned earlier in this chapter, the McKinney-Vento Homeless Assistance Act
was reauthorized for the frst time in two decades in May of 2009 by President Obama
as the HEARTH Act (a part of the Helping Families Save Teir Homes Act), which pro-
vides a variety of remedies focusing on both prevention and response. Te federal bud-
get for fscal year 2009 allotted $2.62 billion of funding for 10 diferent programs spread
across several federal agencies, including the Department of Housing and Urban Devel-
opment (HUD), the Department of Health and Human Services (HHS), the VA, and the
Department of Education (ED), just to name a few. Initially, the increase in homeless-
ness funding did not result in a decrease in homelessness, including a $1.5 billion grant
to be spent on homeless prevention. Unfortunately, in response to the Great Recession
Human Systems
Understanding and Mastery of Human
Systems: Emphasis on context and the
role of diversity in determining and
meeting human needs
Critical Thinking Question: Specific
groups of homeless peopleyoung fam-
ilies, veterans, older adults, and individuals
with mental illness or substance abuse
issueshave a wide variety of underly-
ing needs. In what ways might a human
service professional address the needs of
clients from each of these groups?
208 Part II / Generalist Practice and the Role of the Human Service Professional
spending cuts were made essentially across the board in the 2011 federal budget, af-
fecting virtually all social welfare programs, but particularly those focusing on hous-
ing security. Cuts to housing programs, such as housing for the elderly, and for people
with disabilities averaged about 70 percent in 2011 from prior years. A very creative and
interactive tool on the White House website shows the projected 2012 federal budget,
and indicates that that housing assistance programs constitute only 1.59 percent of the
federal budget and income and housing support programs constitute only 1.44 percent
of the federal budget (see http://www.whitehouse.gov/omb/budget).
Te McKinney-Vento Education for the Homeless Children and Youth Program is
designed to address many of the problems experienced by homeless students. Trough
this act, states can apply for funding to assist them in managing the many academic
challenges associated with a student being homeless. Problems related to enrollment,
attendance, and academic achievement are all addressed in this act, and states apply-
ing for funds must abide by certain standards and meet various criteria in meeting the
complex needs of homeless students. For instance, according to the McKinney-Vento
program, schools:
must provide the same educational opportunities to homeless children and youth
that are available to nonhomeless children and youth.
must not segregate homeless children from the mainstream school environment for
reasons based solely on their state of homelessness.
cannot educate children of-site, such as at a shelter, but must educate them along-
side their peers, in a regular classroom setting.
must make school placement decisions based on the best interest of child, not on
the physical location of the shelter. Tus, whenever possible, the child must be al-
lowed to remain in the school of origin, and the school district must make arrange-
ments for the child to be transported to school, if transportation is an issue.
must designate a liaison to identify homeless students and assist them and
their families in addressing barriers to enrollment, attendance, and academic
achievement.
must immediately enroll homeless students, even if they do not have immunization
records, birth certifcates, or proof of residency. Te liaison must then work with
the family and the former school in obtaining these records in a timely fashion.
Schools are also required to transfer school records immediately when a homeless
student transfers to a diferent school.
must provide transportation for homeless students so that they may remain in their
school of origin.
must allow unaccompanied youth (students who for a variety of reasons, includ-
ing emancipation, do not have a legal guardian) to enroll in school even if they do
not have a parent or legal guardian to sign admittance forms for them.
must make a determination of homelessness on a case-by-case basis according to the
McKinney-Vento defnition of fxed, regular, and adequate nighttime residence.
Tis legislation goes a long way in addressing the many challenges facing homeless
families with school-aged children, yet much more must be done. School human service
Homelessness 209
professionals, for instance, can be utilized to assist in the identifcation of homeless youth
because a great number of families are too overwhelmed and embarrassed to come forward
and report their homeless status. In addition, many homeless parents are simply unaware
of their childrens educational rights, and even though the McKinney-Vento act requires
that school liaisons inform students and their families of these rights, school human service
professionals are ofen the link between the families, students, liaison, and school adminis-
tration and can therefore be extremely instrumental in ensuring that these kids remain in
school, without disruption, despite the immense level of instability homelessness causes.
The Role of the Human Service Professional: Working
with the Homeless Population: Common Clinical Issues
Working with the homeless population is as challenging as it is meaningful. Whether a
homeless client is a grown man, an older adult, a child, or an entire family, being homeless
is traumatic, degrading, and for many actually terrifying as ones foundation slips away
without any sort of safety net to stop the fall. For many people homelessness is not an iso-
lated incident, but is a way of life, and even when employed and residing in a permanent
home, for many people homelessness is only one unexpected fnancial crisis away.
Many believe that there is a reciprocal relationship between many mental and emo-
tional disorders and homelessness. The process of becoming homeless, which typi-
cally comes on the heels of months or years of fnancial and residential instability, is
extremely stressful and ofen leads to anxiety disorders, depression, loss of self-esteem,
substance abuse, and even personality disorders as individuals respond to the harshness
of life in various maladaptive and defensive ways.
Research indicates that children who have experienced extreme poverty and homeless-
ness are at risk for higher rates of physical illnesses, depression, anxiety, behavioral prob-
lems, learning problems, and low self-esteem (Davey, 2004). Children who live in shelters
are ofen negatively afected as they watch their parents caretaking roles and responsi-
bilities taken over by shelter staf and human service professionals. Tus, working with
the homeless population, whether directly at an emergency or domestic violenceshelter,
on the transitional housing program, at a school as a liaison or on other human services
programs, or indirectly as a school human service professional, general counselor, child
welfare worker, or in some other capacity where homeless clients might seek services, will
involve working with an extremely wide range of clients and clinical issues.
Human service professionals provide counseling services to homeless adults and
children, facilitate support groups, and provide individual counseling. But one of the
most signifcant roles that human service professionals play is advocating for the home-
less population, both on a personal case-by-case basis and on a community level by
infuencing policy and the development of legislation designed to aid the homeless pop-
ulation. Human service professionals also supervise shelter residents and provide case
management services for adult and child residents, assisting them in connecting to a
wide array of human services that will help them obtain economic and housing stability.
One of the underlying principle values of the human services feld is to empower
clients by plugging them into a variety of social support systems, moving them toward
210 Part II / Generalist Practice and the Role of the Human Service Professional
a state of self-sufciency. Tis is particularly important when working with the home-
less population and those sufering from severe poverty; thus, networking with other
human service providers to provide a comprehensive continuum of care is a powerful
intervention tool for human service professionals. Te efective human service profes-
sional will not attempt to meet all of a homeless clients needs alone, but will depend
on the services provided by other governmental and not-for-proft agencies in the area.
Even many churches ofer services for homeless individuals, including providing respite
care for children, job training and networking, and fnancial assistance.
Many clients facing or experiencing homelessness tend to have multiple problems,
which the human service professional might fnd challenging to address. Single-parent
families that are either homeless or on the verge of homelessness are particularly chal-
lenging because the human service professional must address the needs of the children
as well as the parent, and these needs might confict with one another. For instance,
consider the young, overwhelmed single mother with two young children and abso-
lutely no one to help her with her child care responsibilities. Life in the shelter is de-
pressing and difcult, her children are acting out more than ever because they miss their
home and do not understand why they have to live in a shelter with so many strangers
and so many odd and confusing rules. It is perfectly understandable for this mother to
desperately need some time alone without her children, yet the tremendous amount of
instability and the trauma associated with being homeless causes the children to need
her more than ever. Tis dynamic can result in increased frustration on the part of the
mother, which in turn creates increased fear and insecurity in the children. Te human
service professional can work with the mother to help her recognize this relationship
interaction and take steps to resolve it through intermittent child care respite and coun-
seling the family so that each member better understands the impact homelessness has
on each other as well as themselves.
In light of the burden and stress placed on the single mother, who never enjoys a
break from the frightening stressors and responsibilities she experiences living on the
streets and in shelters with her children, it is no wonder that many women rush into ro-
mantic relationships believing promises of never-ending love and rescue. And although
it would be tempting for anyone so completely overwhelmed with life to believe a mans
ofer to take over the control of ones life and the lives of her children, a relationship that
moves too quickly will ofen result in domestic violence.
Many single mothers make decisions to proceed too quickly in relationships with
men believing that such a relationship will provide the stability of an intact family for
their children, only to fnd out a short time later that they have entered into yet another
abusive relationship with someone who wants to control them and becomes violent if
not successful. Te shame these women feel is immense and sometimes results in their
choice to remain in the abusive relationship because it seems better than facing home-
lessness again and having to admit that they made yet another devastating mistake. Yet
all this accomplishes is to further lower their self-esteem, and change is rarely possible
when one cannot move past the shame. In light of the fact that so many homeless single
mothers experienced physical and verbal abuse growing up and then repeat this pattern
in adult relationships, it is no surprise that many will eventually believe the horrible
Homelessness 211
things being said to them causing them to further doubt whether they have the ability to
make good choices for themselves and their children.
Many people, including human service professionals, become critical and frustrated
with single mothers who enter into a string of relationships with abusive men, some-
times becoming pregnant, but I have often challenged people to consider how they
might respond if they had no one in the world to help and support them, had no one to
share the burdens and difculties of life with, and did not have the luxury of taking their
time to build a truly loving and healthy relationship because they had never enjoyed a
solid foundation of love and security in their childhoods, causing them to enter into an
adult world desperate for someone to love them and provide for them. I strongly believe
this would make anyone impulsive in jumping into a relationship that looked good at
frst glance, because when you are desperately alone in the world anything looks good
in fact, it is a little like living in a desert with no water and thinking seawater tastes
absolutely wonderful, only to fnd out later that rather than saving you, it will kill you.
Consider Case Study 9.1 about Kim, paying particular attention to the complexity of her
problems and issues, as well as the domino efect occurring in this single mothers life.
CASE STUDY 9.1
Case Example of a Homeless Single Mother
I met Kim when she was homeless and looking for permanent housing and attempting to
put the pieces of her life together. Kim was raised in an unstable and abusive home environ-
ment where she had been told repeatedly throughout her childhood that she was worthless
and that no one would ever love her. Her every move was criticized and served as proof
that she was no good. She had the natural need and desire to be loved and accepted, and by
the time she was 17 this need peaked to a point that she could not resist the afections of
an older man who promised her the world. Although she initially resisted his attempts to
become sexual with her, he eventually convinced her that the only way he would know she
loved him was if they had sex, and if she refused he would leave her. Kims immense inse-
curities and her deep need to be cared for made her vulnerable to his manipulative threats,
so she relented and agreed to become sexual with him, believing that she had fnally found
someone who truly loved and accepted her. Yet when she became pregnant, he became
abusive and used many of the same abusive statements she had confded that her father
had used to manipulate and control her. She believed that her father must have been right
all along, because how else could she explain yet another man seeing such ugliness in her?
Ultimately he abandoned her and her unborn child, and when her father learned of her
pregnancy he kicked her out of the house and refused to allow her to return.
For the next four years she was intermittently homeless, fnding temporary stability
through various transitional housing programs that helped her secure employment and
an apartment, but any crisis put her on the streets again, such as the time her son got the
chicken pox, resulting in her needing to stay home with him for two weeks. Kim was fred
even though she had medical verifcation of her sons illness. Tis led to yet another fnan-
cial downward spiral and another episode of homelessness. By the time her son was fve he
212 Part II / Generalist Practice and the Role of the Human Service Professional
was acting out, considerably adding to her sense of frustration and burden. So when she
met a new man who showered her with attention and compliments, all she could think of
was that she had fnally met the man of her dreams. He said all the right things, ofered
to let her and her son move in with him, and ofered to manage every part of her life. He
even told her that she would not have to work and could stay home with her son, so she
gladly quit her job and embraced being a stay-at-home mom at lastsomething she had
wanted to do for years.
Kim wanted desperately to believe this was real and accepted his seemingly generous
ofers because she believed that to do otherwise would mean robbing her son of his only
opportunity for a real home and family. When her new boyfriend told her that she was the
frst woman he ever wanted to have a baby with, she was so fattered she agreed immedi-
ately to get pregnant. She believed with all her heart that she fnally had it all, and that all
the years of sufering were behind her.
Kim became pregnant quickly and dreamed of her new life with her new boyfriend.
Although she would have preferred they got married, he claimed to not be ready yet, and
because she did not want to create waves in the relationship, she did not push the subject.
She talked endlessly to her son about their good fortune in fnding this man who was go-
ing to take care of them forever. When her new boyfriend hit her for the frst time, she
convinced herself that it was a one-time incident caused by the stress of having a new
family. When she noticed that he drank too much alcohol and seemed impatient with her
son, she convinced herself that he needed time to adjust to having an instant family. Ten
one day he did not come home from work, and when a few days had gone by and he still
did not return with her car, she came to the agency where I worked asking for fnancial
assistance because she had no money to pay for the rent due in a few short days.
Unfortunately, we learned that this man had a pattern of treating women in this way,
and this was not the frst time he had encouraged a single mom to depend on him only
to fee when the good feelings ended. Equally unfortunate was the fact that she had abso-
lutely no recourse against him, even for taking her car, because to make insurance matters
easier, she had agreed to put his name on the title, a decision that seemed foolish now, but
in light of all that he was ofering her it seemed the least that she could do. Now she had no
money; no job; no car; a devastated, hurt, and angry child; and a baby on the way; and she
would be homeless again within the month.
Adding to her burden was the intense sense of humiliation she felt when she realized
that she had once again been taken advantage of. She frmly believed that she deserved
this treatment and argued that there must be something terribly defective about her be-
cause these things kept happening to her. She was devastated that she was so horribly
abandoned in the wake of breathing her frst sigh of relief in years. She was extremely
depressed, which made her at risk for either inadvertently abusing her child or neglect-
ing him in some way, particularly when he expressed anger at her for driving his new
daddy away. And, her additional loss of self-esteem lef her in no shape to problem solve
by gaining employment, fnding low-cost housing, and searching out assistance programs,
most of which would require her to disclose her reasons for becoming homeless, forcing
her to repeat her failures and leaving her vulnerable to the criticisms of others. Although
she should have been hospitalized for severe depression and risk of suicide, she refused
because it would mean placing her son in temporary foster care.
Homelessness 213
Ultimately, she managed to piece her life back together, and it was the security of an
authentic counseling relationship that enabled her to resist getting into another whirlwind
romance and allowed her to see that saying no to a man was not saying no to a secure future,
but likely saying no to another abusive and exploitative relationship. Virtually all my guid-
ance meant her acting in a counterintuitive manner. She was desperate for love and compan-
ionship, yet I cautioned her to resist getting into a relationship until she was out of crisis. She
desperately wanted to avoid revisiting old wounds from her childhood, yet I encouraged her
to delve into her early experiences drawing parallels with relationships in her adult life and
helping her to see the patterns she seemed helpless to escape. It would be difcult to imagine
my client developing the wisdom to respond to her psychological issues and her current life
crisis without the beneft of the objective and unconditional support of a human service pro-
fessional trained to understand and respond to sufering from a social systems perspective
embracing, encouraging, supporting, and guiding in a nonjudgmental manner.
Although Kims life sounds complicated, it is not at all unique. Understanding the
dynamics involved in intergenerational abuse and poverty helps one to understand how
and why people repeatedly make what ofen turns out to be unhealthy choices that when
combined with social and structural factors leave them vulnerable and at risk for severe
poverty and homelessness. Tus, although it might be easy to sit in the comfort of ones
stable and healthy home environment and criticize the immoral lifestyle of single moth-
ers who jump from relationship to relationship getting pregnant along the way, once all
the situational factors are known and someone takes the time to truly look at the world
through the eyes of someone sufering and alone, it becomes far easier to understand
how someone could make the choices my client did. One of the saddest statements of
humankind is that it seems as though for every vulnerable and hurting person, there is
someone waiting to exploit him or her. Fortunately there are just as many people wait-
ing to lend them an accepting, nonjudgmental, and helping hand as well.
Common Practice Settings for Working with
the Homeless Population
Programs designed to aid the homeless population are ofered in three levels of service.
Te frst includes emergency shelters and daytime drop-in centers. Both ofer short-term so-
lutions to a long-term problem. Although emergency services are defnitely needed, par-
ticularly when dealing with a population that might experience a crisis resulting in sudden
homelessness, many emergency shelters are sharply criticized for their ofen unsafe and
infexible environment where residents can stay for as short as one night to as many as 30
days. Another area of criticism is that far greater amounts of funding are appropriated for
emergency services rather than for long-term programs and services (Shlay & Rossi, 1992).
Te second level of service includes transitional housing programs. Tese programs
ofer temporary housing for anywhere from six months to two years, with most pro-
grams ofering a one-year program. Housing is only one part of the program package,
though, and residents are typically required to participate in a wide range of adjunct
214 Part II / Generalist Practice and the Role of the Human Service Professional
social services such as job training, budgeting classes, adult literacy, substance abuse
treatment, and parenting training. Other support services may include child care, job
placement, and medical care. Most transitional housing programs focus on a specifc
target population, such as victims of domestic violence, single-mother families, single
men sufering from substance abuse, adolescents, or the aging. Tese programs tend
to be more successful because they provide a wide range of intensive services aimed
at addressing the root causes of extreme poverty and homelessness, but they are also
challenging to facilitate due to the complexity of the issues being addressed and the cost
associated with administering programs ofering comprehensive services, particularly
because one of the primary root causes of homelessness is the unavailability of low-cost
housing. Tus, to secure housing for homeless clients is just as expensive for the ad-
ministering agency. Unfortunately, transitional housing programs have not garnered the
majority of governmental funding.
A type of homeless service that is actually a combination of levels one and two in-
cludes domestic violence shelters. Because domestic violence is such a signifcant is-
sue in the prevalence of single-parent families becoming homeless, shelters specialize in
meeting the needs of individuals, most commonly women and children, who are fee-
ing from dangerous domestic relationships. Although there is some variation, the most
common scenario involves a woman with children feeing from a boyfriend or hus-
band who is physically, emotionally, and verbally abusive. Domestic violence shelters
operate on a 24-hour emergency basis, providing safe houses whose locations remain
confdential.
Most domestic violence shelters have various homes and apartments spread
throughout the community, each shared by a few women and children. Shelter stays
range from one month to several months, and residents and their children participate
in a broad range of services, including support groups for the mothers and the children.
Human service professionals provide counseling, case management, and advocacy ser-
vices, including assisting clients obtain orders of protection through the court system
and advocating for them during any criminal or civil court hearings. Support groups
focus on empowerment issues and educating the women on the nature of domestic vio-
lence, parenting from a perspective of strength, and developing better boundaries in re-
lationships. Services may also include providing job training skills and job networking,
locating child care, referral for substance abuse treatment, and assistance in locating
permanent housing. In general, human service professionals provide as many services
as are needed by the client.
Issues related to domestic violence will be explored in greater depth in Chapter 12
on violence, but it is important to understand that working with domestic violence vic-
tims can be challenging for a variety of reasons, but one of the most difcult aspects of
working with this population is the cyclical nature of domestic violence where victims
ofen return to their batterers when promises are made to authentically change.
Te third level of service involves the provision of low-cost or public housing projects
provided by HUD, which theoretically provides a permanent solution for the problem
of homelessness. Unfortunately, this solution is the most difcult to provide and does
not have a good track record of providing efective resolution to the homeless problem
Homelessness 215
because traditional public housing units mostly built in the 1950s were developed as
high-rise units in low-income neighborhoods, essentially creating segregated societies
of the poor, not only producing dangerous neighborhoods but also further adding to
the general negative stigma associated with poverty. Gang activity, drug dealing, and
other crimes ofen associated with the urban inner city were common in what is ofen
casually referred to as the projects.
Once government policy makers realized that housing projects of this type were
likely causing more harm than good, an organized attempt was initiated to close the
projects down, particularly in large cities such as Chicago and Philadelphia, and to tran-
sition residents to new low-rise housing units scattered throughout the city. Yet squat-
ting became a signifcant problem, with some squatters even using the empty units as
drug labs or gang hideouts.
A more current form of permanent low-cost housing includes governmental
voucher programs facilitated by HUD. HUDs Section 8 housing voucher program de-
signed for the general population and Section 811 designed for individuals sufering
from disabilities (including mental illness) involve qualifed individuals or families ap-
plying for the program when it is accepting applications (which may only be a few short
periods throughout the year) and having their benefts determined. Te voucher benef-
ciary must then locate a landlord who is willing to accept a government rent voucher as
rental payment.
Teoretically the voucher can be used with any rental, but either through bias or be-
cause of a competitive rental market, many landlords in more expensive communities will
not accept Section 8 or 811 rental vouchers. Tus, even though one intention of this pro-
gram was to avoid the isolation and segregation created by high-rise congregated public
housing, in many communities the result is still much the same because it is not the indi-
vidual landlord of units scattered throughout the city that is most likely to accept a rental
voucher, but the owners of large apartment complexes in low-income
areas where occupancy rates run high who are the most likely to
accept rental vouchers, creating the same sort of isolated high-crime
environment experienced with public housing high rises.
Unfortunately, the need for housing has not kept pace with avail-
ability, and the recent spike in home foreclosures in response to the
Great Recession of 20072009 has resulted in an increase in home-
lessness and a decrease in funding for housing assistance programs,
including signifcant funding cuts in the Section 8 and 811 housing,
and hope is limited that funding will significantly improve in the
near future. For this program to be successful the federal govern-
ment must make a frm commitment to subsidized housing that will
be refected in funding these programs appropriately.
Concluding Thoughts on Homelessness
Homelessness is a complex social problem with multifaceted causes, including sev-
eral root causes that lie in the personal domain (such as domestic violence, substance
Professional History
Understanding and Mastery of Profes-
sional History: Historical and current leg-
islation affecting services delivery
Critical Thinking Question: What have
been some of the unintended conse-
quences of programs such as public
housing projects and Section 8 vouch-
ers? How have these consequences
contributed to the institutionalization
of poverty?
216 Part II / Generalist Practice and the Role of the Human Service Professional
abuse, and teen pregnancy), as well as social causes such as institutionalized racism and
oppression and structural causes related to the changing U.S. economy.
Structural issues related to a capitalist society include declining salaries, particularly
for the poor, and escalating housing prices, which when combined creates an abun-
dance of low-income renters competing for fewer afordable housing units. Te devel-
opment of afordable housing, although a good idea in theory, is challenging due to the
high cost of land and housing in safer areas. In addition, most people who are at risk
of homelessness ofen cannot aford to pay a signifcant portion of
their own rent and many cannot aford to pay any rent at all. Tus,
regardless of how the rental subsidies are structured, focusing on af-
fordable subsidized housing as the primary resolution to the home-
less problem essentially requires permanent governmental support,
and unless adjunct services are provided, some argue that permanent
subsidized housing programs may encourage dependency rather
than fostering independence (Wright, 2000).
It appears then that programs ofering a wide array of social ser-
vices focusing on the personal root causes of homelessness, while
at the same time addressing structural causes such as declining in-
comes and escalating housing costs, will have the greatest likelihood
of successfully addressing the homeless problem with long-term solutions in mind. Hu-
man services agencies are on the front lines of developing such programs designed to
promote self-sufciency and personal security.
Programs offering a wide array
of social services focusing on
the personal root causes of
homelessness, while at the same
time addressing structural causes
such as declining incomes and
escalating housing costs, will
have the greatest likelihood
of successfully addressing the
homeless problem.
1. The rate of homelessness began to increase between
1970 and 1980 due to
a. a decrease in affordable housing
b. an increase in poverty
c. an increase in depression
d. Both A and B
2. Despite considerable research existing to support
the opposite, a 1995 survey revealed that there was
an increase in mainstream societys tendency to
blame ______ for their poverty.
a. the poor
b. racism
c. poor schools
d. a poor economy
3. The 1970s and 1980s saw a dramatic increase in the
homelessness of
a. veterans
b. intact families
c. female single-parent head-of-households with
children
d. adolescents
4. Many homeless single mothers report having had
a. unstable childhoods flled with physical and sexual
abuse
b. numerous sexual partners
c. children with several different men
d. a history of receiving public assistance
5. The majority of homeless single mothers are
a. 25 years of age, native-born U.S. citizens with two
to three children
b. over the age of 35, with four to fve children and
a history of substance abuse
c. Latino, undocumented immigrants who do not
speak English
d. African Americans who have four to fve children
from several men, and a history of welfare fraud
6. HUDs Section 8 housing voucher program is de-
signed for
a. individuals with disabilities (including mental
illness)
b. the general population
c. single mothers and children
d. veterans
The following questions will test your knowledge of the content found within this chapter.
CHAPTER 9 PRACTICE TEST
7. Describe the effect of religious and philosophical ideologies on the perception and treatment of the poor.
8. Describe some of the challenges facing homeless single mothers residing in traditional homeless shelters and how
human service professionals might assist clients in managing various challenges.
Suggested Readings
Jencks, C. (1995). The homeless. Cambridge, MA: Harvard
University Press.
Kozol, J. (1988). Rachel and her children: Homeless families in
America. New York: Ballantine Books.
Liebow, E. (1995). Tell them who I am: The lives of homeless
women. East Rutherford, NJ: Penguin Books.
Stephen, B. (2000). Street crazy: Americas mental health trag-
edy. Redondo Beach, CA: Westcom Associates.
217
218 Part II / Generalist Practice and the Role of the Human Service Professional
Internet Resources
Homeless Advocacy Project: http://www.homelessadvocacy
project.org
U.S. Department of Housing and Urban Development:
http://www.hud.gov
National Coalition for the Homeless: http://www.national
homeless.org
References
Auerswalk, C. L., & Eyre, S. L. (2002). Youth homelessness in San
Francisco: A life cycle approach. Social Science and Medicine, 54,
14971512.
Axelson, L. H., & Dail, P. W. (1988). The changing character of
homelessness in the U.S. Family Relations, 37(4), 463469.
Beech, M., Meyers, L., & Beech, D. J. (2002). Hepatitis B and C in-
fections among homeless adolescents. Family Community Health,
25(2), 2836.
Davey, T. L. (2004). A multiple-family group intervention for
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220
Human Services in Medical and Healthcare Settings
At 9 a.m. Glenn is called to the labor and delivery department of a large
hospital where he tries to talk with a teenage girl who just had a baby. Te
young girl holds her new infant as Glenn initiates a conversation with
her. He explains that he is visiting her because it is hospital policy for the
human service professional to visit with all adolescents who have just had
babies. He asks the young mother a few basic questions, such as whether
she has a place to live once she and her infant leave the hospital, whether
her parents knew about her pregnancy, whether the father of the baby
is involved, and whether she has a plan for raising her child. Te young
mother admits that her parents knew nothing of her pregnancy, as she
managed to hide it by wearing large clothing and spending a lot of time
in her room. She admits she is frightened that if she shares the news with
them, they will force her to leave their home. And she admits that the
father is no longer in her life and that she has no ability, nor any real de-
sire, to raise a child. Glenn understands that this mothers ambivalence
about raising her child is far more related to her age than her charac-
ter. Afer some further discussion, Glenn asks her if shed be interested
in talking with a counselor who can assist her sorting through all the
options available to her. Afer learning that her parents were generally
supportive and loving people, he ofers to call them for her so that they
can help her decide how to best manage this unplanned pregnancy. Te
young mother appears relieved and admits that she considered just leav-
ing the hospital without her baby because she was so desperately fright-
ened and didnt know what else to do. When Glenn returns to his ofce,
he makes the call to the parents; afer a 20-minute emotional phone call,
he makes plans to meet them in 30 minutes in their daughters hospital
room. Afer meeting with the entire family, he supplies them with several
names of counseling agencies that can assist the young mom in either
parenting or placing her infant for adoption.
Healthcare and Hospice
CHAPTER 10
Learning Objectives
Become familiar with the gen-
eral nature of trauma counseling
often conducted in a hospital
setting
Describe the skills necessary for
the rapid assessment of patients
in an acute medical situation
Become familiar with the hos-
pice philosophy including the
defnition and nature of palliative
care
Explore various theoretical
models of grief and mourning,
including traditional stage mod-
els as well as more contempo-
rary task model approaches
Understand common ethi-
cal dilemmas involved in the
care of the sick and dying,
including euthanasia, and the
inadvertent omission of those
individuals who are economically
disadvantaged
Dennis Sabo/Shutterstock.com
Healthcare and Hospice 221
While walking out of the hospital room Glenn is paged to the emergency room.
When he arrives, he fnds the entire unit in chaos. Tree cars collided, and many peo-
ple were injured. Afer talking to the emergency room nurses and physicians, Glenn
learns that one of the cars had several children in it, many of whom were seriously in-
jured. Glenn gets to work right away collecting identifying information, making sure
that each childs parent is accounted for, and obtaining numbers of parents who need to
be notifed of the accident and their childs condition. Afer obtaining all necessary in-
formation, Glenn makes himself available to the parents who had children in surgery
parents who were not in the accident, whom he recently called to the hospitaland the
children who are not seriously injured but had parents who were. He ofers to contact
friends and family for support. Afer contacting spouses and two family pastors, Glenn
sat with one family who had two seriously injured children and provided crisis counsel-
ing so that they could be calm enough to understand all that was going on with their
children. Glenn also ofers to be the conduit between the waiting families and the medi-
cal team, so for over an hour he goes back and forth between the medical personnel
working on the injured and delivering any new information to the family members.
Two hours later, all parties were out of crisis and had support systems by their sides, and
Glenn was cleared to return to his ofce.
Next, Glenn began working on several discharge planning cases for various patients
who were scheduled to be released from the hospital within the next two days. One was
an older patient who was not healthy enough to return home, and it was Glenns respon-
sibility to assist the family in fnding either appropriate alternate housing or in-house
services that would enable the patient to remain in his home. Another case involved a
survivor of a serious car accident who needed continued therapy, but could no longer
remain in the hospital. Glenns job was to locate a rehabilitation center close to family
that would be covered under his insurance plan.
As Glenns day was coming to a close, he was paged again to the emergency room,
where he learned there was a potential victim of sexual assault. Glenn asked the victim
if she was comfortable talking to him, but she stated that she was notshe preferred a
female counselor. Glenn then called the local county rape crisis center and asked for a vol-
unteer to come to the hospital immediately to counsel and support a sexual assault victim.
On his way out of the emergency room he was asked to consult on a potential child
abuse case. Glenn interviewed the parents of a six-year-old boy who sufered a spiral
fracture of the arm. Glenn became concerned when he interviewed each parent sep-
arately and their stories difered signifcantly. Because of this and the childs inability
to describe in detail how he injured his arm, Glenn felt the case warranted a call to
child protective services (CPS). He explained to the parents that he would be making an
abuse allegation report and that the child would not be released until a CPS caseworker
came to the hospital and interviewed everyone in the family.
Prior to Glenn leaving for the day, he was asked to visit with a patient and her adult
son who just learned of her terminal diagnosis. Glenn provided both with some crisis
counseling and made a referral to a local hospice agency. He ofered to meet with them
again tomorrow and to meet with them and the hospice team if they wished. Glenns
last case for the day was to provide counseling to a 60-year-old man who recently
222 Part II / Generalist Practice and the Role of the Human Service Professional
underwent a liver transplant and was about to be released from the hospital. Research
indicates that transplant patients ofen experience depression afer being released from
the hospital, thus Glenns focus was to help this patient adjust to the realities of being
a transplant patient, as well as preparing him for experiencing some depression in the
coming weeks. He made sure this patient lef armed with names of counselors who had
experience working with transplant patients.
Tis is a typical day of a human service professional working in a medical or health-
care setting, and although this description is realistic, it is probably more realistic to
state that there is no such thing as a typical day for a human service professional in
a healthcare setting! In fact, someone interested in a career in the human services feld
and looking for structure and predictability would probably not fare well in a healthcare
center, where the broad range of patient issues determines the range of issues dealt with
by the human service team.
Human service professionals have traditionally worked in hospital settings in a va-
riety of capacities, yet as the healthcare feld branched out to other arenas, including
community-based healthcare centers, primary care full-service clinics, and specialized
health centers serving special populations (such as AIDS/HIV patients, women, or
those sufering from cancer), human service professionals can now be found in a variety
of healthcare-related practice settings.
Healthcare is one feld where most professionals working in hu-
man services are ofen required to be licensed human service pro-
fessionals in some capacity. Tere is some variation from state to
state, but healthcare settings are highly regulated felds and as such
professionals working in these environments are typically required
to have both advanced degrees and state licensing.
Human service professionals working in medical settings are
true generalists: they must be fexible and able to deal with a variety
of issues, ofen in a setting wrought with crisis and trauma. But despite their broad gen-
eralist functions, the scope of human service professional functions in healthcare and
hospital settings can be quite specifc. Tese functions and responsibilities may include
conducting psychosocial assessments on patients as needed
providing information and referrals for patients
preadmission planning
discharge planning
psychosocial counseling
fnancial counseling
health education
postdischarge follow-up
consultation with colleagues
outpatient continuity of care
patient and family conferences regarding health status, care, and future planning
case management for patients
facilitation of and referral to self-help and emotional support groups for patients
and families
Healthcare settings are highly
regulated felds and as such
professionals working in these
environments are typically required
to have both advanced degrees
and state licensing.
Healthcare and Hospice 223
patient and family advocacy
trauma response
assistance in exploring bioethical issues
outcome evaluations on best practice committees
In addition to performing these various functions, some of the issues addressed by
human service professionals working in medical settings include addressing patient
problems related to activities of daily living, assisting patients and their families in deal-
ing with illness adjustment, assessing possible physical and sexual abuse, including
child abuse and domestic violence, and assessing patients with potential mental health
problems (NASW, 1990).
Crisis and Trauma Counseling
A large part of a human service professionals role in a medical or healthcare setting
is to provide crisis and trauma counseling to patients and their families. In fact, when
the hospital has notifed the family of a patient who has been seriously injured either
through illness or accident, it is ofen someone from the human services department
who meets the family at the emergency room doors.
A good model for how to approach an individual or family in crisis is one developed
by Abraham Maslow. Maslow (1954) created a model focusing on needs motivation. As
Figure 10.1 illustrates, Maslow believed that people are motivated to get their most basic
physiological needs met frst (such as the need for food and oxygen) before they attempt
SELF-ACTUALIZATION
NEEDS
ESTEEM NEEDS
LOVE NEEDS
SAFETY NEEDS
PHYSIOLOGICAL NEEDS
FIGURE 10.1
Maslows Hierarchy of
Needs
Maslow, Abraham H.; Frager, Robert D.; Fadiman, James, Motivation and Personality, 3rd Ed., 1987.
Reprinted and Electronically reproduced by permission of Pearson Education, Upper Saddle River,
New Jersey
224 Part II / Generalist Practice and the Role of the Human Service Professional
to meet their safety needs (such as the security we fnd in the stability of our relation-
ships with family and friends). According to Maslow, most people would fnd it difcult
to focus on higher level needs related to self-esteem or self-actualization when their
most basic needs are not being met. Consider anyone you know who sufers from low
self-esteem and then consider how he might react if a war suddenly broke out and his
community was under siege. Maslows theory suggests that thoughts of low self-esteem
would quickly take a back seat as worries about mere survival took hold.
When individuals are facing a signifcant crisis, they ofen feel compelled to get their
most basic needs met. In situations where family members or close friends have been
called to the hospital in response to a loved one having been in a serious accident or suf-
fering from some life-threatening illness, their frst priority is ofen to obtain information
about the medical status of the patient and it is very important for the human service pro-
fessional to avoid escalating in panic or anxiety along with the family. In fact, it is vital that
professionalism be maintained in the midst of the crisis so that amidst crying, screaming,
and perhaps even misplaced anger, the human service professional can serve as a calming
infuence that the family can rely on as they attempt to regain their composure.
Each family handles crises diferently; thus, it is important for the human service
professional to quickly recognize the familys coping style. Some families will focus on
mundane details, such as asking how long their loved one will be in the hospital when
the patient has not even emerged from emergency surgery, and some families will focus
directly on important issues, such as repeatedly asking whether the patient will survive
the surgery, even though there might be no way to answer such a question until the
patient is out of surgery. Regardless of these individual coping styles, the human service
professional must be able to read between the lines recognizing that a family confronted
with the shocking news of a loved one having a life-threatening condition ofen leaves
them feeling dazed and powerless, and many of the questions or actions are rational or
irrational attempts to recover some sense of control over the situation. By understand-
ing this dynamic, the human service professional can take concrete steps to assist the in-
dividual family members in gaining as much control as possible by acting as the conduit
between the medical staf and the family, by helping the family focus on the most im-
portant issues, and by assisting them in developing a plan of action that might include
fnding child care for younger children, having someone go to the patients house to care
for pets, and notifying friends and employers on behalf of the patient.
Te human service professionals role continues with the family as the situation pro-
gresses, but takes on a diferent role, including assisting the patient and family adjust to
any limitations posed by the patients condition or injury, fnding necessary resources,
and conducting discharge planning when the patient is well enough to leave the hospi-
tal. Te human service professional will even follow up with the patient and family afer
discharge to check on their progress.
Single Visits and Rapid Assessment
Most human service professionals assume that they will be able to work with their
clientsregardless of their role in the helping processover an extended period of time.
Yet, this is typically not the case in a hospital setting due to the trend toward signif-
cantly shortened duration of hospital stays. In fact, ofen human service professionals
Healthcare and Hospice 225
working in a hospital setting will see patients only one or two times. Because of this
pattern, there is a growing body of literature on single session encounters with clients,
and how human service professionals can develop a set of skills that allow for rapidly
assessing the patient and their situation, and assist them efectively, depending upon the
role and functions of the human service worker.
Gibbons and Plath (2009) explored this very issue by interviewing several patients
and asking what they found helpful in these single sessions and which skills and quali-
ties were helpful and which were not. Tey isolated seven basic skillsets that medical
social workers needed in order to engage successfully with patients during a single ses-
sion. Tese included the ability to
1. quickly put the patient at ease
2. establish a rapport and a sense of trust quickly
3. exhibit a sense of competence
4. engage in active listening and exhibit empathy
5. be nonjudgmental
6. provide needed information quickly
7. organize support services
Although the study focuses on medical social workers, the applica-
tion is appropriate for generalist human service workers as well, at
least in some general respects. Since many hospitals hire human ser-
vice professionals with certifcates and bachelors degrees to conduct
discharge planning, case management, and patient advocacy, as well
as other functions related to patient care, the skill set discussed by
Gibbons and Plath can be applied to a broader range of roles within
the human services profession.
Working with Patients with HIV/AIDS
Human service professionals working in a medical setting, particularly in public health,
commonly work with various health-related epidemics or pandemics. HIV, which
causes AIDS, is an example of such a pandemic. HIV and AIDS were frst discussed in
the medical literature in 1981 (Gottlieb et al., 1981). Medical treatment during these
early years typically occurred in a crisis setting when patients presented in the emer-
gency room with advanced or end-stage AIDS infections, such as Pneumocystis carinii
pneumonia (PCP) and Kaposis sarcoma, both opportunistic infections common in end-
stage AIDS patients. In August 1981, 108 AIDS cases were reported in the United States
by the Centers for Disease Control and Prevention (CDC). By 1986 the CDC reported
16,458 cases of AIDS in the United States and 8,361 deaths, and just two years later
those numbers rose to 72,024 cases with an estimate that 1 to 1.5 million Americans
were infected with HIV (Centers for Disease Control, 1988).
During the early years of the AIDS crisis, the role of the human service professionals
focused almost exclusively on the crisis of receiving a terminal diagnosis and included
conducting emergency discharge planning, death preparation, arranging for acute care,
and initiating hospice services. By the 1990s education eforts led to earlier diagnoses
and better medical treatment for those who could aford it and clinical intervention
Human Systems
Understanding and Mastery of Human
Systems: Emphasis on the context and
role of diversity in determining and
meeting human needs
Critical Thinking Question: Human
service professionals working in hospital
settings often have only one or two
brief contacts with their clients; and they
are called on to serve a wide variety of
people whose circumstances vary enor-
mously. How might these factors shape
the manner in which the professional
approaches her or his work?
226 Part II / Generalist Practice and the Role of the Human Service Professional
focused more on the psychosocial issues involved with having a chronic, debilitating,
and sometimes terminal disease that carried a stigma with it. Tese psychosocial is-
sues typically included a fear of discrimination, concerns about receiving quality medi-
cal care, job accommodations and other income sources, and housing accommodations
when physical health begins to decline (Kaplan, Tomaszewski, & Gorin, 2004).
When HIV/AIDS frst emerged in the United States, there were no medical treat-
ments available to address the actual disease process (other than symptomatic relief),
but through grassroots eforts (that led to signifcant fund-raising eforts for medical
research) signifcant medical advances were gained throughout the 1990s until HIV/
AIDS is now considered more of a chronic, rather than terminal, diseasefor those
individuals fortunate enough to have access to expensive antiviral therapy. Despite these
medical advances, however, the treatment of HIV/AIDS remains a serious public health
concern, particularly for those individuals who have no access to advanced medical
treatment or who do not respond positively to the most aggressive antiviral therapies,
commonly referred to as the AIDS cocktail.
Te most recent statistics available from the Centers for Disease Control and Preven-
tion (CDC) (2010) indicate that at the end of 2009, about 1.2 million people in the United
States were living with HIV/AIDS (both diagnosed and undiagnosed). Te CDC estimates
that there were approximately 41,540 new cases of HIV diagnosed in 2009. According to
the CDC, the population at greatest risk remains what the CDC refers to as the Men who
have sex with men or MSM group. Tis group represents 2 percent of the population, but
consists of 61 percent of all new HIV cases diagnosed in 2009 and about half of all people
currently living with HIV/AIDS. White MSM and black MSM account for the majority of
new diagnoses in 2009 (11,400 and 10,800 cases, respectively) followed by Latino MSM
(6,000 cases). Heterosexuals consisted of approximately 27 percent of all new diagnoses
in 2009. Young black heterosexual men were the only group that experienced an increase
in diagnoses in 2009. Women consisted of about 23 percent of all new diagnoses in 2009,
with black women consisting of about 65 percent of those cases.
The ongoing trend in the demographics of AIDS that disproportionately affects
people of color, particularly black women, has led to many changes in the psychosocial
needs of the HIV/AIDS population, which has had an impact on the roles and func-
tions of medical human service professionals working with this population. Tere is still
considerable social stigma associated with an HIV/AIDS diagnosis, particularly in light
of the uninformed belief that it is a disease afecting only the homosexual population.
But because HIV/AIDS was a disease that afected primarily Caucasians when it frst
surfaced in the United States, racial discrimination was not a central psychosocial issue.
But now that this disease is afecting many minority communities, racial discrimination
has been coupled with the existing social stigmas that ofen presume immoral behavior,
such as sexual promiscuity and drug abuse. Despite aggressive public awareness cam-
paigns in both the general public and the professional community designed to increase
general awareness and remove stigma, many individuals with the HIV/AIDS virus are
forced to endure numerous barriers to getting basic needs metsome of which are re-
lated to the stigma, some related to institutionalized racial discrimination, and some
related to a combination of both (Kaplan et al., 2004).
Healthcare and Hospice 227
For instance, quality medical care is lacking on most Native American reservations,
and native advocates argue that reasons for this relate to racial disparity and historic
mistreatment and oppression. When reservations were frst confronted with a rapidly
increasing incidence of HIV/AIDS, elders complained that the medical neglect experi-
enced on most reservations was yet another form of racial discrimination and oppression,
evidenced by the fact that the federal government was not allocating sufcient funding
to address this issue on the reservations (Weaver, 1999). Human service professionals
working within the medical feld must be aware of the various ways that racial preju-
dice plays out within the community, whether such discrimination be direct and overt or
institutionalized (such as where federal monies are allocated). Tis awareness can then
translate into advocacy and outreach as well as increased sensitivity as practitioners chal-
lenge their own perception of the HIV/AIDS crisis, including their attitudes about those
populations that are currently being most signifcantly afected by this disease.
HIV/AIDS and the Latino Population
Although the white MSM population still account for the majority of those in the United
States diagnosed with HIV/AIDS in 2009 (the most recent data available), according to
the CDC (2011), the Latino population is disproportionately afected by the HIV/AIDS
virus. While Latinos represent approximately 16 percent of the population, they consti-
tuted about 20 percent of all new HIV diagnoses in 2009, an incidence rate three times
that of Caucasians (relative to their representation in the population). Te largest group
among Latinos diagnosed with HIV in 2009 is Latino MSM.
Among the U.S. Latino/a population, those living in the southern states, where the
Latino/a population has grown by over 200 percent since 1990, are particularly vulner-
able for a variety of reasons. A report focusing on a two-year fact-fnding and coopera-
tion program facilitated by the Latino Commission on AIDS explored the extent and
nature of the HIV/AIDS problem within the Latino/a population living in the Deep
South, which includes Alabama, Georgia, Louisiana, Mississippi, North Carolina, South
Carolina, and Tennessee (Frasca, 2008).
The program, also referred to as the Deep South Project, found evidence that
Latinos/as/ are being infected with HIV at disproportionate and rising rates in the south,
FIGURE 10.2
Bar Graph Compar-
ing Rates (per 100,000
population) of AIDS by
Race/Ethnicity, 2004, 50
States, Including District
of Columbia
Source: Based on statistics from
CDC, HIV/AIDS Surveillance
Report, 2004, Vol. 16.
100
80
60
40
20
0
White Black Hispanic Asian Native
American
Male
Female
Total
228 Part II / Generalist Practice and the Role of the Human Service Professional
and yet are ofen excluded from the healthcare system, as well as HIV/AIDS-related ser-
vices, (such as prevention and educational programs) due to their immigration status,
fear related to an increase in anti-immigrant hostility, the stigmatization of the disease
with the Latino/a community. Tey also lack access to HIV/AIDS-related services due
to geographic isolation. In general, there are insufcient HIV/AIDS-related programs in
the Deep South focusing on the Latino/a population, and an insufcient number of bi-
lingual service providers. Te report found that due to a lack of awareness of the nature
of the disease and lack of access to quality healthcare, many within the Latino/a popula-
tion are diagnosed in the later stages of the disease, which limits the success rate of the
antiviral therapy (ART) protocol (Frasca, 2008).
Many Latino/a relationships tend to refect more traditional gender roles consistent
with machismo culture, which increases the risk of contraction and transmission of the
HIV/AIDS virus. For instance, within the machismo culture, men commonly engage
in high-risk sexual behaviors in order to prove their manhood, such as having multiple
sex partners, despite being married, and not wearing a condom. Latina women ofen
cite an awareness that their male partners sexual behavior places them at greater risk
for contracting the HIV/AIDS virus, but they do not believe they have enough power in
the relationship to make demands for safe-sex practices, such as fdelity and wearing a
condom (Acevedo, 2008).
Human service professionals working within the Latino/a population must develop
a level of cultural competence in working with this population, becoming aware of the
many culturally related risk factors afecting this population. Tey must also be aware
of how racial prejudice, social exclusion based upon immigration status (or perceived
status), and various stigmas impact the Latino/as access to educational and prevention
services, as well as access to quality and timely healthcare (Acevedo, 2008).
Te Deep South project report makes several recommendations, including public
health departments conducting needs assessment of the Latino/a population, increas-
ing outreach eforts in high Latino/a communities, increasing the number of bilingual
service providers, increasing the cultural competency of service providers working with
the Latino/a population, and increase HIV/AIDS research on Latino/a populations so
that the literature more accurately refects the nature and needs of the Latino/a popula-
tion (Frasca, 2008).
Concluding Thoughts on Working with the HIV/AIDS Population
When confronting the HIV/AIDS crisis, human service professionals engage in a four-
pronged approach to psychosocial care, including prevention and educational awareness
(such as the practice of safe sex), client advocacy, and case management/counseling.
Human service professionals are actively involved in both practice and policy aspects of
the HIV/AIDS pandemic, including meeting the psychosocial needs of those diagnosed
with HIV/AIDS, as well as being on the front lines of prevention eforts, community and
patient educational and awareness campaigns, advocacy for increased funding of inter-
vention and treatment programs, and participating in lobbying eforts, advocating for
the passage of laws designed to protect the privacy and legal rights of those diagnosed
with HIV/AIDS.
Healthcare and Hospice 229
Human service professionals working in a medical or healthcare
setting assist those with HIV/AIDS in obtaining necessary medical
services, obtaining the necessary funding for treatment, and pro-
viding counseling for those infected individuals, their families, and
caregivers. Te nature of the counseling will change depending on
the progression of the virus. Clients newly diagnosed will need
counseling focusing on acceptance of a potentially terminal disease,
whereas other clients will need counseling focusing on living with a
chronic illness, accepting a life of potential disability, accepting a life
that includes multiple medications taken on a daily basis, and learn-
ing to live with the consequences of stigmatized disease.
Depending on the demographic nature of the patient, the hu-
man service professional may help secure child care; help the patient
apply for fnancial assistance; obtain home healthcare; maintain or
obtain employment, housing, and medical care, including care for
other health-related issues, such as substance abuse; and fnally help the patient and
family contend with the various stressors involved with having a stigmatized illness
(Galambos, 2004).
The Hospice Movement
Hospice care is a service provided to the terminally ill that focuses on comprehensive
care addressing their physical, emotional, social, and spiritual needs. Although hos-
pices have existed since about the 4th century, the biblical and Roman concepts of hos-
pice involved providing refuge for the poor, sick, travelers, and soldiers returning from
war. Hospice as a refuge or service for the terminally ill was not developed until the
mid-1960s.
Te modern hospice movement emerged from the general dissatisfaction with
how dying individuals were being treated by the established medical community.
Western medicine is curative by design with a focus on restoring individuals back
to a state of healthy functioning. Tis model lef the majority of the
traditional medical community at a loss as to how to treat those who
were beyond the hope of recovery. Dying patients ofen felt neglected
and isolated in depersonalized hospital settings where they were typi-
cally subjected to needless and futile medical interventions. Te hos-
pice movement challenged the treatment provided by the traditional
medical community that ofen failed to address pain management ef-
fectively and ofen neglected the psychosocial and spiritual needs of
the dying patient.
The History of Hospice: The Neglect of the Dying
Dame Cicely Saunders, the founder of the modern hospice movement, recognized this
lapse of appropriate care for the dying and set about to make signifcant changes that
would afect how the world viewed the dying process. Originally trained as a nurse,
Human Services
Delivery Systems
Understanding and Mastery of Human
Services Delivery Systems: Range of
populations served and needs addressed
by human services
Critical Thinking Question: Why is it
critical for human service professionals
to demonstrate cultural sensitivity and
cultural competence in their HIV/AIDS
prevention, education, and treatment
work with Latino/a, African American,
and Native American populations?
The hospice movement challenged
the treatment provided by the
traditional medical community
that often failed to address pain
management effectively and often
neglected the psychosocial and
spiritual needs of the dying patient.
230 Part II / Generalist Practice and the Role of the Human Service Professional
Saunders eventually earned her degree in medicine and quickly challenged what she saw
as the medical communitys failure to address the comprehensive needs of terminally ill
patients. Saunders was passionate about the care of the terminally ill and in 1958 wrote
her frst paper, entitled Dying of Cancer, addressing the need to approach dying as a
natural stage of life. Trough her work with the terminally ill, Saunders recognized that
dying patients required a far diferent approach to treatment than the traditional one
that tended to see death as a personal and medical failure.
In Saunderss personal letters, she describes in detail her discussions with terminally
ill patients in the hospice where she worked, as well as her dedication to the prospects of
developing a system of care committed to a dying process without pain, while enabling
terminally diagnosed patients to maintain their sense of dignity throughout the dying
process (Clark, 2002). Saunders founded St. Christophers Hospice of London in 1967.
Her model of care used a multifaceted approach, where dying patients were treated with
compassion so that their fnal days were spent in peace rather than undergoing inva-
sive and futile medical treatments and where they were free to attend to the business of
dying, such as saying good-bye to their loved ones.
Te Connecticut Hospice, Inc., was the frst hospice opened in the United States in
1974 in New Haven, Connecticut, funded by the National Cancer Institute (NCI). Te
hospice was created for many of the same reasons noted by Saundersthe belief that
good end-of-life care was severely lacking within the U.S. hospital system and the belief
that the dying process was a meaningful one worthy of honor and respect (Stein, 2004).
When the HIV/AIDS crisis frst began in the 1980s, and prior to the development of
antiviral treatment, hospices took on a signifcant role in the end-of-life care of those
dying of the AIDS virus. Although there are some freestanding hospices, hospice is
not a place, but rather it is a concept of care and can be provided anywhere a patient
resides (Paradis & Cummings, 1986).
Te hospice movement has grown immensely in a relatively short period of time,
and what began as a grassroots efort of trained volunteers supported by philanthropic
agencies, such as the United Way, has become a highly regulated and proftable industry
stafed by a team of professional service providers. Although the core goals and philoso-
phy of hospice remain the same, the professionalization and governmental regulation of
this feld has infuenced its service delivery model. For instance, although hospice care
was originally developed as an alternative to hospital care, many hospices in the United
States are now in some way afliated with a hospital or other healthcare organization,
most are accredited, and almost all are Medicare certifed (National Hospice and Pallia-
tive Care Organization, 2003; Paradis & Cummings, 1986).
The Hospice Philosophy
Te hospice philosophy employed today is similar to the one envisioned by Saunders.
Dying is seen not as a failure, but as a natural part of life, where every human being
has the right to die with dignity. Hospice care involves a team approach to the care and
support of the terminally ill and their family members. A core value of the hospice phi-
losophy is that each person has the right to die without pain and that the dying process
should be a meaningful experience. Because Western culture ofen perceives accepting
death as synonymous with giving up, individuals battling illness are ofen inadvertently
Healthcare and Hospice 231
encouraged to fght for their survival to the bitter end; thus, the hospice philosophy is
counterintuitive to Western cultural wisdom.
Hospice treatment involves palliative care rather than curative care. Te hospice
movement is highly supportive of patients remaining in their homes, but when that is
not possible, hospice service is provided in hospitals, nursing homes, and long-term
care facilities and can be an adjunct to other medical services provided. Te only stipu-
lation of most hospice agencies is that the patient has stopped pursuing curative treat-
ment and that the patient received a terminal diagnosis of six months or less.
THE HOSPICE TEAM Te hospice team is interdisciplinary by design, and although
there is considerable overlap in many of the roles of the various service providers, the
hospice human service professional serves a unique purpose on the team, emanat-
ing from the distinct values underlying the human services and social work discipline
(MacDonald, 1991).
Te hospice team typically consists of a hospice physician who makes periodic visits
and monitors each case through weekly reports from other team members; a nurse who
visits patients wherever they reside at least three times per week; a human service pro-
fessional who provides case management services, counseling to the patient and family,
including helping the patient say good-bye to friends and family, help resolve any past
confict, and assistance with end-of-life issues such as preparation of legal documents
such as wills, and advance directives (which will be explored in the next section); a
chaplain who provides spiritual support; a home health aid who provides daily care such
as personal hygiene; a trained volunteer who provides companionship including read-
ing to patients or taking them for strolls in a wheelchair, and a bereavement counselor
who provides counseling and support to surviving family members afer the death of the
patient. One might question whether the interdisciplinary team model works, when so
many varied professions are involved; yet, research indicates that the hospice interdisci-
plinary team model is efective as long as there is good communication, trust, and mutual
respect among team members, as well as administrative support (Oliver & Peck, 2006).
The Role of the Hospice Human Services Worker
Te hospice human service professional provides numerous services to hospice patients
and their families, including providing advocacy for patients, particularly in regard to ob-
taining services and fnancial assistance; crisis intervention when emergencies arise; case
management and coordination of services for the comprehensive care of patients and their
family members; case consultation services among hospice and other healthcare staf; as-
sisting the patient and family in planning for the patients eventual death; and bereavement
counseling to assist patients in accepting their terminal illness and in saying good-bye to
loved ones, as well as counseling surviving family members afer the patients death.
The Psychosocial Assessment
Prior to providing these services, a hospice human service professional must complete
a thorough psychosocial assessment to evaluate the strengths and defcits of the patient
and family members. How are the client and family accepting the reality of the terminal
232 Part II / Generalist Practice and the Role of the Human Service Professional
illness? Can the family realistically provide for current and future needs of the patient?
Family members who are still reeling from the news that their loved one is dying are of-
ten unrealistic in their expectations of the rigors involved with caring for a terminally ill
person and will need help to recognize their limitations and need for outside assistance.
Conducting a thorough psychosocial assessment is the frst step in making these clini-
cal determinations and ascertaining what services are needed. Chapter 4 outlines the basic
criteria of a psychosocial assessment, but the information sought and the focus of the as-
sessment change depending on the issues at hand. Tus, a psychosocial assessment of a
hospice patient will focus more on the patients current living conditions, whether they are
appropriate in relation to the patients declining health, as well as end-of-life issues. Other
dynamics explored may include the state of the patients current relationships, and whether
there are any unresolved issues that need to be resolved before the patients passing.
Intervention Strategies
Once a thorough psychosocial assessment has been conducted, the human service pro-
fessional can determine the nature and level of intervention necessary to meet the needs
of the patient and family members. In fact, the psychosocial assessment in many re-
spects acts as the blueprint for the human service professional, determining the course
of case management and counseling intervention strategies for the patient and family.
For instance, if the psychosocial assessment reveals that the patient is older and has
an aging spouse and no adult children in the immediate area, plans might need to be
made for the patients eventual placement into a facility for full-time care once the ill-
ness has progressed to a point beyond the spouses caregiving ability. Tus, even though
the patients spouse might currently be managing the daily rigors of caring for the pa-
tient, plans will need to be made for the patients care once the illness progresses and
care requirements become more complex. Tis can occur through either placement in
a residential facility, contracting with a home healthcare agency, or utilizing a day re-
spite center (depending on the nature of the illness or condition). If the psychosocial
assessment reveals that the patient has insufcient health insurance benefts, the human
service professional will assist the patient and family with applications for governmental
assistance such as Medicare.
If the psychosocial assessment reveals a mental health history of depression or anxi-
ety, then an intervention involving a course of antidepressant or antianxiety medication
might be in order. Finally, if the psychosocial assessment reveals a history of confict
within the family, then the human service professional can plan an intervention strategy
designed to help the family work out their issues so that they might move toward a place
of resolution before the patient dies.
CASE MANAGEMENT AND COUNSELING SERVICES One of the most common
roles for hospice human service professionals includes providing case management and
counseling services to patients and their family members that address the issues noted
in the psychosocial assessment. For instance, issues related to how the patient and fam-
ily are dealing with the terminal illness, the loss of control because of increasing debili-
tation, and the impending death are all explored and counseling provided as necessary.
Healthcare and Hospice 233
Yet, because each family is diferent, the counseling will vary dramatically from patient
to patient. For instance, if the patient is a fve-year-old child dying of cancer, the human
service professional will need to assess the needs of the parents and siblings involved.
Yet, if the patient is 85 years old with an ailing spouse and adult children in their sixties,
the clinical issues will be diferent, and although it would be incorrect to automatically
assume that the level of grief is lessened simply because this death is expected in the nat-
ural course of life, the needs of the diferent parties involved are obviously going to vary
signifcantly. Tus, the actual nature of the illness or condition, the age of the patient,
and the specifc demographics and characteristics of the family members all combine to
determine the nature of the counseling.
I recall working with one client who was dying of amyotrophic lateral sclerosis
(ALS), also known as Lou Gehrigs disease. She was sufering from almost complete pa-
ralysis and was unable to communicate once hospice was hired, thus I worked primarily
with her husband. Tis couple was in their early eighties and had been married for over
50 years. Te surviving spouse was heartbroken at the prospect of losing his wife who
was also his best friend. Our counseling relationship lasted for months and consisted
primarily of him talking about his wife, their relationship, and how agonizing it was for
him to watch his once capable, articulate wife, who was a leader both in the community
and within their family, become slowly imprisoned and paralyzed by ALS. During our
initial sessions he shared some wonderful memories of their life together and of his
wifes strengths and accomplishments (attending seminary afer raising their children),
but would then become emotionally upset when sharing the pain and powerlessness
he felt as he watched her struggle to communicate, at that point by blinking. My role
was not to put a happy face on his suffering, nor was it to reframe this tragedy in
some positive light, as might be appropriate in another type of counseling in another
practice setting. Rather, my role was to remain comfortable when in the presence of his
emotional expressions of grief and sadness, which in some sense gave him permission
to have these necessary feelings. I did my best to provide comfort and a forum for his
sadness, but I never gave him the impression that his feelings were in any way wrong.
Well-meaning but misguided counselors are ofen uncomfortable when confronted
with a clients intense emotions of sadness and anger and, in an attempt to alleviate this
pain and their own discomfort, try to make the client feel better by pointing out the
positive side of a crisis or by encouraging the client to not dwell on feelings of sadness
and anger. Tis approach ofen leaves grieving clients feeling as though their intense
feelings are somehow unacceptable, or at the least burdensome, which in turn results
not in them feeling any better, but as they shut of communication, they ultimately risk
sufering in isolation.
Hence, one of the greatest challenges facing hospice workers lies
in their ability to increase their comfort level for intense and unpleas-
ant emotions. Tose who are grieving can intuitively sense when those
around them are comfortable with their emotions, and many hospice
clients report that hospice counselors are the only people with whom
they feel safe and comfortable sharing their deepest and most painful
feelings of loss, sadness, anger, and mourning.
One of the greatest challenges
facing hospice workers lies in their
ability to increase their comfort
level for intense and unpleasant
emotions.
234 Part II / Generalist Practice and the Role of the Human Service Professional
RESISTING THE REALITY OF THE DEATH Another challenge facing human ser-
vice professionals working in hospice is resistance on the part of the patient and/or fam-
ily members in directly dealing with the realities associated with a terminal diagnosis.
As mentioned earlier, embracing death ofen feels all too much like letting go of life,
and North American culture is far more comfortable embracing life. Many people are
fearful that if they accept the reality of the terminal diagnosis, they are essentially let-
ting go of their loved one, which not only sends the wrong message, but also feels far
too much like giving up. Tis attitude has helped to create a sort of taboo surrounding
death where many people are resistant to even think about their own deaths, let alone
the impending death of a loved one.
In some families, to accept the reality of the terminal diagnosis is synonymous with
losing hope, thus resisting the acceptance of a terminal diagnosis can feel like fghting
for life. A human service professional might be seen as someone who will attempt to
rob the patient and family of their hope, thus many times families make the decision to
either reject social work services when frst signing up for hospice care or prohibit the
human service professional from talking about the terminal diagnosis in front of the pa-
tient. Yet, because many of the issues addressed by human service professionals working
in hospice are designed to also deal with problems that will confront the family at some
point in the futureperhaps even years afer their loved one has died when social work
services are not available to assist them, it is important that the human service profes-
sional be able to confront the familys denial and assist them in understanding that to
accept the impending death of their loved one is not synonymous with hastening the
death or with losing hope.
Counseling can be particularly challenging when the patient is asking for informa-
tion and the family does not want the information about the terminal diagnosis to be
shared. In this situation, the human service professional must be sensitive, but clear that
the patient is the identifed client, and what is in the best interest of the patient will also
eventually be in the best interest of the family, even if they do not initially recognize it
as such. A human service professional must delicately assist the family with the task of
accepting the terminal illness, facing this approaching loss, and addressing each emo-
tional complication that arises.
Human service professionals working in hospice then must be comfortable con-
fronting the realities of death within themselves before they can ever hope to be com-
fortable dealing with this taboo with patients and families. Knowing how to respond
efectively and compassionately when a family accepts social work services, but prohib-
its any discussion of the terminal illness, requires clinical skills based not only on good
training and education, but also on the human service professionals self-awareness and
comfort level in dealing with these difcult issues.
PLANNING FOR THE DEATH Te human service professional working in hospice
also assists the patient and family with the practical aspects of planning for increased
disability and eventual death. Such practical planning may include something as specifc
as assisting the patient and family prepare advanced directives or as broad as helping the
patient and family sort through their feelings of sadness and even anger in response to
Healthcare and Hospice 235
the reality of the impending death. Generally, advanced directives include the spelling
out of ones end-of-life wishes. Legal documents such as do-not-resuscitate (DNR) or-
ders, living wills, and medical powers of attorney are designed to clearly defne a patients
wishes regarding the nature of their medical care if and when they reach a point where
they are no longer able to make decisions for themselves. Preparing advanced directives
is an emotional process, though. Imagine sitting with a patient who recently learned he is
terminally ill and will likely die in less than six months and discussing whether or not the
patient and his family want extraordinary measures taken to save his life when a point is
reached in his disease process where he is unresponsive and stops breathing. Making a
decision that essentially will mean allowing a family member to die without intervention,
either through the removal of a feeding tube or not using cardiopulmonary resuscitation
(CPR) to revive their loved one, ofen generates feelings of immense guilt at the prospect
of abandoning their family member. Such emotional turmoil has the potential to create
signifcant confict and rifs within a family system that is already buckling under the
emotional strain of their impending loss. A human service professionals role then is not
simply to assist the patient and family with the practical matters involved with preparing
advanced directives, but to help the family navigate this emotionally rocky path as well.
Another role of the human service professional is to assist the patient with the prep-
aration of funeral arrangements. Te thought of planning ones own funeral might seem
rather morbid to some, but it can actually be rather therapeutic for someone who is
facing a terminal illness or other life-limiting condition. Consider experiencing a life
event that stripped you of all controlyou can no longer plan for your future because
you have only six months to live, you can no longer bound out of the door for a morn-
ing jog or even to run errands whenever the mood strikes. A terminal illness robs its
victims of their hopes for the future, but it also robs them of their control in all respects,
particularly in their everyday lives, and patientseven aging patientsofen struggle
with the reality of their increasing dependence on others. Planning their funeral, such
as selecting scriptures, music to be played, whether it will be a celebration of life, or a
more traditional and formal funeral, a graveside service, or a memorial service with no
cofn, gives patients a sense of control in the midst of their increasing powerlessness.
Te hospice human service professional can utilize what might initially appear to be
a practical matter (making funeral arrangements) to facilitate discussions and elicit feel-
ings about the patients increasing debilitation and resultant confnement and depen-
dence. I recall working with a hospice patient who at the age of 93 years shared heartfelt
grief at the thought that he could no longer take his dog for a walk or run to catch up
with a friend. In his confnement to a bed, he recalled how he had taken his physical
freedom for granted and felt powerless and hopeless in response to the realization that
his body could no longer cooperate with what his mind wanted to do. Planning his fu-
neral was the one thing he felt he still had control over in the midst of the powerlessness
he felt in every other aspect of his life.
The Spiritual Component of Dying
Hospice care has its roots in the caring of the dying by religious orders, because reli-
gious leaders recognized the spiritual component of facing ones mortality and eventual
236 Part II / Generalist Practice and the Role of the Human Service Professional
death. Even though religious issues and spiritual concerns may technically fall under
the purview of the hospice chaplain, every professional on the hospice team will likely
be asked by a patient or family member to pray with them, and human service profes-
sionals, including bereavement counselors must be comfortable in doing so, even if they
do not happen to share the same faith as the patient. Facing ones mortality can be a
frightening experience for many, and relying on or reconnecting to the faith of ones
youth is a common experience for those dying of a terminal illness.
Counseling commonly takes on a spiritual tone as hospice patients attempt to make
sense out of their terminal diagnosis. Patients might experience anger, confusion, and
a loss of hope and may seek answers from God, yet pose these questions to the human
service professional. Although no one expects someone in human services to be an ex-
pert in theology, it is important that the human service professional feel comfortable
enough to help the patient sort through these questions, and even if questions cannot
be answered, the human service professional can then direct a pastor or other religious
leader to the patient.
Death and Dying: Effective Bereavement Counseling
Several research surveys have noted that whereas about 60 percent of human services
and social work programs at both a bachelors and a masters level ofered courses re-
lated to death and dying, these courses were primarily ofered as electives, and only
about 25 percent of students actually took them. Related studies found that over 60
percent of new human service professionals felt as though their educational program
did not adequately prepare them for counseling clients dealing with end-of-life issues
(for a complete discussion of these surveys, see Kramer, Hovland-Scafe, & Pacourek,
2003). Tis is unfortunate because many human service professionals work directly or
indirectly with death and dying issues, including loss and bereavement. In light of this,
it is essential that those in the human services feld obtain the necessary education and
training so that they feel competent in providing services to clients dealing with death
and dying.
The Journey Through Grief: A Task-Centered Approach
Several theoretical models are available for dealing with bereavement related to death
and dying. Traditional grief models, including Elisabeth Kbler-Rosss (1969) model
of grief, depict grieving in terms of distinct, but overlapping stages, where a mourner
meets a loss with a sense of denial and disbelief, then moves on to the anger stage, where
the mourner ofen feels a sense of injustice and rage in response to the loss. Te object
of the anger varies depending on the circumstances surrounding the loss, but might
include being angry with God, the loved one who died, or everyone in general. Te
next stage is marked by the mourner bargaining to avoid the loss. Individuals whose
loss is due to a death will ofen bargain with Godperhaps promising a sinless life if
their loved one can be returned to them. Te stage of depression follows the bargaining
stage. During this stage mourners experience deep melancholy, ofen citing a sense of
Healthcare and Hospice 237
hopelessness and despair. Te fnal stage of grieving involves the mourners acceptance
of the loss. Although Kbler-Rosss stage theory has dominated the feld of grief and loss
for many years, there has been a recent turn away from perceiving the mourning pro-
cess as one where the bereaved progress through distinct emotional stages.
Many contemporary theorists have recently focused more on task theories, which
suggest that mourners are confronted with tasks or challenges they need to conquer as
they make their way on their grief journey. Alan Wolfelt, a thanatologist (an expert on
death and grieving), has developed a task-based theory of grief and loss. Wolfelt (1996)
cites seven reconciliation needs that both adults and children need to face and tackle
to fnd healing. It is interesting to note that Wolfelt does not discuss healing in terms
of acceptance, which he believes may put too much pressure on the
bereaved, particularly those mourning a signifcant loss, such as the
death of a child.
Wolfelts seven reconciliation needs include acknowledging the
reality of the death, embracing the pain of the loss, remembering the
person who died through memories, developing a new self-identity
in the absence of the loved one, searching for some meaning in the
loss, receiving ongoing support from others, and reconciling the
grief (reconciling is diferent than acceptance).
Bereavement counseling can be facilitated by human service
professionals from various disciplines, including a human service
generalist with a bachelors or masters degree, a licensed therapist
or social worker, or even hospice volunteers. In fact, it is typically
a volunteer who follows up with family members afer the death of
the patient to explore how the surviving family members are faring,
as well as to determine the need for ongoing bereavement counsel-
ing. Human service professionals who conduct bereavement coun-
seling may do so on an individual basis, but will commonly facilitate
support groups focusing on a particular loss. Groups for children
surviving the loss of a parent or groups for widows or widowers are
examples of grief-specifc bereavement support groups. Most hospices ofer free be-
reavement counseling for up to one year afer the death of the patient as a part of the
full continuum of care. Knowing that their loved ones will be cared for afer their death
ofen provides a sense of comfort for dying hospice patients; thus, bereavement counsel-
ing is an important aspect of hospice care.
Multicultural Issues
In general, individuals from many ethnic minority and migrant groups tend to un-
derutilize hospice care. The reasons for this underrepresentation appear to relate to
numerous factors, including lack of awareness of hospice care; Medicare regulations,
which create barriers for immigrant, low-income, and minority groups; a lack of diver-
sity within the hospice staf leading to a general mistrust and discomfort with hospice
Human Services
Delivery Systems
Understanding and Mastery of Human
Services Delivery Systems: Major models
used to conceptualize and integrate pre-
vention, maintenance, intervention, reha-
bilitation, and healthy functioning
Critical Thinking Questions: Kbler-
Rosss stages of grief and Wolfeldts task-
centered approach to grieving provide
two models that human service profes-
sionals can draw on to assist the families
of clients with terminal diagnoses. How
might a human service professional use
these with clients and their families to
help them prepare for the clients death?
How might they be used following the
death to help the family cope?
238 Part II / Generalist Practice and the Role of the Human Service Professional
services; and a lack of knowledge of hospice care on the part of many physicians who
serve minority populations. Many ethnic groups maintain values that are inconsistent
with hospice values and perceive acceptance of death negatively, and although this at-
titude is not signifcantly diferent from Western values in general, many within the ma-
jority culture have slowly adopted new cultural values that espouse acceptance of death
as an important part of life.
A 1999 study that examined barriers to hospice service for African Americans found
that many African Americans held religious beliefs that conficted with the hospice phi-
losophy. Subjects stated that they did not feel it was appropriate to talk about, plan for,
or accept their death. In addition, a majority of the subjects interviewed stated that they
felt more comfortable turning to those within their own community, particularly their
church, for support during times of crisis, rather than to strangers within the healthcare
system (Reese, Ahern, Nair, OFaire, & Warren, 1999).
Researchers involved in this study acknowledge the importance of not pushing a ser-
vice on the African American culture if it is truly unwanted and perhaps even unneeded,
but they cite leaders within the African American community who argue that members
of the community would in fact beneft from hospice care, stating that a chief reason why
hospice care is ofen rejected lies more in the lack of knowledge about the services pro-
vided. Tus, rather than accepting these diferences in philosophy, the principle investi-
gators suggest that hospice agencies adapt their services to meet the needs of the African
American community (Greiner, Perera, & Ahluwalia, 2003; Reese et al., 1999).
No research has been conducted to date on usage patterns or bar-
riers to service for Asian Americans, Latino/a Americans, or Native
Americans, but similar issues are likely to emerge within these com-
munities as well. It is imperative that hospice agencies remain fexible
enough to meet the needs of all cultural groups and that policies that
either directly or inadvertently discriminate against ethnic minority
groups, such as various admittance requirements, be challenged and
if possible changed so that all individuals who desire hospice care can
beneft from this service. Although there may be multiple barriers fac-
ing some populations in receiving hospice care servicessome fnan-
cial and some culturalone of the foundational values of the hospice philosophy is that
hospice care will be available to every dying individual.
Certainly hospice administrators are responsible for developing admittance poli-
cies that do not directly or inadvertently discriminate against low-income patients while
protecting the fnancial status of the hospice. But human service professionals who are
professionally committed to advocating for low-income and underserved populations
are in the unique position of securing fnancial assistance in the form of private and
government assistance through efective case management.
Another ethical dilemma faced by hospice staf involves the issue of euthanasia, or
physician-assisted suicide. Dr. Jack Kevorkian made national headlines in the 1990s for
assisting numerous terminally ill patients in the ending of their lives and is now serv-
ing a prison sentence. Because euthanasia is illegal in all states except Oregon, patient
Although there may be multiple
barriers facing some populations in
receiving hospice care services
some fnancial and some cultural
one of the foundational values
of the hospice philosophy is that
hospice care will be available
to every dying individual.
Healthcare and Hospice 239
requests for physician-assisted suicide create an ethical dilemma complicated by the il-
legal nature of such an act. Requests for physician-assisted suicide present a particularly
challenging ethical dilemma for conservative faith-based hospice agencies that believe
that issues related to death and dying fall under the sole dominion of God (Burdette,
Hill, & Moulton, 2005).
Tose who believe that euthanasia should be legalized typically cite an argument
based on the inalienable human right to choose death when pain and sufering robs
them of a meaningful life. Although a counterargument could be based on the mean-
ingful nature of sufering, a better argument might be based on the hospice philosophy
that dying persons have a right to die without physical, emotional, and spiritual pain.
In fact, several studies examining similarities among terminally ill patients express-
ing a desire to hasten their deaths found that the chief reasons cited included (1) de-
pression and a sense of hopelessness, (2) poor symptom management, (3) poor social
support, (4) fear of becoming a burden on family members, and (5) a poor physician
patient relationship (Kelly et al., 2002; Leman, 2005). Tus, the question is: If these
issues could be addressed efectively, would these same patients still seek physician-
assisted suicide?
Although the hospice philosophy advocates for neither hastening nor postponing
death, hospice agencies have more in common with supporters of physician-assisted
suicide than one might initially think. In fact, the leading reasons among terminally
ill patients for requesting a quicker end to their lives listed previously include the very
issues hospice care is designed to manage. Hospice workers can respond to this ethical
dilemma by advocating for the meaningful nature of the dying process from spiritual,
psychological, and social perspectives, made possible when patients are helped to con-
front feelings of sadness and hopelessness, when symptoms are well managed, when
social support is bolstered, when families are assisted with the care of the patient, and
when the hospice physician maintains a close relationship with patients based on a
palliative care model. In fact, one human service professional working in hospice ex-
plained that if a choice is made to cut the dying process short, then many opportunities
for growth and even last-minute resolution may be lost, as it is ofen the last weeks,
days, hours, or even minutes of a persons life that many lifelong problems are resolved.
Hospice advocates cite the value of every life experience and remind us how these
types of end-of-life realizations and resolutions also beneft surviving family members
and friends (Mesler & Miller, 2000).
Concluding Thoughts on Human Services in Hospice Settings
Human service professionals perform a valuable service to hospice patients and their
family members and serve an important function on the hospice team. Although other
members of the hospice team may perform case management and counseling services
as a function of their role as hospice team members, neither the nurses nor the chap-
lains have the same approach to service provision as do professionals in the human
services field. Unfortunately, with the increasing reliance of hospices on Medicare
240 Part II / Generalist Practice and the Role of the Human Service Professional
benefts, the psychosocial component of hospice care has eroded. Tis is primarily due
to Medicares (and managed care in general) cost-containment eforts, and because
each service provider is billed separately in many hospice agencies, social work ser-
vices have come to be seen as an optional service unless otherwise prescribed by law
( Reese & Raymer, 2004).
Some hospice experts are concerned that this attitude has led to a turf war, par-
ticularly among some nurses who are in the position of determining the familys needs.
Reese and Raymer (2004) caution that although nurses ofen provide some psychosocial
care, they are not trained to perform services in the same manner and with the same
focus as human service professionals. In fact, Reese and Raymers research study was
borne out of this concern among social work leaders. Te authors recommendations
include that hospices work toward the goals of human service professional involvement
in all intake interviews and that social work involvement not be solely on a crisis or
as-needed basis, because ongoing social work intervention will likely prevent many of
these crises in the frst place.
Finally, the authors challenge the common notion that social service involvement
increases and strains budgets, suggesting that although budgets might increase initially
with social work involvement, consistent social work intervention from case incep-
tion reduces fnancial outgo in the long run as expensive and time-consuming crises
are avoided. Tis contention is based on the well-researched connection between many
psychosocial and physical crises, where many medical emergencies requiring costly in-
tervention have their origin at least in part in the psychosocial realm, such as patient
depression and anxiety (Reese & Raymer, 2004).
Another challenge facing hospice agencies is the well-established pattern of patients
being referred for hospice far too late for any of the meaningful work to be efectively
accomplished. Despite the immense growth of the hospice movement and the general
assumption that hospice care is a wonderful concept, only 22 percent of dying individu-
als are actually referred for hospice services, and of these about three-quarters are re-
ferred within three weeks of their death (Stein, 2004). Lorenz, Asch, Rosenfeld, Lui, and
Ettner (2004) cited numerous barriers to hospice admission including patients being re-
jected for hospice admittance because they were still seeking curative medical treatment
such as chemotherapy. Lorenz et al. recommended that hospices re-examine their en-
rollment policies that might inadvertently exclude appropriate patients from receiving
services. Tey suggested that there might be a link between the general knowledge that
the majority of hospices deny enrollment to patients still undergoing curative treatment
and the fact that the majority of dying patients are either not referred at all to hospice or
are referred so late in their disease process.
It seems clear that hospices must take responsibility for developing educational pro-
grams focusing on the nature of hospice care and the importance of early referral. As ex-
perts in the psychosocial dynamics commonly at play in end-of-life care, those within the
human services feld can lead these educational eforts both with the hospice administra-
tors who determine enrollment policies and within the medical community and general
public. A familys willingness to forgo curative treatment immediately on learning of the
terminal diagnosis (necessary for hospice referral) is likely an unrealistic expectation on
Healthcare and Hospice 241
the part of hospice administrators. Deciding to pull a feeding tube or
stop chemotherapy are psychosocial issues that evoke considerable
emotional turmoil within families and could be considered a psycho-
social goal of hospice counseling. Tus, although continuing to actively
seek a cure is clearly contrary to the hospice philosophy, perhaps the
transition from curative to palliative care could be one that occurs as a
part of hospice care, not a condition of it.
Human service professionals are an integral part of the hospice
team and must remain so for hospice care to remain true to its origi-
nal goals and philosophy. But human service professionals must also
be on the front lines of effecting change within the hospice field,
which will ensure that hospice care is fexible in meeting the needs of
a changing society.
Professional History
Understanding and Mastery of Professional
History: Historical and current legislation
affecting services delivery
Critical Thinking Question: Both Medi-
care and private insurance tend to list the
services of human service professionals
as optional forms of care in a hospice
setting. How does this affect the ability
of human service workers to adequately
perform their jobs? How does it impact
the dying patient and her or his family?
7. What are some ways in which human service professionals can assist patients in an emergency room setting?
8. Describe the hospice philosophy, including some of the tasks a human service professional working in hospice may
engage in with terminally ill clients, and their family members.
1. Since everyone handles a medical crisis differently, it
is important for the human service professional to
a. educate the family on the best way to manage the
crisis
b. match the level of emotion exhibited by the pa-
tients family
c. quickly recognize the familys coping style
d. None of the above
2. During the early years of the HIV/AIDS crisis, the
role of the medical human service professional or
human service professional focused almost
exclusively on
a. the crisis of receiving a terminal diagnosis
b. the chronic care needs often associated with an
AIDS diagnosis
c. the discrimination often endured by AIDS
sufferers
d. Both A and C
3. What groups are the most signifcantly impacted by
the HIV/AIDS virus?
a. Women
b. Homosexuals
c. Ethnic minorities
d. Heterosexual females
4. The frst hospice, St. Christophers hospice of
London, was founded in 1967 by
a. Dorthea Dix
b. Jane Addams
c. Clifford Beers
d. Dame Cicely Saunders
5. A core value of the hospice philosophy is that each
person has the right to
a. keep fghting for life, even when all seems
hopeless
b. die without pain
c. continue curative medical treatment even after
receiving a terminal diagnosis in order to keep
hope alive
d. Both B and C
6. A 1999 study that examined barriers to hospice ser-
vice for African Americans found that many African
Americans
a. held religious beliefs that conficted with the hos-
pice philosophy
b. did not feel it was appropriate to either talk
about, plan for, or accept their death
c. felt more comfortable turning to those within
their own community, particularly their church,
for support during times of crises, rather than to
strangers within the healthcare system
d. All of the above
The following questions will test your knowledge of the content found within this chapter.
Suggested Readings
Byock, I. (1997). Dying well. New York: Riverhead Books.
Callanan, M., & Kelley, P. (1997). Final gifts: Understanding
the special awareness, needs, and communications of the dy-
ing. New York: Bantam Books.
Klaas, D., Silverman, P. R., & Nickman, S. L. (1996). Continu-
ing bonds: New understandings of grief. Washington, DC:
Taylor & Francis.
Lord, J. H. (1992). Beyond sympathy: What to say and do for
someone suffering and injury, illness or loss. Ventura, CA:
Pathfinder Publishing.
McCracken, A., & Semel, M. (1998). Broken heart still beats
after your child dies. City Center, MI: Hazelden.
242 CHAPTER 10 PRACTICE TEST
Healthcare and Hospice 243
Internet Resources
Hospice Foundation: http://www.hospicefoundation.org
Hospice.net: http://www.hospicenet.org/
The National Hospice and Palliative Care Society: http://www.
nhpco.org/templates/1/homepage.cfm
References
Acevedo, V. (2008). Cultural competence in a group intervention
designed for Latinos living with HIV/AIDS. Health & Social
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Burdette, A. M., Hill, T. D., & Moulton, D. E. (2005). Religion and
attitudes toward physician-assisted suicide and terminal palliative
care. Journal for the Scientific Study of Religion, 44(1), 7993.
Centers for Disease Control. (1988). Quarterly report to the domes-
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Centers for Disease Control and Prevention. Table 5a. Estimated
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Lorenz, K. A., Asch, S. M., Rosenfeld, K. E., Lui, H., & Ettner, S. L.
(2004). Hospice admission practices: Where does hospice fit
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MacDonald, D. (1991). Hospice social work: A search for identity.
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growth through grief, and other touchstones for caregivers. Fort
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244
Learning Objectives
Understand the history of
substance abuse in the United
States, including usage trends,
and the various ways in which
society has responded to those
who abuse substances
Become familiar with the dif-
ferent theoretical models of
substance use and abuse
Become familiar with the vari-
ous types of practice settings
where individuals with substance
abuse problems seek treatment
Explore the most effective treat-
ment interventions and modali-
ties most commonly utilized by
human service professionals in
response to various types and
levels of substance abuse prob-
lems in the United States.
Become familiar with the impor-
tance of incorporating cultural
sensitivity when addressing
substance abuse issues, includ-
ing identifying vulnerable groups
and treatment obstacles facing
certain ethnic minority groups.
Over 22 million people in the United States sufer from either a substance
abuse or a substance dependence problem, with the greatest number of
people being addicted to marijuana, and a growing number developing
addictions to prescription drugs (Substance Abuse & Mental Health Ser-
vices Administration [SAMHSA], 2012). Every day, human service pro-
fessionals are intricately involved in prevention eforts and in providing
treatment services for individuals and families in over 11,000 substance
abuse treatment programs in the United States (SAMHSA, 2005).
Despite the widespread nature of the substance abuse problem in the
United States, specialized treatment is ofen viewed as a part of human
service practice set apart from the mainstream, seen as operating com-
pletely independently from all other services. Many human service pro-
fessionals express an aversion to working with substance-abusing clients,
and some believe that one must be a recovering addict to effectively
counsel others with this problem. Until fairly recently, most human ser-
vice and mental health providers did not receive specifc training in sub-
stance abuse issues as a part of their normal course of studies.
In practice, however, all human service professionals are afected by
the issue of substance abuse. Although only a small percentage may work
directly in specialized substance abuse treatment programs, all will fnd
that the issue of substance abuse frequently touches the lives of the cli-
ents with whom they work. All human service professionals need to be
familiar enough with the dynamics of substance use, substance abuse,
substance dependence, and addiction to be able to recognize when it may
be a primary or secondary problem for their clients. Human service pro-
fessionals also need to be aware of their own feelings and attitudes that
may help or hinder their ability to work efectively with both clients who
have substance abuse problems and those whose lives have been afected
by the substance abuse of others.
Substance Abuse
and Treatment
CHAPTER 11
Andy Sotiriou/Andy Sotiriou/
Getty Images
Substance Abuse and Treatment 245
Tose who do choose to work directly in substance abuse treatment will encounter a
diverse feld with many practice settings. Human service professionals may focus on preven-
tion and voluntary treatment with chemically dependent clients and their families, or even
with mandated clients within the criminal justice system. In this chapter,
we will examine the history and evolution of substance abuse treatment
in the United States. We will then explore the many meaningful roles that
human service professionals fulfll in this challenging area of practice.
History of Substance Abuse Practice Setting
Troughout recorded history, people have used psychoactive substances to change how
they feel. Evidence from the earliest prehistoric and ancient civilizations indicate the use of
fermented grains and honey to produce alcoholic beverages and the use of plants contain-
ing psychoactive substances in medicinal and religious rituals. Te particular substance of
choice has varied with time and from one society to another, but the use and abuse of sub-
stances have been so prevalent as to be routinely regarded as part of the human condition.
Most societies sanction some use of psychoactive substances. In the United States, it
is legal for adults to consume alcohol, nicotine, and cafeine, which are all drugs that af-
fect the central nervous system. Te use of other psychoactive drugs in the United States
is either prohibited or regulated. Many uses, such as the medical use of marijuana or
the use of the peyote cactus in religious ceremonies by some Native Americans, remain
controversial and the subject of ongoing legal and public policy debates at the state and
federal level (Inaba & Cohen, 2004).
Societies have also developed ways of responding to individuals whose use of sub-
stances cross the line of what is considered acceptable by creating problems for the in-
dividual and the society as a whole. How a society has responded to this problematic use
has varied according to that societys beliefs about the nature of the problem. For example,
societies that view substance abuse as the result of personal misconduct or moral failure
tend to focus on a call to repentance and/or punishment for the ofender. Societies that
regard substance abuse as an illness are more likely to focus on providing treatment.
History of Use and Early Treatment Efforts Within
the United States
Attitudes and practices regarding substance use and abuse in the United States have un-
dergone signifcant changes over time and continue to evolve. William White (1998)
traced the history of addiction treatment and recovery in the United States, focusing on
the development of the professional feld that has emerged in response to the problem
of substance abuse. Tis historic review provides perspective on the prevalence of the
substance abuse problem from the very beginning of U.S. history. In exploring social
attitudes, White noted that
[a]lcohol use and occasional drunkenness were pervasive in colonial America, but
it wasnt until per capita alcohol consumption began to rise dramatically between
the Revolutionary War and 1830 that Americans began to look at excessive drink-
ing in a new way and with a new language. (p. xiii)
In practice, all human service
professionals are affected by the
issue of substance abuse.
246 Part II / Generalist Practice and the Role of the Human Service Professional
The term alcoholism was first introduced by physician Magnus Huss in 1849, but it
took another 100 years, and the birth of Alcoholics Anonymous (AA), for the term to
become fully accepted (White, 1998).
Early eforts to provide treatment for substance abuse began in the United States
in the mid-1800s, prompted by public concern over the problems resulting from in-
creased levels of public drunkenness. White (1998) traced the roots of this increase back
to colonial America, describing the variety of attitudes and practices regarding drug and
alcohol use held by the diverse cultural groups that immigrated to colonial America.
Many immigrant groups had previously used drugs or alcohol only in moderation and
ofen in the context of social, religious, or medical practices. Wine may have been used
to celebrate a wedding, partake in a communion service, or deaden the pain of an in-
jury, but excessive use of alcohol was ofen condemned.
Coming to colonial America, immigrants were afected by what White described as
the utter pervasiveness of alcohol, which was consumed throughout the day by virtu-
ally everyone: man, woman, and child. Alcohol was commonly integrated into everyday
social and political life, ofen in the form of more concentrated distilled liquor such as
whiskey and rum. Native Americans, who previously used only weak forms of alcohol
ceremonially, were also afected by the introduction of distilled liquor.
A number of laws were passed in an efort to combat public drunkenness and
vagrancy, but drinking itself was not yet perceived as a problem. Other psychoac-
tive substances in common use included laudanum, opium-laced alcohol used for
many medical problems, and tobacco, a major crop for both domestic use and export
(Inaba& Cohen, 2004).
By the end of the colonial period, there was a shif in societal attitudes about the
use of alcohol in the United States. Instead of being seen as a blessing of God, it was
increasingly seen as a curse. This shift in thinking birthed the temperance move-
ment, which initially focused on encouraging moderate use of alcohol (thus the term
temperance), but eventually came to advocate total abstinence from alcohol when it
became clear that problem drinkers were frequently unable to maintain moderate
drinking. Tis shif in thinking coincided with the rise of medicine as a profession.
Dr. Benjamin Rush suggested that chronic drunkenness represented a progressive
medical condition rather than a moral failure, thus introducing the disease concept
of alcoholism (White, 1998).
The Prohibition Movement
Attempts to eliminate drug and alcohol problems through legal prohibition lead to the
passage of several pieces of federal legislation. In 1906, the Pure Food and Drug Act
established the Food and Drug Administration (FDA) and gave it authority to approve
all drugs meant for human consumption, to establish that certain drugs required a pre-
scription, and to mandate warning labels on drugs that were potentially habit forming.
(Prior to this time, drugs such as opium and cocaine were freely available and not regu-
lated.) In 1914, the Harrison Act was passed, which regulated the medical use of certain
drugs such as opium, morphine, cocaine, and their derivatives and, at the same time,
criminalized the nonmedical use of these same drugs (Whitebread, 1995).
Substance Abuse and Treatment 247
Te temperance movement was successful in establishing alcohol prohibition laws
in many states, and eventually the ratifcation of the Eighteenth Amendment in 1919
made alcohol manufacture, transportation, and sale illegal in the United States. Musto
(1999) noted that the Eighteenth Amendment, like earlier state prohibition laws, en-
joyed wide public support and refected societal fear that even small amounts of alcohol
posed a danger both to the individual and to society as a whole.
Prohibition, described by President Hoover as a noble experiment, proved to be
short-lived. The Twenty-First Amendment repealed the Eighteenth Amendment in
1933, ending Prohibition and thereby legalizing the manufacture and sale of alcohol
once again in the United States. Several factors provided the impetus for this change,
including the widespread disregard for the law and the rise of organized crime in the
production and distribution of bootleg liquor. Inaba and Cohen (2004) concluded, how-
ever, that the widespread belief that Prohibition was a failure is incorrect. An exami-
nation of medical records concerning diseases caused by excess alcohol consumption
as well as criminal justice records shows that Prohibition did reduce health problems,
domestic violence, crime, and consumption (p. 323).
Te perceived failure of Prohibition to rid society of drug and alcohol problems,
the closing of specialty addiction treatment programs, and the fnancial hardships of
the Great Depression combined to create an atmosphere in the 1930s that ofered little
help or hope for those with drug and alcohol problems (White, 1998). Tis combina-
tion of factors made the climate right for the birth of the mutual aid society of AA, a
fellowship of men and women who share their experience, strength and hope with each
other that they may solve their common problem and help others to recover from alco-
holism (n.d.). Te growth of AA from two men (known simply as Dr. Bob and Bill W.)
meeting in Akron, Ohio, in 1935 to a worldwide organization with over 50,000 meet-
ings (Abadinsky, 2004) is indeed remarkable and represents a major component in the
develop ment of the current treatment of addictions.
The Rise of Modern Addiction Treatment in the United States
Several factors shaped the course of addiction treatment in the United States during the
second half of the 20th century up until the present time. Te growth of AA played a
major role in the broad (but by no means universal) acceptance of the medical model of
addiction treatment. Te establishment of private health insurance provided increased
access to treatment for a greater percentage of the population; this in turn led to a sig-
nifcant increase in the number of substance abuse treatment programs. Afer initially
operating as separate entities, alcohol treatment and drug treatment services combined
at both the public and private level in favor of substance abuse treatment that serviced
both populations. With this change came further professionalization of the feld.
Finally, the development of managed care as a means of controlling rising health care
costs led to a shif from inpatient hospital treatment to outpatient services as the treatment
setting most frequently authorized and approved by insurance carriers. Each of these fac-
tors has a signifcant impact on how human service professionals provide substance abuse
treatment today (White, 1998). Before examining the various treatment settings available
248 Part II / Generalist Practice and the Role of the Human Service Professional
today, it is important to understand the scope of the problem, the pro-
fessional vocabulary used to defne the problem, and the ongoing ef-
fect that societal attitudes and perceptions have on the availability and
utilization of services.
Demographics, Prevalence, and Usage Patterns
Over the years that I have worked in addiction treatment, I have
spoken to many community groups. I ofen begin by asking them to
describe to me their picture of an alcoholic or a person addicted to
drugs. Tere is always a wide range of responses. As we begin, some-
one will usually mention the man on skid row, drinking out of a bottle
concealed in a brown paper bag. Others think of the image of a drug
bust on a television crime show, police breaking down the door as the
people inside scramble to fush drugs down the toilet. As the discus-
sion progresses, some brave soul will bring the examples closer to home. Tey may say,
I remember my father, drunk and passed out on the couch every night or My favorite
aunt is in detox right now . . . Ive lost count of how many times shes been there. Te next
person may add, My brother is in jail right now for drug possession or Ive been in AA
for fve years now. Invariably, what begins as a discussion that focuses on someone elses
problems out there in society becomes personal to the group. When I have this same
discussion with students, they are ofen surprised to realize how many of their classmates
lives are afected by substance abuse.
Although it is certainly true that substance abuse is a problem that exists within all
levels of society, it is usually this type of facilitated discussion that brings home this very
point. As you continue to read this chapter, I encourage you to consider how substance
abuse afects your life at both the personal and professional level. Because of the preva-
lence of the problem, and because each person with a substance abuse problem afects
the lives of the people around them, most can identify a direct link to this issue.
SAMHSA, a division within the Department of Health and Human Services (HHS),
conducts an annual survey on the prevalence of substance use in the United States
and the problems associated with that use. In 2011, an estimated 133 million North
Americans (12 years of age or older) were current drinkers of alcohol. Tis represents
just over one-half of the population. Just over 58 million people over the age of 12
(22.6 percent of the population) had engaged in binge drinking. During this same time
period about 16 million people over the age of 12 engaged in heavy drinking and illicit
drug use (about 6.3 percent of the population). Marijuana was the most commonly used
illicit drug, followed by psychotherapeutics (nonmedical use of prescription drugs),
cocaine, hallucinogens, and inhalants (SAMHSA, 2011).
What do these numbers mean to the human service professional? At a minimum, they
alert us to the reality that a signifcant number of the clients with whom we work in any
practice setting already have a primary substance abuse problem with illicit drugs or alco-
hol and that many others are using alcohol in a way that may complicate their current prob-
lems and afect their ability to utilize or beneft from any services we may ofer to them.
Professional History
Understanding and Mastery of
Professional History: Creation of
human services profession
Critical Thinking Question: Over time,
societal attitudes about drug and alcohol
consumption and abuse have changed,
driving policies and practices related
to the availability and use of these sub-
stances. How do our cultures current
attitudes about the use of alcohol and
drugs shape the field of substance abuse
treatment, and vice versa?
Substance Abuse and Treatment 249
Tese statistics also reinforce the need for all human service professionals to have a work-
ing knowledge of addictions so that they can accurately assess the needs of their clients.
Te consequences of drug and alcohol abuse in the United States are enormously costly.
Although the costs can be evaluated in dollars, they are more readily understood in human
terms: family discord, neglect and/or abuse of children, personal misery, fnancial straits,
medical problems, fetal alcohol syndrome, HIV infection, lower work productivity, and
job lossand the list goes on. Combating and reducing the source of these problems have
proven to be difcult indeed, but one of the most straightforward and least controversial
ways is to provide efective treatment to drug abusers (Boren, Onken, & Carroll, 2000).
Defning Terms and Concepts
Tus far, we have used the terms substance use, substance abuse, and alcoholism in a gen-
eral way, without providing detailed defnitions. It is important to understand how these
terms are understood in the professional community. As noted earlier, during much of
the 20th century, treatment for alcohol problems was conducted separately from treat-
ment for problems with other drugs (White, 1998). Te term alcoholism came into com-
mon use with the acceptance of the medical model and the understanding of alcoholism
as a disease. Alcoholism and drug dependence has been defned in many diferent ways,
but most experts describe alcohol and drug dependence as a chronic and progressive
disease that is infuenced by ones environment. Individuals who sufer from alcohol
and drug dependence may struggle constantly with their addictions, or cyclically, but
remain preoccupied with alcohol and drugs even though their use has very negative
consequencesboth psychologically and related to their lifestyle. In extreme cases, de-
pendence on alcohol and drugs can be fatal (Morse & Flavin, 1992).
Gradually, during the second half of the 20th century, the treatment community fo-
cused less on the diferences between alcohol abuse and abuse of other drugs and more
on the similarities that existed between them. Most treatment programs are now designed
to meet the needs of clients with alcohol and/or other drug problems. Currently, treat-
ment professionals use the broad term of substance abuse disorders with many subtypes of
the disorder, depending on the substance being used. In keeping with the medical model,
these disorders are defned in the Diagnostic and Statistical Manual of Mental Disorders,
fourth edition, text revision (DSM-IV-TR) of the American Psychiatric Association (2000).
In general terms, individuals are described as abusing a substance when they con-
tinue to use the substance despite experiencing negative consequences from their use.
Tese negative consequences can include health problems; difculties in their family,
work, and social life; and fnancial and legal problems. Individuals are said to be de-
pendent on the substance when, in addition to these negative consequences, they build
tolerance and experience withdrawal if they stop using the drug. Tolerance occurs when
a persons body has become accustomed to the drug and thus needs to use more in an
attempt either to regain the pleasurable efects of the drug or merely to feel normal.
Withdrawal symptoms occur when individuals become physically dependent, meaning
that if they stop using the drug, their body will experience uncomfortable symptoms.
250 Part II / Generalist Practice and the Role of the Human Service Professional
Tese symptoms vary depending on the nature of the drug use. If individuals have
been using a central nervous system depressant, such as alcohol or tranquilizers, they
will experience symptoms associated with their central nervous system speeding up
when they stop their use. Tese symptoms typically include anxiety and agitation, but
may be severe enough to cause grand mal seizures. Conversely, if individuals have been
using a central nervous system stimulant, such as cocaine or amphetamines, they will
likely experience a crash of exhaustion and depression when drugs are withdrawn.
In severe cases, this can include suicidal thoughts and behaviors. Te range of severity
of withdrawal symptoms varies with the individual and with the amount of use. It is
important to note that the withdrawal experienced from some drugs can be life threat-
ening and therefore require medical supervision (Inaba & Cohen, 2004). For these rea-
sons, addiction treatment programs must include appropriate medical professionals,
either on their direct staf or available for consultation.
Theoretical Models of Use and Abuse
Although it might be ideal to present a single theoretical model that explains the nature
of addictions and how they should be treated, no such model currently exists. In fact,
there continues to be signifcant controversy over the best way to understand and to
treat addictions. Tere are also signifcant advances in the knowledge of how the brain
works and responds to drugs that inform and modify current treatment models.
Troughout history, there have been many theoretical models for understanding the
nature and cause of substance abuse and addiction. For thousands of years, addiction
was primarily seen as the result of an individuals moral failure. More recently, theories
have been developed that incorporate new knowledge from psychology, biology, and
medicine. Inaba and Cohen (2004) identifed three prevalent models of understanding
addiction: the addictive disease model (also known as the medical model), which fo-
cuses on the infuence of heredity; the behavioral/environmental model, which focuses
on the infuences of environment and behavior; and the academic model, which focuses
on the physiological efects of psychoactive drugs.
Addictive disease model: We have already introduced the medical model and the
related disease concept of addiction. Disease is defned as impairment of health or
a condition of abnormal functioning. Tis model stresses that addiction, like other
diseases, has identifable symptoms, a predictable course, and a likely outcome if lef
untreated; it further understands that genetic infuences may result in a predisposi-
tion, making the development of the disease more likely.
Inaba and Cohen (2004) explain that the medical model views addition as a dis-
ease that is enduring, will continue to progress (particularly without treatment),
and is ultimately incurable, in fact fatal if lef untreated. Tis model posits that at
the root of all addictions is genetic irregularity within the brains chemistry and
anatomy, which is likely activated when a certain drug is abused.
Behavioral/environmental model: Tis developmental model describes the possible
progression of substance use through six stages:
Abstinence, meaning no use of alcohol or drugs
Substance Abuse and Treatment 251
Experimentation, marked by curiosity that leads to limited use
Social/recreational use, marked by seeking out drugs/alcohol in these settings
Habituation, meaning repeated use without negative consequences
Abuse, defned as continued use despite negative consequences
Addiction, meaning abuse plus the presence of tolerance and withdrawal
Tis model examines how factors in a persons environment, such as peer pres-
sure or easy access to drugs, can foster the progression from one level to the next.
Although abstinence is the only stage that can be seen as risk free, note that it is
not until one reaches the stages of abuse and addiction that the hallmark behav-
iors of continuing to use despite negative consequences, obsession with drug tak-
ing, and loss of control are seen (Inaba & Cohen, 2004).
Academic model: Tis model understands addiction from the standpoint of the
changes that occur in peoples bodies over time as they use drugs. Tese changes
occur at the cellular level and result in the development of toler-
ance, meaning that as persons become resistant to the drugs
efects, they will need increasing amounts of the drug to achieve
the desired efects. Tissue dependence occurs when the body has
become so accustomed to the drug that it needs the drug to
feel normal. Even where tissue dependence does not occur, the
memory of the pleasurable efects of the drug and the ongoing
desire for that feeling may result in psychological dependence. If
use is interrupted, the person may experience uncomfortable
physical and psychological symptoms known as withdrawal; the
fear and dread of withdrawal symptoms plays a major role in the
addict continuing to use (Inaba & Cohen, 2004).
Inaba and Cohen (2004) propose that it is actually an integration
of these models that best explains the predisposition and process by
which addiction develops over the course of ones life. Each provides
a type of lens through which an individuals substance abuse prob-
lem can be understood and solutions explored; they do not need to
be seen as mutually exclusive.
Consider the case example about Jack in Case Study 11.1.
Human Services
Delivery Systems
Understanding and Mastery of Human
Services Delivery Systems: Major mod-
els used to conceptualize and integrate
prevention, maintenance, intervention, re-
habilitation, and healthy functioning
Critical Thinking Question: There is
still no consensus regarding a model for
explaining substance abuse, although the
medical, behavioral/environmental, and
academic models currently all have pro-
ponents. What are each models implica-
tions for treatment, and how important
is it for a human service professional
working in the field of substance abuse
to remain familiar with current scholarly
literature on the topic?
CASE STUDY 11.1
Case Example of an Alcoholic
Jack is a 45-year-old married man with two teenage daughters. Jack is the manager of a busy
restaurant located in a shopping mall. Over many years, Jack has developed a pattern of eating
his lunch in the restaurants bar in the quieter time between the busy lunch and dinner hours.
He initially drank a beer with lunch, but that has increased to three or four beers over the
252 Part II / Generalist Practice and the Role of the Human Service Professional
years. He fnds that he looks for opportunities to ofer a drink to regular customers and has
another drink along with them. Afer the dinner rush, he will sit at the bar and have several
more drinks as his employees do the cleaning before he locks up for the night. Jack is aware
that many of his food servers use speed (amphetamines) to get through a busy shif, and he
fnds that he is doing this more and more himself. When he uses speed, he fnds he needs to
have a few extra drinks so that he can fall asleep at night. Because he still sleeps poorly, he
increasingly needs the speed to get going the next day. Te employees, who used to be happy
to give him speed once in a while, now want him to pay for those pills, creating some fnancial
problems. Jack is starting to feel uncomfortable that his employees know about his use and
worries that it undermines his authority with them. Because Jack is drinking more, he is get-
ting home later and is less involved with his family. Initially this caused arguments, but his
wife and daughters have grown accustomed to his being either at work or passed out on the
couch. Tey have learned to plan their life without much involvement from Jack.
Given the progressive nature of his use, Jack is now likely to experience some of
the many predictable problems that could bring him into contact with a human service
professional. Jack is a likely candidate for getting fred when the owner learns about his
drug and alcohol use at work, for a drunk-driving arrest, for escalating family problems,
or for a major health problem such as a heart attack. Any of these events could create a
crisis for Jack and his family that could lead to their entering substance abuse treatment.
Jacks problem would be understood somewhat diferently depending on the theoreti-
cal model held by the treatment professional assessing it. Tose working from the addic-
tive disease model would identify factors that predispose Jack for substance abuse, such
as a family history of alcoholism and a work environment with easy access to drugs. Tey
would see his increasing sleep problems, fnancial problems, and family tension as symp-
toms of an escalating disease. Tose working from the behavioral/environmental model
would trace how Jacks use has progressed from habitual use to abuse and likely addiction.
Te academic model would explain how Jacks body has developed tolerance for alcohol,
needing more drinks to achieve the same results, and how Jack has begun to attempt to
counteract the negative depressant efects of alcohol with stimulants. No matter which
model seems most helpful to the human service professional in understanding his use,
it is clear that each model provides some relevant information in conceptualizing Jacks
problem. Conceptual models such as these also assist in treatment planning. If, instead of
considering Jack, we examined the history of a 15-year-old cheerleader who is using speed
to lose weight and is partying on the weekends or a 30-year-old homeless veteran addicted
to heroin since returning from the war, we would fnd both similarities and diferences in
their substance abuse that would inform the type of treatment they need.
Types of Substances Abused
Many categories of drugs are subject to abuse because they create effects that are
desirable, at least to some users. Because the psychoactive qualities of drugs difer, dif-
ferent people fnd diferent drugs attractive. It is extremely important that human service
Substance Abuse and Treatment 253
professionals understand the efects of these drugs, so that they are able to recognize the
signs of substance use in their clients as well as to understand how they may afect how
their clients perceive and utilize services. Inaba and Cohen (2004) defned a psychoactive
drug as any substance that directly alters the normal functioning of the central nervous
system (p. 32) and divided psychoactive drugs into these three broad categories.
Uppers are central nervous stimulants, increasing chemical and electrical activity.
Drugs in this category include cocaine, amphetamines (such as methamphetamine),
cafeine, and nicotine. Note that this category includes both legal and illicit drugs. Some
of the reasons people are drawn to the use of stimulants are to increase attention and en-
ergy, to suppress appetite, and to feel more confdent. Tese efects are the result of the
forced release of the brains energy chemicals: norepinephrine and epinephrine, two
neurotransmitters. Because tolerance builds rapidly with stimulant drugs, abuse and ad-
diction can develop quickly.
Many physical and psychological problems are associated with the abuse of central
nervous system stimulants. Te depletion and imbalance of neurotransmitters can lead to
depression, paranoia, and psychosis. Te ongoing speeding up of the central nervous sys-
tem (without time to recover) may result in insomnia and the problems associated with
lack of sleep, cardiovascular problems, and weight loss. In fact, with the use of stronger
stimulants, the brain does not signal the need for food, drink, or sexual stimulation, result-
ing in malnutrition, dehydration, or a reduced sex drive (Inaba & Cohen, 2004, p. 131).
A very serious substance abuse problem relates to what many experts are referring
to as the methamphetamine epidemic. Methamphetamine (also called meth, crystal,
and crank) is a highly addictive synthetic stimulant that acts on the central nervous
system, wreaking havoc on the body, particularly the brain and heart. Meth was frst
developed in Germany in the late 1800s, as a cure for diseases. Te drug appeared on
the illicit drug scene in the United States around 1979 and exploded as one of the most
highly manufactured and used drugs in the United States. In 2009, 1.2 million people
ages 12 and older had used meth at least once in the prior year (National Institute on
Drug Abuse [NIDA], 2010). Although the drug initially gained popularity among males
living in the Western part of the country, it has since grown in popularity and is now a
problem across the country among both genders, and across a variety of lifestyles.
Methamphetamine use has declined considerably, from an all-time high of 731,000
active users in 2006 to 439,000 active users in 2011 (SAMHSA, 2012). First-time use is
also declining, with frst-time users of methamphetamine in 2011 estimated to be ap-
proximately 133,000 (12 years and older), compared to frst-time users in 2006, which
was estimated to be approximately 318,000. Despite this decrease, use of methamphet-
amine remains a considerable problem, with far-reaching consequences.
Symptoms of methamphetamine use include inability to sleep; increased sensitiv-
ity to noise; nervous physical activity, such as scratching, irritability, dizziness, or con-
fusion; extreme anorexia; tremors or convulsions; and increased heart rate and blood
pressure. Long-term afects include dependence, addiction psychosis, paranoia, hallu-
cinations, mood disturbances, repetitive motor activity, stroke, and weight loss (NIDA,
2010). Methamphetamine is similar in structure and afect to other psychostimulants,
such as cocaine, but unlike cocaine, meth remains in the body far longer and is not as
easily metabolized, leading to a more sustained stimulant efect. For instance, the high
254 Part II / Generalist Practice and the Role of the Human Service Professional
from cocaine lasts about 30 minutes, whereas the high from meth can last for up to 24
hours. Te increased potency of meth is one of the reasons why it is so dangerousnot
only with regard to its highly addictive nature, but also because the sustained state of
stimulation can cause a number of serious cardiovascular problems.
Methamphetamine use has become a significant social problem because of how
highly addictive it is, and because of how it ravages the body and the mind. In fact, it
not only causes serious damage to the heart and brain but also destroys users physi-
cal appearance, including leading to rapid weight loss, accelerated aging, severe facial
blemishes, and the rotting of the teeth (commonly referred to as mouth rot). Meth use
has had a signifcant impact on various social systems within the country, including the
criminal justice system, public health, and child welfare agencies. For instance, emer-
gency department visits involving meth use increased 54 percent from 1995 to 2002
(SAMHSA, 2010). Meth use has also led to an increased risk of contracting HIV, and
Hepatitis B and C due to increased high-risk sexual behavior and the sharing of needles
(Centers for Disease Control and Prevention, 2011). Meth use has also had a signifcant
efect on law enforcement due to a dramatic rise in meth-related robberies and domes-
tic violence (National Association of Counties, 2006a). Also, the increasing prevalence
of meth use has brought public attention to the additional dangers posed to children
when their meth-abusing parents neglect their childrens needs or place them at risk by
creating in-home meth labs; responding to these forms of child endangerment creates
challenges for human service agencies, specifcally child welfare agencies, as well as law
enforcement (National Association of Counties, 2006b). Human service professionals
within all of these areas will no doubt be afected by the methamphetamine epidemic
in one way or another; thus it is vitally important that they remain abreast of meth-use
trends and ongoing treatment options.
Downers are central nervous system depressants, slowing down its overall func-
tioning. Depressant drugs include painkillers (such as morphine, Darvon, Demerol,
Vicodin, and OxyContin), sedative-hypnotics (such as Valium, Xanax, and Seconal),
and alcohol (beer, wine, and hard liquor). Depressants slow heart rate and respiration,
relax muscles, dull the senses, diminish pain, and induce sleep. Because they depress or
lower inhibitions, the initial efect of these drugs may seem like a stimulant; someone
who is drinking alcohol may feel increasingly social or sexually disinhibited, however
the long-term efect is that of a depressant. As with the stimulants, tolerance builds with
repeated use. As people need more of the drug to feel high, they experience more of
the negative side efects of the drug: loss of coordination, impaired judgment, memory
problems, and the development of physical dependence.
All Arounders is the term used by Inaba and Cohen to describe psychedelics. Tis
category includes marijuana, LSD, phencyclidine, MDMA (Ecstasy), and mescaline.
Hallucinogens distort sensory perceptions and can create altered or intensifed sense
of sight, touch, and hearing. Users may experience auditory and visual hallucinations
or distorted thinking (delusions). Side efects from hallucinogens vary, but include in-
creased appetite and respiratory damage (with marijuana); bad trips and fashbacks
(with LSD); and increased blood pressure, amnesia, and combativeness (with phencycli-
dine). Because these drugs are generally manufactured and processed illegally, users run
Substance Abuse and Treatment 255
the risk of taking stronger doses than anticipated or even getting a diferent drug than
anticipated. Tese drugs may present even greater risks for individuals with preexisting
mental disorders (Inaba & Cohen, 2004).
Other drugs commonly abused include inhalants (such as glue, metallic paints,
and nitrous oxide), anabolic steroids, and other performance-enhancing drugs.
All these drugs are associated with serious health consequences that can be life
threatening.
Abuse of Prescription Drugs
A growing area of concern in the United States is the abuse of prescription drugs. Much
media attention has been given to the problem of street sales of drugs used as pain-
killers, such as OxyContin, those used to treat anxiety, such as Valium and Xanax, and
those used to treat attention defcit/hyperactivity disorder (ADHD) such as Ritalin.
Drug addicts have long attempted to deceive and manipulate physicians into giving
them prescriptions for pain medication and tranquillizers by creating or exaggerat-
ing symptoms or by altering the number of pills authorized on the prescription form.
Te National Center on Addiction and Substance Abuse at Columbia
University (NCASAC, 1998) conducted a three-year study of the abuse
and diversion of prescription medications including opioids, central
nervous system stimulants and depressants, and steroids. The study
found that from 1992 to 2003, the number of Americans who abuse
controlled prescription drugs had nearly doubled from 7.8 million to
15.1 million. Nearly one-half of physicians surveyed reported that patients commonly
try to pressure them into prescribing controlled drugs. CASA places these fgures in
the context of the widespread acceptance of the use of prescription medication in the
United States in general and the growing acceptance of the use of psychotropic medica-
tions. A more recent study found that in the past fve years the abuse of prescription
drugs has remained relatively stable among females, has declined slightly for adoles-
cents but has increased among males (SAMHSA, 2009).
Problems with prescription drugs include those who intentionally abuse and those who
inadvertently become addicted to legally prescribed medication. Te CASA study suggests
that this is a problem that has not been adequately addressed. In assessing for substance
abuse problems, human service professionals are therefore encouraged to explore use of
prescription drugs with their clients in addition to their use of any street drugs.
Common Psychosocial Issues and the Role
of the Human Service Professional
The Presence of Substance Abuse across All Practice Settings
Although some human service professionals might assert that they have no interest in
working with individuals who have substance abuse problems, it is important to note
that, because alcohol and drug abuse are so prevalent in the United States, it is virtually
impossible to entirely avoid working with this issue.
From 1992 to 2003, the number of
Americans who abuse controlled
prescription drugs nearly doubled,
from 7.8 million to 15.1 million.
256 Part II / Generalist Practice and the Role of the Human Service Professional
Many human service professionals do not begin their careers with the intention
of specializing in substance abuse, but quickly encounter the issue in the lives of
their clients. I began my career over 30 years ago in a county public assistance ofce.
I soon realized that many of the clients applying for General Relief were alcoholics
whose long-term use of alcohol had led to loss of employment, family, and health.
When I worked in hospital settings, I again found that many of the patients needing
treatment were sufering from conditions that resulted from or were complicated by
their use of alcohol or other drugs. I later chose to work directly in substance abuse
treatment programs, eventually providing treatment in outpatient, residential, hospi-
tal inpatient, and partial hospitalization settings with substance-abusing clients and
their families.
Acceptance of Problem
One of the most common practice issues human service professionals must address with
substance-abusing clients is helping the client acknowledge that the substance abuse is
in fact a problem. It can be perplexing for a professional to listen to clients describe vari-
ous incidents occurring in their lives that clearly seem to be negative consequences of
their substance abuse yet know that clients are either unable or unwilling to make that
connection. Such clients may forcefully maintain that their problems have nothing to do
with the substance use. Clients may describe, for example, a recurrent pattern of getting
drunk (or high), followed by getting into fghts with their spouse. Tey may even ac-
knowledge that the fghts only happen when they are using drugs, yet they still maintain
that there is no connection between the two. Clients who have lost relationships, jobs,
and money because of their use may still defend their alcohol or drug consumption, as-
serting that with all the problems I have right now, it is the only thing that is keeping
me going...the only friend I have lef.
Tis denial of the problem is more than a psychological defense mechanism. It
refects the learned experience of most substance abusers that, at the outset of their
use, the substance was giving them positive efects. A common phrase in treatment
programs is what starts out as the solution becomes the problem. In other words, the
drinking that initially provided a mild relaxation of inhibitions to feel more relaxed
and sociable at a party now with increased use results in inappropriate and aggres-
sive behavior at the party. Hence, the solution has now become the problem, but
the persons using the substance are ofen the last to recognize this reality; they have
learned to believe that it is the solution to their problems and are resistant to changing
this belief. An additional consideration is that the psychoactive nature of the sub-
stance being used alters the users thoughts and perceptions in ways that may hinder
their recognition of the problem. Human service professionals who understand this
dynamic are less likely to become frustrated with their clients statements and thus
are more likely to be efective in their attempts to help clients accept their problem.
Figure 11.1 provides a comparison of those who perceived that they had the need for
substance abuse treatment with those who actually entered a treatment program. Tis
graphic clearly indicates the tendency of those sufering from substance abuse prob-
lems to avoid seeking treatment.
Substance Abuse and Treatment 257
Hitting Bottom
Traditionally, addiction treatment professionals have thought it necessary for those ad-
dicted to drugs or alcohol to hit bottom before they recognize their problem and
the need for treatment. Although some individuals were described as having a high
bottom because they reached this point of recognition with relatively minor conse-
quences such as spilling a drink on an expensive rug or one relatively minor verbal out-
burst, the common wisdom was that substance abusers could not be helped until they
were ready to help themselves. Hitting bottom was seen as the starting point, much to
the dismay of concerned family members, friends, and employers who were tired of
waiting for this recognition to occur because from their perspective, their loved one
hit bottom long ago.
Generalist Practice Interventions
Tere have, however, been many approaches utilized to help the substance abuser hit
bottom more quickly. Tose expressing concern for the substance abuser have been
advised by treatment professionals to stop enabling and to instead allow the individu-
als to sufer the natural consequences of their use. Abusers are advised not to call in
sick for the person when they are hungover, not to put them to bed when they pass out,
and not to bail them out when they are in jail. Friends and family members are advised
that although these enabling behaviors are well intended, they actually help substance
abusers to continue to deny or minimize their problem. If, instead of waking up in bed,
the drinkers wake up on their front lawns in full view of the neighbors, they experience
the negative consequences of their drinking rather than having to trust the description
FIGURE 11.1
Perceived Need and
Effort Made to
Receive Substance
Abuse Treatment
Source: SAMSHA,
Offce of Applied
Studies (http://www.oas.
samhsa.gov/nhsda/2k3
nsduh/2k3overview.htm).
Did Not Feel They
Needed Treatment
Felt They Needed
Treatment and Did Not
Make an Effort
Felt They Needed
Treatment and Did
Make an Effort
1.3%
3.8%
20.3 Million Needing But Not Receiving
Treatment for Illicit Drugs or Alcohol
Past Year Perceived Need and Effort Made to Receive
Specialty Treatment among Persons Aged 12 or Older
Needing But Not Receiving Treatment for Illicit Drugs
or Alcohol: 2003
94.9%
258 Part II / Generalist Practice and the Role of the Human Service Professional
provided by a spouse the next morning. Tey are less likely to believe that a spouse is
just exaggerating or lying about events that they may be unable to remember.
Tis, of course, creates true dilemmas for family members. Allowing a loved one to
wake up on the front lawn, lose a job, or remain in jail may lead to serious consequences
for the individual as well as the family as a whole. Human service professionals can help
concerned family members and friends to identify their options and to think through
the implications of the actions they take. Clinicians who are able to listen nonjudge-
mentally and communicate their understanding of the difculty of the decisions to be
made are more likely to be truly efective in this helper role.
Among the options available to families seeking help are interventions. Formal in-
terventions were frst described by Dr. Vernon Johnson, a pioneer in alcohol treatment,
in his 1973 book Ill Quit Tomorrow. Although many variations have been developed in
addition to the original Johnson model, interventions typically bring together all con-
cerned individuals in the lives of the substance abusers in order to confront them with
the negative consequences of their substance abuse. Tey meet as a group, joined by an
intervention specialist, and share ways that their own lives have been negatively afected
by the substance abusers use of drugs and/or alcohol and rehearse ways to present this
information to the substance abusers in the hope of breaking down their denial. Tey
then meet with the substance abuser to share their concerns and encourage the person
to enter treatment, ofen immediately afer the meeting. Te goal is to precipitate a crisis
that will result in change. Styles for conducting interventions vary from collaborative to
highly confrontational. Interventions have sometimes been subject to criticisms of con-
fict of interest when the intervention specialist is part of the staf at a treatment facility
where the person is being encouraged to enter treatment.
Motivational Interviewing
Another common way to help the substance abusers recognize their need for treatment
is through the use of motivational interviewing. Tis approach difers from methods
that use confrontation or coercion to attempt to engage substance abusers in treat-
ment. As defned by Rollnick and Miller (1995), Motivational interviewing is a direc-
tive, client-centered counseling style for eliciting behavior change by helping clients to
explore and resolve ambivalence. Hettema, Steele, and Miller (2005) explain that, in
creating a safe atmosphere, motivational interviewing allows individuals to confront
their ambivalence by examining both the positive and the negative aspects of changing
their current behaviors. Tis approach acknowledges that it is normal for people to have
mixed feelings about change and invites them to explore all sides of their ambivalence.
In recognizing the cost that they pay for maintaining their substance use, individuals
may become more likely to willingly choose to make a change.
Motivational interviewing (and the related motivational enhancement therapy)
stresses that people vary in how ready they are to make changes. Drawing on the work
of Prochaska, DiClemente, and Norcross, an individuals willingness to change is under-
stood as occurring in stages: precontemplation, contemplation, determination, and action
(Miller, 2000). Although not limited to use in substance abuse, it is seen as a helpful
model that allows the human service professional to build an alliance with the client
Substance Abuse and Treatment 259
toward change. Precontemplation, as the name implies, is the stage people are in before
they ever give any thought to the need to change their behavior (although it may be clear
to others that a problem exists). If family members or clinicians try to convince sub-
stance abusers at this stage that they should take action, such as stopping their substance
use or entering a treatment program, it is not likely that the suggestion will be positively
received or even make sense to the abusers. Instead, human service professionals would
focus their eforts on assisting substance abusers to become more ready to change by
exploring with them the impact of their use. As substance abusers explore what they see
as both the positive and the negative aspects of their use, they may begin to contemplate
a need for change. Clinicians may help clients look at various ways to solve the problems
associated with substance abuse, increasing the clients determination to make a change.
Persons who have reached these higher levels of readiness to change are more likely to
respond positively to treatment suggestions made by human service professionals.
In discussing the relative popularity of these diferent approaches to dealing with the
clients denial among treatment professionals, White (1998) described four overlap-
ping stages in its view of the role of addict motivation in addiction recovery (p. 291).
He sees an evolution over the second half of the 20th century from a baseline position
that people must frst hit bottom before they are willing to change, to a focus on teach-
ing those in the substance abusers life to stop rescuing, and allow them to experience
the consequences of their behavior (so that they can hit bottom), to a focus on raising
the bottom through formal intervention. Tese three stages share an emphasis on in-
creasing pain as a motivation to enter treatment. White believes that the treatment com-
munity is currently more accepting of the idea that for some substance abusers it is not
an absence of pain but rather a lack of hope that change is possible that keeps them from
entering treatment. Tis has lead to more treatment programs providing pretreatment
services that assist clients in becoming more ready for change, as described earlier. Here
human service professionals may utilize their generalist practice skills to assist clients in
this stage of the process.
Cultural Sensitivity
As with all areas of human services, gender and culture play a signifcant role in indi-
viduals perception of a problem and their attitude about receiving help. It has long been
recognized that diferent cultures have diferent patterns of alcohol and drug use. For
example, among Western cultures, those that socialize children to drink responsibly by
establishing patterns of when and where to drink, while at the same time discourag-
ing drunkenness, tend to have lower rates of alcohol abuse than those that forbid their
drinking altogether (Vaillant, 1995).
Yet, current research stresses the difculty of describing any cultural group as ftting a
stereotyped pattern of use. Caetano, Clark, and Tam (1998) found that ethnic minorities
are underrepresented in alcohol research in the United States and that existing studies
ofen fail to take into consideration the diferences that exist between subgroups within
a given cultural group. It is therefore wise to assess cultural attitudes with each client and
avoid assuming that stereotypes apply. Because clients may well feel loyal to their culture,
260 Part II / Generalist Practice and the Role of the Human Service Professional
clinicians need to listen nonjudgementally to the information shared by their clients.
Cultural sensitivity also involves practitioners being aware of how their own attitudes
and beliefs have been infuenced by their cultural background (Corey, 2005).
Human service professionals are routinely encouraged to consider those things
that might present obstacles to their clients receiving help. It is important to keep in
mind that even the concept of seeking professional help outside ones family refects
a Western worldview that is open to the idea that outsiders are appropriate sources of
assistance. Many cultures reject the focus on the individual or the belief that it is help-
ful to share ones feelings, a theme that is central to professional counseling. Given the
prevalence of group forms of therapy, this may be particularly difcult in substance
abuse treatment and calls for sensitivity and understanding on the part of the treat-
ment staf. Clients who have difculty sharing feelings with members of the opposite
sex, looking directly at another group member when they speak to them, or confront-
ing an older group member may be refecting their cultural norms rather than resis-
tance (Corey & Corey, 2006).
Defning Treatment Goals
Abstinence
In most treatment programs utilizing the medical model, abstinence is seen as the nec-
essary frst step in treatment. Tis means that the person commits to completely elimi-
nating the use of alcohol and all illicit drugs; in some programs this includes eliminating
even medically prescribed psychoactive drugs and pain medication. Abstinence is seen
as the necessary beginning point before other problems can be accurately assessed and
addressed. It is not, however, generally seen as the only goal of treatment.
Harm Reduction
Although abstinence is the goal in most treatment programs, some argue that harm re-
duction may also be an appropriate goal (Inaba & Cohen, 2004). Harm reduction can
include a variety of goals designed to limit the negative consequences (for both the indi-
vidual and society) of substance use for those unwilling or unable to achieve abstinence.
Tose who favor harm reduction may see abstinence as the eventual goal, but believe
that it may be appropriate to frst focus on smaller/intermediate goals such as using
less-dangerous drugs, decreasing the frequency or quantity of drug use, or limiting the
health risks associated with drug use. For example, those who argue for needle exchange
programs (for intravenous drug users) to reduce the transmission of AIDS base their
position on the concept of harm reduction. As both a public policy issue and a treat-
ment philosophy, harm reduction continues to be very controversial.
Tis approach is more likely to be advocated by programs working with clients deal-
ing with other problems in addition to their substance abuse disorder such as homeless-
ness or mental illness. Advocates for harm reduction argue that clients must overcome
many obstacles to enter treatment and that if they are required to be abstinent prior to
entering a treatment program, they may never do so. Tey draw the parallel that doctors
do not ask patients with other illnesses to eliminate their symptoms before they can be
Substance Abuse and Treatment 261
treated, but that treatment programs ofen require some period of
abstinence before people can enter their program. Like motivational
interviewing, harm reduction approaches favor meeting people
where they are, not where we would like them to be.
Mode of Service Delivery
Availability of Treatment
SAMHSA (2005) lists over 11,000 addiction treatment programs
on its online resource directory, including outpatient, residen-
tial, hospital inpatient, and partial hospitalization/day treatment
programs. Te services provided by these programs include reha-
bilitation, counseling, behavioral therapy, medication, and case
management (NIDA, 1999). In order to be included in the directory,
programs must be approved by the substance abuse agency for the
state in which they are located. Also included are those programs
administered by the Department of Veterans Afairs, the Indian Health Service, and
the Department of Defense. From the earliest days of treatment in the United States,
addiction treatment has been funded by both public (government) and private sources
(payment by private insurers, out-of-pocket payment by the person receiving treatment,
or payment by charitable sources).
Public Programs
Federal and state governments currently provide the majority of funding for substance
abuse programs. Although this is a source of ongoing public policy debate, there has
been a general consensus that money invested in providing substance abuse treatment
is well spent. One study found that for every dollar spent on substance abuse treat-
ment, seven dollars are saved in reduced health care, crime, lost productivity, and the
like. Studies have also established that it is signifcantly less expensive to provide treat-
ment to substance abusers than to incarcerate them. However, in an era where all levels
of government face increasing budget defcits, providing treatment funds despite the
benefts continues to be controversial (Scanlon, 2002).
Private Programs
Even those individuals who have health insurance that provides coverage for substance
abuse treatment are likely to fnd that their insurance plans provide strict guidelines
that limit how they can utilize their benefts. Beginning in the late 1980s, in an efort to
control rising health care costs, employers increasingly opted for ofering managed be-
havioral health (mental health and substance abuse) care as a part of their group health
insurance plans.
Te American Society of Addiction Medicine issued a report on the impact of man-
aged care on addiction treatment in the United States. Teir study, conducted by the
Hay Group, found that from 1988 to 1998, the value of insurance coverage for addiction
Human Systems
Understanding and Mastery of Human
Systems: Emphasis on context and the
role of diversity in determining and
meeting human needs
Critical Thinking Question: The concept
of harm reduction is gaining popularity
among human service professionals,
particularly in fields such as substance
abuse treatment. What are some of the
benefits of adopting a harm reduction
approach? What are some of the risks?
How might a human service professional
address the ethical implications of a
harm reduction policy?
262 Part II / Generalist Practice and the Role of the Human Service Professional
treatment had declined by 75 percent for employees who participated in group health
plans ofered by mid- to large-size companies. During the same time period, the report
found a much smaller decrease (11.5 percent) in the value of overall health insurance
coverage. A major factor in the decrease of the value of addiction benefts comes from a
reduction in the authorization of inpatient hospital treatment in favor of less-expensive
outpatient treatment options (Galanter, Keller, Dermatis, & Egelko, 2001).
For those working specifcally in addiction treatment, it has ofen meant the loss
of a job when their inpatient unit closed. In working with clients, it has meant becom-
ing well versed in the criteria used by managed care companies. Human service profes-
sionals are ofen called on to provide referrals for their clients; clinicians who are able
to provide direction to their clients in navigating the managed care system can be of
great assistance to those needing to arrange for treatment. Many people still associate
substance abuse treatment with the 30-day inpatient programs common in the 1980s.
Because this is no longer a realistic option for most people, human service profession-
als need to be aware of other treatment options and should be familiar with the types of
programs, both public and private, available locally to meet their clients needs.
Continuum of Care
Te currently accepted goal is that communities provide a continuum of care so that
individuals, groups, and families can receive the form of substance abuse treatment
most appropriate for their needs. Tis concept acknowledges both
that different people have different treatment needs and that an
individual persons needs vary over his or her course of treatment.
Prevention services are generally targeted to populations
known to be at higher risk for substance abuse. Although it is pos-
sible for anyone to develop a substance abuse problem, the Center
for Substance Abuse Prevention (2004) identifes six risk factors
that may lead to substance abuse or addiction:
Substance use by parents of other family members
Substance use by peers and the perception that everyone is doing it
Preadolescent use of alcohol, tobacco, or other drugs
Being a victim of physical or sexual abuse
Abusive or violent environment at home or in school
Economic deprivation
Many well-known prevention programs focus on providing youth with information
about the risks associated with using drugs and alcohol and the skills to just say no.
In addition to their role in providing services that help prevent substance abuse,
human service professionals are ofen in a position to recognize warning signs of
drug use in their clients. For example, school social workers should be alert to the
possibility that a students attendance problems, declining grades, poor physical
appearance, or change of peer group may be an indication of substance use. Other
behaviors that may be signs of substance use with clients in any practice setting
include declining work performance, fnancial problems, dramatic mood changes,
The currently accepted goal is that
communities provide a continuum
of care so that individuals, groups,
and families can receive the form of
substance abuse treatment
most appropriate for their needs.
Substance Abuse and Treatment 263
attempts to cover the smell of alcohol, always wearing sunglasses to hide dilated or
constricted pupils, wearing long sleeves to hide needle marks, or stealing from family
and friends (Hepworth, Rooney, & Larsen, 2002). Although any of these behaviors
may be due to issues other than substance abuse, human service professionals should
be alert to the possibility. It is ofen the recognition of these changes in behavior
that lead concerned family members and friends to seek out assistance, initiating a
request for assessment of the problem.
Te skills needed to assess a substance abuse problem vary according to the practice
setting. For the human service professional in a practice setting outside substance abuse
treatment, screening may be a part of the normal intake procedure. Te agencys intake
form may prompt the clinician to ask about current and past drug and alcohol use, fam-
ily history of substance abuse, and any negative consequences associated with substance
use. In some settings, this may be all that is indicated to screen for problems that may
require additional referrals or may afect the clients ability to utilize services.
In agencies where the prevalence of substance abuse is more likely to be high, more
extensive screening may be needed. For example, human service professionals in set-
tings dealing with domestic violence, the homeless, or families at risk for child abuse
may determine that even alcohol use that does not meet the DSM-IV-TR criteria for
abuse might interfere with treatment eforts. Agencies may reasonably set policies that
require clients to refrain from drinking alcohol prior to attending parenting classes, an-
ger management sessions, or any other agency service. Te intake clinician at a shelter
for the homeless may need to have more sophisticated screening skills to determine if a
client presenting for services can be safely housed in a program or instead needs a refer-
ral for detoxifcation.
Likewise, clinicians who deal directly with substance abusers need to be able to as-
sess if a client is in need of medically supervised detoxifcation and, if so, whether it can
be provided on an outpatient basis or requires hospitalization. Clinicians involved in
this level of assessment would normally be part of a treatment team including immedi-
ate access to medical services. Here assessment would require not just the recognition
of a problem, but the ability to refer to the appropriate level of treatment. Tose skills
needed to screen for a possible problem and initiate a referral for further assessment
and possible treatment would appropriately be considered part of generalist human ser-
vices practice. Te ability to assess or treat specifc substance abuse problems would
generally be considered a specialist skill requiring specifc training.
Many assessment tools have been developed to assist clinicians and health care
providers in the assessment of substance abuse problems. Te brief (four-item) CAGE
questionnaire and 25-question Michigan Alcoholism Screening Test are designed
to identify the presence of negative consequences of alcohol use that may indicate
a need for intervention. Te more comprehensive Addiction Severity Index is more
likely to be used in substance abuse specialty programs where it may be used as a part
of treatment planning, outcome evaluation, or in conducting research. As previously
described, diagnosis of substance abuse or dependence to the range of psychoactive
drugs of abuse is performed according to criteria set forth in the DSM-IV-TR (Inaba &
Cohen, 2004).
264 Part II / Generalist Practice and the Role of the Human Service Professional
Treatment Modalities
Once an assessment is completed indicating that a problem exists, treatment options
can be explored. Treatment of a substance abuse problem is a complex process that
occurs in stages over a period of time. Recovery from substance abuse is ofen described
as being a process, not an event. Depending on the treatment setting, staf may be drawn
from a variety of disciplines with different levels of training. The multidisciplinary
team may include psychiatrists and other medical doctors, nurses, psychologists, so-
cial workers, addiction counselors, family therapists, recreation therapists, occupational
therapists, and chaplains. All members of the treatment team may assess the client and
participate, along with the client, in developing treatment goals and plans.
The Role of the Human Service Professional
Human service professionals generally referred to as counselors working in substance
abuse programs come from a wide range of experiences and training backgrounds.
During the period of rapid growth of alcohol and drug treatment programs from the
1960s to the 1980s, few professionally trained counselors had specialty training in
addiction treatment. In most programs, frontline counselors, who conducted much
of the individual and group counseling, came to the feld by way of personal experience
in recovery; such counselors were ofen described as paraprofessionals. In some longer-
term residential settings, it was common for individuals to successfully graduate or
phase out of treatment and return almost immediately as a member of the treatment
team. Tis had the advantage of providing staf who knew the program, were dedicated
to its mission, and were ofen willing to work for low wages.
Common problems arose if the counselors relapsed, had difculty separating their
own treatment experience from that of their clients, or became overwhelmed by the
demands of attending to their own recovery while providing emotionally intense coun-
seling for their clients. Making the transition from being a resident (or patient) in a pro-
gram to being a counselor was generally not easy. Tere was considerable controversy as
to whether personal recovery experience was a help or hindrance to working in the feld
(White, 1998). Over time, most programs developed policies to address the common
problems that arose. For example, programs might require a graduate of their program
to have a minimum of one to two years of sobriety afer completing the program before
they could be hired as an employee.
Many steps have been taken to advance the training of substance abuse counselors.
Certifcate programs were added to the curriculum of many community and four-year
colleges that gave recovering individuals an opportunity to build on their life experience
with academic and professional training. Specialty programs can prepare counselors
who are themselves in recovery to deal with ethical issues that are unique to the feld,
such as how to manage interaction with one of their clients if they attend the same AA
meeting (Bissell & Royce, 1994).
Other advances in the professionalization of the feld are the development of stan-
dards for professional certification and the growth of professional organizations at
the state and national level. At the same time, college programs (for human service
Substance Abuse and Treatment 265
professionals, marriage and family therapists, social workers, and psychologists) have
added substance abuse training to their normal course of studies, as evidenced by the
inclusion to this text of the chapter you are reading.
Stages of Recovery
Many models have been developed that describe the process of recovery in terms of the
stages one must complete to arrive at health. Tese incorporate basic understandings
that problems that develop over a long period of time will take time to heal (in other
words, You didnt get sick in a day, youre not going to get well in a day either). Here
it is helpful to distinguish between the concepts of abstinence and sobriety as used in
recovery. Terence Gorski (1989), a pioneer and leader in the area of relapse prevention,
regards abstinence from mood-altering chemicals as a necessary frst step in learning
what to do to get and stay healthy in all areas of life (p. 4). Sobriety, as described by
Gorski, involves more: abstinence plus a return to full physical, psychological, social,
and spiritual health (p. 4). Recall that when individuals frst begin to use a psychoac-
tive substance, it is for them a solution. Whether it provides the liquid courage to
ask someone to dance, the energy to stay up all night to complete a paper or clean the
house, or a means to feel accepted by ones peers, the substance used has provided some
positive reinforcement for continued use.
When people stop using the substance, at a minimum, they must determine what
functions their use provided for them and how they will go about meeting these needs
in healthier ways in the future. Ofen this journey will involve painful psychological
work dealing with issues of past trauma or abuse. For example, veterans, who have used
painkillers as a way of numbing their memories of war, will have to deal with the emer-
gence of these memories in recovery. For most clients, their substance use has led to
multiple losses: ofen family, friends, job, and health. Grieving these losses is another
signifcant treatment issue.
Most clients also become increasingly aware of the ways that their use has harmed
others and must deal with the associated feelings of guilt and shame; this is ofen par-
ticularly painful work for parents who realize they have abused or neglected their chil-
dren. Te timing of this work requires sophisticated skill on the part of the counselor to
decrease the likelihood of precipitating a relapse.
Relapse Prevention
Troughout the stages of treatment and recovery, counselors increasingly introduce
the concept of relapse prevention. Although not limited to substance abuse treatment,
relapse prevention draws on cognitive-behavioral strategies to help clients build skills
to maintain abstinence and to address relapse should it occur (NIDA, 1999). Individu-
als are taught to recognize potential triggers for relapse such as being in neighborhoods
where they once used, sights or smells associated with use, or experiencing difcult
emotions. Counselors may help clients develop a list of coping strategies such as calling
a friend, attending a support meeting, or thinking through the consequences if they
266 Part II / Generalist Practice and the Role of the Human Service Professional
should relapse. Clients may carry a list of such possible strategies with them in their
wallet so that they will have to see the list if they try to buy a drink or drugs. Counsel-
ors also encourage clients to plan their response should they relapse. Rather than tell-
ing themselves that Ive blown it now, Ill never be able to stop, they are encouraged
to tell themselves, Get back to treatment. Clients are educated to understand that
addiction is a disease prone to relapse, and they are encouraged to be active in their
eforts to prevent relapse.
Common Treatment Settings
As previously noted, since the 1980s, there has been a shif away from inpatient treat-
ment programs as the standard for care of substance abuse in favor of outpatient pro-
grams. In part, this has been the result of managed care eforts to control rising health
care costs. Others, however, argue for outpatient treatment on philosophical grounds.
Te choice of a treatment program is best made based on determining the individual
needs of a specifc client. However, it is important for human service professionals to
familiarize themselves with all the types of programs generally available and with the
specifc resources available in their community. As you read about the various types of
treatment programs, keep in mind that human service professionals are employed in
each of these settings, generally providing the core treatment services of counseling and
case management.
All treatment programs will begin by assessing the needs of the individual (or fam-
ily) requesting treatment to determine if the individual is an appropriate candidate for
that program. In the event that the program is unable to provide the indicated treat-
ment, or the client rejects the services ofered, it is the ethical responsibility of the hu-
man service professional to provide the person seeking help with appropriate referrals.
Most agencies keep up-to-date resource directories to aid in this process. SAMHSA
maintains an online national directory of substance abuse programs; state and local di-
rectories are also available for most communities.
Detoxification Programs
As previously noted, clients who have become physically addicted to drugs or alcohol
need detoxifcation for the medical management of their withdrawal. Although many
substance abusers have stopped using abruptly (ofen referred to as quitting cold tur-
key), this can be both uncomfortable and dangerous, depending on the drugs involved.
Recall that addicts using downers (such as alcohol, barbiturates, and tranquillizers) that
depress the central nervous system will experience a speeding up of their nervous sys-
tem when in withdrawal. Tis can result in life-threatening seizures and therefore re-
quires medical supervision. Although medically necessary detoxifcation has been a
common criterion for inpatient treatment, in most cases, this can be accomplished on
an outpatient basis, a practice that is becoming more common.
Although detox is generally regarded as necessary before treatment can begin, some
clients will seek detox as an end in itself, as a way to either fnd housing or reduce their
tolerance so that they can reduce the cost of their drug intake (Doweiko, 2006). In this
Substance Abuse and Treatment 267
setting, human service professionals play a key role in encouraging clients to remain in
treatment despite the discomforts of withdrawal and the urges to leave and resume their
substance abuse.
Inpatient Treatment Programs
Traditionally, the term inpatient was used to refer both to programs located in hospitals
or freestanding programs (such as the Betty Ford Center) that were stafed to provide
medical services, including detoxifcation. Inpatient units existed in both general hospi-
tals and psychiatric hospitals. Although once common, the 30-day inpatient programs
ofen associated with substance abuse treatment are now relatively rare. Te treatment
focus of these programs, however, continues to shape much of outpatient treatment that
has become more common.
Most inpatient programs utilized what is known as the Minnesota Model of treat-
ment, which has its roots in the 1940s and 1950s in three treatment programs in that
state: Pioneer House, Hazelden, and Willmar State Hospital. Developing over time, a
defning concept of the Minnesota Model was an understanding of addiction as a pri-
mary, progressive disease (rather than a symptom of other problems) that would be the
focus of treatment, with lifetime abstinence as the goal. Seeing addiction as afecting all
areas of a persons life, treatment was provided by a multidisciplinary team including
doctors, nurses, psychologists, social workers, and clergy.
Recovered alcoholics were also part of the counseling staf. Each discipline com-
pleted an assessment of the patient, giving input into an overall treatment plan. Te
principles of AA were incorporated into the treatment, and patients attended meetings
as a part of their treatment program. Other treatment activities included educational
lectures, group and individual counseling, family treatment, reading and written as-
signments, and informal discussions with other patients, which combined to make a
highly structured program (White, 1998). Some programs ofered specialized units for
adolescents, impaired professionals (doctors and nurses), dually diagnosed patients
who sufered from an additional mental illness, or patients who wanted their treatment
integrated with their faith (most commonly Christian). Although all these treatment
activities and areas of specialization continue to be available, they are now more likely to
be provided in an outpatient setting.
Partial Hospitalization Programs
Partial hospitalization allows patients to attend all the day activities provided at an inpa-
tient program, while returning to their home to sleep. For patients who have a relatively
stable home environment, this can allow them to integrate what they are learning in
treatment into their family and home life. If problems arise at home, they can deal with
it in treatment the next day. Because the costs are reduced, insurance companies may
authorize more treatment days for partial hospitalization than for inpatient care.
Residential Treatment Programs
Although inpatient programs may also be referred to as residential, the distinction
made here is that residential treatment is more likely to occur in a homelike setting,
268 Part II / Generalist Practice and the Role of the Human Service Professional
over a longer period of time, providing less medical care. Like hospital-based programs,
residential programs provide 24-hour supervision so that the residents can focus on
their treatment, free of the stresses and responsibilities of their outside life and (at least
theoretically) free of opportunities to use chemicals. Historically, residential programs
(known as therapeutic communities) worked with drug addicts who had generally ex-
hausted all resources. Many utilized a more confrontational approach designed to tear
down the street image and build up a new, healthy identity. Te residents day was
highly structured with active involvement in the needs of the house, such as cleaning
and cooking, in addition to group and individual counseling. Over time, residents gave
up their addict identity in favor of being a member of the program community, ofen
referred to as family (NIDA, 1999, 2002). Human service professionals serve in all treat-
ment roles in residential programs using titles such as case manager, counselor, clinical
director, or program manager.
Some residential programs provide a step-down or transition from inpatient treat-
ment or detox. In these programs, such as halfway houses or sober living facilities, resi-
dents experience living in a supportive community free of drugs and alcohol, but may
continue their employment during the day. Residents are generally required to attend a
set number of mutual aid meetings each week in addition to house meetings. Te inclu-
sion of additional on-site counseling, provided by human service professionals, varies
from program to program.
Outpatient Treatment
Intensive outpatient treatment (IOT) provides community-based treatment for sub-
stance abuse. Programs vary in intensity, but include psychoeducational and therapeutic
eforts such as lecture, group, and individual counseling and activities designed to en-
hance life skills. Programs vary in format, but generally involve the client in a minimum
of 10 hours per week of treatment activities. To accomplish this, IOT uses many of the
same principles as described for inpatient treatment including a multidisciplinary treat-
ment team and individualized treatment planning.
IOT has grown in popularity as inpatient treatment has become less common. In
many ways, it bridges a gap between the 28-day medically managed programs once
prevalent and the traditional outpatient counseling where the client was seen only once
a week. In most programs, the number of hours patients are involved in treatment de-
creases as their length of sobriety increases. Stepped-down afercare services may be
available for a year or longer. At this point, the client may be attending treatment ser-
vices only once a week, in addition to his 12-step participation. Stafng for IOT increas-
ingly includes licensed therapists along with other human service professionals.
Traditional outpatient counseling, where a client sees a counselor once a week,
is likely to be inadequate for the client with a serious substance abuse problem. In
the past, mental health counselors frequently attempted to provide such counseling,
ofen treating the substance abuse as a symptom of underlying problems. It was the
failure of this approach that birthed current addiction treatment. Today, educational
programs that train human service professionals such as counselors, social workers,
and psychologists should include training on recognizing substance abuse problems.
Substance Abuse and Treatment 269
At a minimum, clinicians should be aware that clients substance
abuse will severely afect their ability to participate in counseling
and thus should consider referring their clients to appropriate sub-
stance abuse treatment.
Pharmacological Treatments
Te use of medication to treat substance abuse and substance abusers
has been a source of ongoing debate. Much of substance abuse treat-
ment has been provided in drug-free programs, stressing the need
for abstinence from all psychoactive substances, including medica-
tion prescribed for the treatment of psychiatric disorders such as an-
tipsychotics and antidepressants. Tis meant that substance abusers
with psychiatric disorders were ofen told that they were not appro-
priate candidates for substance abuse treatment programs.
Hospital-based inpatient programs were more likely to include
psychiatric medications as part of treatment, but there was contro-
versy even in those settings. Some argued that a substance abuser
must be drug free for some period of time before being accurately
diagnosed with a mental illness. Others maintained that providing
medication for mental illness would serve to enhance the success of
the substance abuse treatment. Recent epidemiologic studies have shown that between
30 percent and 60 percent of drug abusers have concurrent mental health diagnoses
including personality disorders, major depression, schizophrenia, and bipolar disorder
(Leshner, 1999, p. 1). Because the co-occurrence rate of substance abuse and mental
disorders is high, there has been a growing emphasis on the importance of clinicians
in both substance abuse and mental health treatment being aware of the special needs
of dual-diagnosis patients who sufer from both disorders. Generally, there has been in-
creased acceptance of the need for psychiatric medication for these patients, although
drug-free programs may still decide that they do not have the medical services available
to accept such patients into their program.
Self-Help
Earlier in this chapter, we discussed the birth of AA from the perspective of the history
of addiction treatment. Now we will look further at AA and other 12-step programs
(such as Narcotics Anonymous and Cocaine Anonymous) from the
perspective of treatment. Twelve-step programs play a signifcant
role in the treatment of addiction, both as a primary source of sup-
port and as an adjunct to professional treatment. Because they are
free, well known, and widely available, self-help groups represent a
major resource to human service professionals and their clients.
Twelve-step programs provide a setting in which members can
share their experience, strength, and hope with other members. Although commonly
referred to as self-help programs, the term mutual aid society may more accurately
refect the belief that one who sufers from addiction, but has received help, is in the
Human Services
Delivery Systems
Understanding and Mastery of Human
Services Delivery Systems: Range and
characteristics of human services delivery
systems and organizations
Critical Thinking Question: Currently,
the trend in substance abuse services is
to provide a community-centered con-
tinuum of care, including prevention
programs and a range of treatment op-
tions spanning detox programs, inpatient
care, partial hospitalization programs, and
outpatient treatment. To what extent is
the trend away from intensive inpatient
treatment driven by financial consider-
ations? What are the benefits and risks of
this new approach for clients?
Twelve-step programs play a
signifcant role in the treatment of
addiction, both as a primary source
of support and as an adjunct to
professional treatment.
270 Part II / Generalist Practice and the Role of the Human Service Professional
best position to help a fellow suferer. Providing this help to newcomers helps the older
member to stay sober.
Family Involvement
Many substance abuse programs include a component for family participation such as a
multifamily group, family night, or separate groups for family members. Tese groups
play a particularly important role in programs for adolescent substance abusers, where the
need for family work is immediate. Support groups such as Al-Anon, Alateen, and Co-
Dependents Anonymous also provide ongoing support for family members and friends.
Tese groups help individuals to identify the ways in which their own life has become
negatively afected by the substance abuse of another, and how to make healthy changes.
Commonly, family members come to understand that in focusing too much on the
substance abuser, they have neglected taking care of themselves. Some behaviors that
were intended to help the substance abuser, such as covering for them or taking over
their responsibilities, may in fact have enabled the substance abuser to continue their
use. Support groups for family members help them to determine clearer boundaries be-
tween what my responsibility is and what it is not and to make necessary changes in
their own behavior. Typically, family members come to realize that all attempts to con-
trol the substance abuser have been futile and that they have only the power to control
their own actions. Family members can, therefore, beneft from treatment even if their
chemically addicted member never participates in treatment.
Concluding Thoughts on Substance Abuse
Te use and abuse of psychoactive substances has been present from the earliest known
societies and continues to be a major health problem in the United States today. Ef-
forts to address this problem in the United States have included legislation to regulate or
prohibit the manufacture and sale of drugs and alcohol, prevention programs designed
to decrease risk factors and increase protective factors, and treatment for those with
substance abuse problems. Tese eforts have evolved over time, infuenced by societal
attitudes about substance abuse and, more recently, by scientifc research.
Human service professionals play a major role in the provision of prevention and
treatment services. Because substance abuse afects all areas of an individuals life, hu-
man service professionals will encounter this issue in every practice setting. Research
has established that prevention and treatment are efective and are increasingly utilized
in guiding program development and provision of treatment. In a variety of roles and
settings, human service professionals can assist substance-abusing clients in recognizing
the negative efects of their use, in obtaining necessary treatment, as well as in working
with them throughout the entire treatment process. Skilled human service professionals
routinely fnd this practice setting both challenging and rewarding.
271
The following questions will test your knowledge of the content found within this chapter.
CHAPTER 11 PRACTICE TEST
1. Early efforts to provide treatment for substance
abuse began in the United States in the mid-1800s,
prompted by:
a. a dramatic increase in opium addictions
b. a religious revival where the use of any alcohol
was deemed inappropriate and sinful
c. public concern over the problems resulting from
increased levels of public drunkenness
d. the dawn of psychiatry
2. What of the following factors is commonly consid-
ered contributors to the repeal of Prohibition, which
once again legalized the manufacture and sale of alco-
hol in the United States:
a. widespread disregard for the law
b. a signifcant rise of organized crime in the pro-
duction and distribution of bootleg liquor
c. the frst medical studies that revealed and ben-
efts of moderate consumption of alcohol
d. All of the above
3. The behavioral/environmental model describes the
possible progression of substance use through fve
stages:
a. abstinence, experimentation, social/recreational
use, habituation, abuse, addiction
b. social/recreational use, experimentation, abuse,
addiction, habituation
c. addiction, abuse, habituation, social/recreational
use, experimentation, abstinence
d. social/recreational use, experimentation, addiction,
abuse, habituation, abstinence
4. The academic model focuses on:
a. the infuence of a collegiate environment on the
drinking behavior, particularly the fostering of
binge-drinking behavior
b. the study of addictive behavior
c. the physiological effects of psychoactive drugs
d. Both A and B
5. Motivational interviewing is directive, client-centered
counseling style for eliciting behavior change by help-
ing clients to explore and resolve:
a. past hurts
b. past loss
c. ambivalence
d. unresolved anger
6. Many of the human service professionals who con-
duct individual and group counseling within substance
abuse came to the feld by way of personal experi-
ence in recovery are often called:
a. frontline counselors
b. recovery counselors
c. graduated counselors
d. paracounselors
7. Describe the harm reduction treatment model, including its goals and rationale for utilization with the substance
abusing population seeking treatment.
8. Describe various treatment modalities for substance abuse disorders, including the strengths and defcits of each,
treatment goals, and effcacy levels suggested by research.
Suggested Readings
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Black, C. (1981). It will never happen to me. New York:
Ballantine.
Johnson, V. E. (1980). Ill quit tomorrow. New York: Harper &
Row.
272 Part II / Generalist Practice and the Role of the Human Service Professional
Miller, W. R., & Munoz, R. (1982). How to control your drinking: A
practical guide to responsible drinking. Albuquerque: University
of New Mexico Press.
Philleo, J., Brisbane, F. L., & Epstein, L. G. (1997). Cultural competence
in substance abuse prevention. Washington, DC: NASW Press.
Vogler, R. E., & Bartz, W. R. (1982). The better way to drink: Modera-
tion and control of problem drinking. Oakland, CA: New Harbinger.
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Al-Anon/Alateen: http://www.al-anon.alateen.org
Alcoholics Anonymous: http://www.alcoholics-anonymous
.org
Narcotics Anonymous: http://www.na.org
National Center on Addiction and Substance Abuse at Columbia
University: http://www.casacolumbia.org/absolutenm/templates/
article.asp?articleid=287&zoneid=32
National Institute on Drug Abuse: http://www.nida.nih.gov
SAMHSAs National Clearinghouse for Alcohol and Drug Informa-
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social work practice: Theory and skills (6th ed.). Pacific Grove,
CA: Brooks/Cole.
Hettema, J., Steele, J., & Miller, W. R. (2005). Motivational inter-
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274
Where there are children, there will be counseling, and the U.S. public
school system is no exception. The field of human services has had a
strong presence in the U.S. public school system for over 100 years, and
this presence continues to grow, particularly in urban areas, where crime
and poverty continue to fourish.
Counseling on public school campuses is primarily conducted by
three types of professionals: school social workers, who are typically
trained professionals with a Master of Social Work (MSW) degree; school
counselors, who have a masters degree in school counseling and have a
background in teaching; and school psychologists, who have a masters
degree or doctorate in school psychology and, in addition to instruction
in educational counseling, are trained to conduct specialized educational
and psychological testing of students. Together, these human service pro-
fessionals comprise what is ofen called student services or pupil support
services.
Although each of these providers conducts counseling in some re-
spect, they use somewhat diferent approaches to counseling and student
support, have diferent standards of practice, and even have diferent ser-
vice and treatment goals. And although there are signifcant diferences
in practice guidelines between various states, regions (urban, rural, etc.),
and districts, school social workers tend to focus more on the psychoso-
cial aspects of students lives, providing counseling and case management
that focus on traditional social work concerns such as the students over-
all mental health, violence on campus and at home, the risk of suicide
among the student population, and the need for advocacy on behalf of
vulnerable students, including the homeless student, students of color,
and a range of other students who fall into various at-risk populations.
School counselors tend to focus more on academic counseling, career
guidance, and emotional or psychological issues that directly pertain to
student achievement. School psychologists focus on testing, particularly
Human Services
in the Schools
CHAPTER 12
Learning Objectives
Become familiar with the role
and function of the school social
worker, including gaining an un-
derstanding of the roots of the
various helping models
Understand the various activi-
ties the human service worker
engaged in within a school
setting, including individual and
group counseling, crisis interven-
tion, and case management
Explore the nature of the multi-
disciplinary team within the pub-
lic school system, identifying the
role and function of each mem-
ber, including understanding how
student issues are addressed by
each member
Become familiar with the broad
range of psychosocial and aca-
demic issues facing school-aged
children and adolescents, includ-
ing the difference between ur-
ban, suburban, and rural school
environments
Develop an understanding of
the broad range of psychosocial
interventions most commonly
utilized by human service pro-
fessionals work
Mary Kate Denny/PhotoEdit
Human Services in the Schools 275
in response to numerous federal and state mandates that require the academic testing of
students to place them in the proper educational setting, but may also provide counsel-
ing for students who are experiencing emotional difculties afecting their academic
achievement.
Regardless of a counselors designated role, when one works with human beings
experiencing strife, one immediately becomes a generalist having to deal with a broad
range of issues and serving in several diferent roles. Tus, although a school counselor
might initiate a counseling session with a student regarding academic performance,
study skills, or career planning, the session can take a quick detour focusing on the stu-
dents recent breakup, a bullying incident, a friends suicide, or a parents alcohol abuse.
A school psychologist charged with the responsibility of facilitating all the school dis-
tricts educational testing might easily fnd her- or himself spending extra time with a
student who breaks down during testing because she or he is living in a homeless shel-
ter and knows no one at school. In a similar vein, school social workers whose goal is
to focus on students psychological and emotional issues that are creating a barrier to
learning might fnd themselves conducting a study skills workshop or helping students
explore where they want to attend college or what they want to do for a career. Despite
the overlap in the functions of these three school-based careers, each of these felds has
unique professional standards and roles that, in many respects, delineate them from one
another.
School Social Work
School social work has its roots in the settlement house movement discussed in
Chapter2. Settlement house workers in the late 1800s and early 1900s, all of whom were
women, recognized the poor job urban schools were doing in keeping in touch with and
connecting to the parents of many of their students. Because settlement houses were
designed to provide services and relief primarily to low-income immigrant populations
in large urban areas, most of the children who were the original focus on these early ef-
forts to connect school with home were from families who had recently emigrated from
non-English-speaking countries. Settlement house communities frequently sufered
from overcrowding, both within neighborhoods and within the classroom, where some
schools had as many as 50 students per class (McCullagh, 1993, 1998). Tus, these early
school social workers served an important support function enabling teachers to focus
on the task of teaching academics.
Mass urbanization was also occurring during this time with scores of families mov-
ing from agricultural lifestyles to the city in search of factory jobs. With them came
children, many of whom were not adjusting well to city life, particularly when it in-
volved living in cramped quarters with parents who worked long hours. Of chief con-
cern among school districts that were the frst to use school social workers were child
maladjustment, child handicaps, and erratic school attendance, and it was the school
social workers primary goal to address these concerns by ensuring that childrens
adjustment needs were met, children with handicaps received necessary services, and
children attended school regularly (McCullagh, 1993).
276 Part II / Generalist Practice and the Role of the Human Service Professional
Tese school social work pioneers had many diferent titles: visiting teachers, home
visitors, special visitors, and visiting social counselors (McCullagh, 1998), and they
ofen lived in the settlement houses acting as a liaison between the school, child, and
home. This early work, often referred to as the Visiting Teachers Movement, tended
to focus on school-related matters such as irregular attendance issues, various health
problems, searching the city for children who were not attending schools (such as deaf
children and orphans living on the streets), and various other home-centered matters
afecting students. Te guiding philosophy of home and school visiting committees was
that the child was to be viewed from a holistic perspectivenot solely as a student caus-
ing problems for the district (McCullagh, 1993).
Trough the development of numerous committees, and the creation of a governing
and organizing association called the Public Education Association (PEA), these visit-
ing teachers or counselors gained in popularity and quickly became an integral part of
many school districts throughout New York, Boston, and Philadelphia over the next
several decades (McCullagh, 1993).
By the early part of the 20th century, teachers in low-income, high-need urban
neighborhoods had begun to look to these home visitors for advice and assistance on
several issues related to their students, including those concerning inappropriate behav-
iors, potential problems at home, lack of attendance, and general issues related to school
functioning. Tis reliance and general appreciation of the services provided by these
early school social workers refected the teachers and school administrators increasing
respect for this support service. In fact, by about 1910, many larger school districts were
lobbying to have school social workers become paid members of the school district and
board of education, rather than being contracted volunteers of the settlement houses
supported by philanthropic organizations (McCullagh, 1993).
Schools were also seen as the chief means for Americanizing foreign children (and, it
was hoped, their families), thus government interest remained high in social work eforts
to connect schools with families because it was believed that through such connections
more efective assimilation of the immigrant families would occur. Tis focus on expand-
ing the purpose of schools to include both the education and the social needs of the child
is still widely refected in todays public school systems that not only ofer solely academic
education and services, but also ofer counseling, case management, food programs, and
on-campus health services. But even if the goal of government was social control, the
focus of the school social worker remained on the individual child; the commonly cited
goal of these early social workers involved making certain that the individuality of each
child did not get lost in the chaos of the overcrowded classroom (McCullagh, 1993).
School social work continued to expand and professionalize over the next 40 years,
along with social work in general, and although originally more aligned with teachers and
the feld of education, by the 1940s visiting teachers and counselors were wholly aligned
with the social work profession, and the PEA ofcially changed its name to the American
Association of School Social Workers; later in the decade the name was again changed to
the National Association of School Social Workers (NASSW) (McCullagh, 1998). By 1955,
several diferent social work-related committees merged to create the National Association
of Social Workers (NASW), and although the NASSW still exists, it is now under the
Human Services in the Schools 277
auspices of the NASW. Te role of the school social worker continued to grow and expand
through the 1960s, fueled by the social turbulence that marked this era. Tis awareness led
to many universities developing school social work degree programs (McCullagh, 2001).
Finally, in 1975 Congress passed the Individuals with Disabilities Education Act
(Pub. L. No. 94-142), requiring that public schools provide free and appropriate public
education to all school-aged children between the ages of 3 and 21 years, regardless of
their disability. Tis law has required school districts to provide increased funding for
social work services for students with special needs, when deemed appropriate.
Currently, school social work remains a growing feld that ofers excellent practice
opportunities for those wanting to work with school-aged children. Issues such as in-
ternational academic competition, concerns about increasing violence in schools, and
continued reliance on social work services for the regular as well as special education
students have continued to propel school social work forward into the 21st century
and helped to ofset periodic reductions in education budgets due to cyclical economic
downturns. During difcult economic times though, it is not uncommon for school dis-
tricts to consider cutting back social work services. Tis is unfortunate because research
consistently shows how school social workers make a signifcant diference in the lives
of students and in the levels of their academic success. It is vital then that school social
workers consistently communicate their practices and efective interventions to their
administrators who appear to lower the possibility of cuts in school social work person-
nel (Bye, Shepard, Partridge, & Alvarez, 2009; Garrett, 2006).
The School Social Work Model
The traditional model of school social work involves the social worker providing
school-based social work services as an employee of the school district and as a part of
a multidisciplinary team. Although some districts utilize school-based social workers
employed by outside agencies (primarily as a cost-saving measure), most school dis-
tricts in the United States still employ the traditional model. Regardless
of the school social workers actual employer, the roles and functions of
the social worker are typically generalist in nature, but have become in-
creasingly specialized as managed care has forced many school districts
to seek government reimbursement for services (such as Medicaid or
Medicare), which in turn has prompted an increase in specialized cre-
dentials beyond licensing (Lewis, 1998).
Most states require that school social workers have an MSW with
a specialization in school social work, have accrued several hundred hours in an in-
ternship at a public school, and have passed a state content-area test. Some states still
require only a bachelors degree from an accredited social work program, but there is a
national push toward masters level education.
School Social Work Roles, Functions, and Core Competencies
School social workers perform a variety of tasks, serve numerous functions, and operate
within several diferent roles depending on the demographics of the school population,
the type of children served, and the capacity in which the social worker is functioning. In
The traditional model of school
social work involves the social
worker providing school-based social
work services as an employee of
the school district and as a part of a
multidisciplinary team.
278 Part II / Generalist Practice and the Role of the Human Service Professional
general, school social workers exist to assist children in managing any psychosocial issues
that are creating a barrier to learning. Tese could include physical barriers in the form
of a disability, cognitive barriers such as intellectual or learning disabilities, or behavioral
barriers such as students who are depressed, anxious, or acting out. School social work-
ers also work to develop, enhance, or maintain a close working relationship between stu-
dent families and the school, advocating for the family in a variety of situations.
According to the NASW, school social workers should be competent in providing
individual, group, and family counseling; should be well versed in theories of human
behavior and development; and should have knowledge of and be sensitive to the de-
mographic makeup of the school population with which they work, including relevant
issues related to socioeconomic status (SES), gender, race, sexual orientation, and any
community stressors that might affect a students ability to perform (such as a high
crime rate or gang infiltration). School social workers must also have competencies
in the areas of assessment, must be familiar with local referring agencies, and must be
committed to the values and ethics of the social work profession, including those relat-
ing to social justice, equity, and diversity (NASW, 2003).
School social workers may work with the general school population or may be hired
to work within the special education department either with physically or mentally
handicapped children or with students who are behavior disordered. Direct practice
will ofen include individual counseling and group counseling, as well as some family
counseling, if necessary. In most school settings, for a child to receive social work ser-
vices either they must be designated as a required service per the Individualized Educa-
tion Plan (IEP), which serves as a sort of contract between the school and family for
students identifed for special education services, or the students emotional or psycho-
logical problems must in some way be interfering with academic performance. Tus, if
a student was experiencing depression, but his academic performance was not afected,
this student might not be an appropriate candidate for social work services and would
likely be referred out for mental health services.
Individual counseling might include psychological counseling for a high school stu-
dent, or it might involve play therapy, including drawing, therapeutic games, or doll
play, for an elementary schoolaged student. Likewise, group counseling might involve
getting six or eight students together whose parents recently divorced, or who recently
moved from another school, and providing them with an opportunity to talk about
their struggles and feelings. Yet group counseling might also have a structured and spe-
cifc curriculum focusing on issues such as anger management or social skills training.
School social workers also conduct home visits to obtain vital information about the
students life outside school as well as to ensure a strong link between home and school.
Case management is also provided and can include the organization and coordina-
tion of numerous services received by a student. For instance, a students case might in-
volve an outside therapist who is providing psychological counseling, a psychiatrist who
supervises psychotropic medication such as antidepressants, a truancy ofcer, the police
department, a child welfare agency, the family, all the students teachers, and the school
principal. Tus, depending on the actual issues of the student receiving services, the
social worker will likely be involved in the coordination of services and the appropriate
Human Services in the Schools 279
dissemination of information of a number of involved parties. For instance, new medi-
cations or medication changes in students who are sufering from clinical depression
would be vital information for school social workers.
Crisis intervention is also an important role of a school social worker. Whether the crisis
involves a natural tragedy, such as a tornado or earthquake, the crisis surrounding a student
suicide, or the crisis of on-campus violence such as student-on-student assaults, school so-
cial workers provide crisis counseling to the entire student population, families, and even
the school staf. Crisis counseling might include helping students face the initial shock of
some tragedy, but also ofen involves implementing a safety plan. For instance, the suicide
of a student ofen elicits emotional distress in other students and can lead to an increased
chance of other students committing suicide. A school social worker will be involved in
creating awareness (through classroom presentations or staf meetings), maintaining a vis-
ible presence on campus, and conducting outreach services to vulnerable students.
School social workers may also facilitate confict resolution and violence prevention
programs. For instance, a school social worker might conduct a structured violence pre-
vention workshop or presentation in a classroom or manage a peer-led confict resolu-
tion program, training students to conduct resolution counseling sessions with students
who are engaged in some confict.
Most social workers are assigned to more than one school, thus they might spend
only a few days per week at any one school site. Tey typically have a caseload of stu-
dents they must see on a weekly or biweekly basis either on an individual basis or in a
group, and perform these various other tasks on an as-needed basis. Because the range
of student population types is so wide, it is difcult to describe precisely what a school
social worker does on a daily basis, but as with most human services positions, school
social workers must be generalists to efectively manage the variety of issues with which
they are confronted. Case Study 12.1 provides a wonderful example of some of the is-
sues a school social worker might encounter, but again the specifc nature of the work
depends in great part on the demographics of the student population, the age of the
students, and the capacity in which the social worker was hired.
CASE STUDY 12.1
Case ExampleA Day in the Life of a School Social Worker
Mario is a junior at a public high school in a large urban school in a state bordering
Mexico. He does not have a behavior problem, and does relatively well in his academic
studies, but has come to the attention of school social workers due to excessive absences.
His teachers also report that he seems particularly stressed out lately, and not himself.
Tere is concern that he may be withdrawing emotionally and socially due to an increase
in anti-immigrant sentiment exhibited among some students and school personnel. A psy-
chosocial evaluation reveals that Mario is the oldest of four children. Marios parents are
undocumented immigrants from Mexico, who have been living in the United States for
approximately 15 years, having been recruited to the United States by a large agricultural
280 Part II / Generalist Practice and the Role of the Human Service Professional
company. Marios parents do not speak English, and Mario disclosed that he ofen misses
school so that he can translate for his parents, or intercede on behalf of his parents who
are ofen scared to seek out services themselves in light of anti-immigration legislation
recently passed in the state. Mario also disclosed that he has in fact been the target of
anti-immigrant sentiment in the form of derogatory statements, and scapegoating. For
instance, on several occasions while walking down the halls in school he has heard ran-
dom students shout out to him asking for proof of his legal status. He has also experienced
negative statements directed toward all Hispanic immigrants, including a few teachers
and some ofce assistants making statements appearing to scapegoat the Latino popula-
tion for everything from escalating violence in the drug war, to scapegoating Latinos for
high regional unemployment rates. Te school social worker, Kate, responds to Mario and
his parents reassuringly, and explains that Mario can receive supportive servicesboth
from government human services and from programs within the school. At this point in
the session, Mario admits that he just learned that he does not in fact have legal status.
Mario grew up believing that he was born in the United States, but afer a recent meet-
ing with a state human services agency, he was informed that his Social Security number
was not valid. His parents then told him that he was six months old when they emigrated
from Mexico, and they used false papers provided to them by men from the agricultural
company that recruited them. Mario became extremely distraught when sharing this se-
cret, expressing discouragement and fear that he would not be able to attend college and
receive fnancial aid, despite having lived in the United States almost his entire life, and
working so hard to do well in school, or worse, that he could be legally deported to a
country he has never visited, and where he knows no one.
Before Kate can competently provide guidance, services, and referrals to Mario and his
family she must be aware of several areas of law that impact the migrant populationboth
those who are documented and undocumented. Tese overlapping areas include federal
and state immigration laws (much of what changed signifcantly post-9/11), changes in
public assistance policies in response to 1996 welfare reform (that barred the majority of
residents, documented and undocumented, from receiving any public assistance), difer-
ences in legislation and policies on various levels (federal, state, county, and school), as well
as having an awareness of pending legislation that may have an impact on Mario and his
family, such as the Dream Act, federal legislation that would make it possible for students
like Mario to attend college, under certain circumstances. Gaining this level of awareness
of macro issues afecting the Hispanic students at Kates school is a vital part of providing
cultural competent social work services. One way to learn more about current issues afect-
ing undocumented students is to attend workshops and conferences focusing on this issue,
as well as seeking out resources identifying key issues and dynamics published by advo-
cacy organizations, or other authoritative organizations. For instance, the National School
Boards Association and the National Education Association jointly published an online
report in 2009 in cooperation with several professional organizations, including School
Social Work Association of America, entitled Legal Issues for School Districts Related
to the Education of Undocumented Immigrants (Borkowski & Sorensen, 2009). Tis pub-
lication would be a great place for Kate to start in learning about a public schools obliga-
tions and responsibilities regarding the education of undocumented students.
Human Services in the Schools 281
School Counseling
Historical Roots of School Counseling
Te professional school counselor ofen has an overlapping role with
the school social worker, but typically focuses more on academic con-
cerns and career guidance. School counseling also has a history reach-
ing back to the late 1880s and early 1900s, with roots in the vocational
guidance counseling movement (Schmidt & Ciechalski, 2001). In fact,
early school counselors focused primarily on matching male high
school graduates with an appropriate vocational or job placement.
In the 1920s, theories of intelligence and cognitive development
became popular, infuencing the work of school guidance counselors
who, with the advent of intelligence and aptitude testing, now had
new tools with which to do their jobs. Te 1930s saw advancements
in the areas of personality development and motivation, which di-
rectly infuenced the feld of school counseling, enabling counselors to further assist
students in identifying areas of aptitude, as well as developing motivational techniques.
Social trends and political movements were chief among various infuences that led
to a gradual shif from a primary focus on the vocational needs of students to a more
comprehensive focus where school counselors proactively meet various developmental
needs of students (Schmidt & Ciechalski, 2001). Many school counselors working in a
secondary school setting not only continue to provide general guidance and academic
counseling, but also continue to strive to meet the needs of the whole student.
As with school social work, the Education for All Handicapped Children Act of 1975
(Pub. L. No. 94-142)which required, among other things, that children with special
needs receive all support services necessary to their academic successled to school
counselors becoming involved in special education departments. In addition, govern-
mental committee reports, such as A Nation at Risk (1983), and federal legislation,
such as the No Child Lef Behind Act of 2001 (now referred to as the Elementary and
Secondary Education Act [ESEA]) (U.S. Department of Education, 2001), have meant
an increase in funding in many school districts budgets for school counseling, because
concern for academic achievement (or, in some districts, concerns about academic
decline) has countered budgetary concerns.
School Counselors: Professional Identity
Although school counseling programs have continued to grow within most school
districts, one challenge consistently plaguing the feld is role defnition. A review of
the literature relating to the school counseling field clearly reveals a long-standing
struggle to defne the role and function of school counselors. Tis is perhaps due to the
overlapand even some professional territorial struggleswith school social workers
and school psychologists, all of whom are concerned with psychosocial counseling and
intervention with students.
School districts that have made budgetary decisions to hire only one mental health
provider may employ a school counselor to provide all counseling to students, including
Professional History
Understanding and Mastery of
Professional History: Historical and current
legislation affecting services delivery
Critical Thinking Question: Most states
now require school social workers,
counselors, and psychologists to hold
masters degrees in their fields, with
several hundred hours worth of intern-
ship experience, and often with a special
certification, as well. Why is it important
for human services provider positions in
schools to be so highly professionalized?
282 Part II / Generalist Practice and the Role of the Human Service Professional
guidance, career, and mental health. In this instance, the role of the school counselor is
similar to that of a school social worker. Yet in many schools that employ both school
social workers and school counselors, the latter commonly will provide more academi-
cally related counseling and even be responsible for many administrative functions,
including maintaining school records and monitoring attendance. For instance, Lambie
and Williamson (2004) complained that in many school districts school counselors are
working as assistant principals. Lambie and Williamson cite this practice as an example
of role confusion within the school counseling feld, suggesting that the American School
Counselor Association (ASCA), the professional organization for school counselors,
continue its quest to outline and defne the professional identity of school counselors.
Challenges Facing Urban Inner-city Schools
The plight of urban schools has received considerable attention in the past several
years, from both educators and the federal government. In response to these concerns,
ASCA and the Education Trust (a not-for-proft agency committed to working for high
academic achievement among all children) have made numerous recommendations
regarding school counseling programs, including developing systematic programs de-
signed to address many of the issues currently confronting urban schools, such as gang
activity, poverty, homelessness, child abuse, violence on and of campus, increasing rates
of clinical depression, unplanned pregnancy, and low academic performance (Baggerly &
Borkowski, 2004; Holcomb-McCoy, 2005; Lee, 2005).
In addition, urban schools face what is referred to as an achievement gap when com-
pared to suburban youth. Urban youth are far more likely to drop out of high school
and are less likely to meet the minimum standard on national standardized tests. Urban
schools have far greater difculty retaining quality teachers, must contend with political
issues ofen not confronting suburban schools, and are ofen located in high-crime areas
of concentrated poverty (Olson & Jerald, 1998).
Other issues facing urban schools and school counselors working in these settings
include dealing with high student absentee-
ism, unstable family systems, including a high
percentage of students living in foster care,
and high student transience, where students
ofen transfer in and out of school frequently
(Green, Conley, & Barnett, 2005; Lee, 2005).
Each of these issues is far more complex than
one might think initially. For instance, con-
sider the issue of high student mobility: One
might think that this issue would not neces-
sarily afect the school the student is leaving,
yet students who leave schools suddenly due
to family instability ofen fail to return their
textbooks, which can lead to significant fi-
nancial losses for schools, many of which are
already sufering serious budgetary shortfalls.
Urban schools are ofen overcrowded and located in
high-crime neighborhoods.
Will Hart/PhotoEdit
Human Services in the Schools 283
California is one state that has a signifcantly higher incidence of student mobility
than many other states, due in part to the immigrant population. In a 1999 study of
the impact of student transience on school districts, school researchers made several
suggestions including utilizing school counselors to reach out to departing and in-
coming students to coordinate transfers and minimize disruptions (Rumberger, Lar-
son, Ream, & Palardy, 1999).
Common Roles and Functions of School Counselors
School counseling programs generally focus on three basic areas: academic counsel-
ing, career development, and personalsocial development (Dahir, 2001). What form
this counseling takes depends in large part on whether the counselor is working at an
elementary school, middle school, or high school. Other issues infuencing the nature
of the counseling include the size of the student population, whether the school is in
an urban or rural area, and the nature of surrounding community. A
school counselor who works at a high-crime, overcrowded high school
in inner-city Chicago will certainly have a diferent role and perform
diferent functions than a school counselor working in a high-income
suburban elementary school.
According to the ASCA website (see http://www.schoolcounselor.org),
school counselors may engage in the following activities:
individual student academic program planning
interpreting cognitive, aptitude and achievement tests
counseling students who are tardy or absent
counseling students who have disciplinary problems
counseling students as to appropriate school dress
collaborating with teachers to present guidance curriculum lessons
analyzing grade point averages in relationship to achievement
interpreting student records
providing teachers with suggestions for better management of study halls
ensuring that student records are maintained as per state and federal regulations
assisting the school principal with identifying and resolving student issues, needs,
and problems
working with students to provide small and large group counseling services
advocating for students at individual education plan meetings, student study teams
and school attendance review boards
disaggregated data analysis (American School Counselor Association, 2005, p. 1).
In general, school counselors provide individual student guidance, such as help-
ing students develop good study skills, do some preliminary career planning, develop
effective coping strategies, and foster good peer relationships through the develop-
ment of prosocial skills, such as exhibiting empathy, showing kindness to others, and
managing anger appropriately. School counselors also develop and facilitate programs
on substance abuse awareness and multicultural awareness. School counselors assist
School counseling programs
generally focus on three basic
areas: academic counseling, career
development, and personalsocial
development.
284 Part II / Generalist Practice and the Role of the Human Service Professional
students with goal setting, academic planning, and planning for college. Tey facilitate
crisis intervention with individual students, the student body, families, and the school
as a whole. Tey collaborate with parents, teachers, and school administrators and pro-
vide community referrals as necessary. Tey may also facilitate programs focusing on
making the transition to the next level in school or to work. School counselors identify
and work with at-risk students, managing behavioral and mental health issues such as
substance abuse, suicide threats, classroom disruptions, studentteacher conficts, and
other issues as they arise.
Among school counseling competencies, Lee (2005) lists cultural competence, the
ability to advocate for students in an attempt to remove barriers to academic success, a
willingness to be leaders in educational reform, and the ability to efectively communi-
cate with and collaborate with other educational professionals.
Common Ethical Dilemmas Facing School Counselors
As with many other human service-related disciplines, school counselors face ethical
dilemmas on a daily basis that require them to not only be acutely aware of the ethical
standards of the school counseling profession, but also be aware of common dynamics
they may face that could result in sliding down the slippery slope from genuine caring
about students to the egregious violation of ethical boundaries. Some of these challenges
are pretty straightforward, such as maintaining confdentiality of student counseling
and related records or reporting child abuse in accordance with mandatory child abuse
laws. But there are other areas of ethical concern that are not so clear cut, and involve far
more of that ethical slippery slope, where appropriate responses to complex situations
are very much in the gray area.
For instance, consider the Latina school social worker who is passionate about ad-
vocating for Latina students because of what she endured in school, or the white school
counselor who, without awareness, seems to automatically show bias toward other
white students, and against students of color. At what point does passionate advocacy
become excessive single-minded bias toward one subpopulation, and directly or indi-
rectly, against another? School counselors deal with very complex situations on a daily
basis, and make decisions about how to handle these situations not solely upon their
professional training, but also on their own personal experiencesofen those very ex-
periences that brought them to this career to begin with. Thus, it is important for a
school counselor to be aware of how easy it is for unethical behavior to be rooted in a
sincere desire to show care and concern for students, particularly those students who
are particularly vulnerable.
In the ASCA online website, there is a section devoted to legal and ethical issues
for school counselors. Several articles posted in this section of the website pose ethi-
cal dilemmas, exploring the nature of these dilemmas in such a way as to assist school
social workers in recognizing the ethical and unethical nature of various approaches
to student problems and situations. For instance, one article entitled Boundary Cross-
ing: Te Slippery Slope, features a vignette of a student from a particularly chaotic and
neglectful home who develops a strong attachment to the school counselor, popping
into her ofce spontaneously whenever he needs some additional support. Te student
Human Services in the Schools 285
then invites the school counselor to a wrestling match a considerable distance from the
school on a Saturday evening. Te school counselor attends the match, and then drives
the student home, stopping for dinner on the way home as a gesture of congratulations
for a job well done. Readers are asked whether any aspect of this scenario violated ethi-
cal boundaries and why. Most respondents were somewhat mixed on whether the fuid-
ity of the ofce visits and traveling a long distance to attend a students school-related
event were ethical, but all respondents perceived the school counselor driving the stu-
dent home from the match and stopping for dinner, as clearly representing an ethical
boundary violation (Stone, 2011).
Stone (2011) goes on to explain each level of boundary violations and risks involved,
including the violation of boundaries regarding roles (confusing the role of school coun-
selor with a caregiver), the violation of boundaries regarding time (allowing the student
to so frequently make impromptu ofce visits, an arrangement that cannot be main-
tained for all students), the violation of boundaries regarding place (attending an event
outside of school hours and such a long distance away, driving the student home, and
stopping for dinner). Such boundary violations, while coming from good intentions on
the part of the school counselor, can lead to confusion on the part of the student who
may develop unrealistic expectations of the school counselor, and can also show bias to-
ward one particular student, when many students have similar backgrounds and needs.
In closing, the author summarizes how many ethical boundary violations come out of
good intentions on the part of the school counselor, and seemingly innocuous initial
events:
Boundary violations do not necessarily arise from bad character. When school coun-
selors do not recognize boundary crossings, innocent acts merely intended to be sup-
portive can spiral downward to boundary violations such as counter-transference
or worse. Egregious boundary violations are usually preceded by relatively minor
boundary excursions. (Stone, 2011, p. 12)
Concluding Thoughts about School Counselors
Although it may be true that the school counseling profession is still struggling to assert
a strong professional identity, establish the roles and functions of school counselors, and
maintain a presence among other student services professionals, as educational reform
movements continue to grow, schools will beneft most from a multidisciplinary team
that addresses the comprehensive needs of all students. Although school social work-
ers and school counselors ofen have overlapping roles and missions, a school with a
student body of about 3,000 that employs two school social workers and four school
counselors will certainly have enough student issues to keep all student services person-
nel busy!
School Psychologists
The National Association of School Psychologists (NASP, n.d.) includes the follow-
ing statement on its website: School psychologists help children and youth succeed
286 Part II / Generalist Practice and the Role of the Human Service Professional
academically, socially, and emotionally. Tey collaborate with educators, parents, and
other professionals to create safe, healthy, and supportive learning environments for all
students that strengthen connections between home and school.
If you think this explanation is similar to the description of school social workers
and school counselors, you are correct! As with the other two student services positions
discussed in this chapter, school psychologists have a broad range of responsibilities and
functions that depend on the actual school environment. But one signifcant diference
between a school psychologist and a school social worker and/or school counselor is
that a school psychologist conducts academic testing on students to evaluate and assess
their academic abilities and defcits and ofen is the only student services professional
who is trained in evaluating intervention programs.
Most school psychologists have a masters degree in educational psychology, have
completed a lengthy internship at a school, and have a special credential designating
them as a school psychologist. Tose with masters degrees in social work and counsel-
ing who want to become a school psychologist can earn an EdS (specialist in education),
which will enable them to obtain a school psychologist credential.
Common Issues and Effective Responses by
Human Services Personnel
Due to the overlap that exists in the roles and functions of school social workers, school
counselors, and school psychologists, any of these professionals will encounter similar
clinical issues while working in a public school. Tus, although some of the information
contained in this section might appear to be oriented more toward one discipline or
the other, it is important to remember that all human service professionals working in
a school setting could conceivably confront these same issues, depending on their role
within their assigned school.
I mentioned earlier that the nature of work performed by school social workers,
school counselors, and school psychologists can vary signifcantly, depending on a wide
range of variables and circumstances; yet certain issues will arise on virtually every pub-
lic school campus, and human service professionals working on school campuses must
be trained to both recognize and respond to them when they occur.
Depression and Other Mental Health Concerns
Te National Institute of Mental Health (1999) states that approximately 3 percent of
children and 8 percent of adolescents sufer from some form of depression. Tese statis-
tics underscore the importance of human service professionals having the tools neces-
sary to both recognize and respond to depression in the school environment.
Symptoms of depression in children and adolescents are similar to that of adults,
except that ofentimes children exhibit symptoms of irritability rather than melancholy.
Another important consideration is that it is ofen the quiet children, sitting in the back
of the classroom bothering no one, sufering silently, are ofen the most in need of help,
yet likely to be overlooked by school personnel because they are not acting out in any
visible way.
Human Services in the Schools 287
Abrams, Teberge, and Karan (2005) recommended that school counselors (and
other mental health providers) use an ecological model (discussed in Chapter 1) as
a lens through which a depressed student is assessed. Students who are identifed as
sufering from depression are evaluated from a perspective that considers a students
contextual map to truly grasp the reciprocal nature in the relationships between the
depressed students and their environment, including their families, close friends, neigh-
borhoods, and school (microsystem); to truly grasp the reciprocal nature in the rela-
tionship between depressed students and their broader community (mesosystem); and
fnally to allow the counselor to evaluate the impact of the broadest aspects of the stu-
dents world, including the efect of cultural mores, various social reforms, political poli-
cies, and the impact of natural tragedies (exosystem).
For instance, in assessing and evaluating a potentially depressed student, the clini-
cian would evaluate the relationship the student has with peers, family members, and
even teachers. Is the student experiencing confict with one or both parents? Has the
student recently experienced fghts with peers? Te counselor will then evaluate the re-
lationship the student has with the broader community. Is the student involved with the
legal system? Does the student have involvement with a truancy ofcer? Finally, the cli-
nician will evaluate how anything in the broader society might be afecting the student.
For instance, the terrorist attacks of September 11, 2001, had a devastating impact
on virtually everyone. Te evaluation of any student for depression in the months sub-
sequent to September 11 was likely assessed in the context of these devastating events.
Did the student have any friends or family members who were directly afected by these
attacks? Does the student have a parent or close family member who was deployed to
Iraq or Afghanistan in response to these attacks? Similarly, any signifcant changes in
governmental social policy have the potential to afect students, particularly those who
are living in government-subsidized housing and who have parents who are subsidized
by public assistance. Do these changes in policy affect the students family in a way
that consequently puts pressure on the student because of increased stress within the
household?
In general, the human service professional not only evaluates anything that might
be a contributing factor to the students current mental health status, but also evalu-
ates strengths and support within the students world (Abrams et al., 2005). Does the
student belong to a church body or faith community that ofers or has the potential
of ofering support? Does the student have any extended family members who might
come forward and ofer to support the student during a difcult time? A student who is
experiencing depression because his father was deployed to Afghanistan might have an
untapped support system in a support group for children sponsored by the U.S. Army.
Te value of this model is that it is complementary with the overall model of human
service professionals who are trained to consider the entire context within which the
student is operating. Tis approach also enables the social worker and counselor to pro-
vide more efective case management once contributing factors and support systems are
identifed. Tis model also encourages the involvement of the students family system.
In fact, research so strongly supports the positive impact of parental involvement in the
students mental health on academic achievement that Vanderbleek (2004) suggested
288 Part II / Generalist Practice and the Role of the Human Service Professional
that school social workers and school counselors identify and address any barriers to
families becoming involved in the counseling process. Tese barriers might be cultural
or racial, such as a less-than-welcoming environment toward non-English-speaking
parents or parents who do not feel well treated by school personnel. Barriers can also be
more concrete, such as a parents lack of transportation or a work schedule that makes
meeting with school personnel impossible. Flexibility on the part of support services
personnel, including a willingness to conduct home visitsafter school hours, if
necessarywill help to reduce the majority of these barriers.
Auger (2005) wrote in favor of a multifaceted approach to depression intervention
within the school system and suggested that school counselors collaborate with school
personnel, families, and other mental health practitioners, challenge
the student to address any pessimistic or negative thinking, encour-
age the development of greater insight into feelings and their con-
nection with behavior, help the student develop better social skills,
and create opportunities for the student to succeed. Auger even
advocated encouraging the student to increase physical activity be-
cause there appears to be a relationship between physical activity
and positive mental health.
Tere is, of course, a limit to the amount of mental health ser-
vices a school can provide to its students. Student support person-
nel must learn to recognize when a students mental health problems
have evolved past the purview of the school social workers or coun-
selors area of expertise. Many students experience a level of depres-
sion that can successfully be addressed within the school, but human
service professionals training may not extend to the level necessary
to deal with a student who is profoundly depressed and/or whose
family system is so desperately impaired, that outside referraland
possibly hospitalizationis the only viable option.
Diversity and Race
In virtually every school, some students ft into the mainstream and others do not. It is
ofen the student who does not ft in who is most likely to be vulnerable to scapegoat-
ing, bullying, and violence. Students who do not feel safe in school, who are subject to
bullying, and who are made to feel as outcasts because of race, sexual orientation, or
any reason that seems to set them apart from other students will be at risk for academic
failure or at least academic difculty.
Although the responsibility for keeping students safe lies with all adults associated
with the studentteachers, all school personnel, and even parentshuman service pro-
fessionals are in a unique position to identify potential problems related to diversity and
intervene by advocating for diverse students.
Racial and ethnic diversity can be a wonderful asset to any school environment lead-
ing to a richness in experiences for students and teachers alike. But in some school en-
vironments, racial prejudice and discrimination can lead to violence and confict among
many within the student population. Students who comprise a part of a racial minority
Human Services
Delivery Systems
Understanding and Mastery of Human
Services Delivery Systems: Major models
used to conceptualize and integrate pre-
vention, maintenance, intervention, reha-
bilitation, and healthy functioning
Critical Thinking Question: Many hu-
man service professionals employ a tool
called an ecograma graphic model
that represents clients relationships with
other people and institutions, as well as
stressors and sources of strength and
support. How might this model be used
to assist a school child who is suffering
from depression?
Human Services in the Schools 289
either within the school or within the broader society are at risk for academic failure
for many reasons including social, economic, and political conditions such as poverty,
racial intolerance, and higher rates of violence ofen associated with the urban school
environment discussed earlier in this chapter. A school environment that is hostile to
racial minorities contributes to an environment where students feel unwelcome and
possibly where school policies either directly or indirectly discriminate against students
of color. Te target of racial discrimination is not limited to people of color though, par-
ticularly on a school campus where any student who is a racial minority can be a ready
target for bullying and violence.
Human service professionals can assist teachers and school administrators in rec-
ognizing and addressing discrimination and prejudice on campus. Tey can also as-
sist in the development of cultural diversity training focusing on racial sensitivity and
respect for diversity. Equally important is the cultural competence of the counselors
themselves. It is vital that human service professionals undergo
training, focusing on the nature of counseling from a multicultural
perspective ( Holcomb-McCoy, 2004).
An examination of traditional counseling theories and interventions
reveals a bias against racial minorities, particularly African Americans.
Fusick and Charkow (2004) discussed the tendency of traditional
Euro-American theories to pathologize racial minorities rather than recognizing the
social oppression that contributes to violence, gang activity, and juvenile delinquency.
For those who disregard the power of long-standing racism and its resultant oppression,
one must ask whether they believe that certain racial groups are simply more violent
than others. If not, then credence must be given to the possibility that dysfunctional be-
havior is not solely a result of individual pathology, but can be the result of social causes
as well.
Because of a history of abuse by child welfare agencies (as discussed in Chapter 5)
and a court system that has ofen not recognized the long-standing efect of generations
of racial discrimination, certain minority groups may be mistrustful of counseling and
mental health treatment (Horejsi, Craig, & Pablo, 1992; Surbeck, 2003). Tus, coun-
selors should not assess a students or familys wariness of mental health personnel as
paranoia or as a sign of deception, but should recognize and understand the roots of
such mistrustone that can ofen be overcome through the development of an authen-
tic helping relationship and student-centered advocacy.
Fusick and Charkow (2004) also discussed the efect of biased assessment tools that
were created for assessment and evaluation of the majority culture, with Caucasian
middle-class values and mores. African American students in particular are far like-
lier to be referred for counseling and social work services for behavioral problems, fur-
ther exacerbating the hostility ofen felt toward mental health professionals. Fusick and
Charkow recommend that social workers and counselors be neither too directive nor
too appeasing in counseling sessions, but instead focus on developing a truly authentic
relationship.
I worked as a school social worker in an urban school that was primarily African
American. Not only was I one of very few Caucasians on campus, but my caseload
It is vital that human service
professionals undergo training,
focusing on the nature of counseling
from a multicultural perspective.
290 Part II / Generalist Practice and the Role of the Human Service Professional
consisted primarily of boys, and as a woman, there was a natural discomfort with me
on the part of my students. A fellow social worker suggested that I try to speak to the
students using some of the slang used by many of the African American or Latino
American youth. Knowing that I could never get away with this, I decided to just be
myself and express my desire to get to know each of them. I spent time getting to know
them and their interests, and I quickly learned that many of the boys loved athletics. I
purchased packs of sports cards as encouragement and rewards. In time, the majority of
my students recognized my sincere desire to understand and help them. And although I
never judged them or their feelings, I was never afraid to jump in and make suggestions
for either perceiving or handling situations in a diferent way.
Lesbian, Gay, Bisexual, Transgendered, and Questioning Youth
Students who are in the sexual minority, such as lesbian, gay, bisexual, transgendered,
and those students who are questioning their sexuality in some way (LGBTQ), are of-
ten the victims of violence, both verbal and physical. Many of these children spend a
considerable amount of time feeling diferent and isolated, ofen believing that no one
will understand their feelings and accept them unconditionally. Such individuals have
an alarmingly high rate of suicide attempts, with over 30 percent admitting to having
attempted suicide at some point in their lives. Approximately 75 percent of gay and les-
bian students admit to having been verbally abused at school, and over 15 percent have
been physically abused (Pope, 2003).
Most of the youth in Popes study reported that the violence they experienced was a
direct result of their sexual orientation, with boys being abused more ofen than girls.
Pope discussed this type of abuse in terms of the pressure on most high school students
to conform to the norms of their peer group. When faced with the overwhelming de-
mands to be just like everyone else, students who stand out, either because they look
diferent or, as is the case with gay and lesbian students, when their sexual orientation is
diferent, they can quickly become outcasts.
In 2009, the advocacy organization Gay, Lesbian and Straight Educational Network
(GLSEN) conducted a national survey of LGBTQ students on their experiences with the
following issues:
hearing biased and homophobic remarks in school
feeling unsafe in school because of personal characteristics, such as sexual
orientation, gender expression, or race/ethnicity;
missing classes or days of school because of safety reasons; and
experiences of harassment and assault in school
Te results of the study found that a signifcant majority of LGBTQ students ex-
perience verbal and physical harassment on a daily basis in school, with little to any
intervention or advocacy on the part of school personnel. For instance, between 75 per-
cent and 90 percent of LGBTQ students surveyed heard homophobic terms used in a
derogatory manner, such as gay, dyke, and faggot in school, and most respondents
reported feeling distress in response. Almost 85 percent reported that they had been
verbally harassed at school due to their sexual orientation, and almost as many reported
Human Services in the Schools 291
that theyd been verbally harassed because of their gender expression (not being femi-
nine or masculine enough). About 40 percent of respondents reported that they had
been victims of physical harassment at school because of their sexual orientation, and
about 20 percent were physically assaulted. Over 50 percent of respondents were vic-
tims of cyberbullying and harassment through text messaging, emails, and social media.
In most of these cases, there was little to no response on the part of school person-
nel, leaving the majority of these students feeling very unsafe in their respective school
environments.
Te report details the most frequent consequences of these various types of bully-
ing related to a students sexual orientation and gender expression, including higher-
than-average absenteeism, lower educational achievement, and a negative impact on
their psychological well-being (higher rates of depression, anxiety, and lower levels of
self-esteem). Te authors of the report recommend the following solutions: gay-straight
alliance clubs (GSAs), inclusive curriculum (course curriculum that includes positive
representations of LGBTQ people and events, currently and historically), supportive
educators (training educators in LGBTQ awareness and advocacy), and incorporation
of strict bullying and harassment legislation and policies. Schools that had incorporated
these remedies shows marked reductions in LGBTQ biasbased bullying (Kosciw, Grey-
tak, Diaz, & Barkiewicz, 2010).
It is vital that school personnel address the harassment that most gay and lesbian
students experience and develop a plan for combating this response to students in the
sexual minority. The first step is to establish a zero-tolerance policy, where teachers,
school administrators, and student services professionals make it clear to the student
population through policy and action that harassment will not be tolerated in any re-
spect. Developing a plan for making school safe for all vulnerable students begins with
the education of school personnel.
School social workers, counselors, and psychologists are the ideal candidates to edu-
cate both school staf and students on the importance of tolerating diversity. Such a pro-
gram must begin with the school staf, particularly the teachers, who are most likely to
be present when the abuse of gay and lesbian students occurs. Teachers do not need to
be convinced that homosexuality is an acceptable orientation. In fact, regardless of how
strongly the student support professionals feel about wanting to create a consensus of
acceptance, it is probably unrealistic to assume that everyone on the campus is going
to perceive alternate sexual orientations as a positive, albeit alternative, lifestyle choice.
What needs to be emphasized is that regardless of ones personal beliefs about the issue
of sexual orientation, no human being should be subjected to verbal and physical ha-
rassment and abuse. Nor should people be solely defned by their sexual orientation or
any other singular aspect of their personhood. School personnel should be taught that
personal feelings should be set aside and the focus should be placed instead on teaching
students to respect human dignity and everyones basic right to self-determination.
A particularly efective program facilitated by school social workers, counselors,
and psychologists across the nation is called the Making Schools Safe project (Otto,
Middleton, & Freker, 2002). This program was developed by the American Civil
Liberties Union (ACLU) and was designed to combat antigay harassment on school
292 Part II / Generalist Practice and the Role of the Human Service Professional
campuses. Te ACLU recommends that all teachers and administra-
tors use this curriculum, which focuses on the vital importance of
creating a safe learning environment for all children.
The Terrorism Threat and the Impact of 9/11
On September 11, 2001, members of a terrorist organization called
Al-Qaeda hijacked four commercial airliners and crashed two of
them into the World Trade Center towers in New York City and one
into the Pentagon in Arlington, Virginia. Te fourth airplane, alleg-
edly intended for the White House, crashed in Somerset County,
Pennsylvania, afer passengers temporarily overpowered the hijack-
ers. This series of terrorist attacks was followed by a month-long
bioterrorism attack with letters sent through the post ofce laced
with anthrax (Baggerly & Rank, 2005). Te media was flled with
reports of feared future attacks.
Many school districts scrambled to develop programs to address
students feelings and concerns in the wake of the September 11 attacks. Te most com-
mon psychological response was post-traumatic stress disorder (PTSD), a disorder that
ofen occurs in the wake of a traumatic event. Individuals with PTSD continue to experi-
ence fear, hopelessness, and horror long afer the event (American Psychiatric Association,
2000). Vicarious victimization was also prevalent on many school campuses. Te events of
September 11 were difcult for adults, but were particularly hard on children who lack
the ability to think abstractly and who ofen lack the ability to communicate their feelings.
A 2004 study found that 65 percent of respondents reported that students expe-
rienced moderate to high levels of distress in the weeks following the attacks (Auger,
Seymour, Roberts, & Waiter, 2004). Te most frequently reported symptoms included
fear, worry, anxiety, sadness, anger, and aggression. Students who were personally
affected by these terrorist attacks or who already suffered from some mental health
issues, such as depression, were the most at risk for developing PTSD symptoms.
Auger et al. (2004) also noted that although most schools surveyed took appropriate ac-
tion in responding to the attacks, 12 percent took no responsive action. Te majority of the
schools surveyed took no action to assist school personnel in dealing with their own feel-
ings. Over one-third of school counselors stated that they did not feel prepared to respond
to a serious trauma, suggesting that ongoing training of all school personnel is essential.
Tere have been many longer-term consequences to the September 11, 2001, attacks
but one particularly troubling reaction is a marked increase in what is called Islamo-
phobia, the irrational fear and hatred of Muslims (or those perceived to be Muslims).
Te Runnymede Trusta social policy think tank organizationhas identifed eight
components of Islamophobia:
Seeing Islam as
1. a monolithic bloc, static and unresponsive to change
2. separate and other with values that are dissimilar to other cultures
3. inferior to the Westbarbaric, irrational, primitive and sexist
Human Systems
Understanding and Mastery of Human
Systems: Emphasis on context and the
role of diversity in determining and
meeting human needs
Critical Thinking Question: Lesbian, gay,
bisexual, transgendered, and question-
ing (LGBTQ) youth are at extremely
high risk for bullying and harassment
and the myriad emotional wounds that
result from such treatment. How might
a school social worker, counselor, or psy-
chologist best work to meet the needs
of this vulnerable population?
Human Services in the Schools 293
4. violent, aggressive and threatening, and in support of terrorism
5. having a political ideology used for military advantage
Responded to by non-Muslims by
1. summarily rejecting any criticisms made by Islam of the West
2. justifying discrimination and social exclusion of Muslim populations based upon
this hostility
3. perceiving anti-Muslim hostility as normal (Conway, 1997).
A 2011 policy brief published by the Institute for Social Policy and Understanding
states that bullying of Muslim children in school environments is on the rise since the
September 11, 2001, terrorist attacks (Britto, 2011). While the increase in bias-based
bullying is on the rise in general, this brief identifes the chief reason why Muslim chil-
dren are being bullied is due to American mainstreams limited knowledge, pervasive
misperceptions, and negative stereotypes about Muslims (p. 1). Britto cites the infu-
ence of media on the attitudes of non-Muslim youth, which frequently depicts Muslims
as potential terrorists, and ideological extremists. She recommends using the media to
counteract these negative and incorrect stereotypes, such as creating YouTube videos
depicting accurate refections of Muslim culture.
The Learning Channel (TLC) attempted to do just that with its new series called All-
American Muslimsa reality-based show featuring Muslim families in their everyday lives.
Te show features the lives of several families living in Michigan, including a high school
football coach and his family, and a young newlywed couple expecting their frst child. Te
purpose of the show according to TLC and its producers is to educate the non-Muslim American
population about the range of Muslim culture by illustrating how Muslim- Americans
are ofen concerned about the same ordinary issues as everyone else. Yet, despite the positive
intention of the shows producers, significant controversy ensued, leading to most of the
shows advertisers pulling their ads during the show. Te majority of the criticism came from
a conservative Evangelical Christian organization called Florida Family Association (FFA),
whose founder, fundamentalist David Caton, is better known for attacking GSAs (according
to one parent he once compared gays to murderers) (Freedman, 2011). Caton claimed that
the show, All-American Muslims, had an Islamic agenda, which was a threat to American
traditional values. On FFAs website, a statement about the show reads as follows:
Florida Family Association urged advertisers to stop supporting the Learning
Channels new show All-American Muslims because it appeared to be propaganda
designed to counter legitimate and present-day concerns about many Muslims
who are advancing Islamic fundamentalism and Sharia law. Te show profled only
Muslims that appeared to be ordinary folks while excluding many Islamic believ-
ers whose agenda poses a clear and present danger to liberties and traditional val-
ues that the majority of Americans cherish. (FFA, 2012)
So essentially, Canton and his small fundamentalist organization had a problem
with the show because it did not feature Muslims who were extremists, had values con-
trary to American culture, or who embraced Sharia law! Canton claims that he and his
294 Part II / Generalist Practice and the Role of the Human Service Professional
organization were successful in infuencing the majority of the shows advertisers, citing
that 100 out of 112 of them did not advertise on future episodes in response to Cantons
email campaign. What concerns social justice advocates is that such a small fundamen-
talist organization was able to successfully utilize social media to spread Islamophobic
propaganda to such an extent that it infuenced numerous major advertisers into pull-
ing support (although many have since reinstituted advertising support in response to
strong public criticism).
Tis is just one example of what many fear is becoming mainstream Islamophobia
being projected at attempts to dispel stereotypes and myths regarding the American-
Muslim population. Other examples, particularly those afecting school children, in-
clude making constant references to Muslim children as being terrorists, and making
jokes about Muslim children and their families making bombs (Abdelkader, 2011).
Such bias-based bullying should not be tolerated and school social workers, in coordi-
nation with school counselors, school psychologists, teachers, school administrators,
parents and other students, can counteract Islamophobia through the implementation
of educational programs designed to increase awareness of the range moderate belief
systems embraced by the mainstream Muslims, both in the United States and abroad.
Yet, as TLC found, social workers would be wise to expect controversy on some level,
particularly by parents and those in the community who may be threatened by at-
tempts by any marginalized group to assert its collective right to enter the mainstream
of America.
Substance Abuse
Substance abuse both on and of campus continues to be a growing problem across the
United States, primarily in high schools, but also in some middle schools. School social
workers, counselors, and psychologists must be able to identify the signs of substance
abuse as well as be prepared for the various ways of intervening when substance abuse
is suspected. (See Chapter 11 for more on the issue of the lack of training in the area of
substance abuse.) Although many graduate programs in the mental healthrelated felds
are addressing this issue by including more courses on substance abuse, the majority
of programs still only ofer substance abuse courses as electives. Many mental health
professionals in student services are unprepared to deal with substance abuse issues or
the complexity of adolescent substance abuse, particularly with regard to complicated
family systems (Lambie & Rokutani, 2002). Te reality is that 74 percent of high school
seniors in suburban high schools have reported using alcohol, and 40 percent of high
school seniors in suburban high schools have reported using illegal drugs (Greene &
Forster, 2004), making substance abuse one of the most signifcant issues confronting
school personnel.
School counselors need to be able to identify adolescent sub-
stance abuse and respond with an intervention strategy. That
strategy must include a response from the school as well as from
outside referral sources that will involve the entire family system.
The model most often used to describe the nature of adolescent
substance abuse is similar to an adult model and does not take into
74 percent of high school seniors
in suburban high schools have
reported using alcohol, and 40
percent of high school seniors in
suburban high schools have reported
using illegal drugs.
Human Services in the Schools 295
consideration factors related to adolescent development. Adolescents tend to be egocen-
tric, ofen acting and feeling in ways that tend to be self-focused. Tey also tend to dis-
play behavior that is impulsive, appearing to lack any real sense of consequences. Tis
seeming sense of omnipotence, coupled with developmental egocentrism, ofen compli-
cates traditional models of substance abuse.
Lambie and Rokutani (2002) suggested using a systems perspective in evaluating
substance abuse in the adolescent population. Rather than viewing substance abuse in
the adolescent as an individual problem, a systems perspective views the substance abuse
as a sign of something amiss within the family system. Te substance-abusing adolescent
ofen serves some purpose within the family system, such as enabling the parents to fo-
cus on the adolescents dysfunctional behavior rather than on problems in the marriage.
Te substance-abusing adolescent sometimes serves as an apparent symptom of deeper
problems within the family system that are purposely hidden from view. For instance, the
family who works hard to appear normal and healthy will be compelled to deal with
underlying dysfunction when one or more of the children begin acting out in ways that
require outside attention and intervention, such as abusing drugs and alcohol.
Another issue to consider when using a systems perspective is whether the ado-
lescents substance abuse is mirroring a parents substance abuse. A parents abuse of
alcohol or drugs has been shown to infuence an adolescents decision to begin drink-
ing (Lambie & Sias, 2005; Piercy, Volk, Trepper, Sprenkle, & Lewis, 1991). In general,
families that have system problems such as parental substance abuse and other forms of
maladaptive behavior tend to be rigid closed-family systems and lack the ability or ca-
pacity to handle the increased stressors associated with children entering the adolescent
years. Adolescents demanding changes to long-standing rules, pushing for more privi-
leges, developing a far wider circle of peers, and questioning family rules can ofen leave
a family that is wary of outsiders and rigidly adheres to rules and discipline with few
efective coping skills to adapt to these changes. In addition, problems that have their
roots in early childhood most ofen manifest during adolescents. In fact, I have worked
with adolescents for years and cannot think of a single adolescent who did not act out in
response to an issue or condition with roots in his or her childhood.
A school social worker, counselor, or psychologist working with substance-abusing
adolescents must frst be able to identify the common signs of abuse, including erratic
behavior, mood swings, red eyes, and slurred speech. Tey must then be able to provide
support to both the student and the family, acting as a liaison between student, family,
school, and community-based treatment programs.
On a broader level, student services personnel can institute prevention programs in
the school, such as the Drug Abuse Resistance Education (DARE) program that involves
police and other community agencies coming into the schools and creatively (through
plays, dance, and songs), and in an age-appropriate manner, enlighten students about
the dangers of drug abuse and encourage students to avoid substance use and abuse.
Child Abuse and Neglect
School social workers, counselors, and psychologists are ofen in the position of having
to report child abuse to their local child welfare agency. (See Chapter 5 for a discussion
296 Part II / Generalist Practice and the Role of the Human Service Professional
of child protective services involvement in child abuse cases.) School social workers,
counselors, and psychologists are ofen in the precarious position of having to decide
what should constitute a hotline call. For instance, a child showing up to school with
bruises, who discloses she has been physically abused by her mother, clearly mandates a
call to child protective services, but frequently a counselor might not have such a clear
indication of abuse and must make a determination based on suspicion. It is impor-
tant for student services personnel to understand that they do not need to be certain
of abuse; if there are indicators of any type of abuse, it is their legal obligation to fle a
report and allow child protective services to conduct an investigation.
It is important that the school social worker, counselor, or psychologist remain com-
posed when a student discloses abuse, but express compassion, support, and encour-
agement. It is equally important that promises are not made that cannot be kept. For
instance, the counselor should not promise not to tell anyone, because the student will
feel betrayed when report of child abuse is made (Lambie, 2005). Tere might also be
reticence on the part of the counselors to make a report of child abuse if they know the
parents and are suspicious of the students disclosure, but the counselor must adhere to
the law, which requires that any abuse disclosure be reported as required.
Teenage Pregnancy
A newspaper article in 2005 reported that 13 percent of the female students at an Ohio
high school were pregnant, causing serious concern about why this high schools preg-
nancy rate was nearly double the national average (Garvey, 2005). Although teenage
pregnancy has been on the decline in recent years (Karraker, 2004), it remains a seri-
ous concern, with over 60 percent of high school seniors reporting they were sexually
active (Greene & Forster, 2004). Various research studies have pointed to many factors
that might infuence pregnancy. Beyond sexual activity in the adolescent population,
other factors include early alcohol use (Stueve & ODonnell, 2005) and poverty (Young,
Turner, Denny, & Young, 2004).
Research on prevention points to religiosity (Rostosky, Regnerus, & Wright, 2003),
peer infuence, appropriate parental supervision, good and direct parental communica-
tion, SES, race (Corcoran, Franklin, & Bennett, 2000), and involvement in sports that is
correlated with remaining abstinent in high school or at least becoming sexually active
later in adolescence.
Sex and pregnancy prevention programs have been included in school curriculums
for several decades with mixed reviews. Abstinence-only programs, although somewhat
controversial, have shown to be surprisingly successful (Toups & Holmes, 2002). In fact,
Toups and Holmes reviewed several studies that revealed marked reductions in teen-
age pregnancy afer experiencing a school-based abstinence-only program. In fact, one
cited study evaluated all 5,000 teenagers who participated in an abstinence program in
one year. Not only did few of these teenagers become sexually active, but also over 50
percent of the students who had been sexually active stopped having sex. Proponents
of abstinence-only sex education cite the decrease in adolescent sexual activity as evi-
dence that these programs work. Yet others have questioned whether these programs
are as successful as some of these studies indicate, citing poor study designs and a wide
Human Services in the Schools 297
range of abstinence programs with some defning abstinence as postponing sex until
early adulthood and some more religiously based programs sending the message that
premarital sex should always be avoided. Without a clear defnition of abstinence, crit-
ics claim that its impossible to determine the success of these programs (Kirby, 2002).
Some educators are concerned, though, that abstinence-only programs will not
work for all teenagers, particularly those who have any of the complicating factors men-
tioned earlier. Teenagers living in poverty, who have poor communication with their
parents, and who are not supervised well by their parents may not respond positively to
abstinence-only programs because of the other forces pushing them in the direction of
sexual activity. Based on the belief that some adolescents will have sex no matter who
tells them not to, education programs focus on safe sex practices, such as using con-
doms during sexual intercourse. Many of these programs focus among other things on
HIV/AIDS education, which is ofen later cited as a chief reason among adolescents
for using condoms. Although there has been some concern that educating teenagers
to use contraception and even making contraception available is sending a mixed mes-
sage (i.e., You should not have sex during adolescence, but just in case you do, use a
condom!), which in essence promotes sexual activity during adolescence, a review of
28 studies examining this issue clearly shows that such programs do not increase sexual
activity among teenage participants, nor do they lead to sexual activity at an earlier age.
In fact, many studies indicated that safe sex programs increase the usage of contracep-
tion (Kirby, 2002).
One of the most popular programs currently used in high schools across the nation
is called the Baby Tink It Over (BTIO) program, which uses a computerized doll pro-
grammed to cry and fuss intermittently throughout the day and night to educate teen-
agers on the realities of having a baby. Tis program has been successful in educating
teenagers about the hardship and burden of having a child at such an early age (Somers,
Johnson, & Sawilowsky, 2002).
Another issue commonly noted by school social workers, counselors, and psycholo-
gists who work with female high school students is a pervasive tendency for girls who
are sexually active to report that they had not considered the possibility that they could
have said no to a boyfriends sexual advances. Developing empowerment support
groups where girls can have a safe place to talk about their feelings about sex, support
each other in their right to say no, and consider the positive consequences of doing so
can be a successful tool in encouraging better boundary setting, which is likely to result
in a reduction of sexual activity.
Attention Deficit Disorder and Attention
Deficit/Hyperactivity Disorder
In the past 20 years, diagnoses of attention defcit disorder (ADD) and attention defcit/
hyperactivity disorder (ADHD) have literally skyrocketed, with school personnel being
on the leading edge of those referring children for evaluation and assessment. Accord-
ing to the DSM-IV-TR (Diagnostic and Statistical Manual of Mental Disorders, fourth
edition, text revision), individuals with ADD sufer from inattention, have difculty fol-
lowing directions, have difculty maintaining a sense of organization, and are reluctant
298 Part II / Generalist Practice and the Role of the Human Service Professional
to engage in activities that require sustained mental efort (American Psychiatric Asso-
ciation, 2000). Additional symptoms that might warrant a diagnosis of ADHD include
hyperactivity, impulsivity, and poor self-control (Kos, Richdale, & Jackson, 2004).
Children diagnosed with ADD/ADHD ofen present signifcant challenges in the
classroom due to difculty in paying attention to the teacher and sitting still for ex-
tended periods of time. Classroom management with such children can ofen be dif-
fcult because many children with ADD/ADHD symptoms have difculty with social
skills as well, making peer relations a problem.
Te most common treatment for ADD/ADHD involves the use of medication, most
commonly Ritalin, which is a stimulant that has a calming efect on the child. But many
schools have instituted behavioral plans that include token rewards for children who are
able to remain focused for increasing amounts of time and who display prosocial behav-
iors. School social workers, counselors, and psychologists are ofen called on to work
with children exhibiting ADD/ADHD symptoms, both in the classroom and outside
the classroom. Many schools utilize a therapeutic group model, bringing several such
students together to work on issues such as impulse control, social skills, and maintain-
ing attention. Many therapeutic board games on the market are designed to encourage
these skills by engaging the students in play while teaching them how to delay gratifca-
tion and control their impulses as a winning strategy.
Despite the prevalence in the diagnosing of these disorders, many are concerned
that too many referrals for ADHD are coming from educational circles. With most
disorders, such as depression or anxiety, referrals for evaluation and counseling might
come from ones employer, spouse, or friend. Yet schools tend to be by far the largest
source of referrals for ADD/ADHD, presumably because children with these symptoms
can cause serious disruption in the classroom, and with class sizes increasing, it can be
taxing on a teacher to contend with students who are not paying attention and are act-
ing on their every impulse.
Another concern is that the DSM-IV-TR criteria are too broad and in many respects
self-fulflling. For instance, criteria number 1-d states: Ofen does not follow through
on instructions and fails to fnish schoolwork, chores, or duties in the workplace (not
due to oppositional behavior or failure to understand instructions). Tis criterion is
extremely broad and in many respects could be used to describe just about any child
at one point or another during his academic career. Certainly most clinicians would
not diagnose a child with ADD simply due to one or two incidences of procrastina-
tion, but rather they would look for a pattern of behavior. But, a recent study that com-
pared a group of school-aged children assessed using DSM-IV-TR criteria and a group
of school-aged children using neuropsychological criteria found that the DSM-IV-TR
group had an 18 percent prevalence rate and the neuropsychological group had a preva-
lence rate of only 3.5 percent (Guardiola, Fuchs, & Rotta, 2000). Tis seems to support
the criticism that the DSM-IV-TR criteria may be too broad.
Another criticism of what some claim is the overdiagnosing of ADD/ADHD in-
cludes a concern that boys are disproportionately referred for and diagnosed with
ADHD for what many consider to be typical boy behavior, including being more
naturally active than girls (Sciutto, Nolf, & Bluhm, 2004). In addition, several studies
Human Services in the Schools 299
have found that several other factors might account for ADHD-like behavior including
lack of sleep (Brown & Modestino, 2000) and even gifed intelligence with high creativ-
ity, leading to a concern that many children are being misdiagnosed with ADHD when
other issues might better account for the childs inability to focus, such as fatigue or,
in the case with the intellectually gifed child, a need for increased mental stimulation
(Hartnett, Nelson, & Rinn, 2004).
One of the most signifcant concerns of all, though, involves concern among medical
personnel, therapists, and parents about the wisdom of giving children a stimulant with
cocaine-like properties throughout their developmental years. Historically the medical
community did not believe that Ritalin caused any permanent brain changes, yet many
recent studies seem to contradict this belief. A 2001 study on rats found that Ritalin use
did cause permanent neurological brain changes (Andersen, Arvanitogiannis, Pliakas,
LeBlanc, & Carlezon, 2002), and although rats are certainly not humans, they are amaz-
ingly similar to humans in the sense that they ofen respond chemically in ways similar
to humans. Te results of this study were surprising to researchers because the initial
goal of the study was to evaluate whether long-term Ritalin use made subjects more vul-
nerable to drug abuse later in life. What they found, though, was that the rats who were
on Ritalin desired cocaine less. Further research discovered that this was due to Ritalin
causing an increase in a certain protein that afects the pleasure centers of the brain. So
although this result might be good with regard to decreasing ones desire for drugs, it is
not so good if it makes other activities less rewarding, such as eating and sexual activity.
Another 2001 study also indicates that Ritalin, commonly thought to have a short-
term life in the body, has long-term efects, many of which are permanent and most
of which remain unknown. Tis study found that Ritalin may afect or even alter gene
expression, which may lead to enduring changes in brain cell structure and function
(Acheson, Tompson, Kristal, & Baizer, 2001; Brandon & Steiner, 2003). Basically what
this means is that the Ritalin may actually be turning a certain gene on that then turns
other genes on, a reaction also found in the brains of those who abuse cocaine. Because
these studies are still in the animal model phase, it is impossible to conclude anything
other than the implication of the results, which at this point seems to clearly indicate
that long-term use of Ritalin in developing children will likely have a permanent efect
on their brains. Even at this preliminary stage it seems clear that Ritalin should be used
only in cases of serious hyperactivity and perhaps only with neurological testing to
determine if Ritalin is medically necessary.
Finally, a 2009 longitudinal study on medical and behavioral intervention for
ADHD in children found that while there is some short-term beneft to taking medica-
tion, such as Ritalin and Adderal in controlling ADD/ADHD symptoms, there appears
to be no long-term beneft. In fact, the researchers noted that at an eight-year follow-
up of children diagnosed with ADD/ADHD, children who had stopped taking medica-
tion functioned as well as children who were still medicated. In light of this and other
research, highlighting the risk and limited benefts of medicating children exhibiting
ADD/ADHD symptoms, there is wisdom in approaching the Ritalin Revolution with
some healthy skepticism.
300 Part II / Generalist Practice and the Role of the Human Service Professional
Human service professionals may fnd themselves going against
conventional wisdom, by advocating for behavioral interventions
with short-term medication protocol (or none at all), only if the
childs symptoms warrants taking the risk. Despite these criticisms
and concerns, children who exhibit behaviors that are not conducive
to the classroom environment need assistance to learn to adapt to
a structured world. School social workers, counselors, and psychol-
ogists can work with the students in a manner that both respects
diferent learning and personality styles and at the same time en-
courages children to work efectively in a structured environment.
Concluding Thoughts on Human
Services in the Schools
Human service professionals are an integral part of the public school
system providing emotional guidance and academic counseling to
thousands of students every year. School counselors, school social
workers, and school psychologists work within their respective specialties as a part of a
multidisciplinary team meeting student needs and increasing student success.
Te role of all of these human service professionals is expected to continue to ex-
pand in the future in response to a projected increase in many of the social trends
experienced today, including an increase in poverty, homelessness, and single-parent
families. Teams of human service professionals work together to remove barriers to
learning, paving the way for teachers to do what they do bestteach students in their
designated academic discipline.
Human Services
Delivery Systems
Understanding and Mastery of Human
Services Delivery Systems: Range of
populations served and needs addressed
by human services
Critical Thinking Question: Increasing
numbers of students are being diag-
nosed with ADD/ADHD, often as a
result of referrals from school person-
nel, and treated with medications such
as Ritalin. What are some of the ethical
considerations that a school human ser-
vice professional must take into account
as part of a students treatment team?
301
1. School social work has its roots in the
a. intelligence testing movement
b. settlement house movement
c. English Poor Laws
d. the Vocational Testing movement
2. Most of the children who were the original focus of
the early efforts of early school social workers were:
a. from families who recently emigrated from non-
English-speaking countries
b. identifed for services due to consistent acting
out and rebellious behavior
c. from upper-income families whose children were
often left with caregivers
d. from area orphanages
3. The Disabilities Education Act (Public Law 94-142)
required that public schools provide:
a. free and appropriate public education to all
school-aged children between the ages of 3 and
21, regardless of their disability
b. increased funding for social work services for
students with special needs, when deemed
appropriate
c. before- and after-school care for all children with
Individualized Education Plans
d. Both A and B
4. The feld of school guidance counseling was infu-
enced by:
a. the advent of developmental psychology
b. the advent of intelligence and aptitude testing
c. the need for increased vocational counseling to
fll the gap left by young men going to war
d. A
5. Urban schools face what is referred to as:
a. the urban dilemma
b. the drop out phenomenon
c. an achievement gap when compared to subur-
ban schools
d. the funding paradox
6. Therapeutic board games often used in school
settings are designed to encourage which of the
following skills?
a. Self-suffciency skills
b. Delaying gratifcation and managing impulse
control
c. Competitive skills
d. Both A and C
The following questions will test your knowledge of the content found within this chapter.
CHAPTER 12 PRACTICE TEST
7. Describe the nature of teen pregnancy, including demographics, associated risk factors, and effective intervention
strategies used by human service professionals.
8. Compare and contrast the functions and roles of the various human service professionals working in a school
environment, including origins of the different school-based professions, respective professional identity including
role overlap, and treatment goals.
Suggested Readings
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Torrey, E. F. (2001). Surviving schizophrenia: A manual for
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302 Part II / Generalist Practice and the Role of the Human Service Professional
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International Network for School Social Work: http://
internationalnetwork-schoolsocialwork.htmlplanet.com
National Association of School Psychologists: http://www.
nasponline.org
School Social Work Association of America:
http://www.sswaa.org
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305
Historically, the mental health and medical communities in Western so-
ciety have had a tendency to divide human beings into biological, intel-
lectual, social, emotional, and spiritual parts, with minimal recognition
of how each of these dimensions interacts with the other. But in recent
years there has been a growing interest both within professional circles
and within the general public in moving away from such a dichotomous
view and toward regarding humans from a holistic perspective, where a
person is considered as a whole with each aspect of the person being in-
extricably linked with the other.
Essentially, a holistic approach to mental health involves the process
of acknowledging, addressing, and evaluating the mind, the body, and
the spirit (or soul) when considering any potential issue afecting ones
psychological health. In other words, rather than attempting to deter-
mine whether depression is a biological disorder with psychological
manifestations or a psychological disorder with biological implications,
depression would be seen as a disorder or condition having a reciprocal
impact on the whole person: mind, body, and soul.
Although mental health providers in the past have had a tendency to
shy away from integrating spirituality within the counseling relationship,
recent studies have revealed the dramatic ways in which religion or per-
sonal spirituality afect peoples physical and mental health. In fact, several
recent research studies have focused on the mindbodysoul connection
in an attempt to understand the reciprocal relationship of each, with a spe-
cifc focus on how spirituality afects an individuals physical and mental
health (Idler & Kasl, 1992; Koenig, George, et al., 1998; Koenig, Larson, &
Weaver, 1998; McLaughlin, 2004; Powell, Shahabi, & Toresen, 2003).
For instance, many of these studies have shown that personal reli-
giousness and spirituality have been linked to a decrease in depression,
an increase in greater social support, an increase in cognitive functioning
Learning Objectives
Understand the various ways
in which a faith-based agency is
defned
Become familiar with the vari-
ous ways different faith tradi-
tions provide human services to
those in need
Identify the benefts and po-
tential risks of human services
provided by faith-based agencies
Become familiar with the basic
traditions of giving in the Big
Three faith traditions: Judaism,
Christianity, and Islam
Become familiar with recent
legislation and government
policy that infuences faith-based
agency practices
Faith-Based Agencies
CHAPTER 13
Robin Nelson/PhotoEdit
306 Part II / Generalist Practice and the Role of the Human Service Professional
(Koenig, George, & Titus, 2004), an improvement in the ability
to cope with crises (McLaughlin, 2004), and better ability to cope
with substance abuse problems (Fallot & Heckman, 2005). Al-
though there is some confusion about the diference between re-
ligiousness and spirituality, religiousness is commonly defned as a
social experience grounded in traditional religion, whereas spiri-
tuality is ofen defned as having an independent relationship with
God (Miller & Toresen, 2003). Of course, people can be religious
and spiritual (having a personal relationship with a deity that is
grounded in a particular religious faith), religious without being particularly spiritual (a
cultural or secular involvement in a religious faith), or spiritual without being grounded
in a particular religious tradition. Tus, it is important for practitioners to explore what
religiousness and spirituality mean to their individual clients.
Te issue of faith is one of importance to all clinical practitioners, particularly men-
tal health practitioners and those within the human services feld. Several recent studies
have revealed that the majority of U.S. Americans (between 80 and 90 percent) identify
themselves as being either religious or spiritual, stating that their faith is an important
aspect of their lives (Gallup & Lindsey, 1999; Grossman, 2002). In fact, several of these
research studies suggest that clinicians should both acknowledge and address the spiri-
tual dimension of mental and emotional disorders within the counseling relationship,
particularly if clients identify themselves as being spiritually grounded (Fallot, 2001;
Kliewer, 2004; Miller, Korinek, & Ivey, 2004).
Yet human service professionals (or any service provider) must realize that as much
as incorporating spirituality into the counseling relationship may be helpful for some
clients, there is also the potential for harm, particularly when the religion of a provider
is pushed onto a client in a directive or aggressive manner.
Incorporating spirituality into a counseling relationship requires cultural compe-
tent counseling skills because many religious traditions are rooted in cultural tradition.
Tus, religious abuse is similar in many ways to culture abuse where a provider of a
dominant culture is inappropriately directive in forcing the values of the dominant cul-
ture onto a client of a diferent culture. For instance, prior to the recent surge of interest
in holistic health, practitioners in the West were ofen dismissive of Eastern philosophy,
which acknowledged the mindbodysoul connection for centuries (Tseng, 2004), ren-
dering many in the human services profession ill-equipped to provide efective services
to Asian clients from Buddhist or Hindu traditions (Hodge, 2004).
Religious abuse can be avoided through the sensitivity of the human service profes-
sional who not only recognizes the value of addressing matters of faith but also recog-
nizes that the issue of spirituality is only helpful if this exploration is client driven and
client centered (Hall, Dixon, & Mauzey, 2004).
Faith-Based Versus Secular Organizations
Human service professionals can incorporate matters of spirituality in virtually any
practice setting in response to their clients disclosure that faith is an integral part of
their lives or something they wish to explore. Tus, it is important that providers receive
A holistic approach to mental
health involves the process of
acknowledging, addressing, and
evaluating the mind, the body, and
the spirit (or soul) when considering
any potential issue affecting ones
psychological health.
Faith-Based Agencies 307
training on the nature of various religious traditions, particularly those they might have
an opportunity to encounter in their clinical practice. But there are also numerous hu-
man services agencies that operate within a particular religious faith that reach out to
those within and outside the tradition.
Such faith-based agencies are ofen ignored in discussions of human services prac-
tice settings, but any review of helping agencies should include an exploration of faith-
based agencies because of the long history of religious traditions ofering help to those
in need, and the fact that matters of spirituality are now recognized as being integral to
many peoples lives.
What is a faith-based organization? And what makes it diferentin nature and
service deliveryfrom a secular agency? Its easy to identify a faith-based organiza-
tion when its a synagogue, church, or mosque flled with religious symbols and a mis-
sion statement that identifes serving God as a primary function and purpose of the
organization. But what about agencies that might be considered parachurch organiza-
tions that do not function as churches but more as a human services agencies? Or hu-
man services agencies that have their roots in a particular religious tradition but dont
integrate religion or faith into practice? Would those agencies be considered faith
based?
These are more challenging questions than they might appear. Even the courts
are not particularly clear on what makes an organization religious in nature
(Ebaugh, Pipes, Chafetz, & Daniels, 2003). The difficulty lies in the fact that many
secular agencies provide almost identical services as faith-based agencies and there
is often no distinguishable difference between the two. Ebaugh et al. discussed the
various ways in which policy makers, social scientists, and historians have defined
faith-based organizations, with most criteria relating to an organizations depen-
dency on religious entities or denominations for support, whether the mission state-
ment identifies agency goals that reflect core values that are religious in nature, and
whether the employees of the organization are religious and adhere to a statement
of faith.
However faith based is defned, it is important to remember that faith based
does not necessarily mean Christian, as might be presumed in some Western coun-
tries, such as the United States. In fact, a number of religiously oriented organizations
provide faith-based human services grounded in faiths other than Christianity.
Tus, although it is true that the majority of faith-based organizations are Christian
in nature, many are not. Faith-based agencies may be Jewish, Muslim, Mormon, and
Buddhist, each serving communities either broadly or choosing to serve individuals
of that particular faith.
Faith-based human services can be facilitated as a ministry of a house of worship,
or they can be facilitated as a program within a religious organization that functions as
a human services agency, such as the Salvation Army. Such organizations might have
the goal of converting clients to that particular faith, believing that conversion is the
frst step toward wholeness, or they might deliver human services in a manner similar
to secular agencies, but operating in a manner consistent with the values of its religious
roots. Its important to be aware of the churchs or agencys mission because it will have a
signifcant impact on how human services are delivered.
308 Part II / Generalist Practice and the Role of the Human Service Professional
Federal Faith-Based Legislation
Historically, it has been difcult, if not impossible, for a faith-based agency to receive
government monies in support of services. Te 4th Amendment to the U.S. Constitution,
which guaranteed freedom of worship, had been interpreted by the courts to require
separation between religions and the government. Tus, unless the agency operated as
a secular organization and did not incorporate faith into practice, it could not receive
government funding. Te government remains sensitive to those members of society
who do not share the same faith as the majority culture and, as such, attempts to protect
these individuals by passing laws that ensure that they will not be placed in positions
where they are either directly or indirectly coerced into praying to a God in which they
do not believe.
But in 2001 former president George W. Bush passed the Faith-Based Community
Initiatives Act, also known as Charitable Choice, or Care Services Act (CSA), which
made it legal for faith-based organizations to receive federal funding as long as these
organizations were not involved in religious worship, instruction, or proselytization, at
least within the aspect of the organization seeking federal funding. Many saw this as
a positive step toward reengaging religious organizations in the care of those in need.
Teir belief is that it was unfair to exclude faith-based organizations from government
funding, as well as a belief that churches and other faith-based organizations can ofen
provide human services more profciently than government agencies. Yet others express
concern that faith-based organizations may enforce arbitrary conditions on service de-
livery based on religion-based morality that either directly or indirectly discriminates
against certain groups, such as gays and lesbians, single parents, the poor, or individu-
als who embrace diferent values than the majority population (National Association of
Social Workers [NASW], 2002).
But does making services contingent on the performance of some behavior or act
rob the client of self-determination and risk forcing cultural and moral values on those
who do not share these same social mores? Take, for example, single women in the 1940s
and 1950s who had children out of wedlock. It was not uncommon for these women to
have services denied to them unless they agreed to place their infants for adoptiona
practice based on the cultural and moral belief that premarital sex was wrong and that
it would be immoral for a single mother to raise an out-of-wedlock child (Edwards &
Williams, 2000). Te goal of this chapter is not to determine which side of this debate
has a stronger argument. Certainly each side has merit, and a meaningful debate must
continue.
NASW expressed concerns about former president Bushs faith-based initiative. Tese
concerns relate primarily to issues of forced morality, the value of self- determination,
and the importance of keeping services voluntary for all members of society regardless
of their race, gender, religion, and sexual orientation. All one needs to do is conduct
a cursory review of history to recognize how easy it is to confuse faith with cultural
values. For example, slavery was once considered a practice sanctioned by God, and
scriptural support was even ofered in support of a Christian mans right to have a slave.
In fact, a host of issues once considered sinful (e.g., divorce, homosexuality, women in
Faith-Based Agencies 309
the ministry, single parenting) are now considered appropriate within many mainstream
religious denominations, indicating that the interpretation of biblical scriptureand
thus Gods intentis infuenced by the current moral climate of society.
Most critics of former president Bushs faith-based initiative are not necessarily criti-
cal of faith-based agencies ability to provide efective human services; rather, they feel
that faith-based agencies should not become the primary human services providers in
the United States. Te NASW advocates for government remaining responsible for pro-
viding comprehensive human services programs to the public to guarantee equal and
available access to human services that encourages utilization on a voluntary basis, hu-
man service delivery that is accountable to the public and professional community in all
respects, and a guarantee that service providers have appropriate levels of education and
are professionally licensed in their feld (NASW, 2002).
Potentially in response to these concerns, on February 5, 2009, President Obama
signed Executive Order 13199, which established the White House Ofce of Faith-Based
and Neighborhood Partnerships. Afer signing the order, President Obama pledged to
not favor one religions group over anotherchanging how decisions on funding prac-
tices are made from his predecessor. According to a February 2009 White House press
release, the Ofce of Faith-Based and Neighborhood Partnerships will focus on four key
priorities:
1. Te Ofces top priority will be making community groups an integral part of our
economic recovery and poverty a burden fewer have to bear when recovery is
complete.
2. It will be one voice among several in the administration that will look at how we
support women and children, address teenage pregnancy, and reduce the need for
abortion.
3. Te Ofce will strive to support fathers who stand by their families, which involves
working to get young men of the streets and into well-paying jobs and encouraging
responsible fatherhood.
4. Finally, beyond American shores this Ofce will work with the National Security
Council to foster interfaith dialogue with leaders and scholars around the world.
(White House, 2009, para. 56)
Te shif in priorities will likely alleviate some fears of NASW
and other human service professionals who recognize the value and
long-term contributions of faith-based agencies but advocate for dis-
tribution of funding of agencies from a wide range of religious tradi-
tions and approach social issues from a perspective representing a
wide range of views and perspectives.
Many agree that the arbitrary exclusion of all religious organi-
zation from federal funding is neither fair nor in the best interest
of clients, and human service professionals must advocate for fair-
ness, equity, and objectivity in the dissemination of federal fund-
ing, avoiding the politicization of this issue so that clients of all faith
Professional History
Understanding and Mastery of Profession
History: Historical and current legislation
affecting services delivery
Critical Thinking Question: Recent
changes in policy have opened up more
opportunities for faith-based organi-
zations to receive government funding.
What are some of the potential
advantages of this shift? What are some
potential dangers or drawbacks?
310 Part II / Generalist Practice and the Role of the Human Service Professional
traditions have similar opportunities to seek assistance from agencies that share their
religious views.
Methods of Practice in Faith-Based Agencies
Te counseling methods used in faith-based counseling are also sometimes debated,
with some expressing concern that certain behaviors are moralized in some faith-based
counseling, which can be hurtful to the client. Certainly, some faith-based counseling
techniques may incorporate a moralistic style, a method some will agree with and some
will not. But faith-based agencies can address issues of immorality such as marital un-
faithfulness or child maltreatment with grace and forgiveness as well as a measure of
accountability. What many human service professionals in faith-based agencies may
argue is that too ofen secular practitioners assume that clients are hit over the head
with their sin in a faith-based practitioners ofce, when many times clients who are
buried in shame for past poor choices are taught to approach their past mistakes and
the mistakes of others with a sense of grace, forgiveness, and mercy. Tus, faith-based
counseling can be less about theology and more about grace, forgiveness, mercy, and
loveconcepts that are universal to nearly every religion in the world.
Such debates regarding the appropriateness of how faith-based human services are
provided arise even within religious circles, with some religions or denominations fo-
cusing more on social justice, where issues related to social oppression, racism, and
classism are addressed in the same manner as secular agencies, and other religions and
denominations professing a belief that problems in life are solved by having a relation-
ship with God, thus bringing someone into relationship with God is the necessary frst
step toward healing. Even if a consensus could be obtained on this issue, evangelism
in a counseling relationship outside a ministry setting remains inappropriate in most
circumstances if for no other reason than it would violate the foundational principles
underlying the human services profession.
The Benefits of Faith-Based Services
Te majority of Americans not only identify spirituality as being an important part
of their lives, but also identify themselves as being members of faith communities
(groups of individuals who share similar religious beliefs and come together for a
time of worship and fellowship). Many members of faith communities rely on their
congregations when going through a difcult time. Faith communities provide indi-
viduals with a valuable support system during difcult times, providing both guidance
and emotional support. One goal of human services is to connect people to a broad
support system, and a faith community can easily provide this for its active mem-
bers. Religious coping has also been found to provide more benefts over other coping
methods such as general social support and other counseling methods ( Pargament,
Tarakeshwar, Ellison, & Wulf, 2001).
A recent study questioned individuals within a church congregation who had re-
cently experienced a crisis. Te subjects were asked to rank various resources that
they found helpful during their crisis. Factors included family, friends, religious
Faith-Based Agencies 311
beliefs, praying, reading scripture, and professional services, including counseling,
legal services, and psychological services. Te researchers were surprised to learn
that most people ranked professional services last as far as helpfulness and ranked
religious beliefs and praying the highest (Stone, Cross, Purvis, & Young, 2003).
Another study conducted after the September 11 terrorist attacks on the World
Trade Center and the Pentagon revealed that of 560 adults questioned in a national tele-
phone survey, 90 percent sought positive religion ofen in the context of a faith com-
munity as a way of coping with this tragedy. Examples of positive religion include seeing
God as a source of strength and support and perceiving God and a faith community as
supportive rather than a source of judgment (Meisenhelder & Marcum, 2004). Tese
studies confrm what many therapists would likely say: that in times of crisis, many peo-
ple draw strength and support from their faith communities, which provide them with a
sense of comfort and familiarity while providing a sense of being a part of a larger whole
and reminding them that they are not alone.
Religious Diversity in Faith-Based Organizations
Understanding the distinction in theology and ideology between the various faith-based
organizations, whether that includes interfaith diferences or variations among various
denominations within the same faith, is important because a religious organizations
theology and underlying ideology about human nature will likely serve as a refection of
the types of interventions utilized in the delivery of human services.
Many non-Christian faith-based organizations provide many of the same services
as Christian-based services. Jewish Family Services (JFS), which acts as an umbrella
agency for Jewish community centers, ofers comprehensive human services to Jewish
and non-Jewish communities across the nation. Islamic human services agencies focus
primarily on the Muslim community both within the United States and overseas, such
as Bosnians and Palestinians, but also support causes outside the Muslim faith.
In fact, a recent Associated Press article discussed the outpouring of Muslim support
for victims of Hurricane Katrina, the devastating natural disaster that hit New Orleans
and surrounding states in August 2005 and lef
thousands of people homeless and with abso-
lutely nothing. Faith-based organizations such
as the Muslim American Society, the Council
on American-Islamic Relations, Islamic Relief
USA, and the Muslim American Society all
participated in the Muslim Hurricane Relief
Task Force, which took turns manning relief
shelters and feeding those left homeless by
Hurricane Katrina. Tis is an example of how
various religious faiths and houses of wor-
ship ofen come together to ofer assistance to
the poor and destitute through donations and
assistance during times of crisis and natural
disaster (Associated Press, 2005).
Muslim charity work.
ZUMA Press/Newscom
312 Part II / Generalist Practice and the Role of the Human Service Professional
Faith-Based Agencies: Services and Intervention Strategies
In this section well look at several diferent types of faith-based agencies ofering hu-
man services and examine their success in both identifying and addressing the needs
of their target population. Well also explore the role of the human service professional
working in these faith-based organizations, noting any signifcant diferences between
their role and those played in secular agencies. Most of the agencies featured in this sec-
tion operate separately from any church or religious entity but are either supported by a
particular faith or operated as an arm or branch of a particular denomination. All fea-
tured agencies operate in a manner consistent with the commonly accepted defnition
of a faith-based agency discussed earlier in this chapter.
It is important to have a basic working understanding of the values held by these
diferent religious faiths in the event that a human service professional has a client who
practices a diferent faith or if a human service professional coordinates services with
a faith-based agency of a diferent faith. Having more than a superfcial understanding
of diferent faiths will enhance the human service professionals experience by enabling
them to move beyond common negative stereotypes and see the value of diversity
within a service delivery context.
Jewish Human Services: Agencies and the Role of the
Human Service Professional
If one of your countrymen becomes poor and is unable to support himself among
you, help him as you would an alien or a temporary resident, so he can continue to
live among you. (Leviticus 25:35)
Te Jewish faith is rich in admonitions and examples of charity and general provi-
sion of the poor. Te Torah, the Jewish holy book called the Tanakh, is what Christians
call the Old Testament. The Talmud is the transcribed collection of oral tradition
handed down from generation to generation, guiding the interpretation of the Tanakh.
Charity, as referenced in both the Tanakh and the Talmud, is defned as giving to the
poor and is a requirement for the Jewish people. According to Jewish law, forgiveness of
sins is granted with prayer, repentance, and charity.
As with the Christian faith, the Jewish faith has different denominations called
movements, including Orthodox, Conservative, Hasidic, Humanist, Reform, Sephardic,
Ashkenazi, and Reconstructionist. Some of these movements evolved through geo-
graphic divisions and some through philosophical divisions. Nevertheless, all Jewish
movements hold that charity and benevolence (kindness and compassion) are an in-
tegral part of righteousness. Good fnancial stewardship is highly valued in many faith
traditions, and the Jewish faith is no exception. Unlike some Christian denominations
that consider giving all of ones earthly possessions to the poor a blessed act, giving 5 to
10 percent of ones income to charity is considered an obligation among all Jewish de-
nominations. Charity is not solely related to duty, though, but also refects the value of
community and the commitment to remain connected to all Jews worldwide. Tis sense
of community is based on shared experiences of both current and historical persecution,
Faith-Based Agencies 313
which binds the Jewish people together in a communal determination of self-sufciency
and survival. Te Talmud specifes diferent levels of giving, with the lowest level in-
volving giving begrudgingly and the highest levels including giving anonymously to a
stranger and helping someone attain self-sufciency by giving them work (Babylonian
Talmud, Chagigah 5a; Maimonides, Hilchos Matnos Aniyim 10:714).
Jewish human services agencies are coordinated into a national umbrella organi-
zation that serves as a network of support for smaller human services agencies that
provide direct service. Human services are directed toward Jewish and non-Jewish com-
munities as well as targeting domestic and international causes.
THE JEWISH FEDERATIONS OF NORTH AMERICA The Jewish Federations of
North America (JFNA) is an international umbrella humanitarian organization that
represents over 100 Jewish federations in North America alone. The JFNA provides
humanitarian relief and human services worldwide to those in need. Te goals of so-
cial justice and strengthening Jewish community are a refection of the scriptures in the
Talmud that command giving to the poor, sick, widows, and orphans. Te JFNA exists
to provide fnancial support and educational services to Jewish federations and Jewish
community centers; it also funds the rescue and resettlement of Jews living in high-
confict or unsafe areas worldwide.
A component of the JFNA is the Human Services and Social Policy Pillar (HSSP),
which is responsible for social lobbying action on local and national levels in an attempt
to infuence social policy. Whether its lobbying for increased funding for geriatric ser-
vices, homeless resources, or refugee programs, the HSSP, or the pillar as it is commonly
called, relies on human service professionals and volunteers to coordinate services of
human services agencies within and without the Jewish community.
ASSOCIATION OF JEWISH FAMILY AND CHILDRENS AGENCIES Te Associa-
tion of Jewish Family and Childrens Agencies (AJFCA) acts as the umbrella organiza-
tion for JFS and Jewish community centers across the United States and Canada. Te
AJFCA also acts as an information clearinghouse for local JFS agencies, which provide
comprehensive human services to the Jewish community. AJFCAs also provide funding
for local federations of Jewish human services agencies, advocate for social justice, and
provide information on education and training opportunities.
Local JFS agencies offer a number of different services including individual and
family counseling, marital counseling, substance abuse counseling, AIDS counseling
and awareness programs, anger management courses, employment services, parenting
workshops, childrens camps, teen programs, and geriatric programs including Kosher
Meals on Wheels and hospice. No one is denied services due to an inability to pay, and
payment for services is typically on a sliding scale.
One program that is relatively unique to this organization includes refugee reset-
tlement programs, which assist individuals and families who have legally entered the
United States having fed from persecution. Refugees of either Jewish or non-Jewish
descent come from various countries, including Russia and other former Soviet-bloc
314 Part II / Generalist Practice and the Role of the Human Service Professional
countries, the Middle East, and Africa. Services typically include providing short-term
housing on arrival, emergency fnancial support, case management, medical care, as-
sistance with school enrollment, job placement, and language courses. Tese agencies
have excellent reputations in assisting refugees to gain fnancial independence rapidly,
particularly in light of the ofen tragic circumstances the refugees have faced prior to
coming to the United States.
Services focused exclusively on the Jewish community include Holocaust survivor
services to Jews who lived in European countries under Nazi rule between 1933 and
1945. In addition to providing counseling services related to post-traumatic stress
disorder (PTSD), in-home services related to geriatric care are also provided. Other
Jewish-related services offered include counseling and case management services
for Jewish armed services personnel, Jewish chaplaincy services, family services, and
outreach focusing on assisting families reconnect with their Jewish roots by learning
how to incorporate Jewish traditions and values into their family systems. Premarital
and marriage services are also ofered to Jewish couples and interfaith couples, focusing
on marriage and parenting in a Jewish context.
Human service professionals within these agencies provide a wide range of
services because JFS agencies typically ofer comprehensive human services similar
to those discussed through this entire text. In fact, many of the JFS agencies ofer
just about every type of human services one could imagine! Te primary diference
between the manner in which human services professionals deliver services at a JFS
agency versus a secular agency is the focus on connecting Jewish clients to the broader
Jewish community, both domestically and worldwide, as well as the incorporation of
Jewish values throughout the various programs. Counselors and case managers are
also primarily Jewish and well connected to the Jewish community, including being
familiar with local synagogues and other Jewish services within the local community.
Virtually, all JFS programs are eligible for federal funding as long as proselytizing
does not occur as a function of any program receiving funding. Even synagogues ofer-
ing human services programs are eligible to receive government funding as long as the
programs are operated separately from any religious functions.
Te Jewish human services agency network provides a network of comprehensive
services designed to address human needs on all levels. Tey provide invaluable services
to the Jewish community, as well as those outside of the Jewish faith, both within the
United States and abroad.
CASE STUDY 13.1
Case Example of a Client at a Jewish Faith-Based Agency
Raisa, a 77-year-old Jewish widow, began counseling at a local Jewish community center
about one year ago for depression. Her initial psychosocial assessment revealed a long his-
tory of mild depression with mild anxiety that had escalated in recent years to a point
where intervention was necessary. Raisa shared that her normal sadness increased
Faith-Based Agencies 315
dramatically when she lost her husband four years ago and did not abate even when she
found herself feeling more at peace with her husbands death. Raisa and her husband were
married for 45 years, both having immigrated from Europe shortly afer World War II.
Tey were unable to have children of their own and thus adopted one child, a daughter,
who resides in a diferent state about three hours away by car. Raisas daughter is married
and has one child, also through adoption. Sarah, her counselor, presumed that Raisa may
have been a Holocaust survivor, and if so that some of the earlier trauma and grief issues
were likely at play in her current depressive state, but Sarah chose not to address this pos-
sibility in counseling, choosing to wait until Raisa was ready to share her experience. De-
spite weekly counseling sessions and several courses of antidepressant medication, Raisas
depression and anxiety continued to worsen. During one session approximately nine
months into their counseling relationship, Raisa was discussing the difcult early years of
her marriage when she and her husband frst moved to the United States. Raisa became
extremely emotional as she shared that they were both orphans because of the war and
thus had no family to help or guide them, either in their transition or in their marriage.
Sarah immediately not only recognized the grief Raisa was reexperiencing, but also noted
that once Raisa became obviously distressed, she became equally uncomfortable, apolo-
gized for her outburst, and then quickly changed the subject and regained her compo-
sure. Sarah did not push Raisa, understanding that Raisas decision to share her distant but
obviously still-powerful memories was just thatRaisas decision. As the months pro-
gressed Raisa began to pensively share more stories of her early marriage, which seemed
to be marked by considerable loss and struggle. She was 18 when the war ended. She met
her husband, Reuben, one year later, although they had met once or twice several years
before. Tey became inseparable almost immediately, likely out of sheer loneliness, Raisa
suspected, rather than any type of love at frst sight, although in retrospect Raisa wasnt
sure there was a diferenceboth were emotions that encompassed a signifcant amount
of passionate intensity. Raisa and Reuben spent two years searching for family members.
Her husband located an aunt and uncle in the United States. Raisa learned that her brother
had escaped to Israel. Tey never located any other surviving family members. Afer some
thought and consideration, they decided to move to the United States in the hope of con-
necting with her husbands relatives. When they frst arrived in New York, they experi-
enced a long-overdue measure of relief, but this was to be short lived when Reubens aunt
and uncle announced plans to move to California. Deciding not to follow, Raisa and Reuben
were left to survive on their own in a big city that offered as much risk as opportunity.
Although Raisa spent most of her time focusing on the physical and fnancial hardships of
her early life, she appeared to avoid any discussion of her feelings. In fact, Sarah noted that
whenever Raisa risked becoming emotionally grieved such as when Sarah asked any ques-
tion that required Raisa to refect on her childhood (even positive aspects of her youth),
Raisa became emotionally and physically rigid, as if she were talking herself out of the
nonsense of her feelings to regain composure. Sarah became increasingly concerned
about Raisas psychological stability, particularly in light of her very recent increase in anx-
iousness. In fact, there were two recent occasions where Raisa was so anxious she did not
feel comfortable leaving her home to attend her counseling session. In light of Raisas
worsening condition and her fear that Raisa might be at risk of suicide, Sarah made the
decision to have a session with Raisa where she would more assertively address Raisas
Holocaust experience, believing that to be the root of her unresolved grief and the source
316 Part II / Generalist Practice and the Role of the Human Service Professional
of complicated mourning related to many of the losses she experienced after the war.
Sarah went to Raisas house for this session so that Raisa could remain in the safety of her
surroundings if the session became too difcult. Sarah also had implemented a safety plan
for Raisa, including collecting a list of emergency numbers and the number of a local geri-
atric outreach center that Raisa had been involved with intermittently for several years.
Sarah began her session with Raisa by gently expressing her concern about her emotional
well-being, as well as sharing her belief that Raisa may be sufering long-term efects from
being a Holocaust survivor, and that unless she faced her past, her depression and anxiety
might not get better and may, in fact, continue to worsen. Raisa was immediately uncom-
fortable, but Sarah reassured her that although she wanted to push Raisa a bit, she had
made sure she could remain with Raisa for the entire afernoon, thus Raisa could take her
time. Although Sarah had spent considerable time in counseling sessions with Raisa con-
ducting psychoeducationteaching Raisa about the normal stages of grief and the com-
mon psychological responses to traumaSarah reiterated this information now in the
hope that Raisa would begin to accept that her feelings were normal. During this session
Raisa shared that her early childhood was one of constant happiness. Her father was a pro-
fessor at a local university in Holland. Although they were not very religious, they at-
tended synagogue weekly and observed the Sabbath. Without realizing it at the time,
Raisas family was quite immersed in the Jewish culture, which in her family meant close
ties to extended family and friends within the community who had a shared culture, cus-
toms, and life perspective. Raisa recalled the emergence of a diferent feeling in her neigh-
borhood when she was about 11 years old. She is not sure if this marked the slow invasion
of the Nazi party into her small town, but she does recall that it was about this time that
her family could no longer protect her brother and her from the fact that their lives were
about to change forever. Raisa shared that her family started closing the front door and
drawing the shades more frequently and that various neighbors suddenly began to disap-
pear. She recalls the day, at the age of 13, when almost everyone in her neighborhood was
forced to wear yellow stars on their sleeves, and she marked this as the day she realized
that some of her favorite neighbors were apparently not Jewish, because they did not have
to wear the yellow star. Raisa emotionally shared the night she and her brother, two years
older than her, were awakened in the middle of the night by their parents and told to dress
quietly in the dark. Tey were going on a long trip but had to remain quiet. She shared that
she did not recall thinking much about what was happening. Perhaps she was too scared,
or maybe she had experienced so much change and shock in the past year, she simply ac-
cepted this as one more confusing event in a long line of bewildering experiences. Months
earlier Raisas father had told her that it was important for her to obey him without asking
questions because not obeying him might have serious consequences. She recalled crying
when he said this to her because he was so frm, an emotion she rarely saw in her father.
He responded by telling her that tears were useless nowthey would not help, and that
she needed to be strong. She obeyed him now as she folded one change of clothing into a
small dark knapsack, confused and afraid, but resolved not to cry. Te next thing Raisa
remembers is that she and her family were crouching down outside in the dark and run-
ning along the hedge line. She recalled that there was no moon, and the night was so dark
she was certain she would lose her brother, who was directly in front of her. She kept run-
ning though, trusting that someone would come back for her eventually if she lost her
Faith-Based Agencies 317
way. Tey arrived at a strangers house, and her father knocked on a back door that ap-
peared to lead to a basement. A young woman opened the door and hurried Raisa and her
brother through the door. Raisa had only a quick moment to look back and see her mother
and father, who to her horror were not following behind her and her brother. Instead, her
father and mother were crying, peering into the dark basement with a look of dread and
horror on their faces. Raisa immediately recalled her mother telling her earlier that she
loved her very much, yet Raisa could not recall having said it in return. Tis was some-
thing that would torment Raisa for years. Did she tell her mother that she loved her? She
would never be sure that she had. Tat was the last time that Raisa and her brother saw
their parents. Raisa learned afer the war that their parents were forced to leave their home
shortly afer arranging to smuggle their children out of Holland, and afer a short stay in
what became known as a Jewish ghetto, they were sent to a concentration camp. Although
she was never able to obtain exact information, Raisa learned that both of her parents
were executed likely sometime in early 1943. Raisa and her brother remained in the dark
basement with little food or water for about three days before being driven, during the
middle of the night, to another home. Raisa recalled crying sometimes but her brother,
like her father, told her to stop and to be strong, and she complied. Tis time period was
particularly difcult for both Raisa and her brother, who were tempted to escape and re-
turn home to their parents. She is not sure whether it was fear or wisdom that kept them
from this course, but she realizes now that had they returned home, their fate would have
been the same as their parents. Te next trauma for Raisa occurred when she learned that
she would be separated from her brother. Although her parents had arranged for them to
remain together, increased risk led her rescuers to conclude that two children suddenly
showing up in a home was far riskier than one; thus in the middle of one night several
weeks into their frightening journey, Raisas brother was hurried into one car, and she into
another. Tis, too, would remain a source of considerable pain for Raisa, as she realized
that once again she was denied a proper good-bye. Her last memory of her brother was his
surprised face looking out the car window as he realized that she was being escorted into a
diferent car. Raisa fed to Italy, where she lived in a converted attic, and although enjoying
some measure of freedom, she had to remain relatively hidden until the war was over. Her
foster parents were nice, but stern. Tey were not Jewish, thus Raisa was compelled to live
a lifestyle very diferent from the one she had enjoyed in Holland. She dressed diferently,
attended church rather than synagogue, and ate food very diferent from what she was
used to. It did not occur to Raisa until she was much older that there wasnt any possibility
of seeing her family again. Her attitude during the balance of her childhood was one of
waiting it out until the war was over and she could go home and resume life as she had
known it before the war. But of course that was a dream that would never come true.
When the war ended, her host family wished her good fortune, and at 17 years of age
Raisa was completely on her own and alone in the world. Although God had never played
much of a role in her life before, she found herself praying to the God of her childhood
that her family was safe and waiting for her at home. Raisa got a job in town so that she
could earn enough money to return to Holland. She met Reuben on her frst day of work.
He was employed at the same shop, but for diferent reasons. It was Reuben who told her
there was nothing to return tothat his family, and likely hers, were dead, and the only
choice Jews had was to immigrate somewhere safe. Raisa had been sheltered by her host
318 Part II / Generalist Practice and the Role of the Human Service Professional
family and had heard nothing of the concentration camps and the unchecked slaughter of
millions of Jews. She had difculty describing the way she felt once she learned that her
entire family was likely dead. She described it as both surreal and numb. She had no idea
where her brother had been taken, and she had fantasized for years about fnding him
walking down an Italian street or shopping in the town center, but he was all she could
think of now. She had to find him. She and Reuben made the singular goal of finding
whatever family they had lef. At some point in their planning, they became a couple and
decided to marry. Raisa learned through a charitable organization that her brother was
living in Israel. She shared earlier that their decision to immigrate to New York to join
Reubens family was a practical one. She shared now Reubens fear that if they immigrated
to Israel, they might fnd themselves in the same situation as in Hollandin the center of
a warand he could not risk becoming involved in another war ever again. Raisa let go of
her hope to return to her brother when Reuben decided it would be wiser for them to
move to the United States. Raisa did reconnect with her brother again, but they never en-
joyed the closeness of their childhood. When she and Reuben visited her brother in Israel
many years later, it felt to Raisa as if she were visiting a complete stranger. Her brother had
become quite religious, embracing the faith of their youtha choice antithetical to Raisas,
who in response to their earlier losses chose to distance herself from her Jewish roots.
Raisa shared all these stories with emotion, but no tears; she was still being strong. Al-
though Sarah decided to hold of on approaching the subject of Raisa and Reubens infer-
tility resulting in the adoption of their daughter, she made a mental note that she would
visit this issue in a later session. Sarah knew this too would likely be a very difcult subject
for Raisa and a source of great painboth from a generational perspective (issues related
to infertility were typically not discussed in earlier generations) and from a loss perspec-
tive. Sarah assumed that Raisa and Reuben looked forward to having their own children
not simply as a way of starting their own family as so many couples do, but as a way of re-
placing the family that had been taken from them both. Sarah would learn later that Raisas
frst child was a stillbirth, that the loss was almost too much for Raisa to bear, and that this
was likely when Raisas melancholy transitioned into a clinical depression. Even when
Raisa and Reuben experienced the joy of adopting their daughter, Raisa shared that a
sense of sadness remained hidden within her. Afer this intense and very long session,
Sarah developed a treatment plan for Raisaone that involved both trauma and grief
counseling. Sarah suspected that in addition to depression and anxiety Raisa also sufered
from PTSD, thus she incorporated aspects of treatment designed to help her deal more ef-
fectively with being a survivor of trauma. Sarah suspected that Raisa was in many ways
still operating with a survivor mentality, which compelled her to obey her fathers distant
admonition to resist crying and remain strong. Raisas tendency to equate crying with
weakness could be addressed through cognitive behavioral therapy, where Raisa would be
encouraged to recognize that such rules about emotion may have been necessary in war-
time, but were no longer needed and were actually damaging. Te challenge for Raisa
would likely lie in a fear that to change her perspective on crying might indicate a betrayal
of her father. One of Sarahs ultimate treatment goals for Raisa was to help her develop a
more realistic and timely defnition of authentic strength that did not dishonor her fathers
guidance. Another treatment goal involved helping Raisa learn to grieve all her past losses
and fnally to rebuild the community she lost so many years ago. Although Raisa had a
Faith-Based Agencies 319
daughter, she had avoided ever getting too involved in her community, perhaps out of a
fear that she might lose again what she had lost as a childa close-knit community of
neighbors who shared a culture and a faith and who operated in many respects as an ex-
tended family. Although Sarah suspected that Raisa might have some objections to getting
involved in the local Jewish community, Sarah planned to explore this possibility with her
to reconnect her to the faith and culture of her childhood. A signifcant portion of Raisas
healing came from a pilgrimage of sorts that Sarah helped her plan involving returning to
Holland with her daughter and her brother. During this long-overdue visit Raisa and her
brother tearfully revisited their childhood home, as well as other places of nostalgia, and
although things had changed signifcantly since their youth, Raisa and her brother found
great healing in their trip home. Te fnal leg of their trip involved creating a memorial
for Raisa and her brothers parents and all her lost family and friends. Raisas last session
with Sarah prior to her trip involved writing a poem that they would leave at the site where
the Chelmno concentration camp once stood. Te trip not only helped her to create mean-
ing surrounding the death of her parents, but it also helped her to reconnect emotionally
with her brother and involve her daughter in a part of her life she had previously kept hid-
den. In succeeding years Raisas debilitating depression lifed, and her anxiety receded. She
learned how to genuinely grieve her past losses and learned to recognize how her early
trauma and loss impacted virtually every area of her life. She did ultimately become in-
volved in her community, and in the years preceding her death at the age of 84, she even
resumed attending synagogue. Sarahs relationship with Raisa involved more than coun-
seling. It involved incorporating aspects of faith and culture into sessions, case manage-
ment that involved connecting Raisa to a community from which she had been generally
estranged. It also involved Sarah drawing on her own Jewish faith, which enabled her to
understand much of what Raisa experienced both in her past and in her current life.
Christian Human Services: Agencies and the Role of the
Human Service Professional
For I was hungry and you gave me something to eat, I was thirsty and you gave me
something to drink, I was a stranger and you invited me in, I needed clothes and
you clothed me, I was sick and you looked afer me, I was in prison, and you came
to visit me . . . I tell you the truth, whatever you did for one of the least of these
brothers of mine, you did for me. (Matthew 25:3536, 40)
Because a fair amount of faith-based organizations in the United States are Christian
in nature, it is valuable to have an understanding of the range of theologies and
ideologies within the Christian church. The historic role of the Catholic Church
discussed earlier in the chapter refects Catholicisms strong commitment to caring
for the poor. Tis commitment is refected in todays Catholic Church in ministries
such as Catholic Charities, which facilitates numerous human services programs
throughout the United States.
320 Part II / Generalist Practice and the Role of the Human Service Professional
Mainstream Protestant denominations such as Methodist, Presbyterian, and
Lutheran ofen embraced the social gospel, the Old Testament mandate to provide for
those in society in need, but these denominations did not necessarily link charity to
evangelism. Rather, the predominant view among these mainstream denominations was
to show the love of Christ through giving as well as through addressing social concerns
for the poor and the oppressed.
Conservative Christians, such as evangelicals, fundamentalists, and Pentecostals,
tend to focus on evangelism as the initial priority, addressing social causes and the
needs of the poor through winning souls for Christ. If one truly believes that the only
path toward wholeness is by surrendering ones life to Christ, repenting of ones sins,
and becoming a new creation through a personal relationship with God, then it makes
sense to want this experience for anyone who is sufering. Te confict arises when
such evangelism occurs in the counseling ofce or anywhere else where social services
are being provided, without the client understanding that this is the goal of the service
provider. As mentioned earlier in this chapter, professional standards of the human
services feld, whether social work, counseling, psychology, or psychiatry, discourage
proselytizing to clients. Critics of evangelical practitioners who do attempt to evan-
gelize clients might suggest that as worthy as this act might be perceived, it is more
appropriately conducted in the vein of pastoral counseling or ministry eforts (Belcher,
Fandetti, & Cole, 2004).
Tis ethical dilemma is worth exploring in both secular and religious circles and can
be addressed in a variety of ways. For instance, there is nothing inherently unethical in
talking about matters of faith and spirituality as long as it is client driven. In fact, it is the
human service professionals comfort level in talking about such issues and willingness
to allow the client to determine the depth and direction of the discussion that is impor-
tant. For instance, consider the client who enters a counseling session utilizing negative
religious coping strategies such as perceiving God as punishing, abandoning, and dis-
tant, particularly when tragedy occurs. A human service professional in a faith-based
agency can comfort the client by reframing the clients punitive view of God by teach-
ing the client to use positive religious coping methods where God is
perceived in a positive manner and a source of guidance, strength,
and support. Because research supports the mental health benefts
of positive religious coping, this intervention strategy can be used
with the understanding that it is truly in the best interest of clients
who are being hurt by their negative views of God.
Although evangelizing clients is not appropriate in a secular set-
ting or even in a faith-based organization receiving federal funding,
it is appropriate if the human service professional works for a reli-
gious organization that makes clear its goal is to evangelize the client
so that the client enters the counseling relationship with full disclo-
sure and equal participation. For instance, many outreach ministries
provide emergency services such as food pantries or homeless shel-
ters, but do not hide the fact that the ultimate goal of the agency is to
lead one down the path of greater religious commitment, which may
Human Services
Delivery Systems
Understanding and Mastery of Human
Services Delivery Systems: Range and
characteristics of human services delivery
systems
Critical Thinking Question: How might
human service professionals, especially
those working for faith-based orga-
nizations, walk the fine line between
supporting clients self-determination
and forcing their own (or their organiza-
tions) religious viewpoints on clients?
Faith-Based Agencies 321
involve a deepening relationship in a clients existing faith or may involve a complete
conversion to a new faith.
RURAL COMMUNITIES AND THE BLACK CHURCH Rural com-
munities, typically those with high minority populations, tend to be
signifcantly underserved with regard to mental health services. Yet re-
search in the last 10 to 15 years has revealed that African American
churches, particularly those within rural communities, have picked
up the slack by ofering signifcantly more human services than White
churches (Blank, Mahmood, Fox, & Guterbock, 2002).
There are several potential reasons for including the long-held conflict between
secular mental health providers and clergy. It has been addressed in recent years but re-
mains a point of contention with clergy not necessarily endorsing the medical model,
or secular approaches to mental health concerns, and secular mental health providers
not readily perceiving mental disorders in spiritual terms. Yet as mentioned earlier in
this chapter the church has a long history of providing for the social and mental health-
care needs of individuals within society, and the fact that African American churches
tend to ofer far more human services programs than White churches may be a refec-
tion of the African Americans general sense of distrust of the mainstream mental health
community and having greater trust of African American providers (Blank et al., 2002;
Tomas, Quinn, Billingsley, & Caldwell, 1994).
Regardless, one variable ofen neglected in research on human services in the church
is that for many generations the African American church has been the center and back-
bone of the African American community, thus these clergy might be more willing to
engage deeply in the lives of their parishioners and those within their community. It
appears that in many respects African American churches, particularly those in rural
communities, have acted in some respects as the Catholic Church in the Middle Ages,
taking responsibility for the mental health concerns and basic needs of those within the
community.
CATHOLIC CHARITIES Catholic Charities USA is a network of Christian human
services agencies that has a long tradition of caring for those in need. Services are pro-
vided to all individuals seeking assistance regardless of religious afliation. Currently,
there are approximately 1,600 local Catholic Charities agencies across the United States
ofering a wide variety of human services designed to meet the needs within the partic-
ular community served. According to the Catholic Charities website services provided
at most of its local agencies focus on advocacy and direct services related to reducing
poverty, supporting families, and empowering communities. Tey do this by facilitating
programs that focus on adoption, disaster operations, housing counseling, disaster case
management, racism and diversity, human trafcking, and climate change ( Catholic
Charities USA, 2010).
Catholic Charities USA claims to have provided services to over 10 million individu-
als in the year 2010 alone, making it one of the largest networks of human services agen-
cies in the world, similar in nature to the Jewish federations. Te majority of funding
African American churches,
particularly those within rural
communities . . . , offer signifcantly
more human services than White
churches.
322 Part II / Generalist Practice and the Role of the Human Service Professional
comes from federal and state sources, with only a small percentage coming from the
Catholic Church. Catholic Charities has not had signifcant problems obtaining federal
funding because providing services directly linked to religious ministry is not typically
an aspect of services provided, thus Catholic Charities has not been particularly afected
by the faith-based initiative.
In many respects Catholic Charities provides similar services as secular agencies ex-
cept that most local Catholic Charities agencies also provide support to archdiocesan
schools and parishes. Adoption and childrens services are also provided, but remain
consistent with the values of the Catholic faith, thus option counseling of women ex-
periencing an unplanned pregnancy would not include referrals to abortion services.
Most agencies also provide Catholic Youth Organizations (CYO), an afer-school and
weekend athletic program focusing on the development of sportsmanship-like behavior
and ethical values consistent with the Catholic faith.
Other services include child care, domestic and international adoption, domestic
violence, employment and job training, gang intervention, health care, HIV/AIDS ser-
vices, immigration and naturalization services, nutrition counseling, refugee resettle-
ment services, senior services, homeless assistance and emergency housing, senior
housing, and substance abuse counseling. Most local Catholic Charities agencies also
ofer community centers that focus on providing comprehensive human services for
those who are homeless or at risk of becoming homeless.
Human service professionals are not required to be Catholic, but many of those in
leadership positions are due to the close and supportive relationship with local Catholic
parishes. Human service professionals include social workers with Master of Social
Work (MSW) degree and therapists, psychologists, and caseworkers and practitioners
with Bachelor of Social Work (BSW) degree. Services provided are generalist in nature,
and as is the case within the Jewish federation agencies, human services interventions
and clinical issues depend on the actual services being provided. Human service profes-
sionals working at Catholic Charities have the beneft of working within a broad net-
work of agencies that provide extensive support and educational opportunities.
PRISON FELLOWSHIP MINISTRIES Chuck Colson reached the peak of his political
career as President Richard Nixons aide, or as many referred to him, President Nixons
hatchet man. In 1973 Colson became a Christian, and in 1974 he pleaded guilty to
obstruction of justice charges in association with the Watergate scandal. Colson served
seven months of a three-year sentence and on his release founded Prison Fellowship
Ministries (PFM) in 1976, based on his own dramatic religious conversion and his belief
that no one is beyond hope. His ministry is now one of the largest prison ministries
in the world, reaching out to prisoners, ex-prisoners, their fami-
lies, and victims. PFM is also involved in criminal justice reform
through a PFM afliate, Justice Fellowship, which focuses on nu-
merous social justice issues including prison safety and eliminating
prison rape.
Such social advocacy is particularly important for groups of in-
dividuals who do not evoke sympathy in the average person, and prisoners certainly fall
PFM is now one of the largest prison
ministries in the world, reaching
out to prisoners, ex-prisoners, their
families, and victims.
Faith-Based Agencies 323
into this category. Yet, it is essential for people to realize that prisoners are not a uniform
group of evil pedophiles and serial rapists who deserve whatever hardship the prison
system can dish out. Most prisoners have had childhoods marked by poverty and abuse,
many serve longer sentences because they could not aford adequate legal services, and
some are innocent. PFM is committed to stop the intergenerational cycle of crime and
poverty by ofering prisoners hope for a second chance through the Christian faith.
Citing the diference that this ministry can make in the lives of prisoners as well as in
society in general, Colson references the dramatic shif in climate experienced at Angola
Prison in Louisiana, once touted as the most dangerous prison in the United States, but
now considered the most peaceful under the leadership of Burl Cain, a Christian who
invoked the services of local seminaries to minister to inmates. In a similar vein, PFM
trains volunteers to counsel and minister to prisoners in virtually every prison across
the country.
PFM facilitates a number of ministries including training volunteers to visit prison-
ers, many of whom receive no other visits. Te ministry does not receive federal funding
because PFM volunteers focus extensively on the evangelism of prisoners and their fam-
ily members. Te goal of PFM is to bring the gospel of Christ to every prisoner incar-
cerated in the United States. PFM also facilitates a pen pal program linking prisoners
with volunteers who are willing to minister to them in writing. PFM also provides ser-
vices to the family members of prisoners, particularly those with children. An example
of such services includes the Angel Tree program, which collects Christmas presents for
these children and also facilitates a camp and a mentoring program.
Human service professionals, who are primarily volunteers, working with PFM pro-
vide markedly diferent services than those working in secular agencies. Because evan-
gelism is the primary intervention tool, volunteers facilitate Bible studies and in-prison
seminars, mentor at-risk youth, counsel prisoners and crime victims, serve in youth
camps, organize Angel Tree programs, visit prisoners regularly, counsel ex-prisoners
and crime victims, and write letters to prisoners in the pen pal program. Human ser-
vice professionals also hold paid positions with PFM, including feld director positions,
which manage and provide support of ministry teams, including recruiting and training
volunteers and reaching out to local churches for assistance and fnancial support.
CASE STUDY 13.2
Case Example of a Client at a Christian Faith-Based Agency
Castle Christian Counseling Center (CCCC) is a not-for-proft, ecumenical counseling
center contracted by the county to provide mandated counseling services, including anger
management and alcohol counseling for individuals who have been charged with an alco-
hol ofense. Julie was required to attend anger management as a part of her probation for a
domestic battery charge. Julies initial psychosocial assessment recommended that she
participate in both group and individual counseling. Te group counseling consisted of a
324 Part II / Generalist Practice and the Role of the Human Service Professional
26-week program focusing on anger management and personal accountability. Her indi-
vidual counseling was designed to help Julie deal with the underlying reasons for intense
anger and inappropriate behavior. Julie was 24 years old when she was charged with do-
mestic battery against her husband of three years. When Julie began counseling she was
both emotionally needy and defensive. Her counselor, Dana, suspected that beneath Julies
defensiveness lay a tremendous amount of shame, so she chose not to confront Julie until
much later in their counseling relationship. During the frst several months of counseling
Julie expressed much anger and frustration with her husband, who she perceived as being
quite passive. In response to his seeming inability to make decisions or take the lead in any
aspect of their life, Julie expressed extreme disappointment and at times rage. It became
clear to Dana that Julies husband was in many respects being set up for failure by Julie. For
instance, Julie ofen expressed to her husband that she wished he would be more proactive
in their social life, but if he did forge ahead and make plans without checking with her
frst, she would become irate that he chose an activity he knew she would not like. Yet if he
checked with her frst before making plans, she would become angry that he did not have
the confdence to make plans without her, and she would accuse him of ruining the sur-
prise for her. Te incident that resulted in the charge of domestic battery involved a fght
that escalated over their fnances. Julie had decided to quit her job to try to get pregnant,
even though her husband had expressed concerns that he did not make enough money to
be the sole provider. He ultimately supported her decision, and Julie quit her job, but afer
a few months, when money got tight, and they ultimately did not have enough money to
pay bills, Julie lost her temper. During her tirade she accused her husband of not caring
about their fnances and of sabotaging their plans to start a family. Julie became physically
abusive toward her husband when he attempted to stand up to her by telling her that he
had not in fact wanted her to quit her job because he feared this very thing. Julie became
hysterical, accusing her husband of hating her and of just looking for an excuse to leave
her. Dana recognized Julies tendency to change the facts to support whatever theory she
was attempting to prove at the moment. She also recognized Julies all-or-nothing think-
ingpeople either loved her or hated her, were for her or against her. According to secular
psychology Julie would have met the criteria for borderline personality disorder, but Dana
recognized her behavior as indicative of a contemporary form of idol worship. Julie was
expecting her husband to be God, yet there was only one God who could meet all Julies
needs. Dana knew that over the next several months she would be Julies representative of
Godshowing her unconditional love as well as truth. She made a commitment to Julie
that she would always be honest with her, and there would be nothing that Julie could do
that would lead Dana to end their relationship. She trusted that Julie could handle the
truth if it were delivered in love, not shame. It was only a few days later that Julie seemed
to test Danas commitment. Julie called Dana and lef a frantic message, stating that she
was very upset and needed to talk immediately. When Dana had not returned her call
within the hour, Julie called again and but this time was enraged. She accused Dana of be-
ing like everyone elsemaking promises but then abandoning her when she was most in
need. Before returning Julies call, Dana prayed for wisdom and insight. She immediately
had an image of truth as light, and for Julie, any truth at all was like a fashlight blaring
into her eyes, causing Julie to have to bat the light away to avoid the pain. Dana knew im-
mediately from then on that she would have to be gentle not only in the amount of truth
she shared with Julie, but also in the way she shared her wisdom. In the face of Julies
Faith-Based Agencies 325
intense and abrasive defensiveness, Dana resisted the natural tendency to force truth on
her. Instead she indulged Julie a little, suspecting that Julies initial feeling when she made
a mistake was intense shame, but before she could respond to this emotion she reacted by
flipping her shame outward into anger against anyone who represented the source of
shameanyone who made her feel guilty in some way, who exacted accountability, and
even who cried in response to one of her rages. Danas intuition told her that if she could
relieve some of Julies shametake her of the hook in some mannerthis might give Julie
the emotional space to explore her feelings of intense shame and guilt. When Dana did
call, she suspected that Julie would already be feeling immense shame and guilt, regretting
her tirade. Dana also suspected that Julie would not be able to emotionally manage these
feelings, thus would have a need to rationalize her behavior by escalating Danas sin to
match her own reaction. Dana knew that if she admonished Julie for her tantrum, this
would set this process in motion, so she did something diferent; she took Julie of the
hook and rather than admonishing her, she praised her for her ability to communicate her
feelings! Julie was so taken of guard that it actually enabled her to experience feeling a
small amount of guilt. Afer Dana had fnished complimenting Julie on her willingness to
communicate, Julie admitted that she should have handled her feelings diferently, that she
should have been more patient, and that in some respects she believed she was expecting
to be let down by Dana, thus she didnt even give her a chance to meet her needs. Success!
By taking this counterintuitive approach and lifing the burden of shame, Julie was able to
actually recognize her internal process without rationalizing her feelings away. During the
course of their counseling Dana addressed Julies negative feelings about God. Julie shared
that she felt very insignifcant whenever she thought of God. She then shared new ele-
ments of her childhood. She had already disclosed a childhood wrought with abuse and
emotional humiliation at the hands of both her father and her mother, but during this
particular session, Julie shared that whenever she made a mistake as a child, her father
would tell her she was going to hell, that she was a disappointment to God, and that she
could not hide from Godhe could see her wherever she was and he knew what she was
doing and what she was doing the majority of the time was bad. Julies father would ofen
physically abuse her, sometimes using a Bible to beat her on the head. When Dana asked
Julie to draw a picture of her relationship with God, Julie drew a picture where she was
quite small, crouched down and running, and God, a large presence on the page, was
looking down on her with a stern scowl on his face. Dana asked Julie if she ever turned to
God when going through a difcult time. Julie looked shocked, expressing her belief that
if she was in trouble, God would be the last she would consider turning toward. In fact,
Julie shared that she believed that the only time God paid any attention to her was when
she had messed up. She imagined God saying, Tere you go againI knew you would
blow it eventually! Dana told Julie that she would like to spend some time sharing a dif-
ferent type of God with her, not a punishing God, but a loving God who acted as a father
to his childrenguiding his children when they were walking down the wrong path, like
any good father, and applauding when they did well. Dana shared about her own feelings
toward her young son. She found herself chuckling even when he got himself into a bit of
trouble, like the time he wrote his name in purple crayon all over his closet door, only to
deny his culpability when Dana came upon his artwork. Dana was not harsh, nor punish-
ing, but she did want to teach her son that defacing property was not the best choice. She
did this in love, extending grace and forgiveness because she understood that at this age her
326 Part II / Generalist Practice and the Role of the Human Service Professional
son did not know any better. She also smirked as she admired her sons
artwork, knowing that drawing on the wall with crayon was a perfectly
normal thing to do. Julie could not fathom a God who was anything
but condemning but she was very interested in learning about the con-
cepts of grace and forgiveness. Once Dana was confident that Julie
trusted her, she began to respond to each of Julies rage episodes by frst
empathizing with Julies emotionsher disappointment, her fear, her
angerbut then followed by gently sharing truth. When Julie asked if
Dana thought she was wrong to have such high expectations of her
husband, Dana said yes, but that did not mean that Julie should have
no expectations. Rather, Dana explained that once Julie developed a
more solid emotional base within herself, including having a more
solid relationship with God, her expectations of her husband would
likely be more realistic. Julies counseling also consisted of a signifcant
amount of grief counseling, mourning her lost childhood, gaining in-
sight and understanding of the abuse she had endured, and learning her emotional triggers
and ways to avoid them. Dana taught Julie to contain her emotions, so that she wouldnt
have to react the moment she experienced an intense emotion, such as the intense fears that
she was going to be abandoned, which would ofen turn toward anger. Dana used guided
imagery directing Julie to imagine Jesus holding her frmly, but lovingly. Imagery exercises
of this type also helped Julie make God more real in her life. Dana also encouraged Julie to
read one new scripture per week. Julies favorite was Romans (8:28), And we know that in
all things God works for the good of those who love him who have been called according to
his purpose. For Julie this meant that even the abuse she endured would be used for
goodlike making lemonade out of lemons. Another favorite scripture that brought great
comfort to Julie was Jeremiah (29:1113), For I know the plans I have for you, says the
Lord. Tey are plans for good and not for disaster, to give you a future and a hope. In those
days when you pray, I will listen. If you look for me in earnest, you will fnd me when you
seek me. I will be found by you. Julie felt that this scripture meant that God had good
intentions for her, not evil ones. He wanted the best for her, not the worst. He would not
hide from her, and she did not have to hide from him. Julie continued counseling even afer
she met her mandated requirement. In her second year of counseling Dana shifed focus
from Julies childhood to her current relationships, including the relationship with her
husband. Julies intense fear of abandonment ofen led her to be so self-focused that she was
blinded to the damage she caused other people. As her fear of abandonment subsided and
her shame diminished, Dana was able to coach Julie into looking through the eyes of her
husband. Tis process would have been impossible a year ago because the shame would
have paralyzed her, but with her increasing internal strength, Julie was able to accept her
behavior and the pain it caused. Once she saw herself as deserving of forgiveness, she could
address her own abusive behavior. Within the second year of therapy, Julies anger receded
signifcantly, and she was able to talk through her feelings rather than act them out. She
remained in counseling intermittently for years to maintain her program of faith building,
emotional containment, and extending forgiveness to self and others.
Human Systems
Understanding and Mastery of Human
Systems: Emphasis on context and the
role of diversity in determining and meet-
ing human needs
Critical Thinking Questions: In this case
example, how did the human service
professional utilize her own faith to guide
her practice? Did she get the same re-
sults that a similarly skilled secular prac-
titioner treating the client for borderline
personality disorder would have gotten?
Faith-Based Agencies 327
Islamic Human Services: Agencies and the Role of the
Human Service Professional
It is not righteousness that you turn your faces towards East or West; but it is righ-
teousness to believe in Allah and the Last Day and the Angels and the Book and
the Messengers; to spend of your substance out of love for Him, for your kin, for
orphans, for the needy, for the wayfarer, for those who ask; and for the ransom of
slaves; to be steadfast in prayers and practice regular charity; to fulfll the contracts
which you made; and to be frm and patient in pain (or sufering) and adversity
and throughout all periods of panic. Such are the people of truth, the God fearing.
(Quran 2:177)
And those in whose wealth is a recognized right; for the needy who asks and
those who are deprived. (Quran 70:2425)
Islam is a religion that is ofen misunderstood and mischaracterized, both by the gen-
eral public and by the media. Tis mischaracterization is due in part to the diferences
between more liberal Western values and the more conservative values held by many
in the Islamic community. Te terrorist acts of September 11, 2001, and the subse-
quent increase in xenophobia (an unreasonable fear, dislike, or hatred of foreigners,
or people who are diferent) and Islamophobia have further exacerbated the tendency
to view the entire Muslim world as one that endorses violence, extremist dogma, and
female oppression. In truth, every culture and every religious faction has its peace-
ful members and its violent ones. A domestic batterer who uses the Christian funda-
mentalist concept of submission to justify the oppression and abuse of his wife does
not defne Christianity any more than does a terrorist bent on destruction defne the
Muslim religion.
Te word Islam means submission, and followers of Islam submit themselves to the
monotheistic God, Allah. Te Muslim holy book is called the Quran (sometimes re-
ferred to as Koran, but because this is the Anglicized spelling, most Muslims prefer the
spelling included previously because it most accurately refects the correct pronuncia-
tion in Arabic). Te Quran is considered by Muslims to be the recited words of God
revealed to the Prophet Muhammad in the 7th century. Islam recognizes and relies on
the holy books of Judaism and Christianity (the Old and New Testaments), but Muslims
consider the Quran to be Gods fnal revelation to humankind.
Tere are approximately one billion followers of Islam, which makes it the second-
largest religion in the world. Te majority of Muslims live in Southeast Asia, Northern
Africa, and the Middle East. Tere are two primary sects within Islam due to an early
dispute over who should have been Muhammads successor. Te Sunnis tend to be more
religiously and politically liberal (for instance, they believe that Islamic leaders should
always be elected). Approximately 90 percent of all Muslims are Sunnis. Shiites, on the
other hand, tend to be more orthodox in their religious beliefs and political philoso-
phies, having developed a more strictly academic application of the Quran. Tey be-
lieve that all successors to Muhammad (Imams) are infallible and sinless. Tey appoint
their clergy and hold them in high regard.
328 Part II / Generalist Practice and the Role of the Human Service Professional
The majority of Muslims who live in the United States are Sunnis, 75 percent of
whom are foreign born. Te Muslim community tends to be both college educated and
middle class, thus Muslims tend not to rely on government-sponsored human services
to meet basic needs, and much of the focus of charity is directed toward Muslims in
other parts of the world who are sufering, either because of war or some other form of
oppression, or is focused on concerns related to marriage and family.
Because Muslims hail from many diferent countries there is considerable diversity
within the Muslim community, particularly in the United States. Yet despite the vari-
ability of cultural beliefs and practices, the House of Islam shares fve basic pillars of
faith:
Shahada: Faith in one God
Salat: Ritual prayer fve times a day while facing Mecca
Zakat: Charitable giving to the poor with the understanding that all wealth belongs
to God
Sawm: Fasting from sunrise to sunset during the month of Ramadan
Hajj: Pilgrimage to Mecca
According to the Quran (9:60), there are eight categories of people who qualify
to receive zakat. Tese include the poor, the needy, those who collect zakat, those
who are being converted, captives, debtors, and travelers. Te three foundational
values within the Islamic community include community, family, and the sovereignty
of God. Family is ofen defned as the joining of two extended families, thus what
might be considered enmeshment in North American society is ofen seen as a sign
of respect as extended families are drawn close and remain an active part of the
immediate familys life. Men and women typically adopt traditional roles with men
working outside of the home and women caring for the home and children, although
this trend is changing, just as it is in other cultures within U.S. society. Modesty is
seen as an important ingredient necessary for keeping order within society, and
women ofen wear clothing (hijab) that covers the greater percentage of their bodies
(Hodge, 2005).
Hodge (2005) pointed out the areas of obvious confict between Islamic values and
liberal North American values. For instance, Western culture values individualism,
self- expression, and self-determination, whereas Islamic culture values community,
self-control, and consensus. Tus, whether working with an Islamic human services
agency, coordinating services with one, or directly serving the Islamic community,
Hodge cautions human services workers not to view Islamic values through the eyes of
Western culture.
For example, it is common for Westerners to view the Islamic
tenet of modesty as primitive and oppressive to women, which for
most Westerners is a hop, skip, and a jump away from endorsing
domestic violence. Yet the Quran states that husbands and wives
must express respect and compassion toward one another, and
domestic violence is not endorsed. To truly understand the values
of modesty and traditional roles embraced within the Islamic
Western culture values
individualism, self-expression, and
self-determination, whereas Islamic
culture values community, self-
control, and consensus.
Faith-Based Agencies 329
culture, one must take the time to understand what these values mean to the men and
women within the Islamic culture itself.
Hence, although a human service professional might not share the traditional values
held within the Islamic community, working in association with Islamic human services
agencies provides human service professionals with an opportunity to display their re-
spect for cultural diversity.
Tere has been a recent surge in interest in developing human services programs
within mosques and Islamic centers across the United States in response to growing
concerns about social issues and demonstrated needs within the Muslim community,
particularly related to marriage, family, and general hostility ofen expressed toward
this community in the postSeptember 11 climate. Te discipline of human services
is relatively new to the Islamic community, but charity is not new and has been prac-
ticed within Islamic and broader communities for generations. Islamic human services
professionals include social workers, counselors, and psychologists, but these services
can also be ofered by an Imam, a Muslim religious leader. Islamic human service agen-
cies provide services to those within Muslim and non-Muslim communities, and are
increasingly relied upon to serve as a liaison for Western aid agencies in Muslim com-
munities experiencing a crisis (De Cordier, 2009).
Islamic charities have sufered since the September 11 terrorist attacks, though, be-
cause many Muslims in the United States are afraid that monies they donate in good
faith to Islamic charities may be frozen by the U.S. government and not directed to hu-
manitarian causes as planned. Muslims are also giving less because they are afraid that
they might be held in suspicion if a charity they donate money to is later investigated
for diverting funds to terrorist causes. Mosques and Islamic centers across the nation
are reaching out to legislators in a campaign called Charity without Fear, asking them to
establish a list of Islamic charities in good standing, so that devout Muslims can give to
charity without fear of being accused of supporting terrorist organizations (Council of
Islamic Organizations, 2005).
Although there are not as many Muslim human service agencies as there are
Christian organizations, there are several that make valuable contributions to the
human services feld on a national and international level. Te following agencies are a
few of these:
ISLAMIC SOCIAL SERVICES ASSOCIATION Although human services agencies
are not yet prolifc within the Muslim community, they are increasing in numbers. Te
Islamic Social Services Association (ISSA) (http://www.issausa.org) acts as an umbrella
organization for all Muslim human services agencies in the United States and Canada.
Te ISSA provides training and educational services, acting as a network linking and
equipping Muslim communities.
INNER-CITY MUSLIM ACTION NETWORK One group of agencies is called Inner-
City Muslim Action Network (IMAN) (http://www.imancentral.org), which focuses
on meeting the needs of those in the inner city in Chicago by operating food pantries,
health clinics, and prayer services. Te agencys ofces, which are located in a storefront
330 Part II / Generalist Practice and the Role of the Human Service Professional
on Chicagos South Side, ofer a free computer lab with free Internet service, General
Educational Development (GED) courses, and computer training classes. IMAN is also
involved in community activism such as lobbying against the granting of liquor licenses
in high-crime areas, community development, and coordination of outreach events
with other community agencies both Muslim and non-Muslim.
MUSLIM FAMILY SERVICES Tere is considerable concern within the Islamic faith
community that Muslim marriages are being negatively afected by the casual nature
of divorce in the United States. Muslim Family Services (MFS), which is sprinkled
throughout the United States, focuses on divorce prevention. MFS (http://www
. muslimfamilyservices.org/home) is a division of the Islamic Circle of North America
(ICNA), an organization designed to assist Muslims live a more devout life. MFS of-
fers human services to families and couples, teaching them how to have a marriage
according to Islamic principles.
MFS provides education, such as workshops for married couples and training
for Imams; premarriage, marriage, and parenting counseling; emergency services;
foster care; and advocacy in court and with social services, particularly in relation to
Muslim family values. Islamic values are stressed, including the belief that marriage
is the foundation of society and the pillar on which family is built. Human service
professionals working for MFS understand that Muslim couples living in the United
States are ofen caught between two cultures, thus many are infuenced by the more
liberal Western values. Tis has led to increased divorce rates and also many parenting
challenges as adolescents in particular challenge traditional Islamic values such as mod-
esty and malefemale relationships.
ISLAMIC RELIEF USA Poverty-related crises exist all over the world. Poverty allevia-
tion depends upon the coordination of human service agencies, including government
and nongovernmental organizations (NGOs). Islamic Relief USA (http://www.irusa.org)
engages in poverty alleviation, disaster relief, and development work throughout the
United States and throughout the world.
A similar organization that coordinates services with Islamic Relief USA is Islamic
Relief Worldwide (www.islamic-relief.com) provides services on a worldwide basis, also
enabling communities to deal with disasters, provides disaster relief and recovery services,
and protects vulnerable and marginalized populations by confronting poverty. Islamic
Relief Worldwide and Islamic Relief USA both engage in six types of aid work, including
poverty alleviation in the form of sustainable livelihoods, education, health and nutrition,
child welfare, water and sanitation, and emergency relief and disaster preparedness.
Although there are not an abundant number of human services agencies such as
MFS, human services professions working within these agencies are Muslim and must
be familiar with Islamic family values and the Quran, particularly in matters related
to marriage and raising children. Many human service providers use similar counsel-
ing methods as do providers in secular agencies, but case management and generalist
services are not as widely practiced because a human services network is not as well
developed within this community.
Faith-Based Agencies 331
Te Muslim community within the United States will continue to be confronted
with issues related to acculturation, modernization, and the eroding of traditional val-
ues, and problems within the family will no doubt continue to rise. Competing marital
roles, adolescent rebellion, and at times social isolation, including the internalization of
the majority cultures negative views of the Muslim faith, will continue to add stress to
the Muslim family system. Human services agencies can assist Muslim families feel less
isolated, can provide much-needed education and support, and can provide a sense of
connectedness among Muslims who are feeling unsupported within their communities.
CASE STUDY 13.3
Case Example of a Client at a Muslim Faith-Based Agency
Maya is a 42-year-old Muslim woman who was referred to an Islamic womens center for
advocacy and counseling. She has been married to Asad, a 44-year-old physician, for 18
years. Maya is the stay-at-home mother of their three children, aged 10, 12, and 14. Both
Maya and Asad are originally from Egypt, having immigrated to the United States shortly
afer getting married. Maya reports that she and her husband have always been devout
Muslims, being very involved in their local mosque. Tey have had what she considers
a traditional Muslim marriage, where her husband is the leader of the home and pro-
vides for the family fnancially, and Maya takes care of the home and the children. For
the majority of their marriage Maya believes that their marriage has been a good one. She
believes that her husband was always very respectful of her and relied on her wisdom and
input in making decisions impacting the family, particularly with regard to the children.
Because Maya was an accountant prior to getting married, Asad has relied on her to help
with fnancial matters related to his medical practice. Maya reported that about fve years
ago Asad began to bring his work home with him, which led to an increase in his general
irritability and frustration. In the last two years Maya noted that he began to become more
controlling of her whereabouts, getting angry with her if he could not reach her at a mo-
ments notice. She did not reach out then because she believed Asad when he said that it
was his right to control her in this manner. Although Mayas father did not behave in this
manner, she began to believe that perhaps she needed to endure Asads behavior in order
to be a good Muslim wife. Maya shared that in the past few months his aggression had es-
calated to the point of screaming at her, both at home and in public, backing her into cor-
ners. His drinking has escalated as well. Te incident that prompted Maya to fnally reach
out for help occurred afer she refused to sleep with Asad because he was extremely intox-
icated and verbally abusing her. Asad became irate and began beating her, citing his right
per the Quran (4:3435). Maya initially went to the Imam at her mosque, who supported
her completely and also explained that her husbands use of the Quran was a misinterpre-
tation. He explained that Islam did not in any way condone abuse. He provided her with a
considerable amount of information regarding the cycle of violence and services in the
community for victims of domestic violence, including support groups for both adults and
children. Maya contacted the Muslim womens center that day and saw a counselor later in
332 Part II / Generalist Practice and the Role of the Human Service Professional
the week. During Mayas frst counseling center she expressed relief that her community
was so supportive of her, but she expressed sadness as well because the information and
resources she received seemed so fatalistic and hopeless. Her counselor explained that her
husband was acting in a manner inconsistent with the will of Allah and if he was truly
committed to following Islam and being a good Muslim husband and father, then perhaps
he would be open to receiving counseling as well. Domestic violence, the counselor ex-
plained, not only destroyed everyone in the family but also afected the entire community,
thus the Muslim community was as concerned about Asad as it was about Maya. During
counseling Maya began to understand the underlying dynamics of her husbands behavior
and gained wisdom regarding the diference between a husband who led his family with
respect, as described by Muhammad, and the controlling and abusive behavior exhibited
by her husband. As Maya gained confdence in herself and her decisions, she felt strongly
that Allah was leading her to be strong for the sake of her family. Strength, according to
her counselor, meant that she could not tolerate abuse. Asad met with the Imam for several
weeks and then reluctantly agreed to attend a one-year anger management program that
was led by an Imam at the community Islamic center, and Maya agreed not to make any
decisions about whether to consider a divorce until afer Asad had fnished his program.
Both the Imam and the counselor agreed that family counseling should not occur until
afer Asad had received enough counseling to recognize that the root of the family and
marital problems lay within him. As Maya continued counseling, she began to realize the
intergenerational cycle of abuse that existed in her husbands family and how important it
was, particularly for the sake of her children, that she become strong enough to break the
cycle. Te most difcult aspect of this process for Maya was maintaining good boundaries
with Asad and realizing that he had the choice not to change, which would force her hand
in a sense, forcing her to leave the marriage to avoid repeating the patterns of abuse.
Concluding Thoughts on Faith-Based Human
Services Agencies
As the feld of human services evolves and matures, the scope with
which this discipline is viewed is broadened and the value of ser-
vices provided by those not within the mainstream mental health
community will be increasingly recognized. Whether these services
are delivered informally through church-sponsored programs or
through highly organized faith-based human services agencies, rec-
ognizing that human services delivery can occur through a variety
of systems acknowledges the reality that diferent people seek help
in diferent ways.
Human Systems
Understanding and Mastery of Human
Systems: Processes to effect social change
through advocacy
Critical Thinking Questions: What roles
are Muslim faith-based organizations
playing in changing societal attitudes
about Islam? How are these organiza-
tions supporting Muslim individuals and
families in coping with the increase in
xenophobia and anti-Islamist sentiment
that has grown in the United States since
9/11?
333
1. Recent interest in faith-based counseling is based
upon a:
a. holistic approach to mental health
b. religious revival within the United States
c. recognition that religious organizations often pro-
vide human services more effectively
d. Both B and C
2. Religiousness is commonly defned as ______,
whereas spirituality is often defned as ______.
a. a personal faith expressed within the structure
of religious tradition/faith and general spirituality
without a specifc belief in a deity
b. a social experience grounded in traditional reli-
gion/an independent relationship with God
c. adherence to a traditional religious faith/an in-
tense feeling of faith
d. All of the above
3. Citing biblical support for slavery is an example of:
a. the danger of organized religion
b. how easy it is to confuse faith with cultural values
c. the hypocrisy inherent in most religious traditions
d. Both A and C
4. The Association of the Jewish Family Services and
Childrens Agencies acts as a(n):
a. service agency for all Jewish agencies
b. referral agency for all Jewish agencies in North
America
c. information clearing house for local Jewish Family
Service agencies
d. an advocacy organization that works at an inter-
national level
5. Mainstream Protestant denominations such as the
Methodist, Presbyterian, and Lutheran denominations
embraced caring for the poor, but these denomina-
tions did not necessarily link charity to _______:
a. giving money (tithing)
b. social welfare
c. a biblical mandate
d. evangelism
6. Islamic human service agencies:
a. provide services to those within Muslim and non-
Muslim communities
b. reject the notion of human services due to a clash
in values
c. are increasingly relied upon to serve as a liaison
for Western aid agencies in Muslim communities
experiencing a crisis
d. Both A and C
The following questions will test your knowledge of the content found within this chapter.
CHAPTER 13 PRACTICE TEST
7. What are the benefts and challenges of faith-based counseling? Why is it important for human service profes-
sionals to develop competency in this area? Cite the rationale for incorporating spirituality into the counseling
relationship, including exploring the difference between positive and negative religious coping mechanisms.
8. Compare and contrast the basic tenets of the three religious traditions cited in the text, describing how each
approaches the use of human services within the respective traditions. Cite the various perspectives on the
strengths and challenges of relying on faith-based agencies to provide human services.
334 Part II / Generalist Practice and the Role of the Human Service Professional
Suggested Readings
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336
Te feld of forensic human services includes areas in which the human
services discipline intersects with the legal system. Tus, human service
professionals who work in practice settings dealing with domestic vio-
lence, sexual assault, gang activity, and criminal justice agencies such as
police departments, probation, state, and county prosecutors, and within
correctional facilities such as jails and prisons are considered forensic
human service providers. Te role and function of these practitioners
will vary dramatically depending on the legal or criminal issues at play,
but most forensic service providers require specialized training in areas
such as crime victimization and crisis counseling, as well as developing a
thorough understanding of the legal and criminal justice system.
Violence has always been a part of human history. In fact, violence
exists in all segments of life among living creatures. A lions survival is de-
pendent on its killing of a wildebeest or zebra, which involves an act of vi-
olence. Yet although biologists would likely argue that violence is a natural
aspect of survival in the animal kingdom, controversy abounds when this
theory is applied to humankind. Does a review of history reveal that war
is necessary? Certainly war has always existed, but is our existence depen-
dent on competition for resources won through violent means? At what
point does the act of war become the act of genocide? How can ordinary
people live side by side peaceably for years and suddenly commit heinous
acts, such as was the case during the Holocaust or the more recent geno-
cide in Rwanda, and somehow justify their actions? Perhaps having the
ability to respond in intense anger that manifests in violence is necessary
when one is defending oneself, but doesnt the unjust use of violence make
this defensive response necessary in the frst place?
Determining the answer to these questions lies at the heart of vio-
lence research within the domain of social scientists such as sociologists,
social psychologists, anthropologists, and criminologists, as well as those
Violence, Victim Advocacy,
and Corrections
CHAPTER 14
Learning Objectives
Develop a basic understanding of
the nature of violence in its various
manifestations, including its impact
on both victims and perpetrators
Become familiar with the cur-
rent legislation and government
policy having an impact on
victims of crime, including the
Victim Bill of Rights
Explore the key roles and
functions of human service
professionals working in various
forensic-related practice settings
Understand the dynamics in-
volved in gang activity and other
similar forms of criminal activity
Develop an awareness of the mul-
ticultural issues involved in foren-
sic human services, including how
institutional racism infuences the
punishment of certain crimes and
treatment of prisoners
Andrew Lichtenstein/Corbis
Violence, Victim Advocacy, and Corrections 337
who work in the applied felds such as human services and those working within the
criminal justice system. In this chapter the various types of violence will be explored,
such as domestic violence, sexual assault, battery, and murder. Ways in which society
and those within the human services felds most ofen intervene to reduce violence that
afects not only its victims but also society as a whole will be explored.
Intimate Partner Violence
Intimate partner violence (IPV) (a more inclusive term than domestic violence) involves
the physical, sexual, and emotional abuse acted out between intimates. Tis may include
violence between husbands and wives, violence between boyfriends and girlfriends,
violence within gay and lesbian relationships, and violence between family members
(such as siblings, parents, etc.). IPV can include hitting, punching, slapping, pinching,
shoving, and throwing objects at or near the victim, or threatening to do so. IPV also
includes verbal and emotional abuse including name-calling, harassment, taunting, put-
downs, and ridiculing, and sexual violence, such as forcing an intimate partner to en-
gage in a sexual act without his or her consent.
Te Centers for Disease Control and Prevention (CDC) estimates that one in three
women (36 percent) and one in four men (29 percent) of the U.S. population report
having been a victim of some form of IPV in 2010. One in four women (24 percent)and
one in seven men (14 percent) have experienced severe IPV in 2010. Both men and
women who were victims of IPV reported significantly higher rates of physical
and|mental health problems than the general population. According to a CDC survey
conducted in 2010, although both men and women are victims of IPV,
women are victims far more ofen of multiple forms of violence, such as
physical, sexual, and emotional violence, than men, who are far more ofen
victims of solely physical violence. IPV has resulted in 1.3 million injuries
each year, and 2,340 deaths in 2007, the majority of whom were women
(Black et al., 2011).
Nearly 325,000 women are victims of domestic violence while pregnant, and re-
search suggests that pregnancy can actually make women more vulnerable to abuse.
Once considered a personal family matter, domestic violence in recent generations af-
fects entire communities, both fscally and socially. Women with a history of domestic
violence report having signifcantly higher rates of physical health problems. Physical
problems from assaults, partner rape, and the stress of living in a violent environment
can lead to chronic pain, gynecological problems, HIV/AIDS, other sexually transmit-
ted diseases, gastrointestinal problems, unwanted pregnancy, miscarriage, and prema-
ture births. Te estimated health costs related to domestic violence is close to $6 million
per year and $1.8 billion in lost productivity including lost time from work, unemploy-
ment, and increased dependence on public aid (CDC, 2003).
Domestic violence does not just afect the abused spouse. Te children living in the
home are victims as well, even if the violence is not aimed directly toward them. Boys
who witness domestic violence are twice as likely to commit violence against their part-
ners as adults (NCADV, 2007). IPV costs U.S. society approximately $5.8 million per
Intimate partner violence results
in 1.3 million injuries per year, and
about 2,340 deaths in 2007, the
majority of whom were women.
338 Part II / Generalist Practice and the Role of the Human Service Professional
year in lost revenue with victims of IPV missing collectively about 8 million days from
work, and direct costs for mental and physical healthcare (CDC, 2003). Clearly, then,
IPV is not a private family matter. Te cost to society, both in injured members and in
lost revenue, is far too high to ever allow this issue to be ignored again.
The Nature of Domestic Violence: The Cycle of Violence
Lenore Walker (1979) was the frst to coin the phrase the cycle of violence to describe the
pattern of interpersonal violence in intimate relationships. Most abusive relationships
ofen begin in a honeymoon-like state with the abusers ofen telling their new partners
that they are the only people in the world they can trustthe only ones who under-
stand them. New partners are usually swept of their feet with compliments and many
promises for a wonderful future. Once the abusers feel comfortable in the relationship, a
dual process occurs. Te abusers begin to feel vulnerable by recognizing their partners
power to hurt them deeply, and as familiarity in the relationship increases, the abusers
ofen increase their sense of entitlement to have all their needs met.
Plagued with fears that they will be abandoned, taken advantage of, and humiliated
(as many were in their childhoods), jealousy, possessiveness, and accusations begin.
Emotional immaturity ofen prevents abusers from being able to separate their internal
feelings from possible causes (i.e., are their feelings of jealousy caused by their own inse-
curities or caused by their partners unfaithfulness?), thus a common assumption among
batterers is that if they feel badly, their partners must be doing something to cause it.
In response to these threatening feelings of vulnerability and entitlement, and poised
to be hurt once again, innocent partners ofen become the focus of the batterers mis-
trust, fear, and ultimate rage. Abusers ofen misinterpret the intentions of their partners,
mentally ticking of injustice afer injustice. Tese types of negative misperceptions and
misassumptions are prevalent and are rarely checked against fact.
Most partners of batterers will sense the increasing tension brought about by the
abusers underlying anger that is bubbling to the surface. Batterers might ask more
questions, make sarcastic comments, ask why two cups are out rather than one, or ques-
tion why the phone wasnt answered more quickly when they called. Tey will typically
have a shorter fuse, becoming easily frustrated ofen without provocation. In response,
most victims do their best to walk on eggshells to avoid an explosion. But no amount of
running interference or ofered reassurances will help because the process is an internal
one, occurring within the mind of the abuser. In fact, most abusers have an actual need
to be proven correct in their fear of being hurt and humiliated again because to a bat-
terer, being too trusting is ofen synonymous with being an unsuspecting fool.
Eventually the explosion occurs despite all peacemaking eforts. Abusive rages can
take on several forms including frightening bouts of screaming and yelling; intimidation;
and physical abuse such as hitting, kicking, scratching, grabbing, slapping, and shoving.
Attacks might also include throwing objects at or near the victim, punching walls, and
making threats to harm either the person or the personal property of the victim.
Once batterers have experienced a violent rage, they are ofen temporarily relieved
of their internal feelings of rage and in many respects take on the persona of a remorse-
ful child seeking reassurance and approval. Batterers ofen honeymoon their partners
Violence, Victim Advocacy, and Corrections 339
and other family members who were victims of the abuse, promising never to repeat the
abusive behavior. Tere is commonly a manipulative aspect to the batterers professions
of regret and apologies, with the extent of authentic remorse being somewhat question-
able. One reason for this is that the batterers apologies are ofen riddled with a series of
buts: Im sorry I hit you, but you know how I hate to be awakened early in the morn-
ing. Im sorry I shoved you, but you know I dont like you talking to other men. Im
sorry I slapped you, but you know how stressed I get when work is so busy.
Rarely is the batterers focus authentically placed on the pain and trauma caused
to the partner or other family members. Rather, the honeymoon phase involves more
of a panicked pleading, begging the victim not to leave, to forgive and forget, to move
on quickly by minimizing the extent of the abuse. Statements intended to reframe the
abuse, such as I cant believe you think I shoved you! I clearly remember me reaching
out to you and you jerking away and tripping, are common.
Tis can be an immensely confusing time for the victim, who usually knows instinc-
tively that the batterer needs help, but any attempt to point out a pattern of abuse or to
hold the batterer accountable (particularly afer the batterer gets comfortable once again
and stops apologizing) will hasten the tension-building phase, something the victim
desperately wants to avoid. Attempts to demand authentic change in the abuser ofen
result in the batterer accusing the victim of holding a grudge, being unforgiving, and
punishing. Comments such as, How dare you rub my face in this when Ive already
apologized . . . What do you want me to do? Ive already said Im sorry 100 times. Lets
move on! are common.
With the hope that the honeymoon phase might just last forever, victims ofen com-
ply with the dangerous demands of the batterer to relinquish their own sense of reality
and accept the reality of the batterer that the abuse was not that bad, that it will never
happen again, and that it was a one-time event. Living in the here and now allows both
the batterer and the victim to avoid seeing the pattern of abuse, which in some respects
allows them both to avoid their fear of facing the truth and seriousness of the situation.
But no matter how many promises the abusive partner makes or how desperately the
victim wants to believe the abuse will never occur again, without intervention the cycle
is destined to repeat itself.
Counseling Victims of Domestic Violence
WHOSE FAULT IS IT ANYWAY? ATTRIBUTING CAUSALITY OF ABUSE IN THE
RELATIONSHIP Counseling victims of domestic violence requires specialized train-
ing that focuses on the unique dynamics commonly at play in abusive relationships.
Many of these dynamics relate to the cycle of violence discussed earlier, but many relate
solely to the victim, including understanding common personality traits encountered in
those who have a pattern of getting romantically involved with abusive partners, as well
as traits commonly seen in individuals who will not leave or who continue to return to
their abusive partners.
One significant element of counseling victims of domestic violence is assisting
them in making decisions about their future that will not compromise their safety.
Tus, although human service professionals may not actually tell the clients to leave an
340 Part II / Generalist Practice and the Role of the Human Service Professional
abusive relationship, they will ofen lead abused clients down this path, particularly if it
is the only way to secure their safety and if the batterer has refused to enter into a struc-
tured treatment program.
Many victims of domestic violence have a locus of control that is far too internal.
Tis means that they have a tendency to see themselves as responsible for more than
they actually are and they do not necessarily recognize when their personal responsibil-
ity ends and when someone elses begins. In an unhealthy respect, this makes them a
good match for a partner with an external locus of control. Tose with an external lo-
cus of control have a tendency to see outside factors as responsible for the events in their
lives. Batterers commonly have an external locus of control and blame their partners (as
well as a host of other people and things) for their mistakes and failures. Tose with a
healthy locus of control will be able to recognize when something lies inside or outside
their domain of responsibility. A healthy locus of control indicates that someone has
good personal boundaries and will likely refuse to accept responsibility for something
she knew was not her fault. But many victims of domestic violence do not have healthy
personal boundaries and readily accept responsibility for virtually everything that is
wrong in their relationship or with their partners. So, the batterer externalizes blame,
and the victim internalizes blame.
A theory attempting to explain this core issue in domestic violence relationships fo-
cuses on attribution theory, specifcally exploring how the victim attributes the partners
abusive behavior. If victims hold their partners at fault for the abusive behavior, attribut-
ing the abuse to personality factors such as an inability to manage anger, a refusal to take
responsibility for their behavior, or a lack of empathy, then they will be more likely to
leave the abusive relationship (Pape & Arias, 2000; Truman-Schram, Cann, Calhoun, &
Vanwallendael, 2000). But victims who tend to attribute their partners abusive behavior
to situational or outside sources such as work stressors, family problems, or even alco-
holism will have a greater likelihood of forgiving the batterer quickly and returning to
the abusive relationship (Gordon, Burton, & Porter, 2004).
Te human service professional can assist the victim in learning how to attribute
causality of the abusive behavior to the batterer, incorporating an even if attitude: even
if work is stressful, your mother is ill, youve had too much to drink, youve lost your job,
money is tight, the kids are acting up, or you injured your knee, its never okay to behave
in an abusive manner. Victims of domestic violence also commonly need to develop
more healthy personal boundaries so that they can understand what they are and are
not responsible for in their relationships and with their abusive partners. For instance,
the client might be responsible for responding to her husbands question in an irritable
tone, but she is not responsible for her husbands choice to hit her in response; that was
his choice, and it was unwarranted and an unreasonable response, one for which he was
completely responsible.
A common clinical issue in helping someone develop new boundaries is the ex-
perience of unreasonable guilt. Many victims of domestic violence feel toxic guilt in
response to setting limits with others, ofen believing that saying no to someone or up-
setting another person is equivalent to being unkind. An emotionally healthy individual
with good personal boundaries might feel badly when saying no to a request, or when
Violence, Victim Advocacy, and Corrections 341
frmly telling a partner that she is not responsible for his behavior, but she will not allow
these bad feelings to infuence what she knows to be true. In other words, she knows
that despite feeling some guilt, she must honor her personal boundaries because to ne-
glect them will negatively afect her self-esteem and self-respect. Yet victims of domestic
violence will ofen allow their irrational guilt to determine their actions. If an action
makes them feel guilty, they commonly assume that this action must be wrong.
Human service professionals can help clients see the irrationality of this way of
thinking. Cognitive behavioral therapy (CBT) is a counseling technique commonly
used to help victims of domestic violence recognize and change unhealthy relationship
styles. Helping victims of domestic violence realize that feelings are not always the best
indicators of appropriate action will assist them in setting better boundaries in their re-
lationships and more efciently recognizing the signs that a partner or potential partner
is merely looking for a life scapegoat, rather than a life partner.
DOES SHE STAY OR DOES SHE GO? One of the most frustrating aspects of coun-
seling victims of domestic violence is the pattern of the victim returning to the abusive
relationship despite intervention eforts and the risk of continued abuse. One theory
that attempts to explain this dynamic is called the social-exchange theory. Tis theory
posits that victims of domestic violence enter into a kind of cost-beneft analysis when
attempting to make a decision about whether to stay or leave the abusive relationship.
Is the cost more if the victims stay in the abusive relationship where they will be forced
to endure more abuse? Or will the cost be higher if they leave, possibly facing economic
insecurity, navigating the court system if a divorce is imminent, and managing work
and family responsibilities alone? Te investment model of decision making can be used
when attempting to realistically weigh these pros and cons. Tis model involves the vic-
tim evaluating things such as her resources with and without the batterer, her ability to
manage risk, and the risk involved in leaving, as well as estimating what will be gained
or lost if she leaves the relationship (Rusbult & Martz, 1995).
For the objective observer the cost of staying means enduring abuse of increasing
escalation and the cost of leaving may mean enduring fnancial hardship and other strug-
gles relating to managing work and family alone. While the frst option ofen results in
worsening conditions, the latter option typically promises to improve with time. But vic-
tims of abuse ofen have a somewhat skewed perception of the risks of staying or leaving,
using a positive bias when evaluating the cost-beneft analysis of stayingidealistically
assuming that their partner will really change this time, assuming that the abuse was
really not that bad, and overestimating their ability to rescue and compel change in
their abusive partner. Tey may consider the difculties they are bound to face the frst
few months on their own and assume that this transitional stage will last forever. Tey
may use negative thinking, assuming that they will never get a job, will never be able to
balance work and family, partly based on years of emotional abuse and partly based on
the fear and low self-esteem that may have even been the prime motivators for getting
into the unhealthy relationship in the frst place.
Human service professionals can help victims of domestic violence more efectively
process the pros and cons of leaving by helping them evaluate realistic risk factors and
342 Part II / Generalist Practice and the Role of the Human Service Professional
accurate scenarios. Counseling can also assist victims in learning how to manage risk
more efectively without lapsing into negative thinking. In addition, practitioners can
help the client think outside of the box: exploring all alternatives and avoiding all-
or-nothing thinking (I will be either fnancially secure or living on the streets, I will
either be a part of an intact family or be constantly lonely and a social outcast). En-
couraging the client to consider possibilities not previously acknowledged can help the
client realize that she has far more control over her destiny than she might have previ-
ously thought. For instance, obtaining factual information about her
fnancial situation, including learning laws related to an equitable
division of property and the likely levels of child support and spou-
sal maintenance, will assist victims of domestic violence in making
good decisions that are based on fact, not fear.
Despite the specialized nature of working with victims of domes-
tic violence, a generalist approach is most efective, ofen involving
case management, court advocacy, individual counseling, group
support, counseling children and adolescents, providing housing
assistance, job coaching, and assistance with life skills. Te human
service professional working with victims of domestic violence must
be familiar with contemporary theories of abuse, efective interven-
tion strategies, common clinical disorders associated with being a
survivor of domestic violence such as post-traumatic stress disorder
(PTSD), domestic violence laws, the criminal justice process, and
resources designed to meet the needs of victims and their children.
Domestic Violence Practice Settings
One of the most common practice settings where human service professionals work
with victims of domestic violence is a battered womens shelter. Such shelters typically
ofer numerous services, including the following:
A 24-hour hotline for immediate access to information and services
Immediate safety shelters for domestic violence victims and their children
Individual counseling for all victims
Survivor support groups
Court advocacy
Childrens programs
Teen programs
Information referral
Medical advocates who provide on-site support at hospitals
Immigrant programs (depending on the ethnic makeup of the community)
Although battered womens shelters ofen have a physical site where counseling and
case management occur, their actual shelters are usually sprinkled throughout the com-
munity in confdential locations to ensure the safety of the victims utilizing shelter ser-
vices. Shelters may include houses converted into shelters or even rented apartments
located throughout a community. Victims of domestic violence and their children
Human Systems
Understanding and Mastery of Human
Systems: An understanding of capacities,
limitations, and resiliency of human
systems
Critical Thinking Question: In work-
ing with victims of domestic violence,
a human service professional may
find it deeply distressing when a cli-
ent continues to return to an abusive
partner. What generalist practice skills
might a professional use to assist her/
him in respecting the clients right to
self-determination?
Violence, Victim Advocacy, and Corrections 343
usually remain in a shelter for a time determined by their primary counselor, but the
goal of shelter services focus on self-sufciency, thus job placement, child care assis-
tance, and transportation needs are also addressed.
Most shelters involve communal living, where residents share their living space with
other victims. Residents are required to participate in group counseling sessions with
other residents as well as assisting with the general functioning and maintenance of the
shelter. Human service professionals are assigned to each shelter living space and fa-
cilitate in-house programs to maintain smooth functioning within the home, as well as
among the residents. Most shelters institute rules such as a no alcohol or drugs policy
and mandated maintenance of the confdentiality of the location of the shelter. Resi-
dents who release this information to their abusive partners will be asked to leave the
program. Residents are also required to work on the meeting of program goals, and
serious noncompliance may also be a reason to terminate services.
The Prosecution of Domestic Violence
In 1993 the federal government passed the Violence Against Women Act of 1994
( reauthorized in 2005 as the Violent Crime Control and Law Enforcement Act [Pub.
L. No. 103-322]). Te Violence Against Women Act established policies and mandates
for how states were to handle domestic violence cases, such as encouraging mandatory
arrests, encouraging interstate enforcement of domestic violence laws, and maintaining
state databases on incidences of domestic violence. Tis act also provides for numer-
ous grants for educational purposes (e.g., the education of police ofcers and judges),
a domestic violence hotline, battered womens shelters, and to improve the safety of
public areas such as public transportation and parks. Since the passage of the Violence
Against Women Act incidents of domestic violence have been cut in half. Human ser-
vice professionals are working alongside other advocates and pushing for more protec-
tion for immigrant women, as well as increased safety measures in the work place in
future reauthorizations of Violence Against Women Act in order to address the growing
problem of violence in these two arenas.
Te Violence Against Women Act spurred several states to pass similar legislation,
which continues to change the nature of domestic violence prosecutions. With regard to
current policies regarding the prosecution of domestic violence, it is important to note
that unlike a civil case, where a plaintif brings an action and thus has the right to subse-
quently drop the case, in criminal cases the plaintif is the state and the victims are wit-
nesses. But in the past, prosecutors have allowed victims to drop a case (typically at the
urgings of the batterer). Domestic violence legislation has for the most part put a stop to
this practice. Instead, domestic violence is typically treated as any other crime where the
victim is called as a witness and must appear at the trial to testify on behalf of the state.
Tis can create emotional tension for victims, who may initially want court involve-
ment immediately afer experiencing violence, but then want to resist any intervention
when the honeymoon phase begins and renewed hope for authentic change seems pos-
sible. Counseling for the victim of abuse ofen focuses on the ways in which the victim can
respond (ofen in counterintuitive ways) that will have the greatest likelihood of moving
the batterer toward real change. As long as victims relinquish their own reality of the events
344 Part II / Generalist Practice and the Role of the Human Service Professional
and yield to the batterers demands to forgive and forget without any real accountability,
no real change will occur. Any efective counseling program must address the denial, wish-
ful thinking, indiscriminate forgiveness (without accountability), and a desire to protect the
batterer, as well as the fear of the future that many victims of domestic violence experience,
which can prevent an honest and realistic appraisal of their abusive relationship.
Batterers Programs
It might be tempting to focus treatment eforts solely on the victims of abuse, leaving
the perpetrators of abuse to fend for themselves. But if those who committed abuse were
treated efectively, then domestic violence would no longer be a pressing social problem.
It is also important to be aware that not all batterers are alike. In fact, although there
are many batterers who are narcissistic with antisocial tendencies (sociopathy) and
abuse their intimates with no remorse, there are also those who act out in anger but are
truly remorseful, some who have never committed violence before but a combination
of circumstances lowered their impulse control, some who are in reciprocally abusive
relationships, and some who have been falsely accused.
It is vital that human service professionals take the time to understand the dynam-
ics involved and not assume that if an accusation were made, it must be true. I have
worked in domestic violence for years and worked with many authentic victims who
had extremely abusive partners. Yet I will never forget the case involving a woman who
presented with plausible stories of abuse at the hands of her husband, who was recently
arrested for domestic violence. I was sold before having even met her husband, because
my clients stories were convincing. Yet the criminal trial revealed that she had been
emotionally abusive for years, and when he sought a divorce she threatened to seek re-
venge. She did so by causing self-injury and going upstairs privately to call the police.
Te tape of the 9-1-1 call was chilling as she screamed and cried while reporting the
alleged abuse. If it had not been for the friend she told, who bravely testifed at trial on
behalf of the defense, her husband might have been convicted of a crime he did not
commit, and she might have unfairly gained custody of their children because everyone,
including me, was so quick to believe her simply because of her gender.
In the past the criminal justice system sought traditional forms of justice for those
convicted of domestic violence, but this approach was ofen unsuccessful because judges
were sometimes reluctant to break apart families, and more ofen victims of domes-
tic violence were reluctant to testify against their partners or spouses, particularly if it
meant a possibility of incarceration. Tus, several years ago domestic violence courts
started mandating batterers to attend treatment programs ofen in lieu of jail.
Most batterers intervention programs are based upon the Duluth Modela psycho-
educational program drawn from feminist theory of domestic violence, which posits
that domestic violence is caused by patriarchal ideology, and mens perception that they
have the right to control their female partners. Many batterer intervention programs are
also based upon group treatment using CBT and anger management training. Newer
programs combined these models, based upon the premise that battering is a complex
problem, thus a combination of psychoeducation, CBT, and anger management in a
group setting will be most successful.
Violence, Victim Advocacy, and Corrections 345
Programs range in duration from six weeks to one year and are ofen mandated by
the court as a part of sentencing. Batterers are taught to respect personal boundaries, the
diference between feelings and actions, the concept of personal rights and egalitarian
relationships, and discover the dynamics of social learning theory including modeling
so they can discover how their violent behavior is likely patterned afer their parents or
some other infuential person in their lives. Tey also learn how to identify their personal
triggers and learn strategies for managing their anger, including how to control impulses,
and how to use I statements to avoid getting caught up in making accusations.
Most batterers treatment programs have similar goals, including increasing aware-
ness of violent behavior and encouraging the batterer to take responsibility for violent
behavior. Common program philosophies include the following beliefs:
Violence is an intentional act.
Domestic violence uses physical force and intimidation as coercive methods to ob-
tain and maintain control in the relationship.
Using violence is a learned behavior and as such can be unlearned.
Many participants make authentic changes in group treatment not only because of
the curriculum but also because of the built-in accountability that a group setting pro-
vides. Ironically it is the other group members who have been charged with domes-
tic battery who ofen challenge those who refuse to engage or who consistently blame
the victim. Unfortunately, at least an equal number of participants do not authentically
change while in the program. Some batterers fail to complete the program, and others
are reluctant to change because they actually love the rush and power they get from feel-
ing intense anger (Pandya & Gingerich, 2002).
Whether batterer intervention programs actually work is a question that remains un-
answered for the most part. A 2003 study commissioned by the U.S. Department of Justice
(DOJ) found little support for the success of batterer intervention programs with regard
to recidivism rates, or attitudes toward domestic violence. Te only signifcant diference
found was in the re-ofense rates of men who completed programs 26 weeks or longer. Yet,
while these men had signifcantly lower recidivism rates, their attitudes about domestic
violence did not appear to change much. For instance, men in the experimental group
(the batterers intervention program) viewed their partners only slightly less responsible
for the battering incident, than men in the control group. Te studys authors cited numer-
ous limitations of the study, which may have been responsible for the results, including a
high drop-out rate, and questionable validity of the attitudinal surveys. Based upon these
limitations, the authors recommended that batterer intervention programs be allowed
to continue to evolve (since they are a relatively new tool in the fght against domestic
violence), but in a manner that was responsive to the increased knowledge that is being
gained about the nature of IPV, including common risk factors for becoming a batterer.
Sexual Assault
Another form of personal violence is the act of rape, or sexual assault. Sexual assault
involves forcing some form of sexual act on another person without his or her consent.
346 Part II / Generalist Practice and the Role of the Human Service Professional
Determining the rate of sexual assault in the United States is dif-
cult due to dramatic variations in the way sexual assault is defned.
Although both men and women can be raped, women are victims
of rape far more ofen than men. Approximately one in fve women
in the United States have been raped sometime during their life-
time, and more than half of them were raped by intimate partners
(Black et al., 2011).
For the first time since 1927, the legal definition of forcible
rape has been changed. According to the Uniform Crime Reports (UCR), the former
defnition was: the carnal knowledge of a female, forcibly and against her will. Tat
defnition, unchanged since 1927, was outdated and narrow. It only included forcible
male penile penetration of a female vagina. The new definition is: [t]he penetra-
tion, no matter how slight, of the vagina or anus with any body part or object, or oral
penetration by a sex organ of another person, without the consent of the victim. Tis
is an important victory for advocates since this expanded defnition now includes rape
of both genders, rape with an object, and sexual acts with anyone who cannot give
consent due to mental or physical disability.
Approximately 170,000 women, 12 years and older, and 15,000 men were raped
or sexually assaulted in 2010. About 75 percent of all women who were raped were
assaulted by perpetrators they knew, and about 25 percent were assaulted by strangers
Black women are raped at a higher rate (relative to the population) than White or
Hispanic women. Only half of all rapes and sexual assaults in 2010 were reported to
police (Catalano, Smith, Snyder, & Rand, 2009; U.S. Department of Justice, 2011).
According to the CDC, rape and sexual assaults typically fall into four categories
(Basile & Saltzman, 2002):
1. Completed sexual acts such as sexual penetration, but may also include any act of a
sexual nature attempted or otherwise such as contact between a sexual organ and
another part of the body
2. Attempted sexual assault
3. Abusive sexual contact such as intentional touching even through clothing
4. Noncontact sexual abuse such as intentional exposure and exhibitionism
( fashing) and voyeurism (Peeping Tom)
Why People Commit Rape
Human service professionals who work with victims of sexual assault must under-
stand the psychological dynamics of rape. One of the more common myths of why
rape occurs includes blaming the victim by asserting that the victim wanted it, liked
it, or in some way deserved the sexual assault because she provoked the assailant
(by dressing or acting provocatively, etc.). Myths about rapists include assertions
that only truly evil or insane men rape and that men just cannot control their sexual
desires, and thus are not responsible for sexually assaulting women (Burt, 1991). Te
damage done by the proliferation of these rape myths is plentiful because they blame
the victim while exonerating the perpetrator, which undermines societal prohibition
against sexual violence.
Approximately one in fve women
in the United States have been
raped sometime during their
lifetime, and more than half of
them were raped by intimate
partners.
Violence, Victim Advocacy, and Corrections 347
In fact, a 1998 study at University of Mannheim in Germany (Bohner et al., 1998)
found that such myths actually encourage sexual assault by giving rapists a way of ratio-
nalizing their antisocial behavior. In other words, although Western social customs may
claim to abhor rape, popular rape myths provide rapists a way around such social mores
by convincing themselves that the women in some way asked for it and that men simply
cannot control themselves, thus they really havent done anything wrong, or at least noth-
ing that many other men dont do.
The Psychological Impact of Sexual Assault
Te physical and psychological impact of sexual assault is serious and long-lasting and
may include PTSD, depression, increased anxiety, fear of risk-taking, development of
trust issues, increased physical problems including exposure to sexually transmitted dis-
eases such as HIV/AIDS, chronic pelvic pain, gastrointestinal disorders, and unwanted
pregnancy (CDC, 2005).
In 1975 Lynda Holmstrom and Ann Burgess coined the term rape trauma syndrome
(RTS), a collection of emotions similar to PTSD, commonly experienced in response
to being a survivor of a forced violent sexual assault. RTS includes an immediate phase
where the survivor experiences both psychological and physical symptoms such as feeling
extreme fear, consistent crying and sleep disturbances, and other reactions to the actual
assault as well as the common fear of being killed during the assault. Survivors in subse-
quent phases of recovery experienced a variety of symptoms, including avoidance of social
interaction, experiencing a loss of self-esteem, inappropriate guilt, and clinical depression.
Many survivors deny the efects of the sexual assault because they do not want to be sub-
ject to the negative stigma associated with being a rape victim. In fact, one of the primary
reasons most rape crisis advocates refer to clients as survivors rather than as victims is to
reduce this stigma by focusing on the strength it takes to survive a sexual assault.
Male-on-Male Sexual Assault
Men are also victims of sexual assault, in the form of child sexual abuse, same-sex date
rape, and male-on-male stranger rape. Research on male-on-male sexual assault is
sparse with the exception of some early eforts to identify the nature and dynamics of
male rape. Te reason for the lack of studies in this area may be related to the belief that
male rape is rare, at least outside prison walls. In fact, in many states, the legal defnition
of rape does not even account for men being victims.
Due to the stigma associated with being a victim of male-on-male sexual assault,
most incidences of rape go unreported, thus it is impossible to know just how common
this crime is. Even rapes that occur in prisons are ofen unreported not only because of
the fear of retaliation but also because of the shame men feel in response to being vic-
timized in this manner.
Treating men who have been sexually assaulted is similar in some respects to serving
the female survivor population except that the shame men feel, although equal in inten-
sity, tends to be more focused on their gender identity as males. Heterosexual men who
were victims of rape reported questioning their sexual orientation because they were un-
able to fght of their attackers. Men also have a greater tendency to turn toward alcohol
and drugs in response to the rape. Men also experience sexual dysfunction, problems
348 Part II / Generalist Practice and the Role of the Human Service Professional
getting close to people, particularly in intimate
relationships, and as is the case with female
victims, some male victims become sexually
promiscuous (Mezey & King, 1989).
More studies need to be conducted on both
female and male rape, particularly on the dif-
fering dynamics of sexual assault in minority
populations. What research there is on ethnic
minority populations seems to indicate that
victims of sexual assault who are Caucasian
and have higher levels of academic education
tend to seek mental health counseling more
often than victims of color or those with less
education (Ullman & Brecklin, 2002; Vearnals
& Campbell, 2001). Tis certainly has practical
implications for human service professionals
who through assessment or advocacy have the
opportunity to reach out to victims or potential
victims of sexual assault.
Common Practice Settings: Rape Crisis Centers
Human service professionals working in any practice setting will likely encounter a victim of
sexual assault at some point in their careers. Tis might involve a recent victim seeking sup-
port services on the heels of an assault, but it is far more likely that rape victims will present
for counseling at some point long afer an assault, perhaps even years later, and might not
even connect that the problems they are currently experiencing are with a past sexual assault.
Human service professionals who work directly with victims of sexual assault usually
do so at a rape crisis center or sexual assault advocacy organization. Many states require that
each county have at least one rape crisis center that ofers a wide range
of services including a 24-hour hotline, around-the-clock on-site ad-
vocacy during medical examinations and investigative interviews, and
crisis counseling, as well as long-term individual and group counseling.
Many human service professionals who work with sexual assault
victims receive from 40 to 50 hours of specialized training focusing
on the history of the rape crisis movement, the nature of crisis coun-
seling, the dynamics of RTS, rape myths, and the dangers of gender
oppression. Training also includes information on normal child and
adult developmental stages and how these stages are afected by sex-
ual violence and trauma.
Victims of Violent Crime
Domestic violence and sexual assault are two types of violent crime
that receive considerable attention within the human services feld
Hundreds of people take part in a candlelight march to call
attention to violence against women and children during a
Take Back the Night event.
Bettye Lane/Photo Researchers/Getty Images
Human Services
Delivery Systems
Understanding and Mastery of Human
Services Delivery Systems: Range of
populations served and needs addressed
by human services
Critical Thinking Question: Given
that sexual assault is one of the most
underreported crimes in the United
States, and that many victims do not
seek help until months or years after
being assaulted, how might human ser-
vice professionals be proactive in getting
services to more victims, sooner?
Violence, Victim Advocacy, and Corrections 349
as well as within the public arena. Tere are other types of victimization that do not
garner as much attention, but are also important. Every year millions of people in the
United States become victims of a crime, many of which are violent crimes. In 2004, 24
million crimes were committed, 5.2 million of which were violent in nature (National
Crime Victimization Survey, 2004). Although violent crime has been declining in recent
years, the issue of victimization and the recognition and enforcement of victims rights
remains a relevant issue for human service professionals.
Te victims rights movement is a relatively new phenomenon having gained momen-
tum in the 1980s when victims of crime came together along with advocates in the human
services feld to secure both a voice within the criminal justice community and some basic
rights in the criminal justice system. Historically, victims of crime had virtually no rights
in criminal proceedings because the U.S. criminal justice system is based on the presump-
tion of innocence. Because defendants charged with a criminal ofense are innocent until
proven guilty, legally there can be no victims. If there are no victims prior to a defendant
being convicted, then there are no rights to enforce. In addition, in criminal
proceedings the case is considered an action committed against the state,
thus other than being a witness, historically, victims of crime have had no
special status. Tis logic, which is consistent with the U.S. criminal justice
system, is completely backward for most victims and victim advocates.
The Victims Bill of Rights
Te victims movement is based not on the desire to lessen the rights of criminal defen-
dants, but rather on the desire to increase the rights of victims including being notifed
of court hearings, to appear at all legal proceedings, to make a statement at sentencing,
and to be kept apprised of the incarceration status of the perpetrator.
Most victims and victim advocates state that a primary goal of the victims movement is
to ensure that crime victims have a voice within the community, specifcally within the crim-
inal justice system (Mika, Achilles, Halbert, Amstutz, & Zehr, 2004). How that voice gets
heard is certainly up for debate. Whether through direct face-to-face meetings with criminal
justice ofcials or through an active involvement in victim-sensitive training of police per-
sonnel, prosecutors, and judges, victims advocacy groups continue to work toward a system
that sees victims as a central aspect of the criminal justice process (Quinn, 1998).
In response to the victims movement and subsequent federal legislation (42 U.S.C.
10606[b]), all states now have a Victims Bill of Rights ensuring certain basic rights as
well as protection. Although there is some variation from state to state, most states en-
sure that victims of violent crime be aforded the following rights:
Te right to be treated with dignity and fairness and with respect for the victims
dignity and privacy
Te right to be reasonably protected from the accused ofender
Te right to be notifed of court proceedings
Te right to be present at all public court proceedings related to the ofense, unless
the court determines that testimony by the victim would be materially afected if the
victim heard other testimony at trial
Historically victims of crime had
virtually no rights in criminal
proceedings.
350 Part II / Generalist Practice and the Role of the Human Service Professional
Te right to confer with the attorney for the government in the case
Te right to restitution
Te right to information about the conviction, sentencing, imprisonment, and re-
lease of the ofender (Victims Rights Act of 1998).
VictimWitness Assistance
In response to federal legislation and Victims Bill of Rights state prosecution units
within prosecutors ofces (states attorney, district attorney, and attorney general of-
fces) developed specialized units called VictimWitness Assistance, designed to en-
force victims rights. Human service professionals work within these departments
ofering the following services:
Crisis intervention counseling
Referrals to coordinating human services agencies, such as rape crisis centers, bat-
tered womens shelters, and crime victim support groups
Referrals to advocacy organizations such as Mothers against Drunk Driving
(MADD), who have a presence in court to ensure enforcement of victims rights
Advocacy and accompaniment in court proceedings
Special services or units for victims of domestic violence, child victims, older
adults, and victims with disabilities
Case status updates including notifcation of all public court proceedings
Foreign language translation
Assistance with obtaining compensation such as reimbursement for counseling and
medical costs
Assistance in preparation and writing of victim impact statements to be read by the
victim at the sentencing hearing
Victimwitness advocates may have a masters degree in any of the applied social sci-
ence disciplines (social work, psychology, general human services), but ofen work at the
bachelors level with some specialized training in the dynamics involved in violent crime
victimization. Advocates must also be familiar with the inner workings of the criminal
justice system because victims of violent crime ofen feel revictimized when they must
endure the ofen confusing labyrinth of the prosecution system. Te average person may
not be familiar with the difering duties of a local police department and a state prosecut-
ing ofce, nor may the average person know how a criminal case proceeds toward pros-
ecution. Tose individuals who have become victims of a crime must be quick studies
so that they can be prepared for what is going to happen next. Victimwitness advocates
can help crime victims understand the process of a criminal trial and the importance and
value of each step within the prosecution process.
If a case goes to trial the victimwitness advocate will work closely with the vic-
tims to help prepare them for testifying. Te clinical issues involved depend on the
nature of the crime and victimization. For instance, if the defendant is the victims
spouse who is charged with domestic battery, the clinical issues will likely involve fear
of retaliation and guilt in response to testifying against a spouse, particularly if there
Violence, Victim Advocacy, and Corrections 351
is a possibility that the defendant might have to serve time in jail or prison. If the de-
fendant was charged with sexual assault, the victim will likely experience feelings of
shame, embarrassment, and fear. A victim of home invasion might experience intense
fear of retaliation once the defendant becomes aware of the victims cooperation and
testimony. In each instance the victimwitness advocate will work with community
human services agencies and advocates to provide support and assistance to the vic-
tim in preparation for trial.
Once a defendant is found guilty, through either trial or a plea arrangement, a sen-
tencing hearing is scheduled. In a sentencing hearing both sides have an opportunity to
advocate for a sentence they believe is appropriate. It is the responsibility of the victim
witness advocate to assist victims in writing their victim impact statement, which will
be read in open court before the judge, jury, and defendant. Although the statements are
written in the words of the victim, they have a dual purposegiving victims a voice in
court and assisting the prosecutor obtain the desired sentencethus it is important that
victims receive guidance in the preparation for writing their statement. Tis also serves
as another opportunity for victims to express and work through their pain, thus it is
ofen an efective clinical tool.
Surviving Victims of Homicide
Some of the most emotionally intense and difcult cases for victimwitness advocates
are homicide cases, particularly when the primary victim is a child. Te victimwitness
advocate must develop a high threshold for dealing with anothers emotional pain be-
cause the pain of losing a loved one through violence is ofen unlike any other loss. Revic-
timization through the criminal justice process is almost a certainty as surviving victims
of homicide are forced to balance their desire to represent their loved one in court by
being present at all hearings with the trauma inherently involved in having to witness the
gruesome details of the crime.
Research strongly suggests the importance of providing supportive counseling
services and advocacy in the weeks immediately following the homicide. Surviv-
ing victims of intrafamilial homicides, where one family member kills another, are
particularly prone to psychologically complex reactions involving both internal and
external stressors. Most experts suggest the use of crisis counseling immediately fol-
lowing the crime that focuses on the concrete needs of the surviving victims. Tis
approach is important in light of research, which suggests that surviving victims of
homicide are mostly likely to utilize advocacy services during the initial crisis phase
(Horne, 2003).
Te needs of surviving victims of homicide are complex, particularly in the weeks
and months afer the murder. Surviving victims of homicide must cooperate with vari-
ous law enforcement agencies and attend court proceedings at the same time that they
must plan a funeral and contend with the efects and belongings of the murdered vic-
tim (which may include pets or even children in addition to physical belongings). Tis
can be signifcantly overwhelming during a time when they are dealing with the para-
lyzing shock of losing a loved one in a sudden and violent manner.
352 Part II / Generalist Practice and the Role of the Human Service Professional
Common Clinical Issues When Working with Victims of
All Violent Crime
Regardless of the nature of the crime committed, victims of violent crime all have basic
needs that need to be addressed by the human service professionals working with them
in treatment (Courtois, 2004). Tese issues or treatment goals include the following:
1. Building formal and informal social support systems
2. Reinforcing ways to regain a sense of safety
3. Teaching victims how to manage their emotions, such as anger, sadness, and fear
4. Achieving physical and psychological stability
5. Building skills that will help victims regain a sense of personal power and control
over their lives
6. Educating the client on the nature of the crime victimization so they know what to
expect
7. Reconditioning victims to minimize negative triggering of the traumatic incident
8. Helping victims through the mourning process
9. Seeking resolution and closure, which leads to personal growth and allows the vic-
tim to regain the confdence and strength to trust people once again
By focusing on these core issues, as well as addressing the factors and needs specifc
to each type of crime victimization, the human service professional will be instrumental
in fostering healing and growth in victims of crime so they can begin the process of see-
ing themselves no longer as victims but as true survivors.
Perpetrators of Crime
Forensic human service professionals working in the criminal justice arena ofen work
with victims, but they may also work with ofenders or perpetrators of crime. Direct
practice with ofenders might occur in an agency setting that ofers mandated programs,
such as batterers programs discussed earlier in this chapter, programs for alcoholics
with drunken driving convictions, or group therapy for pedophiles. Many work within
the criminal justice system in probation departments or juvenile justice programs, and
many work in programs that facilitate outreach eforts focusing on gang members, re-
cently released prisoners, or individuals who are at risk for continued criminal activity.
Gang Activity
Gangs consist of groups of individuals who actively participate in criminal activi-
ties on an organized or coordinated basis. Gang activity has become an increasingly
severe problem in recent years, not only with regard to the number of gangs in op-
eration within the United States (estimated to be somewhere between 700,000 and
800,000 nationwide), but also with regard to the type of violent activities in which
many gang members participate. Gang activity remains primarily a big-city phe-
nomenon, with some of the larger cities having more than 30 gangs operating at one
time (National Youth Gang Center, 2005). Smaller towns and rural communities also
Violence, Victim Advocacy, and Corrections 353
experience gang problems, but these tend to be relatively sporadic with gangs that
are loosely organized.
Gang members not only commit crimes such as thef and drug trafcking to support
gang activity, but some of the most serious crimes committed by gang members involve
turf wars where one gang is in confict with another, leading to gang fghts that ofen in-
clude both assaults and homicides. In some inner-city communities drive-by shootings
are a way of life, and parents respond by keeping their young children of the streets and
away from windows.
Most gang members are between the ages of 13 and 25, but some studies found
gangs that have members as young as 10. Most gang members come from backgrounds
of poverty and racial oppression, live in high-crime urban communities, and live in
neighborhoods with high gang activity (Vigil, 2003). Although there has been a recent
increase in female gang activity (Chesney-Lind, 1999), most gangs are still primarily
comprised of males.
Risk Factors of Gang Involvement
Tere are several theories regarding why adolescents join gangs. Most sociological and
anthropological theories focus on the sense of solidarity and feelings of belonging that
gangs can provide disenfranchised youth. Identifying risk factors is important so that
efective intervention strategies can be developed and put into action.
A comprehensive study facilitated by the DOJ evaluated the gang membership and
backgrounds of over 800 gang members from 1985 to 2001 in an attempt to identify
some of the reasons why adolescents join gangs. Tis study, referred to as the Seattle
Social Development Project, confrmed that the majority of gang members are men
(90 percent) and that gang members came from diverse ethnic backgrounds includ-
ing Caucasian (European American), Asian, Latino, Native American, and African
American, with African Americans having the highest rates of gang membership. Inter-
estingly, the study found that the majority of gang members joined for only a short time,
with 70 percent of youths belonging to a gang for less than a year (Hawkins et al., 2003).
Te study identifed multiple risk factors for gang membership, including living in
high-crime neighborhoods, coming from a single-parent household, poverty, parents
who approved of violence, poor academic performance, learning disabilities, little or no
commitment to school, early drug and alcohol abuse, and associating with friends who
commit delinquent acts. Te studys authors recommended early prevention eforts that
target youth with multiple risk factors. Programs need to focus on all aspects of the ado-
lescents life, including family dynamics, school involvement, peer group, and behavioral
issues such as drug and alcohol abuse as well as any antisocial and delinquent behaviors.
What this study seems to underscore is that for youth with multiple risk factors gang
membership may be less an option and more a way of life. Adolescents who are fortu-
nate enough to have cohesive families, where high-functioning parents work hard to
maintain structure, provide accountability, and keep teens engaged in positive activities,
can ofen help adolescents avoid the temptation to join a gang. Tis is particularly true
for black youth living in large urban areas (Walker-Barnes & Mason, 2001).
354 Part II / Generalist Practice and the Role of the Human Service Professional
Adolescents without the beneft of such positive infuences, including those who
have neglectful and uninvolved parents, ofen face a reciprocal pull into gang life where
they are targeted by existing gang members who recognize the existence of these risk
factors, and the adolescents themselves are drawn to gang life because of the benefts
gangs appear to provide such as a sense of belonging, a life of excitement, and the feeling
of empowerment.
Human Services Practice Settings Focusing on Gang Involvement
Human service professionals who work with gang populations may do so on school
campuses, in agencies that target at-risk youth, in faith-based outreach agencies, at po-
lice departments, or within the juvenile justice system. Most outreach programs target
adolescents who live in large urban communities where gang activity is prolifc and vio-
lent behavior a fact of life, especially those who come from single-parent homes, have
poor academic histories, and have shown early signs of delinquent behaviors. Human
service professionals also target social conditions on a macro level such as poverty, rac-
ism, and the lack of opportunities in urban communities, because these factors contrib-
ute to the development of gang activity.
Many human service programs that target at-risk adolescents operate afer-school
programs or evening community programs that give adolescents a place to go to social-
ize other than the streets. Tis is particularly important for youth who are in search of
a sense of cohesion, security, and social belongingness, elements that might be missing
from their home life. In light of the research indicating that most gang members have
relatively loose, short-term afliation with gangs, these types of programs have the po-
tential of being successful in steering even active gang members away from gang life.
Finally, human service programs committed to reducing the gang problem must
be willing to engage in active and aggressive outreach eforts, maintain a highly visible
presence in the community, coordinate services with other gang intervention programs,
and be willing to engage at-risk adolescents and their family on multiple levels.
Human Services in Prison Settings
Te human services profession has a long history of association with the criminal jus-
tice system, most notably working in jails, prisons, government probation departments,
police departments, and agencies ofering services to recently released ofenders. Hu-
man service professionals working within the criminal justice system may be employed
as prison or correctional psychologists who conduct psychological evaluations on re-
cently charged defendants or who provide assessment or counseling to ofenders within
the prison system. Tey may be licensed social workers who provide counseling and
facilitate support groups focusing on various treatment issues designed to reduce recidi-
vism (the process of relapsing into criminal behavior). Tey may be probation ofcers
charged with the responsibility of coordinating treatment and supervising the ofenders
compliance with the conditions of probation (e.g., entering a drug treatment program,
obtaining counseling, attending an anger management program, or completing com-
munity service), or they may be bachelors level correctional treatment specialists or
Violence, Victim Advocacy, and Corrections 355
case managers who provide general counseling to the prison popula-
tion, assisting them prepare for release and reentry into society.
Human service professionals may also work on a community level
advocating for prison reform such as the development of mental health
courts, substance abuse treatment programs in prisons, or increased
mental health services for mentally ill prisoners. Tus, although this feld
of service is broad, the clinical issues are specialized, requiring training
focusing on the common issues facing ofenders both within prison and
on release.
The U.S. prison system is plagued with violence including sexual assaults, drug
problems, and mental illness. Human service professionals working within the area of
corrections will likely encounter a wide range of issues that vary with the level of incar-
ceration security, the gender and race of the prisoners, and the culture and climate of the
specifc prison. One of the chief problems afecting prisons across the country relates to
the problem of overcrowding, with most state and federal prisons operating at either full
or over capacity (Harrison & Beck, 2003). In an environment already wrought with ten-
sion, overcrowding can be the ingredient that leads to increased violence against both
inmates and correctional staf.
The War on Drugs
Many people might be surprised to learn that violent crime in the United States has
steadily declined since the early 1990s. Homicides, rapes, assaults, robberies, frearms-
related crimes, and even violent juvenile crimes have all plummeted in recent years,
yet the population in prisons and jails across the country has skyrocketed. In fact, the
United States has the highest prison population of any country in the world (Walmsley,
2003). So what is to account for this seeming contradiction? Why, when virtually all
forms of violent crime are on a downhill slide for many years, is the nations prison sys-
tem experiencing such a dramatic increase in population? Many social scientists agree
that the primary reason for prison overcrowding relates to the U.S. War on Drugs.
In fact, approximately 55 percent of all federal prisoners are incarcerated for drug-
related ofenses (Harrison & Beck, 2003), and 80 percent of the increase in prisoners in
the federal prison system between 1985 and 1995 is related to increased convictions of
drug-related ofenses (Bureau of Justice Statistics, 2004).
Te U.S. war on drugs might seem like a good policy on the surface. Certainly no
one would argue that the using and selling of illicit drugs is good for the American
public. But many argue that the federal governments aggressive policies related to the
prosecution and punishment of drug ofenders unfairly targets poor, young ethnic mi-
norities, many of whom are serving extremely long prison sentences due to minimum
federal sentencing guidelines (sometimes 20 years to life), despite not committing any
violent crime (Human Rights Watch, 2000a).
Human service professionals should be concerned about any governmental policy
that either directly or indirectly targets a certain segment of the population. Te war
on drugs appears to do just this, evidenced by the signifcant overrepresentation of eth-
nic minorities, particularly African American men, within the federal and state prison
A key goal of the criminal justice
system is to reduce recidivism; thus,
success in terms of treatment is
often focused on whether a prisoner
once released reoffends and returns
to prison.
356 Part II / Generalist Practice and the Role of the Human Service Professional
system (Human Rights Watch, 2000b). Whether by design or not, one must ask why the
U.S. government has not waged a War on Domestic Violence and a War on Child
Sexual Abuse, two social ills that have seriously negative consequences for U.S. society
and that would target ofenders across all socioeconomic levels and
racial groups.
Human service professionals working within the U.S. criminal
justice system must be aware of potentially unfair political policies
to develop a truly objective perspective of social conditions lead-
ing to the overrepresentation of minorities in correctional facilities,
the reasoning behind sentencing guidelines for various criminal of-
fenses, even identifying social infuences that tend to hold one be-
havior in a particular era as socially acceptable, only to criminalize it
several decades later.
For instance, determining what drugs are socially acceptable and
which ones are not is infuenced by constantly shifing social mores.
During the Prohibition era the use and sale of alcohol was consid-
ered criminal, yet today it is considered perfectly socially acceptable.
Thus, there is a temporal aspect to the criminalization of certain
behaviors, and it is vital that human service professionals recognize
this dynamic.
Clinical Issues in the Prison Population: The Role of the
Human Service Professional
Te issues confronting human service professionals working within the criminal justice
system, particularly within a correctional facility, will vary depending on the gender,
race, and type of crime committed by the defendant. A key goal of the criminal justice
system is to reduce recidivism, thus success in terms of treatment is ofen focused on
whether a prisoner once released reofends and returns to prison.
MENTAL HEALTH PROGRAMS IN CORRECTIONAL FACILITIES Behavioral
programs within prisons can focus on many clinical issues, some related to criminal
behavior and some related to other issues the inmates might be experiencing. Pro-
grams related to criminal behavior typically focus on issues such as drug abuse, sexual
violence, domestic violence, anger management, and the development of social skills
(for prisoners with antisocial tendencies). Programs designed to address psychosocial
issues not directly related to criminal behavior typically focus on grief and separa-
tion issues, sexual abuse victimization (particularly for female inmates because a large
proportion of the female inmate population has been the victim of sexual violence
at some point in their lives), self-esteem, and issues related to the impact of being
incarcerated.
PRISON AND PREGNANCY Female inmates are ofen incarcerated for ofenses re-
lated to drug addictions (writing bad checks, petty thef, prostitution, etc.), and those
who are pregnant or parenting ofen have to rely on the county foster care system for
Human Systems
Understanding and Mastery of Human
Systems: Processes to effect social change
through advocacy
Critical Thinking Question: At first
glance, the War on Drugs appears to
be a beneficial social policy; however, on
further inspection it turns out that this
policy is having the effect of putting large
numbers of young, ethnic minority men
in prison for long periods of time for
nonviolent drug offenses. How might a
human service professional advocate on
behalf of the populations disproportion-
ately affected by the War on Drugs?
Violence, Victim Advocacy, and Corrections 357
the care of their children during their incarceration (Siefert & Pimlott, 2001). Human
service professionals working in a correctional facility will likely encounter women
(particularly women of color) who are grieving over the loss of their children or are an-
ticipating their loss once they give birth. One of the roles of human service professionals
is to work with outside agencies that can arrange to transport children to see their incar-
cerated mothers to maintain the motherchild bond. Parenting issues are ofen explored
as well as the impact of drug abuse during pregnancy, with the goal of maintaining close
family ties and reducing the incidence of prenatal damage and infant mortality related
to drug use during pregnancy.
Some prisons have grant-funded programs that provide intensive prenatal care, nu-
trition counseling, substance abuse treatment, and individual and group counseling.
One such program is called the Women and Infants at Risk (WIAR), which helps moth-
ers break intergenerational cycles of abuse, giving infants the best start in life possible.
Tis is particularly important in light of how the cards are already stacked against
infants who are born behind prison walls (Siefert & Pimlott, 2001).
SEXUALLY TRANSMITTED DISEASES AND AIDS Another signifcant issue ofen
confronting both inmates and human service professionals involves the high rate of
infectious diseases that exists within the prison population, made worse by the ongoing
problem of sexual assaults. Diseases such as hepatitis B and hepatitis C are prevalent
in some prisons, and HIV/AIDS remains a serious concern among prisoners and
correctional staf alike. A 2002 report by the National Commission on Correctional
(NCCHC) indicated that the incidence of AIDS in the U.S. prison population is fve
times that of the general population, and the primary method of transmission is sexual
assault ( Robertson, 2003).
Te fear of being raped is the number one fear among men serving time in prison,
and although no one is certain of the exact number of male-on-male sexual assaults
within the prison system, it is estimated that between 7 and 12 percent of the male
prison population have been a victim of sexual assault while incarcerated, although
the actual number is presumed to be much higher (Human Rights Watch, 2001), with
many prisoners sufering multiple rapes throughout their incarceration. Tis issue is
of such signifcant concern that in 2003, President George W. Bush signed an act ap-
propriating $13 million to fund rape prevention programs within the prison system
(Robertson, 2003).
Barriers to Treatment
One complaint among mental health providers in correctional settings is the under-
funding and understafng of mental health programs ofen experienced in many jails
and prisons across the country. Developing efective and comprehensive mental health
services within correctional facilities is an important aspect of eforts to reduce recidi-
vism rates among the prison population, but the U.S. criminal justice system is punitive
in nature and not based on a rehabilitation model; thus mental health programs are
ofen not a priority within the criminal justice system, evidenced by a consistent lack of
funding, understafng, and limited outreach.
358 Part II / Generalist Practice and the Role of the Human Service Professional
Yet even in prisons that have sufcient mental health services, bar-
riers still exist that ofen prevent prisoners from accessing these ser-
vices. A 2004 study surveying prisoner attitudes about mental health
services identifed several perceived barriers to service, including be-
ing uncertain how or when to access counseling, a belief that mental
health services are for crazy people, the lack of confdentiality in-
volved in the counseling relationship with a fear that the information
shared would later be used against them, a fear that other prisoners
would believe they were a snitch, a belief that people should deal with
their own problems, a preference for talking with friends and family
rather than a professional counselor, and having had a past bad expe-
rience with counseling (Morgan, Rozycki, & Wilson, 2004).
Human service professionals need to be aware of these common
perceptions held by prisoners so that strategies can be designed to
overcome both real and perceptual barriers to seeking mental health
counseling. Although many of these negative perceptions held are
common among the general population as well, many are related
to being in custodial care where prisoners personal rights are ex-
tremely limited by necessity.
Concluding Thoughts on Forensic Human Services
Working within the criminal justice system ofers rich opportunities for human service
professionals at all education levels. Te opportunity to interact with several other ad-
vocacy organizations and to coordinate services with agencies ofering complementary
services provides the human services professional with a broad range of professional
experiences. Human service professionals provide counseling, case management, and
advocacy to both victims and ofenders, thus making a diference in the lives of the
members of society most in need.
Victims of violent crime such as domestic violence, sexual assault, and other violent
crimes need advocacy and counseling to turn tragedy into triumph and powerlessness
into empowerment. Human service professionals are on the front lines of bringing is-
sues formerly kept in the dark out into the open, removing stigmas, and creating change
that makes survivors out of victims.
Criminal activity and subsequent incarceration leaves long-lasting scars on the fam-
ilies of ofenders, ofen plunging them into a cycle of poverty and social isolation. Tis
process signifcantly increases the likelihood of creating an intergenerational pattern of
incarceration, thus some of the most important work that forensic human service pro-
fessionals do involves working with the family members of prisoners, particularly chil-
dren who not only feel abandoned by their incarcerated parents but ofen are forced to
enter the foster care system if no family members are available to care for them.
Rehabilitation offers the most hope of lowering recidivism rates among the
prison population, yet a correctional philosophy that incorporates rehabilitation is
Human Services
Delivery Systems
Understanding and Mastery of Human
Services Delivery Systems: Range and
characteristics of human services delivery
systems and organizations
Critical Thinking Question: Providing
human services to incarcerated individu-
als is a distinctly different experience
from working with clients in contexts
other than the criminal justice system,
and even different from working with
those who are court-mandated to at-
tend treatment but who are not in jail.
How might a human service professional
adapt her/his methods of service deliv-
ery to best meet the special needs of
incarcerated clients?
Violence, Victim Advocacy, and Corrections 359
controversial because in the eyes of many in the general public, counseling and other
mental health programs feel too much like a luxury, not deserved by those who have
committed crimes. Yet not only are prisoners not a homogeneous group (i.e., many
prisoners have been incarcerated for relatively minor offenses), but those who have
committed the most serious ofenses are in many cases those who need mental health
services the most. Unfortunately, mental health programs are ofen the frst to be cut
from state and federal budgets because on the whole the prisoner population does not
garner much sympathy within the general public. For this reason it is imperative that
human service professionals advocate for the basic rights and needs of prisoners, as they
do with all vulnerable populations.
360
1. Human service professionals who work in practice
settings dealing with domestic violence, sexual as-
sault, gang activity, and criminal justice agencies such
as police departments, probation, state and county
prosecutor offce, and within correctional facilities
are considered:
a. criminal justice social workers
b. forensic human service providers
c. criminal justice human service workers
d. Both A and C
2. Domestic violence includes
a. violence between heterosexual intimate partners
b. violence between same sex partners
c. violence between siblings
d. All of the above
3. Approximately ____ percent of sexual assault victims
knew their assailant.
a. 12
b. 32
c. 70
d. 55
4. Myths about rapists include assertions that
a. only truly evil or insane men commit rape
b. men just cannot control their sexual desires
c. all men rape women
d. Both A and B
5. Most victims and victim advocates state that a pri-
mary goal of the victims movement is to ensure that:
a. crime victims have a voice within the community,
specifcally within the criminal justice system
b. the rights of defendants are minimized
c. defendants charged with violent crimes are not
released on bond
d. All of the above
6. Risk factors of gang membership include all but the
following:
a. living in high crime, impoverished neighborhoods
b. coming from a single-parent household
c. having signifcant health problems early in life
d. poor academic performance and/or learning
disabilities
CHAPTER 14 PRACTICE TEST
The following questions will test your knowledge of the content found within this chapter.
7. What is the War on Drugs? Has this government policy and approach to drug enforcement been successful
in stemming the drug trade? Why or why not? What have social advocates cited as complaints about this set of
policies?
8. Describe the roles and functions of human service providers working within prison settings. Provide some key
demographic information of inmates, including female inmates. Include ways in which recidivism rates can be
lowered.
Suggested Readings
Lord, J. H. (1990). No time for goodbyes: Coping with sorrow, anger and injustice after a tragic death. Ventura, CA: Pathfinder
Publishing.
Internet Resources
American Civil Liberties Union: http://www.aclu.org
Family Violence Prevention Fund: http://endabuse.org
Legal Services for Prisoners with Children: http://
prisonerswithchildren.org/index.htm
National Center for Victims of Crime: http://www.ncvc.org/
ncvc/Main.aspx
National Coalition against Domestic Violence: http://www.
ncadv.org
Violence, Victim Advocacy, and Corrections 361
National Organization for Victim Assistance: http://www.trynova.org
Office for Victims of Crime: http://www.ojp.usdoj.gov/ovc
Prisoner Policy Initiative: http://www.prisonpolicy.org/index.html
Rape, Abuse & Incest National Network (RAINN): http://
www.rainn.org
YWCA: http://www.ywca.org
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363
Learning Objectives
Recognize current and historic
disenfranchised populations
and understand societal condi-
tions and dynamics that render
groups vulnerable to abuse and
exploitation
Understand the various aspects
of macro practice such as com-
munity development, community
organization, and policy practice
Become familiar with the nature
of globalization and its affect on
the human service profession
Identify major human rights
violations such as crimes against
women and children, indigenous
populations, labor violations, the
effects of civil war, and genocide
Identify some of the ways in
which the international com-
munity responds to global crises
and international human rights
violations
Macro Practice and
International Human
Services
When students consider entering the feld of human services, they ofen
do so because they want to help people meet their basic needs by coun-
seling them, helping them obtain much-needed services, and teaching
them to learn new ways of meeting their needs in the future. In other
words, most students think of direct clinical practice with individuals
and families when considering a career in the human services profession.
But many times the personal troubles a client is encountering are being
caused by some external sourcean injustice that is structural or sys-
temic such as the school system that ofers no bus service and therefore
inadvertently contributes to low-income students truancy rates, or a gov-
ernment social welfare policy that inadvertently punishes single mothers
who work part-time by cutting their benefts, or a three-strikes law that
sends a young man to jail for 25 years for a third, yet relatively minor,
ofense. How does the human service professional combat harmful poli-
cies that punish when they should reward or unfair legislation that hurts
certain segments of the population?
Te human services profession is grounded in the notion that people
are a part of larger systems and to truly understand the individual one
must understand the broader system this individual is operating within.
Te discussion of Bowens Family Systems Teory in Chapter 4 is a good
place to start in understanding how systems work, noting that there is a
reciprocal dynamic involving both the individual and the system, where
each has an impact on the other. Hence, an individual can receive years
of counseling, but until structural defciencies are addressed, they will
continue to experience difculty in some manner.
Since when do you have to agree with
people to defend them from injustice?
Lillian Hellman
CHAPTER 15

UNHCR/J. Wreford
364 Part III / Macro Practice, International Human Services, and Future Considerations
It is important, then, for human service professionals to rec-
ognize that people can be helped by approaching problems on
various levels. By way of comparison, if as a human service pro-
fessional you were committed to eradicating violence within society,
you might choose to work with victims of domestic violence in
the hope that counseling them might help your clients recognize
the signs of abuse and avoid engaging in abusive relationships
in the future. Tis approach would involve micro practiceprac-
tice with individuals. You might also decide to facilitate treatment groups for batterers,
believing that the greatest likelihood of change can be accomplished by addressing the
perpetrators of violence in a group setting where each group member can learn from
others. Tis approach would involve mezzo practicepractice with groups.
But, if you decided to address the problem of violence by working with an entire
community, locally, nationally, or perhaps even globally, by creating a new program
in your agency, by conducting a public awareness campaign to educate the population
about the prevalence of violence, or by lobbying for the passage of antiviolence legisla-
tion, then you would be conducting macro practicepractice with communities and
organizations.
Macro practice involves addressing and confronting social issues that can act as a
barrier to getting ones basic needs met on an organizational level by creating structural
change through social action. Te most basic themes involved in macro practice include
advocating for social and economic justice and human rights for all members of society
to end human oppression and exploitation (Weil, 1996). Tere are several ways social
change is accomplished through macro practice, including program development, com-
munity development through community organizing, policy practice, and international or
global advocacy.
Tus, although direct clinical practice is important, working with entire systems to
promote positive structural change on all fronts is equally important. Some human ser-
vice professionals work solely in macro practice in administrative positions or policy
practice conducting no direct practice whatsoever, but a great many human service pro-
fessionals who are involved in micro practice are also involved in macro practice on
at least some level. For instance, when I worked as a victim advocate for a local states
attorneys ofce, I counseled victims of violent crime. But I also served on a domes-
tic violence advisory coalition that evaluated community concerns and interagency
coordination.
Why Macro Practice?
Human service professionals might ask themselves why they should be concerned about
what is happening to people in an entire community, in a diferent part of the coun-
try, or in a completely diferent part of the world. But a foundational value of the hu-
man services profession is a commitment to social justice and human rights achieved
through social action and social change. Tis is particularly relevant to human service
professionals living in the United States in light of the fact that many clients in need
The human services profession is
grounded in the notion that people
are a part of larger systems and to
truly understand the individual one
must understand the broader system
this individual is operating within.
Macro Practice and International Human Services 365
of human services assistance have emigrated from countries where they were victims of
oppression and human rights violations. Tis requires an understanding on the part of
the human service professional of the wide range of global abuses related to social injus-
tice and human rights abuses, as well as recognizing how these abuses have implications
on direct practice with individual clients.
Human service professionals must also be aware of the history of social injustices
and human rights abuses that have occurred within U.S. borders as well as develop an
awareness of what groups are most likely to be targets of discrimination and oppres-
sion. For instance, Calkin (2000) discussed the abuse and oppression of minorities and
the poor within the U.S. criminal justice system and the importance of human service
professionals accepting a call to social action:
Moment by moment in the practice process, there are opportunities to recognize
and support, or to ignore, the power that people bring or could bring to their lives
and communities. Tere are opportunities to act respectfully toward someone for
whom that is so uncommon, or not toand to acknowledge when we really cant
understand, to acknowledge the errors of sensitivity we make so ofen. Human
services organizations and professionals can easily be seduced into colluding with
violations of human rights, ranging from disrespect toward people already strug-
gling with mental illness or substance abuse to acceptance or resignation in the
face of deprivations of basic human rights. (p. 2)
Tis foundational commitment to social justice is so integral to the human ser-
vices profession that the professional obligation to social action is refected in the eth-
ical principles of the discipline. For instance, the National Organization for Human
Services (NOHS) (1996) ethical standards reference the human service professionals
responsibility to society, which includes remaining aware of social issues that impact
communities, and initiating social action when necessary by advocating for social
change. Te National Association of Social Workers (NASW) (1999) ethical standards
go one step further by expanding the social workers responsibility to the international
level stating that [s]ocial workers should promote the general welfare of society, from
local to global levels, and the development of people, their communities, and their
environments (p. 26).
Unfortunately, the human services profession has gradually moved away from its
original call to community action, turning instead to a model of individualized care
(Mizrahi, 2001). Tis is likely due to an increased focus on the increasing popularity of
individual psychotherapies within all the mental health professions in the 20th century.
Tis doesnt mean that macro practice or social advocacy has ceased. Rather, as those
in the human services felds have pulled away from community work, other disciplines
have moved in to fll the vacuum, such as urban and public planners and those in the
political sciences. Tis pattern has resulted in the human services profession ofen being
out of the loop of community building and organizing eforts (Johnson, 2004). Con-
cerns have also been expressed regarding the trend of neglecting the subject of macro
and community practice in human services and social work educational programs, thus
compounding the tendency for human service professionals to avoid macro practice
366 Part III / Macro Practice, International Human Services, and Future Considerations
because many recent graduates feel ill equipped to enter into social advocacy or policy
practice on an organizational level (Polack, 2004).
Tis movement away from macro practice is apparently an international trend as
well because studies generated outside the United States have made some similar ob-
servations. For instance, Weiss (2003) cited examples of how many human service pro-
fessionals in Israel do not feel competent addressing social issues on a community or
global level because the majority of their training focused on practice with individual
clients. Weiss encourages those in the human services professions both in Israel and
abroad to reengage in policy-related activities and social advocacy on a macro level.
Te reality is that social issues such as poverty and human exploitation must be ad-
dressed through advocacy eforts for social change on a macro level as well as a micro
level to create much-needed structural changes. Infuencing changes in social policy
that afects public aid (such as welfare reform legislation), mental healthcare (such as
mental health parity laws), and even domestic violence issues (such as policies that
mandate cooperation between criminal justice agencies and battered womens shelters)
are an integral aspect of human services that directly afect clients daily lives.
At-risk and Oppressed Populations
Before beginning any discussion on social advocacy efforts it is important to identify
populations that are ofen the target of social injustice, oppression, and human rights vio-
lations. It is challenging to comprise a comprehensive list of at-risk populations because
there is some shifting in oppressed people from era to era. For instance, Chapter 5
discussed how children although still quite vulnerable are no longer considered an
oppressed group in the same way that they were around the turn of the century when
poverty and harsh economic conditions led to thousands of children fooding the streets
of New York, leading to a signifcant reduction in sympathy toward orphaned children.
In essence, an at-risk population can include any group of individuals who are vul-
nerable to exploitation due to lifestyle, lack of political power, lack of fnancial resources,
and lack of societal advocacy and support. Currently, at-risk and oppressed populations
include ethnic minorities, immigrants (particularly those who do not speak English),
indigenous people, older adults, women, children in foster care, prisoners, the poor, the
homeless, single parents, lesbians, gays, bisexual transgendered individuals, members of
a religious minority, and the physically and intellectually disabled. In addition, in many
regions of the world certain groups of individuals are selected and
oppressed due to their ethnic background, religious heritage, and
caste (their level of status within society, which in many regions of
the world is a level one is born into), and although these individ-
uals may not be in the minority as far as numbers, they typically
have little to no political power and are subject to mistreatment and
exploitation.
At-risk populations often share unique characteristics not
shared by others within a particular culture (within mainstream population and/
or those in the majority) (Brownridge, 2009), and it is this uniqueness that can ofen
increase their risk of oppression, discrimination, injustice, and exploitation. At-risk
An at-risk population can include
any group of individuals who are
vulnerable to exploitation due to
lifestyle, lack of political power, lack
of fnancial resources, and lack of
societal advocacy and support.
Macro Practice and International Human Services 367
populations are thus at greater risk of experiencing a variety of social problems than
other populations within the mainstream of society, which undoubtedly then afect the
broader population (even if those in power do not believe so).
Vulnerability increases with what is called intersectionalitywhere an individual pos-
sesses more than one social and cultural vulnerable characteristic, leading to increased
risk of disadvantage. Te concept of intersectionality was originally applied to race and
gender; the concept is now applied to a variety of marginalizing categories in addition to
gender and race, such as level of disability, sexuality, socioeconomic status, social class,
immigration status, nationality, and family status (Knudsen, 2005; Meyer, 2002; Samu-
els, 2008). An example of intersectionality of vulnerability would be an African Ameri-
can older lesbian who is economically disadvantaged, physically disabled, and struggling
with homelessness. This profile reveals a woman who experiences
multiple forms of vulnerability to injustice on a variety of levels, likely
needing various types of advocacy (Martin, in press).
Social forces can combine as well, increasing the risk of dis-
crimination, prejudice, oppression, and injustice. For instance, social
conditions such as white privilege (advantage experienced by Cau-
casians to varying degrees), nativism (a bias against foreign-born
residents or those who are perceived as threats to a countrys nation-
alism), xenophobia (an irrational fear of immigrants and foreigners),
and other forms of prejudice ofen combine to increase a groups vul-
nerability to oppression, marginalization, and exploitation (Martin,
in press). Within the human services feld there is a recognition that
at-risk populations ofen need advocacy because many of the chal-
lenges that lie before them are created within society through poli-
cies, laws, and attitudes that create an uneven playing feld, where
some groups enjoy greater access to benefits (often referred to as
privilege) whereas other groups are systematically excluded from
such societal benefts.
A Human Rights Framework: Inalienable Rights
for All Human Beings
Before human service professionals can effectively engage in work on a macro level,
whether doing community organizing or more direct social justice advocacy on behalf
of at-risk and oppressed populations, they must frst become aware of what a just society
looks like. What is an ideal society? At the root of any discussion of an ideal society is the
assumption that all human beings have inalienable rights simply because they are human.
Yet, history is replete with examples of egregious human rights violations, ofen waged in
the belief that such actions are justifed on some level. Slavery, a caste system that deems
one group of people more worthy than another, a patriarchal system that subjugates fe-
males within society, the genocide or ethnic cleansing of a particular cultural group, and
the sale and exploitation of women and children are all examples of the gross mistreat-
ment of individuals, ofen because there is some defning characteristic about these in-
dividuals that makes them diferent from another group. Such diferences are ofen used
to justify their mistreatment, where members of a more powerful group place themselves
Human Systems
Understanding and Mastery of Human
Systems: An understanding of capacities,
limitations, and resiliency of human
systems
Critical Thinking Question: Inter-
sectionality refers to the combined
influence on an individual of two or
more characteristics that place her/him
in an at-risk population: for example,
being Native American AND being
female. How can human service
professionals use their understanding
of the concept of intersectionality to
guide their treatment of, and advocacy
for, such clients?
368 Part III / Macro Practice, International Human Services, and Future Considerations
above the members of a more vulnerable group. Members of a just society recognize that
no one group should have oppressive power over another, and that all human beings have
basic rights that must be protected. Since some groups of individuals are more vulnerable
than others, human service professionals working in macro practice, particularly on an in-
ternational level, take responsibility for being the voice of the voiceless (Martin, in press).
In the next few sections I will explore some ways in which human service profes-
sionals engage in practice on a macro level, including community development, com-
munity organizing, and policy practice. Tese areas of macro practice are quite general,
and youll likely notice that there is quite a bit of overlap between each of these areas, but
gaining at least a cursory understanding of the diferent types of macro practice is impor-
tant so that you can better understand how human service professionals work goes from
identifying social problems within society to fnding ways of efectively addressing them.
Mobilizing for Change: Shared Goals of Effective
Macro Practice Techniques
Macro practice is a multidisciplinary feld shared by those in the human services, social
sciences, political sciences, and urban planning disciplines. Within the general feld of
macro practice, models have been developed to frame the various ways of approaching
social concerns on a broad level. Although there is a very broad range of theories and
models of macro or community practice, most models have at their core the basic goal of
societally based social transformation where a community on any level (local, national, or
global) incorporates values that refect the human dignity and worth of all its members.
Within most macro practice models empowerment strategies are used that focus on
social and economic development, creating liaisons between community members and
community organizations, political and social action, which will likely involve advocat-
ing for policy changes that address injustices and inequalities within society (Netting,
Kettner, & McMurtry, 2009). Various aspects of macro practice will vary depending on
the area of concern and the vulnerable population being targeted, but virtually all mod-
els of macro practice include a focus on community development, which can refer to the
development of a geographic community, such as a neighborhood or city, or a commu-
nity of individuals, such as women, immigrants, or children.
Common Aspects of Macro Practice
COMMUNITY DEVELOPMENT Community development dates back to the settle-
ment house movement when Jane Addams and her colleagues worked with politicians,
various community organizations, political activists, and community members to cre-
ate a better community for all members. Addams was personally concerned with child
labor, compulsory education, rights of immigrants, and voting rights for woman (wom-
ens sufrage). By engaging residents, community leaders, local politicians, and other
community organizations, Addams was able to develop a sense of community cohesion,
which resulted in several laws being passed that benefted the members of her commu-
nity, including those who resided in the settlement houses.
Macro Practice and International Human Services 369
Community development in Addamss day is similar in many respects to today,
where efective community building depends on the participation of community or-
ganizations and community members working together to address issues that are of
concern to the entire community (Austin, 2005). Te actual issues involved could be
anything from addressing crime in the community to educational concerns such as low
state test scores, developing an afer-school program to combat juvenile delinquency,
bringing new businesses to the community to create jobs for community members, or
rallying community leaders to develop more open spaces, including parks in densely
populated neighborhoods.
A community development approach is empowering because the mutual collabora-
tion of several agencies and area organizations provides support for community mem-
bers in ways not possible through human service agencies alone. Another empowering
aspect of community development is that the collaboration process can create a sense
of collective self-sufciency that ofen leads to civic pride for community members. In
fact, efective community development is based on the conviction that any community
is capable of mobilizing economic, social, and political resources to support families
(Austin, 2005, p. 109).
Tere are several necessary components of successful community development, in-
cluding diversity among group members, a sense of shared values among members, pos-
itive and collaborative teamwork, good communication, equal participation of all team
members, and a good network of connections outside the community (Gardener, 1994).
Good community development also depends on the ability to secure enough funding to
support group members activities and eforts. Good networking skills are also essential
as are good technology skills because so much of networking in contemporary society is
accomplished through email and other technological means (Austin, 2005; Weil, 1996).
COMMUNITY ORGANIZING Community development depends on the eforts of
community organizing eforts, which in turn depends on the eforts of community or-
ganizers. Te frst step in community organizing is to create a consensus on what the
community needs, in particular what negative issues the community is facing or ar-
eas of needed improvement. Once community members agree on the problems to be
addressed, community organizers set about to recruit members to join in the efort to
create change. It is important to once again note that the term community does not nec-
essarily refer to a geographic community, but might also refer to a community of people,
such as women, victims of domestic violence, prisoners, or foster care children.
Community organizers can be professional policy makers or licensed social work-
ers, or they can be individual people with a particular passion and calling for social ac-
tion. A schoolteacher who gets a group of his students together to remove grafti from
public buildings is a community organizer. Te single mother of three who organizes
a voluntary afer-school tutoring program for the kids in her neighborhood is a com-
munity organizer. Te father of a child victim of sexual abuse who organizes a campaign
to increase prison time for sexual ofenders is a community organizer. Te licensed so-
cial worker whose agency is hired to canvas a neighborhood in an antidrug educational
campaign is a community organizer.
370 Part III / Macro Practice, International Human Services, and Future Considerations
Community organizing eforts usually begin around a problem or concern of many
people in a community. Once a problem has been identifed, community organizers
must conduct research to defne the issues, understanding how the problem or issue
developed and what if any forces exist to keep the problem in place. For instance, the
community activist who is organizing eforts to increase the labor rights of undocu-
mented immigrants will likely encounter opposition from factory owners who beneft
by paying untaxed low wages to undocumented workers. Toroughly researching this
issue will enable community organizers to identify constituents in the community who
will support their cause as well as those who will oppose it. Research will also enable
community organizers to identify additional harm done by unfair labor practices not
initially identifed that might increase the strength of any collating forces.
Once the problem has been identifed and research has been conducted, a plan of
action must be determined based on the research conducted. Community organizers
might decide to picket factories where they perceive abuse of undocumented workers;
they might decide to distribute press releases and have a press conference to gain media
involvement, organize a work walkout, or conduct a letter-writing campaign to local
political leaders. Successful community organizers also organize fund-raising eforts to
support their social activism. Sources of fund-raising can include a number of strategies
including a direct request for donations, auctions, fund-raising dinners, membership
fees, or government grants.
POLICY PRACTICE Policy practice is a more narrow form of community practice
where the human service professional works within the political system to infuence
government policy and legislation on a local, state, federal, or even global level. Te
form that policy practice takes depends in large part on the issues at hand, but certain
activities in policy practice are consistent despite the issue. Tis is a relatively new feld
within human services, with few researchers focusing on policy practice prior to the
1980s. It remains an ofen neglected area of practice, both within human services and
social work education and within human services practice setting. One reason for this
may be that efective policy practice relies on a broad range of skills that reaches far
beyond the clinical realm (Rocha & Johnson, 1997).
Policy activities center on either reforming current social policy or initiating the de-
velopment of new policy that addresses the needs of the underserved and marginalized
members of society with the primary goal of social justice through social action and ad-
vocacy. Policy practice is based on the belief that many problems in society, such as pov-
erty, are structural in nature and can be addressed through making structural changes
within society (Weiss, 2003).
Although various approaches to policy practice have been defned within academic
literature, Iatridis (1995) has defned several skills necessary for efectively integrating
social policy practice into direct service or micro practice. Te frst skill involves the
human service professionals ability to understand the nature of social policy, including
what it is, how it is developed, its infuences and efect on society, as well as how social
welfare policies are most ofen implemented. Te second skill involves the ability and
willingness to view direct practice from a systems perspective, where individual practice
Macro Practice and International Human Services 371
is seen as a part of a greater whole. In other words, human service professionals engaged
in policy practice must be able to link issues confronted in direct service to structural
problems in society (i.e., institutionalized racism, laws that oppress certain groups) by
using a P-I-E paradigm (Person-in-Environment), a concept addressed throughout this
text relating to the importance of viewing social issues such as poverty on a societal
as well as an individual level. Another equally important skill involves the human ser-
vice professionals commitment to improving social justice within society by working
toward a more equitable distribution of the communitys resources.
Tose who engage in policy analysis research various social issues in an attempt
to determine the short- and long-term effect of new policies and legislation. Policy
activists and analysts might focus their attention broadly on social injustices in gen-
eral, or they may focus on more narrow issues such as the quality of mental health
delivery systems, or the focus may be extremely narrow such as the social injustices
confronted by those seeking mental healthcare. Human service professionals engag-
ing in policy practice must be able to identify key trends and issues,
as well as become familiar with legislation or pending legislation
that will affect the area of concern. Lets assume you are involved
in policy practice working for an agency concerned with the older
adult population. The federal administrations policies regarding
Social Security funding would be a matter of great concern to you.
Yet if you were involved with policy practice advocating for the
rights of the children of undocumented immigrants, youd be very
concerned about possible legislation that would prohibit these
children from attending public school. Regardless of the area of
concern, policy analysts must be able to identify the ripple efect
of new policies and legislation to identify their potential harm or
beneft to their target population as well as the entire community.
The Global Community: International Human Services
The world is getting smaller, not in terms of population, of course, but in terms of
globalizationthe increase in international connectedness among all countries and,
consequently, all people. No longer are countries completely isolated either in their f-
nancial economy or political climate. In the worlds new globalization, each country is
connected to every other country through increased ease in communication, the de-
velopment of a global economy (international fnancial interdependence, mutual trade,
and fnancial infuence), and increased international migration, combining to create a
situation where the political state of one country infuences the economic and political
climate of another (Ahmadi, 2003).
Although many consider the term globalization to refer solely to matters of eco-
nomics where businesses can sell goods and trade services as if there were no
geographic borders, it also refects the increased awareness, communication, and co-
operation among social advocates. In fact, social reform on a global level is more pos-
sible now than ever before. Consider the impact the Internet has had on the exchange
Human Services
Delivery Systems
Understanding and Mastery of Human
Services Delivery Systems: Skills to effect
and influence social policy
Critical Thinking Question: How does
a human service professional engaged
in policy-related advocacy use the
Person-in-Environment (PIE) perspective
to guide her/his formulation of social
problems and their solutions?
372 Part III / Macro Practice, International Human Services, and Future Considerations
of information between relatively remote communities and on regions wrought with
oppression. Although limits can be placed on information exchange, the Internet has
made global awareness of social issues as easy as pressing a few buttons. Of course
that is a somewhat simplistic statement, but the importance of the Internet cannot be
underscored both in regard to direct communication and in regard to global aware-
ness of social issues through website publication. For instance, Amnesty International
(www.amnesty.org) includes a comprehensive list of human rights abuses and concerns
occurring throughout the world. Within this website, individuals can obtain detailed
information on the types of abuses currently occurring throughout the world, as well
as instructions on how to take steps to assist in the global campaign to stop such op-
pression and abuse.
This increased ease in global communication has meant that human service
professionals in one part of the world can quickly communicate with human ser-
vice professionals in another part of the world, sharing valuable information and
coordinating efforts and services. In fact, there are several international organi-
zations that exist for this very purpose. The International Federation of Social
Workers (IFSW) is an international organization founded in 1956 that works with
other international human services and human rights organizations to encourage
international cooperation and communication among human service professionals
around the globe. The IFSW has members from 80 different countries throughout
the world, including countries in Africa, Asia, Europe, Latin America, and North
America.
The International Association of Schools of Social Work (IASSW) is a support
organization and information clearinghouse that works to develop and promote
excellence in social work education, research and scholarship globally in order to
enhance human well being (www.iassw-aiets.org). The IASSW also supports an
exchange of information and expertise between social work educational programs.
The International Council on Social Welfare (ICSW) is an independent orga-
nization founded in 1928 in Paris, which is committed to social development and
works with the United Nations (UN) on matters related to social development,
social welfare, and social justice throughout the world. The work of the ICSW is
an excellent example of community development at work using networking and
international liaisons with other organizations to achieve its goals. The ICSW mis-
sion captures the way in which macro practice occurs through a comprehensive
network of agencies and organizations on all levels of society to achieve the global
mission of eliminating social injustice (refer to paragraph 3 at http://icsw.org/
intro/missione.htm).
Even professional counselors whose training has traditionally leaned more
in the direction of clinical practice have recently been encouraged to venture
into global matter by advocating for social justice. Chi-Ying Chung (2005) made
Macro Practice and International Human Services 373
several recommendations to professional counselors to get involved in interna-
tional human rights work, suggesting that they apply their training in multicul-
tural counseling and competencies to the international arena to combat human
rights abuses.
Although the human services profession exists worldwide, and concerns about spe-
cifc social issues such as violence and childrens rights are shared among all countries,
the nature of the social issues and the function and role of the human service profes-
sional will vary depending on the political and economic conditions unique to each
country. Human service professionals around the globe have many shared values but
have diferences in values as well. For instance, in the United States, self-determination
is very highly valued in all the human services, particularly the social work profession,
but not only is self-determination not considered a core value of the profession in other
countries, in Asia, Africa, and even Denmark the concept of self-determination is con-
sidered either unimportant or dangerous as it detracts from the value of community
and cooperation (Weiss, 2005).
Overall, though, human service professionals in virtually every country place a high
value on the protection of human rights, social justice, and the end to human oppres-
sion in whatever form it might be taking within that particular region. For instance, a
primary concern of the human service professionals in South Africa relates to issues of
race emanating from its former system of apartheid. School social workers are com-
monly used to teach positive race relations among the students in South African public
schools. Race issues take on a diferent form in the United States related to its history of
slavery and mass immigration.
HIV/AIDS Pandemic
AIDS, a life-threatening disease found disproportionately in sub-Saharan Africa, has
had a devastating efect on families, particularly children. Te life expectancy in many
African countries has dropped from 61 to 35 years of age, and has had a profound
efect on children and the quality of their childhoods. For instance, as of 2007, of the
approximately 17 million children estimated to have been orphaned by the AIDS
epidemic, approximately 15 million live in Sub-Saharan Africa UNAIDS, 2008;
UNICEF, 2012). This represents an increase over prior years despite the fact that
adult HIV-infection rates have declined in recent years, and use of antiviral medica-
tions have become increasingly available, particularly in several sub-Saharan African
countries (UNAIDS, 2008). In Zimbabwe alone United Nations Childrens Fund
(UNICEF, 2004) estimates that 30 percent of all children have been orphaned due to
AIDS. Many developing countries have neither the funding nor the capacity to place
child welfare issues as a priority (Dhlembeu & Mayanga, 2006). Women bear the pri-
mary burden of this disease with regard to both stigma and the brunt of caregiving,
374 Part III / Macro Practice, International Human Services, and Future Considerations
despite the fact that they are being infected at far higher rates than men (Joint United
Nations Programme on HIV/AIDS, 2004).
Human service professionals working in the highest risk countries in sub- Saharan
Africa, including Ethiopia, Nigeria, South Africa, Zambia, and Zimbabwe, must con-
tend with the devastating impact of the HIV, including the very complicated and far-
reaching implications of so many children being orphaned as a result of the death of
one or both of their parents due to AIDS. Tis situation is further complicated by the
fact that many of the child welfare agencies in these countries (if they even exist) are ill
equipped to handle the vast number of orphans, many of whom are not being well cared
for and may be infected with the HIV virus as well.
In many countries in Africa as well as other regions, traditional beliefs and stig-
mas exist which are counterproductive to HIV/AIDS treatment protocol compliance.
But even in situations where a country is highly compliant with international health-
care protocols, such as the case of Rwanda, the management of the AIDS pandemic is
extremely complex and presents numerous challenges to human service professionals.
For instance, in Rwanda, thousands of women were infected by HIV/AIDS by Hutu,
the genocidal governments Interahamwe militia who raped the majority of women
during the genocide. Tose women who were not then cut down by machetes, learned
months or years later that they were infected with HIV (Des Forges, 1999). Tus in the
Rwandan context, an entirely new generation of orphans was created due to conditions
directly linked to the 1994 genocide. Further, many of these orphans are HIV-positive as
well. Te agency WeActx in Kigali works with HIV-infected women and their children,
providing them with both healthcare and trauma services. Te director of this agency
recently shared that a signifcant concern among the youth population being served by
this agency relates not only to their daily provision and education needs, but also to the
common refusal of many of the youth to adhere to the AIDS treatment protocol because
they are in denial that they have this disease. Teir HIV status is yet another ongoing
reminder of the genocide, which has afected and will continue to afect the Rwandan
population, particularly Tutsi survivors, for generations to come (it is important to note
that many Hutu women were raped during the genocide as well, and were also infected
with HIV, which is why the WeActx agency does not restrict its services to only Tutsi
genocide survivors, but to Hutu women as well).
Several human services agencies exist solely to care for these orphaned children. Other
agencies focus their efforts on education and testing. This public health crisis has far-
reaching implications that must be addressed internationally if there is going to be any real
remedy that will positively afect the lives of those infected and those at risk of infection.
Crimes Against Women and Children
Crimes against women and children are of concern to countries throughout the world,
and human service professionals, including social workers, psychologists, and profes-
sional counselors as well as human rights workers are involved in advocacy, counseling,
and political activism on all levels to create international awareness and social action to
put a stop to atrocities such as government-sanctioned honor killings, punitive sexual
assaults, exploitation and harassment, and discrimination that strips women and chil-
dren of their basic human rights.
Macro Practice and International Human Services 375
FEMALE GENITAL MUTILATION Another
issue ofen confronting human service profes-
sionals in all of Africa involves female genital
mutilation (FGM), or female circumcision,
where historical tradition and tribal culture
prescribes that a girls external genitalia, typi-
cally including her labia and clitoris, be cut
away in a rite of passage ceremony celebrating
her entry into her womanhood. Te most seri-
ous type of FGM is Type 3, which includes the
cutting away of the labia minora and the sew-
ing together of the labia majora (the outer vag-
inal lips), which then creates a seal with only
a small opening for the passing of menstrual
blood and urine. Te vaginal seal is intended
to keep the women in the tribe from having
sexual relations before marriage. It is literally
torn open during the womans frst sexual encounter with her husband, which not only
causes extreme pain, but also has serious health consequences such as bleeding and
possible infection. In some cultures the torn pieces of labia are actually sewn together
again if the woman becomes pregnant and are then torn open again during childbirth.
It is estimated that nearly 100 to 130 million girls have undergone FGM, which can
cause serious health risks including lifelong pain, infertility, and death (World Health
Organization, 1998). FGM is rarely performed by a physician, but is frequently con-
ducted by a village leader with no pain medication. Girls are ofen tied down and sub-
jected to this surgery, which is intended to ensure chastity and purity. Tere has been a
recent backlash among women in some African countries who are discouraging FGM in
their communities, although this practice is still quite prevalent in many rural regions.
Human service professionals are conducting educational campaigns to infuence local
leaders who have the power to discourage this practice, as well as infuencing many
Western countries to add those escaping FGM to qualify for refugee status.
HUMAN SEX TRAFFICKING Human service professionals in many Asian countries
must contend with numerous human rights violations, the most prevalent and disturb-
ing of which includes the human trafcking of women and children for the purposes of
slavery, forced marriage, and the sex trade. For instance, according to the Human Rights
Watch (HRW, 2002), approximately 10,000 women and girls are recruited from Burma
to brothels in Thailand each year. The most recent U.S. Department of State (2010)
Trafcking in Persons report states that government corruption and the involvement of
public ofcials in the human trafcking trade makes matters even more challenging for
human rights workers who are attempting to achieve social justice for these women and
children.
As of 2011 there were approximately 12.3 million individuals who were victims of
human trafcking worldwide, the majority of whom were young females, the majority
Young girl endures female genital mutilation in Somalia. (Source:
http:// www.global-sisterhood-network.org/content/view/1470/59/)
Jean-Marc Bouju/Impact/HIP/The Image Works
376 Part III / Macro Practice, International Human Services, and Future Considerations
of whom were trafcked for sexual purposes (U.S. Department of
State, 2012). In fact, young girls are the most sought afer targets
of large criminal organizations that are in the business of trafck-
ing human beings. Although people can be sold for various reasons,
including forced servitude and child labor, the majority of human
trafcking involves forced sexual slavery, where young women and
girls are forced to become prostitutes. Girls are sold into sex slavery
by family members in need of money, are kidnapped, or are lured
into the sex trade with promises of modeling contracts or domestic work in other coun-
tries. Many of these girls are kept in inhumane environments where they are forced to
have sex with up to 10 men a day. Many contract HIV/AIDS and are cast out onto the
street once they become too sick with AIDS to be useful (U.S. Department of State,
2012).
Much of the efort of human service professionals in countries with high rates of
human trafcking, including India, Burma, Tailand, and Sri Lanka, is focused on res-
cuing these women and children and ensuring that they are delivered to safe commu-
nities where they will not be exploited again. Complicating intervention strategies is
the fact that many government ofcials in these Asian countries either look the other
way when confronted with the illegal sex trade or openly contribute to it by protecting
criminal organizations responsible for human trafcking. Human rights organizations
have reported that many police ofcers, members of the military, and other government
ofcials in Tailand ofen arrest victims who attempt to escape, putting them in prison
on charges of prostitution, a clear act of retaliation, rather than helping them to escape
(HRW, 2004).
STREET CHILDREN Human service professionals in Central and South American
as well as Eastern European countries must contend with the signifcant problem of
thousands of homeless street children roaming the streets in search of food and shel-
ter. Te problem of street children is growing around the globe, leading several human
rights organizations to call human service professionals to action. Street children are
sometimes orphans, but are ofen children who have parents but
have lef home due to poverty or lack of supervision. In many
Eastern European countries, including Romania, the problem of
street children is a direct result of political policies resulting from
families having a large number of children with the promise of
government provisions, only to be left in terribly vulnerable
positions when these governments failed, leaving parents with
no means for providing for their exceptionally large families.
Street children are at risk of abuses by older children as well as
police and government ofcials who ofen physically abuse chil-
dren as young as 5 years (HRW, 2002). Children have even been
murdered by the police with no ofcial response. Drug abuse is
also rampant within the street children population, who ofen
snif glue to keep warm and to abate hunger pains.
A child from the Untouchable caste in India
begging for food
Xander Martin
As of 2011 there were approximately
12.3 million individuals who were
victims of human traffcking
worldwide, the majority of whom
were young females traffcked for
sexual purposes.
Macro Practice and International Human Services 377
Human service professionals have organized agencies that reach out to these chil-
dren by fnding homes for them, either with religious organizations or through inter-
national adoption. International human services agencies work with local agencies
to bolster aid eforts, including lobbying government ofcials to address this issue by
funding child welfare eforts.
CHILD LABOR AND ECONOMIC INJUSTICE Child labor is a social justice issue
across the globe, but is a particular concern in Asian, African, and Latin American
countries, where children as young as 4 years are required to work up to 12 hours per
day in jobs that put them in both physical and psychological danger. Child labor abuses
include children in India who plunge their hands into boiling water while making silk
thread and children as young as 4 years in Asia who are tied to rug looms for many
hours a day and forced to make rugs.
Of the 120 million children forced into full-time labor, 61 percent reside in Asia, 32
percent in Africa, and 7 percent in Latin America (HRW, 2004). International human
rights organizations such as HRW, Amnesty International, and UNICEF work diligently
to protect childrens rights, including lobbying of international policies and legislation
that protect children as well as funding human rights eforts in specifc countries al-
lowing for intervention at the local level. But the problem of child labor, particularly in
sweatshops in the Global South (Central and South America, Southeast Asia, India, and
the Southern region of Africa), remain a serious problem impacting the entire world
both socially and economically.
For instance, Polack (2004) discussed the impact of hundreds of billions of dollars
in loans made to countries in the Global South by countries in the North (England,
Spain, France, the United States, etc.). Polack argued that the cumulative impact of these
loans to some of the poorest countries in the world has been devastating to the poor-
est members of these countries because these
loans (1) fnanced large-scale projects, such as
hydroelectric plants, that either benefited the
North or displaced literally millions of people,
pushing them even further into poverty, (2)
fnanced military armaments for government
regimes that oppressed the countries most vul-
nerable and poorest residents, or (3) lined the
pockets of corrupt leaders of many countries in
the Global South, resulting in increased oppres-
sion of the countrys least-privileged members.
Very little if any of this loan money has
benefted the majority of the citizens of these
countries; rather, it has harmed them and in
fact continues to harm them by increasing the
poverty within these already devastatingly poor
regions. In an attempt to repay this debt many
countries of the Global South exploit their own
Teenage boys working in the ship breaking yards in Bangladesh
Xander Martin
378 Part III / Macro Practice, International Human Services, and Future Considerations
workers to make loan payments. For example, countries in South America have sold sec-
tions of rain forest formerly farmed by local residents to Northern timber companies,
and other countries have been forced to privatize and then sell utility services formerly
provided by the government, resulting in dramatic increases in the cost of utilities. Tese
developments have resulted in many Northern companies making millions of dollars
literally at the expense of the poorest residents of these debt-ridden countries.
One of the most devastating impacts of what has now evolved into trillions of dollars
of debt for these Southern countries is the evolution of the sweatshop industry, large-
scale factories that develop goods exported to the North. Some of the poorest people in
the world, including children, work in sweatshops throughout Asia, India, and Southern
Africa, where horrifc abuses abound. Tis occurs legally in many of these countries be-
cause in a desperate attempt to attract export contracts, many countries in Asia, including
India, created free-trade agreements or free-trade zones for Western corporations, allow-
ing them to circumvent local trade regulations, such as minimum wage, working hour lim-
its, and child labor laws, if they would open factories in their impoverished countries.
Polack (2004) suggests that literally every major retail supplier in the United States
benefts from these sweatshop conditions such as extremely low wages, extremely poor
working conditions, physical and sexual exploitation without retribution, excessively
long working hours (sometimes in excess of 12 hours per day with no days of for weeks
at a time), and severe retribution such as immediate termination for complaints or re-
quests for better working conditions. Child labor is the norm in these sweatshops with
most sweatshop owners preferring adolescent girls as employees because they tend to be
more compliant and are more easily exploited.
Although local and international human rights advocates work diligently to change
these working conditions, at the root of the problem of child exploitation is economic
injustice rooted in generations of intercountry exploitation. Tus, there is signifcant
complexity not easily confronted without government involvement, which is ofen slow
in coming when large corporations are making millions of dollars with the system as it
currently operates. For instance, as labor unions have become the norm in the United
States, many companies such as Nike and Wal-Mart moved their factories to Asia and
Central and South America, where millions of dollars can be saved in wages and benefts
cuts (National Labor Committee, n.d.). Addressing the issue of child labor and economic
injustice will take the lobbying eforts of many international human rights organizations
working with the media to create public awareness where buying power is ofen the only
tool powerful enough to infuence sweatshop owners and large retail establishments.
CASE STUDY 15.1
Testimony of Mahamuda Akter, MNC Garment Factory, September 2002
My name is Mahamuda Akter. I am 18 years old. Ive only had the chance to go through
ffh grade. I was 13 when I began working in the garment factories. For the last two years
I have been working at the MNC factory in the Chittagong Export Processing Zone, where
we sew clothing for Wal-Mart. I am a sewing operator.
Macro Practice and International Human Services 379
Until September 5, we were working on Ozark Trail shirts. Before thatfor six or seven
monthswe worked constantly on Sportrax athletic clothing. Now we are sewing Faded Glory
shorts. Depending upon the type of garment we are working on, my job is to join the collar,
or to sew either the pocket or the hem of the sleeves. Attaching the collars is very complicated
since you must match the patterns of the fabric. Te supervisors scream at us to do 40 pieces
an hour. But its impossible. Working as fast as we can, I can only fnish 30 collars in an hour.
Te supervisors tell us we have to meet Wal-Marts target. Tere is constant pressure
on us to work faster. Tey beat us. Tey slap our faces or slap us on the back of the head.
Tey grab us by the hair and jerk our heads. Tey push and shove us.
I was beaten several times in August and September. My supervisor, who is a man,
slapped my face and cursed at me that I was a son of a bitch and that my parents were
whores. Tey use vulgar and flthy words, they made me cry. Many of us girls cry, but they
make you keep working.
I work on Line D. In July, the supervisors kicked one of the girls on our line, yelling
that she had made a mistake. Tey threw her against the wall and her mouth was bleeding.
Tey took her to the ofce and fred her that afernoon.
Another thing they do as punishment is to make a girl stand on a bench in front of all
the other workers, forcing her to hold her ears and pull them down. Its a shameful insult.
Tey do this especially to the young girls and it makes them feel terrible.
Tere are 4,000 workers in our factory. Eighty-fve percent of us are women. We have
lots of helpers who are 10 to 12 years old.
Our regular work schedule is from 7:30 a.m. to 10:00 p.m. But they ofen force us to work
until 3:00 a.m. In August, I had to work 13 nights till 3:00 a.m. In other sections it was even
worse, and they had to work 2025 nights to 3:00 in the morning. We work seven days a
week. In August we had just one day of. For the year, I think I got a total of 15 days of.
When we work through to 3:00 a.m., we get three breaks, a half hour for lunch from
1:00 to 1:30 p.m.; 10 minutes from 7:00 to 7:10 p.m., and an hour of for supper from 11:00
to midnight. Afer the 3:00 a.m. shif, we sleep in the factory. It is so crowded that we sleep
sitting on our benches slumped over our sewing machines. Tere is no place to even lie
down on the foor. At 5:00 a.m. they ring a loud bell to wake everyone up, so we can get
ready to start work again. We wash our faces, use the bathroom, eat something and go
back to work. Sometimes we are forced to do these 19-hour shifs three days in a row.
We are exhausted. Many times the workers faint. Te supervisors throw water on their
faces and they have to get back to work. Tey also play loud music to keep us awake.
I earn 2,100 taka a month, which is $35.60. Im told this comes to 17 cents an hour.
We are not allowed to talk at work, and if we are caught we are punished. You need
permission to use the bathroom. When we work until 3:00 in the morning for example, we
can use the bathroom just three times in the entire shif.
We have a daycare center at the factory, but it is a joke. It is just for show to the buyers.
It is never really used.
We are not allowed sick days, or national holidays, or any vacation.
Tey also cheat us on our overtime wages. Tey keep two sets of time cards. Te phony
one is for Wal-Mart. It says that we work just from 7:30 a.m. to 6:30 p.m., in other words, that
we work two hours of overtime a day. It also says that we receive every Friday of. Tats a lie.
None of us have ever heard of the Wal-Mart Code of Conduct. Before the Wal-Mart
buyers come to the factory, the factory is always cleaned. Te supervisors tell us to lie if
380 Part III / Macro Practice, International Human Services, and Future Considerations
Indigenous People
Protecting the rights of indigenous people is a common con-
cern of human service professionals practicing in countries
such as the United States, Australia, and many Central and
South American countries. Indigenous populations are ofen
forced to engage in harsh and dangerous labor practices, such
as working in fields sprayed with insecticides, transporting
supplies on their person, or begging, in order to survive.
Te human rights issues pertaining to indigenous peoples
of Australia, primarily comprised of Aborigines, are simi-
lar in nature to those in the United States, where the historic
immigration of Europeans displaced the indigenous tribal
communities. In addition, both countries engaged in an of-
ficial campaign of discrimination and cultural annihilation
as indigenous tribes were forced of their lands and onto re-
stricted areas, where they were unable to practice traditional
methods of self-support. Both Native Americans in the United
States and Aborigines in Australia were subject to the mass
forced removal of children, who were mandated to attend
schools where they were forced to abandon their cultural heri-
tage and native language.
the buyers ever question uswe are supposed to say that we work just
to 6:30 p.m. and that we have one day of a week. Te buyers always
walk around with the manager. Everyone is so frightened, no one
dares complain. Sometimes the buyers ask us to smile and they take a
picture. Tey usually come around 1:00 or 2:00 in the afernoon. Tey
never come at 10 p.m. or 3:00 a.m.
I live in one room with three other girls who are coworkers. We
must pay 1,150 taka rent each month. We cannot even aford a fan or
a TV. We share one water pump, an outhouse, and one gas stove with
20 other people.
Every day we eat rice, rice with lentils or with mashed potatoes.
Sometimes we have an egg at night. Im always hungry. I weigh 79
pounds. Maybe once in a month we can eat beef.
We work so hard, but it is not right that they mistreat us so and
pay us so very little.
I am afraid of getting old. Living and working like this, by the time
you are 20 you are already old, and your health is failing. When you reach 30, they fre
you. It is not just. I have no savings. I have nothing.
I would like a better life for myself and the other girls.
Source: Institute for Global Labour & Human Rights (formerly National Labour Committee)
Indigenous populations are ofen forced to live
in the midst of environmental degradation
Xander Martin
Human Services
Delivery Systems
Understanding and Mastery of Human
Services Delivery Systems: International
and global influences on service delivery
Critical Thinking Question: The ethi-
cal codes of organizations such as the
NASW call on human service profes-
sionals to advocate for social and eco-
nomic justice around the world. What
responsibilities do human service work-
ers in the United States have to children
like Mahamuda Akter?
Macro Practice and International Human Services 381
Te 36-year civil war in Guatemala, which ended in 1996, involved what many hu-
man rights organizations consider the genocide of indigenous populations, or what
is commonly referred to as the disappearance of indigenous populations. The UN
Truth and Reconciliation Committee estimates that up to 200,000 people were killed by
government forces (HRW, 2008).
In response to the intergenerational trauma that has resulted from physical and
cultural genocide, many indigenous people have experienced a decimation of their pop-
ulation as well as extreme poverty, forced migration, and marginalization ofen mani-
festing in physical and mental health problems. Human service professionals work with
indigenous people in reconciliation eforts to restore them to a level of self-sufciency
and cultural pride. Several movements are underway within indigenous tribal com-
munities intended to move them toward wholeness and a life without substance abuse,
depression, and the brokenness in families that has so ofen been the result of social ills.
One program within a Native American community was developed by a tribal
member who sufered from alcoholism for years and who received inspiration and input
from tribal elders who shared wisdom regarding traditional cultural laws for authentic
change. Te four laws of change became known as the Healing Forest Model, which is
based on the philosophy of the Medicine Wheel, a Native American concept that ad-
dresses the interconnectedness of everything in life. According to the teachings of the
Medicine Wheel, the pain of one person creates pain for the entire community, thus
there are no individual issues or concerns. Tis community concept of healing is very
consistent with a model of macro practice, which posits that there are no such things as
individual problems but instead people make up communities and therefore all individ-
ual problems become community problems. Tis philosophy may be counterintuitive
to North Americans, who as a society place an exceedingly high value on individual-
ity, ofentimes at the cost of community. Yet many believe that the key to reclaiming
physical and mental health in indigenous culture is through such a community practice
approach (Coyhis & Simonelli, 2005).
Refugees
According to the Office of the United Nations High Commissioner for Refugees
(UNHCR) there are approximately 42 million displaced people who have been forc-
ibly removed from their homes and communities due to civil war, confict, political and
cultural persecution, natural disaster, ethnic cleansing, and genocide.
Te Immigration and Nationality Act defnes refugee as:
(A) any person who is outside any country of such persons nationality or, in the
case of a person having no nationality, is outside any country in which such person
last habitually resided, and who is unable or unwilling to return to, and is unable
or unwilling to avail himself or herself of the protection of, that country because
of persecution or a well-founded fear of persecution on account of race, religion,
nationality, membership in a particular social group, or political opinion, or (B)
in such circumstances as the President afer appropriate consultation (as defned
in section 207(e) of this Act) may specify, any person who is within the country of
382 Part III / Macro Practice, International Human Services, and Future Considerations
such persons nationality or, in the case of a person having no nationality, within
the country in which such person is habitually residing, and who is persecuted or
who has a well-founded fear of persecution on account of race, religion, national-
ity, membership in a particular social group, or political opinion. (Sec. 101(a)(42))
Individuals may become refugees through a variety of circumstances. In the last two
decades there have been between 17 and 33 armed civil conficts at any one time, lead-
ing to civil unrest and instability in several developing countries. In the midst of a civil
war innocent civilians are ofen forced to fee in search of safety, a phenomenon referred
to as forced migration. If civilians fee but do not cross international boundaries, they
are referred to as internally displaced persons (IDPs), but if they are forced to fee into
another country, then they ofen receive the legal designation of refugee. Refugees may
live in secret, in a country with closed borders, thus are considered by the host country
as illegal immigrants. Life as an illegal immigrant is lived on the fringes, in constant fear
of detection, detainment, and repatriation. In other situations, refugees are warehoused
in refugee settlements or camps. Most refugee camps are managed by the UNHCR, and
despite such management, they remain a place of great risk and despair. In many refu-
gee camps refugees are not allowed to leave and are ofen considered a serious risk to
the host country. Most refugee camps are established in border regions and may re-
main in close proximity to the war that caused the displacement in the frst place. Te
majority of refugees in protracted situations develop a sense of signifcant despair as
their situation lingers on for generations, as with the Burundi, who have been in refugee
camps in Tanzania since the early 1970s. Tose refugees fortunate enough to be selected
for resettlement in the United States ofen face years of challenges as they struggle to
survive in a complex society, ofen underemployed and socially isolated (Hollenbach,
2008; Loescher, Milner, & Troeller, 2008). Human service professionals ofen work with
refugees in a variety of practice settings, including refugee resettlement agencies (con-
tracted with the U.S. Department of State), schools, and mental health agencies. Macro
practice involves advocacy and policy practice efecting changes in policies that create
additional challenges to an already immensely vulnerable and traumatized population.
Refugee communities, also referred to as diaspora, should not be considered power-
less victims without personal agency though as many come together to form quite pow-
erful lobby groups advocating for their agendas both within their host countries as well
as in home country afairs. In fact, recent research has shown that a country in postcon-
fict is at a signifcantly higher risk of renewed confict if there is a related diaspora that
is politically active and advocating against the home country government (Collier &
Hoefer, 2000; Lyons, 2007). Tus it is vital that human services workers working with
diaspora groups be aware of the sociopolitical dynamics related to the history of confict
in the refugees country of origin so that they can assist the diaspora members to engage
in ways that will support peace processes, and not exacerbate old and existing conficts.
Lesbian, Gay, Bisexual, and Transgendered Rights
Individuals who have nontraditional sexual orientations, including lesbian women, gay
men, bisexual men and women, and transgendered individuals (those who have under-
gone surgery to physically become the opposite gender) have long been the victims of
Macro Practice and International Human Services 383
abuse, discrimination, and at the very least a tremendous amount of misunderstanding.
Homophobia is defned as irrational fear of homosexuals or of homosexual behavior.
Lesbian, gay, bisexual, and transgendered (LGBT) individuals are subjected to homo-
phobic sentiments and outright discrimination and violence in all parts of the world.
Until recently the majority opinion of those in Western culture was that LGBT individu-
als were either morally perverse or mentally ill. In fact, it wasnt until 1987 that all refer-
ences to homosexuality were completely removed from the Diagnostic and Statistical
Manual of Mental Disorders.
Acts of harassment and violence against LGBT individuals based on their sexual ori-
entation are prevalent all over the world, causing signifcant distress, depression, and
even suicidal ideation (Huebner, Rebchook, & Kegeles, 2004). LGBT youth are at risk
of discrimination in school and community settings in both the United States and the
United Kingdom, although many school districts now use policies designed to protect
adolescents whose sexual orientation are known to others in the school or community
(Ryan & Rivers, 2003). LGBT individuals are commonly the victims of direct or subtle
discriminatory practices, verbally abused and harassed, and the victims of violence,
sometimes even murder, solely because of their sexual orientation.
Although abuse and discrimination against LGBT individuals is assumed to be
far worse in developing countries, this is not always the case. In many regions of the
world the line between heterosexuality and homosexuality is quite porous, particularly
compared to Western cultural norms. Tis contention is based on the practice of male-
on-male sexual activity commonly practiced in many parts of the world when one or
both men are married. For instance, in Bangladesh married men ofen frequent male
prostitutes but do not necessarily consider themselves homosexual. They are rarely
victims of harassment or abuse because they do not violate gender stereotypes, which
essentially means that men continue to act like men and women continue to act like
women (Dowsett, 2003). Te relevance of this
is that in many parts of the world violence
against LGBT is based more on behavior that is
contrary to traditional gender stereotypes than
it is on their sexual activities.
Yet in many regions of the world homosex-
ual behavior is considered a criminal act pun-
ishable by anything from a prison sentence to
death. Homosexuality is considered illegal in
South Africa, and LGBT individuals are ofen
the victims of human rights abuses, includ-
ing punitive rapes. In addition, they are ofen
unjustly blamed for the HIV/AIDS crisis cur-
rently occurring in Africa (Graziano, 2004).
LGBT individuals in Saudi Arabia are subject
to public foggings and imprisonment for even
suspected homosexual behavior. In Egypt vice
ofcers travel through towns in vans arresting
in excess of 100 men at a time for suspected
Rally against California Proposition 8 barring gay marriage in
New York City 2008.
Tricia Serfas
384 Part III / Macro Practice, International Human Services, and Future Considerations
homosexuality. Many of these men were arrested because they knew what the word
gay meant, a North American word assumed to be known only by homosexual men.
Men arrested on suspected homosexuality are then subject to severe beatings until
they agree to sign arrest papers admitting to their homosexuality. Signing these
papers means a lifetime of certain harassment and refusing to sign them means
certain death. In Jamaica LGBT individuals are ofen the target of horrible human
rights abuse, ofentimes fueled by the police who ofen invite bystanders to attack
men suspected of homosexual behavior. One incident reported to a human rights
organization involved a man suspected of being gay who was attacked by police and
ultimately beaten and stabbed to death in the middle of the street by bystanders who
joined in the beating. Police in Jamaica also commonly stop individuals suspected of
being LGBT on the streets, searching them looking for any sign of homosexual activity
such as condoms or lubricants. If these items are found, the men are ofen beaten and
arrested (HRW, 2005).
Several countries in Africa, including Uganda and Nigeria, are currently consider-
ing antihomosexuality laws that would make homosexual activity illegal and punish-
able by brutal penalties, including death. What is particularly disturbing about this
recent antihomosexuality trend in Eastern Africa are reports that some U.S. Evangeli-
cal leaders are behind the efort to criminalize homosexuality, based upon a belief that
the homosexual agenda threatens the traditional family (Gettleman, 2010). Human
rights organizations have expressed outrage in response to the reported link between
antigay legislation in Africa and the U.S. Evangelical church for a variety of reasons,
chief among them the potential for dictatorships with poor human rights records to use
such legislation to silence (either through long-term incarceration
or death) anyone who opposes their autocratic rule (HRW, 2009).
One might question whether any such organized eforts emanat-
ing from any developed country is a form of neocolonialization,
refecting signifcant ignorance of the history of the region as well
as paternalistic attitudes common during colonial rule of African
countries. Regardless, such misplaced advocacy has a great pos-
sibility of signifcantly increasing human rights abuses against an
already marginalized population.
Human service professionals and human rights workers around the globe are work-
ing tirelessly to reduce crimes against LGBT individuals through the passage of policies
and legislation designed not only to protect individuals whose sexual orientation is not
traditional, but also to decriminalize homosexual behavior in all countries. Te recent
passage of the Matthew Shepard & James Byrd Jr. Hate Crimes Prevention Act (P.L. 111-
84) in the United States, signed into law in October 2009 by President Obama, makes
it a federal crime to assault individuals because of their sexual orientation, gender, or
gender identity. Te passage of this highly contested legislation has been lauded by civil
rights organizations as a signifcant step forward in this fght for equality and protection
of the LGBT population (Human Rights Campaign, 2009).
What might be one of the most important issues to consider is that regardless of
whether one considers homosexuality a lifestyle choice, a genetically predetermined
Several countries in Africa,
including Uganda and Nigeria,
are currently considering
antihomosexuality laws that would
make homosexual activity illegal
and punishable by brutal penalties,
including death.
Macro Practice and International Human Services 385
orientation, a nontraditional sexual orientation no better or worse than heterosexual-
ity, or an act of perversion and immorality, violence against someone based on their
sexual orientation is never permissible under any conditions, thus even those human
service professionals who because of religious faith or cultural tradition believe that het-
erosexuality is the only physically and psychologically healthy lifestyle, should be called
to action to ensure that all individuals, despite their sexual orientation, are treated with
compassion and dignity.
Torture and Abuse
Countries in Eastern Europe as well as countries in Northern and Western Africa are over-
whelmed with the repercussions of war and genocide where human service profession-
als and human rights workers deal with numerous human atrocities such as torture, war
crimes, and the crisis of thousands of refugees. But the problem of abuse and torture is truly
worldwide, and as much as members of industrialized countries would like to believe that
human torture is a problem known only to lesser developed countries, the physical and
sexual torture of the Iraqi detainees at Abu Ghraib prison is a clear reminder that human
torture occurs on all soils at the hands of people from the most civilized of countries.
Countries in the midst of war are particularly vulnerable to human rights abuses
involving torture because war seems to have a diminishing efect on human compassion
and empathy. Human torture and abuse can include anything from random physical
abuse to the systematic abuse and even murder of groups of people common in geno-
cide, prisoner of war camps, and refugee camps. Many of the abuses documented in the
Taliban-ruled Afghanistan included sexual assault, government-sanctioned gang rapes
of women who brought disgrace on their countrymen, and physical torture such as the
cutting of of limbs for minor infractions (U.S. Department of State, 2001).
Most if not all victims of wartime atrocities such as rape and torture, many of whom
are being revictimized in refugee camps, suffer from post-traumatic stress disorder
(PTSD) and other psychiatric conditions related to grief and loss. Human service pro-
fessionals work with victims of torture on all frontssome within refugee camps, and
some in other countries who have accepted victims on refugee status. Te psychological
issues involved are vast and in addition to the disorders mentioned earlier include de-
pression, anxiety, and adjustment disorders. Most human service professionals in devel-
oping countries and former Soviet bloc countries are employed by the government and
deliver broad-ranging services on a community level, focusing on the manifestation of a
history of war, as well as the ramifcations of transitioning from a communist society to
a democracy. For instance, a relatively signifcant portion of human services in Croatia
is focused on postwar issues as well as the care of Bosnian refugees and other war vic-
tims, focusing on trauma recovery and helping victims to manage the comprehensive
impact of war on the individual and families (Kneevi & Butler, 2003).
Troughout the Bush/Cheney administration several advocacy organizations, in-
cluding Amnesty International, HRW, and the International Red Cross, cited numerous
egregious examples of torturing prisoners suspected of involvement in the September
11, 2001, terrorist attacks, or of being a supporter of enemy combatants. Both former
president George W. Bush and former vice president Cheney defended their policy of
386 Part III / Macro Practice, International Human Services, and Future Considerations
using enhanced interrogation techniques, denying that such practices constituted a vi-
olation of the Geneva Convention, a collection of international humanitarian laws that
among other remedies provides parameters on how prisoners of war are to be treated.
In 2006 the HRW submitted a report to the Human Rights Committee detailing
numerous human rights violations occurring under the Bush/Cheney administration in
violation of International Covenant on Civil and Political Rights (ICCPR), including the
secret and indefnite detention of prisoners at Guantanamo Bay and at undisclosed lo-
cations abroad. According to the report, most of these prisoners have not been charged
with any crimes and have thus been denied due process. Other human rights violations
include the use of torture as an interrogation technique, such as sleep deprivation, iso-
lation, sexual humiliation, and water boarding (which gives the subject the sensation
of drowning). Federal legislation that was enacted in 2005 supported the use of infor-
mation obtained from torture and also precludes detainees at Guantanamo Bay from
bringing any future challenge to their ongoing detention or conditions of confnement
before the courts (HRW, 2006, p. 7), including torture, and cruel inhuman and degrad-
ing treatment. Te following case studies were included in an HRW report submitted to
the United Nations Human Rights Committee:
Consider the cases of Kahled el-Masri and Maher Arar. El-Masri, a German citi-
zen, states that he was seized in Macedonia in December 2003 and eventually
transferred to a CIA-run prison in Afghanistan where he was beaten and held
incommunicado for several months. In May 2004, he was fown to Albania, de-
posited on an abandoned road, and eventually made his way back to Germany.
El-Masri states that one of the detaining ofcials admitted that his arrest and de-
tention was a mistake. El-Masri fled a suit in U.S. federal court against the for-
mer CIA Director George Tenet and the corporations and individuals allegedly
involved in his rendition. He alleged violations of his due process rights and the
international prohibitions against arbitrary detention and cruel, inhuman, or de-
grading treatment. Te U.S. government, however, moved to dismiss, arguing that
discovery in the case would require revealing state secrets. Despite the fact that
the case had been widely reported in the U.S. and international media. [sic]Te
court agreed and on February 16, 2006, dismissed the case. El-Masri plans to ap-
peal the ruling. If he loses, he will have no avenue for seeking relief and compensa-
tion for the 5-month period of physical and psychological abuse. Maher Arar, a
Canadian citizen, was detained by the United States in September 2002. U.S. im-
migration authorities held him for two weeks, during which time he was unable
to challenge either his detention or imminent transfer to a country likely to tor-
ture him. Relying on diplomatic assurances from Syria, the United States then few
Arar to Jordan, where he was driven across the border to Syria and detained there
for ten months. Arar reports that he was beaten by security ofcers in Jordan and
tortured repeatedly, ofen with cables and electrical cords, during his confnement
in a Syrian prison. Arar sued former Attorney General John Ashcrof and others
involved in his detention and rendition for compensation for the physical and psy-
chological harm sufered in Syria. Te United States asserted a national security
Macro Practice and International Human Services 387
privilege. Te district court agreed and dismissed the case, reason-
ing that it could not second-guess the governments claims that the
need for secrecy was paramount and that discovery about what
happened in the case could have negative impacts on foreign rela-
tions and national security. Arar, like el-Masri, is denied a rem-
edy, even though the facts of his case, like in the el-Masri case, are
widely reported. In both cases, the U.S. government has shut down
any inquiry into practices that appear to violate international pro-
hibitions on non-refoulement and use of torture and cruel, inhu-
man, and degrading treatment. Violations of non-derogable rights
cannot and should not be justified or shielded from review on
grounds of national security. (OHCHR, 2006, p. 10)
Some of the most egregious policies have been passed during
times of crisis when people are scared and willing to sacrifce civil
and human rights for the sake of security. Yet as human service pro-
fessionals we must advocate for human rights in all situations, and
resist the temptation to dehumanize any group, which tends to make
it far easier to justify such horrendous mistreatment.
Genocide and Rape as a Weapon of War
The 1948 UN Convention on the Prevention and Punishment of Genocide defines
genocide as any act committed with the intention to destroy, in whole or in part, a
national ethnic, racial or religious group: killing members of the group; causing
serious bodily or mental harm to members of the group; deliberately inficting on the
group conditions of life calculated to bring about its physical destruction in whole or in
part, imposing measures intended to prevent
births within the group, and forcibly transfer-
ring children of the group to another group
(UN General Assembly, 1948).
Genocides most typically occur within a
broader armed civil or international confict,
thus determining whether civilian deaths as a
result of a confict rise to the level of genocide
is somewhat political in nature, as is determin-
ing that massacres or crimes against human-
ity do not rise to the level of genocide. Such
a determination can be made by any country
that is a signatory of the Genocide Conven-
tion, as well as by the General Assembly of the
United Nations. Yet it is important to note that
just because an incident of civilian killings is
not deemed genocide by the international
community does not mean that genocide has
Human Services
Delivery Systems
Understanding and Mastery of Human
Services Delivery Systems: Range of
populations served and needs addressed
by human services
Critical Thinking Question: There are
tens of thousands of torture survivors
living in the United States, many of them
from Latin America, Africa, Eastern Europe,
and the Middle East. In addition to having
been tortured, they struggle with issues
common to immigrants: adjustment to
a new culture, language barriers, loss of
family and community support networks,
and lack of employment. How can human
service professionals best serve the
numerous and interconnected needs of
this vulnerable population?
Tutsi Genocide survivor Yvette Nyombayire Rugasaguhunga
washing her grandmother, Tereza Kamagajus, a genocide
victims bones, in a post-genocide ritual honoring the dead
Yvette Nyombayire Rugasaguhunga
388 Part III / Macro Practice, International Human Services, and Future Considerations
not occurred, as there may be political reasons why the United Nations does not level
charges of genocide against a particular government.
Tere have been several genocides in the worlds recent history, each one seemingly
more gruesome than the next. Te U.S. genocide of Native Americans during the 1700s
through the 1800s and Turkeys genocide of the Armenians in 1917 are examples of
genocides that have never been ofcially recognized by the international community.
More recent genocides include the Nazi Holocaust against the Jews in Europe during
World War II, the Serbian genocide against the Bosnians in 1992 through 1994, and
the Rwandan genocide in 1994 where approximately 800,000 to 1,000,000 Tutsis were
macheted to death by government-sponsored Hutu militia. Each of these genocides
also involved rape as a weapon of warthe raping of women of the targeted ethnic or
religious group for the purposes of either humiliating the targeted group, or impreg-
nating the women forcing them to have children of another ethnic/religious group.
For instance, in Rwanda, the Habyarimana governments armed forces, government-
sponsored militia groups called Interahamwe, and Hutu civilians not only used machetes
to kill and maim hundreds of thousands of Tutsis, but they also subjected hundreds
of thousands of Tutsi women to sexual violence with the goal of impregnating them
as well as infecting them with HIV (Buss, 2009; Cohen et al., 2009; Des Forges, 1999;
HRW, 1996).
Rape as a weapon of war is a systematic tactic used in armed confict targeting the
civilian population (primarily women and girls) involving sexual violence in an of-
fcially orchestrated manner and as a purposeful policy to humiliate, intimidate, and
instill fear in a community or ethnic group (Buss, 2009; HRW, 1996). Tus, as articu-
lated by Buss (2009), rape during wartime is not a by-product of armed confict, but an
instrument of it. In June of 2008 the United Nations Security Council passed Resolu-
tion 1820, which recognizes rape as a weapon of war and establishes a commitment to
addressing sexual violence in confict, including punishing perpetrators (UN Security
Council, 2008). Tis resolution became an important part of convictions by interna-
tional criminal tribunals in response to genocides in former Yugoslavia (the ICTY),
Rwanda (the ICTR), and in the United Nationsbacked Special Court for Sierra Leone
(SCSL) (UNDPKO, 2010).
Macro Practice in Action
Local advocacy organizations such as the YWCA (Young Womens Christian
Association) lobby for governmental policies and laws that protect victims of crime,
including sexual assault. Mothers against Drunk Driving (MADD) has been instru-
mental in lowering the legal alcohol limit for driving to 0.08 from 0.10, as well as
establishing stifer penalties for alcohol-related crashes. Amnesty International advo-
cates for human rights and social justice for oppressed individuals around the world,
releasing annual reports of human rights violations within each country. Te passage
of one domestic violence law can protect thousands of women. An antidrug educa-
tional campaign can convince thousands of adolescents to stay of drugs. One press
release can lead to a boycott that can increase wages for thousands of young women
Macro Practice and International Human Services 389
in sweatshops in India. Direct practice with individuals can change the lives of a few
people, but macro practice can change the lives of an entire community or a whole
country. Te power of macro practice should serve as an impetus for all human ser-
vice professionals to consider embracing macro practice on some level, whether that
means conducting voter registration drives in politically underserved areas, conduct-
ing a letter-writing campaign in support of legislation designed to protect a vulner-
able population, or working on behalf of an international human rights organization
that works tirelessly on behalf of exploited children, abused women, or traumatized
refugees. Such positions ofer signifcant rewards to those human service profession-
als willing to develop multidisciplinary expertise through education and experience
that when combined with the networking power of other organizations can create
positive change for all members of society.
Supporters of same-sex marriage organized a very successful and well-attended
series of rallies held across the United States in response to the passage of an amend-
ment to the California Constitution that defned a valid marriage as being between
a man and a woman. Te legislation was placed on the ballot afer the California
courts legalized gay marriage. The LGBT community and their many supporters
flooded the streets in cities across the nation demanding equal rights under the
U.S. Constitution.
An example of a grassroots organization that is working to end FGM in Eastern
Africa is Termination of FGM, a project of the Loreto Sisters of Eastern Africa Prov-
ince, located in Kenya. Te project was started by Sr. Dr. Ephigenia Gachiri, a member
of the Kikuyu tribe, who lives in a convent in Nairobi. Gachiri grew up with FGM as
a part of her culture and didnt realize the very serious ramifcations of the ritual until
she had the opportunity to attend a UN convention on womens rights and heard a
presentation on the grave consequences of FGM. She states that she made a decision
afer this conference to spend the rest of her career fghting FGM in her native coun-
try of Kenya. Sr. Ephigenia conducts educational seminars with village elders, tribal
leaders, as well as school-aged children in order to confront dangerous long-standing
myths, such as the belief that women who are not circumcised will become promis-
cuous, even potentially entering the life of prostitution. Sr. Ephigenia has developed
alternate rites of passage based upon Christian beliefs which she advocates should
replace FGM as a rite of passage into adulthood. In order to facilitate the replacement
rite of passage, Sr. Ephigenia and her colleagues conduct training seminars in schools
across Kenya where girls and boys engage in educational activities culminating in the
alternate rite of passage ceremony where they and their families commit to not allow-
ing the girls in the family to undergo FGM. Sr. Ephigenia describes the serious rami-
fcations of this choice since in many tribes, including the Maasai tribe, a girl who
is uncircumcised is not only unable to marry, but will ofen be completely shunned
from her communitybarred from engaging in communal meals, and even barred
from collecting water at the same time as the other women. Sr. Ephigenia credits her
success to the fact that she is not perceived as an outsider among her neighboring
villages, thus she has greater legitimacy and credibility than outsiders from Western
countries would likely have.
390 Part III / Macro Practice, International Human Services, and Future Considerations
Social Action Effecting Social Change
One of the most dramatic forms of social change occurred during the 2008 presiden-
tial campaign when millions of Americans, many of whom had not been previously
politically active, including many disenfranchised groups, advocated for now Presi-
dent Barack Obama, the countrys frst African American president. President Obamas
message of real change for the countryone that promised for human rights and a
renewed commitment to social justice led to a grassroots movement that many believe
was something this country has never seen in previous elections. Political afliations
aside, what is important for our purposes is the recognition that virtually all people
have the power to afect social change on a broad scale when they are motivated and
well organized.
It is sometimes easy to see all of the problems in our world and respond with a feel-
ing of futility, yet what many human service professionals soon realize is that making
the world a better place is possible, particularly for those with a passion for meeting the
needs of the most vulnerable members of society in a way that refects empathy, com-
passion, justice, and respect for human dignity.
391
1. Macro practice involves addressing and confronting
social issues that can act as a barrier to optimal func-
tioning by working
a. on an organizational level by creating structural
change through social action
b. with families to create change on a systemic level
c. with groups to create change on a systemic level
d. with individuals to create changes within society
2. According to Calkin (2000), human service organiza-
tions and professionals can easily be seduced into
colluding with violations of human rights, including:
a. disrespect toward people already struggling with
mental illness or substance abuse
b. acceptance or resignation in the face of depriva-
tions of basic human rights
c. actively advocating for the oppression of margin-
alized populations
d. All of the above
3. The frst step in community organizing is to:
a. create a consensus on what the community needs
b. develop steps in developing new policies
c. create a consensus on intervention strategies
d. create an intervention strategy addressing nega-
tive areas impacting the community
4. Of the 120 million children forced into full-time labor,
the majority reside in:
a. Africa
b. Asia
c. Latin America
d. the Middle East
5. Rape as a weapon of war
a. is a systematic tactic used in armed confict tar-
geting the civilian population (primarily women
and girls)
b. involves sexual violence during war time that is
offcially orchestrated
c. is a purposeful policy to humiliate, intimidate, and
instill fear in a community or ethnic group
d. All of the above
6. Refugees who are housed in camps for long periods
of time are referred to as
a. long-term diaspora groups
b. extended refugee problems
c. protracted refugee situations
d. nondurable refugee situations
The following questions will test your knowledge of the content found within this chapter.
CHAPTER 15 PRACTICE TEST
7. Describe the treatment many LGBTQs experience worldwide and current advocacy efforts on a local and global
level.
8. Describe dynamics associated with human sex traffcking including a description of those most vulnerable to be-
ing traffcked, underlying reasons for why traffcking occurs and current efforts to stop the practice of human sex
traffcking.
Suggested Readings
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Van Soest, D. (1997). The global crisis violence: Common
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394
Te human services profession exists to assist people meet their basic needs. One of
its strengths is its multidisciplinary approach wherein individuals with education
and training in various disciplinesincluding human services, social work, and coun-
selingwork side by side, addressing the barriers to self-sufciency and optimal liv-
ing. Unlike many other mental health disciplines, human service professionals are true
generalists, and their specializations are less ofen focused on particular psychological
disorders, and more ofen focused on a particular social problem, such as interfamily
violence or child welfare.
The passion to create meaningful change in the lives of others creates a drive in
many human service professionals that may compensate for the relatively low pay and
ofen less-than-ideal working conditions (although it would be incorrect to assume that
just because one wants to enter the human services feld, he or she cannot earn a decent
living). Nonetheless, it is this drive and passion that pushes so many individuals forward
in a career that does not have particularly high status, but afords the unique experience
of having the power to make a signifcant diference in the lives of others by reminding
people of their worth, holding the hand of the dying, reminding a grieving child that
there is still hope, or standing with victims of violence who are facing their attackers in
court. Tis is an empowering career, one that changes with every new client.
Human services is a unique career in that it can ofen lead to other opportunities in-
cluding a career in academia, writing, public speaking, policy analysis, or international
human rights work. Even a career track that leads to clinical private practice can remain
exciting and varied if the human service professional remains committed to social jus-
tice and advocacy.
Avoiding Professional Burnout
As wonderful as this career is, it is also wrought with stress, crisis, and a signifcant
potential to burn out quickly. Tere are many ways to avoid burnout, and several
of these ways involve developing mental paradigms that help professionals avoid
becoming overinvolved in the lives of their clients. One paradigm that benefts many
human service professionals is to recognize that their clients are on a journeyon
their own journeyand the role of the human service professional is to assist the cli-
ent on a small portion of this journey. Many human service professionals experience
professional burnout because they take too much responsibility for the lives of their
clients. Understanding that clients are on their own journey and trusting that the
Epilogue
The Future of Human Services in
an Ever-Changing World
Epilogue 395
human service professional is one of many mentors, counselors, or guides who will
come along in their clients lives puts the clinicianclient relationship into healthy
perspective.
Another paradigm that can be useful in helping human service professionals to
avoid burnout is to make a commitment to never work harder than your clients. Human
service professionals typically enter the helping profession because they care about peo-
ple and want to help them have better lives. It is easy for human service professionals to
fall into the trap of overworking for a client whom they so much want to help. But one
must ask whether doing too much for a client is actually helpful. Or could it be harmful
to clients who may already feel powerless and unable to take the steps necessary to make
positive changes in their lives? Tis does not mean that it is inappropriate for a human
service professional to help an overwhelmed client make a telephone call or that it is
enabling for the counselor to make initial contact to a referral. But whenever I begin
to feel overwhelmed working with certain clients, the frst question I ask is whether I am
working harder than they are. If the answer is yes, then I need to step back and give
my clients the room to decide whether or not to take the necessary, albeit ofen difcult,
steps to create positive change in their lives. If my clients choose not to exert the neces-
sary energy, then, as saddened as this might make me, I must accept my clients inaction
as a choice to remain in whatever situation they are in.
Human Services and Technology
Technology has changed (and continues to change) the world; the human services
profession has been slow in making use of technological changes. Reasons for this
include the lack of security in e-mail communication, which has an impact on con-
fdentiality. E-mail communication between practitioner and practitioner discuss-
ing clients or e-mail communication between practitioner and client may expose a
human services agency to legal liability if privacy cannot be guaranteed. Another
reason for human services agencies general reluctance to become more technologi-
cally based relates to the costs associated with purchasing and maintaining computer
systems.
Despite these concerns, the Internet can be a wonderful resource for human service
professionals searching for appropriate referrals for clients. Most counties have websites
that include comprehensive information about available services. Many human services
organizations, government assistance programs, and various grant-giving agencies not
only have invaluable information on their websites, but also allow applicants to apply
for services online, expediting the application process.
Te Internet can be tremendously useful for human service professionals who want
to coordinate services with other professionals or obtain information on a particular
issue. Technology is also being used to facilitate various types of testing, including per-
sonality and career assessments, ADHD (attention defcit/hyperactivity disorder) evalu-
ation, and adaptive functioning evaluations. Advocacy eforts have been made easier
through the Internet: Legislation can be researched online and a virtual letter-writing
campaign can be conducted in minutes.
396 Epilogue
Despite the concerns about privacy and confdentially, technology can serve both
human service professionals and clients. Te Internet can be empowering for clients,
enabling them to be more self-sufcient in fnding resources, including housing, job op-
portunities, and child care. In addition, there are resources for homebound individuals
who might not be able to beneft from an on-site support group but can garner some of
the same benefts from online support groups or bulletin boards.
The Effect of the Economic Crisis and Changes in
the Political Landscape on Human Service Practice
Te human services feld is expected to continue to grow in the coming decades. Tere
are various reasons for this, including the increasing complexity of society that results
in numerous challenges for families. As the challenges facing societies increase, human
services agencies will continue to be a valuable resource providing services for a broad
range of clients. Whether working in schools, hospitals, criminal justice agencies, or the
government, human service professionals serve those individuals who do not have the
resources to meet their most basic needs.
Te economic crisis that began in 2007 resulted in numerous employment layofs,
home loan foreclosures, and a significant increase in the economic vulnerability of
many people living in the United States. Any one type of vulnerability within the lives of
individuals will no doubt increase their vulnerability in all areas their lives, thus increas-
ing the incidence of all of the social problems explored in this book, including domestic
violence, child abuse, homelessness, mental health issues, and physical illness, which
in turn will increase the need for human service professionals across the wide range of
populations and practice settings. Unfortunately, this increased need exists in the face
of signifcant fscal cuts on local and national levels, most of which afect the funding
of social service programs. Te long-term efect of this economic crisis on the human
services feld remains to be seen, but those in the human services feld have a lot to be
optimistic about in light of the Obama administrations stated commitment to social
justice in policies afecting the countrys most vulnerable members.
Globalization
Our world is shrinking due to a variety of domains becoming globalized, which is hav-
ing a dramatic impact on the world and how it functions. Te globalization of world
market economies means that if one country sinks into a recession, it will likely take the
rest of the world with it. If civil war rages in a far-of country, the ripple efect will be felt
worldwide, whether through forced migration and refugee fow or international com-
munity involvement. Te globalization of communication means that we can switch
on our television sets, or our laptops, and know instantly what is happening thousands
of miles away. We can Skype friends and family across the globe, text for free using
our smart phones attached to a wireless connection, and make connections with old
friends from elementary school and new friends in foreign countries using social media
sites such as Facebook, Tumblr, or Twitter. Tese are exciting times for communication,
Epilogue 397
but such rapid technological developments create both positive and negative conse-
quences. Migrants can remain connected to home on a daily basis (good), and wage
virtual war against their homeland governments using the Internet (bad). Child por-
nography is rampant online (bad), but law enforcement can use virtual online stings to
catch consumers (good). Te human services profession has no doubt been afected by
the globalization of technology because our clients have.
Tose in the human services feld are committed to addressing problems in society,
ofen before those within society are prepared to admit that such problems even exist.
Human service professionals are consistently on the frontlines of social problems,
creating change in the lives of individuals and communities, and globally. Society is
constantly evolving, which creates the sometimes negative by-products of confict, com-
plexity, and challenges for many. It is for this reason that human service profession-
als will always be needed to recognize and confront human problems, helping societys
most vulnerable members meet their basic emotional, physical, and spiritual needs.
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399
Abstinence-only programs, 296
Abuse
of the elderly, 375ph
female genital mutilation, 375
against homosexuals, 382385
Academic counseling, 283
Academic model, 251
Academy of Criminal Justice (ACJS), 52
Achievement gap, 282
Active listening, 66, 6768
Acute psychiatric hospitals (inpatient), 178
Addams, Jane, 2730, 9192
Addiction, 247255, 259263, 266270. See also Substance abuse
Addiction Severity Index, 263
Addictive disease model, 250
Administration on Aging, 149
Adolescents
abstract thought, ability for, 126
behavior, causes affecting, 127128
behavior, internalized, 128
behavior, self-abusive, 129
behavior evaluation, 124
childbirth and, 220
clinical issues, 134135
conduct disorder (CD), 127128
cultural context, 124, 137138
development stage, 122123
eating disorders, 133134
ethnicity, effect of, 137138
historical context, 124
homelessness and, 203205
identity, search for, 125
immigration, effect of, 125
maladaptive behavior, 127128
mental health and, 204
oppositional defiant disorder, 127128
practice settings, 135137
psychiatric hospitals, 135
psychosocial issues, 125
rebellion, 126127
regional context, 124
residential care, 135
self-injury (self-mutilation), 129131
services, 122140
suicide, 131133
in sweatshops, 378
Adoption
Adoption Assistance and Child Welfare Act of 1980, 9394
and Catholic Charities agencies, 321322
cultural issues, 114116
Fostering Connections to Success and Increasing Adoptions
Act of 2008, 94, 113
incentive program, 100
and practice settings, 15
rights unavailable to LGBTQ, 33
with termination of parental rights, 99100
transracial, 116
Adoption and Safe Families Act, 94
Adoption Assistance and Child Welfare Act of 1980, 9394
Adoption incentive program, 100
Adult Protective Services (APS), 160
Advance directives, 234
Advocacy
foster parents, 110
Mothers Against Drunk Driving (MADD), 388
social justice, 5354
Young Womens Christian Association (YWCA), 388
Affective disorders, 172173
Affective flattening, 172
African Americans, 3133, 92, 113114, 116, 138, 179, 182183,
289290, 353
churches, 321
presidential election, 3941
Aftercare movement, 175
Age Discrimination in Employment Act of 1967, 91
Ageism, 150151
Age-restricted community, 151152
Aging. See Geriatrics and aging
AIDS (acquired immune deficiency syndrome), 357. See also
HIV/AIDS
AIDS cocktail, 226
Aid to Families with Dependent Children (AFDC), 37, 200
Al-Anon, 270
Alateen, 270
Alcohol, 245247. See also Substance abuse
Alcoholics Anonymous (AA), 246247, 267, 269
Alcoholism, 246, 249
All-American Muslims, 393
Alogia, 172
Alpha Kappa Alpha, 32
Al-Qaeda, 292
Alzheimers disease, 159161
American Academy of Neurology, 169
American Academy of Pediatrics, 169
American Adoption and Safe Family Act of 1997, 100
American Association of School Social Workers, 276
American Association of University Professors (AAUP), 52
American Bar Association (ABA), 50
American Civil Liberties Union (ACLU), 291
American Counseling Association (ACA), 5253, 58
Index
Note: Page numbers followed by an f refer to figures. Page numbers followed by a ph refer to photographs. Page numbers followed by t refer
to tables.
400 Index
American Psychiatric Association, 151, 159
DSM-IV-TR, 249
American Psychological Association (APA), 52, 58, 169
American Recovery and Reinvestment Act of 2009, 40
American School Counselor Association (ASCA), 282
American Society of Addiction Medicine, 261
American Sociological Association (ASA), 52
Americas Law Enforcement and Mental Health Project, 181
Amnesty International, 372, 377, 385
Angel Tree program, 323
Anger management, 82, 101
Anger management training, 344
Anorexia nervosa, 133
Anti-immigration movements, 42
Antisocial personality disorder, 171
Anxiety, and depression, 129
Apprenticeships, 8485, 86. See also Indentured servitude
Area Agencies on Aging (AAA), 149
Assessment
clinical, 67
psychosocial, 6668
Assessment tools, 289
Assisted-living facilities, 152
Association of Jewish Family and Childrens Agencies (AJFCA),
313314
Atchley, Robert, 154
At-risk populations, 366367
Attention deficit disorder (ADD), 134, 297298
Attention deficit/hyperactivity disorder (ADHD), 134, 297300
Attribution theory, 340
Autonomy, 51
Baby boomers, 144
Baby Think It Over (BTIO), 297
Bachmann, Michele, 39
Battered womens shelter, 344345
Batterers programs, 344345
Beck, Aaron, 173
Behavioral/environmental model, 250251
Behavioral programs, 356
Behavior(s)
assessment/ intervention/ treatment of suicidal, 132133
continuum, 7273
cultural influences, 5152
evaluating, 49
externalizing, 127128
internalizing, 128
Beneficence, 51
Bereavement counselor, 231, 236237
Biopsychosocial depression, 173
Bipolar depression (manic), 167, 172
Bisexual rights, 383
Bisexuals, 290292
Black Church, and rural communities, 321
Boom, Corrie ten, 48, 49, 51
"Boot camp" programs, 136
Borderline personality disorder, 171, 174
Boundary setting, 6365
Bowen, Murray, 6869
Brace, Charles Loring, 8889
Bronfenbrenner, Urie, 12
Ecological Systems Theory, 1213
Bulimia nervosa, 133134
Bureau of Justice Assistance (BJA), 181
Burgess, Ann, 347
Bush, George W., 184, 186, 308309, 357
Bush/Cheney administration, 385
Butler, Robert, 150
Byrd, James, 33
CAGE questionnaire, 263
Cain, Burl, 323
Calvinism, 29, 30
Career development, 283
Caregiver burnout, 161
Caregiver support groups, 161
Care Services Act (CSA), 308
Case management, 278
definition, 7374
direct counseling services, 7374
hospice, 232233
social work, 7374
Case studies
child abuse, intergenerational, 102103
child labor, 378380
Christian faith-based agency, 323326
homelessness, 211213
Jewish faith-based agency, 314319
Muslim faith-based agency, 331332
school social work, 279280
substance abuse, 251252
Task-Centered Approach, 7577
Castle Christian Counseling Center (CCCC), 323
Catholic Charities USA, 319, 321322
adoption and childrens services, 321322
Catholic Youth Organizations (CYO), 322
Causality of abuse, 339341
Center for Substance Abuse Prevention, 262
Centers for Disease Control and Prevention (CDC),
225226, 337
Central nervous system
depressants, 254, 266
stimulants, 253255
Charitable Choice Act, 308
Charity, 20, 22
Charity Organization Societies (COS), 2627, 87
Charity without Fear, 329
Child abuse
determining, 60, 99
forensic interview, 9697
homelessness and, 204, 376
intergenerational, 102103
international, 374376
investigation, 9499
Index 401
maltreatment categories, 9596
mandated reporters, 9495
and neglect, 295296
recanting, 105
reporting, 95
self-injury (self-mutilation), 129131
sweatshops, 378
types of, 9596
Child Abuse Prevention and Treatment Act of 1974 (CAPTA), 93
Child and family services, 8283
Child at Risk Field System (CARF), 9899
Childbirth, adolescent, 220
Child Emergency Response Assessment Protocol (CERAP), 98
Child labor, 377378, 377ph
in Colonial America, 8485
during the Industrial Era, 86
Jane Addams and, 9091
laws, 84
oppressive, 91
slavery and, 8586
Child maltreatment, 9596
Child placement, 99101
Child protective services (CPS), 82, 118, 221
Children
abuse of. See Child abuse
African American, 92
apprenticeships and, 8485
behavioral problems, 103104
education and, 203
exploitation of, 378
and factories, 86
farming out, 8890
female genital mutilation, 375ph
foster care, 9193
grandparents, raised by, 155, 156t, 157158
grief, 105106
health-care insurance, 157
historic treatment of, 8384
homelessness, 195, 201203, 207209
human rights, 111113
identity development, 106108
identity issues, 106108
indentured contract, 89
indentured servitude and, 8485
labor law, 84
loss, 105106
maltreatment, 9596
mistreatment of, 8385
mourning, 105106
parent reunification, 101, 110111
psychological problems, 103
rights of, 377
runaways, 203205
sex trade of, 375376
slavery and child labor, 8586
of the streets, 376377
in sweatshops, 86
Child welfare, 114116
laws in the United States, 84
Child Welfare League of American (CWLA), 98
Child welfare system
factors, affected by, 83
goals of, 93
historic roots, 8391
overview, 9199
Christian human services, 319321
Christianity, 307, 327
Christian Right, 3738. See also Welfare reform
Civilian Conservation Core (CCC), 30
Civil Rights Act of 1964, 92
Civil Works Administration (CWA), 30
Class conflict, 197
Clinical diagnoses, 7073
Clinical issues
prison population, 356357
responses, effective, 286300
substance abuse, 255257
violent crime, 352, 354355
Clinton, Bill, 46
Cocaine Anonymous (CA), 269
Code of Ethics, professional
American Counseling Association (ACA), 52
developing, 50
National Association of Social Workers (NASW), 52, 58
Co-Dependents Anonymous, 270
Cognitive-behavioral theory, 173
Cognitive behavioral therapy (CBT), 134, 341
Colson, Chuck, 322323
Commission on Mental Health, 184185
Community building, 322
Community development, 368
Community mental health centers, 170, 177, 179, 180
Community Mental Health Centers (CMHC) Act of 1963, 170
Community organizing, 368
Comorbidity, 129
Competencies
boundry settings, 6365
and skills, 6166
sympathy and empathy, 6163
Comprehensive care, 29
Conduct disorder (CD), 127128
Confidentiality, 5861
and informed consent, 5861
limits of, 5961
Conflict, class, 197
Conflict resolution, 279
Consent, informed, 5861
Contextual map, 287
Contraception, 297
Cooper, Anna, 33
Coping skills, 74, 75
Core values, 307
Correctional facilities, 356
Council for Standards in Human Service Education (CSHSE), 6
402 Index
Council on American-Islamic Relations, 311
Counseling, professional
case management, compared with, 7374
death, 232
hospice, 232233
listening skills, 66, 6768
patience, 6667
psychological testing, 70
reframing, 7778
sympathy/empathy, 6163
techniques, 61
Counseling methods, 310
Court, Mental health, 181182
Court-appointed special advocates (CASA), 83
Crime, 348349, 352353, 374. See also Domestic violence;
Sexual assault; Violence
Criminal justice system, 356, 357, 358
Crisis, economic, 145, 195, 196
Crisis intervention, 231, 279
Cultural competence, 7879, 284
Cultural diversity, 7879
effect on adolescent development, 137138
Cultural sensitivity, 79, 259260, 306
Cutters (self-mutilate), 130
Cycle of poverty, 21
Cycle of violence, 338339
Darwinism, 2326, 37, 41
Daytime drop in-centers and emergency shelters, 213
Day treatment programs, 177
Death/dying
bereavement counseling, 231, 236237
euthanasia, 238239
grief, 236237
hospice, 229241
seven reconciliation needs of, 237
spiritual component of, 235236
Deep South Project, 227228
Defense of Marriage Act, 33
Deinstitutionalization (mentally ill), 169170
Deliberate Self-Harm (DSH), 129131
Delusions, 172
Dementia, 159, 161
Department of Defense, 261
Department of Health and Human Services (HHS), 248
Department of Housing and Urban Development (HUD), 192, 194,
207
Department of Veterans Affairs (VA), 206, 261
Dependent personality disorder, 174
Depression, 286288
and anxiety, 129
biopsychosocial model, 173
bipolar (manic), 167, 172
causes of, 173
cognitive-behavioral theory, 173
homelessness, 178179
older adults, 158
prevalence, 172173
risk factors, 158
social-contextual model, 173
symptoms, 173
Depressive disorder, major, 128
Detoxification programs, 266267. See also Treatment programs
Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-
TR), 7073, 127, 170, 249, 297298
Diseases, 204, 225229, 233, 373374
Disorganized thinking and speech, 172
Diversity, 7879, 288290, 311
Dix, Dorothea, 169
Domestic violence
batterers programs, 344345
counseling victims of, 339341
forensic human services and, 336337
practice settings, 354
prosecution of, 343344
Domestic violence shelters, 214
Dont Ask Dont Tell (DADT) repeal, 3334
Drug Abuse Resistance Education (DARE), 295
Drugs. See also Substance abuse; Treatment programs
all arounders, 254255
downers, 254, 266
medical use of, 246
nonmedical use of, 246
prescription, 255
uppers, 253
war on, 355356
DSM-IV-TR (American Psychiatric Association), 7073, 127, 170,
249, 297298
Dual-diagnosis patients, 269
Duluth Model, 344
Duty to warn/duty to protect, 5960
Eating disorders, 133134
Ecological model, 287
Ecological Systems Theory, 1213
Economic crisis, 145, 195, 196
Economic policies, Neoliberal, 3437
Ecosystems, 12, 13f
Eco-Systems theory, 1314
Education, 208209
licensure and human service, 69
requirement of Human service professionals, 56
Education for All Handicapped Children Act of 1975, 281
Education Trust, 282
Elder abuse, 159161
Election, presidential, 3941
Elizabethan Poor Laws, 2123
Emergency services, 320, 330
Emergency shelters and daytime drop in-centers, 213
Emotional abuse (child), 96
Emotions, vs. ethics, 4748
Empathy
defined, 61
and sympathy, 6163
Index 403
Empowerment theory, 72
Enmeshment, 328
Equality, marriage, 3334
Equal Pay Act of 1963, 91
Erikson, Erik, 146147
Ethics
boundaries, 6365
conflicting values, 4849
cultural influences, 5152
definition, 46
dilemmas, 46, 5052, 54
vs. emotions, 4748
hospice care, 238239
of human service professionals working with mentally ills,
186187
principles of, 53
professional Code of, 50
standards of, in human services, 5253
Ethnic diversity, 288290
Ethnocentrism, 79
Euthanasia, 239
Evangelizing, 320
Evidence-based practice, 79
Exosystem, 12, 287
Externalizing behavior, 127128
External locus of control, 340
Factories, children and, 86
Failure to Protect: The Taking of Logan Marr
(PBS documentary), 110
Fair Labor Standards Act, 91
Faith-based agencies
benefits of, 310311
Black church, 321
Catholic Charities USA, 319, 321322
Christian human services, 321322
federal legislation, 308310
history, 305306
human service professionals role in, 332
Islamic human services, 327329
Jewish human services, 312319
methods of practice, 310
Prison Fellowship Ministries (PFM), 322323
religious diversity in, 311
rural communities, 321
vs. secular organizations, 306307
services and intervention strategies, 312
Young Womens Christian Association (YWCA), 388
Faith-Based Community Initiatives Act, 308
Faith communities, 310
Family, 270
Family continuity, 108
Family foster care system, 8890
Family preservation programs, 111113
Family Systems Theory, 6870
Family violence, 337338
Federal Deposit Insurance Corporation (FDIC), 31
Federal Emergency Relief Act, 30
Female genital mutilation (FGM), 375, 375ph, 389
termination of, 389
Feudalism, 19
Florida Family Association (FFA), 393
Food and Drug Administration (FDA), 246
Forced migration, 382
Forensic human services, 336359
Forensic interview (child abuse), 9697
Foster care
African Americans, 113114
behavioral problems, 103104
biological parents, 9394, 99101
children, number of, 92
continuity, importance of, 108
crisis, 109
demographics, 9293
different race, 113
documentary, PBS, 110
family preservation, 111113
Fostering Connections to Success and Increasing Adoptions Act
of 2008, 94, 113
identity issues, 106108
issues, 103
legislative goals, 9394
length of stay, 93
licensure requirements, 109
minorities, 113
placement criteria, 93
placement settings, 109
primary goal, 93
psychological problems, 103
reunification, 110111
separation, 104105
service plan, 103
siblings, 107108
training sessions, 109
Fostering Connections to Success and Increasing Adoptions Act of
2008, 94, 113
Freud, Sigmund, 146
Friendly visitors, 2627
Full-service human service agency, 177
Fundamental attribution error, 197
Gachiri, Ephigenia, Sr., 389
Gang activity, 352353
Gang involvement
practice settings, 354
risk factors of, 353354
Gay, 290292
Gay, Lesbian and Straight Educational Network (GLSEN), 290
harassment, 290291
Gay & Lesbian Alliance Against Defamation (GLAAD), 3334
Gay marriage rally, 383ph
Gay rights, 3334, 39, 382383
Gay-straight alliance clubs (GSA), 291
Gender sensitivity, 259260
404 Index
Generalist practice, 61, 7475
Generalist practice interventions, 257258
General systems theory, 12
Genocides, 387388, 387ph
Genograms, family, 6870
Geriatrics and aging
activity levels, 149
Adult Protective Services (APS), 160
ageism, 150151
"age-restricted community, 151152
caregiver burnout, 161
caregiver support groups, 161
coping strategies, importance of, 149
dementia, 159
demographics, 144145
depression, 158
developmental theories, 145148
elder abuse, 159161
employment discrimination, 150151
financial vulnerability, 145
grandchildren, raising, 155, 156t, 157158
homelessness, 152153
housing, 151152
life expectancy variables, 145, 151
life reflection, 147
psychosocial development, 145148
retirement, 153155
services, 142163
special populations, 162163
stereotypes, 150
successful aging, 148149
Gerotranscendence theory, 147148
Gesture, suicidal, 131
Gingrich, Newt, 4041
Global assessment of functioning (GAF), 71
Global Financial Crisis. See Economic crisis
Globalization, 371
Grandchildren, raising, 155, 156t, 157158
Graying of America, 144145
Great Depression, 31, 41, 198199
Great Society program, 30
Grief (children), 105106
Group counseling, 176, 278
Growth, Personal, 6566
Gurteen, S. Humphreys, 26

Hajj, 328
Hall, G. Stanley, 122123
Hallucinations, 172
Harrison Act of 1914, 246
Hate Crimes Prevention Act, 33
Hazelden, 267
Healing Forest Model, 381
Healthcare and hospice
history of, 229230
hospice movement, 299231
hospitals, 220
human service professional, 220222
multicultural issues, 237239
philosophy of, 230231
Hierarchy of Needs, Maslow's, 14, 14f
Hijab, 328
HIV/AIDS, 195, 204, 225229, 230, 373374
concluding thoughts on, 228229
and latino population, 227228
Holistic perspective, 305
Holmstrom, Lynda, 347
Holocaust, 48
Holocaust survivor services, 314
Homeless Emergency Assistance and Rapid Transition to Housing
(HEARTH) Act, 192194
Homelessness
African-American(s), 179
aging, 152153
America, 191194
causes of, 195198, 199, 214, 216
children, 195, 201203, 207209
clinical issues, 209211
definition of, 192193
depression, 178
education and, 203, 208209
elderly, 206207
emergency shelters and daytime drop-in centers, 213
Great Depression, 198
history of, 198199
legislation for, 207209
McKinney-Vento Homeless Assistance Act of 1987, 207209
mental health and, 204205
mental illness, 178179
minorities effected by, 191192
number and demographic characteristics of, 194195
poverty, 196
public assistance, 198, 200
school, effect on, 203
shelter living, 201203
single men, 205206
single parents, 199201, 211213
substance abuse, 205206
transitional housing programs, 194
Homicide, 353, 355
victims of, 351
Homophobia, 383
Homophobic terms, 290
Homosexuality, 34, 290292
Honeymoon-like state, 338
Hospice
case management, 234235
counseling, 236237
crisis intervention, 231
definition of, 229
ethical dilemmas of, 238239
history of, 229230
human service, concluding thoughts on, 239241
intervention, 232
philosophy of, 230231
Index 405
psychosocial assessment, 231232
spiritual component of, 235236
team, 231
Housing
government-subsidized older adult, 152
of older-adult, 151152
Housing and Urban Development (HUD), 194
Housing Management Information System (HMIS), 194
Hull House, 2829
Human rights, 111113, 380, 386387
Human rights framework, inalienable rights, 367368
Human service agency, 6
Human service professionals
adolescents, 125, 206207
at-risk populations, 366368
boundaries, 6365
children, 374
and Christian human services, role of, 319321
in clinical issues of prison population, role of, 356357
criminal justice system, 365
crisis and trauma, 223
crisis intervention, 231
curriculum requirements, 8
definition, 3, 5
duties, 9
education requirements, 56, 7t
empowerment theory, 72
ethical considerations of, 186187
families, 224
functions and responsibilities in, 224
generalists, 11
goals of, 5
historic roots, 1920
HIV/AIDS, 226227
homelessness, 197, 209213
homosexual rights, 384385
hospice, 231232, 234235, 239241
human rights abuses, 385
human trafficking, 376
inalienable rights, 367368
international, 373376
intervention, 232
and Islamic human services, role of, 327329
and Jewish human services, role of, 312313
licensing requirements, 56
macro practice, 364368, 382, 388389
medical, 220223
mental health courts, 181182
mezzo practice, 364
micro practice, 364
National Association of Social Workers (NASW), 223
negative bias, 183
objectivity, 23
practice settings, 1516
professional standards, 56
psychosocial assessment, 231232
purpose of, 364
refugees, 382
schools, 286288
students, 363
theoretical orientation of, 1012
variety of, 5
Human Services
defined, 3
ethical standards, 5253
frameworks, theoretical, 10
goal, 4
job titles, 3
need for, 35
in prison settings, 354355
Human Services and Social Policy Pillar (HSSP), 313
Human Services Board Certified Practitioner (HS-BCP), 8
Human sex trafficking, 375376
Hunter, Jane, 33
Hurricane Katrina, 311
Huss, Magnus, 246
Identity development, 106
Identity issues, 106108
Ideology, 311
Ill Quit Tomorrow (Johnson), 258
Indentured servitude, 8485, 86. See also Apprenticeships
Indian Child Welfare Act, 117
Indian Health Service, 261
Indigenous people, 380381, 380ph
Individual and family services, 313
Individual counseling, 278
Individualized Education Plan (IEP), 278
Individuals with Disabilities Education Act of 1975, 277
Indoor relief, 22
Industrial Era
child labor during, 86
Informed consent, 51, 5861
and confidentiality, 5861
defined, 58
Inner-City Muslim Action Network (IMAN), 329330
Inpatient treatment programs, 266267. See also Treatment programs
Insight counseling, 176
Intensive outpatient treatment (IOT), 268
Internalizing behavior, 128
International Association of Schools of Social Work (IASSW), 372
International Council on Social Welfare (ICSW), 372
International Covenant on Civil and Political Rights (ICCPR), 386
International Federation of Social Workers (IFSW), 372
International human services, 371372
Internet resources
adolescents, 140
aging, 165
ethics and values, 56
faith-based agencies, 334
forensic human services, 361362
healthcare and hospice, 243
homelessness, 218
human services, history of, 44
406 Index
Internet resources (continued)
importance of, 371
international human services, 392
mental health, illness, 189
school systems, 302
skills and intervention strategies, 81
substance abuse, 272
Intersectionality, 367
Intervention, 78, 79, 175176, 232
Intimate partner violence (IPV), 337338. See also Domestic
violence
Investment model of decision making, 341
Islam, 332
Islamic Circle of North America (ICNA), 330
Islamic human services, 327329
Islamic Relief USA, 311, 330331
Islamic Social Services Association (ISSA), 329
Jewish Community Centers (JCC), 135
Jewish Family Services (JFS), 311
Jewish Federations of North America (JFNA), 313
Jewish human services, 312313
Jewish movements, 312
Johnson,Vernon, 258
Justice, 51
Justice Fellowship, 322
Juvenile detention centers (juvenile hall), 135, 136
Keeping Children and Families Safe Act, 93
Kevorkian, Jack, 238
Kitchener, K. S., 51
Kitcheners model, 51
Kohlberg, Lawrence, 4950
Lathrop, Julia, 91
Latino Commission on AIDS, 227
Laws and legislation
4th Amendment, 308
18th Amendment (1919), 247
21st Amendment (1933), 247
Adoption and Safe Families Act, 94
Adoption Assistance and Child Welfare Act of 1980, 9394
American Adoption and Safe Family Act of 1997, 100
American Recovery and Reinvestment Act of 2009, 40
Care Services Act (CSA), 308
Charitable Choice Act, 308
child labor, 9091
Community Mental Health Centers (CMHC) Act of 1963, 170
Education for All Handicapped Children Act of 1975, 281
Executive Order 13199, 309
faith-based, 308
Faith-Based Community Initiatives Act, 308
Harrison Act of 1914, 246
Homeless Emergency Assistance and Rapid Transition to
Housing (HEARTH) Act, 192194
Individuals with Disabilities Education Act of 1975, 277
International Covenant on Civil and Political Rights (ICCPR), 386
Matthew Shepard & James Byrd Jr.Hate Crimes
Prevention Act, 384
McKinney-Vento Homeless Assistance Act of 1987, 207209
No Child Left Behind Act, 281
Patient Protection and Affordable Care Act of 2010 (PPACA),
185
Stewart B.McKinney Homeless Assistance Act of 1987, 192
Violence Against Women Act of 1993, 343344
Violent Crime Control and Law Enforcement Act of 1994, 343
White House Office of Faith- Based and Neighborhood
Partnerships, 309
The Learning Channel (TLC), 393
Least restricted environment, 170
Lesbian, 290292, 382383
Lesbian rights, 39
Levinson, Daniel, 147
LGBTQ (lesbian, gay, bisexual, transgendered, and questioning
and/or queer), 3334
Licensed Clinical Professional Counselors (LCPC), 135
Licensed Clinical Social Workers (LCSW), 135
Licensure and Human service education, 69
Life reflection (development stage), 147
Lindsey, Elizabeth, 202
Listening, active, 66, 6768
Lou Gehrigs disease (ALS), 233
Lowell, Josephine Shaw, 27
Macro practice
in action, 388389
at-risk populations, 366368
community development, 368369
community organizing, 369370
movement away from, 365
policy practice, 370371
purpose of, 364
techniques of, 368
vulnerable populations, 382
Macrosystem, 12
Making Schools Safe project, 291
Male-on-Male sexual assault, 347348
Managed care, 247, 261
Mandated reporter(s), child abuse, 9495
Marriage
equality, 3334
same-sex, 33
traditional, 34
Maslow, Abraham, 14, 223224
Maslows Hierarchy of Needs, 14, 14f, 223f, 224
Matthew Shepard & James Byrd Jr. Hate Crimes Prevention Act,
384
McKinney-Vento Education for the Homeless Children and Youth
Program, 208209
McKinney-Vento Homeless Assistance Act of 1987, 207209
Medical and healthcare settings, human services in, 220
crisis and trauma counseling, 223224
single visit and rapid assessment, 224225
working with HIV/AIDS patients, 225229
Index 407
Medications, 255. See also Pharmacological treatments
Mental disorders, 170
affective, 172173
diagnosing, 7073
personality, 171172
psychotic, 171172
Mental health
acute psychiatric hospitals (inpatient), 178
aftercare movement, 175
agency, human service, full-service, 177
continuum, 72, 174, 175
courts, 181182
discussed, 167187
federal funding, 184186
group counseling, 176
homelessness and, 204205
insight counseling, 176
insurance coverage, 184
legislation, 183!86
minority populations, 182183
parity, 183184
partial hospitalization (day treatment programs), 177
pathological perspective, 175176
program requirements, 179
programs, 356
psychotropic medication, 176
refugees and, 382
service access, barriers to, 179
social workers, role of, 175
Mental Health Courts Program, 181182
Mental Health Parity Act, 184
Mental Health Parity and Addiction Act of 2008, 184
Mental illness
clinical issues, 170171
Colonial America, 168169
defined, 187
deinstitutionalization, 169170
disorders, 170171
history of, 168169
and homelessness, 178179
housing assistance, importance of, 179
intervention strategies, 175176
least restricted environment, 170
mentally ill, severely, defined, 168
Middle Ages, 168
Moral Treatment era, 169
personality disorders, 171172
prison population, 180181
psychotic disorders, 171172
schizophrenia, 172
strengths perspective, 176
violence against, 181
violent behavior, 181
Mentally ill. See also Mental illness
criminalization of, 180181
Mesosystem (Mezzosystem), 12, 287
Methamphetamine, 253
Methods of practice, 310
Mezzo practice, 364
Mezzosystem. See Mesosystem
Michigan Alcoholism Screening Test, 263
Micro practice, 364
Microsystem, 287
Military, 287
Minnesota Model of treatment, 267
Mission statement, 307
Modern addiction treatment in the United States, rise of, 247248
Monnet, Jean, 40
Morality, 47
development of, 4950
Moral reasoning
development of, 4950
Moral Treatment era, 169
Mothers against Drunk Driving (MADD), 350, 388
Motivational interviewing, 258259
Mourning (children), 105106
MSM group, 226
Muslim American Society, 311
Muslim Family Services, 330
Muslim Hurricane Relief Task Force, 311
Mutual aid society, 269
The Myth of the Welfare Queen (Zucchino), 35
Narcissistic personality disorder, 171
Narcotics Anonymous (NA), 269
National Association for Mental Health, 169
National Association of Black Social Workers (NABSW), 114
National Association of School Psychologists (NASP, n.d.), 285
National Association of School Social Workers (NASSW), 276
National Association of Social Workers (NASW), 52, 58, 169, 223,
276, 308309, 365
National Board of Certified Counselors (NBCC), 53
National Cancer Institute (NCI), 230
National Center on Addiction and Substance Abuse at Columbia
University (CASA), 255
National Center on Elder Abuse (NCEA), 159
National Commission on Correctional Health Care (NCCHC), 357
National Education Association (NEA), 53
National Health Policy Forum, 2010, 160
National Institute of Child Health and Human Development
(NICHD), 97
National Institute of Mental Health (NIMH), 158, 286
National Organization for Human Services (NOHS), 3, 5, 5253,
58, 365
A Nation at Risk, 281
Native Americans, 116118, 182, 246
Needs, 35
barriers to satisfy, 4
Maslows Hierarchy of, 14, 14f
physiological, 14
psychological, 3
safety, 14
social, 3
Negative symptoms, 172
408 Index
Neglect (child), 96. See also Child abuse
Neoliberal Economic Policies, 3439
Neoliberal philosophies, 36
New Capitalism? The Transformation of Work (Monnet), 40
New Deal program, 3031
New Freedom Initiative, 184
New York Childrens Aid Society, 88
Nixon, Richard, 322
No Child Left Behind Act, 281
Nongovernmental organizations (NGO), 330
Nonmaleficence, 51

Obama, Barack, 3334, 3941, 160, 184, 185, 186, 384, 390
Observation skills, 68
Obsessive-compulsive personality disorder, 174
Occupy Wall Street movement, 196197
Older adult housing, government-subsidized, 152
Older American Act, 149, 160
Oppositional defiance disorder (ODD), 127128
Oppressive child labor, 91
Orphan asylum(s) (orphanages), 8788
Orphan problem, United States, 8687
Orphan trains, 8890, 90ph
Outdoor relief, 22
Outpatient treatment, 268269. See also Treatment programs
Outward Bound, 135
Outwork, 86

Paraprofessionals, 264
Parenting techniques, 103
Parent reunification goals, 101
Parents
emotional trauma, 101
reunification delays, 110111
service plan, 101, 110111
Parity, mental health, 183184
Partial hospitalization (day treatment programs), 177
Patience, 6667
Patient Protection and Affordable Care Act (PPACA), 160, 185
Permanent placement plans, 101
Perpetrators of crime, 352
Personal growth, 6566
Personality disorders, 171, 173, 174
Personal Responsibility and Work Opportunity Act (PRWORA)37
Personal-social development, 283
Person-in-Environment (PIE), 13
Pharmacological treatments, 269, 298299. See also Treatment
programs
Physical abuse (child), 96. See also Child abuse
Physiological needs, 14. See also Needs
Piaget, Jean, 126
Pioneer House, 267
Placement settings, foster care, 109
Pneumocystis carinii pneumonia (PCP), 237
Policy practice, 370371
Poor laws, Elizabethan, 2123
Poor laws, England, 2021
Post-traumatic stress disorder (PTSD), 292, 314, 342
Poverty
colonial America, 22
Darwinism, 2326
homelessness and, 176
immigration, 28
indigenous people, 381
international, 377
medieval times, 1920
stock market crash, 30
Practice settings
domestic violence, 342343
mental health, 176178
older adults, 161162
Predestination, Calvins theory of, 2324
Pregnancy, 296297
and prison, 356357
Prescription drugs, 255
Presidential Election
Africam Americans, 3941
Prison, pregnancy in, 356357
Prison Fellowship Ministries (PFM), 322323
Prison human services, 354355
Prohibition Movement, 246247
Pro-Life movements, 42
Proselytizing, 314, 320321
Protestant ethic, 2326, 30
The Protestant Ethic and the Spirit of Capitalism (Weber), 23
Psychiatric disorders, 269
Psychiatric hospitals, in-patient, 136
Psychiatric rehabilitation, 170, 171, 176
Psychoactive substances, 245
Psychological assessment, 6668
and active listening, 6768
and observation skills, 68
and patience, 6667
Psychological needs, 3. See also Needs
Psychological testing, 70
Psychosocial assessment, 231232
Psychotic disorders, 171
Psychotropic medication, 176
Public assistance programs, 200
Public Education Association (PEA), 276
Public housing projects, 214
Pupil support services, 274
Pure Food and Drug Act of 1906, 246
Puritan asceticism, 24
The Purpose Driven Life: What on Earth am I Here For? (Warren), 38

Quran, 327328, 330, 331
Racial diversity, 288290
Rape, 345348, 388. See also Sexual assault
reasons for committing, 346347
Rape crisis centers, 348, 350
Rape trauma syndrome (RTS), 347
Rate of the antiviral therapy protocol (ART), 228
Index 409
Reagan, Ronald, 35
Rebellion, Adolescent, 126127
Recidivism, 354, 357
Reframing, 7778
Refugee communities, 382
Refugee resettlement, 313, 322
Refugees, 381382
Relief
indoor, 22
outdoor, 22
Religious diversity, in faith-based agencies, 311
Religiousness
vs. spirituality, 306
Residential treatment programs, 267268. See also Treatment
programs
Retirement, 153155
Reunification, 110111
Richmond, Mary, 27
Ritalin, 298299
Ritalin Revolution, 299
Roberts, Dorothy, 100102
Roosevelt, Franklin D., 30, 91
Runnymede Trust, 292
Rural communities
and Black Church, 321
Rush, Benjamin, 246
Safety needs, 14. See also Needs
Safety plan (suicide prevention), 133
Salat, 328
Same-sex marriage, 33
Saunders, Cicely, 229230
Sawm, 328
Schizoid personality disorder, 174
Schizophrenia
symptoms, 172
umbrella term, 171
violent crime, 171172, 181
School, homelessness, 203
School counseling, 274, 281285
School counselors
activities of, 283
concluding thoughts about, 285
facing ethical dilemmas, 284285
School of Social Services, University of Illinois, 75
School psychologists, 274, 283285
School social work, 275279
roles and functions, 277279
school social work model, 277
School system, human services in the, 275300
Scientific charity, 26
The Seasons of a Mans Life (Levinson), 147
The Seasons of a Womans Life (Levinson), 147
Seattle Social Development Project, 353
Secular organizations
vs. faith-based agencies, 306307
Securities and Exchange Commission (SEC), 31, 50
Self-actualization, 14
Self-determination, 65, 72
Self-esteem, 14
Self-injury (self-mutilation). See also Deliberate Self-Harm (DSH)
Separation stages, 104105
September 11, 287, 292294, 311, 327, 329
Muslim population and, 293294
Servitude, indentured, 8485
Settlement house movement, 2730, 275
Sexual abuse
child, 96, 97, 102
noncontact, 346
Sexual activity, 296297
Sexual acts, completed, 346
Sexual assault, 345348
attempted, 346
categories of, 346
defined, 346
male-on-male, 347348
psychological impact of, 347
Sexual contact, abusive, 346
Sexuality, 290292
Sexually transmitted diseases, 357. See also Rape; Sexual assault
Shahada, 328
Shattered Bonds: The Color of Child Welfare (Roberts), 100
Shepard, Matthew, 33
Shiites, 328
Simkins, Modjeska, 32
Skills
active listening, 6768
boundry settings, 6365
and competencies, 6166
observation, 68
sympathy and empathy, 6163
Slavery, 367
child labor and, 8586
Social change, 390
Social-contextual depression, 173
Social-exchange theory, 341
Social gospel, 320
Social justice, 364
Social needs, 3. See also Needs
Social Security Act, 3031
Social welfare, federal system of, 30
Social workers
African American, 3941
definition, 6
medical, 221222, 225
Socioeconomic status, 107
Special Court for Sierra Leone (SCSL), 388
Special populations, 162163
Spencer, Herbert, 25
Spirituality
vs. religiousness, 306
Starr, Ellen Gates, 90
Statement of faith, 307
Stewart B.McKinney Homeless Assistance Act of 1987, 192
Stimulus package, economic, 40
410 Index
Strengths perspective (mental health), 176
Student services, 274
Substance abuse, 101. See also Alcoholism; Drugs; Treatment programs
action, 259
among indigenous people, 380381
contemplation, 258259
demographics, 248249
denial, 256
dependent, 249250
determination, 259
Healing Forest Model, 381
homelessness, 205206
interventions, 294
methamphetamine, use of, 253254
precontemplation, 259
prevalence, 248249
prevention efforts, 244
psychological dependence, 251
role in, 249, 270
school system, 294295
societies view of, 245
tissue dependence, 251
tolerance, 251
treatment, modern-day, 247248
types, 253255
usage patterns, 248249
withdrawal symptoms, 249250
Substance abuse disorders, 249
Substance Abuse & Mental Health Services Administration
(SAMHSA), 181, 244, 248, 261, 266
Successful aging concept, 148149
Suicide
adolescent, 131133
behavior, treatment for, 132133
gestures (adolescent), 131
hospitalization warranted, 133
intervention, 133
predictors, 133
risk factors, 133
safety plan, 133
Sulzer Bill, 91
Sunnis, 327328
Survival of the fittest, 25
Survivors, 347, 352
Sweatshops, 377378
Sympathy
defined, 61
and empathy, 6163
Taft, William, 91
Take Back the Night event, 348ph
Talmud, 312313
Tanakh, 312
Tarasoff v. The Regents of University of California, 60
Tardive dyskinesia, 172
Task-Centered Approach, 7577, 236237
The Tea Party Movement, 39
Teenage pregnancy, 296297
Temperance movement, 246247
Temporary Assistance for Needy Families (TANF), 37, 200
Termination of FGM, 389
Terrorism, 292294
Theology, 310, 311
Tissue dependence, 251
Torah, 312
Torture and abuse, 385387
Toynbee Hall, 28
Traditional marriage, 34
Transgendered, 290292
Transitional housing programs, 213
Transracial adoption, 116
Treatment programs. See also Alcoholism; Drugs; Substance abuse
abstinence, 260, 265
academic model, 251
availability of, 261
continuum of care, 262263
in correctional settings, barriers to, 357358
detoxification programs, 266267
enabling behaviors, 257258
generalist practice interventions, 257258
goals, 260
harm reduction, 260261
history, 245246
human service professionals role in, 245, 256, 264265
inpatient, 267
intensive outpatient treatment (IOT), 268
interventions, 258
medical model, 247, 249250
Minnesota Model of treatment, 267
modalities, 264265
model, 250251
modern-day, 247248
motivational interviewing, 258259
mutual aid society, 269
partial hospitalization, 267
pharmacological treatments, 269
practice, 263
private programs, 261262
public programs, 261
recovery, stages of, 265
relapse prevention, 265266
residential, 267268
self-help, 269270
service delivery, mode of, 261263
settings, 266
sobriety, 265
specialist, 263
substance abuse, need and effort made to receive, 257f
twelve-step, 269
Truman, Harry, 169
Twenty Years at Hull-House (Addams), 90
United Nations Convention on the Rights of the Child (UNCRC), 112
Urban inner-city schools, challenges facing, 282283
Index 411
Urban schools, 282283
U.S. Constitution, 39
U.S. Department of Justice, 181
Vagrancy, Elizabethan Poor Laws, 21
Values
conflicting ethical, 4849
Value systems, 49
Veterans, 179, 206
Victims, 347
of homicide, 351
of violent crime, 348349
Victims Bill of Rights, 349350
Victim-Witness Assistance, 350351
Violence, 336, 348349. See also Domestic violence; Sexual assault
Violence Against Women Act of 1993, 343344
Violence prevention, 279
Violent crime. See also Domestic violence; Sexual assault
victims of, 348349
Violent Crime Control and Law Enforcement Act of 1994, 343
Visitation schedule, 103
Visiting Teachers Movement, 276
Voluntary services, 308
Walker, Lenore, 338
War, 292
Warren, Rick, 38
Washington Risk Assessment Matrix (WRAM), 98
Weapon of war, genocide and rape, 387388, 387ph
Weber, Max, 23
Welfare reform, 3439
and Christian Right, 3738
Wells, Ida B., 29, 31, 32
White House Office of Faith-Based and Neighborhood
Partnerships, 309
Willmar State Hospital, 267
Wolfelt, Alan, 237
Women and Infants at Risk (WIAR), 357
Word salad (schizophrenia), 172
Xenophobia, 182, 327
Young Womens Christian Association (YWCA), 33, 388
Zakat, 328
Zero-tolerance policy, 291
Zucchino, David, 35
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1
ANSWER KEY TO PRACTICE TEST
Below are the answers to the multiple choice practice tests.
Chapter 1
1.) D 2.) B 3.) B 4.) A 5.) D 6.) D
Chapter 2
1.) D 2.) C 3.) D 4.) A 5.) C 6.) B
Chapter 3
1.) B 2.) A 3.) A 4.) B 5.) D 6.) C
Chapter 4
1.) C 2.) A 3.) C 4.) B 5.) D 6.) C
Chapter 5
1.) B 2.) D 3.) D 4.) A 5.) A 6.) D
Chapter 6
1.) C 2.) A 3.) A 4.) D 5.) D 6.) B
Chapter 7
1.) C 2.) D 3.) A 4.) A 5.) D 6.) B
Chapter 8
1.) B 2.) C 3.) B 4.) A 5.) D 6.) C
Chapter 9
1.) D 2.) A 3.) C 4.) A 5.) A 6.) B
Chapter 10
1.) A 2.) A 3.) C 4.) D 5.) B 6.) D
Chapter 11
1.) C 2.) D 3.) A 4.) C 5.) C 6.) A
Chapter 12
1.) B 2.) A 3.) D 4.) B 5.) C 6.) B
Chapter 13
1.) A 2.) B 3.) B 4.) C 5.) D 6.) D
Chapter 14
1.) B 2.) D 3.) C 4.) D 5.) B 6.) C
Chapter 15
1.) A 2.) D 3.) A 4.) D 5.) B 6.) C
Why Do You Need This New Edition?
If youre wondering why you should buy this new edition of Introduction to
Human Services: Through the Eyes of Practice Settings, here are 9 good
reasons!
1. Integrates the 2010 CSHSE National Standards, with critical thinking questions and practice tests to
assess student understanding and mastery of standards
2. Cites new trends within the Human Services profession
3. New content throughout including:
Multicultural issues, with particular focus on Latino, African American, and Native American
populations
Refections on historic and current philosophical and religious ideological perceptions of the poor
and well as the Immergence of the Tea Party
Theoretical perspectives on the aging process and successful aging
Focusing on mental illness among special populations
Biased-based bullying and Islamophobia in the public school system
4. Increases focus on LGBTQ populations throughout.
5. Highlights changes in legislation that pertain to LGBTQ, child welfare, geriatric and homeless issues.
6. Highlights the mistreatment of individuals on a global scale with a focus on human rights violations
against the LGBTQ population, genocide, rape as a weapon of war, and female genital mutilation.
7. Includes research and statistics on health-related issues, particularly those affecting vulnerable ethnic
minority populations, such as how the ongoing HIV/AIDS crisis is affecting the male Latino population.
8. Updated statistics and research within each chapter
9. An Instructors Manual and Test Bank, PowerPoint Slides, and a MyTest Test Bank are available with this text
u p l o a d e d b y [s t o r mr g ]