Social Work & Social Welfare: Modern Practice in a Diverse World

Social Work & Social Welfare: Modern Practice in a Diverse World

Overview

This text is intended for use in introductory social work classes at the college level. Chapter topics include the foundations and history of social work and social welfare; generalist social work; ethics and values; social policy; race & ethnicity; sex, sexism, & gender; LGBTQ+ clients; poverty and financial assistance; school social work; families and children; healthcare and disabilities; substance use; mental health; criminal justice; and older clients. Mick Cullen, LCSW, CADC, MA, is a professor and chair of the social work/human services department at College of Lake County in Grayslake, Illinois. Matthew Cullen, LICSW, LCSW, M.Ed., is a counselor at Green River College in Auburn, Washington.

About the Authors

Mick Cullen, LCSW, MA, CADC, is a professor and the chair of the social work/human services program at College of Lake County in Grayslake, Illinois, where he has taught since 2005. He earned his bachelor's degree in social work from Troy University in 1999, his Master of Social Work degree from the Jane Addams College of Social Work at University of Illinois at Chicago in 2001, and a Master of Arts in sociology from Arizona State University in 2019. Mick maintained a private practice until 2012, conducting individual, family, and couples therapy, specializing in addictions, sexuality, mood disorders, and anxiety disorders. His other social work jobs have included acting as a primary therapist in an intensive outpatient program for adolescents with substance use disorders, a therapist in a residential treatment facility for adolescent sex offenders, and a caseworker for a therapeutic foster care program. He is the father of four sons and has been married to his partner since 2010. In his spare time, Mick enjoys marathon running, hosting a community radio show, collecting records, and playing miniature golf. This is the second edition of his first book.

Matthew Cullen, LICSW, LCSW, MEd, is currently a faculty Counselor at Green River College in Auburn, Washington, where he has worked since 2019.  Prior to moving to the Pacific Northwest, he was the coordinator of the counseling center, in addition to being a faculty Counselor, at Moraine Valley Community College in Palos Hills, Illinois, where he worked for eight and a half years.  He earned his Bachelor of Social Work degree, with minors in Human Behavior and Policy Evaluation, from Northern Michigan University, his Master of Social Work degree from the Jane Addams College of Social Work at the University of Illinois at Chicago, and a Master of Education in school counseling from Loyola University Chicago.  Matthew began his career helping previously incarcerated individuals transition to the workforce, then working in community health as a drug prevention specialist.  He later transitioned to higher education, first as an adjunct social work instructor before moving on to Moraine Valley, where he taught career planning and college transition courses as well as provided academic, career, and personal counseling to students.  He and his wife are big foodies, love traveling and experiencing new cultures, and speak both English and Spanish at home.  Matthew spends his spare time collecting hockey cards, playing miniature golf, and building furniture and home decor out of reclaimed wood and old sporting equipment.  This is also the second edition of his first book.

 

Cover image: "Diversity quilt" by OregonDOT is licensed under CC BY 2.0

Dedication

From Mick

To my wife Kate, who always impresses me, and without whom I am lost

To my sons Xavier, Elijah, Maxwell, and Tobias, who are the most genuinely fascinating people I know

To my parents Dianne and Michael, who always demonstrated the value of education and made it clear how important it was to do something I love

To Matthew, for being the only person I could have asked and trusted to help me do this

To my professors Pat, Rich, Robert, Suzy, Ben, and Harriet, who ignited in me a desire to teach, and a belief that I could

To my colleagues and friends Janet, Frank, Chris, Mary, Jeff, and Kathryne, whose guidance and friendship make me a better teacher and person

To all my other friends, too many to name, for encouraging me to be myself and accepting exactly that

To my former students, especially Gaganjit, Kelly, Kyle, Jessica, Jessi, Michael, Kayla, Kat, Jeremiah, and Christy, whose pursuit of social justice inspires me to keep striving in the classroom

To the students of College of Lake County, who will solve bigger problems than I ever could

And to Friedlieb Runge, without whose work I might never have finished my own

 

From Matthew

A mi Bella, por la vida que hemos construido, el amor que compartimos, y todo su apoyo y fe en mi

To Mom and Dad for instilling in me the foundational values needed to do the work I do everyday

To my brother Mick, for choosing to work with me a second time on this project

To my counseling colleagues and friends, Sumeet, Souzan, Linda, Anna, Teresa, and Sharon who continue to support, teach, and laugh with me to this day, even though I am 1700 miles and two time zones away

To the students I've had the privilege of serving, they're the reason I keep growing as a professional

And to mi gatita preciosa Almond Joy, who I miss everyday

 

 

Chapter 1: Foundational Concepts

This chapter is designed to give you an idea of the basics of the profession of social work. Perhaps you are taking this class because you want to be a social worker; perhaps you’re majoring in another area related to social work, or you’re investigating the possibility of entering the field. Whatever your level of interest, this chapter should help you understand what social work is, setting the stage for the greater specifics in the chapters ahead. When you have finished reading this chapter, you should be able to:

1. Define social work and social welfare;

2. Explain social work’s relationship to other disciplines;

3. Detail the elements of liberal and conservative political ideologies;

4. Define generalist social work and explain its importance;

5. Describe systems theory and its relevance to social work;

6. Recognize the power of language in working with clients;

7. Identify key characteristics of social workers.

Seeking help Hands reaching out. Abstract background can be used for advertising background royalty free stock photography

Social Welfare: An Institution and a Discipline

What comes to mind when you hear the word welfare? If you’re like a lot of Americans, the word carries a lot of negative connotations for you. People often think of words like poverty, entitlement, handout, or free money. However, while these terms all have an association with poverty to many Americans, what the word actually means is far less contentious and divisive.

Put simply, welfare means well-being. The reason many of us think of specific public assistance programs when we hear the word welfare is because those programs are part of the social welfare system. Those programs are meant to help provide for the well-being of individuals in need. The social welfare system includes all those organizations, programs, agencies, and other entities meant to help people meet their educational, financial, social, and health needs. If it seems to you like that is a really broad definition, well, you’re right! Among the social welfare institutions you come across in your everyday lives are:

  • Schools
  • Police and fire departments
  • Libraries
  • Hospitals
  • Houses of worship
  • Social work agencies
  • Counseling centers, and many others.

Some people speak negatively of those who are “on welfare,” but considering the actual meaning of the term, all of us are on welfare. We all benefit from the programs that exist to provide for the well-being of all members of our society. In 2012, President Barack Obama got considerable negative press, especially from conservative pundits and media outlets, when he stated during a campaign speech,

If you were successful, somebody along the line gave you some help. There was a great teacher somewhere in your life. Somebody helped to create this unbelievable American system that we have that allowed you to thrive. Somebody invested in roads and bridges. If you've got a business – you didn't build that. Somebody else made that happen. The Internet didn't get invented on its own. Government research created the Internet so that all the companies could make money off the Internet (Obama, 2012).

Opponents of President Obama particularly seized upon the phrase “you didn’t build that” as an indication that he believed entrepreneurs didn’t earn their success, or at least, that success was not possible without government assistance. The President’s supporters countered, saying the remark was taken out of context, noting that it was in fact true that everyone benefited from government programs in some way. We do all pay taxes, so we are in effect (to borrow a modern term) crowdfunding many social welfare programs in a tangible way. However, in essence, President Obama was correct—we are all “on welfare,” not just those who are receiving public assistance. In that light, we should be able to have more empathy for people who receive public assistance benefits, since the only difference between all of us is a matter of how much or what kind of social welfare assistance we receive.

Social work, as you may have deduced, is part of social welfare. The services provided by social workers in a variety of positions and roles do have the common thread of working toward the well-being of society. So how do we define social work? According to the National Association of Social Workers (NASW) Code of Ethics, the primary goal of social work is to “enhance human well-being and help meet the basic human needs of all people, with particular attention to the needs and empowerment of people who are vulnerable, oppressed, and living in poverty” (NASW, 2021).

 

Social Work Defined

If you have told people you are taking a social work class (or perhaps majoring in social work), you may have encountered some common questions. “You can major in that?” “Isn’t that just helping people? How hard can it be to know how to help people?” “You mean sociology?” “Why aren’t you majoring in psychology instead?” There is often very little understanding about what it means to be a social worker. In fact, stereotypes about social work often can be more negative than positive. While some see social workers as crusaders, social justice seekers, and valuable allies of people who are experiencing injustice and/or disenfranchisement, others hear the term “social worker” and automatically have a negative reaction. They may first think of a school social worker they were compelled to speak to at some point, or even more commonly, social workers who are employed in child protective services (CPS) programs. It’s not unusual for social work students to hear from peers, “So you’re going to be one of those awful people who take children away from their parents?!” Obviously, while removing children from abusive and neglectful situations is one role that social workers fulfill (and quite a difficult one at that), the vast majority of social workers are not involved in such endeavors.

Psychology is “the study of mental processes and behaviors” (Comer, 2014), though that field is split up into many specific areas of study and specialty like abnormal psychology, organizational psychology, social psychology, and clinical psychology. Psychology is certainly important to social work, particularly clinical social work, but while psychology is often more focused on individual functioning and internal processes, social work tends to have a greater emphasis on looking at the client(s) as part of a larger system that both influences and is influenced by the client(s) in question. Social work is very interested in not only the individual functioning and mental processes of its clients, but also in the bigger social movements, norms, practices, and influences that have had an impact on where that client is today.

Brain Model
Psychology focuses on, among other things, analyzing the workings of the brain. This is one component of the knowledge base drawn upon by social workers. 
"Brain Model" by biologycorner is licensed under CC BY-NC 2.0

In truth, social work draws from knowledge and research in a wide array of disciplines: psychology, sociology, anthropology, medicine, criminal justice, communication, and many more. This multidisciplinary approach is one of social work’s greatest strengths. The profession works to integrate as much empirical knowledge on human behavior, cognition, and functioning as it can for the purpose of helping clients to reach their identified goals and to improve their overall health and satisfaction with their lives.

 

Social Work and Politics

By its nature, social work cannot escape being involved in the political process. Social work’s quest for social justice (which will be expanded upon further in chapter 3) requires, at times, a savvy knowledge of the way things work at various levels of our government. Therefore, to help give you a basic understanding of the political underpinnings of social work, it is necessary to cover some of the basics of our political parties in the United States.

Many countries have several major competing parties holding various degrees of power within their governments. The United States’ political system, however, is largely dominated by two parties, the Democrats and Republicans, groups which are often depicted as opposite terminals on a continuum. The diversity of political views, of course, is far more complex; many people find that their views do not fit neatly within one party’s views or the other. Political scientists and other observers have at times posited that the true variations in political ideology would be better captured on a grid, or even some sort of three-dimensional construct, rather than a simple spectrum with two ends. This two-party domination of American politics has caused frustration for many U.S. citizens in recent years, as they’ve watched American politics became more and more polarized. Congress, in particular, has seen its approval ratings dip to some of the lowest levels ever recorded—9% in 2013, and never rising over 31% between August 2010 and January 2021 (Gallup, 2021)—as partisan gridlock has prohibited much work of consequence from being done in the legislative branch. Despite the vast disapproval voters hold of Congress, in the 2020 elections, 96% of Senators and Congressmen/women whose seats were up for grabs won reelection (Ballotpedia, 2021). America’s frustration hasn’t led to a change in leadership.

Precinct 86 voting booths
Despite widespread disapproval of Congress, American voters continue to elect most of the same people to continue their tenures in the House and Senate. We tend to view the party we don’t agree with as the cause of the problem, rather than acknowledging the problem belongs to everyone.
"Precinct 86 voting booths" by Big Dubya is licensed under CC BY-NC-ND 2.0

 

Conservative ideology

Conservative political views (also called “the right” or "right-wing politics") are typically held by Republicans in the United States. Conservatives tend to think of themselves as traditionalists, valuing the maintenance of the status quo and opposing wider social change in many cases. Republican politicians typically favor the so-called “traditional” nuclear family as the ideal family structure, for example, despite the fact that a home with a working father, a stay-at-home mother, and child(ren) has never actually been the dominant family structure in America for any extended period of time (see Chapter 11). Republicans also are more likely than Democrats to favor:

  • the right to personal firearm ownership (sometimes without limits or exceptions)
  • less access to abortion, and in some cases, contraception
  • greater restrictions on drug use
  • fewer limitations on the way businesses operate
  • less transparent government
  • prohibition of same-sex marriage (though most Republicans now approve of it)
  • more controlled spending on social services
  • higher military and police budgets
  • more tax breaks, particularly for wealthier Americans
  • more punitive criminal justice systems
  • stricter controls on immigration.

Please note that while these tenets of the Republican platform are shared by many elected Republicans, by no means are they universal among all members of the party. Some of these views may be more strongly held by certain Republicans than others, and some individuals within the party may break with the party line on certain views. Some Democrats may even favor some views on this list. While Republicans are often portrayed as favoring “small government,” when it serves their purpose, they appear to be greatly invested indeed in having significant governmental control over individual choice (e.g., on abortion access, substance use, etc.).

Liberal ideology

Liberal political views (also called “the left” or "left-wing politics) are typically held by Democrats in the United States. Liberals tend to believe the world is in a continual state of change for a good reason, and feel that changing attitudes about topics like marriage, gay rights, gun ownership, abortion, and birth control reflect the nation’s evolution toward new viewpoints on those topics--viewpoints which should be acknowledged by the government as valid. Democrats greatly value diversity and often express appreciation for many different forms of families as being acceptable and desirable. Liberals also typically favor:

  • stricter controls on gun ownership
  • more access to abortion (often considered a part of “reproductive rights”)
  • less punitive policies on substance use, favoring decriminalization or treatment over incarceration
  • more stringent limitations on the ways businesses conduct themselves
  • more transparent government
  • validation of same-sex marriage and equal rights for same-sex couples
  • continuing or expanding social service funding to widen the social “safety net”
  • greater taxes on wealthier Americans
  • more rehabilitative programs within our jails and prisons
  • more accessible opportunities for immigrants to become citizens.

Just as with the Republican Party platform, not all Democrats strictly adhere to all of these typical stances of the left (and some Republicans may agree with some of these views). For instance, it was under President Bill Clinton (a Democrat) that Congress passed the Personal Responsibility and Work Reconciliation Act of 1996, which replaced Aid to Families with Dependent Children (AFDC) with Temporary Assistance for Needy Families (TANF), a move generally considered quite conservative in that it put stricter limits on the length of time one could receive benefits, as well as tighter requirements for qualifying for the program in the first place (U.S. Department of Health and Human Services, 2009). (This change will be discussed in greater detail in Chapter 9.) It was also under President Clinton that a national Three Strikes law was passed after he voiced support for the measure in his 1994 State of the Union address. This law sometimes resulted in life sentences for criminals who committed a third offense as minor as stealing a pair of socks or possessing less than a tenth of a gram of heroin (Taibbi, 2013). It was certainly a law more in line with stereotypical conservative hardline criminal justice rhetoric than Democratic ideals, but one nonetheless championed by a Democratic president.

Box 1.1: Political typology

Where do you stand?

You will notice as you read this text that many of social work’s values and ethics seem to be in line with ideals often voiced by the Democratic Party. It is therefore no coincidence that many social workers consider themselves to be politically liberal. The simple fact that Democrats are more likely than Republicans to support expanded social service funding is perhaps enough to explain why many social workers support Democratic politicians: more funding means more social work jobs, and social workers generally like to stay employed and to see a panoply of services available to their clients. However, do not take that to mean that all social workers are liberal, or that it is somehow mandatory to vote Democrat in order to be a social worker. Social workers are diverse and the range of differing views they have reflects that diversity. As will be discussed later in the book when we cover ethics and values of the profession, it is essential to leave one’s personal views out of working with clients; therefore, a staunchly conservative clinical social worker who follows the Code of Ethics would not impose their views on their work with clients suffering from various mood or anxiety disorders. The social worker’s views, in fact, would not be coming up in a session at all, since the ethical social worker would be striving to put themself in the client’s shoes.

Other parties

As noted, more than two parties exist in the United States, though they have a hard time getting much traction when it comes to election results. In fact, as of 2021, only two members of Congress—Angus King of Maine and Bernie Sanders of Vermont, both Senators—were unaffiliated with one of the two major parties, both identifying as independents (though both caucusing with the Democrats). Many other parties put forth candidates on major ballots, despite the lack of significant electoral success. Here are a few of the most well-known.

Green Party: The Green Party states its major values as social justice & equal opportunity, ecological wisdom, decentralization, community-based economics, feminism & gender equity, respect for diversity, personal & global responsibility, future focus & sustainability, grassroots democracy, and nonviolence (Green Party, 2020b). Many of their views line up with stances of the Democratic Party, but they go even further in some areas of their platform, supporting a reduced-hour full-time work week and at least a month of vacation for all workers, statehood for the District of Columbia, abolishing the Electoral College, ending the war on drugs, universal health care, free child care, a living wage, preventing the establishment of media conglomerates, and free college tuition at public schools and trade schools (Green Party, 2020a). Perhaps the most notable Green Party candidate in history was Ralph Nader, who earned 2.74% of the votes for President in the 2000 general election. Beyond Nader, no other Green Party nominee for President has garnered as much as 0.4% of the vote (Woolley & Peters, 2015).

Libertarian Party: The Libertarian Party favors small government; that is, they tend to want the government to reduce the amount of regulation on both the economy and on individual rights/freedoms. Therefore, some of their views line up with Democrats, some with Republicans. For instance, they are in favor of abortion access but also strongly in favor of gun ownership rights (Libertarian Party, 2020). Libertarians generally support a free market, much like Republicans, while opposing government interference in matters of personal expression, property ownership, and the like (Libertarian Party, 2020).

Reform Party: The Reform Party has occasionally made some noise on the national election scene, most notably in 1996 when H. Ross Perot won 8.4% of the popular vote for President (Woolley & Peters, 2015). Their platform is more vaguely worded on some points, however, than some of the other political parties. For instance, the party takes no official stance on abortion or marriage equality, while making multiple mentions of fiscal responsibility in its platform and advocating “the ability to access affordable [health]care” (Reform Party, 2020). The Reform Party did not field a Presidential candidate in 2020.

Cynthia Smoot, Ross Perot, Jane McGarry
1996 Reform Party Presidential candidate H. Ross Perot, the most successful “third-party” candidate for President in recent history.
"Cynthia Smoot, Ross Perot, Jane McGarry" by Oh So Cynthia is licensed under CC BY-NC-ND 2.0

 

            Constitution Party: The Constitution Party says they support a platform based upon what they see as the original intent of the Founding Fathers in The Constitution, The Bill of Rights, and the Declaration of Independence. The party’s official platform supports phasing out Social Security, eliminating the Internal Revenue Service (IRS) and the national income tax, and encouraging private charities, houses of worship, individuals, and other groups to provide for the poor rather than the government doing so through a system of social welfare programs (Constitution Party, 2012).

 

Views of Social Welfare

There are two major views of social welfare in the United States, and a third which we will also discuss. These are known as the residual, institutional, and developmental views. The residual view tends to align itself with conservative ideology (i.e., the Republican Party) while the institutional view is more liberal in nature (i.e., aligning with the Democratic Party). The final view, the developmental view, provides some hope for a compromise between the two major opposing views.

The residual view of social welfare

Those who agree with the residual view see our nation’s safety net of social welfare programs (particularly public assistance programs) merely as temporary programs meant to provide help to people for as little time as necessary. According to the residual view, these programs should exist only in times of particular need, lest they become crutches on which people might rely, thereby making them dependent upon the government for support. People holding this view tend to believe that poverty is an escapable situation if one simply has the proper will and motivation.

Adherents to the residual view see many of the components of the social welfare system as gifts—they do not believe anyone is entitled to benefits like medical care or housing assistance. They also tend not to be terribly invested in making these services easy or pleasant for people to obtain. In the residual way of thinking, if benefits are easy to get, people will be less likely to work hard to get out of a situation where they no longer need to get assistance from the government. If services are unpleasant to obtain, that will discourage people from overusing the programs, and then money that would have been spent on supporting the poor can be redirected to other areas, or taxes can be lowered for everyone.

The institutional view of social welfare

The institutional view is the typical view held by social workers and political progressives. According to the institutional view, people generally end up in dire economic circumstances due to forces beyond their control: getting laid off, significant medical problems, death of a breadwinner, the COVID-19 pandemic, economic recession, for example. It is the role of the government, therefore, to provide for these individuals, who may very well be hardworking, educated, moral individuals that simply have fallen on hard times.

This view sees social welfare programs as rights. Adherents to this view say that as members of a society, it is incumbent upon all of us to use our resources to help those who are currently in great need, especially since we may end up in a similar situation ourselves someday (or may have emerged from such a situation in the past). It believes these programs are legitimate and necessary for the overall healthy functioning of a society where people depend upon one another. Not surprisingly, holders of the institutional view believe these services should be as humanizing as possible to obtain. People who believe in the institutional view recognize that in many cases, people have come to seek public assistance only after exhausting every other possible avenue, and many of them have encountered significant negative reactions and judgment from others before resorting to applying for assistance. Therefore, it is imperative that those who are employed in such programs be as supportive and caring as possible in their approach to applicants for aid, rather than adding to their already considerable stress and negative judgment.

Finally, the institutional view believes these programs should be permanent. That is not to say that everyone who gets benefits should be on that program and receiving benefits forever, but that there will likely always be a need for that program due to different people needing assistance at different times. Therefore, supporters of this view also support well-established funding sources for these programs.

The developmental view of social welfare

As noted earlier, our government has experienced a remarkable amount of partisan gridlock over the last several years. In 2021, Senate Minority Leader Mitch McConnell (R-KY) even said, "The era of bipartisanship is over" (Carney, 2021). With so little cooperation between differing views, it is clear that we need some sort of middle ground to appease both sides if we ever want anything to be accomplished in providing for the social welfare of our citizens. With this in mind, the developmental view provides some hope.

The developmental view comes down to one basic idea: social welfare programs can exist provided they are economically justifiable. Of course, this is more complicated than it sounds. When it comes to businesses, it is often fairly straightforward to determine profitability. Subtract expenses from revenue and what remains is profit. (Your economics professor may disagree with the simplicity of that definition, but you get the idea.) However, when it comes to social welfare programs, the same determination can be fairly tricky. Many social welfare programs do not bring in revenue in the way that businesses typically do. Even those that do may not be looking to offset all of their expenses with the fees charged for their services—for instance, counseling received through a county health department may have a fee determined by a sliding scale (based on what the client can afford to pay), even though in reality the cost of providing that counseling session is the same for the agency regardless of the client’s income.

Therefore, the developmental view can seem a bit murkier, since social welfare programs may seem very expensive to maintain while not charging their consumers an amount equivalent to the cost of providing the service. (For example, an in-prison drug abuse rehabilitation program must pay its staff counselors and supervisors, as well as paying for materials that are used in the program, office equipment for staff, and more while providing those services at no out-of-pocket cost to the client at all.) However, social welfare programs provide a lot of benefits to the economy that are not easily put into hard numbers. For instance, the benefit of an in-prison drug abuse rehabilitation program is that it decreases the chance that inmates who complete it will be recidivists—that is, prisoners who complete such a program have a lower chance of returning to prison than inmates who either don’t complete or never start one. Estimates of the annual cost of imprisoning a single inmate often hover in the $30,000-$60,000 range—for instance, Illinois estimates their yearly cost per inmate at about $33,400, while California leads the nation with a cost of over $64,000 annually per prisoner (Vera, 2017).

If an in-prison drug abuse rehabilitation program could stop just 32 inmates a year from becoming recidivists, that would mean (using California’s numbers) a savings of over $2 million for each year those 32 inmates stayed out of prison. That wouldn’t even be the full savings; the economy would also theoretically benefit from those former inmates being out and working in society, contributing to the tax base rather than draining taxpayer dollars used to imprison them. Even if those former inmates were on public assistance programs that paid them $17,500 in benefits a year in order to help them get back on their feet, the savings to the economy would still be around $1.5 million each year.

Another important way to determine the economic benefit of a given social welfare program is to look at the costs society would incur without it. What costs would there be to society if we didn’t have public schools? What if we didn’t have child protective services and foster care programs, or Medicaid? What would happen? Would there be more crime, ballooning the expensive prison population? Greater expenses incurred by hospitals as poor people came in for treatment they could never pay for, but which legally had to be provided? More homeless children? How would society counteract these costs?

Worlds Apart
Some social welfare programs are very expensive to maintain, but the cost of not having them could be even greater. What would occur if we had no resources to assist people in getting housing, or to help abused children get out of dangerous homes?
"Worlds Apart" by James Willamor is licensed under CC BY-SA 2.0

The developmental view, therefore, supports investments in “education, nutrition, and health care” as well as “infrastructure” like transportation, highways, and utilities (Midgley & Livermore, 1997, p. 577-8). It looks to find ways to help people become self-sufficient rather than depending upon the public assistance system (and therefore costing taxpayers more money). This view provides hope for agreement between liberals and conservatives because it both recognizes the importance of providing basic services and a standard of living for everyone (a big plus for Democrats) while also keeping the social welfare system fiscally accountable (a frequent focus of Republicans).

 

Generalist Social Work

The Council on Social Work Education (CSWE), which is the organization responsible for accrediting colleges’ social work programs, is clear in its expectation that social workers trained at the baccalaureate (bachelor’s degree) level should be prepared for generalist social work—that is, the use of a diverse, wide-ranging knowledge base, the core values of social work presented in NASW’s Code of Ethics (see Chapter 3), and a formidable set of practice skills for the purpose of facilitating client and/or organizational/community change.

Why is it important that social workers be generalists? Well, no matter what sort of agency employs a social worker, (s)he can expect that a number of clients will have struggles or concerns that go beyond the typical scope or thrust of what that agency does. For example, a social worker at a domestic violence shelter will benefit from having a working knowledge of gender issues, substance abuse and dependence, the criminal justice system, family dynamics, eating disorders, human sexuality, general mental health, and more. Those are all topics that are likely to come up at various times with particular clients in that agency. It is important that social workers have enough of an understanding of many areas of practice to help their clients identify areas where they could benefit from some additional assistance or services. At times, of course, it will be necessary to refer clients to clinicians or other professionals who specialize in a given area; however, a solid generalist social worker can at least recognize when an issue needs that specialized treatment and can then hook a particular client up with the appropriate provider or service.

           

Systems Theory

The medical model is used by a number of professions to conceptualize human problems. This model tends to look at people as patients rather than clients—that is, they are seen as people who need to be diagnosed, treated, and cured. This sort of approach can occasionally be utilized in a progressive way, but in many cases it blames individuals for their problems, discounting outside factors and influences. This isn’t the way social work prefers to operate, as the people with whom social work professionals interact are usually called clients. This word tends to be less stigmatizing (a factor which we will discuss further later in this chapter) and puts more agency in the client’s hands, acknowledging the importance of the client being an active participant in the process of change and feeling empowered throughout the process.

Connecting People
Just as people are connected to each other, the parts of our individual lives are also connected in various ways, a key principle of systems theory.
Bowen Chin; "Connecting People" by Bowen Chin is licensed under CC BY-NC-ND 2.0]

 

A major component of social work practice, something which particularly sets it apart from professions such as psychology, is an emphasis on systems theory (also known as the systems model or systems perspective). Systems theory has been the primary approach of social workers to helping clients since the 1960s, when there was a renewed focus on sociological perspectives like environmental reform (see chapter 2) and other ideas popular in the foundational years of the profession. Systems theory consists of three major concepts: wholeness, relationship, and homeostasis (Zastrow, 2010).           

Wholeness: The idea of wholeness is a simple one. In the view of a systems theorist, a system cannot be adequately assessed or described by assessing or describing its components. For example, if one were to assess a lawnmower, would it be useful to disassemble the machine into each of its separate parts and assess whether there was anything wrong with each individual piece? One might find some glaring issues in this manner, but those same issues would likely have turned up from an evaluation of the mower as a whole. Conversely, an analysis of each separate component does not truly tell us if those parts all work in symphony when the lawnmower is reassembled. In other words (often applied to Gestalt psychology), the whole is different than the sum of its parts. (It is not “greater” than the sum of its parts, though that is a frequent misinterpretation of the concept.)

How does this automotive analogy relate to social work? Well, imagine working with a school system as a school social worker. The teachers are all individuals with various strengths and weaknesses, and the administration could be described the same way. The students are also, in all likelihood, a diverse group of people with a wide range of healthy, unhealthy, and neutral attributes. If we do an individual interview with each person in the building (a daunting task), will that give us an idea of how the school functions as a whole? It will give us a lot of perspectives, but how will we know what is accurate? Coming onto school property during a regular school day multiple times will probably give us a much better idea of the well-being of the system of that school. Seeing the school functioning as a whole is much different than knowing the various assets and liabilities of all the people within it (not to mention a lot less time-consuming).

Relationship: Another key of systems theory is the recognition that the various parts are all related to each other in a variety of ways. For example, if you were talking about that same school system, the teachers have a relationship with the students, the administration with the teachers, and the students with the administration as well. However, there are also other elements involved in this system: parents, the community at large, and perhaps still other entities. Understanding the relationships among these parts of the system is essential to understanding the system itself.

However, it should be noted that there are no simple, predictable relationships between the parts of the system. For example, imagine the teachers go on strike in the school system. How will that change the relationship of the students with their teachers? Perhaps the students will initially be supportive of or indifferent to their teachers’ plight; eventually, however, as the strike drags on, students may become resentful for a number of reasons: they know their summer vacation will be starting significantly later; their parents have political views that oppose the strike; media coverage may portray the strikers negatively. Any number of factors may change their view. How will the students’ relationship to the administration change, or the teachers’ relationship with administration? Multiple possibilities exist there as well. Further, there are many possible factors that may have led to the teachers deciding to go on strike in the first place, which will help determine how long the strike continues.

There is no simple, predictable result of a change within the system; the only thing that is certain is that a change will lead to some other change, since all the parts of the system are related to each other. This idea has often been expressed in a phrase sometimes used by social workers and other helping professionals: change does not occur in a vacuum.

Homeostasis: Homeostasis refers to a tendency to seek balance, for changes to be countered by other changes which seek to stabilize the system as a whole. These changes may be healthy or unhealthy, but the goal will be the same—to try to maintain some stability within the structure of the system.

For example, if a parent develops an addiction that effectively stops him/her from being a responsible parent, it is not unusual for the oldest child in the family to step up and take on some of the parenting duties. This will prove beneficial in some ways for the system, since there is still a need for someone to do things like making school lunches for the younger children, picking other kids up from extracurricular activities, or helping the younger children with homework. However, this can also cause problems—the kids may struggle to see the oldest sibling as a parental authority figure, and the stress of the additional responsibilities may be more than a teenager can handle. Even if the “replacement parent” handles it well, it may cause future psychological or relationship problems: the teen may grow up resenting one or both parents for the loss of the end of his/her childhood, or may be overly perfectionistic due to the early pressure to be more grown-up. Of course, it’s also possible that the new role forces the teen to give up some unhealthy behaviors and actually increases his/her healthy functioning. Again, the effects are not necessarily easily predictable; it is merely certain that there will be effects. Systems theory tells us to be on the lookout for them, and to help systems to find the healthiest possible ways to adjust to changes both planned and unexpected.

In addition to the theory’s three major components (wholeness, relationship, homeostasis), there are two concepts related to systems theory known as the client system and the target system. The target system is where the change must occur in order for the established goal of the change process to be achieved; the client system is who will directly benefit from the change. For example, in a situation where a community is experiencing high unemployment, it may be due to a lack of employment opportunities, low educational levels in an area with more professional jobs, or (as occurred in the COVID-19 pandemic) an increased need to stay home and supervise and care for children. In such a case, the school or the bully (quite possibly both) would be the target system; the client system would be the client who has been the target of the bullying.

Note that with many social work relationships, the client system can be hard to identify, since many different entities potentially would be able to benefit from this change: the school, other children who may be bullied, the bullied children’s families, the teachers, and so on. Therefore, the client system is often simply identified as the person(s) who benefit most directly from the change.                                                   

Critical Thinking

One major skill which will be emphasized throughout this book, and in your possible future social work career, is critical thinkingan essential part of the change process (which is discussed further in Chapter 4) and something social workers should strive to exemplify throughout their careers. Instead of simply accepting a statement that is made about statistics, “the truth,” or some sort of current state of affairs, a critical thinker questions what others take for granted.

For example, the presence of television shows like MTV’s 16 and Pregnant (which aired from 2009 to 2014) and the seeming ubiquity of news reports about teen pregnancy over the last 20 years have a lot of people saying things like, “Teen pregnancy is becoming a bigger and bigger problem; in fact, a lot of teen girls are getting pregnant now just because they see it glamorized on television.” This sort of statement certainly riles up the establishment and gets parents and policy makers talking about what to do to combat the supposed epidemic of teen pregnancy. Further, people who claim the problem is extreme are often quick to point to the reasons behind it, as in the statement above. Unfortunately, they are putting the metaphorical cart before the horse.

Pregnant teenager in urban setting
Is teen pregnancy an epidemic? What would the media have you believe? What have your own experiences shown you?
”Pregnant teenager in urban setting" by pennstatenews is licensed under CC BY-NC-ND 2.0

First of all, with a statement like this, it’s important to ask questions in response, rather than simply accepting it as truth. Is teenage pregnancy really on the rise? Is there any way to know why teenage girls are getting pregnant? What is the role of the fathers, many of whom are teenagers themselves? Are we including adults age 18-19 in this population, even though they are legal adults and most of them are out of high school, some even legally married? How can we measure if a given teen pregnancy falls into the “problem” category? It’s not as simple as saying teen pregnancy is a problem, even if we can agree on whether or not its prevalence is increasing. Who defines it as a problem, and why?

Secondly, in critical thinking, it is essential to answer the questions you’ve asked—usually through a search for data that looks at whether the statement is verifiable. In this case, we’d start by looking at whether teenage pregnancy is on the rise. We can verify rather easily that it has fallen considerably since 1991, from a peak of 61.8 pregnancies per 1,000 women and girls age 15-19 in that year to a low of 17.4 pregnancies per 1,000 females age 15-19 in 2018 ((Livingston & Thomas, 2019). That alone would be enough to disprove the original statement, in this case. Of course, it doesn’t answer the issue of what is defined as a “problem” pregnancy, it doesn’t separate married teen mothers from unmarried teen mothers, and it doesn’t address the role of fathers in the situation. However, the decrease of over 72% in the teen pregnancy rate in a 27-year period is fairly significant and would likely remain statistically notable even if the data were controlled for these other considerations.

Finally, in critical thinking, given the data and facts uncovered in the second phase, it is the thinker’s job to advance a position. Despite the oft-repeated public concern about the rise in teen pregnancy, the opposite has actually been happening—teen pregnancy is significantly less common than it was just a generation ago. Therefore, review of the facts supports a position that teen pregnancy is not a bigger problem, and that by extension, the supposed glamorization of teen pregnancy on television cannot be leading to an explosion in pregnancies. Of course, it’s possible that teen pregnancy might be even lower without that television exposure; that cannot be determined with the data assessed for this statement.

 

Vancouver Global Marijuana March 2015 - by Danny Kresnyak
"Vancouver Global Marijuana March 2015 - by Danny Kresnyak" by Cannabis Culture is licensed under CC BY 2.0

 

Box 1.2: Critical Thinking

Asking Questions About Questions

Sometimes, critical thinking must be done not in response to a statement of fact, but in response to a question. People may not have a specific opinion or policy position in mind yet when they take on a difficult topic. One such question could be: should recreational marijuana use be legalized by the federal government?

Let’s review the steps in the critical thinking process:

1. Ask questions.

2. Answer those questions.

3. Advance a position.

What questions might we ask in order to address the question as it was posed to us? Here are some possibilities.

  • What has been done about this in other countries?
  • What have the results of those varying policies been?
  • What has happened in states like Colorado and Washington, which legalized recreational marijuana use (with certain limitations) in recent years?
  • How would the recreational marijuana market be regulated?
  • What would this mean for states with medicinal marijuana laws?
  • Are there potential behavioral or psychological impacts of marijuana use that could cause unintended problems?
  • What benefits or problems would exist for the criminal justice system?
  • What would we do with people currently serving prison sentences for marijuana possession or trafficking?

There are many other questions that could be asked, of course, but that’s a good start for addressing a thorny issue. Secondly, again, we endeavor to answer our own questions. A lot of data that would need to be compiled, studying the effects of a variety of marijuana legislation in dozens of countries and some U.S. states. (Bigger questions about nationwide policy issues like this, understandably, often require a lot more time to research them thoroughly.) After we have collected sufficient data on the issue, we advance our position. Social work’s position on drug prohibition in general has been that it disproportionately impacts youths and minorities, and that approaching drug use from a position of treatment for abuse and dependence—rather than simple punishment like imprisonment—is more in line with the profession’s values and also more likely to lead to a positive outcome for the health and safety of our communities, states, and the nation (NASW, 2013).

Gambrill and Gibbs (2009) identify a number of ways that critical thinking can aid the helping professional (and, frankly, anyone). First, critical thinking helps people to identify propaganda—opinions or assertions that attempt to push a particular agenda or to damage an opposing agenda. Propaganda is generally offered up by someone who has something to gain by getting the viewer/consumer to accept the point(s) without applying critical thinking skills. In a project our Introduction to Social Work students have been assigned in class, they must visit a local social service agency and report about it in both oral and written form. A few of our past students have visited a local religiously-based agency that provides advice and some assistance to expectant and new mothers. The agency is known for having strict anti-abortion views, and at times they have handed out pamphlets to students (and other visitors) detailing a wide range of negative effects that can result from having an abortion—everything from suicidal thoughts to an increased risk of breast cancer. The obvious hope is that anyone who reads the pamphlet will be scared to have an abortion, and will also tell others about the dangers. However, “scientific research studies have not found a cause-and-effect relationship between abortion and breast cancer” (American Cancer Society, 2015), nor any causal link between abortion and mental health problems (Cohen, 2006). The propaganda is easily contradicted by basic research into the facts, though with an emotionally charged topic like abortion, it can be very difficult to find a source that is unbiased. Looking for potential sources of bias like this is another part of what makes critical thinking such an essential social work skill.

Next, critical thinking can help you to focus on word usage in statements or questions—words that may be meant to lead you in a particular direction. For example, imagine someone were to say to you, “People who get public assistance from the government should have to take random drug tests to ensure that they aren’t using drugs while they’re on welfare. Why should we pay taxes to support drug users? That’s not fair.”

What words are trying to get you to have a specific reaction? Certainly, the end of the quote wants to appeal to your sense of fairness, to be upset about people being mistreated. Social workers are certainly interested in fairness and justice. Is it acceptable to pay for people’s food if those same people are using some of their limited funds to buy drugs? Many people get fired up by this particular concept, but they seem to overlook the fact that many public employees have salaries paid by tax revenue and they are not all subject to random drug screens, despite costing the system much more than a typical family receiving public assistance does. This seems to indicate a prejudice on the speaker’s part—a belief that poor people are more prone to use drugs, and we should really keep an eye on them to make sure they’re not taking advantage of the system. However, there rarely seems to be any similar sort of concern about the public university professor or the parks and recreation landscaper who is drawing a salary funded by public taxes, and making more money than any individual person receives in public assistance.

How would “fairness” even be assessed? It’s a subjective concept, to be sure. We could counter with questions like:

  • Would it be fair to remove welfare benefits from children because their parent is using drugs?
  • How many other personal decisions of public assistance recipients should we be supervising and judging for fairness to taxpayers?
  • Would it be fair to taxpayers to spend a lot of money on drug testing welfare recipients when there may not be any financial gain made by such an endeavor?

This brings up another key point mentioned by Gambrill and Gibbs. Critical thinking also helps us to be on the lookout for emotional appeals, which are meant to sway us by zeroing in on our emotions, in a sense bypassing our logic in order to elicit a stronger response. The mention of “fairness” in the statement about drug-testing welfare recipients is perhaps meant to appeal to your sense of justice, and therefore to make you feel angry and/or motivated to act.

Emotional appeals are very powerful tools used in advertising and other forms of mass media, and we are accustomed to using them in our communication with each other as well. How might they come up in social work?

Imagine a situation where the media is reporting on the death of a 10-year-old boy in the foster care system, a child who had been removed from his home due to his single father’s neglect and serious alcoholism. The child was moved around to three different homes before landing in the placement where he ran away and was found dead a few days later. The media may portray this as a failure of the foster care system, showing pictures of the boy smiling and happy, talking to people who describe him in loving ways and bemoan his death, and capitalizing on the tragedy by bringing in viewers with their in-depth coverage. They may talk about the obvious problems in a system where a kid was moved to multiple homes and ended up running away, calling for the caseworker and his/her supervisor to be fired.

Make no mistake about it, a story like this would be a tragedy, and occasionally, we hear even more profoundly sad stories about the social welfare system’s clients. However, while the boy’s death is tragic, can we justify the emotional call to fire those involved with his case before we have more information? Do we know the circumstances well enough to understand whether anyone was truly negligent in this situation? Could there be explanations for the multiple placements that would make sense to us? Perhaps the child was allergic to dogs and did not know this because he hadn’t lived in a home with dogs previously, but had to be moved out of one foster home due to the presence of a dog. Perhaps the first placement was meant as a temporary placement because it was an emergency move after the neglect case was opened. When a more permanent solution was believed to be found, the boy was moved to that home.

Children sometimes run away, even from healthy homes. It’s possible the foster parents were not at fault, nor the caseworker. Maybe the child said he was going to play in the backyard and ran off because he was homesick. Is it possible that the foster parents were ill-prepared or poorly trained, or that the system put the child into an inappropriate placement with little follow-up? Yes, but that simply isn’t known. We have to avoid allowing the emotional situation to prevent us from looking at the circumstances and learning about what truly has happened. If there is a problem in the process, we must find it so it can be fixed; if the system worked the way it should and there was no tragedy, then it would be unjust to punish the caseworker, the agency, or the foster family for what has occurred.

 

The Importance of Language

Some people bemoan the advent of what is often termed “political correctness”—the changing acceptability of certain terms and phrases in our society. Some things are disputed by few—for example, not many people would argue that Negro or cripple (once common descriptors) are acceptable words to use to refer to people today. However, the process that changes our usage of these terms tends to be a gradual one. In most cases, some people easily move on to the newly accepted term while others struggle to let go of the old one, and some fiercely hold on to the previous way of speaking, insisting there isn’t anything inherently wrong with it, or that people are simply being too sensitive.

In social work, we tend to believe that people have the right to be known by terms they prefer and find to be accurate. For example, if we want to know what people with hearing difficulties want to be called, we should probably ask them. Do they prefer deaf, hard of hearing, or hearing impaired? (The answer, according to the National Association of the Deaf, is generally the first two.) This is part of people’s right to define themselves, and to determine what is empowering to them and what is offensive.

 

Evolution of language

What many people decry as the oversensitivity of modern Americans is really not a new phenomenon. Our language has continuously evolved, and certain terms have been falling in and out of favor repeatedly over time. We wouldn’t dare use many terms of the 19th century to refer to people today, and it’s likely that in 100 years, people will look back on some of the terms we now favor as hopelessly outdated, even possibly demeaning. Throughout this text, we will be encouraging the use of modern language and terms that people favor today, particularly focusing on the words preferred by the people to whom those terms apply.

The National Association of Social Workers (NASW) Code of Ethics insists upon respecting and recognizing the dignity and worth of our clients.  Language has greater power to impact people than we often like to recognize. “Sticks and stones may break my bones, but names will never hurt me” sounds great in theory, but it doesn’t work out that way in practice. Not only do words have the power to hurt others, but they also shape our realities and impact the way we think about people. To you, there may not sound like a big difference between calling someone a “disabled person” versus a “person with a disability.” However, the implications of these language differences can be significant. What is most important—the person or the disability? What should be mentioned first?

When we insist upon continuing to use language to which we are accustomed and refuse to acknowledge the changing attitudes of our culture, as well as research findings that indicate the labels may be inaccurate, we are failing to recognize the rights of our clients—and all people—to define themselves as they see fit. It is not appropriate for any group to impose their terms and definitions on other groups. Social workers strive to understand the experiences of people who have been disenfranchised or marginalized, and language can be used as a tool to do both of those things.

Therefore, throughout this book, we make an effort to use the most accepted terms for other people—and particular conditions—as we understand them today. We will use the term preferred language to reflect this idea. No doubt, some of these terms will change in the coming years, and future editions of this textbook will differ as a result. It is no more than a minor inconvenience to social workers and the rest of society to adjust to changes in terminology. As far as this profession is concerned, it is a major aspect of respect for others.

Person-first language has often meant using the word "person" before a condition, as in "person with schizophrenia" rather than "schizophrenic person." However, not all groups and individuals prefer such construction of language. People diagnosed with autism generally prefer to be called "autistic" rather than "people with autism," for example. This is sometimes called identity-first language (as opposed to person-first language). We should always strive to use terminology preferred by those to whom the words apply.

 

Is Social Work for You?

Perhaps you are taking this class (and reading this book—a good idea) because you are sure you want to be a social worker and this is the first of many steps in that process. Perhaps you are majoring in another area, like sociology or criminal justice, and this class applies to that major. Maybe you don’t have any idea what you want to do, and this class just fit into your schedule. Whatever your reason for taking this class, it is our hope that you get a better idea of what social work is all about. Even if you don’t go into social work professionally, you have a good chance of interacting with social workers at some point, and if you are more educated about what their job entails, your interactions with them will be more likely to be meaningful and satisfactory.

PNG counselling service for women. PNG 2008. Photo: AusAID
Social workers are employed in a wide variety of settings. Though some types of social work discussed in this book may not be appealing to you, you may find that some others are more your style. Would you prefer to work with families in crisis? Mental health clients? Public assistance recipients? Hospital patients? You may know already, or you may have more of an idea by the end of this course. 
"PNG counselling service for women. PNG 2008. Photo: AusAID" by DFAT photo library is licensed under CC BY 2.0

What sort of traits and characteristics can be found in typical social workers?

  • Possessing an empathic attitude and approach
  • Open-mindedness
    • Being open to new ideas
    • Being open to and strongly interested in other people
    • Being open to different perspectives
    • Being open to feedback and critique
  • Being an alliance builder
  • Flexibility
  • Being an active listener
  • Having good emotional health
  • Striving to understand others
  • Welcoming toward others
  • Energized by, and invested in, diversity
  • Strong writing and oral communication skills
  • Interest in social justice and equality for all people
  • A belief that all people have strengths and can be helped

Many of these are self-explanatory, but I’d like to define one term in particular. Empathy is the process of trying to understand a situation or experience from someone else’s perspective—we often think of this as “putting ourselves in someone else’s shoes.” This is distinct from the idea of sympathy, which is feeling sorry for someone. Generally, clients do not want us to feel sorry for them, but they do want to see that we are trying to understand their experiences from their perspective. It is always our goal to do what we can to approach client problems with a firm comprehension of their point of view.

Does this sound like you? Are you still unsure? It’s all right if you do not know yet. Over the course of this class, you will be challenged in the way you think about some of these issues, and encouraged to view them from the micro, mezzo, and macro perspectives of a social worker (see Chapter 2). You may find some of these areas really ignite a passion in you and that you find yourself wanting to learn more—you may be frustrated that we don’t go into greater depth about some of these interesting topics. Since this course is just an overview of many areas of the profession, you will likely feel we have not paid enough attention to a particular area of personal interest to you. Almost any of these chapters could be expanded into a full-semester class, and you will probably take some of those classes if you decide to pursue social work or a closely related major.

It is also a good idea for you to talk to people who are currently working in the field. Ask them what their experiences are like. (Talking to your professor is probably a good place to start.) You will find that different areas of the field, and even different agencies within that practice area, produce diverse experiences and work environments for their employees. People often find their passion through the internships they complete as undergraduates or graduate students, or through a particular reading in one course they take. It may be that you will start off with an idea of what you want to do, but end up working in a completely different area, and find yourself totally enamored with it. Be open to the possibilities as you explore the field. Social work affords you the opportunity to work in schools, hospitals, social service agencies, mental health agencies, government offices, private practice settings, and more. Don’t put too much pressure on yourself to know exactly what you want to do just yet—chances are good that you will figure that out along the way.

 

References

American Cancer Society (2015). Is abortion linked to breast cancer? Retrieved from http://www.cancer.org/cancer/breastcancer/moreinformation/is-abortion-linked-to-breast-cancer.

Ballotpedia (2021). Election results, 2020: Incumbent win rates by state. Retrieved from https://ballotpedia.org/Election_results,_2020:_Incumbent_win_rates_by_state.

Carney, J. (2021, June 10). 'The era of bipartisanship is over:' Senate hits rough patch. The Hill. Retrieved from https://thehill.com/homenews/senate/557690-the-era-of-bipartisanship-is-over-senate-hits-rough-patch.

Cohen, S. (2006). Abortion and mental health: Myths and realities. Guttmacher Policy Review 9(3).

Comer, R. J. (2014). Fundamentals of abnormal psychology. Worth.

Constitution Party (2012). National platform in brief. Retrieved from http://www.constitutionparty.com/assets/Platform-in-Brief.pdf.

Gallup (2021). Congress and the public. Retrieved from https://news.gallup.com/poll/1600/congress-public.aspx.

Gambrill, E. & Gibbs, L. (2009). Critical thinking for helping professionals: A skills-based workbook. Oxford University Press.

Green Party (2020a). Green Party platform. Retrieved from https://www.gp.org/platform.

Green Party (2020b). Ten key values. Retrieved from https://www.gp.org/ten_key_values.

Libertarian Party (2020). Libertarian Party platform. Retrieved from http://www.lp.org/platform.

Livingston, G., & Thomas, D. (2019, August 2). Why is the teen birth rate falling? Pew Research.

            Retrieved from https://www.pewresearch.org/fact-tank/2019/08/02/why-is-the-teen-birth-rate-falling/.

Midgley, J., & Livermore, M. (1997). The developmental perspective in social work: Educational implications for a new century. Journal of Social Work Education, 33(3), 573-586.

National Association of the Deaf (n.d.). Community and culture—frequently asked questions. Retrieved from http://nad.org/issues/american-sign-language/community-and-culture-faq.

National Association of Social Workers (NASW) (2021). Code of ethics. NASW.

National Association of Social Workers (NASW) (2013). A social work perspective on drug policy reform. NASW.

Obama, B. (2012). Remarks by the president at a campaign event in Roanoke, VA. Retrieved from www.whitehouse.gov/the-press-office/2012/07/13/remarks-president-campaign-event roanoke-virginia.

Reform Party (2020). Our solutions. Retrieved from https://reformparty.org/our-solutions/.

Riffkin, R. (2014). 2014 U.S. approval of Congress remains near all-time low. Retrieved from http://www.gallup.com/poll/180113/2014-approval-congress-remains-near-time-low.aspx.

Taibbi, M. (2013, March 17). Cruel and unusual punishment: the shame of three strikes laws. Rolling Stone (1180). Retrieved from http://www.rollingstone.com/politics/news/cruel-and unusual-punishment-the-shame-of-three-strikes-laws-20130327?page=5

United States Department of Health & Human Services (2009). Aid to Families with Dependent Children (AFDC) and Temporary Assistance for Needy Families (TANF). Retrieved from http://aspe.hhs.gov/hsp/abbrev/afdc-tanf.htm.

Vera Institute of Justice (2017). The price of prisons. Retrieved from https://www.vera.org/publications/price-of-prisons-2015-state-spending-trends/price-of-prisons-2015-state-spending-trends/price-of-prisons-2015-state-spending-trends-prison-spending.

Wooley, J. & Peters, G. (2015). The American Presidency project. Retrieved from http://www.presidency.ucsb.edu/index.php.

Zastrow, C. (2010). Introduction to social work and social welfare: Empowering people (tenth edition). Brooks/Cole.

 

Chapter 2: History of Social Work and Social Welfare

This chapter will discuss the history of social welfare and social work. As you will see, our history of social welfare programs stretches back much longer than the history of the social work profession, but their stories are unavoidably intertwined. When you have finished reading this chapter, you should be able to:

1. Understand the early attempts at social welfare programs in England;

2. Name and explain the laws that aimed to provide a basic standard of living for the poor;

3. Explain how the settlement house movement was important in the development of the social work profession;

4. Name and explain the various public assistance and social insurance programs in place in America and how they started;

5. Explain the War on Poverty and Economic Opportunity Act;

6. Identify the changing attitudes toward social welfare programs throughout American history to the present day.

 

File:Sleeping in a Parking Lot.jpg - Wikimedia Commons
This image was originally posted to Flickr by Franco Folini at https://www.flickr.com/photos/78425154@N00/7834887066.

The History of Social Welfare

            Efforts to enhance or secure social welfare predate the existence of any professional activity that might be considered social work. Since the United States is still a relatively young country, we draw the beginnings of our attempts at social welfare back to our mother country, England. Several of the early attempts at providing assistance for the poor and insurance against social problems that were developed on the other side of the Atlantic had equivalent movements in the United States (or earlier on, the colonies)—sometimes simultaneously, sometimes after a delay of some years.

            Before there were government efforts to assist the poor, such tasks were typically handled by feudal landowners. Many people who needed help from those lords did not receive it, however, and there were also people in poverty who did not reside on someone’s property, and therefore had no one to whom to turn. In some of those cases, churches and charity organizations (which were frequently connected, as is the case today) stepped up to provide basic needs. Government was reluctant to get involved in addressing the plight of those in poverty; some people were concerned—again, much like today—that providing assistance with no strings attached would cause people to become dependent upon the government and lose any incentive to work their way out of poverty themselves.

            In the late 16th century, a series of poor harvests led to famine conditions.  The Act for the Relief of the Poor in 1597 was England and Wales’ first attempt to provide a true plan for provision of basic standards of living for the needy. The English Parliament passed the laws in an effort to both “prevent starvation and to control public order” (Boyer, 2002).

 

The Elizabethan Poor Law

            The 1597 law was quickly amended as the situation became more clearly dire. Severe inflation coupled with wage stagnation had reduced the purchasing power of the poor significantly even though those who were employed were working just as hard—and perhaps making equal or even higher wages—as in generations past. Since feudal landowners could not necessarily be trusted to take adequate care of their own workers, the government felt the need to intervene.

The resultant policy, the Elizabethan Poor Law (officially the Act for the Relief of the Poor), is the most well-known early attempt at providing some basic benefits to destitute residents of England; it became law in 1601. The law wasn’t passed due to philanthropic sentiments on the part of the government, however; it is generally acknowledged that the major impetus for the law was the fact that the poor were becoming so numerous and their panhandling so publicly visible that it was a nuisance. The well-to-do simply couldn’t enjoy their time out on the town while being accosted by beggars simply looking for a few spare pence. The Elizabethan Poor Law was therefore put into place to provide an opportunity for the poor to get basic necessities covered—enough, at least, that they wouldn’t be forced to steal or beg on the streets to survive.

Benefit recipients were separated into three basic categories. The different categories were handled in unique ways and considered to be differently worthy of help. The following list begins with the group considered most deserving.

  • Dependent children: Children of the poor were not blamed for their situation; after all, there was little (if anything) they could do to prevent their families’ economic situation. Since the families were seen as being unable to provide for the basic welfare of these children, they were put to work as apprentices. They would remain apprentices until young men reached the age of 24 and young women either reached age 21 or became married.
  • Impotent poor: People who were deemed unable to work due to a physical or mental disability (or simple old age) were seen as somewhat less deserving than dependent children. There was still a prevalent idea that many people with disabilities had somehow been punished by God due to their own sinful acts (or those of their parents) (Sharma, 2003). However, the Poor Law also acknowledged that it was unrealistic to expect these individuals to work to earn their benefits. They could be placed in almshouses, which were basically shelters that gave them a place to stay and receive benefits rather than begging from passersby. The presence of people with disabilities on the streets was particularly distressing to the upper class who wished to enjoy their leisure time on the town, so getting this group out of sight was a crucial part of the law.
  • Able-bodied poor: These individuals were physically and mentally capable of holding jobs but found themselves unemployed for other various reasons—systemic unemployment, lack of skills, discrimination, etc. They were provided jobs. Initially, they were not provided with shelter, but later the act was amended to provide those accommodations as well, making the workhouse the center of relief efforts for this category of the poor (Spicker, 2014; Socialist Health Association, n.d.).

This tendency to see certain groups as worthier of aid than others can still be seen in today’s conversations (both governmental and private) about public assistance programs in the United States. Washington Post writer Darlena Cunha penned a very personal piece detailing the reactions she got when she drove her old Mercedes to pick up her food stamp benefits after her husband had lost his job and she gave birth to twins: “When you lose a job, your first thought isn’t, ‘Oh my God, I’m poor. I’d better sell all my nice stuff!’ It’s ‘I need another job. Now.’ When you’re scrambling, you hang on to the things that work, that bring you some comfort. That Mercedes was the one reliable, trustworthy thing in our lives” (2014). The same attitude about who is deserving of benefits and who is not has led to welfare reform decisions like the replacement of Aid to Families with Dependent Children (AFDC) with Temporary Assistance to Needy Families (TANF; see Chapter 9).

The Elizabethan Poor Law recognized that the previous systems of depending on voluntary contributions from people were not adequate to provide for a growing needy population; therefore, parishes (geographical divisions) of England that did not collect enough in donations to provide for all the poor people entitled to receive benefits under the law were to have further money collected by government-appointed overseers. They effectively collected property taxes when necessary in order to enforce the provisions of the law (Socialist Health Association, n.d.).

Many elements and amendments of the law, surprisingly, continue to be seen in programs that we have in the United States even today:

  • Local administration: Though the law was a national one, there were few enforced federal standards to it, and it was meant to be overseen on a local parish level. This was good in that local officials were more likely to have an accurate idea of the precise nature of the situation in their area; however, it was bad in that it had the potential to cause vastly different systems from parish to parish, and in the case of poor individuals relocating, it could be quite confusing. This tendency toward local administration can be seen in many public assistance programs today that are funded by local taxes and/or overseen by local officials.
  • In-kind benefits: Benefits that are not paid out in cash are considered in-kind benefits. Examples include the provision of shelter, food vouchers, medical care, and clothing. Instead of giving program beneficiaries money with which to purchase these basic essentials, an in-kind benefit program provides these assets directly. This way the government (and taxpaying citizens) can be certain that the money is used to cover the needs that the policymakers deem most important. This characteristic is seen today in programs like the Housing Choice Voucher Program (often simply called Section 8) and Medicaid. Some lawmakers and citizens, reflecting a distrust of the poor, believe recipients would make irresponsible spending choices if cash were given instead of in-kind benefits.
  • Residency requirements: Since recipients of Elizabethan Poor Law benefits were given assistance through their local parish officials, the law established that recipients had to have been residents of a parish for a given amount of time before they were eligible to receive benefits. This, in theory, prevented people from moving from parish to parish in order to discover which one had the best benefits or conditions (almshouses often were deplorable settings—overcrowded, disease-ridden, without heat in winter, dangerous). If they attempted to move in order to get benefits from a different parish, applicants could be forcibly moved within 40 days of relocation, or simply refused assistance (Spicker, 2014).

This was due in part to the Settlement Act of 1662, which gave parishes the right to expel people based upon their residency status. However, historians have noted that the law was applied somewhat selectively to “single women, older workers, and men with large families” since these individuals and families were more expensive to assist (Boyer, 2003).

Today, residency requirements exist for many programs, and can be quite confusing; there may simply be a need to prove one has established residency before applying for benefits, or there may be a minimum amount of time one most reside in a state or county before receiving benefits.

  • Means tests: In later versions of the Poor Law, means tests were introduced. In order to qualify for Poor Law benefits, prospective recipients had to be able to prove their need; in other words, they had to show they did not have the means to provide for themselves. This is standard procedure for public assistance programs in the United States today and is a major feature that distinguishes them from social insurance programs. (Social insurance and public assistance will be covered further in Chapter 9.)

 

The Speenhamland System

            In 1795, much of England adopted a practice of guaranteeing a basic minimum income for all citizens. The income level—a sort of early poverty line—was not fixed, but rather, in continual flux since it was based on something else which ebbed and flowed: the price of bread. Based on the size of one’s family and the current price of bread, a subsistence-level income was identified and guaranteed; if a worker did not make enough money to reach that income, then the government would cover the shortfall in order to close the gap between the worker’s income and the designated minimum. On the surface, this appears to be a tremendously liberal approach, an attempt to ensure for everyone what is often called a living wage today (“Speenhamland system,” n.d.)

File:Fast food workers on strike for higher minimum wage and better benefits (26154683940).jpg
People striking for $15 per hour minimum wage as well as other workers' rights in 2016.  As of June 2021, while some cities have a $15 minimum wage, no states mandate it.  In fact, the federal minimum wage in June 2021 was only $7.25, having remained the same since 2009 (Sources: Wall Street Journal, 2013; Paycor, 2021).
"Fast food workers on strike for higher minimum wage and better benefits" by Fibonacci Blue is licensed under CC BY 2.0

 

            However, the system was a colossal failure for two major reasons. First, there was not yet a minimum wage law in place in England (that wouldn’t occur until the 20th century); therefore, there were no controls in place to prevent employers from systematically lowering wages. If an employer knew that some of its workers were already not making enough money to get up to the minimum income level guaranteed by the Speenhamland System, they had no incentive to increase those workers’ wages. In fact, they could lower the wages of those workers without actually having any negative impact on the standard of living those workers had. The employers knew the government would simply cover the difference regardless of how large that difference might be.

            As a result, wages fell. Workers were not suffering economically from the lower wages being paid by their employers since the government was now providing a guaranteed basic income; however, they also did not appreciate the fact that their employers were paying less and less for the same work, which would bring in the same overall profits for the company. In essence, shrewd business owners exploited a loophole that allowed them to become richer by exploiting the Speenhamland System’s guaranteed income.

            Imagine if you were working a minimum-wage job at a coffee shop and the United States government had passed a similar law. You are now receiving biweekly checks from the government to cover the difference between your earnings and what the company is paying you. Sounds like an improvement so far, right? Then imagine your employer cuts your wages by 10%. Perhaps that wouldn’t bother you too much, since you know the government will just cover it. But what if your employer cut your wages by 25%? Fifty percent? At what point would you say, “Take this job and shove it,” knowing the owner of the business was getting richer by taking advantage of this law and paying you less and less for doing the same quality and quantity of work?

Paycheck
If you knew that the government would make up for the lost income, how much would your employer have to reduce your wages—while still bringing in the same revenue themselves—before you’d quit? 
"Paycheck" by AZAdam is licensed under CC BY-SA 2.0

            Therein lies the second problem: unemployment rose as a result of the system. Workers did not appreciate ownership becoming richer on the back of their exploited labor and many chose not to participate in the process, leaving jobs where they felt they were being mistreated. While the law was a well-intended effort to make sure all workers had the ability to survive and pay for the basics, instead it ended up lining the pockets of the rich, who counted on the fact that the government would take care of poorer workers so employers didn’t have to do it themselves. The manipulation of this law by the upper class caused it to be a fairly cost-prohibitive policy, requiring much more tax revenue than they would originally have believed to be necessary to fund it.

            In a just world, the populace would have seen the situation for what it was: the rich acting in what many would say is an unethical way, indirectly pocketing tax revenue while those in poverty were used as tools to increase the profits of their bosses and business owners. Instead, many people looked at the fact that the poor were leaving their jobs and depending entirely upon the government for their income, and they drew the conclusion that the poor were simply lazy. The public attitude toward recipients of benefits from the Speenhamland System (and thereby people in poverty as a whole) became more negative than it previously had been. Since the Speenhamland System was such a spectacular flop, England sought to replace it with a system that was more in line with what people believed the poor deserved (Kirst-Ashman, 2012).

 

Poor Law Amendment Act of 1834

            In 1834, modifications were made to the system to appease the public, who had grown disenchanted with the Speenhamland System and felt their taxes were going to waste. Commonly known as the English Poor Law Reforms, the act mandated that the able-bodied poor could only receive assistance in the form of indoor relief, which meant they could no longer be given assistance in their own homes (outdoor relief) but had to enter workhouses to get their benefits. Outdoor relief was curtailed for other recipients as well, and continued to be reduced through efforts like the Crusade Against Outrelief, which had the backing of the Charity Organization Society (to be discussed in more detail later in this chapter) (Boyer, 2002).

 

The Industrial Revolution and Social Welfare

            As rapid industrialization occurred in both America and Europe through much of the 1700s and 1800s, ideas about the poor and their plight shifted to reflect the times. The Industrial Revolution brought with it a focus on laissez-faire economics and the Protestant ethic (Zastrow, 2010). Laissez-faire economics was a philosophy that favored businesses being generally permitted to operate without interference or regulations from government entities, doing whatever they found would lead to greater profits. The idea behind laissez-faire economics is that the market is capable of being self-governing; if anyone tries to raise prices on a commodity too much, then the competitors dealing in that commodity will see an increase in business, forcing the overcharging company to lower its prices to match the competition, for example. Similarly, if an employer tries to take advantage of its workers by paying them an unfairly low wage, those workers will leave and go to a company that can pay them a fair amount for the same work.

            The Protestant ethic is the idea that people are responsible for their own lot in life. If one is rich, according to the Protestant ethic, it means one deserves it—that person has worked hard, been a moral and upstanding individual, and has not depended upon the help of others. Conversely, a poor person suffers in poverty due to their own personal and moral shortcomings: laziness, lack of education, poor will power, poor money management, greed, irresponsibility.

The Protestant ethic remains a popular idea today, especially among people who hold the residual view of social welfare (see Chapter 1) and those with other conservative views. Many stereotypes persist about the poor that show the general public opinion of them is rather low. For example, many states have made an effort to drug-test recipients of public assistance in order to be sure they are not using drugs; if they are found to have drugs in their system, their benefits may be revoked and/or the individual may be sent to a treatment facility. In the states where these policies have been implemented, the rates of welfare recipients who are found to be using drugs is actually lower than the national average (Covert & Israel, 2015), yet the myth about public assistance being a way to fund drug users’ habits persists. It’s just one example of an idea held by many—that people who fall below the poverty line must have done something to deserve being in that position, or that they haven’t done the right things to get themselves out of the situation.

These two philosophies put together created a very dangerous situation for the less fortunate. With employers being allowed to do whatever was necessary in order to make a buck, they didn’t have to treat their workers fairly. If one company got away with subpar working conditions, others followed suit. The resultant lack of jobs that paid a living wage exacerbated the already existent divide between the haves and the have-nots. Despite the fact that the poor were powerless to shape policy or challenge the status quo, they were blamed for their own circumstances.

Charles Darwin
Charles Darwin would not have endorsed the idea of Social Darwinism, despite the name. 
"Charles Darwin" by Franco Folini is licensed under CC BY-SA 2.0

Another prominent philosophy that really grew in popularity during this time was Social Darwinism. What do you think of when you hear the name Darwin? Evolution, survival of the fittest, origin of the species—something from that list probably popped into your mind. Darwin did not come up with the idea of Social Darwinism; it was an unfortunate application of his ideas regarding evolution among living organisms to human social systems and safety nets. The underlying principle of Social Darwinism is that we should not help the poor when they struggle. In order to survive, organisms must adapt. If we assist the poor by paying them enough to live in minimal comfort and security, we are preventing them from adapting to their struggles, and thereby hindering their ability to improve themselves and their skills. Conversely, if we let the poor suffer without help, then those who do not have the genetically superior traits that will allow them to survive will, in fact, die out. According to Social Darwinism, that will make the human race stronger, because we will be eliminating the less desirable genes from the population.

If this sounds horrifying to you, you aren’t alone—people holding the institutional view of social welfare would agree (and even many of those holding the residual view would consider Social Darwinism overly harsh). This philosophy and its close relatives have been one reason why many have opposed expanding (or even maintaining current levels of) social welfare spending. As David Macarov put it, “Not only does Social Darwinism block social change; it is also at the root of some opposition to social welfare;” according to this theory, “social welfare activities somehow maintain the unfit at the expense of the fit…and thus undermine the rights of those who strengthen society and support the development of a new and better way of life” (1995, p. 214).

            Macarov (1995) also points out the inherent flaw in Social Darwinism—it’s a self-fulfilling prophecy. First, we assert that poor people are somehow deficient and therefore do not deserve to thrive. Due to this belief, we refuse to help them in their time of need. When they thereafter fail to survive or thrive, we say, “See? We told you they didn’t have what it takes to make it.” Taking this approach may help us feel absolved of responsibility, but it’s really just an example of blaming the victim, similar to the reaction of the English to the failed Speenhamland System. When the poor stood up for themselves and refused to be mistreated, they were branded “lazy” and treated as if they lacked moral fortitude. When they are not helped and go on to struggle further, we blame them for not working hard enough to get out of a situation that was quite possibly out of their control in the first place.

Box 2.1: Blaming the victim

It is always easier to blame someone in a difficult situation for their own circumstances than it is to truly assess the reasons behind the situation. This is especially true because we don’t want to believe the same bad things could happen to us for reasons beyond our control. One common way we blame the victim in our society is when it comes to sexual assault. When people are sexually assaulted—usually women—we ask them what they were wearing, if they were drinking, if they led the assailant on, if they had had sex with the attacker previously, if they fought back, and many other questions. Imagine if we did this with other crime victims!

“Hello, Officer, I’d like to report a mugging.”

“You were mugged?

“Yes, ma’am.”

“I see. Well, were you wearing expensive clothing or jewelry?”

“What does that have to do with it?”

“Perhaps you gave the mugger the impression you wanted to be mugged, sir.”

“Why would I want to be mugged?”

“I don’t know you, sir. Maybe you’re the type of person who likes being roughed up now and then.”

“No. I’m not.”

“Do you ever give money away, sir?”

“Sure. What does that have to do with…”

“Can you prove you didn’t willingly give up your money this time?”

“The guy had a gun. I handed over my wallet. I don’t have any bruises or anything.”

“Did this just happen?”

“What? I…yes.”

“What were you doing out late at night in this neighborhood, sir? Why would you be there if you didn’t want to get into an altercation?”

 

It sounds absurd, right? Yet we treat sexual assault survivors this way on a regular basis.

Can you think of any other circumstances in which we blame the victim? Think beyond the world of crime. What sort of people do we blame for their own circumstances, though they may occur due to factors beyond their control?

            Social workers are well aware of the fact that people land in poverty and other difficult situations not because they are deficient or lack redeeming qualities, but because they have encountered any of a range of issues that could not have been predicted or prevented by anything they could have done: discrimination, tragedy, medical problems, layoffs, outsourcing, and many more. Regardless, this isn’t a view shared by all of society today, and it certainly wasn’t at the time of the Industrial Revolution. It took one of the worst times in American history to shake the country out of the commonly held ideals behind the Protestant ethic.

 

The Great Depression

            Much like they had been in England, poverty and its related issues were mostly addressed by private charity in the United States; the federal and state governments took little to no role in helping people. Since the ideas of Social Darwinism and the Protestant ethic were still popular, the government saw little need to get involved. However, when the stock market crashed in October of 1929, everything America thought it knew about hard work was called into question.

            Unemployment more than doubled in the first five months following the crash. President Herbert Hoover, tasked with the monumental challenge of leading the country through the economic crisis, maintained a stiff upper lip, saying that worries about the future economic stability of the United States were misplaced and predicting the worst of the Depression would pass by May 1930. By the peak of the Great Depression in 1933, official unemployment rates had climbed from 3.2 percent before the crash to 24.9 percent. In some cities (e.g., Akron and Toledo, Ohio), unemployment was well over 50%. Nationally, the production of the manufacturing industry dropped by 54% (Katz, 1996; PBS, n.d.)

            Hoover’s lack of response to the frightening rise in unemployment caused him to quickly fall out of favor with the American people, who named the ramshackle towns constructed by people who have lost their homes “Hoovervilles” in mocking tribute to the President’s inaction. He continued to believe the neediest should be helped by charity, but charities struggled to raise sufficient funds since so many people were now unemployed and far fewer could afford to donate than in previous years. Hoover resisted efforts to do much until 1932, the year he was running for reelection. By that time, the Depression had become synonymous with Hoover’s presidency, and his chances of winning appeared slim. He was summarily defeated in November 1932 by Franklin Delano Roosevelt, who would take office in March 1933 (PBS, n.d.).

A Home in Sullivan's Gulch (A Portland Hooverville)
“Hooverville” on the Seattle waterfront, ca. 1930. 
"A Home in Sullivan's Gulch (A Portland Hooverville)" by A. Davey is licensed under CC BY-NC-ND 2.0

            Roosevelt had promised that he would immediately get to work restoring America to prosperity, famously talking about making a noticeable turnaround within the first 100 days of his term. He put a lot of temporary relief programs into place immediately, having promised “a New Deal” for America upon being elected. His efforts helped to revive American confidence that there was a chance to pull out of the Depression. Under the New Deal, Roosevelt established a number of programs that sought to alleviate the conditions of the economic disaster through the provision of jobs in programs like the Civilian Conservation Corps (CCC) and Works Progress Administration (WPA). The CCC sent young men to do government work in rural areas, national parks and forests, while the WPA worked mostly with young men who were still in school and wanted part-time jobs (Katz, 1996). Several other programs were active in providing either jobs or temporary financial assistance as well.

            While economists may debate the extent of the New Deal’s role in the economic recovery (and there are valid criticisms to be made about institutional racism in some New Deal policies), it did give Americans confidence in their leaders again, and it appeared to show that government intervention had the potential to make a big difference in dire situations like the Great Depression. This in turn set the tables for the biggest unit of social welfare legislation in American history.

 

The Social Security Act

            In 1935, as part of FDR’s “Second New Deal,” the Social Security Act both established a series of programs meant to provide for the well-being of Americans in a variety of circumstances and established a set of rules and guidelines for states to follow in order to receive the federal funding necessary to pay for these initiatives. Three categories of programs were established:

  • Public assistance: This category required the passage of a means test, as noted earlier in this chapter, to determine if one qualified. If someone was in great enough financial need, then they could obtain the assistance, provided they were part of the group it was meant to serve. Programs under this umbrella are aimed at alleviating poverty.
  • Social insurance: These programs were more reflective of the institutional view of social welfare, which recognized that some programs needed to be in place permanently and not simply providing a band-aid effect. This category was established due to the recognition (as recently vividly illustrated by the Great Depression) that sometimes people experienced hardship due to events that they could not prevent or change. Programs in this category intend to prevent poverty.
  • Public health and welfare services: The government established itself as the provider of particular social services that had previously been handled by private organizations.

 

Public Assistance

            The public assistance programs established under the Social Security Act were:

  • Old Age Assistance: Aid to people age 65 and up who are in poverty.
  • Aid to the Blind: Aid to people with permanent and significant blindness.
  • Aid to the Disabled: Assistance for people with disabilities that render them unable to work full-time; this program was actually added in a 1950 amendment.

(note: the above three were later combined into Supplemental Security Income [SSI])

  • Aid to Dependent Children: Assistance for poor families with children at home, often headed by single mothers. This later became Aid to Families with Dependent Children, and then was replaced by Temporary Assistance to Needy Families (Social Security Administration, 1935).

 

Social Insurance

The Social Security Act established the following social insurance programs:

  • Old Age, Survivors, and Disability Insurance (OASDI): The program that people refer to today as Social Security.
  • Unemployment Insurance: Meant to provide some replacement income for people who have lost their jobs through no fault of their own (Social Security Administration, 1935).
Soup kitchen line
Unemployed men wait in line outside a free soup kitchen opened by Al Capone during the Great Depression. (Source: National Archives.)

Public Health and Welfare Services

            Finally, the Social Security Act established the following programs, among others, and determined the government had a responsibility to provide the services in question.

  • Adoption
  • Foster care
  • Child protective services

 

Minimum Wage

            After the laissez-faire nature of the Industrial Revolution and its concomitant support of Social Darwinism, as well as the horror of the Great Depression, the United States government finally became invested in establishing a fair minimum wage to cut across all fields of work. Though President Roosevelt had attempted to establish a minimum wage as part of his plan to pull America out of the Great Depression, the minimum wage law was ruled unconstitutional by the Supreme Court in 1935. A second attempt in 1938 was successful and again established the minimum wage at 25 cents (equivalent to just over $4.80 in 2021 dollars) (U.S. Department of Labor, n.d.).

            The minimum wage has been periodically raised by Congress ever since it was first established. It first reached the $1.00 level in 1955, and as of June 2021, the federal minimum wage is now $7.25 for all non-tipped workers (U.S. Department of Labor, n.d.). States, however, are free to set their own minimum wages, and many have. As of 2021, Washington’s state minimum wage of $13.69 was the highest in the United States; some cities have also enacted their own minimum wage laws that surpass federal and/or state laws (U.S. Department of Labor, 2021).

Box 2.2: Minimum Wage through the Years

Infographic: A Brief History of the U.S. Minimum Wage | Statista
Source: Statista (2021).

LBJ and the War on Poverty

            Although many other issues pertinent to social welfare occurred in the quarter-century following the Social Security Act, the next major push for the expansion of the social welfare system was under President Lyndon B. Johnson in the 1960s. Johnson had taken over as President following the assassination of John F. Kennedy in 1963. He saw the United States experiencing less prosperity than he believed possible, and noticed systemic inequality that he didn’t believe should exist in our country. As a result, he declared a “War on Poverty” and aimed to move the United States forward as a “Great Society” (Ambrosino, Heffernan, Shuttlesworth, & Ambrosino, 2005). Johnson and his administration saw poverty not as evidence of individual faults held by poor people, but an indication that there was a problem with the economic system that caused such wide earning and achievement gaps.

President Lyndon B. Johnson meets with Civil Rights leaders Martin Luther King, Jr., Whitney Young, and James Farmer
Lyndon B. Johnson (second from left, meeting with civil rights leaders Martin Luther King, Jr., Whitney Young, and James Farmer) believed the U.S. could reach greater levels of equality and prosperity. His War on Poverty resulted in the establishment of several new social welfare programs.
("President Lyndon B. Johnson meets with Civil Rights leaders Martin Luther King, Jr., Whitney Young, and James Farmer" by Jared Enos is licensed under CC BY-NC-ND 2.0)

 

                      Programs and laws launched under Johnson to assist in the War on Poverty included:

  • The Economic Opportunity Act: Passed in 1964, the EOA established a number of programs aimed at helping people in poverty to have a greater chance at social mobility. Two such creations were Job Corps and Head Start, both of which remain in operation today. Job Corps aims to provide vocational training to at-risk youth ages 16 to 24, at no charge, and sometimes while day care is provided for children of the trainees. Head Start provides access to preschool programs for children in poorer households, so everyone has a chance to attend preschool before kindergarten and therefore begin their formal education on the same footing (Vinovskis, 2005).
  • The Older Americans Act: Passed in 1965, this act formed a foundation for programs designed to assist seniors, from recreational resources to Meals on Wheels (Ambrosino et al., 2005). (This act is discussed further in Chapter 16.)
  • The Civil Rights Act of 1964: The most famous legislation of the 1960s, the Civil Rights Act was an attempt to eliminate the discrimination suffered by nonwhite Americans in many spheres, from employment to banking to education (Ambrosino et al., 2005)
  • Medicare: Health care benefits were made available to the aged, with the basic benefits free of charge and some others available for a fee (Ambrosino et al., 2005).
  • Medicaid: Established in 1965 (like Medicare), Medicaid provided people on public assistance with access to medical care free of charge (Ambrosino et al., 2005).

Throughout the 1970s, 1980s, and 1990s, as the political parties in power vacillated, so did social welfare spending. Presidents Richard Nixon, Gerald Ford, and Jimmy Carter all voiced conservative approaches to social welfare spending, choosing not to back any major new initiatives, but social welfare spending continued to increase regardless. Under Ronald Reagan (President from 1981-1989), however, social service spending was cut in favor of increasing defense spending, though we were not at war with anyone at that time (Zastrow, 2010).

The beginning of the 1990s brought about the Americans With Disabilities Act, the largest piece of social welfare legislation in American history aimed specifically at helping people with disabilities. (See Chapter 16 for more information.) Under President Clinton in the 1990s, social welfare made strides and had some setbacks as well. The move from Aid to Families with Dependent Children (AFDC) to Temporary Assistance for Needy Families (TANF) took place during this time, a move that is generally considered more conservative in nature despite Clinton being a Democrat.

Former U.S. Presidents
Former President George W. Bush (center) championed “compassionate conservatism;” Former President Bill Clinton (2nd from right) presided over the dismantling of Aid to Families with Dependent Children in favor of Temporary Assistance to Needy Families. Also pictured are former Presidents Barack Obama (2nd from left), George H. W. Bush (far left), and Jimmy Carter (far right).
"2009 Five Presidents, President George W. Bush, President Elect Barack Obama, Former Presidents George H W Bush, Bill Clinton & Jimmy Carter, Standing" by Beverly & Pack is marked with CC PDM 1.0

President George W. Bush, son of the man who had preceded Clinton in the White House, attempted to appeal to both conservatives and liberals by advocating what he called compassionate conservatism, a philosophy that (true to Republican ideals) eschewed the idea of having too much direct involvement in people’s lives, lest they become dependent on the government; instead, the idea was to help people learn how to pull themselves out of their bad situations. Bush, like Hoover in the 1930s, believed that most of the needs of society could be addressed by private charity, opining that they were less wasteful and bureaucratic than the government in addressing these issues. What sounded like a compliment to faith-based organizations and charities also conveniently served as a rationale for refusing to expand social welfare services in favor of establishing the Department of Homeland Security and spending money on another war in Iraq.

            Under President Obama, whose first term started in 2008, the most significant social welfare reform law was the Affordable Care Act (ACA), often called Obamacare (particularly by its detractors). This law will be covered further in Chapter 12, but is likely to go down in history as the signature legislation of President Obama’s tenure. It continues to be a point of contention between Democrats and Republicans in our government, as Republicans have called for votes to repeal the Affordable Care Act dozens of times in Congress, while aspects of the law continue to be rolled out to more positive reviews than negative ones. Since the passage of the ACA, 10 to 12 million more Americans have medical insurance coverage, and no one can be refused insurance coverage due to a preexisting condition (Cohn, 2014). Despite harsh opposition by Republican leaders, the ACA has nonetheless made its mark on the American healthcare industry, with many insurance companies eagerly joining the government-run exchanges. While President Donald Trump promised Obamacare would be repealed and replaced under his administration, this never occurred.

Healthcare and the law
Though it has provided insurance for millions of previously uninsured Americans, the Affordable Care Act (sometimes called Obamacare) has remained a subject of serious debate and division.  However, it was upheld by the Supreme Court in June 2021, despite efforts to have it dismantled.
"Health, Doctor and Legal Issues" by weiss_paarz_photos is licensed under CC BY-SA 2.0

            President Trump attempted at times to slash funding for many assistance programs and bragged in his campaign rallies that he had succeeded in doing so; however, some of those cuts were rejected by legislators or courts, particularly as need increased during the covid-19 pandemic (Hsu, 2020).

            The future direction of social welfare policy is inevitably going to be tied to the political process and the balance of power between Democrats and Republicans at the highest levels of our government. If anything is certain, it’s that public opinions will shift and many of us will likely think differently of many of our current laws down the line. New policies will continue to be proposed and developed, and social workers hope to have significant influence in that process through lobbying and educational efforts.

 

The History of Social Work

            Compared to the history of social welfare, and the history of many sorts of professions, social work has a relatively short tale to tell, but still a compelling one. The beginnings of social work are often traced back to charitable organizations of the 18th and 19th centuries, many of which were connected to religious organizations. Many of these programs had their roots in English programs and ideas.

            Early American chemistry professor John Griscom and a number of associates devised in 1817 the Society for the Prevention of Pauperism, a collective of like-minded individuals who wished to eradicate the problem of American poverty. (Pauper, as you may know, is a somewhat outmoded term for a poor person.) As noted in Griscom’s memoir, the purpose of the Society was:

To investigate the circumstances and habits of the poor; to devise means for improving their situation, both in a physical and moral point of view; to suggest plans for calling into exercise their own endeavors, and afford the means of giving them increased effect; to hold out inducements to economy and saving, from the fruits of their own industry, in the seasons of greater abundance; to discountenance and, as far as possible, prevent mendacity and street begging; and, in fine, to do everything which may tend to meliorate their condition, by stimulating their industry and exciting their own energies (1859, p. 157-158).

Put another way, the Society saw poverty as the natural effect of certain deficiencies in the poor: laziness, a lack of resiliency, and listlessness.    

Griscom and his associates in the Society delineated the following as the major causes of poverty with which they aimed to do battle:

  • Ignorance
  • Idleness
  • Excessive drinking (“emphatically the cause of causes”)
  • Poor spending habits
  • Getting married too quickly and/or for poor reasons
  • Lotteries
  • Pawnbrokers
  • Brothels
  • Charity
  • War (Griscom, 1859, p.159)
Pawn shop
John Griscom, founder of the Society for the Prevention of Pauperism, recognized that pawn shops often preyed on the poor. Today, pawn shops are still found more often in low-income areas. (Source: Library of Congress.)

So perhaps Griscom and the other members of the Society weren’t solely blaming the poor for their circumstances; after all, they appear to have acknowledged that certain capitalistic and political entities and events that were out of the poor’s control caused them to suffer economically (i.e., war, pawnbrokers). However, it is also clear that there was a lot of emphasis on the faults of the poor—idleness, alcohol consumption, indiscriminate spending, questionable morality—and a perception that remains common in some circles today: charity is doing more harm than good, by failing to require the poor to rely on their own initiative to escape their problematic financial circumstances. You may have heard someone say the poor “should look for a hand up, not a handout” as a way of saying that it’s okay to ask for help as long as it’s the right kind of help—that is, not simply mooching off the government and costing taxpayers more money. This is a centuries-old example of that sort of thinking, which is virtually unchanged in some political and social circles today.

Since there wasn’t much in the vein of direct government intervention, and that which did exist was far from centralized, the organizations (charitable and otherwise) that wished to address poverty and other social ills were basically operating independently of one another. There was no one to make sure that programs were efficient, effective, cooperative, or even ethical. This is another case where an idea that started in England laid the groundwork for a similar movement in the United States.

Charity Organization Societies (COSs) were an attempt to get everyone on the same page when it came to helping the poor. Different groups were providing redundant services, there was no way to track whether someone was getting duplicate assistance from multiple entities all for the same issue, and perhaps most importantly, the lack of coordination meant that resources were being wasted—resources which could have been making a bigger dent in the serious problems of poverty. There was also a residual element to the establishment of COSs—they standardized the application and investigation process so it could be more definitively determined if someone truly needed assistance or was simply trying to take advantage of flaws and cracks in the patchwork system. Charity reformers who favored the expansion of the COS approach disapproved of what is often called income redistribution—taking from some (in the form of taxes, usually) in order to help others to survive (with the assistance of charitable programs)—unless it could be shown to be beneficial to the people on both sides of the equation. Still, there was an acknowledgment that any “civilized community…had an obligation to prevent its members from dying as a result of hunger or cold” (Katz, 1996, p. 72).

The first Charity Organization Society in the United States was established in Buffalo in 1878. Like many social welfare agencies then and now, it struggled to make ends meet, at times having to cut programs or staff due to budget shortfalls (Katz, 1996, p. 45-46). To keep in line with the mission of helping the poor while also benefiting society as a whole, COSs had to abide by five self-imposed rules:

  • Let no one go without the most basic needs (e.g., food, shelter)
  • Do as little “moral harm” as possible to both the recipient of assistance and to the larger community
  • Provide the assistance for as little time as is reasonable
  • Fund such programs through as small a tax obligation as possible
  • Inform the community that the needs of the poor will be handled in this way, so they do not need to take it upon themselves to further contribute to charitable causes (Katz, 1996, p. 72).

These tenets were embraced by New York COS champion Josephine Shaw Lowell (author of Public Relief and Private Charity), an early advocate of scientific charity, which claimed on the surface to be a new approach that aimed to push the poor closer to self-sufficiency as they were being assisted. The idea was that the poor needed to be given advice and taught how not to be poor (a parallel, to be sure, with Griscom’s Society for the Prevention of Pauperism), rather than simply being given monetary or in-kind assistance (Katz, 1996).

Mary Ellen Richmond
Mary Richmond​​
(Public domain photo)

This COS model employed people who were perhaps the first paid social workers—executive secretaries (usually men) who helped to coordinate applications, investigate financial means, and determine eligibility for assistance. These workers were trained to take on their roles and were considered professionals. Among the early men and women who trained these agents was Mary Richmond (who wrote what is often considered the first social work textbook, Social Diagnosis) and Edward T. Devine, who went on to found the Columbia School of Social Work, America’s first college social work program (Cox, Tice, & Long, 2016; Rasmussen, 2001).

However, they also relied upon friendly visitors—volunteers (usually women) who went to visit the poor who were receiving benefits. During those visits, the volunteers offered guidance—save your money, don’t drink, consider putting your children into apprenticeship programs—that was meant to help the relief recipients to become more self-sufficient. Note that clients were not allowed to refuse the visitors when they stopped by; in fact, they were expected to display gratitude and deference throughout the interaction. Such behaviors were seen as indications that the charitable work was having its intended effect. Rather contrarily, it was believed that any show of independence on the part of the client represented ungratefulness. Insofar as they encouraged such shows of dependence on the part of relief recipients, Charity Organization Societies have also been criticized as perpetuating poverty rather than decreasing it (Katz, 1996, p. 70).

            To your authors, and to many historians of social work, the true beginnings of social work in America go back to the settlement house movement. The approach embodied by the movement was rather progressive: educated, sometimes wealthy people would buy property in the midst of a poor neighborhood of a city in order to establish a settlement house; they would live there so as to better understand the actual day-to-day living circumstances of the poor; and they would endeavor to help those in poverty to have better lives, sometimes in small ways, sometimes in larger ones. Instead of occasionally visiting the poor and giving them advice, or forcibly relocating the poor to almshouses or workhouses in order to receive outdoor relief, settlement house workers were better able to earn the trust and respect of those whom they were helping, because they lived among their clientele. To them, the living conditions of their clients were not abstract or distant. Settlement house workers saw those realities daily with their own eyes, woke up in the midst of them, and dealt with the consequences of those conditions (Crocker, 1992).

            The settlement house movement, while still endeavoring to teach the poor new behaviors that could potentially help them experience upward social mobility, embodied principles that came to be known as hallmarks of social work—ideas like environmental reform. Unlike previous efforts to eradicate or reduce poverty by essentially diagnosing what was wrong with the poor and telling them how to change—thereby defining poverty as a problem of the individual—the leaders of the settlement house movement recognized that the system was set up to produce inequality; people in power manipulated rules, procedures, and laws to their own benefit while the often voiceless, nearly politically invisible poor became more and more disenfranchised in the process.

            This shift in philosophy brought with it an increased sense of duty and commitment to reform on a broader level. Helping people with their individual problems was important, but not sufficient to counteract the very powerful forces that were causing the problems in the first place—it was analogous to giving a competitive athlete with knee pain a prescription for a painkiller. While the drug alleviated the discomfort and made it easier to function on a day-to-day basis, it didn’t help to heal the knee or cure whatever the underlying problem might be.

Settlement house workers could (and did) teach English classes, provided medical treatment at little to no cost, made strides on issues of public health, assisted job seekers, and provided counseling and myriad other services to clients who were in great need of those services, benefits, and skills. However, the never-ending stream of people who truly needed these kinds of assistance showed that the services provided were the equivalent of treading water—clients may not have been drowning, but they weren’t necessarily progressing either. More to the point, even if people did rise out of poverty and no longer required the services of settlement house professionals, there was always someone else who did.

Jane Addams Hull House Museum - Exterior 1
Hull House Museum, on the campus of University of Illinois at Chicago.
"Jane Addams Hull House Museum - Exterior 1" by Chicago Architecture Today is licensed under CC BY 2.0

            Settlement house workers’ political activism led to a myriad of reforms in the system. Among the changes they helped to instigate were:

  • Child labor laws
  • Improved conditions for women in the workplace
  • Improved public health and safety in cities like Chicago
  • The founding of the National Association for the Advancement of Colored People (NAACP)
  • The founding of the American Civil Liberties Union (ACLU)
  • Protecting domestic workers (often single mothers of minority races) from unfair working conditions and treatment
  • Desegregation of urban hospitals (Crocker, 1992)

Our knowledge of the settlement house movement is tied to one American more than any other: Jane Addams, the founder of Chicago’s Hull House, still the most recognizable name among the many settlement houses that operated in the 19th and 20th centuries. Addams was born in Cedarville, Illinois and attended Rockford Female Seminary (now Rockford College) in her home state. She went on to study medicine but did not complete her studies for her own health reasons; still, her desire to help others continued to drive her. She spent considerable time traveling, reading, and writing in order to determine how she might fulfill her drive to serve the needy (Haberman, 1972).

      While traveling with her companion Ellen Gates Starr, Addams had the experience of visiting Toynbee Hall, a settlement house in London. This helped her to put her drive into a specific direction, as she’d been considering establishing some sort of social service center in a poor Chicago neighborhood. Addams and Starr purchased a home in Chicago in order to establish Hull House, which would go on to became the most well-known settlement house in the country, particularly making an impact on the lives of Chicago’s immigrant residents. The famous settlement house provided early childhood education, after-school activities for kids whose parents were still at work, medical care, a kitchen for the hungry, and mental health counseling services. The evening hours were just as busy as the day, as Hull House provided a range of classes to adults, both professionally and personally oriented. Fine arts opportunities also abounded; the agency had an art gallery, art and music classes, and a theatre troupe (Haberman, 1972).

Box 2.3: Jane Addams writes to President Woodrow Wilson

     Jane Addams famously penned this letter to Woodrow Wilson imploring him to keep America out of World War I. Though women could not yet vote, Addams was not shy about being politically active.

October 29, 1915

To the President of the United States,

Washington D.C.

 

Dear Mr. President:

            Feeling sure that you wish to get from all sources the sense of the American people in regard to great national questions, officers of the Women’s Peace Party venture to call to your attention certain views which they have reason to believe are widespread, although finding no adequate expression in the press.

            We believe in real defense against real dangers, but not in a preposterous “preparedness” against hypothetic dangers.

            If an exhausted Europe could be an increased menace to our rich, resourceful public, protected by two oceans, it must be a still greater menace to every other nation.

            Whatever increase of war preparations we may make would compel poorer nations to imitate us. These preparations would create rivalry, suspicion, and taxation in every country.

            At this crisis of the world, to establish a “citizen soldiery” and enormously to increase our fighting equipment would inevitably make all other nations fear instead of trust us.

            It has been the proud hope of American citizens who love their kind, a hope nobly expressed in several of your own messages, that to the United States might be granted the unique privilege of not only helping the war-worn world to a lasting peace, but of aiding toward a gradual and proportional lessening of that vast burden of armament which has crushed to poverty the peoples of the old world.

            Most important of all, it is obvious that increased war preparations in the United States would tend to disqualify our National Executive from rendering the epochal service which this world crisis offers for the establishment of permanent peace.

 

Jane Addams

(Source: Carroll, 2008)

      Addams herself became openly active politically, fighting for the rights of the poor, immigrants, children, and women at every turn, despite the fact that women still did not have the right to vote in America. She was an outspoken feminist and pacifist, qualities which earned her fans and enemies alike, and became well known internationally through her work with organizations like the Women’s Peace Party and the Women’s International League for Peace and Freedom. Efforts like these led to Addams becoming only the second woman in history to be awarded the Nobel Peace Prize (Haberman, 1972).

      Hull House continued to operate for many decades after Addams’ 1935 passing, closing in 2012 after falling several million dollars into debt. In its final years, Hull House served more than 60,000 clients yearly with services ranging from foster care and domestic violence counseling to vocational programs and family assistance services (Thayer, 2012).

 

The Emergence of Social Work as a Profession

            Though efforts to help the poor were becoming more refined and less client-stigmatizing, the term “social work” didn’t really get used much. Social work was seen as a paraprofessional field by some, which was in line with its early beginnings—many people who had a hand in the early years of the profession’s existence were simply people with a heart to help and time to give. There wasn’t any consistency in their education or experience; in fact, some early social welfare workers really had no training at all. Hence, there were many varied philosophies, approaches, and tactics used by people in the field, and that could have a negative impact on service delivery and the consistency of outcomes.

In 1934, Puerto Rico was the first jurisdiction in the United States to place legal constraints on who could call themselves social workers; California became the first state to do so in 1945 (Thyer & Biggerstaff, 1989). There were several different social work organizations on the national scene in the 1940s and 1950s, and they recognized the need to consolidate for the good of the profession and the benefit of clients.

            The founding of the National Association of Social Workers (NASW) took place in 1955 with the hope that the profession could be more consistently regulated nationwide. There were no universally agreed-upon standards of ethics, certification, education, or licensure, and conversations and problem-solving efforts for all of these topics were necessary in order to help legitimize social work as a profession. NASW lists its major functions as:

  • Enhancing social workers' "professional growth and development"
  • Identifying and maintaining standards for professional practice
  • Pushing for "sound social policies"  (NASW, n.d.a)

NASW publishes a journal, Social Work, highly respected as a source of social science-related research, as well as four additional specialized journals (Children & Schools, Health & Social Work, Social Work Abstracts, and Social Work Research). They also maintain statewide and local chapters in every state and U.S. territory. NASW helps the social work profession to have a political voice, as it aims to educate and lobby elected officials on matters of importance to social work clients and social justice in general. Further, NASW informs its members about candidates whose campaign goals and promises are in line with or opposed to social work values and ethics, as well as emerging trends, ideas, and new endeavors of our fellow professionals, and even job opportunities for current practitioners or new graduates (NASW, n.d.b).

Senator Barbara Mikulski Visits NASA Goddard
Senator Barbara Mikulski (D-MD) is the Senate’s longest-serving female Senator, first elected in 1986. She was the first Democratic female Senator elected, and also a professional social worker.
"Senator Barbara Mikulski Visits NASA Goddard" by NASA Goddard Photo and Video is licensed under CC BY 2.0

Perhaps most importantly, NASW has become the accepted authority on the ethics and values of the profession, which are going to be covered extensively in Chapter 3. Without the NASW Code of Ethics, it is likely that social workers would operate under quite varied ideas of how to determine the best course of action to take for clients in various ethical and clinical scenarios.

Shortly before NASW was founded, the Council on Social Work Education (CSWE) was established in 1952 to help set national standards for the college education of social workers (Suppes & Wells, 2013). Initially, CSWE only accredited master of social work (MSW) programs, but it also began governing and approving baccalaureate (bachelor’s degree) programs in 1974 (Suppes & Wells, 2013). (There is further information about CSWE’s role in American social work education in Chapter 4.)

These organizations have helped social work move from a field that was well-intentioned but disorganized to one with predictable standards of care and service, a reliable program of education for everyone to complete before entering the field, and a means of judging the quality of practitioners once their careers have started. The profession is recognized as a legitimate career, with hundreds of colleges offering social work majors fully accredited by CSWE and every state having licensure and/or certification standards.

 

References

Ambrosino, R., Heffernan, J., Shuttlesworth, G., and Ambrosino, R. (2005). Social work and social welfare: An introduction (5th ed.). Brooks/Cole.

Boyer, G. (2002). English poor laws. In EH.net Encyclopedia. Retrieved from http://eh.net/encyclopedia/english-poor-laws/.

Carroll, A. (2008). War letters: Extraordinary correspondence from American wars. Simon & Schuster.

Cohn, J. (2014). 7 charts that prove Obamacare is working. Retrieved from http://www.newrepublic.com/article/119623/obamacare-one-year-seven-charts-show-law working.

Covert, B., & Israel, J. (2015). What 7 states discovered after spending more than $1 million drug testing welfare recipients. Retrieved from http://thinkprogress.org/economy/2015/02/26/3624447/tanf-drug-testing-states/.

Cox, L.E., Tice, C.J., and Long, D.D. (2016). Introduction to social work: An advocacy-based profession. Sage.

Crocker, R.H. (1992). Social work and social order: The settlement house movement in two industrial cities, 1889-1930. University of Illinois Press.

Cunha, D. (2014, July 8). This is what happened when I drove my Mercedes to pick up food stamps. Washington Post. Retrieved from http://www.washingtonpost.com/posteverything/wp/2014/07/08/this-is-what-happened-when-i-drove-my-mercedes-to-pick-up-food-stamps/.

Griscom, J. H. (1859). Memoir of John Griscom, LL. D, late professor of chemistry and natural philosophy, with an account of the New York High School; Society for the Prevention of Pauperism; the house of refuge; and other institutions. Robert Carter and Brothers.

Haberman, F. W. (ed.) (1972). Nobel lectures, peace 1926-1950. Elsevier Publishing Company.

Hsu, S. S. (2020, October 18). Federal judge strikes down Trump plan to slash food stamps for 700,000 unemployed Americans. Washington Post.

Katz, M. B. (1996). In the shadow of the poorhouse. BasicBooks.

Kirst-Ashman, K. K. (2013). Introduction to social work and social welfare: Critical thinking Perspectives (4th ed.). Cengage Learning.

Macarov, D. (1995). Social welfare: Structure and practice. SAGE Publications. National Association of Social Workers (NASW) (n.d.a). About. Retrieved from https://www.socialworkers.org/About.

National Association of Social Workers (NASW) (n.d.b). NASW Press Journals. Retrieved

           from https://naswpress.org/content/1401/journals

PBS (n.d.). Timeline of the Great Depression. Retrieved from http://www.pbs.org/wgbh/americanexperience/features/timeline/rails-timeline/

Rasmussen, F. N. (2001, March 17). Richmond was a pioneer in social work nationally. The Baltimore Sun.

Sharma, V. (2003). Residual sighted children. Discovery Publishing House.

Socialist Health Association (n.d.). Poor Law 1601. Retrieved from http://www.sochealth.co.uk/resources/national-health-service/health-law/poor-law-1601/.

Speenhamland system. (n.d.). In Encyclopedia Britannica online. Retrieved from http://www.britannica.com/EBchecked/topic/559184/Speenhamland-system.

Spicker, P. (2014). An introduction to social policy. Retrieved from http://www2.rgu.ac.uk/publicpolicy/introduction/historyf.htm.

Suppes, M. A. & Wells, C. C. (2013). The social work experience: An introduction to social work and social welfare. Sixth ed. Pearson.

Thayer, K. (2012, January 25). Hull House closing Friday. Chicago Tribune.

Thyer, B. A. & Biggerstaff, M. (1989). Professional social work credentialing and legal regulation. Charles C. Thomas.

U.S. Department of Labor (n.d.). History of changes to the minimum wage law. Retrieved from http://www.dol.gov/whd/minwage/coverage.htm.

U.S. Department of Labor (2021). State minimum wage laws. Retrieved from https://www.dol.gov/agencies/whd/minimum-wage/state.

Vinovskis, M. A. (2005). The birth of Head Start: Preschool education policies in the Kennedy and Johnson administrations. University of Chicago Press.

Zastrow, C. (2010). Introduction to Social Work and Social Welfare: Empowering People. Tenth ed. Brooks/Cole.

Chapter 3: Social Work Values and Ethics

Many professions have certain ethical standards by which they must abide. Social work has not only a Code of Ethics, but within that Code, a set of values that professionals in the field are expected to embody. The values and principles in the Code of Ethics define and govern social work, informing both practitioners and the general public what is to be expected from people who represent the field. Though the guidelines are extensive and may even seem cumbersome, they are there to protect both clients and social workers. Without them, the discipline of social work would be subject to inconsistency and unpredictability; with them, workers have guidance in the event of ethical dilemmas and clients can know what to expect from the people charged with their care. When you’ve finished reading this unit, you should be able to:

1. Articulate the purposes of the NASW Code of Ethics;

2. Name and define the core values of the social work profession;

3. Explain the various ethical guidelines by which social workers must abide;

4. Give examples of various applications of these ethical guidelines and core values in practice situations;

5. Define confidentiality and explain its limits;

6. Recognize the difference between personal morals and professional values and ethics.

 

NASW State House Day
NASW State House Day in Massachusetts
"NASW State House Day" by Mass_HHS is licensed under CC BY-NC-SA 2.0

History of the NASW Code of Ethics

            After the establishment of NASW in 1955, one of its early tasks was to establish guidelines for the profession. After a period of focus on environmental reform, social work had shifted toward a diagnostic way of looking at human problems, in part due to the significant influence of the psychodynamic treatment movement led by Sigmund Freud. With several different organizations of social workers operating independently from one another, there had been no central governing body to determine the ethical roadmap for the field. NASW’s original Code of Ethics, adopted in 1960, identified 14 single-sentence principles to guide social workers in carrying out their duties, noting that a social worker had an obligation to maintain “certain standards of behavior…in his professional relationships with those he serves, with his colleagues, with his employing agency, with other professions, and with the community” (NASW, 1960). (Ironic, isn’t it, that the language of the time used male pronouns despite the fact that social work was—and still is—a female-dominated profession?) The ideas embodied in the 221 words included in those 14 original ethical guidelines are still alive in the Code of Ethics as we know it today. (The single-page original Code of Ethics can be viewed here.)

There have been nine revisions since the original Code was put into place, some larger than others, and each one has gone into greater detail about the specifics of social work practice. The first revision, in 1967, merely added a fifteenth guideline—a non-discrimination clause: “I will not discriminate because of race, color, religion, age, sex, or national ancestry and in my job capacity will work to prevent and eliminate such discrimination in rendering service, in work assignments, and in employment practices” (NASW, 1967, p. 1). 

The 1979 revision was the first to go into enough detail that the Code of Ethics couldn’t be contained on a single page. Practice had shown us that there were many situations that arose in typical social work that called for greater guidance than the Code of Ethics provided, and therefore, considerable uncertainty and conflict remained about the best way to handle particular scenarios. This expansion of the Code was the most significant in its history, as NASW moved from 15 guidelines to a staggering 82, grouped into six major areas:

  • “The social worker’s conduct and comportment as a social worker” (NASW, 1979, p. ii)
  • Ethical responsibilities to clients
  • Ethical responsibilities to colleagues
  • Ethical responsibilities to employers
  • Ethical responsibilities to the profession
  • Ethical responsibilities to society (NASW, 1979)

While the specific names of the categories have changed somewhat, these six groupings largely remain in place in today’s version of the Code. In this chapter, as an introduction to the Code, we will largely be focusing upon ethical responsibilities to clients and appropriate professional behavior.

In the 1990s, the Code of Ethics was revised on four different occasions in response to a number of specific concerns. The first tackled issues such as how prices for service were determined, the acceptability of being paid for referring a client to another professional or agency, and how clients appropriately could be recruited for enrollment in services (NASW, n.d.). The 1993 revision addressed “social worker impairment and dual relationships,” which will also be defined later in this chapter (NASW, n.d.).

The most recent major adjustment to the Code of Ethics occurred in 1996 due to an ongoing broadening recognition of a range of issues not addressed in the 1979 version of the document, as well as increased media and public scrutiny of the profession. Social workers found that stories about clients who had been done a disservice or even harmed by members of the profession were more likely to be covered by newspapers, television networks, and other outlets, and the increased publicity caused NASW to cast a critical eye inward to clarify details of the Code and add new elements to deal with issues not really considered decades before (NASW, n.d.)

The four most recent adjustments of the Code have been relatively minor. Further clarification was made in 1999 regarding the limits of confidentiality (a topic that will be discussed in depth later in this chapter). Nine years later, the non-discrimination guidelines of the Code were expanded to include sexual orientation, gender identity, and immigration status. In 2017, the Code was updated to address issues related to the use of technology, and 2021's revision largely emphasized the importance of social workers' self-care (NASW, n.d.).

Pride Flags
In recent years, the Code of Ethics has been updated to reflect a support of non-discrimination toward people on the basis of sexual orientation and gender identity.
"Pride Flags" by celesteh is licensed under CC BY 2.0

 

In the future, the Code of Ethics will no doubt require additional modification and revision as we encounter still-unknown areas of practice, social injustice, and additional dimensions of diversity. The Code is in effect a living document, as it should be; its dynamic nature reflects the ever-changing field of social work and our consistent desire to modify practices and procedures in order to best meet the needs of a clientele that continues to display its tremendous diversity.

 

The Core Values of Social Work

            First, we should take a moment to define what we mean by values, and how they are distinct from ethics. Values are what one considers to be good or important—the things one holds in esteem. For instance, what do you find important in your own life? You might recognize the importance of family, education, success, independence, freedom, faith, or any number of other abstract concepts or concrete items in your own life. Those are your values!

Chances are, if you’re considering becoming a social worker, your values have been a big part of what has driven you to evaluate whether this is the right direction for your future. Perhaps you were raised in a home where you were taught the importance of giving back to the less fortunate. Maybe your faith imbued in you a sense of purpose in serving your fellow human beings. Maybe you personally have experienced difficulties, had someone help you through them and come out stronger, and you want to provide that same sense of resiliency and self-efficacy in someone else. Whatever your reasons, it’s likely that your values had a hand in influencing you to look into social work.

Though it is clear that our values are important, and probably influenced our decisions to enter the social work field (or simply study it), it is essential that we recognize that our clients have values as well, and theirs supersede ours in our work together. Social workers often talk of leaving their biases at home when they go to work, and this is exactly what they mean. Your personal values, while important, have limited application in your work with clients. Only where they align with the values of the profession presented in the Code of Ethics should they really influence practice. For instance, if you have a personal value of social justice, which is one of the six core values we’ll cover shortly, obviously that is fine to pursue in your work with clients. (If you don’t value social justice, your job as a social worker still demands that you make efforts to pursue it—for instance, by eradicating racial inequality, even if you personally believe people should be satisfied with the current level of racial inequality.)

On the other hand, if you have an important personal value of faith in God, and you have an atheist client, it really isn’t permissible (or even in the client’s best interest) to try to emphasize the importance of faith when it comes to working with your client. No matter how important your faith is to you, and how much you believe it would help your client if they believed in God, it’s not ethical for you to pursue that direction. If you want to convert people or proselytize, social work is not the profession for that. The client’s values and the values of the profession take precedence over our own.

With this in mind, let’s examine the six core values identified in the Code of Ethics: service, social justice, dignity and worth of the person, importance of human relationships, integrity, and competence (NASW, 2021).

Volunteers
Volunteering is a common activity for social workers, exemplifying the value of service.
"Volunteers" by vastateparksstaff is licensed under CC BY 2.0

Service

            Our most basic task as social workers is to serve our clients. Service, simply put, means we put our clients’ interests before our own. Sometimes, social work students (or even social workers themselves) make the mistake of looking at the worker-client relationship as a superior-subordinate relationship. This may happen in part because social workers occasionally do have some element of power—for instance, the power to remove children from homes where they are being abused or neglected—but it should always remain prominent in the social worker’s mind that, if anything, the client is the one in charge. In the end, no matter what the social worker hopes the client does, the client is the one who makes the final decision. The social worker ultimately has no control over the client’s actions, and that is as it should be. There may be consequences to the client’s actions, of course (particularly if there is a court order or child protective services case involved), but the client still has the right to choose their course of action (NASW, 2021).

            The core value of service means the social worker recognizes that they are working for the client, using skills, knowledge, and resources to help the client reach the goals that have been identified for the helping relationship. It also means that social workers are encouraged to spend part of their time volunteering, providing pro bono services to clients and programs that could use their expertise and experience to their advantage. Social workers generally enjoy this sort of work (at least at times); in fact, many people in the field discovered or confirmed their love for social work through volunteering as adolescents or young adults. Nevertheless, fitting in a job, volunteer work, and a personal life can seem daunting at times, especially if one’s job is particularly demanding.

BLM Protest #56
"BLM Protest #56" by sasastro is licensed under CC BY 2.0

Social justice

            Both as individuals and as a collective profession, social workers fight for social justice. Social justice is the belief that all people deserve equal rights, opportunities, and access to economic and political resources. This holds true regardless of race, ethnicity, religion, sex, gender, sexual orientation, or other dimensions of diversity. It is incumbent upon social workers to combat instances of social injustice, when it is clear that a group (or individual people in a particular group) is/are being disadvantaged or disenfranchised (NASW, 2021).

            What are some examples of social injustice? One commonly discussed topic in recent years has been discrimination against LGBTQ+ (lesbian, gay, bisexual, transgender, queer/questioning, and other sexual/gender minorities) people. In the 1960s, the United States saw the pinnacle of the civil rights movement as a response to “separate but equal” policies of having separate schools, separate drinking fountains, and separate lunch counters for whites and nonwhites. It eventually became clear to most Americans that those practices were reprehensible, and the Supreme Court and Congress worked to overturn some laws, pass new ones, and generally make it known that racial discrimination was not an acceptable part of a free and just democratic society.

            NASW would argue that we are now in a similar place when it comes to discrimination against LGBTQ+ individuals. People are more aware than ever of the issues being faced by LGBTQ+ Americans, but their treatment and rights remain major sources of controversy. You may be familiar with stories that have been popping up in the media about bakers refusing to make wedding cakes for same-sex couples, or dress shops refusing to sell a dress to a lesbian for her wedding to her future wife (Roth, 2015; Terrero, 2011). The question often discussed is what reigns supreme: the customer’s right not to be discriminated against or the business’s right to refuse service to someone based upon supposed religious grounds?

In the 1960s (and certainly earlier), there were many businesses who would have used religious arguments to support their choice to refuse service to nonwhite people (or an interracial couple), or provide them with lesser service. Now, we generally recognize those arguments are invalid, and one’s religion does not give one the right to discriminate against customers in a place of business.

            Despite this, a number of states passed laws either making it legal for businesses to refuse service to someone based on religious beliefs. Some went as far as to prohibit municipalities in the state from passing anti-discrimination ordinances (Guo, 2015). To social workers with an eye toward social justice, this was a clear violation of the principle. NASW would say that LGBTQ+ customers deserve to be served just like anyone else without their sexual orientation or gender identity being used as a disqualification for that service. The Supreme Court eventually agreed in Bostock v. Clayton County, finding that the language of the 1964 Civil Rights Act also affords protections to LGBTQ+ people and laws permitting employers to fire people based on sexual orientation and/or gender identity alone were unconstitutional (Totenberg, 2020). NASW lobbied in support of declaring these discriminatory practices illegal.

            Other examples of fighting for social justice would include taking the government to task for the longer prison sentences nonwhites receive for the same crimes as whites (Palazzolo, 2013) and fighting for equal pay for women, in an effort to close the wage gap between men and women that still exists. Social workers may take up the battle on the behalf of a specific client on their caseload when they feel the client has been disadvantaged in some way, or they may be part of larger community-wide, statewide, or nationwide movements to overturn unjust policies and implement replacements that make social justice more attainable.

 

Dignity and worth of the person

            It seems like this should go without saying, but it’s important to discuss. Every client with whom a social worker interacts is worth that worker’s time and effort. Every one of those clients has a right to dignity, to be treated as an individual who deserves assistance in reaching their goals. Many clients have been treated badly by multiple people in their lives, perhaps (most disconcertingly) even some professionals who were supposed to help. It is not unusual for people to be judged by others without full knowledge of their circumstances. Frankly, it is easy to pass judgment on someone when that person appears either to have brought negative circumstances upon themselves or not to have done enough to get out of a bad situation. Of course, the view from outside someone’s life is rarely similar to the one that person has from the inside.

            Still, many of you are probably reading this and thinking, “Well, of course everyone has the right to dignity, and everyone is worth something. If I didn’t believe that, why would I be studying social work?” That sounds like a perfectly good question. In practice, though, it may not be so easy to see everyone so generously. In fact, it might seem totally reasonable to look at people in a different light if they were in your personal life than you would if they were in your social work office. People who have done things you might find morally reprehensible could be very difficult to tolerate if they play certain roles in our lives, like your kid’s kindergarten teacher; however, if a client has done something you find morally reprehensible, that client still has a right to be treated with dignity and worth. If you struggle to treat a client with dignity and worth, then a) you should discuss this with your supervisor, and b) you may ultimately need to refer that client to another professional.

Female Inmates in a RDAP Program
Could you work with a client who had spent time in prison? Would you be able to treat that client with the same dignity and worth as a client with a clean record?
"Female Inmates in a RDAP Program" by CoreCivic is licensed under CC BY-ND 2.0

 

            There is an idea called the looking-glass self that was popularized by 20th-century sociologist Charles Horton Cooley. He suggested that a major component of each person’s self-concept is based on the way other people treat and react to that person (Gray, 2002, p. 509). In other words, people know how to think of themselves based on the way it appears others see them. If everyone treats you like everything you say is interesting, would you not believe you are an interesting person? Conversely, if most people reacted to you as if everything you say is unintelligent, it would be natural for you to believe you were unintelligent, right? Of course. So how does this apply to our work with clients?

            Think about the way many clients have experienced the world before coming to seek assistance from a social worker. They may have been told they deserve what has happened to them; that life would be better if they simply tried harder; that their problems are all in their head and simply a matter of perspective. As the concept of the looking-glass self indicates, it would not be unusual for clients to come to your office already feeling pretty badly about themselves. The social worker’s office is one place that clients should be able to know they can come and feel welcomed and respected—a judgment-free zone.

            Imagine how it would feel, instead, to have a social worker treat you like you were not worthy of dignity and respect—that something about you, perhaps something you had done, rendered you instead worthy of judgment, even from someone who is not supposed to judge others. What sort of self-concept would that foster? Even if the worker’s judgment of the client led to kindly and quickly referring that client to a new social worker right at the beginning of the relationship, it could send a message that the worker does not personally think it is worth her/his time to work with that client. At any given time, with any given client, that could be a devastating blow to one’s self-concept. That could end the individual’s willingness to engage in a helping relationship not just with that social worker, but with any social worker.

            Does this mean you should be able to work with any client at any time? Not necessarily. For instance, if you were going through a breakup or divorce due to a partner's infidelity, it might be difficult (if not impossible) to work well with a client who was having an affair and considering leaving their partner. While you might have been able to work with a client like that in the past, and potentially could again in the future, it may not be the right time for you. It is important to acknowledge your limits and always keep the client’s best interests in mind.

Box 3.1: Challenges of the Job

Questions to Ask Yourself

What kinds of clients would be most difficult to work with, and why would you struggle? Do you have personal experience with that specific issue?

Do you have memories of difficult circumstances in your life that a particular kind of client could trigger? Do you see those clients as unworthy of assistance?

How would you react in the moment if a client revealed something about her/his personal history that caused you to realize you couldn’t help that client any further?

Should social workers expect to work with clients that have done things they find morally reprehensible? Should it be required that they do so? Why or why not?

 

Finally, keep this idea in mind when it comes to dignity and worth. There are certain criminal acts which nearly everyone finds unacceptable: rape, child molestation, domestic violence, and so on. It might seem totally reasonable not to wish to work with clients who have engaged in acts like these in the recent past. Imagine, though, if no one were to be willing to work with those clients. What would the outcome be? Without assistance, it is likely their behaviors would continue, resulting in further damage being done to victims of these acts. If no one sees an abusive spouse as worth helping, then not only are we refusing services to that potential client, we are allowing the cycle of abuse to continue unchecked. Being able to see people with dignity and worth involves a “dual responsibility to clients and to the broader society” (NASW, 2021, para. 17).

            Elements of this principle will be discussed in greater depth later in this chapter when we cover the strengths perspective.

 

Importance of human relationships

            Out of all the items in the social worker’s metaphorical toolbox for working with clients, the ability to build a relationship with clients is perhaps the most important. Very little can be accomplished without first establishing rapport and possessing an ability to talk openly about some very difficult subjects.

            Remember, our relationship with clients is a partnership. We are working together to help them reach the goals that we’ve identified for our helping relationship. The quality of that partnership can make all the difference. We also recognize that the relationships people have with each other are key both to dysfunction and to the recovery/change process. Relationships our clients have with other people can be assessed and strengthened in order to help them through the change process. We understand that the relationships among people in organizations impact how well those organizations function as well (NASW, 2021).

We can help our clients to identify positive relationships in their lives and maximize the support they can obtain from those friends, family members, and significant others; we also help to identify relationships that could be improved—or perhaps reduced or eliminated, when the client feels they are ready and it is necessary—always with an eye toward accomplishing the client’s identified goals.

            It is important to note that we do not tell clients what people in their lives are positive for them and which are negative. It is important that they come to those recognitions themselves and present their own arguments for these changes. We can encourage clients to explore these ideas, of course, and it may be important for us to do that in particular situations where we can see the damaging effects of certain people in the client’s life. However, it’s not our job to dictate or suggest whom the client should and should not have in their lives. It is our job to help them come to the healthiest decisions they are ready to make, and assist them in the execution of those decisions.

 

Integrity

            Without acting in a trustworthy manner, social workers would never be able to foster the rapport needed to establish a healthy helping relationship with any client. This is the same basic directive that underlies the next core value of social work: integrity. Social workers are expected to be honest and deserving of trust in all their behaviors in the course of their job. Lying or misleading a client is typically unacceptable (though exceptions exist, based on safety needs). It is usually preferable not to answer a client’s question rather than to answer it dishonestly (NASW, 2021).

            Integrity goes beyond trustworthiness and honesty to point out that social workers are bound to stay updated on the Code of Ethics and emerging ethical issues, being certain to promote ethical practice while adhering to the mission and values of the profession itself. It is our responsibility to be sure that we are complying with ethics, obviously, but we also are expected to ensure our organizations and employers are acting in a consistently ethical manner as well. If they are not, it is our obligation to act upon our knowledge of any unethical practices, bringing attention to them and working to change them (NASW, 2021).

For example, let’s say our agency has a large and diverse service area within a city. This service area has within its boundaries a number of neighborhoods, some of which are crime-ridden and more profoundly impacted by poverty, some of which are more middle-class and perceived as less dangerous. If the agency has a policy that the most tenured employees get to choose their assigned territory first, and this has resulted in the poorer neighborhoods within the agency’s service area consistently getting assigned to the least experienced workers at the agency, this is problematic. While the agency did not in all likelihood intend to do anything unethical, the end result of this policy is that the areas that probably need the most assistance get workers who may be less prepared to help them. It would be easy not to speak up about such a policy for fear of “rocking the boat,” but the core value of integrity dictates that we say something about it. The policy is a clear violation of the value of social justice we spoke about earlier, and failing to bring it up would be akin to giving it the stamp of approval, since we would knowingly be allowing it to continue.

            Another example of integrity applies when clients ask a social worker about her/his personal history. Imagine a client named Esther is in treatment for depression, including periodic suicidal thoughts. She asks her social worker, Lexi, “Have you ever dealt with depression yourself?” Lexi has never been clinically depressed, but worries that Esther isn’t going to trust her if she’s never experienced similar feelings. Lexi decides it wouldn’t be a big deal if she just told Esther she was in treatment for depression as a teenager. This does seem to put Esther at ease, and she opens up about more of her struggles. Lexi is relieved.

Later, Esther asks Lexi if she ever felt suicidal, and Lexi finds herself in a difficult position: should she continue the lie, admit the truth, or deflect the question? While she may have had good intentions—helping the client feel comfortable enough to open up—Lexi has violated the principle of integrity by intentionally misleading a client. If Esther discovers her dishonesty, she understandably might no longer trust Lexi—or any social worker or counselor. If Lexi continues to lie, she’s also continuing to exhibit a violation of social work values. Furthermore, if Esther strikes up a conversation in the waiting room with another client of Lexi’s who has different information, Lexi may have compromised her practice with that client as well. We have to remember clients may (and often do) talk to each other. We cannot and should not expect them to keep secrets about us, even though we need to respect confidentiality with them. (More on that topic is coming later in this chapter.)

Opening Conference Speakers
Attending professional conferences can be an important part of a social worker's ongoing education during their career.
"Opening Conference Speakers" by Nor-Shipping is licensed under CC BY-NC-ND 2.0

Competence

            Social work is a relatively young field, and given its ever-increasing focus on empirically supported practice, there is always new information emerging about how best to help our clients. Many journals publish research that helps those of us in the field to understand what the latest developments are in order to stay current in our knowledge and approaches. Whether through these publications, presenting seminars to colleagues, or other means, social workers are encouraged to contribute to that expanding knowledge base upon which the profession depends.

            It is impossible to be an expert in every area of social work. It is still expected that social workers do their best to have knowledge in as many areas of practice as possible. This includes staying abreast of the developments in their own particular area of specialty or expertise, if they have one, but also learning more about areas in which they are less well-versed. It is ethically questionable to work with a client whose major problem is outside the worker’s area of expertise, especially if there are experts in that area of practice readily available and willing to take a referral. This core value of competence indicates it is the worker’s responsibility to have the proper knowledge to best help their clients.

            In line with this value, social workers are generally expected to continue their education beyond graduation. However, different states all have their own unique requirements. For instance, in the state of Illinois, licensed clinical social workers (LCSWs) are required to get 30 continuing education units (CEUs) during every two-year licensure period, three of which must cover ethics three of which must cover cultural competency, and one which must address sexual harassment (NASW Illinois Chapter, 2021). Tennessee instead requires an LCSW license to be renewed yearly with 15 CEUs, with at least three in ethics and ten in general social work (Tennessee Department of Health, n.d.). It is important for you to understand the continuing education requirements of your state so you can stay in compliance with the expectations of your governing body. Additional requirements may exist in particular states or with particular licenses (e.g., a requirement that a certain number of hours must be completed face-to-face rather than online or by mail).

            Continuing education units generally represent clock hours spent in educational settings. Among the ways CEUs can be earned include:

  • Attending seminars, workshops, or conferences
  • Taking college courses
  • Teaching college courses
  • Conducting seminars or other training events
  • Writing and publishing research or books related to social work
  • Approved self-study courses

If there is any doubt about whether a particular educational provider is approved, you should be certain to check with your local governing body to verify the status of the provider before you pay for the program.

 

Ethical Standards

            As noted, the Code of Ethics continues to break its general elements into social workers’ ethical responsibilities to clients, to colleagues, in practice settings, as professionals, to the social work profession, and to broader society. The next part of this chapter focuses upon this rather extensive portion of the Code. We will not examine each ethical principle—since this is an introductory text, we will provide a basic overview with some particular key points highlighted. Keep in mind that it is important for you to fully understand all parts of the Code of Ethics when you are a professional. Should you continue to study social work, you will be required to learn about the Code in much greater detail in some of your upper-level courses.

 

Ethical Responsibilities to Clients

            This section of the Code is extensive, and aims to cover many of the dilemmas we may encounter in our daily interactions with clients, as well as laying out the client’s basic rights in interactions with a social worker and the social welfare system. The client’s best interests come first in the vast majority of cases, but the social worker also has to honor a responsibility to the community and larger society, and therefore may at times make decisions that favor the safety of the community over the client’s happiness. The circumstances in which that can occur are specific and limited.

Self-determination

            Clients have the right to determine the course of the helping relationship with any social worker, except in those cases when in the worker’s “professional judgment, clients’ actions or potential actions pose a serious, foreseeable, and imminent risk to themselves or others” (NASW, 2021, para. 24). Examples of this would include if the client intended to give his child some medication that was not meant for children to use, or to allow the client’s four-year-old son to care for his two-year-old sister for eight hours while the client was at work.

            Ultimately, unless a client’s choice puts the client or others at risk of serious harm, the social worker cannot interfere in that choice. Our clients have the right to make decisions about their own lives, including unhealthy ones. It’s no different than if you go to see your doctor, she recommends a particular prescription for a medical condition, and you refuse to take that medication. The doctor may have a lot of information and experience that indicates you will benefit from that medication, but you have the right to refuse it, unless a court hears a really compelling argument that you are incapable of understanding the decision or its potential ramifications.

            Self-determination is not just a client’s right, but it is also for the social worker’s own good. Imagine for a moment that you tell a client he should dump his boyfriend, saying that the relationship appears to be making your client unhappy. If the client follows your advice and breaks up with his boyfriend, but finds himself single one year later and clinically depressed when his ex-boyfriend adjusts well and finds a new relationship, then obviously, the advice did not lead to a positive life change. That potential negative result is one reason that client self-determination is the key, rather than a social worker’s advice or recommendation.

            However—and this may come as a surprise—it is also problematic if the social worker’s advice is well-received and results in a positive outcome. Sticking with the same example, suppose your client finds he is happier since ending his relationship, and he feels very grateful to you for the suggestion that he end his relationship. On the surface, it might seem like that’s a great result. However, what you’ve done has robbed the client of the satisfaction of making his own healthy decision, of learning that he does not need to rely on others to make those decisions for him. This denies the client the opportunity to develop self-efficacy, which is an essential component of healthy, independent functioning—our ultimate goal.

 

Informed consent

            It is important that a client knows, as much as possible, what to expect from participation/enrollment in a treatment program or other social work service relationship. This includes understanding:

  • The purpose of the services being provided (e.g., housing assistance)
  • Potential risks of receiving those services (e.g., legal consequences for failed drug screens)
  • Limits to services related to the involvement of a third-party payer like an insurance company
  • Costs of services
  • Possible alternative methods of service provision
  • Their ability to refuse or discontinue receiving services (e.g., if services are court-ordered, what will happen if the client stops attending services?)
  • An expected end date for service provision (NASW, 2021).

Clients should have the opportunity to hear a verbal explanation as well as receiving written explanation of the services to be provided. Clients may be better able to process one or the other, and they should have the opportunity to take the written copy of the consent home so they can have more time to review it or show it to someone else who can help them understand it (in case they feel shy or embarrassed about asking the social worker for clarification). This can also be helpful when a client may struggle with literacy or having a full understanding of the language in which services (and documents about those services) are provided. If possible, interpreters and translated documents should be made available.

Remember, clients have the right to refuse services, even if they are court-ordered. Social workers and their agencies are not ordered to provide services; we may receive referrals from the criminal justice system, but any mandate applies to the client, not the worker. It is important that clients know the consequences of refusing services, but ultimately, it is their choice to make (NASW, 2021).

Diversity quilt
Working with diverse people requires an interest and desire to understand many dimensions of diversity.
"Diversity quilt" by OregonDOT is licensed under CC BY 2.0

 

Cultural competence and social diversity

            The importance of cultural/racial issues and other matters of diversity will be addressed more fully in another chapter, but it is worth mentioning here that it is essential for social workers to recognize that every culture has its own unique characteristics and traits that serve as assets to people in that culture. Social workers should always strive to be culturally competent and to learn more about groups with whom they will interact, particularly those with whom they do not have a lot of experience and may serve in their professional career. Part of understanding the realities and differences among diverse groups includes a recognition of the oppression and unequal outcomes some of these groups face, and how those unequal outcomes may contribute to the problems that bring our clients into agency offices (NASW, 2021). It is not acceptable to bring up the fact that minority groups once had it worse, or that they should be happy with the advancements that have been made. The fact that inequality was once worse doesn’t mean the current state is acceptable or that people should be satisfied with progress moving slowly or stalling.

 

Conflicts of interest

            The primary role any social worker should have is the betterment of the client, and we should avoid any circumstances which may give even the appearance of impropriety, or the impression that we could have something further to gain from our interactions with a client. One way in which we might put ourselves in a position for our motives to be questioned is if we have a conflict of interest.

            It is unethical for a social worker to gain anything financially from an interaction with a client (beyond their salary, of course). This could happen, for example, if a social worker were to be paid a commission for every client signed up for a program. When the social worker has the opportunity to gain financially from certain decisions made by the client, it compromises their ability to concentrate exclusively on the client’s best interests. When conflicts of interest exist or may arise, the social worker must both inform the client of the conflict (or potential conflict) and take steps to minimize or eliminate it. It may be necessary for the client to work with a different social worker if a conflict of interest cannot be resolved.

            A conflict of interest may also occur if a social worker is working with two people who have a relationship with each other. In such cases, the social worker must clarify who the actual client is and what the worker’s responsibilities are to the various parties involved in receiving services. Whenever possible, social workers should avoid providing individual counseling services to separate people who are dealing with problems in the same relationship. (Obviously, this does not apply to couples counseling.)

            One specific example of a conflict of interest is a dual relationship. This describes a situation in which a social worker has two kinds of relationships with a client: one as his/her social worker, and another in some other capacity. (The other relationship could also have been in the past rather than presently active.) Dual relationships are to be avoided; it is impossible to be truly impartial and objective with a client with whom one has some other sort of relationship. Some dual relationships are strictly prohibited—for instance, one should not be a social worker to one’s own friend, relative, coworker, or significant other. Others may be more difficult to avoid; for instance, if one lives and works in a rural area, there are likely to be fewer agencies that serve particular needs or populations, and so there may not be many referral options to help someone avoid a dual relationship. A social worker may end up having a client whose son is in the same classroom as the social worker's daughter, or who goes to the same house of worship. In those cases, it is essential that the social worker set boundaries that are firm, “clear, appropriate, and culturally sensitive” (NASW, 2021, para. 39).

 

Privacy and confidentiality

            Social workers should strive only to obtain necessary private information from clients—that is, only the information the social worker must know in order to serve the client successfully. All of that information is to be kept in the strictest confidence. The client has the right to expect both privacy—the knowledge that no unauthorized people are listening in on the conversation between the client and social worker—and confidentiality, which is more complex.

            Confidentiality is the policy that forbids the social worker from sharing information gleaned during the course of a relationship with a client unless it meets certain criteria that trigger the social worker’s mandated reporter status. A mandated reporter is someone who is required by law to share certain information with authorities when it is presented to them. Teachers, nurses, doctors, child care workers, social workers, and many other people are legally designated as mandated reporters.

            It is important that a client understands what confidentiality is and what its limits are as early as possible in the relationship with a social worker. Therefore, it is expected that a social work professional will explain these principles at the beginning of the first meeting with the client whenever possible and appropriate, and revisit the rules throughout the relationship to keep the client aware of possible reasons confidentiality may be broken. Although some people might expect that once clients know about the limits of confidentiality, they would be reluctant to share anything with a social worker that would trigger a mandated report, clients still often share information like this with their social workers. It is important that when they choose to share such information, clients know how the social worker is going to react.

 There are several reasons that confidentiality may cease to apply, resulting in a report to authorities or other individuals. The most frequent reasons are often called “the three hurts.” This means a social worker must disclose information to authorities when it is “necessary to prevent serious, foreseeable, and imminent harm” (NASW, 2021, para. 43). That includes:

  • When the client is going to hurt her/himself
  • When the client is going to hurt someone else
  • When someone else is going to hurt the client

In other words, if a client says he or she is going to commit suicide, or assault someone, or that someone else is going to assault the client, the social worker must report this to police or other authorities that can potentially intervene or prevent the situation from occurring. However, the social worker should only share that information which is necessary in order to reasonably protect the client or others from harm. In addition to the three hurts, social workers’ mandated reporter status is activated in the following situations:

  • Child abuse and neglect (even if the client is not involved)
  • Elder abuse and neglect (even if the client is not involved)

Furthermore, social workers can also break confidentiality (though it is not mandated) in the following scenarios (judgment must be applied, and a supervisor’s opinion should be sought in some cases):

  • When the client has signed a consent to release information to a particular party
  • When it is necessary to obtain payment from a client’s insurance carrier or other third-party payer (and the client has been informed that information will be shared with the carrier or payer)
  • When some crimes have been committed on agency property
  • When a client notes they intend to commit a crime (NASW, 2021; Wilson, 1978)

Depending on the state in which one resides, an obligation known as duty to warn may also apply. If a client makes a specific threat of imminent harm against an identifiable person, your state may legally require you to make a reasonable effort to contact that individual (in addition to informing law enforcement of the threat). Nearly 30 states (including Illinois) have mandated duty to warn policies for mental health professionals, while 16 allow these professionals to do so at their discretion (National Conference of State Legislatures, 2013).

               Note that social workers can talk to their supervisors and coworkers at the same agency who are working with a particular client and share information with those coworkers; these communications do not violate confidentiality as long as the information being shared is pertinent to the client’s care and is being shared with people who should know it in order to optimize that care. (It is also likely that the agency has noted this sharing of information in the informed consent documents the client signed in order to receive services.) Should information about a client’s criminal record be shared with the receptionist at the social work agency? It’s not germane to the receptionist’s job, so the answer is no. May it be shared with the social worker’s supervisor in the context of a supervision meeting, or one of the other mental health professionals involved in the program who works closely with that client? In all likelihood, the answer is yes.

            Social workers may discuss their cases in general terms with other colleagues, with students, or even with important people in their own lives, provided there is no sharing of identifying information—data which could make it clear what specific person is involved in a helping relationship with the social worker. For example, your social work professor could talk to you about a former client who had lost his job due to his alcohol use provided there wasn’t enough information provided for someone to recognize the client within the example. If your professor said they had worked with a cashier at a local fast food restaurant, that is far too much information since it significantly narrows the potential number of people to whom your professor could be referring. Obviously, this means data like names, addresses, names of relatives, places of employment, physical descriptions, and more should be omitted from discussion of any client with someone who is not in a position to legally know who the client may be. This is also why workers will change certain details when discussing a case—this makes it even less likely anyone will deduce the client’s identity.

 

Sexual relationships

            Hopefully, in the earlier discussion of dual relationships, it was clear that a social worker should never have a romantic relationship with a client. It is also expected that social workers will not have sexual relationships or contact (including electronic sexual communication) with close relatives or friends of their clients. Finally, it is expected that social workers will not engage in sexual relationships with any former clients. While no specific guidelines for a time limit exist in the Code of Ethics, if a social worker feels an exception to this guideline should be made in a particular case, the social worker must be able to demonstrate the former client has not been harmed, “exploited, coerced, or manipulated, intentionally or unintentionally” (NASW, 2021, para. 63). In actual practice, let us be clear: it is a basic expectation of working in this field that any sexual relationship with a former client is at best ethically questionable and should be avoided at all costs. Despite this, data indicate that about 4.4% of therapists (7% of male therapists and 1.5% of female therapists)—some of whom are likely clinical social workers—at some point engage in sexual contact with a client (Pope, 2001). It is certain that social workers in non-clinical roles also occasionally make this egregious mistake.

            We enter relationships with clients in a very different way than we enter other relationships. We have a position of privilege and power when we meet them, as they open up their lives to us without the reciprocal nature of having us open up to them about our own secrets and problems. This unequal beginning makes a future relationship unfair to the client on top of being unethical. It is understandable why attraction may occur between a client and social worker; the worker generally treats clients with great respect, understanding, and kindness, and those are traits that may seem in short supply in the client’s life. It can be difficult for some clients to see the difference between such behaviors and genuine romantic interest in someone. It would be easy for a social worker in such a situation to use the client’s trust to the worker’s advantage. Doing so, however, not only risks the mental health and functioning of the client, but also the social worker’s own livelihood and career. We must not allow the client’s trust in us to be used for our own selfish purposes.

 

The Strengths Perspective

            Though not part of the Code of Ethics, the strengths perspective is considered standard operating procedure in social work. It is the default setting from which we must operate in all of our interactions with clients. Failing to do so can not only mean that we struggle to help the client—we may even cause harm.

            Dr. Dennis Saleebey, professor emeritus of social work at University of Kansas, is a prominent writer on the topic of social work’s use of the strengths perspective. While it serves as the closing topic of this chapter, its placement does not indicate its relative importance. This is an essential approach that social workers need to take in their professional interactions with individuals, groups, and systems.

            In general, as people, we do not typically see others from the strengths perspective. We may look at the people we care most about from this point of view, but overall, we often see people’s warts, idiosyncrasies, faults, and “baggage” very clearly, perhaps even more prominently than their assets. In social work, we have to take this common tendency and flip it, choosing to actively see people from the more positive, optimistic, and hopefully empowering viewpoint.

            The whole goal of the strengths perspective, actually, is just that: empowerment. It’s an interesting balance we keep in social work; we recognize that there are many factors beyond individual clients’ control that have a major impact on their lives, but we also know that in order to have a good chance of moving forward in their lives, they need to feel empowered, like their lives can truly improve through their own sincere, concerted effort. Without the sense that they have control, it is totally understandable for a client to feel downtrodden and fail to put in their best work. Without the client’s self-efficacy, we face an even tougher road in our helping efforts.

            In the 1980s, the University of Kansas’s School of Social Welfare strove to use a strengths-based approach in their case management work with a population dealing with prolonged, significant mental illness diagnoses and concerns. Their overwhelming success with the method prompted them to bring together a number of practitioners noted for using similar approaches and to work on defining the strengths perspective more clearly (Saleebey, 2008). Let’s look at some of the principles of this strengths perspective as articulated in Saleebey’s various works (1996; 2008; 2009).

 

Principle 1: Every client has strengths.

            This is the very foundation of the strengths perspective. It is very easy to say, but perhaps not so easy to put into practice. It could be said that this principle falls in line with the core value of dignity and worth of the person. Do you remember how earlier in this chapter we discussed how every client has dignity and worth and deserves to be treated as such? Well, a big part of that is seeing the positives the client brings to the table—in this case, we’re going to think of those positives as strengths.

            Every client with whom you work will have considerable strengths. Some of those strengths have perhaps not been fully utilized. Some of them may not even be recognized by the client themself. Still more of those strengths may perhaps be perceived by the client or others as liabilities.

How could strengths be perceived as liabilities? Well, many pairs of words describe the same trait (or nearly the same trait) in a negative and positive way. For instance, stubbornness could be seen as determination. What makes a person manipulative could also be what makes one persuasive. The key, perhaps, is the way in which these strengths are directed. If I have the ability to convince you of my point of view, to get you to see things my way, am I being persuasive or manipulative? How you answer may depend on the specific situation and the goal of my efforts. If I’m trying to convince you to vote for a particular candidate, I may be acting persuasively. If I want you to feel badly about something you did to me months ago so you’ll feel guilty and want to take me out for an ice cream sundae, I may be acting manipulatively. (I may also be a 10-year-old kid, but I digress.) However, the skills being used in each situation are really not that different.

It is essential that we make an ongoing effort to identify our clients’ strengths, which should be noted as part of their assessment and their service plan. Even clients who have perpetrated what you might consider to be terribly deviant or immoral acts have strengths within them. If you cannot find the strengths in a client, a) you aren’t looking hard enough and b) you probably will not be able to help that client. If you’re struggling to identify strengths, you may want to look at some of the traits considered particularly challenging about that client and ask yourself, “If those same skills were applied in a positive direction, what would we call them?”

 

Principle 2: Trauma, abuse, discrimination, tragedy, and other difficult circumstances are opportunities for growth.

            When clients come to social workers for help, even if they come of their own accord rather than being encouraged or coerced by loved ones (or ordered by the courts), they have more than likely endured quite a few challenges in their lives already. People do not often seek out the assistance of social workers when everything is going well. During the course of assessing and getting to know our clients, we will discover many parts of their past and perhaps even their present situations that have been difficult for them to handle.

            These situations are not something we want the client to have gone through, of course; still, the fact that they have been through their personal gauntlet and not yet given up means they are survivors. They have been through circumstances that would have caused some to give up, to quit trying. Yet here they are, in your office, when they could have made the choice not to show up at all. Some may see them as victims, but we choose instead to see them as survivors.

            When a client tells some people about the struggles in his life, it may seem like complaining, whining, or victim-playing. Those events may come off as limiting factors. You may know someone in your life that always seems to have bad things happen to them. People may begin to perceive that they are the reason behind their own struggles, and there may be some truth to that at times. However, as social workers, we would instead use the knowledge of those events, struggles, and misfortunes to identify the strengths in that client’s character. If a client was sexually abused by a stepparent growing up and now struggles with the idea of being in a sexual relationship as an adult, from the strengths perspective, we would recognize that the client has a healthy desire to protect themself. We wouldn’t say, “You’re going to have to get over it eventually,” or “You just need to let go of it and not let it ruin things for you now.” That’s oversimplifying a very complicated issue. If anything, we need to praise the client for considering the ramifications of the abuse and for having a desire to conquer it, even if it’s been difficult. We need to celebrate the fact that they haven’t simply stopped trying to interact with others, that they haven’t sworn off relationships altogether.

            Similarly, other challenges show us what the client is made of, figuratively speaking. Whenever a client survives a difficult situation and comes out on the other side, even with a set of new challenges or struggles to overcome, we can identify within that client strengths that helped them to make it: perseverance, resiliency, determination, grit. Clients may not see themselves that way! If you can see them more positively than they see themselves, you may start to have a positive influence on their self-concept and confidence.

Working together to help Syrian refugee children in Lebanon
Collaboration involves making sure the client's strengths are being put to use. We start learning collaboration at an early age when we are taught to involve others and to appreciate the merits of teamwork.
"Working together to help Syrian refugee children in Lebanon" by DFID - UK Department for International Development is licensed under CC BY 2.0

Principle 3: Collaboration is best.

            This can relate to the core value of service discussed earlier in this chapter. Essentially, this is about working with the client rather than dictating to the client what needs to be done. From the beginning of the relationship, we establish and reassert the fact that we are not in charge of the client’s recovery or positive growth—the client is.

            Sometimes, a client (and/or a client’s family and loved ones) may expect us to set about on a plan to “fix” the client. They think of social work the same way that some people think of going to a doctor—the doctor gives the patient a prescription, the patient gets it filled and takes the pills, and everything gets better. However, not only is medicine not exactly like that, neither is social work.

            Why is collaboration best? There are many reasons.

  • If the client (as we’ve acknowledged already) has strengths, then we would be foolish not to take advantage of those strengths to help the client find a way to reach the service plan goals. Why use only our own skills as a social worker when the client has considerable skills that would be advantageous to employ?
  • When the client is involved in coming up with the goals and plan in a social work helping relationship, then the client is more likely to take ownership of that plan and want to see it through. If the client feels the plan is something that’s been determined by outside forces with little or none of the client’s input, then it is more likely that the client will find a reason not to buy into the plan at all, or the client will simply struggle to be as motivated as if he had been a part of the planning process.
  • The client knows themself best. A plan you devise on your own as a social worker may not fit the client’s needs, interests, or capabilities, for reasons you may not even recognize. The client is an expert on themself—use their expertise to help guide the creation of a plan and the individual steps of carrying it out.
  • Imagine if you were the single entity in charge of determining the service plan for every client you had, and no one else had any input. You’d get a lot of credit when things went well, but what about when they didn’t? There would be no one to blame but you. It’s too much responsibility to take on the success or failure of each client that enters your office. You would burn out very quickly from the pressure alone.

The client has the ability to have a major positive impact on their own life. If we don’t collaborate with the client, we aren’t using all the resources at our disposal, and we are limiting our chances for success.

 

Principle 4: Do not assume you know the limits of a client’s capacity for change.

            As noted earlier, clients generally do not come to social workers because everything is going well. Because they may have been struggling for some time now, they may also have encountered many people in their lives who have been an additional source of discouragement. Many people may have clipped your clients’ wings, telling them they aren’t capable of reaching their goals, that they should just stop trying, that they’ll never amount to anything anyway.

            Since clients have already heard a lot of negativity about themselves from various sources and angles, it is crucial that we do not become another cog in that same discouragement machine. It may be true that we do not even know our own ultimate capacity for change and improvement. How could we ever know that about a client?

            If you are a limiting presence in a client’s life, again, you are decreasing the chances of a successful helping relationship. Don't be that person. If a client has big goals, that’s great! We want our clients to think they are capable of great things. We do not want to be another voice telling them what they cannot do. If we show them that we believe they are capable of great work, then they will be more likely to believe the same things about themselves.

            Have you ever had the experience of working with someone who didn’t have a very high opinion of you? They probably didn’t even have to tell you that—you were simply able to pick up on it through clues like tone of voice, body language, and word choice. Our clients can read us in the exact same way. We can subtly discourage them in ways we don’t intend if we aren’t careful about the way we communicate. Imagine for a moment what it would feel like for a client: they come to a social worker for assistance getting their life in order. After some time building a rapport, the client feels comfortable enough to tell their social worker they're thinking about going back to school and changing careers, and they eagerly await the social worker’s response. If the social worker seems to question the necessity of that change, or indicates a belief that the client may really struggle with that, then how will that feel to the client? The social worker—the one person who is supposed to see them positively and be a source of encouragement and support—seems to doubt the likelihood of that plan working out. If the social worker doesn’t believe in it, who will? That worker, in an effort to temper the high expectations of the client, may instead have thrown the client into significant self-doubt, even despair. It would have been far better to help the client look at ways to break down that large goal into small, manageable chunks so that they could experience small successes along the way.

            This doesn’t mean a social worker should just blindly accept every goal a client has—some literally may not be possible to achieve (e.g., a 65-year-old client with no criminal justice experience cannot get hired as a police officer, even if they go back to get a degree). Even in cases like that, we should use the client’s motivation and enthusiasm to help them identify a goal that will give them a similar sense of satisfaction. For example, that 65-year-old client may simply want to help make the streets safer for their family and neighbors. There are more than likely many ways to accomplish the same end.

 

Principle 5: Every environment has resources.

            It logically follows that if every person has strengths, every environment must have resources, since every environment has people living and/or working there. It is easy to look at an environment as a problem rather than as a resource. Sometimes, a parent of a teenage client might say something like, “If we could only get him out of this community and away from these bad influences, everything would be different.” There may be an element of truth to that in some cases; however, it is also true that just as people have strengths and areas in need of improvement, communities have their own challenges and resources.

            One of us worked in rural Alabama for his first year as a professional social worker and was struck both by the incredible sense of community in those sparsely populated areas and the interest in helping each other through difficult times. It seemed that people in these small towns knew more about what was going on with a fellow resident who lived three miles away than we knew about our suburban neighbors growing up, or than people who share an urban apartment building may know about their next-door neighbors. Although those rural communities no doubt struggled with great amounts of poverty, unemployment, and other considerable obstacles, they still had major strengths. They looked out for each other. They could quickly rally to provide a helping hand if, for instance, the breadwinner in a home took ill and had to be out of work for an extended period of time. People would share what extras they had, even if they weren’t truly “extras” at all. They came together in times of crisis.

            A high-crime inner-city neighborhood may look like it doesn’t have a lot of resources to offer its residents, but the fact is that environment also has strengths. There may be community events aimed at discouraging school dropouts. There may be informal low-cost (or even free) child care options among single parents who have a system of making sure their kids always have supervision from someone in the neighborhood. There are pillars of strength and resiliency in every community. While the wealthier communities may have more obvious and attractive ones, all communities have something to hang their hat on, something that is a source of pride and fortitude for their residents.

 

Principle 6: Language is key.

            Social work is often accused of being too “politically correct” and stifling in its expectations of the use of language. Social workers are among the driving forces in getting people to look at their use of some common terms of the past that have come to be recognized as offensive to particular groups. However, our language both reflects the world we live in and continues to shape it through the way we use it.

            I already introduced you to one such idea of language—using the word survivor rather than victim. The latter feels final and negative, the former like a badge of honor and an acknowledgment of great abilities. You may also notice as you move through your social work studies and into your internship and professional career, other specific terms that are favored for various reasons:

  • Areas for improvement rather than weaknesses
  • Challenges rather than problems
  • Slip rather than relapse
  • Setback rather than failure

Do you see a pattern? (Can you think of any examples of your own to add?)  Language has the power to “lift and inspire or frighten and constrain” (Saleebey, 1996, para. 11). We don’t tend to see our clients in terms of weaknesses (at least, we should strive not to); after all, that would be antithetical to the whole purpose of the strengths perspective! Instead, we strive to empower them, and part of that is acknowledging their right to be seen in a positive light. We should not only use more inspiring, less constraining language toward our clients, but we should encourage them to do the same for themselves. When a client routinely uses negative words or phrases in self-reference, that is a pretty good reflection of how the client feels about themself, and it continues to keep the client in that same sort of self-doubting, perhaps even self-loathing mindset. Encouraging the client to change the words they use may at first be met with skepticism, but is an important part of getting the client to see themself the way they ultimately would want to be seen by others—as someone fully capable of reaching their goals.    

            When you approach your work with clients through the strengths perspective, you will find yourself believing in their capacity for change, and hopefully getting them to buy into that same belief. Without using the strengths perspective, you are at best a recorder of events—certainly not a catalyst for change. We should strive to treat our clients even better, with more optimism, than we treat people in our own lives. If you are working with a client and you can’t identify at least as many strengths as weaknesses, you just need to keep looking. Ask a colleague for help if necessary. They’re there, and you need to find them to help that client take healthier control over his circumstances.

  

References

Curwen, T. (2015, January 24). State high court’s vote affecting Scout affiliation stirs debate

anew. Los Angeles Times. Retrieved from http://www.latimes.com/local/california/la-me-0125-boy-scouts-judges-20150125-story.html#page=1

Gray, P. (2002). Psychology (4th ed.). Worth.

Guo, J. (2015, February 23). Everything you need to know about the gay discrimination wars in

2015. Washington Post. Retrieved from http://www.washingtonpost.com/blogs/govbeat/wp/2015/02/25/these-states-are-marching-ahead-with-laws-that-would-allow-gay-discrimination/.

National Association of Social Workers (NASW) (n.d.) History of the NASW code of ethics.

Retrieved from https://www.socialworkers.org/nasw/ethics/ethicshistory.asp.

National Association of Social Workers (NASW) (1960). NASW code of ethics. Retrieved from

https://www.socialworkers.org/nasw/ethics/pdfs/NASW%20Code%20of%20Ethics%201960.pdf.

National Association of Social Workers (NASW) (1967). NASW code of ethics. Retrieved from

https://www.socialworkers.org/nasw/ethics/pdfs/Code%20of%20Ethics%201st%20Revision%201960%20and%20amended%201967.pdf

National Association of Social Workers (NASW) (1979). NASW code of ethics. Retrieved from

https://www.socialworkers.org/nasw/ethics/pdfs/1979-Code-of-Ethics.pdf

National Association of Social Workers (NASW) (2005). Social workers mobilize in wake of Hurricane Katrina [Press release]. Retrieved from http://www.naswdc.org/pressroom/2005/090605.asp

National Association of Social Workers (NASW) (2021). NASW Code of Ethics. Retrieved from https://www.socialworkers.org/pubs/code/code.asp.

National Association of Social Workers (NASW) Illinois Chapter (2021). CEU requirements. Retrieved

from https://www.naswil.org/continuing-education.

National Conference of State Legislatures (NCSL) (2013). Mental health professionals’ duty to warn. Retrieved from http://www.ncsl.org/research/health/mental-health-professionals-duty-to warn.aspx.

Palazzolo, J. (2013, February 14). Racial gap in men’s sentencing. Wall Street Journal. Retrieved from http://www.wsj.com/articles/SB10001424127887324432004578304463789858002.

Pope, K. (2001). Sex between therapists and clients. In J. Worrell (Ed.), Encyclopedia of women and gender: Sex similarities and differences and the impact of society on gender, pp. 955-962.

Roth, S. (2015, February 3). Bakery risks large fine for anti-gay discrimination. USA Today. Retrieved from http://www.usatoday.com/story/news/2015/02/02/bakery-same-sex-oregon-fined-wedding cake/22771685/.

Saleebey, D. (1996). The strengths perspective in social work practice: extensions and cautions.

Social Work, 41(3), pp. 296-305.

Saleebey, D. (2009). The strengths perspective in social work practice (5th ed.). Allyn & Bacon.

Saleebey, D. (2008). Commentary on the strengths perspective and potential applications in

school counseling. Professional School Counseling, 12(2), pp. 68-75.

Tennessee Department of Health (n.d.). Board of Social Workers: continuing education.

Retrieved from http://health.state.tn.us/boards/SW/education.htm.

Terrero, N. (2011, August 11). N.J. bridal shop refused to sell wedding dress to lesbian bride:

Owner says: “That’s illegal.” ABC News. Retrieved from http://abcnews.go.com/US/nj-bridal shop-refused-sell-wedding-dress-lesbian/story?id=14342333.

Totenberg, N. (2020, June 15). Supreme Court delivers major victory to LGBTQ employees. National

Public Radio [NPR]. Retrieved from https://www.npr.org/2020/06/15/863498848/supreme-court-

delivers-major-victory-to-lgbtq-employees

Wilson, S. (1978). Confidentiality in social work. Macmillan.

Chapter 4: Generalist Practice

So far we have provided a basic understanding of what social work is, how it has evolved, and what social workers value.  As you may have realized, social work is a broad field that can address many different concerns in many different ways in our society.  This chapter will discuss the fundamentals of generalist social work practice, including how and where one can practice it.  By the end of this chapter, you should be able to:

  1. Outline and explain the steps used to implement change;
  2. Define the different levels of social work practice;
  3. Identify various settings and their foci for social workers;
  4. Understand the multiple roles practitioners can utilize with client systems;
  5. Summarize the education and licensure process for professional social work.
Person sitting at a desk talking to two other people.
"Social Work Students' Accreditation Visit 3.26.13" by Southern Arkansas University is licensed under CC BY 2.0

 

Social Work as a Career

Choosing a career takes a lot of thought, and one needs to consider several different aspects of an occupation before deciding what path to pursue.  While often our own experiences can draw us to a specific field, like social work, our values also help guide us to choose those careers that will be fulfilling to us not only professionally, but personally as well.  The last chapter reflected on the various values and ethical perspectives of the social work field; and if you are pursuing this line of work because you also believe in the importance of helping others and giving back to society, you are in good company.  Social work can often be a thankless job and, as a true helping profession, less importance is placed on income than on intrinsic rewards when one helps parents adopt a child, works with family members to prepare for and grief the loss of a terminally ill relative, or teaches a student stress management skills that allow her to effectively take her math tests.  However, values alone are not going to guarantee career congruence if you are thinking about social work.

When it comes down to it, social workers are helpers, plain and simple.  How they help, the clients they work with, and where they perform their duties, can vary a great deal.  It is important for social work students to have at least a basic understanding of the different roles they could play in different practice settings so they can find the employer and job that will fit them best.  It is just as key to know your own limits and boundaries so that you are not entering a position in which you will be ineffective due to your own uneasiness or inability.  This chapter will focus on generalist social work practice and roles, main settings for social workers, and the educational paths to joining the social work profession.  While you read the chapter and gain an understanding of what social workers do in the most basic form, take time to imagine yourself performing the various roles in the numerous settings.  This will give you a greater understanding of how and who you want to help. 

 

The Generalist Social Worker

The generalist social worker is the greatest common denominator when it comes to social work practice.  The Council on Social Work Education (2015), or CSWE, the accrediting body for social work education, describes generalist social work practice this way:

Generalist practice is grounded in the liberal arts and the person-in-environment framework.  To promote human and social well-being, generalist practitioners use a range of prevention and intervention methods in their practice with diverse individuals, families, groups, organizations, and communities based on scientific inquiry and best practices.  The generalist practitioner identifies with the social work profession and applies ethical principles and critical thinking in practice at the micro, mezzo, and macro levels.  Generalist practitioners engage diversity in their practice and advocate for human rights and social and economic justice.  They recognize, support, and build on the strengths and resiliency of all human beings.  They engage in research-informed practice and are proactive in responding to the impact of context on professional practice. (p. 11).

In order to conceptualize this definition of generalist social work practice, the CSWE  (2015) outlines core competencies, which they update every seven years, that all accredited Bachelor of Social Work programs are required to instill in their graduates.  They are: 

  1. Demonstrate Ethical and Professional Behavior
  2. Engage Diversity and Difference in Practice
  3. Advance Human Rights and Social, Racial, Economic, and Environmental Justice
  4. Engage Practice-informed Research and Research-Informed Practice
  5. Engage in Policy Practice
  6. Engage with Individuals, Families, Groups, Organizations, and Communities
  7. Assess Individuals, Families, Groups, Organizations, and Communities
  8. Intervene with Individuals, Families, Groups, Organizations, and Communities
  9. Evaluate practice with Individuals, Families, Groups, Organizations, and Communities (pp. 7-9)

The only change currently drafted for the 2022 update is "Competency 2: Engage Anti-Racism, Diversity, Equity, and Inclusion in Practice" (CSWE, 2021b).  These competencies give social workers a solid foundation upon which to build their practice and how they carry themselves as a professional.  The last of these can further be broken into a four-part process social workers use when engaging in direct work with their clients to affect change.  Let us look at how one social worker uses this change process in her work in a women’s correctional facility.

 

Engagement

             Paula Wright is a social worker at a women’s correction facility, and Janice Smith is a new inmate on her caseload who has been incarcerated for drug possession.  Janice has been mandated to meet with Paula on a weekly basis.  All social work begins with engagement.  In this instance, engagement begins before Janice comes in for her first visit.  Having an understanding of the background of the client is important even before you meet with the client.  What are the concerns being identified?  What are some of the demographics of the client?  These can be useful in preparing an approach for working with the client.

Once Janice comes in, Paula then needs to build a relationship with her before even beginning to help her work on any goals.  If Janice does not feel connected to Paula, feels Paula is not invested in the relationship, or senses Paula does not care about her, she will not be able to work toward any change she wants to achieve.  Getting Janice’s perspective on the issues that lead her to be incarcerated, showing empathy, and being genuine are all basic skills Paula will use to build the connection between the two of them.  Allowing the client to direct the focus of the helping relationship will further allow the relationship to grow.  Often in mandated situations, some of the focus of the helping relationship is dictated by outside entities, making it difficult to allow clients to be directive in what they want to accomplish.  However, a social worker can still, and truly need to, help clients establish their own goals and create the change they want to see in their own lives.

It is important to note at this point that since Janice is being mandated to work with Paula, the whole process can be difficult to get through.  In fact Paula may never be able to truly connect with Janice and work toward helping Janice make any significant change in her life.  Clients are not always going to be invested in the process, even if they are self-referred, through no fault of the social worker.  Yet it is still important to continue to work on engaging clients before trying to help them create change in their lives.

Drawing of two people with speech bubbles overlapping.
Building rapport with our clients is an integral part of establishing an effective helping relationship.  Without a connection, clients are not as invested in the change process.

 

Assessment

            In the assessment part of the process, it is important for Paula to get a better understanding of not only how Janice came to be on her caseload, but also the state of affairs in Janice’s life and Janice as a person.  This includes not only knowing the details of her arrest, her emotional state of mind at the time, what was going on in her life that led up to her possessing drugs, and how she feels about the situation, but we also need to have a better understanding of who Janice is as a person, especially her strengths.  As was talked about in Chapter 2, the strengths perspective is a very important part of social work.  This is the time when we can utilize that perspective and assess what the strengths of our clients are while understanding what their limitations might be.

After building rapport by establishing a connection with Janice and talking with her a few times, let us say that Paula found out Janice was pulled over for speeding, suspected of driving while intoxicated, and the drugs were found in her car because her husband, Frank, had left them there when he used her car to make a deal.  She is currently very angry at Frank, and wants very much to get back at him for allowing her to go to prison.  Janice also told Paula at one point that she does not believe in divorce and wants to still try to make her marriage work.

Paula has to be careful here in how she works with Janice to choose goals of the helping relationship.  Paula may be inclined to think Frank is not good for her and want a goal to be helping Janice understand the usefulness of and work toward a divorce.  However, it is Paula’s duty to help Janice identify goals and what she wants to change in her own life, Paula cannot dictate that Janice needs to leave her husband.  It may seem as though Paula is the expert here, but Janice is the expert on Janice; she knows better than anyone what she wants from life.  The goals should be something that Paula and Janice agree will be positive in Janice’s life, not something that will be harmful to her.  If she wants to work on her marriage, getting back at Frank by, say, beating him with a baseball bat is counterproductive and could cause more problems in her life.  In this way, Paula’s professional assessment of the data can help with interpreting the efficacy of Janice’s goals.

Once initial goals are established, Paula then needs to identify appropriate intervention strategies that will allow Janice to meet these goals.  Where Janice is the expert on what she wants to accomplish, Paula will work with her to come up with different strategies to achieve these goals.  In their discussion on generalist social work practice, Morales and Sheafor (1998) state, “The social worker is required to have a broad knowledge and skill base from which to serve clients or client systems and to have the ability to appropriately select from that base to meet the needs of the clients.” (p. 39) Janice will still be an important part of determining which strategies will be implemented, again relying on the fact that she is the expert on herself, but Paula brings the options to the table.

 

Intervention

This is the stage of the process in which the bulk of the work is done in the relationship.  Depending on the client, the first few stages may not take as much time to get through.  This stage, on the other hand, will make up the majority of what social workers do with clients.  In the previous stage of the process, Janice and Paula decided that one of Janice’s goals was to work on better managing her anger.  In order to do so, it was decided that Janice would keep an anger journal and would attend an anger management group in the prison.  In the intervention stage, these strategies are implemented and monitored.  Paul and Janice can process the entries in Janice’s anger journal and discuss her anger triggers consequences, and coping skills.  They can also discuss how the group is going for Janice and what she is getting out of it.  At this stage, Paula is focused on helping Janice resolve the problems she identifies and works on the behalf of the client.

It is important to note that all the work done during intervention is not just when the social worker and the client are together.  There will be times when we have to connect with others to help get the needs of the clients met.  In order to get Janice into the anger management group, Paula may have to touch base with the social worker that runs that group and advocate for Janice to be able to join.  There may be other times that Paula will have to interact with the prison system, other case managers, even her supervisor, on behalf of Janice.  As generalists, our work is not confined solely to the space in which we interact with our clients; that is just where it starts.

african american, african descent, afro, analyzing, black people, brainstorming, business, businesswoman, colleagues, communication, computer, digital device, discussion, diverse, focus, helping, ideas, laptop, meeting, note, notebook, notepad, office, partnership, people, planning, preparation, strategy, stressed, talking, team, teamwork, technology, togetherness, training, wireless, women, work, working, writing, electronic device, vision care, eyewear, job, conversation, glasses, girl
The evaluation piece of the change process is an integral part of serving others.  It is needed to inform the work done at any level.

 

Evaluation

            While the evaluation stage is separate from the intervention stage, it is important to acknowledge the close interplay between the two.  In order to best inform our work with the clients when it comes to the interventions we utilize, it is important for us to evaluate their effectiveness not only on a case by case basis, but as an intervention strategy in general.  Therefore the evaluation stage can be broken down into two distinct parts.

The first piece is evaluating the current work we are doing with our clients.  In the case of Janice, Paula can determine, while processing with her, how effective the strategies are in helping Janice manage her anger.  If Janice reports that she does not like the anger journal, Paula will try to get a better understanding of why that is so she can determine if the anger journal is really a strategy that should still be pursued.  If Janice states that she writes in it but feels even angrier once she is done, the two of them need to process why this is and determine how to proceed.  If the intervention is not being done correctly, the two of them can revisit how and what to write in the journal.  If it is determined that the intervention is not working, they can implement a different strategy.  In this sense, it is easy to see why the evaluation is critically important to the intervention part of this process.

            The second piece of evaluation comes when Janice is no longer on Paula’s caseload.  At the end of the helping relationship, Paula should be evaluating how effective the strategies were for helping Janice reach her goals.  This will help bring an understanding of how useful strategies are with different clients or with different goals.  While journals can be utilized to help clients achieve a variety of goals, not just anger management, Paula may need to improve how the strategy is introduced to clients to make sure they know how to utilize it.  If Janice stated that the journal was not helpful, Paula may want to look into other strategies that are useful in helping manage anger.  This will allow her to build her knowledge base of effective interventions and, in the end, help her become a better social worker.  While distinct, both parts of the evaluation process are necessary and important in informing our work as helpers.

 

Fluid Process

            The four-part process outlined above should be thought of not simply as a step-by-step procedure that needs to be followed in a specific order to make change happen, it is important to be aware that the whole process is fluid in nature and parts may be repeated.  While there is always a beginning and end to any helping relationship, and therefore an engagement stage and an evaluation stage, each relationship is unique and may not follow a preordained path to change.  Social workers do not get to work with clients in a closed system, even when someone is incarcerated like Janice.  The interchange between the various systems in a client’s life can lead social workers to revisit the assessment phase and rework goals or plan new interventions, back to the engagement phase to rebuild a broken connection between practitioner and client, or jump forward to the evaluation phase if a helping relationship ends before expected.

While Janice is incarcerated, she is still interacting with a number of systems.  Her husband may or may not be visiting her, either option having significant impacts on Janice’s state of mind.  She may not be getting along with some of the other inmates, resulting in physical altercations and further punishment.  Janice may even have been transferred before she and Paula had a chance to implement intervention strategies.  No matter what happens with clients outside of the direct interactions within the helping relationship, generalist social workers are prepared to apply the most appropriate stage of the four-part process.

 

Levels of Social Work

Other than the processes the tenth competency outlines for generalist practice, it also mentions the spectrum of clients with whom social workers have helping relationships.  In our case example, Janice Smith was the individual client with which Paula Wright was directly working.  However, Paula may have to expand her understanding of who the client is to the entire inmate population in her prison or even the entire state correctional department.  Miley, O’Melia, and DuBois (1998) state that:

Generalist social work practice provides an integrated and multileveled approach for meeting the purposes of social work.  Generalist practitioners acknowledge the interplay of person and collective issues, prompting them to work with a variety of human systems – societies, communities, neighborhoods, complex organizations, formal groups, families, and individuals – to create changes which maximize human system functioning (p. 9).

Generalists can utilize the four-part process with any client.  While it might involve more people, the basic ideas of engaging, assessing, intervening, and evaluating are not only easily applied to larger systems, it is necessary to apply them in order for change to happen.

Community Worker holding a service brochure called "Aged and Disability Services."
Caption: Community agencies can provide a number of programs for individuals and groups, as well as work to address policy concerns for their clients.  Social work is performed on different levels, with each level impacting a different size of system, anywhere from the individual to a whole society. "CEH - Aged Care Community Workers" by Eva Collado Molleda is licensed under CC BY 2.0.

Social work can be divided into three distinct levels of practice, each focusing on the size of the system or systems in which the change is trying to be affected.  DuBois and Miley (2011) state, “Generalist social workers define client systems’ difficulties in the context of person:environment transactions.  Likewise, plans of action potentially create changes at a variety of system levels.  Social workers consider any system as containing options for change,” (p. 67).  The point is that generalist practitioners serve a wide range of different client systems, from the individual to families, community groups to school systems, American society to our global community.  Generalist practice seeks to affect healthy, positive change in varying systems affecting human functioning.  Ideas vary among social work educators which systems are addressed at which level of practice.  For instance, Zastrow (2008) identifies micro practice as working specifically with an individual, while the family system’s needs are addresses in mezzo level work.  DuBois and Miley (2011) place family work as part of the micro level, but list mezzo systems as being formal groups and complex organizations.  Still, the Encyclopedia of Social Work (Mizrah & Davis, 2008), in its Macro Social Work Practice entry, cites Rothman, Erlich, and Tropman in stating that macro level interventions are performed within communities, organizations, and small groups.  While there may be some crossover between what systems are worked with at each level, a useful way of looking at the different levels of social work is to understand the focus, rather than the specific systems, the level addresses.

 

Micro Level

            The most basic system of human functioning is at the heart of the micro level, and that is the individual.  The work done by practitioners at the micro level is focused on change within the individual.  While at times it may involve other people and working with other systems in a person’s life, such as the family unit, a friend group, or even the school district, it is still focused on impacting change within the individual members of these smaller groups.  A practitioner’s focus at this level is a particular individual with whom the social worker has a direct helping relationship.

 

Mezzo Level

            Social workers working at the mezzo level will definitely work with groups of individuals, rather than individuals themselves.  The focus of the efforts for change is directed at helping the individuals function as a cohesive unit rather than focusing on their own needs.  In this sense, mezzo level practice can be a team of employees, a school board, or a community task force, as long as the social worker is not working one-on-one with the individual members or in conjunction with the group to create larger social change.  Families are often considered to fall in between mezzo and micro levels; they are certainly small groups, but family work also often involves intensive work with individual members of the family.

 

Macro Level

            Macro level social work is focused on changing the largest systems of human functioning.  In the article “The Future of Macro Social Work,” Netting (2005) talks about how macro level practice is at the heart of social work in that it works with systems to sustain or improve the quality of life.  The focus at this level is to create change in the largest level of systems in which people exist.  Neighborhoods, communities, societies, even the world, are systems that are targeted by macro social work.  Oftentimes focused on social policy change, targeting both legislation (formal societal policy) and informal social policies that may have no physical or legal existence, macro level social work seeks to improve the quality of life for all individuals existing within the systems.

 

Box 4.1: Skill Levels

Social work practice at each level can be done by generalist social workers.  However, it should be pointed out that not all levels use the same skill sets to implement the change process.  With any skill, these can be nurtured and strengthened through your training as a social worker, so don’t worry if you don’t feel comfortable with all of these skills just yet.  Practice and experience will help.  For now, take a look at the varying skills needed at each level and think about what area you might want to focus on.

Micro level skills focus on being able to connect with individual clients on a more intimate level, as the work is done between two people.  The work done is built on a good connection with the client.  Some skills are:

  1. Empathy for what the client is going through, even if you have not experienced it yourself
  2. Interpersonal communication skills to be able to talk with and connect to the individual
  3. Flexibility and being able to change plans and focus of a session if needed
  4. Genuineness in how you interact with the client and what you say
  5. Understanding of problems they are experiencing and their background
  6. Being non-judgmental toward what is shared and the choices the client has made

Mezzo level skills can incorporate some of the micro skills, but involve working with a number of people as part of a bigger client system.  In this instance you cannot favor one group member over the other.  These skills include:

  1. Ability to unite group members for a common goal
  2. Mediation skills to handle conflict between group members
  3. Ability to switch focus rapidly from one issue to the next for each member
  4. Being comfortable with conflict between group members and understanding its usefulness in working toward change
  5. Good memory for recalling information shared by the different members as well as their personalities and experiences

Macro practice skills are more about accomplishing a task and moving people to action.  Your client is a locality, society, or the global community.  Some skills macro workers need to be strong in are:

  1. Leadership skills that motivate others and get them working toward a common goal
  2. Oratory skills to be able to clearly convey your intent and get your message across
  3. Social skills and proper etiquette to be able to connect with people in power
  4. Ability to “play the game” or knowing how the system works while using it to your advantage to get your needs met.
  5. Public speaking skills in order to be comfortable in front of large groups of people who may very well be judging you.
  6. Dedication, perseverance, and patience in order to stay with your goal despite the many obstacles that may get in your way.

 

Social Work Settings

The Bureau of Labor Statistics (2021) acknowledged three significant concentration areas for the social workers 713,200 in the field in 2019: child, family, and school social workers; healthcare social workers; and mental health and substance abuse social workers. For the purpose of gaining a better understanding of social work, we can outline seven different common practice settings that social workers are employed in:

  1. Short and long-term healthcare facilities, including hospitals (civilian and military), primary care settings, clinics, and nursing homes.
  2. Community mental health agencies
  3. Schools, including primary, secondary, and higher education
  4. Federal, state, and local governments
  5. Correctional facilities
  6. Child welfare agencies
  7. Private practices

We will explore each of these settings further to get a better understanding of who the clients may be and what social workers may focus on when working in these arenas.  In this way we can see how each of these settings allows practitioners to practice at the different levels.

 

Healthcare Facilities

            Healthcare facilities employ a large number of people in general.  Pair that with the main function of helping people get better and the one can understand why this is one of the most popular settings for social workers.  Healthcare covers a wide array of services to improve both physical and mental health and, as such, facilities for these services vary greatly in form and function.  From smaller community clinics to nursing homes to large university hospitals, social workers can be found throughout the healthcare system.  They work with patients that have both physical and emotional/cognitive ailments, as well as families of patients.  Many patients, though not all, benefit from the help a worker provides in crises intervention, grief counseling, connecting them to resources, and helping them create a plan for dealing with their specific situation after they leave inpatient services.  Their function is often secondary to that of the nurses and doctors, but a vital part of the patient’s progress toward release.  For patients who are in long-term care and those who may never leave, like those in nursing homes, the social worker has a more lasting relationship with them and provides the mental health services the other patients would seek from outside agencies.  Actually, some healthcare facilities provide only mental health care services, both short- and long-term care, in which social workers play a primary role in addressing the patients’ health needs.  Some of the smaller clinics may even have this emphasis, but more closely resemble mental health agencies which will be the next setting discussed.

            More recently, social work has seen an increase in employment in military settings.  Specifically, because the number of service personnel who return from war with some kind of traumatic brain injury and posttraumatic stress disorder (PTSD) has increased, the government has amplified its hiring of mental health professionals, specifically social workers.  They can be found on military bases and in military hospitals, providing mental health treatment.

Social worker in the background facing the camera and talking with a client who is a veteran in the foreground.
One of the biggest areas in which social workers are employed is mental health.  Community mental health agencies do more than just individual therapy, and social workers can serve a number of different functions to clients in this setting. "Social Work" by Army Medicine is licensed under CC BY 2.0

 

 

 

Community Mental Health Agencies

            The mental health field is focused primarily on working with individuals to help them deal with concerns in their lives that have a negative and overwhelming impact on them.  There are many different specific reasons clients seek the help of a mental health professional, for instance, divorce, death of family member, domestic abuse, depression, addiction, even mental disorder are just a few.  However, there does not need to be a more specific reason for clients to seek out help other than the fact that they are not happy with something in their lives, even if they are not sure why, and they want help in addressing the issue.  Most employment opportunities in mental health are in mental health agencies, although, as was mentioned, some of this can be done in a healthcare setting as well.  Community mental health agencies can be either public or private, but almost always provide a variety of individual and group services to meet a wide range of needs.

Most often the work social workers do at this level is focused very much on the individual, usually one-on-one therapy, to address specific issues.  However, caseworkers are often in the mental health setting as well.  While they may not directly treat individuals who come in for help, caseworkers are often part of the team working with the clients and connect them to resources in the community to address other needs.  Moving up a level, mental health counseling can be done with couples or families as well.  A couple may seek help in their marriage after it is discovered that one of them has a gambling problem in order to repair the marriage.  Each of them may also seek help individually to work on issues specific to them, but in couple’s therapy, the focus is on repairing the relationship.  Finally, at the macro level, mental health work can be done in terms of impacting policy or changing societal views.  Fighting the stigma of mental health is something that needs a broader focus on what strategies to use.  In the same sense, increasing ease of access to mental health resources can take a lot of manpower and is aimed at changing a larger system to better serve individuals.

 

Education

            Social workers can be found in all levels of education, from pre-school settings to primary school, high schools to post-secondary.  In a later chapter we will delve deeper into school social work, so for now, we will briefly discuss some of the functions practitioners have in this setting.  Is important, however, to know that social workers in school settings do not just work directly with students (and their parents at times), but an essential function of educational practice is to work with the school system itself.  The focus is always on working with the students as they relate to and interact with the school system, yet there are times the students are not even part of the work being done.  Some of the duties of social workers in school settings include running process groups, serving on threat assessment teams, individual crisis intervention, facilitating academic strategy workshops, and creating individualized educational plans (IEPs) for students with documented needs.  Collaboration with other stakeholders in the school and in the students’ lives, such as parents and teachers, is paramount in fulfilling these roles.  Practitioners need to help create the best learning environment for students so they can more effectively focus on their education.

            One role of social workers in a school setting that really stands out and warrants special mention is that of social work educators.  In order to teach social work in higher education, one must have a master’s degree to work at the community college level and usually a Ph.D. to teach full-time at the university level, so this is not necessarily a role a bachelor’s level generalist will take on.  While they may not carry out the duties we typically associate with social work, they are an integral part of the social work profession, by educating future practitioners and conducting research to inform social work practice.  Some social workers in this setting may even have a dual role of instructor and practitioner in the school.  However, the duties of each are very different and workers need to be careful how they manage both.

 

Government

            Government settings are a little tricky to discuss when it comes to social work practice because many government-run or government-funded agencies are in all the other settings, except for private practice.  Therefore, we will not discuss the whole gamut of services that are provided by government agencies, but rather concentrate on the work social workers can perform directly for the government.  Social workers can be employed by all levels of government with expressed directives of practicing at the macro level.  Practitioners can influence new policy, reform old policy, set standards of care, oversee various agencies or programs.  The work they do is intended to guide how various other government agencies, social systems, even individuals interact with intended beneficiaries of these systems.  A local government can decide to implement school lunch programs in their district for students from low-income families or the state could consider options for admission and treatment of those presenting with self-harm in order to lower suicide rates.  As we will see, one of the roles we can play is that of community change agent.  Working in government can afford social workers greater opportunity to take on this role.

 

Box 4.1: Career Choice

    When one of your authors was going through his Master of Social Work program, he was interning with a youth mentoring program where high school students paired up with middle school students, participating in various after-school activities.  One of the regular activities we did was to visit different nursing homes and participate in activities with the older adult residents there.  Every time they went, he could not wait for the event to end.  He spent most of the time feeling uneasy, being uncomfortable, and counting the minutes until they left, clearly not focusing on the students or the interactions with the residents of the nursing home.  It wasn’t what his group was doing or the population they were interacting with.  What bothered him the most was the smell in the air when they got inside the homes.  It all could have been in his head, but for whatever reason, he just couldn’t handle it.  He knew that he would never be able to work in that sort of environment.  When thinking about these different work settings and trying to imagine where you would fit best, answer the three following questions:

  1. What would I like about working in this setting?  Is it the clients I would interact with, the type of roles I would play, the problems I would be dealing with?
  2. What about this setting would be hard for me to deal with?
  3. With how I am now, is it something I can realistically move past in order to focus on the clients?

There is nothing wrong with admitting when you are not going to be a good fit for a specific environment.  Not doing so would be neglecting the well-being of our clients.  Don’t expect that you will eventually be able to deal with those things that bother you.

 

Corrections

Prison systems may not be what we typically think of in terms of social work environments.  Yet when you really get down to it, having social workers in corrections actually fits with social work values nicely and makes a lot of sense.  In valuing human worth and dignity, we help them make changes for a more productive and positive quality of life.  The clients in this case are mainly people who have been convicted of a crime, although family members may also be a part of the client system.  As seen with Paula Wright and Janice Smith in our case example earlier, the main function of social workers within the actual prison is centered on the rehabilitation of the person who has been incarcerated.  Family members may be a part of the work done, but the focus is on the person in prison.  Social workers can function as case workers and perform a variety of roles, but this will include mental health or substance abuse counseling with the inmates either individually or in a group setting within the prison.  Another possible route within the corrections environment, but not necessarily housed in the prison itself, is that of parole officer/probation officer.  These positions can help those who were in prison make and sustain positive changes in their lives that will keep them from returning.

This work can be done with adults and juveniles alike.  Services for juveniles become more involved with the family, at times with a child welfare twist, and need to include an educational component to them as well.  Since juvenile centers tend to be more concerned about preventing repeat offenders than adult facilities, there is more work done with the various environments in the client’s life.

 

Child Welfare Agencies

            In the beginning of their book on child welfare, Mather and Lager (2000) said, “Child Welfare is not just about the welfare of children, it is about the welfare and future of humankind.  As we touch a child in any way, we influence tomorrow and the tomorrows to come.” (p. 1).  The prevalence of this practice setting, although a little disconcerting, should be seen as a strong dedication to working for those who have little authority and may feel as though they have no voice.  Arguably the most recognizable function in child welfare agencies is child abuse and neglect investigation.  However, social workers in these agencies are not working only with children in these situations.  At times, workers will work with various other domains that are a part of the child’s life such as the family setting, the child’s school, a place of worship, or even their park district.  They can even work with families that do not have abuse in the home, but are struggling to provide their children with basic needs such as food, shelter, and education.  The idea is to work to provide children with the proper safe and loving environment that will nurture their growth through adolescence into adulthood.

            This can be done in many ways depending on the specific issue.  Some new parents may need basic child care instruction, or a school district wants to train their staff on how to identify signs of abuse and neglect, and how to intervene.  Abused children might need mental health treatment to deal with trauma, whereas a community may benefit from implementing an afterschool program for children from single-parent households.  Let us not forget about the social welfare policy work that can be done in influencing legislature to better address the needs of the families and children working with these agencies.  These are all activities that child welfare agencies can address.  The work they provide is not only about removing children from unsafe and unhealthy environments, it is about providing for the whole spectrum of needs a child may have and helping the environments they interact with nurture them.

Child alone playing in the dirt.
We often equate child welfare to child abuse and neglect, but it more than that.  It covers anything related to providing a nurturing environment for children to grow into adulthood.  Social workers in child welfare work with families, schools, mental health agencies, and juvenile justice systems to name a few.  
(This photo can be found here on pxfuel and is free for commercial use according to DMCA.)

 

 

Private Practice

            Working in a private practice setting can be very different from working in a community mental health agency, despite the fact that both focus on mental health.  Private practices cater to individuals and smaller family units, and often the practitioners are contracted, masters-level licensed social workers, or professional counselors, who do not work for the practice full-time.  At times these professionals may even need to solicit clients on their own in order to get appointments and earn money.  The services they provide these clients are usually focused during the regular weekly hour appointment, with responsibility to implement the different interventions or strategies lying with the clients.  Social workers may help plan for and provide an environment for the change process, but it is really up to the client to move forward and actually make the change. 

Other than the macro/mezzo level work they do, helpers' roles in private practice settings usually do not allow for anything more.  While social workers who work in these settings may be involved in higher level practice, it is usually part of another job they have or on their own time.  Even in terms of the working environment, those that work for the practice may not engage in professional activities or efforts as a team.  In fact, they may not even interact much with each other in the office setting.  In this sense, private practice very much revolves around creating change on an individual level.

 

Social Work Roles

            No matter what practice setting they are in, social workers will need to take on a number of different roles to address the varying issues they will be faced with when working with different client systems.  Oftentimes, we might be called to play a number of roles when working with one specific client.  So it is imperative for the generalist practitioner to not only understand each role, but know which one is appropriate with each client, given any situation.  While the list we will discuss is by no means all-inclusive in terms of the functions social workers might have, we do want to stress those roles that are basic to the foundation of generalist practice.

            Colorado State University (2015) identifies six practice roles for generalist social work that students going through their BSW program will master: Advocate, Broker, Community Change Agent, Counselor, Mediator, and Researcher.  To supplement this list, we will add mentor/teacher.

 

Advocate

            The Encyclopedia of Social Work stated that the advocate role of social workers has been a part of the profession since 1887 (Mizrah & Davis, 2008). Today it continues to be one of the most vital and consistent roles social workers play at all levels of practice.  Advocacy is at the heart of social work values.  Being an advocate allows a worker to fight for social justice when it comes to their client system.  In the most basic form, advocacy is simply being a voice for the client system with which you are working.  However, there is much involved in being an advocate for your client.  It is more than just understanding the needs of the client system, injustices the client may be facing, or and how you can intervene.  At times, advocating for a client takes tact and patience in order to bring about the desired result.  It takes knowing the client system, knowing the system in which the client is not getting needs met, and being assertive in communicating in a matter-of-fact way rather than a blaming or demeaning way.  Whether it is helping parents of a child with autism obtain the appropriate accommodations for their child in a school setting, or lobbying a government body for monies for a homeless shelter, advocacy can be seen at all levels of social work practice.  If we revisit our social worker, Paula Wright, and her client, Janice Smith, we can have a better idea of how this role plays out.

Advocate spelled out in Scrabble tiles with other tiles laying around the word.
Advocate is one of the main functions social workers take on when working with clients.  As an advocate for those we help, we are their voice when they have been silenced by injustice, marginalization, discrimination, or personal crisis.  
“Advocate” by Nick Youngson is licensed under CC BY-SA 3.0.

 

During one of their sessions, Janice reports that her husband has not brought her kids to visit her in prison during visiting hours.  She tells Paula that Frank had promised to bring her kids at least once a month but has not seen them for several months now.  She states that whenever she talks to Frank about it, he changes the subject and ends the call quickly.  Janice starts to cry and Paula can tell she is feeling dejected and lonely.  She had said her children were everything to her.  Understanding the situation, Paula prepares a plan to advocate for Janice.

            At times, there is a fine line between advocating for a client and enabling a client to continue with a behavior that has a negative impact on her life.  In this situation Paula may need to help Janice use her own voice in advocating for herself by helping her be assertive in her conversations with Frank about her children.  However, this is where understanding your client is so important.  When Paula advocates for Janice, she would want to talk to Frank – with a signed consent from Janice – about the importance of seeing her children.  If it is a case of Frank not having adequate transportation or that his new job requires him to work during prison visiting hours, then there is something else that Paula can address.  If Frank states that he simply does not want to bring the kids to see his wife, then Paula can continue to advocate and get other systems involved, such as different family members or even a lawyer.  Either way, Paula is working to give Janice a voice in a time when she needs one, when she may not feel like she has one, and when she has been on the receiving end of some level of injustice or unfairness.

 

Broker

            The broker role is another role that has been around a long time in social work.  It too relates to valuing our clients and their worth, because we know that they are deserving of a high quality of life and we want to be able to help them get the services and goods that will allow them to have that life.  The broker and advocate often go hand-in-hand because when we are helping our clients have a voice, we are often helping connect them with resources they may not have known about.  It is our duty as social workers, then, to be well-informed of the resources available locally, throughout the state, and at the federal level that will address a multitude of needs for the client systems with which we may work.  This of course is a basic tenant of generalist social work practice and is something that needs to be continually updated, as social service agencies may add new programs, stop offering other programs, or close their doors altogether.  Funding sources can drive program needs, so it is important that, as brokers, we reacquaint ourselves with resources to identify new ones and stop referring to those that are no longer around.

            As Janice gets closer to the end of her sentence, she and Paula discuss the progress she has made with her anger management and what is going to happen once she leaves prison.  Janice admits it will be tough for her to not fall back into old habits and wants to be proactive about it.  Paula does some research for anger management support groups in or around her hometown.  During their visits, Janice had admitted that, although she did not use illegal drugs, she had a problem with alcohol and wanted to continue her sober ways once she got out.  Paula can provide Janice with meeting times for Alcoholics Anonymous, numbers for 12-step programs in her area, as well as Narcotics Anonymous and Al-Anon information that may be helpful for her husband, her children, and her.  Janice is also interested in holding a steady job, but is not sure where to begin to find one, especially with her criminal record.  Paula works to locate any agencies that help formerly imprisoned individuals secure gainful employment, such as Goodwill Industries, or possibly connect Janice to her local community college for job skills training.  Being able to identify the needs in clients’ lives and link them with resources that can help identify those needs can truly make a difference for them.  What could seem like a very overwhelming situation to be in, and not knowing how to obtain even basic needs, is eased by a generalist’s knowledge of what programs to look for, what agencies are out there, and how to hook clients up with those resources.

Person speaking at a podium during a Black Lives Matter rally.
Social workers, as community change agents, work to educate the community and fight against injustices of any kind.  Helping bring awareness to social issues, such as anti-Black racism, can include peaceful protests and marches. 
"Black Lives Matter Protest Times Square New York City June 7 2020" by Anthony Quintano is licensed under CC BY 2.0.

 

Community Change Agent

            Whether it is a result of the work done with an individual client or as part of a larger organization, social workers are often called to be agents of change within communities of various sizes.  At times our work with an individual client may prompt us to address a bigger issue within the community in order to help all those negatively impacted by social perception, behavior, or policies.  This role is most closely related to macro level practice because of the clear focus on changing formal and informal social policies.  Wherever injustice is found in how a community, large organization, or society at large functions, generalists should be confronting it and working for change.  Social workers can strive to create positive change in communities in many ways such as:

  • Helping to secure additional funding for schools that serve primarily low-income neighborhoods
  • Working with an organization to train various agencies and businesses in how to become compliant with non-smoking laws
  • Creating a social media campaign in a school district aimed at anti-bulling education
  • Organizing a coat drive to provide individuals who are homeless with proper winter protection

Identifying the needs of various communities with which we have contact will better guide us in what kind of change we should be working for.

            The prison setting itself is a large community that may have its own issues that need to be addressed.  Paula may realize a large number of inmates may benefit from job skills training, including Janice.  She may be a part of a committee in the prison that identifies needs and finds resources to address them or she may have to recruit other caseworkers to help her in finding different agencies, funding sources, or training to facilitate a job skills curriculum with the identified inmates.  In the process, Paula will still be working for the benefit of her clients, but is imparting change on the much larger prison system to be able to function better as an institution of rehabilitation.  community change agents want the communities they are working with to provide the best environment for all members, without neglecting anyone.

 

Counselor

            As an occupation, a counselor is often a title given primarily to professionals who possess a master’s degree in counseling, psychology, or a related field and hold a state license to practice counseling.  At times when master’s level social workers are doing one-on-one therapy with clients, this is often considered counseling as well.  However, when using it here as a social work role, we want to differentiate between the specific title of counselor and what we mean as the counseling function generalist social workers perform.  Counseling is most often associated with going to an office and talking to someone about your problems and in return they give you advice on how to approach those problems.  This is a common misconception because counseling is not about giving advice at all. In reality, when counseling, practitioners help clients understand their concerns better, work with them to create a solution to address the concerns, and help them gain skills and modify behaviors that will better equip them to deal with similar concerns in the future.  Why this role can be distinct from the others is that, unlike brokering or advocating through connection with outside entities or resources, counseling is working to build clients' capacity for change within themselves.  This can be done at both the micro level with individual counseling, or at the mezzo level with families or support groups.

            Since Janice talked about wanting to manage her anger better, Paula was able to connect her with an anger management group in prison that met on a weekly basis.  The two of them also addressed her anger management in session by processing what happened in group, discussing progress through the use of other strategies such as her anger journal, and building behavioral skills to address her anger when needed.  In this way, much like a professionally titled counselor might do, Paula is helping, not directing, Janice to create the capacity within herself to manage her anger in a more positive and constructive way on her own.  In her anger management group, the social worker leading the group is doing much of the same in helping the group members work with and support each other in improving these same skills.  Counseling is a unique role because the main resource used to help clients change is each individual client.

 

Mediator

            While advocacy allows us to give our clients a voice, mediation can allow us to help our clients hear each other.  As mediators, social workers are often called to help bring resolution to a situation between two or more parties that is equitable to everyone.  Mediation can help divorcing spouses more amicably divide possessions, parents disputing custody come to an agreement about visitation rights, even school systems and family systems come to agreement on educational accommodations for children with special needs.  However, in this role, our client is everyone who is involved; we do not side with any one party and must remain neutral.  That way we can guarantee that there are no favorites and we are not finding a solution that is more beneficial for one person or party than another.  There may be times when the groups involved in mediation have their own social workers with them, but this is more as a means to advocate for their client and to protect them from being taken advantage of or unjustly treated.  As mediators, we should view the client as being the system in which those represented are a part; a great example of mezzo social work.

            In the case of Paula and Janice, Paula would not be able to mediate the dispute between Janice and Frank in regard to bringing her children to visit.  Paula has built a counseling relationship with Janice.  If Paula were to become a mediator, Janice might see this as siding with Frank because Paula has to look out for Frank’s rights as well, and Frank might feel like Paula is helping out Janice more because she is Janice’s caseworker.  Ideally, another social worker would be brought in to mediate between Frank and Janice and set up an agreement about visitation that was beneficial to both of them and did not demand more from one or the other.  Paul would be able to mediate a similar situation between inmate and spouse or even a situation in which there was a property dispute between two inmates that were not on her caseload because both parties have no formal connection to her.  Mediation allows us to hold true to our social work values by not helping one person or group have an unfair or unjust advantage over another person or group, thus treating everyone as deserving.

 

Mentor/Teacher

            Not everything that we learn as children is taught to us by our classroom teachers.  Parents, siblings, even friends teach us how to function in the social setting when we are younger.  Unlike formal education in which schools need to meet state standards in order to ensure children are progressing at the appropriate level, there are no formal assessments when it comes to social-emotional learning and other learning done outside the classroom.  There is really no assurance, is there, that all humans are learning or have learned social mores, what others assume is common sense, and how to behave in various situations.  When we work with clients who are having a hard time navigating environments they are uncomfortable or unfamiliar with, we have a duty to help them gain the skills they need to effectively deal with these and other situations.  Whether it is teaching someone how to budget their money, lending support as they enter a new job, or teaching them how to engage someone in a conversation, skill-building is often an integral role practitioners play in empowering clients to gain control of the stressful and anxiety-provoking situations they come up against.

            While mentoring and teaching can be two distinct roles, in a social work view they should be thought of as interrelated.  Counseling professors often pass along information in a formal way, with the information being fact-based or accepted knowledge, and expect the students to take on a responsibility to learn it.  Any follow-up to clarify confusion, address questions, or get additional help with the material is primarily the responsibility of the student.  Mentoring is much less formal and often more advice giving or guidance that is based on the mentor’s experience.  It is caring about the mentee, being a support and providing direction for the person along the way; taking a more proactive approach to addressing confusion and not just leaving it up to that person to tell you when they need help.  In social work, we are trying to combine these two to make the “learning environment” one in which we can give our clients knowledge or skills needed for their situation and be there for them.  Since we are invested in the success of our clients, we do not want to just teach them and leave them.  We need to be there as they try the skills out and learn how to use them properly.

            In a prison setting, there is a lot that can be new for someone, even if they have been in prison before.  Different prisons may have different social rules one must follow.  Paula can work with Janice to help her understand her daily routine.  She can advise Janice how to deal with the guards and the other inmates as different situations come up.  In terms of Janice’s anger management, Paula can instruct Janice on specific meditation techniques she herself has used to help Janice keep calm in times of high stress and work with her on improving her emotional intelligence so her anger does not translate into aggressive and destructive behavior.  Being attuned to Paula’s needs, even if Paula does not bring them up, and helping address them is an important aspect of mentoring.

Person sitting at a desk in front of a laptop with a notebook on the side.
Research is an integral part of social work.  It helps with evaluation of interventions and overall work done with clients.  Staying current as a professional also requires researching effective strategies for addressing the various needs our clients bring to us.  
This photo can be found here on pxhere and is licensed under CC0 1.0.

 

Researcher

            All social workers are called to be researchers in a number of ways, all of which will help inform other roles they play with clients.  While university faculty members are often on the forefront of conducting research studies, the type of research in which generalists partake is not necessarily completing research to be published in professional journals.  Research can be done to find the most effective intervention strategies for working with children who wet the bed, at the end of a drug education program to evaluate student learning, while working with a taskforce to assess the community’s understanding of their homeless population, or even with individual clients to gain a better understanding of our work with them and the effectiveness of the strategies we implement during treatment.  The purpose of researching is to make sure we are informed professionals directing efforts in an effectual and valuable way.  As we saw earlier in the chapter, the core competencies specifically address utilizing practice that is backed by research and by using our practice to better direct research.  Others are expecting this proof of usefulness as well.

            More and more practitioners are needing to provide some evidence that the work they are doing with various clients is effective.  Depending on the setting in which the generalist is practicing, various funding sources, boards of directors, or even client systems themselves are looking for proof that they are not wasting time and resources on directives or programs that are not making a big enough change.  Before, reports of positive changes, improved mood, and better quality of life were sufficient to justify the work being done.  Yet, as our field relies a greater deal on outcome-based funding, we also need to continue to make our client systems a priority.  We have a duty to provide the best services we can and research helps us do that.

            Prisons often deal with issues of overcrowding and underfunding.  Other than the continuous process of evaluating how well the interventions she and Janice have implemented and researching best-practices and evidence-based interventions for anger management, Paula may have to collect quantitative data from Janice and others on her caseload to show how much improvement is being made.  Depending on the political climate and public policy, governments are often looking to see where they can save money and make budget cuts.  Paula has been working under a three-year grant that is currently up for renewal.  As a result, Paula has to provide detailed results of how they have used the money, what kind of changes she sees in the inmates with whom she works, and a plan for how the grant will be utilized for the next three years.  At times this can seem tedious and distracting from the direct practice Paula is doing with the inmates, including Janice.  Still it is important to remember this is a part of the greater effort to provide Janice, and the other women who are incarcerated, with the most up-to-date, efficient, and helpful service Paula can give them.

 

Box 4.2: Case Management

The NASW Standards for Social Work Case Management (National Association of Social Workers, 2013) state, “Case management dates its development to the emergence of the social work profession and remains integral to 21st-century social work practice.”  With the importance case management plays in social work practice, NASW has outlined the following 12 standards for case management:

Standard 1. Ethics and Values – The social work case manager shall adhere to and promote the ethics and values of the social work profession, using the NASW Code of Ethics as a guide to ethical decision making in case management practice.

Standard 2. Qualifications – The social work case manager shall possess a baccalaureate or advanced degree in social work from a school or program accredited by the Council on Social Work Education; shall comply with the licensing and certification requirements of the state(s) or jurisdiction(s) in which [they practice]; and shall possess the skills and professional experience necessary to practice social work case management.

Standard 3. Knowledge – The social work case manager shall acquire and maintain knowledge of current theory, evidence informed practice, sociohistorical context, policy, research, and evaluation methods relevant to case management and the population served, and shall use such information to ensure the quality of case management practice.

Standard 4. Cultural and Linguistic Competence – The social work case manager shall provide and facilitate access to culturally and linguistically appropriate services, consistent with the NASW Indicators for the Achievement of the NASW Standards for Cultural Competence in Social Work Practice.

Standard 5. Assessment – The social work case manager shall engage clients—and, when appropriate, other members of client systems—in an ongoing information-gathering and decision-making process to help clients identify their goals, strengths, and challenges.

Standard 6. Service Planning, Implementation, and Monitoring – The social work case manager shall collaborate with clients to plan, implement, monitor, and amend individualized services that promote clients’ strengths, advance clients’ well-being, and help clients achieve their goals. Case management service plans shall be based on meaningful assessments and shall have specific, attainable, measurable objectives.

Standard 7. Advocacy and Leadership – The social work case manager shall advocate for the rights, decisions, strengths, and needs of clients and shall promote clients’ access to resources, supports, and services.

Standard 8. Interdisciplinary and Interorganizational Collaboration – The social work case manager shall promote collaboration among colleagues and organizations to enhance service delivery and facilitate client goal attainment.

Standard 9. Practice Evaluation and Improvement – The social work case manager shall participate in ongoing, formal evaluation of her or his practice to advance client well-being, assess the appropriateness and effectiveness of services and supports, ensure competence, and improve practice.

Standard 10. Record Keeping – The social work case manager shall document all case management activities in the appropriate client record in a timely manner. Social work documentation shall be recorded on paper or electronically and shall be prepared, completed, secured, maintained, and disclosed in accordance with regulatory, legislative, statutory, and organizational requirements.

Standard 11. Workload Sustainability – The social work case manager shall responsibly advocate for a caseload and scope of work that permit high-quality planning, provision, and evaluation of case management services.

Standard 12. Professional Development and Competence – The social work case manager shall assume personal responsibility for her or his professional development and competence in accordance with the NASW Code of Ethics, the NASW Standards for Continuing Professional Education, and the licensure or certification requirements of the state(s) or jurisdiction(s) in which the social worker practices.

 

Case Management

            In a sense case management is not really a unique role, but a function that needed to be addressed all the same.  It was purposefully left for the end of this section because case manager or caseworker are often specific jobs social workers can have.  Case management is a collection of the many different roles which social workers regularly do.  In whatever setting, they need to be working in many different ways for their clients.  Whether it is to connect them with housing assistance, work with school officials to obtain better accommodations for a child who is deaf or hard-of-hearing, or help build time management skills with the client, they will need to utilize their generalist social work knowledge base.  They need to understand their clients and their clients’ needs, and tailor the services they provide to facilitate the desired change.

 

Social Work Education and Professional Regulation

            As mentioned earlier in the chapter, generalist practice is the central foundation for any social worker, and we visited the nine competencies set forth by the Council of Social Work Education.  The CSWE created, and regularly evaluates and updates, the competencies in order to ensure graduates from accredited programs have gained the knowledge needed to be competent social workers.  Currently, the CSWE accredits programs at both the bachelor and masters level.  While there are various programs at the associate level and many universities offering doctoral programs, the CSWE does not offer accreditation at these levels of education for various reasons.  In the frequently asked questions section of their website, the CSWE (2009) addressed this by stating:

CSWE limits its accreditation function to programs that prepare students for professional social work practice, i.e., baccalaureate and master’s degree programs. In general, associate degree programs prepare students for paraprofessional-level positions in social service agencies.  Doctoral degrees in social work are typically research-oriented and primarily prepare students for academic, research, or administrative positions. In most instances, persons seeking a doctorate in social work already have a master's degree in social work. (online)

Following this reasoning, we will further discuss the two levels that are accredited by the CSWE.

 

Bachelor’s Programs

            There are currently 533 baccalaureate programs of social work accredited throughout the United States, with another dozen in candidacy (CSWE, 2021a).  Each of these programs, with their curriculum designed to address the core competencies, will allow graduates to enter the field of social work as a generalist practitioner and work under the title of “Social Worker”.  As previously stated, these programs help students gain a broad knowledge base to be able to provide an array of functions, and to do so at each of the three levels of practice.  While the mandates of the CSWE direct curriculum design, there is some autonomy in what courses colleges and universities use to achieve those goals.

Aside from the liberal arts foundation mentioned previously in the chapter, specific social work courses may include topics such as introduction to social work, generalist practice, social welfare policy, human behavior, research methodology, diversity, and practice methods.  Other than course work, both bachelor’s and master’s accredited programs provide students with field experience working in a human service organization setting.  Larrison and Korr (2013) refer to Goldstein in identifying field practice as a very necessary part of generalist education.  As a result, recently graduated social workers join the workforce with a solid knowledge base in social work theory, concepts, and practice methods, as well as real field experience applying what they have learned.

Person dressed in graduation regalia with a paper in her hand and other graduates in the background.
All students graduating from an accredited social work program have the knowledge and skills to be generalist social workers.  You can continue for a master’s degree to specialize in a specific concentration.  Even with a degree, all states require professional licensure and continued education if you want to practice as a professional social worker.  
(This photo can be found here on pxfuel and is free for use under DMCA.)

 

 

Master’s Programs

The Educational Policy and Accreditation Standards (EPAS) set forth by the CSWE (2008) view master’s programs as educating the advanced practitioner, stating, “advanced practice incorporates all of the core competencies augmented by knowledge and practice behaviors specific to a concentration.” (p. 8).  In other words, aside from the generalist foundation bachelor’s level graduates gain in their education, master’s level students receive both training in generalist practice and advanced training in an area of specialization, such as mental health, child and family, school social work, policy and evaluation, and community leadership.  While Colby (2014) points out that there is no EPAS requirement that outlines how graduate programs are organized, these programs typically utilize the first year of the program to build the generalist foundation students would have received in a bachelor’s program and second year to hone in on the students’ chosen specialization.  Naturally some programs may impose additional courses on graduate students whose undergraduate coursework may not have included key foundational ideas and knowledge for social work practice.  In the same way, many universities offer advanced standing programs for qualified individuals entering master’s programs after graduating from an accredited bachelor’s level program.

With the election of a specialization, as well as the foundation of generalist practice, graduates of accredited social work programs are much more prepared to effect change in their selected concentration.  Since the generalist approach is, by necessity, broad in theory and practice, the advanced practitioner training allows students to learn more in-depth skills and knowledge in their chosen concentration.  As a result, master’s students are situated to enter the field in higher level jobs.  While bachelor’s level graduates should still be seen as very capable and able to perform as generalists, master’s level graduates should be acknowledged as having more expertise in their selected field of practice.  Once in the field, the experience all graduates receive will allow them to continue to grow as professionals.

 

Licensure

            Graduates from accredited master’s and bachelor’s programs should be able to perform the functions needed of professional practitioners, not only upholding the values and working toward the goals of the occupation, but demonstrating the knowledge and skills they developed over the span of their education.  However, passing grades do not always translate into competency.  There are many professions that require licensure in order to legally perform the duties of their chosen line of work, and social work is one of them.  The Association of Social Work Boards (2015), or ASWB, a non-profit organization created solely to regulate social work, states:

The purpose of licensing and certification in social work is to assist the public through identification of standards for the safe professional practice of social work.  Each jurisdiction defines by law what is required for each level of social work licensure. (online)

While the ASWB has tests for five different levels of practice, Associates, Bachelors, Masters, Advanced Generalist, and Clinical, states may not offer licenses at each level.  It is important for future social workers to understand which licensure is required for the career path they want to pursue and what exam they need to take.

Many colleges and universities only focus on relating specific information to their students about licensure as a professional in the state in which the school is located.  For students who plan on living and working in a state other than the one in which they are getting their education, they need to do research on their own.  This tool on ASWB's website will generate the official website for any state's official regulating body.  And though the requirements may differ from state to state, there are some standard conditions candidates must meet:

  1. Education from an accredited generalist or advanced practice program
  2. A passing score on the state licensing exam
  3. Supervision for clinical or advanced licensure

In rare cases, those who have not earned an accredited social work degree may be able to get licensure in some states, but these instances are most definitely exceptions, not the rule.  That is why the best educational path to state licensure is through an accredited institution.  Once a worker has her or his license, the work is not over.  Social workers are required to engage in continue education opportunities regularly, based on state of licensure, to make sure social workers are up-to-date on important legal, practical, and theoretical aspects of the field.  This ensures social workers are providing effective, ethically sound, and professional services when working with their client systems.

 

Conclusion

            As we have seen, generalist social work practice is, by definition, broad in how it works with client systems, what kinds of concerns it deals with, even in what settings it can be found.  As a student of this class, it will be imperative that you start to get an understanding of what will be required of you in various settings and how you become a practicing professional.  Understand that you will be required to take on all of the roles discussed in this chapter, as well as others that may not have been highlighted; this is true of any social work setting.  However, it is also important for you to compare all this with your values, ideas, and limitations.  Not all social workers can work in all settings, and it will save you a lot of time, money, and stress if you are able to identify those arenas in which you cannot work.  There is nothing wrong with knowing what your boundaries are.  If you would not function well in a particular setting, you would not be an effective worker for the clients.  When all is said and done, this is a central tenet of being a social worker: making sure you do what is best for those you serve.

 

References

Association of Social Work Boards (2013). About licensing and regulation. In Licensees. Retrieved from https://www.aswb.org/licensees/about-licensing-and-regulation/.

Bureau of Labor Statistics (2021). Social workers. In Occupational outlook handbook. Retrieved from https://www.bls.gov/ooh/community-and-social-service/social-workers.htm#tab-3 on July 21, 2021.

Colby, I. (2014). Challenging social work education's urban legends. Journal Of Social Work Education, 50(2), 206-218. doi:10.1080/10437797.2014.885239.

Colorado State University, College of Health and Human Sciences (2015). B.S.W. practice roles. In School of Social Work. Retrieved from http://www.ssw.chhs.colostate.edu/students/undergraduate/bsw-practice-roles.aspx.

Council on Social Work Education (2009). Accreditation. Retrieved from https://www.cswe.org/About-CSWE/FAQs/Accreditation.aspx.

Council on Social Work Education (2015).  2015 educational policy and accreditation standards for baccalaureate and master's social work programs. Retrieved from https://www.cswe.org/getattachment/Accreditation/Standards-and-Policies/2015-EPAS/2015EPASandGlossary.pdf.aspx.

Council on Social Work Education (2021a). Accreditation. Retrieved from https://www.cswe.org/Accreditation.

Council on Social Work Education (2021b). 2022 educational policy and accreditation standards for baccalaureate and master's social work programs. Retrieved from https://cswe.org/getattachment/Accreditation/Information/2022-EPAS/EPAS-2022-Draft-1-April-2021-(2).pdf.aspx.

DuBois, B, & Miley, K. K., (2011). Social work: An empowering profession (7th ed.). Allyn & Bacon.

Larrison, T. E., & Korr, W. S. (2013). Does social work have a signature pedagogy?. Journal Of Social Work Education, 49(2), 194-206. doi:10.1080/10437797.2013.768102.

Mather, J. H., & Lager, P. B. (2000). Child Welfare. Brooks/Cole.

Miley, K. K., O’Melia, M., & DuBois, B. L. (1998). Generalist social work practice: An empowering approach (2nd ed.). Allyn & Bacon.

Mizrah, T., & Davis, L. E. (Eds.). (2008). Encyclopedia of social work (20th ed.). doi:10.1093/acref/9780195306613.001.0001

Morales, A. T., & Sheafor, B. W. (1998). Social work: A profession of many faces (8th ed.). Allyn & Bacon.

National Association of Social Workers. (2013). NASW standards for social work case management.

            Retrieved from http://www.socialworkers.org/practice/naswstandards/

               CaseManagementStandards2013.pdf.

Netting, F.E. (2005). Future of macro social work. Advances in social work, 6(12), 51-59.

SocialWorkLicensure.org (2015). Social work licensure requirements. In Licensure resources.  Retrieved from http://www.socialworklicensure.org/articles/social-work-license-requirements.html.

Zastrow, C. (2008). Introduction to social work and social welfare (10th ed.). Thomson Brooks/Cole.

Chapter 5: Social Policy

One of the most identifiable methods of macro social work is social policy reform. In fact, the Council on Social Work Education (2008) lists policy practice as one of the core competencies all generalist social workers should have. In terms of social justice, it can offer the largest amount of change, impacting the greatest number of people. Upon completion of Chapter 5, students should be able to:

  1. Define social policy;
  2. Explain how social policy practice addresses social welfare and social justice;
  3. Understand and analyze political ideologies in relation to formulating policy;
  4. Identify past social welfare policies;
  5. Distinguish the various arenas and efforts political social work can encompass;
  6. Apply the four-stage change process to policy practice;
  7. Analyze policy for effectiveness.
A picture of the beginning of the US Constitution, "We the People."
"We the People" by StevenANichols is licensed under CC BY-NC-SA 2.0

Social Work and Social Policy

            The U.S. Constitution, and essentially the United States, were created, “in Order to form a more perfect Union, establish Justice, insure domestic Tranquility, provide for the common defence, promote the general Welfare, and secure the Blessings of Liberty for ourselves and our Prosperity.” (U.S. Constitution, 1787, p. 1). With the foundation of our nation, the groundwork for macro social work, as it relates to affecting policy implementation and change to provide for the well-being of those who live and work in this country, was laid. The problem is the United States has not always been able to adequately or justly provide for the inalienable rights all humans have. Thus, social policy focuses on addressing the needs, oftentimes at the most basic level, of all humans through programs, procedures, legislation, agency, and environmental factors by filling the gaps not met or ineffectually met by current services. Policies are created for the good of everyone, however, social policies and programs address specific populations of people, especially those who do not seem to have even the most basic of rights. This makes it easy to see exactly how the value of Social Justice, in terms of social work, applies to social work policy practice, or political social work as it may be called. In this chapter, we will look at what social policy is, various political views and how they relate specifically to policy, historic and current social welfare policy, and engaging in policy practice.

 

What is Social Policy?

           In understanding what social policy actually encompasses, it is important for us to be aware of how it fits in with general federal legislative policies. Dear (1995) makes it a point to differentiate between three terms that have often been used interchangeably in social work policy practice literature: policy, social policy, and social welfare policy. He states that social welfare policy is a subset of social policy, which itself is a subset of general policy. So while general policy in the United States might encompass goals, principles, and means of all legislative processes, and social policy focuses in on issues of social well-being, including education, transportation, and health care for the general public, social welfare policy further zeroes in on meeting the basic needs of families and individuals (Dear, 1995; Katz,

2000). Still, many would argue that social welfare policy itself is so broadly defined, that meeting the most human of needs can encompass a lot, and therefore should be identified as almost anything done by the government to improve the quality of life (DiNitto, 2000). Political social work primarily affects change in social policy, including in a very big way social welfare policy, no matter what the definition is.

Social workers are often called to engage in discourse on various topics related to social policy. Much social work literature dedicates time to discussing the implications for practice at all levels, including how the knowledge can help guide policy advocacy. As the frontline of interacting with those who are utilizing social service agencies and government-directed programming, many social workers are the experts on what is working, what needs improvement, and what or who is being neglected. Political social work is not just about creating policy, either. Practicing macro social work also includes interpreting and evaluating various social policies and the programs with which they intersect, very vital pieces to social policy work. As social workers, we should be able to recognize where policy falls short both in what issues are covered and how they are addressed. We ought to understand the letter and intent of legislation to ensure policies and their programs are implemented correctly. As mentioned in Chapter 1, critical thinking is an important part of social work. The advocate in us must utilize this skill to move beyond simply accepting the way things are for our clients. For social work practitioners, questioning authority is not about being a rebel. It is about being an activist and creating the best conditions for everyone in our society, including the clients we work with directly, to become self-actualized.

Social Welfare Policy

Reaching your full potential and truly getting the most out of life is a wonderful thing. When we help our clients improve their own situation to the extent that they feel like a contributing member of society, it is a wonderful thing. What about those clients, though, who are not even concerned about reaching their potential? What happens when we work with a person or a population of people just trying to make it to the next month, the next week, or even the next day? Some of those more ethereal goals are unrealistic in those times our clients are just looking to subsist. This is where social welfare policy comes into the picture. In relation to Maslow’s hierarchy of needs, social welfare policy directs efforts to attend to the physiological, safety, and, sometimes, belonging needs people cannot fulfill on their own, for whatever reason (Maslow, 1970). Social welfare can allow for income assistance or food subsidies to help with paying for groceries, housing supports to provide basic shelter, or even foster placements for abused or neglected children where they can feel safe and loved. These programs not only help people survive but also, when effective, can empower them to persist and thrive.

Box 5.1 – Maslow’s Hierarchy

Maslow's Hierarchy of Needs pyramid.
Abraham Maslow described his hierarchy of needs in his 1954 book, Motivation and Personality.  It talked about how people can work to meet higher-level needs without first meeting lower-level needs.  Social policy helps people meet their physiological and safety needs, the lowest two levels.  
"File:Maslow's Hierarchy of Needs Pyramid.png" by Saul McLeod is licensed under CC BY-SA 4.0.

It is true that political social work itself is not just about providing for the basic needs of those with who we work. We do need to go beyond that, and social policy advocacy should definitely be a part of how we work for and with client systems at the macro level, as a way to help them get the most out of life. However, working for education reform to help a young, single mother take college courses to build her future does no good if that same mother has no income and cannot afford to feed her children; we would be putting the cart before the horse. Granted having a college degree will allow her to better provide for her family in the long run, but that does nothing for her current situation. It is essential, therefore, that social workers place emphasis on macro-level work to meet our clients’ most basic needs. The National Association of Social Workers (NASW) (2008) Code of Ethics even addresses this in two specific areas:

Social workers should promote the general welfare of society, from local to global levels, and the development of people, their communities, and their environments. Social workers should advocate for living conditions conducive to the fulfillment of basic human needs and should promote social, economic, political, and cultural values and institutions that are compatible with the realization of social justice. (sec. 6.02).

and

Social workers should engage in social and political action that seeks to ensure that all people have equal access to the resources, employment, services, and opportunities they require to meet their basic human needs and to develop fully. Social workers should be aware of the impact of the political arena on practice and should advocate for changes in policy and legislation to improve social conditions in order to meet basic human needs and promote social justice. (sec. 6.04a).

These two sections refer to the importance for social workers to advocate for our clients for the most fundamental requirements of life. One thing that stands out, of course, is the need to promote and realize social justice through social welfare policy.

Social Justice

These parts of the NASW Code of Ethics also refer to working with those who are often neglected or completely ignored by society at large, as often working for social welfare reform includes working for social justice. Those groups that tend to be forgotten or targeted in the United States deal with much injustice as a result and are relegated to lower statuses. Too frequently, people tend to attribute the problems these groups deal with to personal attributes of the group instead of recognizing the problems as a result of being disenfranchised. When we think of social justice, we have a tendency to equate it with advocacy, working for our clients and giving them a voice when they feel that they do not have one. Steele (2008) identifies the common practice of using the two terms interchangeably or even combing the terms into one. As a result, he provides a definition of social justice advocacy as working for marginalized clients whereby the change agent understands, identifies, and confronts barriers to positive, healthy functioning. Hong and Hodge are cited as also defining social justice in a way that requires action to be taken in addressing the injustices we see in our society (Kilbane, Pryce, & Hong, 2011). Social justice is not just about understanding there are groups that are discriminated against, either overtly or unknowingly, it is about using that understanding to address the deficits in providing for these groups. Social workers actively pursue change in order to deal with oppression at the institutional, cultural, and individual ranges (Hackman, 2005), at all levels of service. Social justice at the macro level is embodied in social policy improvement directed at correcting various systemic problems that prevent certain groups from moving beyond trying to meet just their basic needs.

Advancing social justice through policy practice can be a large undertaking. There are many different problems out there with inadequate policy abounding; it can be overwhelming realizing how much work needs to be done. However, framing social justice into target areas can help us identify what policies need to be changed—or implemented—and how to work for that change. In their book Social Welfare Policy, Programs, and Practice, Segal and Brzuzy (1998) outline five particular emphases as a means to fight for social justice and reform welfare policy. Specific chapters in our book will address some of the issues in these areas further, so for now let us take a quick look at what each entails. As you read, bear in mind the possibility of overlap between some of the following categories.

Children and families: Providing children with the best opportunity to grow and mature as a functioning member of our society, which includes providing a loving and nurturing home life, a good education, and a safe environment overall. Policies here can include providing for children who are without parents, removing children from abusive homes, assisting single mothers in need, and providing access to contraceptives.

The poor: Addressing housing, food, and employment/income needs of those at or below the poverty line. This can include minimum wage increase, income assistance, housing subsidies, and financial aid grants for college. Being poor has a lot of interplay with race/ethnicity, immigration status, and the makeup of the family unit.

The elderly: Focuses on health-care and income assistance. As we age, our health-care needs, and costs, rise even though our ability to earn an income falls. Both Medicare and Social Security are programs that have been around a long time to help those of us who are advanced in years.

Healthcare: Increasing access to affordable and adequate healthcare. Medicaid, Medicare, the Affordable Care Act, and even policies to curb litigations against doctors to lower malpractice insurance costs, and doctors’ fees in relation, are ways to deal with this problem. Many of the issues stemming from this lack of access usually accompany one of the other five areas of social justice.

Civil rights: Providing equal access to education, housing, employment, income, marriage, and adoptive rights, to name a few, for those who have been directly or indirectly marginalized and discriminated against based on race, ethnicity, religion, sex, sexual orientation, gender identity and expression, age, disability, and socioeconomic status. When it comes to civil rights, there are simply so many systemic issues and societal beliefs that continue to ostracize groups of people. Historically, the abolition of slavery, the repeal of Jim Crow laws, and allowing women to vote have been policy reformation that has addressed civil rights.

Side-angle photo of the U.S. Capitol building.
American policy is definitely influenced by the political ideology of those creating and implementing it.  Different ideologies view social welfare policy differently.  Where do social work values fit?

 

Policy & Political Ideologies

            The first chapter in this book addressed various political ideologies, main tenets of each, and how their views aligned with basic social work values. These political stances are reflected in the ways each addresses social policy and social welfare. Keep in mind that these viewpoints are general ideas and that political ideologies should be thought of as a part of continuum, with the left generally thought of as liberal, or in alignment with Democratic approaches, and the right as more conservative, aligning with Republican approaches. By no means should we assume that all people claiming to be part of one party or another espouse the stereotypical approaches of that party (e.g., Bill Clinton and TANF). One study even shows that while people identify with a particular party, they do not necessarily hold all the same ideological beliefs of that party (Malka & Lelkes, 2010). As social workers, it is also important for us to remember this and not just blindly accept and follow the value system of one party or the other. No matter which group we affiliate with, we need to understand their stances on important issues and see if they mesh with our own values and beliefs, as we fight for social justice.

Conservatism

            When it comes to social policy position, conservative values encourage minimal government involvement when it comes to policy creation. In essence, they espouse ideas that people and companies will benefit greater from being able to make decisions with little interference from government regulation. With hard work and dedication, any obstacle should be able to be overcome and can lead to greater independence and stronger country as a whole. When it comes to social welfare, those that need additional help should be served by governmental policy with requirements and limits as a way to empower them to improve and thrive in their own lives. For instance, if a single-parent is receiving food stamps, the program should limit how long they can get food stamps and require them to actively search for work. They also believe in the traditional family as the foundation of our society, a way to properly raise and educate the future of the United States. Thus, social policy should encourage, promote, and reward this structure (GOP, 2012). The Defense of Marriage Act and banning adoptions by gay couples are policies that protect the heterosexual family unit. Finally, faith and religious freedom is a third overarching focus for the Republican Party. They are in favor of policy practice that does not force citizens to go against their religious beliefs, like children not being allowed to pray before eating their lunch at school or faith-based companies having to pay for birth control for their employees. The idea is to keep true to the ideals that the founding fathers built this country on, those ideals of allowing people freedom and protecting our rights of life, liberty, and the pursuit of happiness.

Liberalism

           The Democratic National Party also wants to protect the freedom and rights of citizens here in the United States. Similar to those on the right, Democrats believe, “hard work should pay off, responsibility should be rewarded, and each one of us should be able to go as far as our talent and drive take us.” (Democratic National Committee, 2012, p. 1). However, their belief is that this does not happen in our society. While they also address issues like work, family, and religious freedom, they believe that these can all fall under the umbrella of equal rights. Unlike the conservative Republican opinion arguing that our policy has created a dependent, welfare state, liberal viewpoints on policy reflect the idea that we do not do enough for those marginalized and favor policy creation and implementation that will more effectively provide everyone equal rights. These policies look to provide for those who currently are being or historically have been mistreated, such as providing equal pay for women, marriage equality for same-sex couples, and providing income services for those experiencing poverty. Liberal policy also looks to attack the institutional and societal schemes that perpetuate the relegation and discrimination of certain groups. Hate crime laws, Affirmative Action, and ending tax breaks for the wealthy are examples of policies that force people to consider the racist and discriminatory aspects of actions others take, both consciously and unconsciously. The liberal view of Democrats believes that policy is needed in order to ensure these things for all of us in the United States, that without it, these groups will continue to be neglected or forgotten.

Three public train station turnstiles with "Republican?" "Democrat?" and "Undecided?" signs on them.
The Democratic and Republican parties win most of the major federal and state elections. However, as was mentioned earlier in the book, politicians from other parties or who are independent have won big elections and possibly a number of smaller, more local elections. We need to understand their views in order to address policy more effectively.  "Republican? Democrat? Undecided?" by edenpictures is licensed under CC BY 2.0

Radical views

            Chapter 1 addressed several other parties, many of which had views on social policy, including social welfare policy, similar to those outlined above. However, there is a different view on social and social welfare policy that should be addressed, and that is the radical view. Radicals, who have no substantial political representation (Katz, 2000), are similar to liberals in that they support governmental intervention. However, Radicals want to take it even further. They favor governmental influence to create an equal economic balance for all those in the United States, through governmental redistribution of power and wealth, and programming to provide the same opportunities for everyone (DuBois & Miley, 2011). Their policy approach, therefore, provides big governmental change to give everyone equal footing economically and socially.

Box 5.2 - Political Allegiance

When one of your authors was in his Intro to Social Work course in college, he remembers the day they discussed political ideologies and how they lined up with social work values.  What was interesting was that values social work embodied were the same values he had - seeing the worth of every individual, wanting to help others have a high quality of life, equality for everyone.  These were the reasons he chose social work as a career to begin with.  However, when the instructor told him that social workers line up with Democrat values, he had an internal fit.  There was no way he was going to be a Democrat!  Your authors were raised as Republicans and believed Republican was the better party; history told us so.  Abraham Lincoln freed the slaves and he was Republican.  How could social work not be aligned with those values?  His instructor then proceeded to show the class exactly how social workers' values lined up with views of the Democratic Party.  It made sense but your author was just too connected to the Republican identity.

It is important that social workers connect the values of the field with political practices, not necessarily choose allegiance to one party or another, and understand what parts of a political ideology are in line with social work goals.  What are your political views?  How do they compare to the values of social work and why you are considering the profession?

Deficiencies

As social workers, it is up to us to understand how these ideologies impact policy creation so that we can better serve our clients in addressing the deficiencies we find. In an ideal world, we would not have to worry about creating policy to help the needy because, if there were needy or disadvantaged individuals or groups, society would take it upon itself to help these people. However, we are not living in an ideal society and there are still many problems in the world in which we live and how we view those who need help. One can find pros and cons with any political viewpoint, mainly because there is no blanket set of rules to govern how policy is created. For instance, while liberal views do tend to meld best with social work values, conservatives may have a valid argument about not regulating income assistance to families. How can we empower those who need aid efficiently in order for that need to no longer be there? Still, putting in specific regulations and requirements with the assumption that everybody’s situation can be handled the same way denies the unique struggle that individuals have. All these ideologies can add perspective to what we are doing (Miley, O’Melia, & Dubois, 1998). Again, it is not about blindly accepting one view or the other, but about effectively evaluating the objective and understanding the motive behind the policy. We need to be open to differing angles of looking at how to solve a problem, acknowledge the merits others have in their approach, and incorporate those things that are going to lead to positive changes for those we serve.

Furthermore, we need to understand these ideologies and how the role they play in the political climate of wherever we are working for change. It will help us better understand how to formulate policy and how to better persuade those with who we will be working. If we want to advocate for more money to be given to unemployed single mothers but our state has a republican majority, we should highlight the negative effects on the rest of the state if the current practices are not amended since a conservative viewpoint places a lot of personal responsibility on individuals. Similarly, if we are aware that people are taking advantage of the local food pantry, but the area has a strong liberal presence, our focus should be on how those taking advantage of the service are negatively impacting those who need to use the food pantry in order to help add restrictions to the process of getting food. Social workers should always understand how the political and social climate of the times and in the community in regards to social welfare and governmental responsibility before trying to pass any kind of policy reform.

 

U.S. Social Policy

            Beginning with the idea of the deserving poor, social welfare policy in the United States has been a slow and reluctant progression. The idea that individuals’ behavior and social standing is more a reflection of their character and has nothing to do with their environment is a persistent theme in getting to the current state of welfare policy (Pozzuto & Arnd-Caddigan, 2008). History has shown time and again that people favor individual growth and the right to keep whatever money they worked harder for than those who are poor. Even when he mentioned how horrible some rich people are in not helping out poor people, Theodore Roosevelt (1897) was stressing how the wealthy in society would improve the prosperity for even the poor man. He believed that while some governmental intervention was necessary, such as in the abolition of slavery, he felt that too much regulation was not good for the Union.

It was not until his own relation, Franklin D. Roosevelt, ushered in the New Deal that people realized that welfare was everyone’s responsibility (DiNitto, 2000). Still, the country wanted to limit how much welfare was distributed and continue to hold able bodied people somewhat responsible for their personal status in society. Today, we still see the poor being neglected. Even in the platforms of both major parties, helping the middle class—not the poor —is believed to be an essential piece in keeping the United States a great and powerful nation (Democratic National Committee, 2012; Republican National Committee, 2012). There is no denying, of course, that Americans grew in their understanding of social justice and our responsibility to fight for basic civil rights for groups that have been held down by society. We have come a long way and our social welfare policies reflect that change. However, is it enough? Some of the most prominent current social welfare policies will be discussed in the chapters that follow.  Social workers not only need to be aware of what programs are out there, but also understand the political context of the policy, values inherent in the system and society, the needs of client systems, and how well these programs are providing for the welfare of our nation.

 

Engaging in Policy Practice

            As helpers, it is important to realize that although we want to do all that we can to help as many people as we can, not all solutions can be obtained through individual services. When working at the micro level, it may even become inefficient to continually advocate for the same issue with individual clients. We need to be able to focus our attention in those needs of the client system(s) we are currently working with in order to effectively help them improve. While it is clear that engaging in policy practice gives us the opportunity to provide services on a larger scale for more people, it may not be something that social workers are always comfortable doing. As such, it is important to take the opportunities to understand where you can practice social policy advocacy, know how to work for policy reform, and continuously look for opportunities to utilize and enhance policy practice self-efficacy. Indeed, your macro social work practice skills, like those skills at any other level of practice, should be nurtured and enhanced. Hopefully, this will be the first of many opportunities you will encounter to gain knowledge and practice in social policy work as you journey toward becoming a generalist social worker.

Lack of Experience with Policy Practice

There are many articles that describe the deficiency of experiences with policy practice in social work education. Students disinterest and low self-efficacy in this area of social work, unavailability of practice sites, and lack of adequate supervision can keep schools from incorporating policy work as a significant part of the curriculum (Pritzker & Lane, 2014). In fact, only .8% of students in master’s-level social work programs as well as .8% of those in bachelor’s-level programs had field placements in social policy (CSWE, 2014). However, social work students should see social welfare policy practice as a viable activity for professional work as a social worker. Too often clinical social work may be thought of as the only true practice route for social workers, especially based on licensing requirements (Donaldson, Hill, Ferguson, Fogel, & Erickson, 2014). Even with many students eventually focusing their education on clinical work or other lower levels of social work practice, we need to make sure that we take the educational opportunities to engage in macro level, social policy, specifically social welfare policy, practice. There will be times when all social workers are called to impact policy change for the client systems with which they work.

When too many of our clients are experiencing the same barriers or dealing with same problems, policy practice allows us to help everyone, even those we do not work with directly, get their needs met (Rocha, 2007). For instance, if in our clinical work with clients who experience suicidal ideation who have been hospitalized, we realize that those who do not have adequate health-care coverage are released from hospitals earlier than those who do have adequate coverage, we may want to look into advocating for legislation that provides longer inpatient treatment for those who are planning on taking their own lives. In moments such as this, we need to be ready and capable to impact change at the community, state, or federal levels, otherwise we are missing out on an opportunity to help those we serve. Sure the thought of trying to push ideas through to legislation and make it law can seem daunting, but being able to understand how clinical work is tied to policy work can help practitioners and social work students understand the importance of building their macro skills as well as their clinical ones (Kilbane, Pryce, & Hong, 2013). It is not enough to plan for after treatment, discuss coping strategies, and help our clients build a network of support. While those are all great individual intervention strategies, that is not everything that can be done. Too often, social workers help their clients navigate the various aspects of their environment as it is when they really need to be working to help them change it as well.

Areas of Practice           

In talking about social welfare policy, it is easy to focus on those federal laws and programs created by the government in order to address issues for the whole country. Yet, social policy practice is not just about creating legislation. There are various efforts that can be made to direct, interpret, and implement that change. Cummins, Byers, and Pedrick (2011) describe four settings for social policy practice to affect change: the three branches of local, state, and federal government (executive, legislative, and judicial) and community advocacy. Rocha (2007) reflects these same four areas of political social work, but instead refers to the executive arena as bureaucratic practice seeing as law interpretation and implementation is not only done by the executive branch of the government but by social service agencies and community organizations as well. It is important to keep in mind that each of these settings exist at the various levels of government, local, state, and federal, and the strategies discussed in the following sections can be applied at each governmental level. However, be aware that as the level gets bigger, so does the difficulty in implementing policy reform. As a means to better understand each policy practice setting, we will follow Dennis, a social worker in a community-based agency, as he pursues change in social policy.

Among many of his duties in the agency, Dennis provides adolescent out-patient group therapy for drug offenders in his county. The majority of the youth who make up the group are mandated by court to attend this sort of counseling instead of being sent to juvenile detention. While it is rarely an easy process to get buy-in from mandated clients, Dennis has seen success in the positive impact the group has had on the youth. During a recent meeting, the topic of alcohol came up and several of the participants discussed how easy it is to obtain alcohol in the area, whether through purchasing it on their own or having someone else provide it for them. Dennis redirected the group but made it a point to remember the discussion after the group meeting was over.

Photo of a town hall meeting, with two people in the foreground discussing an issue.
Community-based policy practice involves members of the community coming together to address a concern.  "Good Morning America town hall meeting" by John Edwards 2008is licensed under CC BY-SA 2.0.

Community-Based Policy Practice

Community-based policy practice is most easily related to grassroots campaigns. Whether it is a group of citizens that come together or a practitioner from a local social service agency, community-based practice is founded in the common interest of those in the community to combat a perceived systemic gap in policy and programming. Many times these community groups can start off as task forces or coalitions, with a number of community stakeholders from different organizations, public service agencies, or even the community at large. All have a vested interest and bring a unique perspective to the table. The people involved spend time in researching the issue, planning strategies to change policy, and actually working to make the change happen.

In Dennis’s case, he did some research on teen alcohol consumption in his county and state, based on arrest and ticketing data. He also talked with law enforcement agencies, health-care providers, school administrators, and other social work professionals to get their take on the issues, all of which brought him to the conclusion that something needs to be done about the high rate of teen alcohol use. As a result, a coalition was put together consisting of himself and a couple of other social workers in the county, principals of a few of the school districts, local police officers, some parents from various school PTAs, and some local doctors. Together, this group of people can come up with ideas for programming and policy implementation or correction in each setting.

Immediately in the community, however, each of the members of the coalition can analyze how their various milieus deal with the problem and make any adjustment necessary. The group can also advocate for reform in policies of outside organizations, groups, or businesses that may be contributing to the problem. For instance, the coalition may realize that local bars and liquor stores use sports-related alcohol advertisements that catch the eye of adult customers and teenagers alike. In an effort to impact the consumption of alcohol by youth, working with alcohol vendors to use more appropriate advertising that does not cater to minors might be an effective strategy. However, this is not the only approach of the coalition and they have plans to touch base with local and state lawmakers to discuss possible legislation.

Legislative Policy Practice

The legislative branch of government is the one that creates the laws that govern our country, state, and local municipalities. It is often misunderstood as the only setting to get political social work done. Thinking about policy, we tend to focus on the laws and systems the government put into place to remedy social ills. Although this is not the only setting for social policy practice, it does get straight to the point, directing efforts to influence those who write the policies. However, it takes dedication, hard work, and patience in order to bring one’s planned change to fruition. It is a challenge, but one that all social workers should be equipped to handle, eased with the understanding of what can be done to pursue reform legislatively. Segal and Brzuzy (1998) identify three key activities—lobbying, public testimony, and voting—that are utilized by social workers in the legislative setting in order to implement or change policy. Employing these three strategies, let us see how Dennis and his coalition look to address the teen drinking issue.

Lobbying: Dennis and his constituents decided to name their coalition the Jones County Coalition Against Underage Drinking to become a more formal presence as they pursue change in the legislative setting. They are currently planning only on addressing the issue at the county level because they feel that this will give their area the quickest results. All the members of the group are open to possibly pursuing action at the state level in the future, but all their current research and work has been focused on the county and its communities. One of the first things they plan on doing is contacting some of the Jones County Board members. They utilize the connections some of the coalition members already have with the county board members to inform them of their efforts and urge them to bring the concern to the rest of the board. The hope of the coalition is that the county board will find validity in establishing directives to curb underage drinking.

Public testimony: Five coalition members, including Dennis, a parent, one of the principals, a law enforcement officer, and another social worker, attended the next county board meeting in order to speak on behalf of the coalition and the matter they wanted to bring forward. The invitation came after persuading a couple of the board members to convey the problem of teen alcohol use to the rest of the county board members, and it was decided by the coalition that only five of them should attend and speak from their area of expertise. When the representatives from the Jones County Coalition Against Underage Drinking were given the floor, they talked about the research they had done, the observable consequences in the school system, and some personal stories from families negatively affected by underage drinking. They brought facts and figures and also humanized their discourse and provided insights for possible solutions. The Jones County Board unanimously agreed with the coalition and decided something needed to be done.

Voting: In order to fight underage drinking, the board came up with several possible policy enactments, one of which was to have a referendum increasing real estate taxes voted on by the public. This tax increase would provide supplemental funding to the Safe and Drug Free Schools money which the schools already received and would allow for evidence-based alcohol and other drug prevention programming to become a part of the curriculum in the schools at both the middle-school and high-school levels. Dennis’s coalition was very excited about the opportunity but knew that they had a lot of work still to do if they were going to get the referendum passed. Members of the coalition knew how they were going to vote, but they needed to have a lot of other supporters as well. Their main concern at this point was to inform the voters about the drive force behind the referendum and the good that would result when it passed.

While we made this process seem fairly smooth and results happened quickly, it is rarely like that in the field. In reality, Dennis and his fellow coalition members would have met any number of roadblocks, even some that would cause them go back, reevaluate, and reformulate their approach. It should also be noted that the activities themselves are not necessarily a step-by-step process that needs to be followed whenever we are trying to get legislators to act. Often there is interconnectedness between the tactics, but one is not dependent on the other. For instance, there are times when groups or even single people do not necessarily connect with members of the legislature and, instead, simply attend board meetings or forums to present their case. Policy practice through voting is not done just on referendums or policy implementation but can also take the form of voting for those representatives whom we think will do the best job of providing social justice. We can write letters to our representatives to voice our opinion about an issue we have a strong stance against and may never be called to speak on the topic or even get the opportunity to vote on any policy. There is even crossover between policy practice venues, as Dennis’s coalition needed to return to the community to educate the public on the need for additional funding to combat minors’ alcohol use. The point is that policy practice has no one specific path it must take in order to be accomplished and can take many routes at the same time. In this instance, it really is the goal and not the journey.

There are a few things that can make the journey easier, however, when it comes to working in the legislative sector. When we are passionate about fighting for a cause, we get fired-up, energized, and motivated to move forward. Legislators are not necessarily looking at it from the same angle we are and can be more skeptical about the whole matter. We may have great ideas for programming that we are sure will work, but we are not always able to convince our representatives about that. It can be a lot easier to be heard and have our message accepted and adopted by legislators when we present a great idea instead of just a single program (Sherraden, Slosar, & Sherraden, 2002). Programs are concrete and less flexible than a great idea. Legislators can take ideas and put their expertise on it, developing programs or policy that will be able to fit and interact well with existing policies and programs. They can navigate the system from a political aspect.

At the same time, we still need to provide them with the information that will help them not only understand our push for change but also how to implement the change as well. While they are the experts when it comes to committee meetings and legislation creation in the political arena, we should be the experts of the concern we are bringing to them. It is up to us, as community health experts, to provide our busy representatives with accurate and critical evidence to make an informed judgment on the issue and use the data in crafting their policy (Milford, Austin, & Smith, 2007; Weiss-Gal, 2013). Legislators are not experts in all areas of public well-being, nor should they be. Just like when we are called to provide our expert opinions through testimony at committee meetings, we can express our professional judgment with hard evidence we offer legislators. When we provide the research, this saves them the work of having to do it, which they probably would not have had the time to do anyway, fostering collaboration between us and our public officials. Getting to know and build a positive working relationship with our public representatives can go a long way in helping us fill the deficiencies in social services and programming. It is key to not only understand the process but also how our representatives work in that process and what would be the best way to approach them. Linking with those who make the laws and create the programs, and developing that connection, will enable us to understand how we can serve their needs in order to meet our needs and act accordingly.

President Obama signing an executive order in the Oval Office with a number of witnesses standing behind him.
The President, as the head of the Executive Branch of the U.S. Government, can create executive orders to implement policies.  Congress's approval isn't required for them to be implemented.  "Signing an executive order on the Employment of Veterans in the Federal Government" by The U.S. Army is licensed under CC BY 2.0

Executive/Bureaucratic Policy Practice

When policy reform efforts are successful in moving a great idea from the drawing board to a discussion in legislative committee and to getting the bill signed into law, the final goal is not necessarily achieved. The new policy still has to be interpreted and implemented by the executive branch of government. Executive branches of governmental bodies, including the federal government of the United States, are made up of a branch head, such as the President, state governor, or city mayor, and various governmental departments or bureaucracies and agencies that may be involved in overseeing the policy in action. While the makeup of this branch varies from governing body to governing body, their functions are aligned when it comes to social policy. In executing new policy, all the members in this setting could theoretically contribute to the process, including designing how the policy will be applied, how programs will be run, and what the parameters of service are going to be. Even when policies are passed and directives given on how to employ these policies, there can still be a trickle-down effect. Vagueness in public policy allows agencies and departments a certain amount of decision-making power in how they deliver services to meet the orders of those policies (Rocha, 2007). As a result, we can impact policy in both these points of the process. This is a perfect opportunity for those who practice policy reform to step in and advocate.

The Jones County Coalition Against Underage Drinking was able to celebrate the passing of the referendum to increase monies provided to schools for addressing alcohol consumption by teens. However, they knew their work was not done. Now that the funds will be available, the county board is trying to figure out exactly how to regulate the spending of the money by the schools. Part of the concern is that their schools, in the past, spent the money on one-time programming that was not evidenced based and had little lasting effect on students. Dennis and his partners decide that they want to provide the board with various options of research-based or best practices programs that can be incorporated into the curricula of the schools in the county.

The board, however, decides that requiring all schools to utilize the same programs may not be in the best interest of the students as the population of the county is very diverse. Instead, they decide to distribute the funding to the schools but restrict it to only fund best practice types of programming. The coalition members are not in agreement with this decision but turn their efforts now to working with the schools. They will offer suggestions when it comes time but want to meet with the school boards to see if they can help the schools plan how to best use their money.

Judicial Policy Practice

The U.S. government was designed with three separate branches in order to create a systems of checks and balances that would not allow one branch to have too much power. Most of the time we think of courts as the enforcers of laws. When someone is accused of breaking a law, not following policy, or violating the rights of others, they are brought before a judge or group of judges and, possibly, a jury. If the accused is found guilty, the court hands down a sentence of its choosing, based on professional judgment and the legislation. Law enforcement is not the only function of courts, as they also consider the constitutionality of laws. Judicial bodies do not necessarily evaluate every policy that is implemented, however, with some laws getting through that neglect the rights of some citizens. Oftentimes this legislation is not assessed until a suit is brought against the state by a citizen or larger entity, such as an agency, an organization, or a coalition, as being unlawful. Of course, even with constitutional laws, suits can be filed against those people or entities that have broken the law. Where the courts deal with policy, both in enforcement and appraisal of legislature, social policy work can be done.

In addition to working with schools to provide prevention education, the Jones County Coalition Against Underage Drinking is looking into alcohol sales practices throughout the county. There is a chain of stores that has had a number of incidents of selling to minors without facing serious legal consequence. Through their research, the coalition found cases of injury and death of youth that has been tied to alcohol illegal purchased from this chain. As a result, the coalition decided it would be worth it to team up with the parents of these youth to file a class action lawsuit against the parent company of the stores to provide reparation to the families. This action, they feel, will bring light to the issue as well as send a message to other stores that these sales practices will not be tolerated. In keeping with this, Dennis and his compatriots want to make sure that those stores that do still sell to minors are properly punished. Their plan is to have someone from the coalition represent the group during proceedings for any store that is charged with selling to minors to make sure that they are not let off the hook easily and that the court does its job of properly enforcing the law, similar to what Mothers Against Drunk Drivers does with those convicted of drunk driving (Rocha, 2007). Furthermore, they have decided that monitoring legislative changes to current legal code or implementation of new policies dealing with consumption, sales, and advertising of alcohol are protecting the well-being of minors and their families.

While it may seem like most of policy reform should be done in the community and legislative settings, it is imperative to remember that there are still efforts that can be brought to the other two branches of government as well. While the activities in each arena takes on a different function, they are all addressing the same big idea with which social workers begin their policy practice. The important thing to understand is that there are various settings, with a myriad of ways, in which to approach social policy reform depending what your overall goals are. As generalist social workers, we should be familiar with this oft neglected method of change for our clients.

Addressing International Social Policy

As much of this text does, we have related the topic of the chapter, social policy practice, to the functional context of the United States. Specific political ideologies, current social policies and programs, and the organization and function of government in terms of policy creation were discussed with the idea that policy practice would be applied domestically. Yet it would be wrong to completely dismiss what political social work can do on an international level. Though it may seem like a grand undertaking, there are still a lot of things that we, as social workers in the United States, can do to work for social justice on the world stage. The caveat in international policy practice is that there is no governing body large enough to create policies that every country must follow. While there are things that can be done when some countries start imposing too much on the rights of other countries, other countries’ citizens, or even the citizens in their own country, there is no universally accepted procedure or rules of behavior that can then be enforced like they are within any one country. Although the United Nations is a unifying organization of 193 current sovereign state members, with an International Court of Justice (n.d.) that follows international law, it only has jurisdiction in disputes between states that are brought to it and in which these states submit to its jurisdiction. Sovereignties that are not part of the UN cannot necessarily be sanctioned and required to follow the ruling of the court. Still, some countries may take it upon themselves to fight perceived illegal activities in other countries through military force, like the United States did when they believed Iraq had weapons of mass destruction, but this usually only happens when there is a much greater perceived global threat. Consequently, many of the injustices that go on globally are never be addressed properly and are just allowed to happen by governing bodies around the world.

Box 5.4 – International Advocacy Groups

Awarded a Nobel Peace Prize, Amnesty International is probably one of the most well-known human rights advocacy groups in the world, fighting on an international level. Their Web site simply describes them as, “A global movement of people fighting injustice and promoting human rights.” See the human rights issues they address that also match up with social work practice on an international level on their Web site: http://bit.ly/1HGDQJK.

            Social workers in the United States can still intervene in the situations when governments are not. The values we have and the ethical responsibilities we follow can, and should, be used to provide social justice wherever we identify the need for it, and policy practice at this level can use similar strategies to those above to address deficiencies of protection. When providing for the rights of humanity globally, however, you just have to understand the governmental system with which you are intervening. It can be a hard undertaking for one practitioner to fight global injustice, which is why much of international political social work utilizes a group approach. Rallies for the support of marginalized or mistreated peoples, international groups advocating for the release of wrongfully imprisoned individuals and domestically contacting government officials and urging them to support or discontinue support for those governments that are causing international suffering are all activities of which U.S. social workers can be a part. While it is hard to do it individually, it only takes one person to lead a group of people to provide for the needs of many.

Kamala Harris shaking hands with a supporter during her campaign, with other supporters in the background.
All politicians campaigns are founded on the issues they want to address during their time in office, even Vice President Kamala Harris's.  For social workers, holding political office can be a very effective way of practicing political social work.  "Kamala Harris with supporters" by Gage Skidmore is licensed under CC BY-SA 2.0

Political Office as Social Policy Practice

Although most of the time we equate politicians with someone who has a law degree and has been involved with legal practice at some point, it might not be completely accurate. A quick look at the demographics of the 113th U.S. Congress can show that while in the Senate, the majority (57%) have at least one degree in law, a smaller percentage (38%) of Representatives have the same (Manning, 2014). This is not to say that following an educational path in legal studies is a poor choice to become a politician; rather, many different paths can lead to public service as an elected official. Getting a formal education in social work can be one of those paths. However, the fact of the matter is that political office is a career trajectory that is discussed very little, if at all, in social work education programs, despite the fact that our training is perfectly suited to serve the public (Lane, 2011). Even our professional experience supports the fact that we have a solid understanding of human behavior, the interaction between people and the systems of which they are a part, and how social policy affects them.

Currently across the United States, there are 189 local and state offices held by those who possess or are working toward their BSW or MSW degree (NASW, 2015). In addition, nine members of congress, seven representatives and two senators, also identified a past occupational field of social work (NASW, 2014). Comparatively speaking, this total of 198 people spread across local, state, and federal government is nothing in percentage of actual elected positions available. It is still important to realize politician as a legitimate way to practice social work, especially when it comes to social policy. Too often, lawmakers are creating policy and making decisions without fully understanding the impact of these programs on the citizens or the values of the profession providing them (Figueira-McDonough, 1993). However, becoming members of various governmental bodies gives the field more direct say over how to best address social welfare in our country. In the discussion on how we can best leverage our skills in political social work to impact social policy, public official offers us instrumental access to creating, implementing, and enforcing social policy at all levels of government.

Box 5.5 – Skills for Social Workers as Politicians

Because of the values and drive we have to better society for everyone, social workers have the necessary focus for effective politics. In addition to the drive, generalist social workers have plenty of skills and abilities that can help us be great tools for change. The following are just a few of the characteristics of social workers as politicians:

  • Good communicators: We can connect, motivate, inform, and persuade others in relation to our goals.
  • Person centered: The work we do is about helping others and not personal gain.
  • Ethical: We operating in a way that is consistent with our goals and values, does not ignore or abuse the rights of others, and never abuses the power of our position.
  • Socially informed: We stay abreast on the issues and struggles of the client systems we serve.
  • Experts on human behavior: We use our expertise on understanding human behavior in the social environment to inform the work that we do.

Policymaking Process

           Dennis and the Jones County coalition originally formulated as a result of a perceived need by Dennis and other stakeholders in the community, the idea that alcohol was too accessible to minors and there was a problem with underage drinking. Once the coalition was formed, they further researched the issue and formulated a plan to impact policy and affect change. When all their planned work is completed, they will eventually evaluate their efforts to see if they were effective enough in curbing underage drinking. Through this evaluation, they can then determine their next course of action. If Dennis was working with an individual client, we could see the same process played out. He would meet and engage with the client, discussing what brought the client in; assess the situation further and formulate a plan of strategies to accomplish the goals of the client; intervene by implementing the strategies that they had agreed upon; and evaluate how effective those interventions were and what else, if anything needs to be done. The four-step change process, as outlined by the CSWE (Council on Social Work Education) EPAS (Educational Policy and Accreditation Standards) and discussed in Chapter 4, easily applies to policy practice. Generalist social workers will have already gained the basic skills to affect change at any level, micro through macro, so the policy practice process should not be entirely new. Yet, trying to affect change in one person is quite different than trying to work for change in a large system with a number of different stakeholders. Through a further expansion of this model, we can get an even better understanding of how it applies to social policy work.

Engagement

With individual clients, the engagement phase happens as a result of the client coming into a practitioner’s office, either voluntarily or being mandated to come. A social worker can find out why help is being sought and get a better understanding of the background of the situation. In policy practice, there is no physical client with whom to meet, one cannot sit down in an office and engage the client system in a one-on-one conversation. The practitioner needs to seek out the system in order to interact with it, once there is a recognized gap in services. This takes on the form of interacting with others in the system who might also recognize that this need or have more information pertaining to it. Discussions and research gathering gives those practicing social policy reform the opportunity to know the system better and further understand why they are looking to make change. Thus, we should be looking to answer a few essential questions when we are collecting data:

  1. What is the actual problem?
  2. Who is affected by it?
  3. How has it been/is it being addressed?
  4. Why does it need to be addressed?

Answering these questions can allow us to become more acquainted with the issue overall. Initially, the extent of the problem might not even be known. People may also disagree about how to exactly frame the concern, or what the real problem is. In the engagement phase, our understanding of what the problem is can shift and refine as we gather more information (Brueggemann, 1996), sometimes resulting in a whole new definition of the issue. The engagement phase should be understood as an information gathering and problem clarification stage in policy practice. In our case example, Dennis heard through his adolescent group about the ease of getting alcohol and thought it would be a good idea to pursue it further. He gathered with other practitioners, as well as other stakeholders in the community, including parents, educators, and law enforcement to figure out what to do. They researched county statistics and had discussions with other entities on perceptions and understanding, all related to underage drinking. They realized:

  1. The problem was not as simple as just underage drinking and included issues relating to easy accessibility of alcohol to minors, acceptance of drinking among minors by teens and adults in the community, and marketing techniques and campaigns that make alcohol use appealing to youth.
  2. Teens and families are most directly affected by underage drinking. Immediately, teens can deal with legal trouble from being caught drinking (or drinking and driving) and can end up in the hospital, or even die, from too much drinking. In the long term, early alcohol use more easily lead to alcoholism and longer-term health concerns. Families can take on many of these effects as well, most notably grief over the loss of a child.
  3. While there are liquor laws that focus on underage use, these laws were not strictly enforced. Furthermore, there was nothing effectively being done in the schools to teach youth about the dangers of alcohol use specifically, which can add to the attitude of acceptance prevalent among teens.
  4. Dennis and the coalition knew, and validated through broader research, that there were a number of negative effects for teens and communities, including alcoholism, increased alcohol-related injuries and deaths, and low educational attainment, if underage drinking in the county was not addressed.

Box 5.6 – Data for Understanding the Problem

In understanding the prevalence of a social issue in the community, there are a number of different data sources available to us, depending on which level of community we are targeting. The following are some examples of possible sources to help us in the information gathering process:

  • Crime rates
  • School district report cards
  • Police arrest records
  • Existing laws
  • Bureau of Labor Statistics
  • Death records
  • Community climate surveys
  • Political voting records
  • Student drug use surveys
  • State unemployment rate
  • Poverty levels
  • Bureau of Justice Statistics
  • U.S. Census Bureau

What are other sources of useful data that already exist?

Assessment

Once all the pertinent information about the problem has been gathered, it is time to figure out what should be done about it and how. Essentially, this stage of the process has two parts to it, setting goals of what should be accomplished and planning the strategies of intervention to meet those goals. Rocha (2007) distinguishes between these two parts in her policy planning process as well, outlining the need to define the overarching goal of policy intervention, including measurable objectives, and then plan intervention strategies that target the outcomes. After clearly defining the problem in the engagement phase, it makes it easier to determine not only the bigger picture goal of policy practice, in the Jones County case, it is lowering the amount of underage drinking, but also the smaller goals (or objectives), including decreased acceptance, increased law enforcement, and increased education. Once those are in place, effective strategies can be planned that will accomplish the goals. In order to do so, we need to incorporate the policy analysis that we did during engagement in order to more effectively plan policy strategies during this stage. By evaluating where other policies fall short and keeping in mind the political environment of the area in which we are targeting change, we can design policy interventions that will complement, supplement, or even replace what is currently being done and will be more readily accepted by those in power.

Dennis’s coalition realized nothing was being done about education in the school systems and aimed at increasing education about the consequences of alcohol use. They researched various methods that would be useful and learned that one-time motivational presentations, although containing a great message and entertaining, did not make a difference in youth attitude over the long run. Instead, they learned that there were evidence-based curricula that could be implemented in a classroom setting during sixth, seventh, and eighth grades, as well as at the high-school levels, to address alcohol and other drug use. These types of programs are not cheap, however, and the coalition would have to find additional funding. Both of these aspects drove the strategy of approaching the county board to put a referendum on the ballot. The coalition also created strategies aimed at stricter law enforcement and lowering acceptance, including working with the police and court system to target and penalize stores known for selling to minors and media campaigns in the county that inform citizens of the dangers of underage drinking.

Large group of people at a rally for policy change to stop climate change.
Coalitions can plan many different approaches to change policy.  This picture shows a number of people and groups, including coalitions, rallying for climate change policy.  "We want policy change not climate change" by Joe in DC is licensed under CC BY-NC-ND 2.0

Intervention

Once goals are set and strategies devised, it is time to move forward and implement the action plans. Dennis and the Jones County Coalition Against Underage Drinking demonstrated how this can be done with communities and the three branches of government. Keep in mind that each arena of policy practice involves a different focus and different strategies. It also requires an understanding of the legislative process and how we can affect change during each step of policy realization. As a result, the intervention phase takes a lot of time and effort, similar to when intervening with an individual client, and will get frustrating when things take too long or we are not able to impress upon others the importance of our concern. When things do not go the way they are planned, social workers will revisit the assessment stage to formulate new strategies, keeping in mind what roadblocks came up the last time. In addition to dedication and hard work, another big piece of the intervention process is building connections with those who have the power to implement, execute, and enforce policy. Knowing who they are, what their political viewpoints are, and what they have done in the past gives insight into how they function and what we need to do to be heard. Social workers can use their skills in building relationship and communication to enhance their ability to effectively practice at the macro level with policy reform.

Evaluation

Evaluation in policy practice is a very important part of the process because it provides an opportunity to realistically look at the effectiveness of the policy efforts. While the phase is distinct, evaluation does not just happen following the intervention phase. It should be happening at different times throughout the change process. Formal evaluation can be done when a group cannot identify intervention strategies, all efforts to change policy are exhausted, a perceived problem turns out to be the effect of a completely different problem, or even when bureaucratic agencies are not implementing the policy correctly. The social worker, task force, or agency can revisit the issue and see what was not effective, why it did not work, and what can be done differently about it. Evaluation can then direct the work back to the assessment phase to formulate a different plan of action. Informal can be something that is carried out throughout the policy planning process, as individuals use critical thinking to direct the work they are doing. As any point during the process, we should be able to take a step back and understand the logic and rationale behind what we are doing. If we are unsure or feel lost at any point, it is indeed time to sit down the revisit our goals, objectives, and strategies to see how well they are connected not only to each other but also to the initially defined problem.

The Jones County coalition Dennis headed up was forced to reevaluate their strategy to direct what alcohol and other drug education curriculum the schools used. If we recall, the county board rejected their idea that all schools in the county should use the same curriculum and the group had to change their efforts. They met and figured out what might be an effective approach to make sure the schools still meet the needs of the students when it came to drug education. Dennis and the others will also need to evaluate the outcome of the strategies and policies they were able to implement in Jones County. While results might not be immediate, the groups should, at some point in the future, gather data to see if their strategies are really making a difference. If they are not effecting change, then the coalition will have to revisit the assessment stage and create new tactics with which to address their defined problem. If they are making a difference and underage drinking is dropping, they can further decide what, if anything, they want or have to do in order to continue the trend.

Policy Analysis

As with the evaluation stage, there are various points in the policy planning process that requires practitioners to analyze policy. Whether it is evaluating policy that is already in place, formulating policy efforts that will be implemented to deal with a deficiency in the system, or appraising the effectiveness of a policy strategy we recently implemented, policy analysis is a key component to the planning process. Many policy analysis models include defining the problem and implementing policy as parts of their analysis process (Saint-Germain, 2001). These steps, however, fit more with the policy planning process described above rather than the action of just evaluating the effectiveness of a policy, which is what the focus should be. Kirst-Ashman (2009) defines policy analysis as, “a systemic evaluation of how effectively a policy address the targeted problem or issue, meets people’s needs, and achieves its goals.” (p. 226). In this articulation of the concept, there is no mention of defining the problem, as the problem should have been defined prior to the formulation of the policy, nor is there mention of implementation of the policy, as that is a separate action altogether. With policy analysis, we want to be able to take a step back and rationally evaluate the policy as it was intended, without emotion or bias. The policy analysis framework put forth by Miley et al. (1998) brings together popular components from other models, simplifies the process into three basic components—the specifications of the policy, the feasibility of the policy, and the merits of the policy—and allows policy practitioners to focus just on the evaluation of the policy.

Policy Specifications

Knowing the specifics of the policy will allow social workers to better evaluate the other two aspects of the policy. We cannot determine the practicality and the viability of a policy without understanding what it is trying to do and how it is trying to do it. While it is not incumbent upon the analyst to define the target problem, it is necessary to know what the policy states it is trying to accomplish and why, specifically what values are driving it. Outlining the logistics of the policy, such as funding, implementation, target population, and requirements, is also essential to evaluation. Again this applies to policy already in place as well as any policy being planned to be implemented. Arguably, this should also be done by those implementing and executing policy as well, in order to make sure it is being done right.

Policy Feasibility

Once we understand the policy, we can look at how practical it is, in other words, how much sense it makes in a cost–benefit approach. Is it, or will it be, supported by the recipients, those in with political power, and by the general public? A policy not valued by key constituents will not be seen as important, will not be regulated or run properly, and will falter. The policy must also make use of resources responsibly, including funding and demands on the system. For example, if we want to eliminate homelessness, one logical thought would be to give everyone a house. With everyone owning a house, no one would be without a home, in the most literal sense of the phrase. However, in understanding the monetary ramifications, it is unlikely there would be enough money in the government’s budget to fund such an undertaking. Another real-world example could be the demands made on child abuse and neglect agencies. Certain states or areas may not be able to investigate all the reports of child abuse and neglect, instead focusing on the ones in which young children are being physically harmed. While the policy is ideal in protecting all children, it is unreasonable to expect an overworked, understaffed agency to be able to enforce the policy properly.

Policy Merits

Say we wanted to address the gap in educational attainment between white middle-class adolescents and poor inner-city African American youth. If one of our smaller objectives was to increase graduation rate of African American students, it could easily be accomplished by simply lowering test standards for this population of students. In terms of resources, it would not require additional funding or manpower to accomplish. Even if students, parents, and administrators felt this was an equitable approach, the policy would not be properly addressing the overall goal or the underlying barriers to educational opportunity this specific population may be facing. Sure numbers of graduates would increase, but knowledge would not, and we would be doing more harm than good. This is why evaluating the policy on the basis of its effectiveness is necessary. The policy should be able to work the same for all target systems, produce the same results, and truly address the problem it defined. One last piece mentioned by others, including Kirst-Ashman (2009), is the need to compare current or planned policy with alternatives, including policy that is already in place dealing with the same problem. This is another way to judge the merit of the policy by comparing it to the merits, feasibility, and intent of other policies. After evaluating alternative policies to see how effectively and efficiently they are handling/would handle the defined problem, we can make a more informed choice. Having alternatives will provide an array of options, instead of settling for one that may or may not get the job done well. Once we have been able to choose, through thoughtful analysis, our best option we can move forward with the policy practice process.

Photo of a box with several cups to collect change, with signs that say, "Will work for food," "Hungry Cold Homeless," and "An everyday campaign for change."
Although social work policy practice can take a lot of time and energy, it can also allow us to make a big impact on the largest number of people.  "Will Work for Food" by Technosailor is licensed under CC BY-NC-SA 2.0

Conclusion

            It may not be the task most associated with social work, but policy practice is an important part of providing for our clients. Understanding policy, the political climate, as well as opportunities and activities for practice can help us better understand just how we can make a difference in social welfare policy. The key is understanding how social justice can be achieved by what we do when trying to influence policy makers, implementers, and enforcers. It is not a stretch for generalist social workers to utilize their skills, training, and knowledge of client systems to reform policy, despite the fact that many practitioners feel less confident in their ability to do so. Workers must continue to seek out opportunities and experience with impacting social welfare policy at all levels in order to build their self-efficacy and continue this essential macro-level work function. Social work’s history is deeply connected to social welfare policy, so it should be that we continue to work to enhance our society for everyone.

Chapter 5 References

Brueggemann, W. B. (1996). The practice of macro social work. Nelson-Hall.

Council on Social Work Education (2014). 2013 Annual statistics on social work education in the United States. Retrieved from http://www.cswe.org/File.aspx?id=74478.

Cummins, L. K., Byers, K. V., & Pedrick, L. V. (2011). Defining policy practice in social work. In Policy practice for social workers: New strategies for a new era. Retrieved from http://www.pearsonhighered.com/assets/hip/us/hip_us_pearsonhighered/samplechapter/0205473768.pdf.

Dear, R. B. (1995). Social welfare policy. In R. L. Edwards (Ed.-in-Chief), Encyclopedia of Social Work (19th ed. Vol. 3, pp. 2226-2237). NASW Press.  Retrieved from http://www2.uncp.edu/home/marson/348_social_welfare_policy.html.

Democratic National Committee (2012). Moving America forward: 2012 Democratic national platform. Retrieved from http://assets.dstatic.org/dnc-platform/2012-National-Platform.pdf.

DiNitto, D. M. (2000). Social welfare: Politics and public policy (5th ed.). Allyn & Bacon.

Donaldson, L. P., Hill, K., Ferguson, S., Fogel, S., & Erickson, C. (2014). Contemporary social work licensure: Implications for macro social work practice and education. Social Work, 59(1), 52-61.

DuBois, B, & Miley, K. K., (2011). Social work: An empowering profession (7th ed.). Allyn & Bacon.

Figueira-McDonough, J. (1993). Policy practice: The neglected side of social work intervention. Social Work, 38(2), 179-188.

Hackman, H. (2005). Five essential components for social justice education. Equity & Excellence in Education, 38, 103–109.

International Court of Justice (n.d.). How the Court Works. In The court. Retrieved from http://www.icj-cij.org/court/index.php?p1=1&p2=6.

Katz, D. H. (2000). PowerPoint presentation. Social welfare policy analysis: Module II. Retrieved from https://www.msu.edu/course/sw/820/.

Kilbane, T., Pryce, J., & Hong, P. P. (2013). Advocacy week: A model to prepare clinical social workers for lobby day. Journal of Social Work Education, 49(1), 173-179. doi:10.1080/10437797.2013.755420

Kirst-Ashman, K. K. (2009). Introduction to social work & social welfare: Critical thinking perspectives (3rd ed.). Brooks/Cole, Cengage Learning.

Lane, S. R. (2011). Political content in social work education as reported by elected social workers. Journal of Social Work Education, 47(1), 53-72. doi:10.5175/JSWE.2011.200900050

Malka, A., & Lelkes, Y. (2010). More than ideology: Conservative–liberal identity and receptivity to political cues. Social Justice Research, 23(2/3), 156-188. doi:10.1007/s11211-010-0114-3

Manning, J.E. (2014). Membership of the 113th Congress: A profile. Retrieved from http://www.senate.gov/CRSReports/crs-publish.cfm?pid=%260BL%2BR%5CC%3F%0A.

Maslow, A. (1970). Motivation and personality. Harper and Rowe.

Milford, J. L., Austin, J. L., & Smith, J. E. (2007). Community reinforcement and the dissemination of evidence-based practice: Implications for public policy. International Journal of Behavioral Consultation & Therapy, 3(1), 77-87.

National Association of Social Workers (2008). Code of ethics. In About. Retrieved from http://www.socialworkers.org/pubs/code/code.asp.

National Association of Social Workers (2014). Social workers in Congress (113th Congress ed.). Retrieved from http://www.socialworkers.org/pace/swcongress2013.pdf.

National Association of Social Workers (2015). Social workers in state and local office. In Advocacy. Retrieved from http://www.socialworkers.org/pace/state.asp.

Pozzuto, R., & Arnd-Caddigan, M. (2008). Social work in the US: Sociohistorical context and contemporary issues. Australian Social Work, 61(1), 57-71. doi:10.1080/03124070701818732

Pritzker, S., & Lane, S. R. (2014). Field note—integrating policy and political content in BSW and MSW field placements. Journal Of Social Work Education, 50(4), 730-739. doi:10.1080/10437797.2014.947905

Republican National Committee (2014). Family values. In Issues. Retrieved from https://gop.com/issue/family-values/.

Rocha, C. J. (2007).  Essentials of Social Work Policy Practice. John Wiley & Sons, Inc.

Roosevelt, T. (1897). How not to help our poorer brothers. Review of Reviews. 15, 36. Excerpted in Lerner, K. L., & Lerner, B. W., eds., (2006). Social policy: Essential primary sources. Thomson Gale. 

Saint-Germain, M. A. (2001). Session two: Six-step policy analysis. In PPA 670 Public policy analysis. Retrieved from http://web.csulb.edu/~msaintg/ppa670/670steps.htm#670 Policy Analysis Process

Segal, E. A., & Brzuzy, S. (1998). Social welfare policy, programs, and practice. F. E. Peacock Publishers

Sherraden, M. S., Slosar, B., & Sherraden, M. (2002). Innovation in social policy: Collaborative policy advocacy. Social Work, 47(3), 209-221.

U.S. Department of Health and Human Services (2009). Aid to Families with Dependent Children (AFDC) and Temporary Assistance for Needy Families (TANF) overview. Retrieved from http://aspe.hhs.gov/hsp/abbrev/afdc-tanf.htm.

United States Constitution (1787).  Retrieved from http://www.archives.gov/exhibits/charters/constitution_transcript.html.

Weiss-Gal, I. (2013). Policy practice in practice: The inputs of social workers in legislative committees. Social Work, 58(4), 304-313.

 

 

Chapter 6: Race, Ethnicity, and Oppression

Majority culture has dictated how society lives since the beginning of the United States.  Unfortunately, our society is not as inclusive as we would like to believe and many people seen as “different” have been and continue to be oppressed because perceived – not actual – superiority has been translated into social and systematic discrimination and relegation of groups.  Social workers need to understand these groups and what they face in order to more effectively fight for social justice.  This chapter will teach you to:

  1. Understand why society has and continues to discriminate based on cultural differences;
  2. Identify the ways in which racial and ethnic discrimination continues in society today;
  3. Define key concepts in minority oppression;
  4. Describe historicity and strengths of various minority groups in the United States;
  5. Explain the struggles faced by these groups in society;
  6. Identify practice perspectives and methods for social workers in working with and addressing the needs of minority groups.
Group of kids of varying backgrounds standing in a field, looking at the camera.
"CB106492" by hepingting is licensed under CC BY-SA 2.0

 

Social Work, Race, and Ethnicity

             The United States has often been called a great “Melting Pot” because of the various immigrant populations that have come to the country, bringing their cultures and traditions combining and mixing into one.  While this idea may be seen as a positive attribute of the country, a place where all the wonderful aspects of the peoples can be incorporated into one unified group of Americans, Melting Pot is actually a misnomer that can cause greater divide among the diverse residents here.  Smith (2012) discussed how despite the discourse of many scholars on the falsehood of such a term and the importance of ethnic identity for U.S. citizens, many public officials, including Presidents, have clung to the term, holding it up as a standard to strive for: the assimilation of all new immigrants to the American way of life.  Unfortunately, it is exactly that standard that has caused those holding onto their ethnic roots and ways of living to be marginalized.  When it comes down to it, the American Way can be seen as a term encompassing the beliefs and way of life of those in power, mainly White wealthy men, so even those who are born here in the United States that are deemed different because of their background, language, or socioeconomic status are outcast and discriminated against.

Our country has a long history of trying to make people fit the mold those in power think is ideal.  Thomas Jefferson himself believed the Native Americans should either assimilate or be forced to move halfway across the country (Bragaw, 2006).  As a result, racially and ethnically different groups have been oppressed for many years and, although we would like to believe our society has come a long way from the blatant racism and discrimination of slavery and Jim Crow laws, continue to face a number of social injustices still today.  “How does social work fit into all of this?” you may ask.  Well by now it should be clear that social work is dedicated to social justice and working with those groups and individuals who are experiencing hardships in their life for any reason, including those stemming from racial and ethnic discrimination.  However, social workers need to have a general understanding of how these groups and individuals may experience life in the United States, as well as how our country continues to place them on the outskirts of society.  We need to have an understanding of the different systems that may be attributing to their experience and how we can work with and for them to bring about positive change to improve our life together.

 

Race & Ethnicity

             If you were to ask anyone in your class what race they were (although we do not suggest you do so), they would, most likely, be able to give you an immediate response.  If you did not ask them, you might come to a conclusion on your own by looking at the individual’s skin and other physical characteristics.  Even when someone is considered multiracial, many of us believe the signs are obvious as to which categorical race that person belongs.  The Merriam-Webster Dictionary (n.d.) gives one definition of race as, “a category of humankind that shares certain distinctive physical traits.”  The problem is races do not actually exist in the biological sense society has come to believe as fact.  While there is still debate about the usefulness of creating a racial taxonomy, specifically in understanding geographic origins of people, it has become a widely belief that race is nothing more than a social construction.  The American Anthropological Association (1998) stated, “With the vast expansion of scientific knowledge in this century, however, it has become clear that human populations are not unambiguous, clearly demarcated, biologically distinct groups.”  In fact in 1987, Rebecca Cann, Mark Stoneking, and Allan Wilson traced all modern humans, through analysis of genetic material, to the same maternal ancestor in Africa, now commonly referred to as Mitochondrial Eve (Gitschier, 2010).  Yet, despite sharing a basic genetic makeup and historic heritage, we continue to believe in, perpetuate, and discriminate based on this biologically null conceptualization of race.

Person with their hands on their head, leaning against a wall.
We often use what we believe to be typical physical characteristics of a race of people to determine an individual's racial or ethnic background.  Looking at this picture, what would you say is this person's background?  How can you tell?  Discuss your thoughts with your classmates and see what they say.

            It is in this belief of race that race actually exists and does so with negative consequences to those who are considered racially different.  Without a biological foundation for it, race is still a very real experience for many people in the United States (Coleman, 2011) and it is important for social workers to not only acknowledge the existence of race, even if only as a means of discrimination, but also understand how it impacts the clients with whom we work.  For the purpose of this text, we will define race as a socially-constructed and perceived biological differentiation of individuals based on observable and/or socially acknowledged unobservable characteristics, and as a concept used by groups with higher social status to oppress and relegate certain groups to lower social status.  Breaking this definition down, we understand that race is not a real biological differentiation and can be based on differences in not only physical characteristics, such as skin color, eye shape, nose shape, height, and hair texture, but also often erroneously held beliefs about innate characteristics, such as athletic ability, intelligence, and personality.  For instance, people have believed that all Black people have wide noses and are more athletic than other races, Asian people have slanted eyes and are good at math, Native Americans have big teeth and are prone to aggression, and that White people are pale-skinned and ignorant.  While not one of these things can be contributed to the entire group or can even be linked to only that group, these characteristics are believed to be connected to these groups as genetic indicators of race.  This definition of race also acknowledges the use of differentiating between people as a mechanism of discrimination by those with the power against those without power.  In the case of the United States, those with the power tend to be White Christian heterosexual males, mostly of European descent.

            It is important to point out the difference between our concept of race and that of ethnicity, if not only to understand how these two terms are used in greater society.  While race is attached to physical characteristics, ethnicity aligns with cultural characteristics.  Ethnicity can be conceptualized as one’s heritage and socio-cultural connection to an original population of people from a certain geographical location.  When constructed this way, ethnicity can be used to describe a direct connection to a group of people originally from a certain location, even if you were not born in that area.  This is the case for many people in the United States who are proud of their ethnic identities but were born and raised here.  Others cannot deny someone of a claim to genealogical heritage just because they were not born in a specific location.  Waters (1990) even argued that those who have a multiethnic background have a great deal of choice over which ethnicity or ethnicities become a part of their identity and to what extent, although much more so for White people than for non-Whites; a choice that can vary with situation or time.  Unfortunately, ethnicity, like race, is also used as a socially conceived means to marginalize people.  Recent history can demonstrate how ethnicity has been used by the “in” group to deny the “out”-group resources, citizenship, basic needs, and even life (Coleman, 2011).  This can be seen today, played out in how our society treats certain ethnic groups, such as Arabs and those from Latin America, as second-class citizens who are encroaching on invading our country and of whom we need to be watchful, even though that may be considered "White."

 

Box 6.1 – Ethnic Identity

Both of your authors both attended the same graduate school program in pursuit of their Master of Social Work degrees, only a year apart. One of the courses required them each to write a paper about their ethnic identity, describing who they were and how their cultural identity presented itself in their lives. Both of your authors knew their European heritage because their parents had told them about it since they were old enough to understand. Their dad’s family was 100% Polish while their mom had a German father and an Irish mother. (And their grandfather on their father’s side would tell them there was a tiny bit of Cherokee blood running through their veins.) But one of them felt that his heritage did not show up all that much in his everyday life, other than in the insensitive jokes that he would hear about Polish people being stupid. As a result, he decided to talk about how he was a typical American. He ate typical American food like pizza, hamburgers, hot dogs, and peanut butter and jelly. He celebrated American holidays like Fourth of July, Memorial Day, Christmas, and St. Patrick’s Day. He loved being competitive and listening to rock ‘n’ roll. He was American. After he handed his paper in, he talked to his brother about the assignment and his brother could not disagree with his approach more. The brother wrote about the pride he had in his heritage and knew exactly how it was shown in his life. They found it odd how two people from the same parents and living in the same house could have such different perspectives about their ethnic heritage. But that’s how self-identification works when it comes to ethnicity. Your culture can be what you identify it as.

There is a lot of crossover between the two concepts of race and ethnicity, with groups of people from what is considered the same race, sharing ethnic identity.  However, these two ways of categorizing individuals are not mutually inclusive.  Individuals who are Japanese and individuals who are Indian are both considered Asian populations, but there can be considerable difference between them culturally.  The U.S. Census Bureau (2013a) recognizes Hispanic as an ethnic group that can include people of Black, White, or Native American races.  Even among the early nineteenth century European White settlers, all from the same supposed race, there was a clear division between the various ethnic groups that immigrated to the U.S (Smith, 2012).  These constructs do a poor job of outlining all aspects of the groups that have been identified.  Schwarzbaum and Thomas (2008) discuss how broad ethnic categories encompass numerous subgroups that could be considered separate ethnicities.  In addition, race as a biological category has been widely rejected by academic fields everywhere.  So, what does this mean for identity?  Both race and ethnicity are ways to identify individuals and for individuals to self-identify.  Sure, race was originally used to discriminate against Africans and justify their enslavement, and ethnicity has allowed the connection of people with culture and creates ethnic boundaries in cities and states.  Yet, the perpetuation of these, at times forced, labels has shaped how we identify others and how we identify ourselves.

When working with clients, social workers need to understand how clients identify themselves and how these identities influence the client and the situation that has led them to seek or need help.  Race and ethnicity, though not concrete truths, do impact how we experience life in the United States, whether it is as a member of the majority group or a minority group.  They can dictate how others treat us, how we treat others, and how we treat ourselves, even if it is not overt or a conscious decision.  It is through these experiences that can best direct how practitioners work with and for client systems in addressing needs, helping obtain resources, and combating social injustices.

 

Defining Minority

Minority group status should be considered in a context of power and control rather than that of population size.  It is estimated that “White not Hispanic or Latino” individuals comprised about 60% of the inhabitants of the United States in 2019, a clear majority in sheer numbers (U.S. Census Bureau, 2019b).  However, minority group status is synonymous with being marginalized in a society and is not dependent on relative group size.  Thinking about the power imbalance in South Africa, for instance, Black people outnumbered White people for a clear majority of the population, yet the White people held the political and social influence in South African society before apartheid ended.  Louis Wirth gives a thorough definition of minority group as:

A group of people who, because of their physical or cultural characteristics, are singled out from the others in the society in which they live for differential and unequal treatment, and who therefore regard themselves as objects of collective discrimination...Minority carries with it the exclusion from full participation in the life of a society. (as quoted in Shepard, 2010, p. 240)

Wirth’s explanation of minority can demonstrate how, when race and ethnicity are used to discriminate, people can be assigned minority status, proscribed from having any power or influence in society, and are often neglected in terms of resources and social amenities.  Currently, federal data collected on race and ethnicity is regulated by 1997 standards from the U.S. Office of Management and Budget that outline five racial and two ethnic groups in the U.S.: White, Black or African American, American Indian or Alaskan Native, Asian, Native Hawaiian or other Pacific Islander, Hispanic/Latino and non-Hispanic/Latino, respectively (U.S. Census Bureau, 2020).  However, even the U.S. Census Bureau itself is aware of how limiting and prescriptive these categories, sharing that, when given the opportunity to self-identify, many Hispanic/Latino, Middle Eastern and North African individuals often select “Some other race” as opposed to “White” (U.S. Census Bureau, 2021).  As we will see later on in the chapter, there are more than five racial and ethnic minority groups in the United States social workers need to be knowledgeable about.

Museum exhibit of a bathroom sign from a courthouse in the south that says, "For colored."
Racism in the past was much more overt, socially acceptable, and legalized, such as having to use the bathroom labeled "for colored," as demonstrated by this Collin County Courthouse sign from before 1964.  Today's racial discrimination, while not legalized can be both overt and covert, even unconscious. "'For Colored' bathroom sign, old Collin County Courthouse" byTrevor.Huxham is licensed under CC BY-NC-ND 2.0.

 

Prejudice and Discrimination

In the introduction to the book Race and Ethnicity, Thernstrom and Thernstrom (2002) discuss how much the United States has changed since the Civil Rights Movement, with the weak prevalence of White racism that continues to shrink.  However, that is not to deny the fact that groups of people are still treated poorly and unjustly based on nothing more than a fictional preconceived notion related to who they are and how they are because of their skin color or ethnic background.  Still many people believe that society will always, at some level, use race and ethnicity to oppress and marginalize groups in some way shape or form.  While racism may not have been a cause of slavery as much as it was a product (Collins, 2001), it has helped perpetuate colonial ideas of White superiority versus racial and ethnic inferiority and has helped create other forms of persecution.  Social workers have the training, the values, and the responsibility to continue to work to end prejudice and discrimination in all forms, including that based on race and ethnicity.

Although closely related, prejudice and discrimination are distinct concepts of interaction between minority groups and dominant groups in a society and differ in how they come to be and how they manifest.  Prejudice is best thought of as the cognitive dimension of the group relationship while discrimination is the behavioral dimension, both of which can be applied to individuals or to groups, communities, and society (Healey, 2001).  Healey found that these dimensions are not necessarily dependent of each other – societal perspective could include beliefs that unemployment rates of African Americans are lower because they have a poor work ethic while still creating policies designed to stop discriminatory hiring practices, or an individual can make fun of an Asian person’s eyes just to fit in, despite having positive feelings about Asian people.  Furthermore, being a part of a biased society does not guarantee an individual will be biased, just as prejudiced beliefs and discriminatory behavior can be established independently of societal influence.  No matter what though, biased thoughts and feelings as well as unfair behavior only work to create a greater divide between groups and can continue to subjugate those with little or no power.  Following this thread, prejudiced ideology and discriminatory behavior need to be addressed at all social work practice levels in order to combat the imbalanced power structure between the dominant group and minority groups.

Discrimination in the U.S. Today

Looking back at Jim Crow laws, it was easy to identify the racist beliefs and behaviors underpinning the White majority’s interaction with the Black minority.  Signs directing you to which water fountain to use, where to sit in a restaurant, or what club you could go to made it clear if you were or were not accepted.  Overt racism and overt racists were not only tolerated, but accepted, with White individuals often being allowed to break the law if their actions were a result of an interaction with a Black individual.  Civil rights laws and greater diversity in the population, including a higher intermarriage rate between different racial and ethnic groups (Thernstrom & Thernstrom, 2002), brought a shift in attitudes in the United States (Forrest-Bank & Jenson, 2015).  Donald Trump’s election to the Presidency, on the other hand, saw an increase in discriminatory governmental policies and actions.  In their article on the role of social workers in helping individuals and communities targeted by hate crimes, Kaplan and Inguanzo (2020) explore the ways in which Trump’s “rhetoric of hate propaganda” has led to a significant increase violence and terrorism against marginalized populations.

Unfortunately, racist ideology and behavior still exist, even aside from that explicitly exhibited by White supremacy and nationalist individuals and groups.  Through depictions, or lack thereof, of minority groups in the media and educational texts, as well as what we learn from friends and family, we build this unconscious schema of prejudice that misinforms our feelings and, at times, directs our behavior.  Even if we don’t align ourselves with discriminatory ideology, we may have beliefs about people of minority groups not because we directly attribute it to their race, but because our maturation process has reinforced these unconscious beliefs.  The same thing can be said about our country.  Despite Donald Trump’s presidency, there are those that argue the government provides for fair treatment and equal opportunities for everyone, essentially closing the door on the racial and ethnic divide in the U.S.  This is simply not true.  Social workers cannot be blind to the prejudice and discrimination others refuse to acknowledge.

Box 6.2 – What Does Society Teach Us?

Photo of a Speedy Gonzalez Toy.
"Speedy Gonzalez" by Thomas Hawk is licensed under CC BY-NC 2.0

We learn a lot about people from different cultures without being aware of it, based on what we see in our everyday lives. The media often represents minorities in stereotypical ways and it starts from when we are young. Speedy Gonzales is an older cartoon character, but one that was on often in the 1980s. Most kids who watched Speedy Gonzales cartoons thought that they were just being entertained but didn’t realize that they were being imprinted with stereotypes about Mexicans. And it wasn’t just based on Speedy himself, all the supporting characters exemplified stereotypical characteristics of Mexicans, like they all wear big sombreros, don’t wear shoes, and have thick accents. What else do Speedy Gonzales cartoons (or shows or movies you might have seen when you were younger) teach you about minorities?

Think about the following aspects:

  • Work ethic
  • Language and speech
  • Clothing style
  • Importance of family
  • Religious beliefs
  • Behavior
  • Education
  • Economic status

 

Microaggressions

Back in the 1970s, Chester Pierce first used “racial microaggression” when discussing the small acts of discrimination that racial and ethnic minorities experience on a daily basis (Forrest-Bank & Jenson, 2015).  Sue et al. (2007) expanded on this by defining racial microaggressions as, “brief and commonplace daily verbal, behavioral, and environmental indignities, whether intentional or unintentional, that communicate hostile, derogatory, or negative racial slights and insults to the target person or group” (p. 273).  Although this definition is specific toward those acts that focus on race, it can still be applied to microaggressions that deal with race or ethnicity.  It should be pointed out that Sue’s definition specifically mentions environmental factors as well, not just interpersonal interactions.  In order to better explain microaggressions, we can utilize the three forms outlined by Sue et al. (2007): microassaults, microinsults, and microinvalidations.

 

Microassaults

These are overt, purposeful discriminatory verbal or nonverbal actions meant to negatively impact or convey prejudice toward the target person or group.  These actions are done in private or public when the person doing them feels safe or comfortable enough.  This can include things like pulling the corners of one’s eyes to appear “Asian”, telling an African American person they look like a monkey, or sharing racist jokes.  This type of microaggression is basically an attack targeting race and ethnicity.

 

Microinsults

This form of microaggression is subtler in nature and the person performing microinsults often does not realize what they are saying or doing.  The actions, whether verbal or behavioral, are insensitive and demeaning to a person or group, indicating minority groups are not as intelligent, capable, deserving, or important as the majority.  These can include things like telling an individual with a graduate degree, who is Latina, that she is a credit to her people, correcting the pronunciation of an Asian woman with an accent, or using caricatured logos or derogatory names of Native Americans to represent sports teams.  Microinsults are not necessarily meant to be hurtful, which is why they often go unrecognized as such by the perpetrator, but are real representations of unconscious prejudice.

Desktop background of the Cleveland Indians' "Chief Wahoo" logo.
The Cleveland Indians' logo of the big-toothed caricature head of a Native American is a racist and demeaning depiction of American's Indigenous Peoples.  It is a microinsult because it makes fun of Native Americans, though it was originally supposed to honor a former Cleveland player.  Cleveland announced in December 2020 that they would change their name after the 2021 season. "Cleveland Indians Desktop Wallpaper" by Hawk Eyes is licensed under CC BY-NC 2.0.

 

Microinvalidation

Microinvalidations are those things said and done that indicate a person of minority’s experience as a minority is not legitimate or that they are not recognized as an American citizen.  This can include asking a Latino colleague where he was born, telling an Arab American friend you have known since childhood that you do not believe her when she says she has never heard what you believe is a typical American phrase, or even telling a couple of African American friends that what they experienced as a microaggression was nothing really and harmless.  This form of microaggressions seems to come more from a place of ignorance of what persons of minority go through and believing that all people in American society experience life the same way.

The three types of microaggressions should not necessarily be thought of as rigid categories of behaviors or communications, as some microaggressions can invalidate as well as be insulting to the experience of those of a particular race or ethnicity, some are an overt demonstration of prejudice even though it was not meant to be hurtful.  It is less important to be able to categorize microaggressions than it is to acknowledge that they are a real occurrence, the different messages these actions send to those belonging to a minority group as well as those who are a part of the majority, and how these microaggression affect those they are directed toward.  Sue and colleagues (2007) further created a taxonomy of various microaggressions and the messages they convey, which can be found in Box 6.3.

Box 6.3 – Microaggressions

Sue’s list Taxonomy of Microaggressions can be found here. Go to Table 1 in the article and read through the list.  Think about the times you might have witnessed these things or something similar being said. You might have even said or thought them yourself. It is important that we recognize microaggressions exist and work to combat them.

 

Institutional Oppression

This does not mean, however, that racism and ethnic discrimination is no longer present in American society.  Even without a strong presence of people who admit to having negative feelings, attitudes or behaviors towards others based on race and ethnicity, racism still has a firm presence in structure and culture of our society; something Eduardo Bonilla-Silva (2014) termed “racism without racists”.  The idea is that, due to the historical oppression of minority groups, majority groups’ interests are attended to while further relegating the needs and interests of minority groups (Harris & Lieberman, 2015).  So while the country no longer condones racism, our society is continuing to oppress those who have generally had less power as a people through the policies and laws we implement, the issues we focus on (or ignore), and the way in which we view each other.  Herein lies the defining characteristic of institutional oppression, that many institutions, structures, and schemas impacting our daily lives are, even if inadvertently, creating a disparaging gap between the resources and opportunities available to the majority and those in the minority.

Institutional oppression is not always apparent, and many still believe that any inequities between the White majority and racial and ethnic minority groups in terms of employment, educational attainment, financial resources, housing, and safety is best explained by a personal fault, like the fact that a greater number of Black people are unemployed because they have a poor work ethic.  However, this is grossly misrepresenting both cultures of minority groups and the role American institutions play in the scenario.  What is forgotten or left out of the reasoning is that schools in predominantly Black neighborhoods tend to have fewer resources available to the students, including money for instructional materials and qualified teachers.  Whether students work hard or do not try at all, their educational quality is going to be far below that of students from middle-class White neighborhoods.  Educational opportunities beyond high school are going to be much more limited for students who are academically unprepared to continue on to college and many of these Black students are pushed even further behind their White counterparts.  When it comes time to enter the workforce, the job possibilities are going to be higher quality and quantity for those who are from that middle class area.  Yet, there is a pervasive belief in society that everyone has the same opportunity and all it takes is hard work to move oneself into the next highest socioeconomic status, not acknowledging how many more barriers minorities have to deal with than the majority group.

All this is not to say that the country, both people and government, want things to continue this way, that we want to keep minorities in a place of lesser value.  In fact, when issues of racial or ethnic inequality do appear, both minority and majority group members are standing together against the injustices they identify, more so today than they did during the civil rights movement.  Therefore, it is hard to imagine that policies, structures, and institutions would function in such a way as to disadvantage certain groups of people more so than others.  However, a belief that treating everyone equally is the same as treating everyone fairly denies the historical marginalization of minority groups that has created a situation in which the majority has access to more resources, and thus an unfair advantage.  This continues the dysfunctional practices and beliefs of equality, further oppressing minority groups (Henkel, Dovidio, & Gaertner, 2006).

 

Ethnocentrism

America as a melting pot is, at its core, a fantastical notion that all immigrant groups should shed their ethnic and racial identities in order to become real Americans (Smith, 2012).  Basically, you can come to the United States and start over, forgetting all you were to take on this new, better identity and fit in with the majority.  However, this is truer for European, White immigrants than it is for other groups that may be considered White, such as Arabs and Latinx individuals, or other races.  This lets minority groups know that the White majority can accept them, to a certain extent and by ignoring their heritage and background, as one of the majority.  The desire of the majority group to get everyone else to be more like them stems from the idea that their group is superior to all other groups and that their values are the correct values, ones all groups should espouse (Johnson, 2013).  This is ethnocentrism, the belief that one’s group is better and more important than any other group.  A reconceptualized definition of ethnocentrism as, “a strong sense of ethnic group self-centeredness,” (Bizumic & Duckitt, 2012, p. 888) demonstrates how this concept is expressed in six different facets by groups:

  1. Preference – Liking your group and its members more than other groups based on the fact that they are from your group.
  2. Superiority – Believing your own group is better, or superior, than all other groups in certain dimensions, specifically the ones important to your group.
  3. Purity – Maintaining the purity of your group by not mixing with members of other groups both socially and physically.
  4. Exploitiveness – Using other groups in any way, under the guise of doing what is best for your group, to promote and maintain the ideals that are important to you.
  5. Group Cohesion – Valuing the needs of the group over your own needs, and working and connecting with other group members to make sure these needs are met.
  6. Devotion – Being loyal to the group and its interests no matter what because the group is of central importance to its members.

When a group is ethnocentric, these six aspects of ethnocentrism can be expressed in various levels depending on where in the power structure a group is.  Ethnocentrism as a concept is not only applicable to groups in power and can be present by those groups who are minorities in their societies.  Highly ethnocentric minority groups may not be able to exploit other groups nearly as much, but they can still leverage purity to maintain a close intergroup connection while keeping outgroup members at a distance.  Of course, any group can vary on their level of ethnocentrism, being able to value other groups and seek connection with those ethnically and culturally different from them.

However, a strong sense of ethnocentrism can cause problems in a society, creating more divide between groups and oppression of minority groups; and since the majority group has the power, it makes it much easier for them to integrate their values and way of life into the formal and informal structures of society.  One aspect of ethnocentrism that may be forgotten about, aside from the positive thoughts from the ingroup and its superiority, is that there is a sense of outgroup inferiority (Raden, 2003).  This is something that has historically been a part of U.S. history, used to justify taking land from the Native Americans and to enslave peoples brought from Africa.  Although it is not usually consciously accepted or recognized as such, ethnocentrism and its ingroup superiority versus outgroup inferiority is still engrained in how we interact with and create policies that deal with immigrant groups and native minorities.  When we talk about the “American Way,” it is truly a reflection of majority group values interwoven into official and unofficial thinking and doing.

Busy New York street with three women with hijabs walking up the sidewalk.
People who are not Muslim might think that wearing the hijab is a ridiculous practice and not a woman's choice.  It's a very ethnocentric view when we do not see the value in a woman's religious right to choose to wear the hijab. ​​​​​"Three Hijabs - D7K_1636_ep_gs" by Eric.Parker is licensed underCC BY-NC 2.0.

 

White Privilege

In an episode of the Daily Show on Comedy Central, host John Stewart was talking to his guest Bill O’Reilly about the idea of White privilege (check out this video on YouTube).  John was trying to get Bill to admit that Bill himself benefitted from White privilege, despite working hard to get to where he was.  For the majority of the discussion, as humorously tilted as it was, the serious struggle the two TV personalities were having was more to do with how they each defined the phrase than it did with whether or not the White majority actually benefitted from it.  The phrase itself is often misunderstood with people thinking that just because someone is White, they will receive more noticeable or tangible benefits, such as Bill O’Reilly was arguing.  It is sometimes understood as blatant bias based on skin color or ethnicity.  With a popular belief in the United States that blatant discrimination based on race and ethnicity is wrong, this misunderstood explanation of White privilege is often rejected.  Antiracist essayist, educator, and author Tim Wise (2014) defines White privilege as:

White privilege refers to any advantage, opportunity, benefit, head start, or general protection from negative societal mistreatment, which persons deemed White will typically enjoy, but which others will generally not enjoy. These benefits can be material (such as greater opportunity in the labor market, or greater net worth, due to a history in which Whites had the ability to accumulate wealth to a greater extent than persons of color), social (such as presumptions of competence, creditworthiness, law-abidingness, intelligence, etc.) or psychological (such as not having to worry about triggering negative stereotypes, rarely having to feel out of place, not having to worry about racial profiling, etc.). (question 5).

While Wise states that this advantage is enjoyed by White people, it may be easier to understand as a benefit since many White people will not even be aware that they are receiving the advantage.  This is closely related to the process behind institutional oppression and ethnocentrism that the White majority in the United States is often oblivious to and how societal structures discriminate or marginalize minority groups.  Although we have touched upon the social and material benefits the White majority has been given, one aspect of the definition Wise offers up that needs to be pointed out is the psychological benefits White privilege provides.  Minority group members have to, on a daily basis, deal with many psychological barriers, due to their racial or ethnic background, which remind them of their minority group status.  It is a part of their identity they cannot ignore, even if they wanted to.  White people, on the other hand, rarely come across moments in which they are reminded of being White; and those that they do come across are more likely to reinforce their positive attributes or even dominance.

             White privilege can be considered a side effect of both ethnocentrism and institutional oppression, as these concepts often reward those who look and act the right way.  Although this should not be taken to mean that all White people are going to be economically advantaged and have no worries, and this is another reason White privilege is not accepted by people.  One argument might be that if there was such a thing as White privilege, why are there poor White people?  Why do so many White people struggle in life as well?  In fact, less than 10% (8.3%) of “White alone, not Hispanic" people in the United States were living below the poverty level in 2019 (U.S. Census Bureau, 2020b).  If there were White privilege shouldn’t this number be much smaller, even nonexistent?  Yet White privilege is not about providing every White person the exact same opportunities and benefits.  To truly understand White privilege, one must understand that even the poorest White person will have an advantage over minority people in a similar or even better economic position.  While there may not be unanimity across the whole White majority in terms of socioeconomic standing, educational attainment, or access to resources, White privilege will still allow those disadvantaged Whites to be more advantaged than minorities.

 

Box 6.4 – Identity Privilege

White Privilege is just one form of Identity Privilege that individuals benefit from.  Other parts of one’s identity that can afford privilege include, but are not limited to, gender and gender identity, sexuality, religion, economic status, and ability.  While this chapter focuses on race and ethnicity, which can afford the greatest privilege for the majority group, it is still important for social work students to recognize their identity privilege and how it manifests in their lives.  In doing so, we can also begin to understand the experience of our clients that don’t have that privilege.  Need help in understanding identity privilege?  Use the questions in this Privilege Walk activity from Eastern Illinois University to help give you better understand how you might have privilege.

 

Minority Groups

When fighting for social justice, it is important for social workers not only to be aware of how groups are oppressed in our society, but also for them to understand some general characteristics each group possesses and the common barriers they face as a minority group in the United States.  In an effort to address minority groups that have been historically, continue to be, or have been more recently marginalized in America, we will look at groups based on the categories used by the U.S. Census Bureau to classify people by race and ethnicity: African American/Black, Asian/Pacific Islander, Latinx, and Native American (U.S. Census Bureau, 2013a).  One additional category that needs to be included in the discussion is that of Arab Americans as they have a distinct culture and have increasingly become targets of ethnic and religious discrimination since the terrorist attacks of September 11, 2001.  The following descriptions of these minority groups are designed to provide a background and a foundational knowledge of various minority groups as a precursor to understanding how social workers can serve minority client systems.  Of course, like anything else, not all of these aspects or issues will affect every individual from a certain group and we need to keep this in mind to prevent us from stereotyping or prescribing strategies for our clients without a thorough understanding of their personal experience or concerns as an individual.

Large African American or Black family posing outside of a restaurant.
Not all Black people consider themselves American or African American.  It is important to get to know your client and understand how they identify. "friends and family" by LesterSpence is licensed under CC BY 2.0

 

African Americans and Black People

In a discussion about racism, African American and Black people are arguably the most recognized racial minority in the United States.  They represent roughly 13 percent of the entire population in 2019, making them the second largest racial group in the U.S, behind Whites (U.S. Census Bureau, 2019b).  The most obvious trait that places people into this category is the dark skin tone, although any American who has ancestry from indigenous people of Africa can belong to this group, no matter how dark or light their skin tone is.  It is important to note, however, that not all Black people in the United States identify as African American and lay claim to other heritages, such as Latin American, before recognizing their African ancestry.  Since the U.S. Census counts Black/African American as a race and Hispanic as an ethnicity, the two are not separated in terms of national statistics.  However, due to their skin color, many of the issues African Americans deal with in today’s society are also of concern for Black Latin Americans.

Racist oppression Black people have suffered throughout the history of the United States started with slavery.  As slaves, Black people were bought, sold, and treated like animals, having to work in the fields without pay.  Oftentimes they were separated from their families and lost connection with some of the cultural traditions and customs of their homeland (Zastrow, 2008), though many of the African values have persisted and are seen in the lives of African American and Black families today (DuBois & Miley, 2011).  After the Civil War and Lincoln’s Emancipation Proclamation, freedom for Black people looked much better on paper than it was in real life.  Jim Crow laws allowed the government, businesses, and individuals to legally discriminate against and oppress African Americans, keeping life segregated, especially in terms of housing, education, and employment.  If they did not act properly, Black people could suffer severe physical punishment, even death, by White law enforcement and regular citizens.  World War II and the Civil Rights Movement helped move society away from this societal “slavery” toward more positive gains for African Americans and improved relations with Whites.  Segregation was outlawed and many different people and groups have continuously and earnestly worked for social justice for African Americans and Black people, including Martin Luther King, Jr., Malcolm X, the National Association for the Advancement of Colored People, and the National Urban League to name a very few.  We are much closer now than ever before to having equality between the two largest races in the U.S., though there is still a lot of work to be done.

Today many of the struggles of Black people have to deal with can be understood through the lens of anti-Black racism.  A term attributed to Dr. Akua Benjamin, a social work professor at Ryerson University in Toronto, anti-Black racism describes policies, practices, beliefs, and attitudes of both societal institutions and individual members that reinforce negative stereotypes, perpetuate prejudice and discrimination, and perpetuate the marginalization and dehumanization of people of African descent (Amherst College, n.d.; Black Health Alliance, n.d.).  A historic example of this can be seen in housing discrimination Black people have had to face.  [You can watch this satirical clip of John Oliver discussing this idea more in-depth.]  After slavery ended and Jim Crow began, the neighborhoods Black people were allowed to live in were burdened with unemployment and underemployment, higher levels of poverty, and unequal educational opportunities.  Despite the growing Black middle class and greater attainment of high school education among African Americans, this trend persists still today and has negative social and psychological effects on Black individuals (Danzer, 2012; Palmer & Little 1993).  This is one example of the historically traumatic interaction between White-dominated society and institutions and Black people that has produced fear, anger, rejection, and self-prejudice in Black people.  Mays (1986) discussed how the psychological effects of this relationship are important contributors to identity formation in African Americans during the different stages of African American history.

Identity development among African Americans and Black people, as well as other minority groups, deals with the idea of dualism where individuals are essentially part of two very distinct cultural spheres of influence: that of the greater society – in this case America where the cultural norms are focused on the White majority – and that of their family and community – one that encapsulates the cultural norms of their race or ethnicity.  When there is an incongruence between these two systems, the conflicting struggle within an individual can cause much psychological distress.  The greater society is pressuring BIPOC folks to fit in and become acculturated to the majority way of life, essentially rejecting their heritage and possibly being ostracized by their community.  The family and community influence works to instill its cultural viewpoint in the individual, telling the individual to reject those of the racist and discriminatory nature of the majority, thus risking further prejudice treatment by those in power.  This battle just adds to the barriers already faced with trying to figure out one’s place in society as well as trying to establish a positive self-identity.

In dealing with this dualism, as well as other oppressive obstacles faced on a daily basis, there are important strengths and values of Black communities that should be noted.  Because family is such an important part of the African American culture, we will look at what aspects of African American families stand out as a way of supporting the growth and success of the community in meeting the needs of its members.  It is important to note that Black families in the United States may be described as, “networks of households related by blood, marriage, or function that provides basic instrumental and expressive functions of the family to the members of those networks.” (Hill, 1999, p. 40).  In opposition to the nuclear family unit that dominates White America, this sense of family demonstrates the importance of community in helping meet the needs of family members.  Schaefer (2012) summarized Hill’s five strengths of African American families in helping support members and their growth as:

  1. Strong kinship bonds – Black people are more likely than Whites to care for children and the elderly in an extended family network.
  2. A strong work orientation – poor Black people are more likely to be working, and poor Black families often include more than one wage earner.
  3. Adaptability of family roles – in two-parent families, the egalitarian pattern of decision making is the most common.  The self-reliance of Black women who are the primary wage earners best illustrates this adaptability
  4. Strong achievement orientation - working-class Black people indicate a greater desire for their children to attend college than do working-class Whites.  Even a majority of low-income African Americans want to attend college.
  5. A strong religious orientation – since the time of slavery, Black churches have been impetus behind many significant grassroots organizations. (p. 207).

These factors help African American communities protect their members and provide much needed support in dealing with the discrimination they face on a daily basis from outside, majority-driven systems.  Too often society focuses on troubling issues that a smaller portion of Black people face and fails to recognize all the positive characteristics of these communities.  So, while there are number of oppressive factors negatively impacting the lives of African Americans, social workers need to remember the strengths of this group in meeting the needs of their members in order to work with and for them effectively.

 

Asian Americans

Having Asian Americans, Hawaiian, and Other Pacific Islanders as a singular category on the U.S. Census is misleading, appearing to combine two related groups to give a more accurate count of this population in the United States.  However, in breaking down the makeup of this governmental category, it can compare to Arab Americans in terms of the number of differing cultural groups making up this category.  Typically, when we think of Asian peoples, we are drawn to economic powers, such as China or Japan, or countries that have been identified in the media as military concerns, such as North Korea; all three groups of which are distinct.  We less often bring to mind the Vietnamese, Filipino, Malaysian, Thai, Indonesian, and Indian immigrants from Asia– to name just a few – when we consider Asian Americans in the United States.  Adding Hawaiian and Other Pacific Islanders and the fact that countries like China and the Philippines themselves have various ethnic groups (Schaefer, 2012) creates a whole gamut of diverse eastern world experiences being brought to America.

The start of the oppressive history of Asian Americans is not unlike the other groups already discussed, as well as those we will discuss after this.  Immigration efforts by Asians were met with resistance, their presence in society was unwanted, and they were targeted for poor treatment socially and legally.  A term first used around the turn of the century to describe the sentiments of the majority society towards Asians was “Yellow Peril”, which saw this group, especially the Chinese, as “heathen, morally inferior, drug addicted, savage or lustful.” (Schaefer, 2012, p. 283).  This prejudiced view held by Americans of Asian people translated into overt discrimination through legislature prohibiting further immigration, interracial/multiethnic relationships and marriages, the owning of land, and becoming a citizen (Alvarez, Juang, & Liang, 2006; Chou, 2008).  They have also historically been treated as foreigners in the U.S., even if they were native born and their family had been established in America.  The example that drives this point home more so than any other is the internment camps Japanese Americans had to endure during WWII when there was a prevalent fear that all Japanese people in the U.S. were potential spies.  This skewed characterization of Asians as being recent immigrants with limited English and not knowing much about American culture persists to this day.  Like many minority groups, Asians suffer from stereotypical representation in the media that propagates these prejudicial beliefs.

One such depiction, the “Model Minority”, is unique to Asian Americans amongst the minority groups in the United States.  At first glance, this idea may seem like a compliment, honoring Asians for what we believe are positive characteristics and behaviors.  This term is used to describe the ability of this minority group to succeed through dedication, hard work, educational attainment, and abiding by the laws.  Other minority groups are then indirectly faulted for not reaching the same level of success and assimilation as Asian Americans, denying the social circumstances of minority experiences and focusing on inferior characteristics.  The minority model is a socially constructed ideal held by the White majority as what is good and desirable.  It represents the ability of Asian Americans to assimilate to American culture, which can be the result of denying theirs.  It also does a poor job of adequately representing the marginalization of this group.  This way of describing Asians does nothing to address the poor treatment of the White majority toward this group, further demonstrating our imbalanced behavior of expecting people to accommodate us while we can treat anyone however we want.  The truth is, despite higher educational attainment for Asian Americans overall, their average income is less than those in an equal educational demographic (Chou, 2008).  In addition, this is the overall statistic, if you the group down into the many various ethnic groups, the results demonstrate how some of the ethnic groups skew the data to be more favorable (Chou, 2008; Schaefer, 2012).

Even though there are so many ethnically diverse groups in the one lump category of Asian Americans, experiences based on being categorized this way have helped create this need for ethnic subgroups to come together and share one broad identity while still acknowledging their differences.  Schaefer (2012) referred to this concept of coming together as one group as panethnicity and can help strengthen the more general minority group identity and help provide resources to address their needs.  Ho (as cited in Morales & Sheafor, 1998) outlined seven values believed to be consistent among all Asian cultures that can be a common thread for the diverse groups:

  1. Filial piety – Loyalty to family, especially familial authority figures, to the point of possibly sacrificing individual goals.
  2. Shame as a behavioral influence – The threat of shame, translating into loss of community and family support, directs how Asians act at all times.
  3. Self-control – Not letting emotions dictate how one reacts to situations.  This can be shown through patience, stoicism, humility, and tolerance depending on the situation.
  4. Middle-position – This value is related to self-perception in that one should not feel superior to or inferior to their peers, nurturing togetherness and equality.
  5. Awareness of social milieu – Similar to the idea of filial piety, Asian individuals are influenced by social norms, focused on group welfare, and work for social solidarity in thoughts and behavior, avoiding individualism.
  6. Fatalism – Acceptance of life events pragmatically and without philosophical discourse as a means to continue moving forward, especially in situations out of their control.
  7. Inconspicuousness – Early Asian immigrants did not want to attract attention for fear of backlash and racism.

The problem with these seven values is twofold.  First, with such a diverse group, we do not want to assume all Asians we come in contact with hold these values as important.  Second, it is easy for us to understand these values through American eyes, meaning we view these attributes based on how important or useful they are in our society.  Even in how they were described, it looked at the possible negative impact these sorts of values can have on an individual.  Working with clients, we cannot ascribe value to cultural norms or beliefs.  We need to follow the clients’ lead in how they perceive these influences in their lives.  Where we might see them as detrimental, they might see them as dedication to family and community, respect and equality, and strength in times of hardship.

American Indian dancing in traditional dress at a modern day Pow Wow in front of guests.
Native Americans are a people that generally take a lot of pride in their heritage and are still connected cultural roots and traditions. "Native American Pow-Wow" by Sam Howzit is licensed under CC BY 2.0.

 

Native Americans

Life of the indigenous peoples of the Americas was forever changed when Christopher Columbus came to the West Indies.  The coming of the Europeans brought both physical and psychological pain and suffering to the many groups of Native Americans already present on the continents.  Like Asian American and Latinx, Native American is a general designation for numerous groups that can be cultural distinct, and can be further broken down into American Indians and Alaska Natives (although this section of the chapter will focus primarily on the experiences of American Indians).  The Europeans, however, had little regard for differences between tribes and focused more on the differences the natives had with the Europeans.  Many U.S. policies dealing with the American Indians, such as the Reorganization Act, aimed at assimilation or relocation of tribal groups to lands that were foreign to their way of life.  The White majority has believed that they had a right to the land because the “savage” natives did not work the land agriculturally, subsisting by taking from the land only what was provided naturally (Bragaw, 2006).  Not uncommon from the rest of the world in the treatment of native peoples when usurping their lands, the European way of life brought to American was deemed sophisticated and superior to that of the native tribes (Schaefer, 2012).  The belief of Manifest Destiny was the justification for the poor treatment natives suffered and wars against them.  Europeans were not only more deserving than the American Indians, it was their destiny to dominate the natives.  These same views are not generally held by the public or the U.S. government today.  Since the 1960s and 1970s, the White majority has become more aware of the tragic policies and events American Indians have had to endure.  Public acknowledgement of the wrongdoings by the U.S. such as the Trail of Tears National Historic Trail, which follows the path American Indians traveled from the Eastern United States to Oklahoma as a result of the U.S. Relocation Act, is much more supported than previously.  Even the Bureau of Indian Affairs (BIA), which was initially created to execute the treaties the Federal government forced upon the native tribes to spur assimilation of people and land (Palmer & Rundstrom, 2013), has since acknowledged the misguided nature of their early involvement with tribal peoples (Schaefer, 2012).

Much of what the BIA did early on was misguided to say the least.  At times they believed they were being helpful, such as providing land for relocated tribes, trying to establish a three-branch system of reservation government, and remove government involvement with tribes to allow for more sovereignty.  Really these acts were more designed to benefit the U.S. then they were to truly help the American Indians.  Reservations have high poverty rates, low employment rates, under-enrollment in schools at all levels, and fewer resources than White communities (Schaefer, 2012).  Aside from institutional oppression, natives still have to deal with stereotyped and prejudiced beliefs from society.  Unfortunately, many non-native Americans are not educated enough when it comes to Native Americans, and microaggressions involving native stereotypes are rampant in American culture.  A great illustration of this is the use of Native American mascots.  While thought by the majority to be an honor, these mascots are often derogatory depictions of natives, either by team name or mascot personification, which is not always recognized by the public, especially fans of these teams.  Many White people do not realize that seeing Indigenous Peoples as nothing more than fierce warriors is to belittle what is means to be an American Indian.

Despite this and their dreadful history of oppression, Native Americans, still find much pride in their identity as a native, specifically in their tribe, and their traditions and values live on today (Indian.org, 2015).  While there are many different strengths tribal cultures have in terms of supporting members of the community through their lives, Goodluck (2002) identified three domains of well-being factors that allow Native American youth to find strength in their heritage:

  1. Helping each other – Establishing social connection by participating in many traditional events and activities, as well as sharing in responsibility of caring for others.
  2. Group belonging – Connecting to the extended family of the group by identifying with and claiming membership in the group and being active in group clubs and organizations.
  3. Spiritual belief – Focused on ritual and ceremonial participation, through knowledge of and belief in tribal or group religion and its traditions.

These domains identify the values and traditions that allow Native Americans to establish a strong self-identity and connection with their heritage, which can counteract the current situation into which they have been forced.  For American Indians, as with all native people, it is important to be respectful and honor their beliefs, traditions, and practices, especially given the centuries of disrespect they have received from non-native Americans.

 

Hispanic and Latino

Mexican Americans represent the largest group of Hispanic or Latino people in the United States, at about 62% of the total population (U.S. Census, 2019a).  The other 38% of Latin Americans come from a variety of various countries in Central and South America.  The terms Hispanic or Latino have been used as umbrella terms to identify all people of Spanish or Latin origin living in the United States, though not without debate about what is more appropriate and respectful.  An article titled “Hispanic of Latino: Which is Correct?” in Profiles in Diversity Journal (Austin & Johnson, n.d.) described the arguments for both terms, but concludes with an idea that most people labeled as Hispanic or Latino prefer to be recognized by their nationality first and foremost.  Even with the more recent introduction of Latinx as a gender-neutral term inclusive of all gender-identities, it is important to understand what individuals’ personal preference is in terms of being identified.  For this section, we will use the term Latinx (pronounced lah-TEEN-eks as opposed to Latin-X).  It is currently used by academics and diversity, equity, and inclusion experts as a way to discuss this very diverse population, with the understanding that this panethnic grouping gives only a vague general understanding of cultural experiences.

 

Box 6.2 – Hispanic & Latino as identifiers

With any terms we use, understanding a word’s origin or actual definition can help us decide if it is appropriate and/or respectful for us to use.  For instance, it can be helpful to know the term Hispanic in essence refers to someone who comes from a Spanish-speaking background.  This can be a problem if we are working with someone who is Brazilian.  While Brazil is a South American country, Portuguese is the official language.  So those with ties to the largest country in South America are then excluded if we use this term.  Along the same lines, it would include anyone with heritage from Spain, a European country with a White majority.  As practice, what can you find out about Latino vs. Latinx?  What about the term Latine?  Try to research first, but click here to see a comic by Terry Blas that covers the topic.

Latinx is considered an ethnic group in the United States.  It is by far the largest minority in the United States, with 60,095,000 people of various races claiming a Hispanic or Latino background in the 2019 (U.S. Census Bureau, 2019a).  Projected population growth for this group by the year 2060 is double the size it is today (U.S. Census Bureau, 2014), partially because of the large, steady immigration population from Latin American countries such as Mexico and Cuba.  Despite this influx of new immigrants, Hispanic peoples have been a part of American history since it was first “discovered” by Europeans.  While the English were busy settling the eastern part of what is now the United States, the Spanish were doing the same thing in Central and South America, as well as parts of North America and the Caribbean islands.  Many of the indigenous people in these areas had fates similar to the American Indians met by the English, which included illness, war, and eventual conquer.  As a result, those we recognize as Latinx today largely have ancestral backgrounds from this Spanish invasion of the native peoples and settlement of their land.  As the English were founding the United States and moving eastward, taking land from the American Indians, the Spanish peoples were spreading across what is now Mexico and into areas of the Southwest.  Much like the American Indians, these early Mexicans were also taken over by the non-native American push to conquer the continent.

Part of the reason for the poor treatment of those of Spanish or Spanish and native origin by non-native Americans relates back to conflicts in Europe between Spain and other European countries.  Propaganda used by the English, French, and Germans branded the Spanish as “cruel, bigoted, tyrannical, lazy, violent, treacherous, and depraved,” attacking the moral character of this nationality and creating La Leyenda Negra – the Black Legend (Sánchez, 2013).  Sánchez stated that it was the revitalization of this Black Legend by the Americans in their quest to control North America that justified their subjugation of Mexicans and eventually laid the foundation for prejudiced stereotypes of today’s Latinx population.  As more Latinx immigrants enter the United States, with and without documents, these prejudiced beliefs are still very much alive in American society.  Aside from these beliefs, many Latinx immigrants, as well as those who are native-born, have to confront a number of institutional issues, such as barriers to education, unemployment and underemployment, and poverty.  Two issues that have a profound effect on people who are Latinx, as well as how society views them, are language and immigrant documentation.

There is a strong belief that people living in the U.S. need to be able to speak English.  Learning a language other than what you speak natively is not easy, and it takes time and practice to become fluent in.  This can result in children not performing well in schools and adults having a hard time finding employment, among other concerns.  Although efforts have been made to be more accommodating – such as bilingual education for native Spanish speakers and many organizations providing materials and services in Spanish – they, as well as Spanish speakers, are too often met with prejudice.  Even those who are fluent in English but have a noticeable accent are treated as if they cannot be understood, are uneducated, or do not belong in the U.S.

It is not uncommon for those with accents to be assumed to be “illegal” immigrants.  Though this is an extreme and unfounded generalization, there are a number of undocumented (the proper and ethnically sensitive word) Latinx individuals living in the United States.  Too often it is assumed these immigrants are crossing the border to take advantage of all the benefits the U.S. has to offer – employment, healthcare, and education – without having to pay taxes.  The reality is that for many of the undocumented immigrants in the U.S. it was a matter of survival.  The family that was living in extreme poverty and risked the lives of its members to find a way to subsist as well as the individual whose only option was to either escape to the U.S. or face death in their country are invisible to most of American society.  Even if they were children when their family made the choice to come to the States, they still face fear as well as the attitude from others that they do not belong here and are not worthy of being called Americans.

In order to deal with all this, Latinx individuals have a number of general cultural strengths.  Other than a (mostly) common language and similar cultural heritages, Delgado and Burton (1998) identified three value themes in local Latinx art relevant to our discussion:

  1. Ethnic and racial pride – connecting with their noble origins and their nationality is an important part of being proud of who they are.  Ethnic pride is also a way to stay connected to their country of origin.  Even if it did not provide the best living circumstances, it will always be home.
  2. Religion – Latinx individuals have a strong connection to their faith that plays out in their lives on a daily basis through the use of religious symbols and prayer.  Spirituality gives them strength and hope for the future, and provides a guideline for living a positive life.
  3. Social justice – This directly relates to the unjust oppressive experiences Hispanics have had.  By remembering past trials and tribulations, they want to work to address the causes of these issues to better the future for the community.  They remember heroes and honor their culture.

In addition, one more value should be addressed:

  1. Family Value – Unlike the majority focus on individuality in the U.S., Latinx culture is one of collectivism, placing a lot of importance on the family system, including what Americans consider extended family.  Responsibility to family members and attending to family needs is more important than individual wants, and has all members contributing to family care.

These strengths can be seen across Latinx cultures, in some form or another, and provide a framework for them to be able to function in the United States while staying true to their heritage.  As a result, they have been able to make advances in getting their needs met and addressing the rampant discrimination this group faces, though there is still work to be done.

A close-up picture of an older Arab man's face.
Too many people assume that all Arabs are Muslim, when in fact they are a really diverse group.  In the United States, most Arab Americans identify as Christian. "Elderly Arab Man, black and white" by Liam Kearney is licensed under CC BY-NC-ND 2.0.

Arab Americans

This group has too often been left out or inadequately covered in discussions of minority groups, including in social work education.  In fact, the U.S. Census Bureau racially classifies Arab Americans as White people, similar to non-Black Latinx individuals.  However, unlike the Hispanic White category that Latinx individuals can choose, there is no Arab ethnicity category.  As such, Arab Americans as a minority group can be viewed as the invisible minority.  Though they are discriminated against and marginalized like other minorities, they are less often identified as a group needing social justice and not officially recognized as a minority by the U.S. government.  Arab Americans are defined as those native-born Americans and immigrants with familial ties to any of the 22 countries that are a member of the Arab League, or group of Arab countries that share cultural aspects, including the Arabic language.  They are, in alphabetical order: Algeria, Bahrain, Comoros, Djibouti, Egypt, Iraq, Jordan, Kuwait, Lebanon, Libya, Mauritania, Morocco, Oman, Palestine, Qatar, Saudi Arabia, Somalia, Sudan, Syria, Tunisia, United Arab Emirates, and Yemen.  Despite erroneously being equated with Muslims and Islam, there is no set Arab religion or spirituality, though Islam has significant influence on the Arab world (Sabbah, Dinsmore, & Hof, 2009).  In fact, the majority of Arab Americans are Christians and the majority of Muslims in the United States are African American (Naser, personal communication, March 21, 2015).

Unfortunately, many other misconceptions of Arabs have permeated American society and given rise to prejudiced thought and discriminatory action.  Although today many people in the U.S. connect this oppression to the terrorist attacks on 9/11, Arab people have been discriminated against for much longer than that.  Prejudiced thoughts about Arabs as religious fanatics, morally evil, a physical/military threat to Europe and Christianity, and oppressors of women were well established, passed on by European influence, prior to that fateful Tuesday in September (Suleiman, 1999).  The first big wave of Arab immigration was in the late 19th century and brought with it racial discrimination, including being considered “colored,” facing issues with voting rights, and being targeted by the KKK (Saloom, 2005).  Arabs have also been negatively portrayed in popular American media, often as hateful radical terrorists, further perpetuating prejudice against this group (Saloom, 2005; Suleiman, 1999).  Still, with the incidents of 9/11, discriminatory behavior against Arab Americans has increased, including being disproportionately selected for “random” searches at airport security checks.  However, Arab Americans are still classified as belonging to the majority White population, despite the great disconnect between this group and the European American Whites.  When it comes to the census, Arabs have been historically unable to adequately self-identify with the varying categories the U.S. government has used to label Arab Americans, and many have taken up the practice of selecting “Other” and writing in their identifier (Kayyali, 2013).

Even though American society might identify this group as Arab Americans, they should still be considered a diverse population in their own right.  Arabs in the U.S. can vary in many ways, including religion and spirituality, country of origin, acculturation, and language.  Yet, there are some general values and norms that can be considered strengths in regard to Arab people, as outlined by Sabbah et al.(2009):

  1. Arabic language – The most popular language used by Arabs, Arabic is the fourth most often spoken language in the world and helps create the Arab consciousness, helping provide a link to their heritage and culture.
  2. Religion – Religion, whether Islam, Christianity, or Druze, is an important dimension of personal identity and has a strong influence on their world.
  3. Family structure – The family in Arabic culture values nuclear and extended family members, and is the central force in providing a foundation of growth for all members.
  4. Time orientation – Having a more relaxed concept of time than Western cultures, while being present in the moment. (p. 33-34).

In addition, two other strengths of Arabic culture can be added to this list:

  1. Sense of community – In the United States, Arab communities are a strong influence and support network, connecting individuals with others they can relate to.
  2. Strive for achievement – Many Arab Americans value professional and financial success, and see it as a means to honor and provide for one’s family.

Although Arab Americans have historically, with an increase more recently after 9/11, dealt with discrimination and prejudice, these aspects of their culture can help them deal with the outer societal subjugation and should be seen as protective factors.  While too often this group is neglected or forgotten, even in discussions of oppressed groups, their experiences as a minority group should not be discounted, nor should their resilience and fortitude in meeting the needs of their members.

Box 6.3 – Current Issues with Marginalized Populations

It is no coincidence that a number of social crises occurred during Donald Trump’s time in office.  These crises have been very polarizing politically and socially, with Trump ignoring, denying, or deflecting away from the real issues.  Social workers need to familiarize themselves with the following topics and what their role is in serving those affected by these concerns:

  • Black Lives Matter
  • The immigrant ban
  • Keystone Pipeline controversy
  • COVID-19 pandemic
  • The border wall
  • Anti-Asian violence

 

Social Work Practice with Diverse Populations

There is no doubt that minority populations have had to deal with too many injustices, both historic and current, during their history in the United States.  Many of the discriminating acts they have had to face in the past as a people are very much still a part of their minority identity, and the racism and ethnic discrimination they face today continues to be a remind of their place in our society.  Despite being socially conceived ways of categorizing and, essentially, dominating people, race and ethnicity are still very real aspects of identity that carry with them hardships, anguish, and trauma.  As a helping profession, it is social work’s duty to help our individual clients address these injustices in their own lives and combat the oppressive characteristics of society for our client groups.  In building our generalist skills as practitioners, working with diverse clients requires us to become culturally competent.  The National Association of Social Workers Code of Ethics (2008) specifically recognizes the need for cultural competence and the understanding of culture’s meaning in society and for an individual.  We need to understand the realities of minority experiences in American society, giving validation and significance to daily struggles.  Social workers must also be aware of the historical treatment of, current issues specific to, and positive characteristics of different minority groups.  Even though all groups that have ever been considered minorities faced similar problems stemming from marginalization by the majority group, they have incurred those problems, and challenged them, in ways that catered to their unique values and strengths.  Awareness of distinctive cultural traits allows us to have a more empathic view of their life experiences, better equipping us to build the helping relationship and work with them to address needs.  In addition to knowledge about diverse populations, there are theories and approaches to social work that can help further structure our efforts with diverse clients in an effective manner.

 

Critical Race Theory

Critical Race Theory (CRT) acknowledges the role race – and we can assume ethnicity as well – plays in the segregation of groups of people in the U.S.  CRT functions on three main principles in order to identify society’s oppressive nature and work to correct it: 1) race is not biological but a social creation, 2) race saturates all aspects of individual and group life in the United States, including personal identity, and 3) race-based ideology has been integrated into formal and informal institutional structures in our society (Ortiz & Jani, 2010).  Thus CRT helps provide a functional framework for understanding these covert and unintentional forces and can be leveraged in the efforts social workers provide at all levels.  Individually and with groups, we can use CRT to appreciate our clients’ cultural perspectives and how it might have impacted their personal views of themselves.  At the community level we can use this to direct our efforts in confronting institutional oppression through social policy work that, even if indirectly, unjustly targets minority groups and places them at a disadvantage.  We can also work to properly educate communities, supporting community agencies and advocacy groups as they bring awareness to ongoing injustices endured by individuals of racial and ethnic minority groups.  Although race may be downplayed or ignored in these instances, social work can help bring light to the unconscious or invisible discriminatory aspects of American society.

 

Dual Perspective

Dual perspective proposes that minorities are living in two very distinct cultural spheres, that of the greater American society, which is primarily White influenced and values focused, and that of their ethnic or cultural group, which can vary greatly in values.  As a result of dealing with these two conflicting worlds, the psychological effects can be overwhelming.  If an individual is thought to identify too much with the majority, this person may be seen as a traitor to their race or ethnicity by their community.  If they are seen as becoming too entrenched in their own culture, they may be seen as troublemakers and discriminated against even more. Understanding this idea is a key component to systems theory which recognizes that people are a part of different systems and that these systems can greatly influence cognitions and behaviors.  When working with clients who are minorities, we need to be aware that there are two – or possibly more if an individual is multiracial/multicultural – cultural spheres of influence for clients that often conflict and, as a result, can create personal turmoil.

 

Color Blind vs. Cultural Awareness

Social workers absolutely must see color and difference.  There is a perception that one needs to be color-blind so that a person is not judged by skin color and everyone is treated equally.  Yet, when we fail to recognize the impact of race and ethnicity, especially the historical subjugation based on cultural factors, we are essentially saying race and ethnicity are not important.  Chao (2013) pointed out that a strong color-blind mind-set has been correlated with ignoring institutional oppressive factors for problems affecting cultural minorities.  Essentially, this approach can be equated to attributing problems to cultural values or within control of individuals or groups instead of a result of external influence.  Even though race has no biological foundation, it very much has a social foundation and significantly contributes to how people are treated socially and institutionally.  All social workers, even those who identify as a minority, need to understand how race and ethnicity can play a role in current marginalization of cultural groups and how this interacts with the development of a personal identity.  Color-blind is really just another term for being culturally unaware.  Social workers need to be aware of how race and ethnicity are still very much a part of our society and imbalance of social power and access to resources in order to better fight racism at a systemic level and provide our individual clients with the most effective services (Abrams & Moio, 2009).

 

Self-Awareness

One of the critical aspects of working with diverse client systems is having a thorough understanding of who you are.  It does not come just from knowing your background, where you come from, and the history of your people.  It comes from awareness of the role your own racial and ethnic identity have played in your life, both socially and psychologically.  This includes acknowledging the cultural stereotypes, both conscious and unconscious, that we have learned growing up in American society, even if we are not part of the majority.  Too often we believe we are not racist and respond from a defensive front if and when someone suggests we are.  However, social workers need to be more introspective than that.  We need to recognize when our prejudice appears, where it came from, and why it is there, and connect if we actually believe it.  If some microaggressions we commit are more likely born out of subliminal acculturation, our minds may be making judgments with which we do not necessarily agree.  Our brain may identify a thought or social attitude, but that does not mean we have to make it our own.  It is our responsibility to fight those of our thoughts that can further marginalize people based on race and ethnicity.

Social workers must do this in our personal and professional lives.  “Counselors can strive to be culturally competent by recognizing how their own beliefs and biases may seep into the counseling context.” (Kohatsu, Victoria, Lau, Flores, & Salazar, 2011).  As mentioned earlier in discussion about Asian American values, it is paramount that we do not allow our ethnocentric views of values direct our interpretation of the unfair pressure cultural beliefs put on the client.  We must meet the client where they are in regard to their personal values and cultural identity, without judgment about what is right or wrong.  We are looking at what is right or wrong based on our standards and not theirs.  If their values conflict with their culture’s values, then we can help them process through that and address that in the proper manner.  However, social workers work from a strengths-based perspective and are charged with helping clients address the self-identified concerns in their own lives.  Allowing our own worldview to dictate how we work with clients can adversely affect the work done with the client, such as misdirecting therapeutic interventions, conflict within other cultural systems of which the client is a part, or even disrupt and breakdown the therapeutic relationship.  Our thoughts on what is best for the client, without taking their input into consideration, will do more harm than good.

 

Box 6.7 – Who Are You?

Earlier I related a story about my understanding of who I am. What do you define your identity? Think about who you are based on the following topics:

  1. Race or ethnicity
  2. Gender
  3. Religion/spirituality
  4. Favorite food
  5. Favorite type of music
  6. Family relationships
  7. How you celebrate your heritage
  8. Your personality
  9. Leisure time activities and hobbies.

 

Social Justice

While it is necessary to be aware of some of the things that impact how we work with clients, it is also important to understand what to target when it comes to the work we provide to our client systems.  Work with individual clients can direct what we do in that helping relationship.  However, when it comes to larger systems such as communities and society, while part of the identification of issues is by hearing it from the clients, another piece is the evaluation of policies and statistics indicating a discrepancy between populations.  For instance, an article by Voborníková (2014) discusses the racial discrimination in the private housing market and role the Federal Housing Administration is playing to continue such segregation.  No Child Left Behind was created to address the achievement gap between White students and their minority counterparts, but with little effective change in many schools across the country (Lagana-Riordan & Aguilar, 2009).  Housing, education, health care, employment and income, and crime, just to name a few, are all areas that have been shown to have discriminatory practices toward minorities or barriers preventing equality with the White majority (Chou, 2013; Palmer & Little, 1993; Schaefer, 2012; Zastrow, 2008).  Social work efforts need to identify the areas that need improvement and address these social injustices through policy practice, community campaigns, activism, and social marketing.

 

Conclusion

Being culturally competent does not mean knowing everything there is to know about working with every diverse population in the U.S.  In fact, it is highly unlikely that we will ever become or feel completely culturally competent as social workers.  Saunders, Haskins, and Vasquez (2015) described cultural competence as a continuous effort individual social workers, as well as social work as a profession, must take to build their skills in working with diverse groups.  We must continually seek to improve our efforts in effectively working with racial and ethnic minority students.  When it comes to racial and ethnic minorities, we need to recognize and celebrate the differences we have as one people in the United States.  No longer should we strive to be a “melting pot” where diversity is devalued, belittled, feared, or used to hold people down.  Instead, the United States should strive to be a “salad bowl” in which all the all races and ethnicities can live together yet retain their vibrant cultural identity.  Majority oppression clearly hurts minority populations, but by instilling values and beliefs, especially subliminally, that are prejudiced in nature, we create a society where all groups encounter negativity, hatred, and fear.  The field of social work leads the change in creating a better, more nurturing environment for all.  As practitioners we need to create an understanding in ourselves about the world in which we live and how others experience that world in unique ways.  We also need to be introspective by recognizing, confronting, and changing those prejudiced thoughts and beliefs – both conscious and unconscious – we have within ourselves about those who are different from us.  In doing these things, we can better work for positive change in society for all ethnicities and races.

 

References

Abrams, L. S., & Moio, J. A. (2009). Critical race theory and the cultural competence dilemma in social work education. Journal of social work education, 45(2), 245-261.

Alvarez, A. N., Juang, L., & Liang, C. H. (2006). Asian Americans and racism: When bad things happen to "model minorities". Cultural diversity & ethnic minority psychology, 12(3), 477-492. doi:10.1037/1099-9809.123.477

Amherst College (n.d.). Race and ethnicity terms and definitions. In Multicultural Resource Center. https://www.amherst.edu/campuslife/our-community/multicultural-resource-center/terms-and-definitions.

American Anthropological Association (1998). “American Anthropological Association’s statement on race”. In About the Projecthttp://www.understandingrace.org/about/statement.html.

Austin, G., & Johnson, D. (n.d.). Hispanic or Latino: Which is correct? Profiles in Diversity Journal, online. http://www.diversityjournal.com/9724-hispanic-or-latino-which-is-correct/.

Bizumic, B., & Duckitt, J. (2012). What is and is not ethnocentrism? A conceptual analysis and political implications. Political Psychology, 33(6), 887-909. doi:10.1111/j.1467-9221.2012.00907.x

Black Health Alliance (n.d.). Anti-black racism. In Our Impact. https://blackhealthalliance.ca/home/antiblack-racism/.

Boundless. (2014). Boundless Sociology. https://www.boundless.com/sociology/textbooks/boundless-sociology-textbook/race-and-ethnicity-10/minorities-81/minority-groups-475-3392/.

Bragaw, S. G. (2006). Thomas Jefferson and the American Indian nations: Native American sovereignty and the Marshall Court. Journal of Supreme Court History31(2), 155-180. doi:10.1111/j.1540-5818.2006.00133.x.

Centers for Disease Control and Prevention. (2014). “Racial & ethnic minority populations”. In Minority Healthhttp://www.cdc.gov/minorityhealth/populations/remp.html.

Chao, R. C. (2013). Race/ethnicity and multicultural Competence among school counselors: Multicultural training, racial/ethnic identity, and color-blind racial attitudes. Journal of counseling & development91(2), 140-151. doi:10.1002/j.1556-6676.2013.00082.x

Chou, C. (2008). Critique on the notion of model minority: an alternative racism to Asian American? Asian ethnicity, 9(3), 219-229. doi:10.1080/14631360802349239

Coleman, S. (2011). Addressing the puzzle of race. Journal of Social Work Education47(1), 91-108. doi:10.5175/JSWE.2011.200900086

Collins, R. (2001). Ethnic chance in macro-historical perspective. In E. Anderson & D. S. Massey (Eds.), Problem of the century (pp. 13-46). Russell Sage Foundation.

Danzer, G. (2012). African-Americans' historical trauma: Manifestations in and outside of therapy. Journal of Theory Construction & Testing16(1), 16-21.

Delgado, M., & Barton, K. (1998). Murals in Latino communities: social indicators of community strengths. Social Work43(4), 346-356. doi:10.1093/sw/43.4.346

DuBois, B, & Miley, K. K., (2011). Social work: An empowering profession (7th ed.). Allyn & Bacon.

Forrest-Bank, S., & Jenson, J. M. (2015). Differences in experiences of racial and ethnic microaggression among Asian, Latino/Hispanic, Black, and White young adults. Journal of sociology & social welfare, 42(1), 141-161.

Gitschier, J. (2010). All About Mitochondrial Eve: An Interview with Rebecca Cann. Plos genetics, 6(5), 1-4. doi:10.1371/journal.pgen.1000959

Goodluck, C. (2002).  Native American children and youth well-being indicators: A strengths perspective.  In Resources. http://www.nicwa.org/research/03.Well-Being02.Rpt.pdf.

Harris, F. C., & Lieberman, R. C. (2015). Racial inequality after racism. Foreign Affairs, 94(2), 9-20.

Henkel, K. E., Dovidio, J. F., & Gaertner, S. L. (2006). Institutional discrimination, individual racism, and hurricane Katrina. Analyses of Social Issues and Public Policy, 6(1), 99-124.

Hill, R. B. (1999). The strengths of African American families: Twenty-five years later. University Press of America, Inc.

Indian.org (2015). Native American life. In Articles. http://www.indians.org/articles/native-american-life.html.

Johnson, L. A. (2013). Social stratification. Biblical Theology Bulletin, 43(3), 155-168. doi:10.1177/0146107913493565

Kaplan, M.A. and Inguanzo, M.M., (2020). The Historical Facts about Hate Crime in America The Social Worker’s Role in Victim Recovery and Community Restoration. Journal of Hate Studies, 16(1), pp.55–68. doi: http://doi.org/10.33972/jhs.147

Kayyali, R. (2013). US Census classifications and Arab Americans: Contestations and definitions of identity markers. Journal of ethnic & migration studies, 39(8), 1299-1318. doi:10.1080/1369183X.2013.778150

Kohatsu, E. L., Victoria, R., Lau, A., Flores, M., & Salazar, A. (2011). Analyzing anti-Asian prejudice from a racial identity and color-blind perspective. Journal of counseling & development, 89(1), 63-72.

Lagana-Riordan, C., & Aguilar, J. P. (2009). What's missing from No Child Left Behind? A policy analysis from a social work perspective. Children & Schools, 31(3), 135-144.

Mays, V. M. (1986). Identity development of Black Americans: The role of history and the importance of ethnicity. American Journal of Psychotherapy40(4), 582-593.

Morales, A. T., & Sheafor, B. W. (1998). Social work: A profession of many faces (8th ed.). Allyn & Bacon.

Naser, S. (2015). Personal interview.

National Association of Social Workers (2008). Code of Ethics.  In Abouthttp://www.socialworkers.org/pubs/code/code.asp.

Ortiz, L., & Jani, J. (2010). Critical race theory: A transformational model for teaching diversity. Journal of Social Work Education, 46(2), 175-193.

Palmer, E. L., & Little III, G. L. (1993). The plight of Blacks in America today. Social Behavior & Personality: An International Journal21(4), 313-325.

Palmer, M., & Rundstrom, R. (2013). GIS, internal colonialism, and the U.S. Bureau of Indian Affairs. Annals of the Association of American Geographers, 103(5), 1142-1159. doi:10.1080/00045608.2012.720233.

Race. (n.d.). In Merriam-Webster Onlinehttp://www.merriam-webster.com/dictionary/race.

Raden, D. (2003). Ingroup bias, classic ethnocentrism, and non-ethnocentrism among American Whites. Political Psychology, 24(4), 803. doi:10.1046/j.1467-9221.2003.00355.x

Sabbah, M. F., Dinsmore, J. A., & Hof, D. D. (2009). A comparative study of the competence of counselors in the United States in counseling Arab Americans and other racial/ethnic groups. International journal of psychology: A biopsychosocial approach / Tarptautinis psichologijos zurnalas: Biopsichosocialinis poziuris, 3(2), 29-45.

Schaefer, R. T. (2012). Racial and ethnic groups (13th ed.). Pearson.

Schwarzbaum, S. E., & Thomas, A. J., (2008). Dimensions of multicultural counseling. Sage Publications, Inc.

Saloom, R. (2005). I know you are, but what am I?  Arab-American experiences through the Critical Race Theory lens. Hamline journal of public law & policy, 27(1), 55-76.

Sánchez, J. P. (2013). Comparative colonialism, the Spanish Black Legend, and Spain’s legacy in the United States: Perspectives on American Latino heritage and our national story. Spanish Colonial Research Center: National Park Service.

Saunders, J. A., Haskins, M., & Vasquez, M. (2015). Cultural competence: A journey to an elusive goal. Journal of social work education, 51(1), 19-34. doi:10.1080/10437797.2015.977124

Shepard, J. M. (2010). Sociology (10th ed.). Wadsworth, Cengage Learning.

Smith, D. M. (2012). The American melting pot: A national myth in public and popular discourse. National Identities14(4), 387-402. doi:10.1080/14608944.2012.732054

Sue, D. W., Capodilupo, C. M., Torino, G. C., Bucceri, J. M., Holder, A. M. B., Nadal, K. L., and Esquilin, M. (2007). Racial microaggressions in everyday life: Implications for clinical practice. American Psychologist 62(4), 271-286. doi:10.1037/0003-066X.62.4.271

Suleiman, M. W. (1999). Islam, Muslims and Arabs in America: The Other of the Other of the Other. Journal of Muslim minority affairs, 19(1), 33.

Thernstrom, A., & Thernstrom, S. (Eds.). (2002). Beyond the color line: New perspectives on race and ethnicity in America. Hoover Institution Press

U.S. Census Bureau. (2010a). Race and Hispanic or Latino origin: 2010. In Community Factshttp://factfinder.census.gov/faces/tableservices/jsf/pages/productview.xhtml?src=CF.

U.S. Census Bureau. (2010b). Hispanic or Latino by type: 2010. In Community Facts.http://factfinder.census.gov/faces/tableservices/jsf/pages/productview.xhtml?src=CF.

U.S. Census Bureau. (2013a). About.  In Racehttp://www.census.gov/topics/population/race/about.html.

U.S. Census Bureau. (2013b). People in poverty by selected characteristics: 2012 and 2013. In Poverty.http://www.census.gov/hhes/www/poverty/data/incpovhlth/2013/table3.pdf.

U.S. Census Bureau. (2014). Projections for the size and composition of the U.S. population: 2014-2060 (P25-1143). Washington, DC: Colby, S. L. & Ortman, J. M. http://www.census.gov/content/dam/Census/library/publications/2015/demo/p25-1143.pdf.

U.S. Census Bureau. (2015). State and county QuickFacts [Data set]. http://quickfacts.census.gov/qfd/states/00000.html.

U.S. Census Bureau. (2019a). The Hispanic population in the United States: 2019. [Data table]. https://www.census.gov/data/tables/2019/demo/hispanic-origin/2019-cps.html,

U.S. Census Bureau. (2019b). Population estimates, July 1, 2019. In Quick Facts.https://www.census.gov/quickfacts/fact/dashboard/US/PST045219.

U.S. Census Bureau. (2020a, October 16). About racehttps://www.census.gov/topics/population/race/about.html.

U.S. Census Bureau. (2020b). Table B-6 Poverty Status of People by Age, Race, and Hispanic Origin: 1959 to 2019 [Data table]. In Income and poverty in the United States: 2019.

U.S. Census Bureau. (2021). Research to improve data on race and ethnicity. In About the bureau.https://www.census.gov/about/our-research/race-ethnicity.html.

Voborníková, P. (2014). Divided we live: racial and ethnic segregation in housing in the U.S. Scientific Journal Of Humanistic Studies, 6(10), 43-51.

Waters, M. C. (2001). Personal Identity and Ethnicity. In A. M. Garcia & R. A. Garcia (Eds.), Race and Ethnicity (pp. 69-71).

Wise, T. (2014). F.A.Q.s. In Extrashttp://www.timwise.org/f-a-q-s/.

Zastrow, C. (2008). Introduction to social work and social welfare (10th ed.). Thomson Brooks/Cole.

Chapter 7: Sexism, Inequality, and Women's Issues

This chapter was finished at a time when our Vice President is a woman, when there is a legitimate chance to have a female candidate for President on a major-party ticket again in the near future, and when the majority of college students are women. It can be easy to believe that we are living in a post-sexist era in America. However, that’s far from the truth. Women and men both suffer from considerable obstacles put in their path due to gender role socialization and expectations; both may also see some benefits, though men’s benefits tend to be more impactful and permanent than women’s. Social work is well aware of the unique challenges that our sexist societal norms and rules cause for everyone, especially for women, and the profession strives to equalize access to resources, rights, and privileges received in society that are based upon gender. This is one element of social work’s commitment to social justice. Though many improvements have certainly been made, women still find themselves disadvantaged in the world of politics, economic power, family life, religion, and the working world. When you’ve finished reading this chapter, you should be able to:

1. Articulate the difference between gender and sex;

2. Name several elements of traditional gender-role expectations;

3. Explain some of the agents of gender role socialization;

4. Identify the major tenets and victories of the feminist movement;

5. Define sexual assault harassment and list factors that are involved in its ongoing occurrence;

6. Compare gender-role norms of the past with today’s expectations;

7. Advocate for greater equality between the sexes and identify strategies to help achieve it;

8. Analyze the role of social work in both perpetuating and fighting sexism.

 

            From the days of Jane Addams and Mary Richmond to the present, social work is a profession that has been led by women. As you learned in Chapter 2, the early days of social work saw many innovative women take the reins to guide the development of the fledgling field. Although more men populate the profession than were seen in the early days, over 80% of the nation’s social workers are women (U.S. Census Bureau, 2012; Salsberg, Quigley, Mehfoud, Acquaviva, Wyche, & Sliwa, 2017) and it appears that the number of men entering the field may be dwindling. One survey in the early 2010s indicated that fewer than 10% of social workers under age 34 were men (Carey, 2011), and four years later, another study found that just one out of every seven new social work graduates was a man (Salsberg, Quigley, Mehfoud, Acquaviva, Wyche, & Sliwa, 2017), indicating that the profession may become even more gender-disproportionate in the coming years. Add to this the fact that a majority of social work clients are women, and one can conclude that even if sexism were not a concern today, it would only make sense that social workers were particularly attuned to the needs of women.

However, social workers and other professionals with knowledge of the impact of sex roles and sexism know that they can be harmful to men as well. This recognition of the deleterious effects of sexism on everyone is important, for though women are often painfully aware of the problematic impact of this sort of discrimination, men may not feel as motivated to do anything to combat the problem if they do not realize it also has a negative impact on their own health and wellness. Efforts toward true equality of the sexes are obviously most likely to be successful if supported by men and women alike.

Gender Versus Sex

If you’re sitting there saying, “Wait—I thought gender and sex were the same thing,” you’re not alone. Although this will be explored in much greater depth in Chapter 8, we need to draw the distinction here so it’s clear.

            Sex is a biological term that refers to one having the chromosomes (and typically the genitalia) associated with being male or female. As some of you may remember from biology class, a sex chromosome combination of XX typically results in the birth of a girl and XY means a boy. When forms ask you to indicate what your sex is, they are speaking of your biological condition of being (in most cases) male or female.

However, certain conditions can cause one’s sex to contradict one’s physical presentation; for example, someone with de la Chapelle syndrome has XX chromosomes but may appear to have genitalia that are more male than female; in fact, some may have a typical male body appearance and may be unaware of their chromosome arrangement (Abusheikha, Lass, & Brinsden, 2001). In cases where there are ambiguous genitalia, ambiguous (or non-XX/non-XY) chromosomes, a physical presentation that is not typically found with a given chromosomal arrangement, or some combination of these factors, the individual is typically referred to as intersex. (Intersex people will be discussed in greater detail in Chapter 8.)

File:Third International Intersex Forum.jpg
Activists and intersex people at the Third International Intersex Forum
"File:Third International Intersex Forum.jpg" by Organisation Intersex International Australia is licensed under CC BY-SA 3.0

Gender, on the other hand, refers to one’s personal identity as man (or boy), woman (or girl), or a nonbinary category (see Chapter 8 for more details on this).  It is an emotional, social, and psychological characteristic, though some research is now also exploring whether it has a biological basis too. As sociologist Michael Kimmel (2013) puts it in his book The Gendered Society:

Sex refers to the biological apparatus, the male and the female—our chromosomal, chemical, anatomical organization. “Gender” refers to the meanings that are attached to those differences within a culture. “Sex” is male and female; “gender” is masculinity and femininity—what it means to be a man or a woman. (p. 3)

            When this text discusses the expected traits and behaviors of men and women in our society, we will use the term gender role rather than sex role. These behaviors and characteristics are not inherently, biologically connected to men or women; they are reflections of society’s expectations and definitions of masculinity and femininity.

            However, there are some notable differences between males and females that are biological in nature. For instance, most females (at least from the onset of puberty until menopause) menstruate and can become pregnant. Men typically have more facial hair. These are sex traits rather than being connected to one’s gender. A trait is not determined or defined by society, while a role is. Of course, it turns out that there is actually quite a bit of variation even in these traits. You may have noticed the use of the words “most” and “typically” earlier in this paragraph—that’s because we recognize that not all women menstruate, there are men with less facial hair than some women, and in some cases, people legally recognized as men have given birth, as in the famous case of Oregon’s Thomas Beatie (Colburn, 2008), who birthed three children while legally married to a woman in a state that did not recognize same-gender marriages until 2014 (Brence, 2015).

            From a social work perspective, it may be best simply to realize there are no absolutes, and the world is much more complex than many people realize. Even supposedly established facts get challenged regularly, and social work embraces that ever-growing diversity of humanity.

Box 7.1: Gender Roles

Traits

Traditional Gender Role Expectations

            Even though there has been some movement away from the tendency to see men and women as naturally and intrinsically bound to behave in certain ways, there remains a prevailing sentiment among most Americans that men and women are noticeably and predictably different. Most of us expect certain behaviors out of men and women, boys and girls, and react with at least mild surprise when people do not match up with those expectations. This reflects just how ingrained our ideas of gender roles are. In truth, gender roles are based on stereotypes about men and women. Stereotypes represent fixed ideas about a certain group of people, often based on broad generalizations. Stereotypes sometimes have a grain of truth to them but get blown out of proportion, and they can be quite unfavorable to the groups they purport to describe.

            Though gender roles are more rigid in some parts of the country, or with some segments of the population, there are elements of the roles that seem to exist in many places and with most people. What we will go on to describe are the traditional ideas of gender roles, some of which are more prominent and emphasized than others. In no way does social work consider these traits to be inborn or assumed for any men or women. However, we recognize that these gender roles can have a considerable impact on people’s lives.

            Masculinity is the term used to describe those traits and behaviors generally associated with what society considers to be appropriate for a male. Men are often expected to be:

more individualistic, more aggressive, more independent, more in need of social stature, more [leader-like], more rational and yet paradoxically more controlled by a forceful sex drive, less interested in their physical appearance, less naturally paternal, less emotional, less socially adept, and in general, people whose self-esteem [is] based on their social success and being…the spiritual, social, and economic leaders within the governing structure of both church and family. (Hopkins, 1998, p. 34)

You may think of other items to add to the above list, like more athletic, handier around the house, stronger (both emotionally and physically), prouder, more confident, and so on. In fact, if each reader of this text were to come up with his or her own list of what it has traditionally meant to be masculine, it’s likely we’d have as many different lists as people. However, there would undoubtedly be many commonalities on the lists as well. Many of these traits listed for masculinity are perceived positively by most men; who wouldn’t like to be seen as more independent, effective leaders? However, the stereotypes of masculinity also carry with them some unflattering negatives, and even some contradictions (which should make it clear just how foolish it is to stereotype people in the first place).

            Femininity is the term used to describe what society considers to be appropriate for a female. Women are often assumed to be:

more emotional, more verbal, more in need of security, love, and attention, more interested in their physical appearance, more interested in family than individual success, naturally maternal, less logical, less sexual, less aggressive, less [leader-like], and in general, people whose self-esteem [is] (properly) wrapped up in relationships and doing for others. (Hopkins, 1998, p. 34)

punk rocker
This punk rock fan has some stereotypically 'feminine' accessories, clothes and style choices; others are much less associated with femininity. Does any of it tell us what this person's gender identity is? Can our perceptions be incorrect? Is the title of the photo even sure to be correct?
"punk girl" by ♪♫PSICO--MOD♪♫ is licensed under CC BY 2.0

 

Naturally, you may also believe there is more to add to this list as well. Women are often pressured or simply expected to be domestic, thin, nurturing, passive, kind, soft-spoken, and more. Again, there are some traits here that would elicit pride (greater selflessness, kindness) and some that might make women bristle (less leader-like, less logical). Even as we write this, however, we have to be cognizant of the fact that the traits we see as positive and negative are likely influenced by our own upbringing in a family, community, and society that has been (both subtly and explicitly) pushing gender role expectations on me from birth, if not before. Perhaps you see some of these traits quite differently than we do when it comes to their respective values!

 

            Androgyny is a term that is often misunderstood—it’s taken to mean that someone is not clearly male or female in appearance.  However, the actual definition of the word is a bit more complex than that. The word itself is a combination of the Greek-derived prefixes associated with male (andr-) and female (gyne- or gyneco-).  Androgyny is a state of having many supposedly masculine and many supposedly feminine traits—and although this is sometimes directed toward appearance, the term can refer to a person having many of the behaviors, tendencies, and characteristics commonly associated with being male or female. Many people find when they really look at their own characteristics that they have some traits that would be considered more stereotypically female and some that are more stereotypically male; that is a more common situation than someone fitting firmly and wholly into a traditional gender role. The traditional roles are so monolithic that, in truth, they do not apply to many people. However, the word “androgynous” has taken on somewhat of a negative connotation, so people may be reluctant to use the term in reference to themselves.

Janelle Monae
People who are more androgynous in appearance may confuse people or make them feel uncomfortable. Many people do not know how to react when someone isn’t clearly male or female, even though it should not make a huge difference for one’s basic interactions. Janelle Monáe has often sported an androgynous look in live concert appearances.
"Janelle Monae" by thomyboecker is licensed under CC BY-SA 2.0

 

            Despite this negativity about androgyny, there is research evidence that androgynous individuals have better communication skills (Hirokawa, Yagi, & Miyata, 2004), higher self-esteem (Pauletti, Menon, Cooper, Aults, & Perry, 2017), and are more open-minded (Garcia, 1982), more adaptable and flexible in their behaviors (Shimonaka, Nakazato, Kawaai, & Sato, 1997), and more independent (Bem, 1975). So, although people may not desire the “androgynous” label,

androgyny has often been held up as a model of well-being. The assumption is that an androgynous person is not compelled to “prove” her femininity or his masculinity. Rather, such a person has successfully integrated both masculine and feminine traits…and ultimately benefits psychologically from this integration. (McAnulty &  Burnette, 2004, p. 152)

It seems possible we might all be a bit happier if we weren’t so restricted by gender roles! Yet we continue to have a tendency as a whole to punish children for stepping outside of the expectations we have of them. This is particularly true for boys, who get judged more negatively when they step outside those role-based behaviors to engage in activities like playing with dolls, or if they prefer quiet make-believe play to contact sports and rough-and-tumble activities (Sandnabba & Ahlberg, 1999; Carroll, 2013). What’s more, when boys and men do not adhere to prescribed gender roles, their sexual orientation is often called into question; that is, a boy who “acts like a girl” may prompt concerns from parents and others that he may be gay. (This also indicates a sense, fear, or belief that homosexuality is shameful in comparison to heterosexuality, but that will be addressed in your next chapter.) Of course, when we conflate sexual orientation with gender role, we’re making a big (but common) mistake. People who do not “fit” with their gender roles come in all sexual orientations, and people of various sexual orientations have varying roles of gender-role conformity. These are very different concepts, and the tendency to make them into parallel or even identical categories is misguided.

Box 7.2: Gender Roles Across Cultures

Gender roles

Gender Role Socialization

            We start to notice differences in the behaviors of males and females pretty early in our lives—children often begin imitating their same-sex parent by the age of two (Carroll, 2010). Before we even get to the point where girls aim to imitate their mothers and boys their fathers, our families and the rest of society have been, in a way, coaching us into our expected gender roles. The process by which we learn society’s expectations of males and females is known as gender role socialization.  Some of this is quite deliberate and intentional, while other aspects of socialization are more indirect. It is often intended to be helpful or beneficial, though in reality strict adherence to expected gender roles can be detrimental to both men and women.

Infancy

            When does gender role socialization begin? It is easy to say it happens at birth, but one could take the stance that it actually starts while the child is still in the womb. Before a baby arrives, parents often discuss names; decorate the nursery; have a baby shower where they receive clothes, books, and toys meant for the baby; and even start talking to the baby in the womb. Additionally, parents’ dreams and plans for the baby come into clearer focus. Thus, the way the baby is going to be treated starts to be determined, and that treatment will naturally have an impact on the way the child behaves (Carroll, 2010).

            After the infant arrives, they may be wrapped in a blue or pink blanket to identify their sex, and parents often talk to the baby differently depending on whether they are a boy or girl. Boys are more apt to hear phrases like, “Who’s a tough guy?” while girls may hear, “Who’s mommy’s/daddy’s sweet little girl?” A landmark study by Rubin, Provenzano, and Luria (1974) showed that parents begin to perceive their children differently within 24 hours of birth based on whether they are sons or daughters; this was especially true for fathers. Parents are more likely to describe their young sons as “strong, firm, [and] alert” and daughters as “delicate, soft, and awkward” (Reynolds & Herman-Kinney, 2003, p. 772).

The toys and books bought for very young children are often different too—girls are more likely to be given toys that are domestic (tea sets, kitchen tools) or beauty-related (mirrors, makeup kits, costume jewelry), while boys are more likely to be given toys that encourage active, physical play like tool sets and sports equipment. Parents tend to place greater restrictions on the movement and play of female babies while allowing male babies to be more independent and self-directed (Skolnick, 1992). While none of these adult behaviors may be inherently problematic, they do set a very clearly decorated pink or blue stage early in childhood, establishing norms that are socially driven and maintained throughout our lives in various ways.

Boy With Doll, Luang Prabang Laos
While parents often say they would treat a young son and young daughter the same, in practice, this rarely happens. Parents often react negatively to children who exhibit cross-gender play, like boys playing with dolls (other than “action figures”).
"Disabled Boy With Doll, Luang Prabang Laos" by AdamCohn is licensed under CC BY-NC-ND 2.0

Childhood

            The socialization process doesn’t slow down in childhood; if anything, it just finds new fertile ground to sow. The toy and playtime differences that were first socialized in infancy continue into the early school years. “Children who play with toys thought appropriate only for the other sex are often rebuked by their parents. Because children are sensitive to these expressions of displeasure,” they often modify their play and end up finding themselves preferring toys and play styles that match their parents’ expectations of them (Crooks & Baur, 2014, p. 137).

            Feminist author Gail Dines (2010) recalls taking her nieces and nephews to Toys ‘R’ Us:

While there was some gender division among the toys in the 1990s, today the store has an almost tangible barrier down the middle. One half was full of toy guns, knives, swords, wrestling figures, and violent computer games, and the other half magically turned pink with princess dresses, dolls, makeup, and hairdryers. My two nephews walked out with the latest wrestling figures, and my two nieces each had a pink Barbie hairdryer and a pink makeup bag, all bought by their loving feminist aunt. I did try to steer them to the few gender-neutral items, such as jigsaws and board games, but was stopped short by the look of disgust across all four faces (p. 61).

            As we become old enough to have more responsibilities around the house, taking on chores and other duties to assist the family, we see a division of male/female labor in many families. Not only do male children do less housework on average than female children (10 hours versus three), the types of chores being done are quite different (Kimmel, 2013). Boys are far more likely to do yard work and to take out the trash, but these are virtually the only areas in which there are consistent and significant differences. Girls are more likely than their brothers to do laundry, wash dishes, shop for groceries, care for siblings, and take on general household cleaning tasks (Kimmel, 2013). Is this because children continue to copy the behavior of their same-sex parent, or is it because these are the tasks their parents assign to them, perhaps unwittingly, due to their gender-role expectations? In all likelihood, both factors play a part.

Mumbai: Washing Dishes on the Street
 We often learn what the expected household duties for our gender are by watching and imitating our parents. Girls are far more likely than boys to do laundry while growing up.
"Mumbai: Washing Dishes on the Street" by babasteve is licensed under CC BY-NC 2.0

 

            Our activities also differ as we age and that differentiation may grow over time. One example is in the realm of athletic competition. Women have enjoyed greater access to sports over recent years than at any previous time in our history, but even in the sporting world, there can be divisions. Can you think of some sports that would be considered more masculine or more feminine in nature? Despite the fact that all sports involve a degree of skill, training, practice, strategy, and execution, we still see sports separated into male and female realms. What’s more, if a girl decides to play a “male” sport, she may be praised for her determination and for trying to “play at the boys’ level,” while a boy who chooses to play a “female” sport (like softball) may be ridiculed for “lowering” himself to the level of the girls.

Some sports now seem to transcend gendered divisions (like soccer, basketball, or track), but it wasn’t long ago that women didn’t have equal opportunities to participate in those sports either. For instance, the NCAA has contested a men’s national basketball championship since 1939; the women’s version has only been around since 1982 (NCAA, n.d.). The Tokyo Olympics in 2021 featured 16 men's soccer teams and only 12 women's squads; the 2023 Women's World Cup will include 32 teams while the men's tournament in 2026 will feature 48. You may be aware that the U.S. women's soccer team has sued for equal pay with the men's team, as they have continued to be paid less despite having far greater competitive success and bringing in greater revenue (Hess, 2019). Unbelievably, it wasn’t until 2014—90 years after their male counterparts— that women were allowed to enter the Olympic ski jumping competition for the first time, as male officials kept claiming into the 21st century that it was too dangerous because the sport could render women infertile and unable to perform household duties (Gibson, 2014).

            Beyond sports, we see gendered participation in a number of other activities. Boys are more likely to be encouraged to pursue carpentry, mechanical work, and other manual labor hobbies and tasks. Girls are still more encouraged to read, write, draw, join a drama group, and engage in other artistic expressions.

Questions

It is also interesting to note that the ways in which boys and girls are treated, while different from each other in virtually every culture, are hardly universal. It is true that cross-cultural studies have shown a common tendency of parents to “pay more attention to boys than girls, to interact more sociably with girls, and to emphasize more achievement and autonomy with boys” (Lips, 1993, p. 271). However, some of the differences that exist come down to the relative value of boys and girls in a given culture. In some cultures where male children are particularly highly prized, girls are fed less, neglected, and even literally left out in the cold without adequate protection more often (Ryle, 2012). Imagine how it would feel to be raised as a girl in such a culture, even if those terrible things were not happening to you! It would be difficult, if not impossible, to feel like the equal of a boy.

Here in the United States, the situation may not be as extreme, but so much of what we see around us does still communicate that men are more highly valued than women in many ways. The differences also seem to vary in scope depending on race and class; for instance, African-American girls are more likely to be prepared by their parents for greater independence than Caucasian girls are, perhaps owing to more egalitarian parenting roles and greater prevalence of women as breadwinners in African-American families (Smith, 1982; Kimmel, 2013). When we are raised in such a gender-unequal environment, it’s predictable that we’d see very different results and life circumstances for men and women as adults.

While we’ve focused mostly on family, it’s also important to note that peer groups and the larger society have a major influence in this as well. Even if a child has parents who are very egalitarian in their own expression of gender roles and encourage their children to engage in activities and behaviors that they most enjoy without regard to these norms, the children are still living in a world that is very gendered, and the freedom of expression and behavior they experience at home may not be shared by those in the outside world. By the time we start attending school, we are in an atmosphere where children who participate in play activities not associated with their gender role are likely to be rejected by their peers, sometimes forcefully so. Some research has found children perceive gender-role violations to be as significant as violations of moral standards (Blakemore, 2003). Therefore, a boy who wears lipstick might be seen as equivalently immoral to a boy who steals from a friend. Again, with social sanctions like these in place, it is little surprise that most of us end up conforming to gender-role expectations in many ways.

Adolescence

            As you all probably remember, adolescence is a time when we are working to assert our existence as independent people, separate from our parents, and establish a reputation of some sort within our peer group. In fact, our peer group is perhaps at its pinnacle of influence during these years. Therefore, their behavior during this time in our lives does considerable work to continue the process of gender role socialization, even though gender roles have been pretty firmly established by the time we reach teenage status.

            Popularity and peer approval help to keep us entrenched in these stereotypical roles, as popular kids are more likely to have a greater number of friends and be desirable dates. Boys come to recognize that their social status is dependent in part upon their athletic ability, their sexual exploits and interests, their ability to be stoic in the face of challenges, and a lack of interest in “girly” activities (Carroll, 2013). Girls learn that they should be less interested in sex (or at least more resistant to having it), but should still be interested in boys. They tend to have overall greater latitude than boys in other areas of behavior—for instance, a girl can be popular as a star athlete, as a singer in the choir, as president of student council. Just as in younger years, the consequences for boys deviating from their gender stereotypes are more significant than they are for women (Carroll, 2013).

            There has been some movement on this front; girls are more likely to initiate dating relationships or sexual behavior than they were in the 1970s, and some studies indicate that 10th-grade girls’ rates of sexual intercourse exceed those of boys; despite the social expectation that they should be more chaste, girls at this age also experience greater pressure to have sex, a confusing double bind (Nahom et al., 2001). Teen girls have been taught to assert their independence more now than in years past, but they still have to deal with the social judgment that comes toward a girl who proudly expresses her sexuality (Carroll, 2013). This same social stigma about sexual activity does not apply to boys, who are praised by peers and sometimes even by adults for their sexual behavior. This is what has often been called the double standard of sexual behavior.

            Many adults look back on their teenage years with discomfort and a sense of relief that they do not have to relive those trying times. Adolescence can be especially challenging for lesbian, gay, and bisexual youth. As noted, during this time we base a lot of our evaluation of ourselves and our peers on popularity, which is in part measured by whom we date. Heterosexual teens can openly discuss their crushes and what happened on their dates over the weekend, and often do, to the delight of their friends. Teens who are dating someone of the same gender, or who are interested in doing so, often cannot talk about it as openly. They may still share their desires with close friends or siblings, if they are accepting of the individual’s sexual orientation, but many do not feel comfortable being more outward and open about their identity as a gay, lesbian, bisexual, or pansexual person (Carroll, 2013). More about the process of navigating life as an LGBTQ+ person will be covered in your next chapter.

Adulthood

            In adulthood, all of the gender role socialization we have endured up to that point continues to play itself out. For example, by the time we finish high school, we’ve seen a lot of representations of traditional gender roles in the media and in families around us—mothers taking care of children, fathers going to work, sons playing sports and doing yardwork, girls helping with dinner and shopping. This is despite the fact that (as noted in more depth in Chapter 11) the so-called “traditional” nuclear family of a working father and stay-at-home mom with children is only the reality in a minority of American households, and an ever-shrinking minority at that (Kimmel, 2013).

            The differences in household duties that we saw in childhood are echoed in adulthood, with the additional potential time burden of child care. If one asks a typical heterosexual couple to write down their duties around the house, the lists may be relatively similar in length, but that’s deceptive. Men have (on average) as many tasks that are “theirs” around the house, but they’re done much less frequently on average than the women’s tasks. (Two examples would be mowing the lawn versus cooking, or doing home repair versus doing laundry.) This results in women averaging about 31 hours per week of housework compared to men’s 14 hours (Belkin, 2008). Only about one in five couples have a truly equal amount of time spent on household chores—and guess what? Those are the couples with the highest levels of marital happiness (Belkin, 2008).

            Child care still falls disproportionately on women. While into the 1800s it was common in American families for men to spend the majority of time with their sons and women with their daughters, the rapid growth of industrialization took more men out of their family homes more often, leaving the care of the kids to the mother (Kimmel, 2013). Twenty-five percent of kids now live in single-parent homes, and the large majority of those single parents are mothers. (Sixty-two percent of kids live with both biological parents, while the remaining 13% live with other relatives, in adoptive homes, or in the foster care system; Kimmel, 2013).

Black Families Matter
 In 25% of black families with two heterosexual parents, fathers do at least 40% of the housework; only 16% of white fathers can say the same (Kimmel, 2013). Regardless of race, in most cases, women do more than their fair share of child care.
 

              Women are working outside the home more now than in previous generations, and they also consistently report higher levels of stress than men do in industrialized nations. This is likely partially explained by the fact that women have to come home and work what has been called the second shift, moving from being employee to housewife/mother as they come home. Do men perform child care as well? Certainly, and it seems they do it more than they did in previous generations. However, women still are more likely to have a disproportionate share of these duties, and men are more likely to perceive that it is simply their wives’ role to fulfill (Kimmel, 2013). Notably, there are racial differences to this pattern as well. In two-parent African-American homes, child care and domestic work tend to be split much more evenly than in Caucasian homes, for example, and differences also exist along divisions of class—blue-collar families have more egalitarian roles in child-rearing and household chores (Kimmel, 2013).

            When it comes to career choices, we can see that many fields are strongly gendered. While some fields show very good balance (for instance, about 53% of U.S. pharmacists are women), others are greatly skewed in a way that neatly falls in line with traditional gender-role expectations: over 80% of librarians, social workers, elementary and middle schoolteachers, and hairdressers are women (U.S. Census Bureau, 2010). Many of the gendered divisions also fall in line with the subordinate/superior nature of the workforce (see box 7.2). That further illustrates why children don’t need to be actively taught men and women are different; they see them fulfilling different roles throughout their lives and take lessons away from that. Sometimes, as illustrated in the box, the message is “Men are in charge, and women work under them.” That probably isn’t something we want to perpetuate, for either our daughters or our sons.

Box 7.3: Gendered Professions

Gender imbalance at work       

Female automotive technician engineer
While men and women can really do any job, there remains among many a belief that certain jobs—automotive mechanic, for example—“should” be done by a specific gender.
"Female automotive technician engineer" by This is Engineering image library is licensed under CC BY-NC-ND 2.0

Sexism

            Gender role socialization and the prominent evidence that shows men and women have major differences in status and a perceived difference in ability often leads to sexism: the act of being prejudiced or discriminating against women. While people can certainly hold prejudicial views or act in discriminatory ways toward men, most sociologists would argue that sexism specifically refers to mistreatment and prejudice focused toward women, since they have less power in society. Still, inflexible ideas about gender roles can cause negative outcomes for men and women alike. In many cases, the views people have about others due to sexism are “assumed to disqualify the person [from] certain vocations or prevent him or her from performing adequately in these jobs or some social situations” (Rathus, Nevid, & Fichner-Rathus, 2014, p. 165). This might mean that women are discouraged from pursuing careers in the hard sciences, while men are looked at suspiciously if they want to be day-care workers.

Causes of sexism and inequality

            The big question is: do the differences between men and women lead to inequality, or vice versa? Why do men dominate nearly every society in history? Is it due to natural differences or the way we’re socialized? Some combination of the two?

            There are certainly some biological differences based on sex, but are they enough to lead to inevitable gender difference in power, employability, earning potential, or political prowess? Some pundits would have you believe so. People like John Gray (1992), author of Men Are from Mars, Women Are from Venus, have promoted the idea that men and women are inherently different and only by recognizing those unchangeable differences will they ever be able to truly understand each other.

However, what exactly those differences are is a matter of some debate, even among people who hold this view. During the 2012 Presidential campaign, Republican candidate Rick Santorum said that it was a bad idea to have women serving alongside men in the military because the men would naturally want to protect the women, and that could compromise the mission at hand; on the other hand, journalist Liz Trotta said that the uptick in sexual assault of women in the military in the 21st century was a predictable result of putting military men and women in close contact and suggested the money spent to combat the problem of military rape could be better spent elsewhere (O’Neil, 2012). Which is it? Are men naturally inclined to be protective of women or to sexually assault them? Surely it cannot be both. At the very least, contradictions like this should make us skeptical of any claim that male/female differences are simply biological.

            Many social influences have a major impact. In nearly every religion, for example, lower status is ascribed to women, even though women in America (and worldwide) are more apt to practice religion faithfully or consider themselves devout (Zastrow, 2010; Kimmel, 2013).  In Judaism, a strict separation of men’s and women’s spheres has been advocated through some scriptural interpretation, though women’s roles are expanding today and all but Orthodox Judaism allow women to serve as rabbis. The Bible has been used by Christians as well to justify placing women in subordinate positions (e.g., in Catholicism, nuns can serve the people but women may not be ordained as priests, and men are seen as the spiritual leaders of their households). However, that should not be taken to mean that most practicing Christians favor the same views; even most Catholics, members of one of the more traditional Christian faiths, favor ordination of women, use of birth control, and acceptance of divorced believers, despite official Vatican doctrine (Lindsey, 2011). Muslims also differ in their adherence to conservative traditional views, which favor woman’s subservience and devotion to her husband and children, and her charge to give her husband male heirs. The Hindu tradition of sati (a widow throwing herself on her husband’s funeral pyre to end her life as well) has been outlawed in India, but still occurs occasionally; the Hindu faith shares with other belief systems a conflicted view about the role of women, from the traditionally submissive to being an important and equal counterpoint to masculinity (Lindsey, 2011).

            Women are presented in hypersexualized ways in the media, and we’re not just talking about pornography, but advertising, movies, television, print media, and more. Women’s body exposure in print media is about four times more common than men’s (Plous & Neptune, 1997). Automobile shows regularly make use of attractive young women, often dressed in tight and/or skimpy outfits, to draw attention to their displays (Greenberg, Bruess, & Conklin, 2011). Men’s portrayals in the media, conversely, tend to place them in more active, assertive, and dominant roles and positions. Men are more apt to be shown solving problems; in athletic or work situations; using alcohol or driving cars; and in scenarios that show them in power (McAnulty & Burnette, 2004). Women’s magazines also feature over ten times as many advertisements for weight-loss products as men’s magazines (Guillen & Barr, 1994).

The growing presence of pornography is an additional concern, as its easy access on the internet has made more readily consumed by a larger number of people. The increasing amount of relatively extreme pornography has caused an escalation in porn consumption, particularly among men, that has caused some to struggle to relate or feel sexually aroused by female partners in their lives (Dines, 2010; Schneider, 2000). One study found that 36% of Internet users access pornography online at least monthly, with the average user conducting a visit every 3-4 days for an average of 12 minutes (Edelman, 2009).

            The way we are treated in the educational system is also different. From elementary education through the college years, female students get less active instruction. Teachers often perceive boys and girls as “naturally” different. They are more apt to call on male students, spend more time talking with them, and encourage them more. Boys are more likely to be asked higher-order thinking questions, and their rule-breaking behavior in the classroom is less likely to be redirected or corrected when it occurs (though they are more likely to be suspended than girls). Additionally, female characters in classroom stories and books are often vastly stereotyped and are underrepresented (Kimmel, 2013).

            There is evidence that girls are pushed to value their appearance as they approach adolescence while boys are more steadily and consistently evaluated on the basis of their talents (Sadker & Sadker, 1995). Girls, whose self-esteem has been higher than boys’ on average heading into adolescence, become less confident in themselves in the junior high years as puberty takes hold and their sexualization increases. Alarmingly, girls’ IQs drop by an average of 13 points during the middle school years, while boys’ scores drop by 3 points (Kimmel, 2013), though this may also be due to the gender bias of standardized tests (and IQ tests are hardly the gold standard of intelligence measures). However, there is hope for women in the educational system. Despite these early challenges, most college students today are women, a disparity that is even greater among racial minorities; women also earn more than half of all master’s degrees. Unfortunately, that greater educational achievement hasn’t translated into income equality. 

Box 7.4: Male Privilege

Additional results of sexism and gender roles

            We’ve already discussed some of the impacts of these differing gender-role expectations. Child care and domestic duties are more often left to women; women and men enter certain careers in vastly different proportions; boys and girls in school are treated differently by teachers. This only scratches the surface of the impact of gender roles.

Economic impact

            Women, perhaps they are perceived as less driven for success, or perhaps because there are fewer opportunities afforded them to advance through the ranks of most companies, have very little of the economic power in this country. As noted earlier, only about one in four CEOs in American companies is a woman. Women get passed over for promotions due to perceptions that they could miss work due to their family commitments (or getting pregnant). Men are rarely asked in interviews how they will balance work and family, as it’s presumed there will be a woman to take on that burden. There is also a perception that men need the promotions more because women’s jobs are more likely to be seen as a “second income” than a breadwinning one. The flip side of this is that a lot of men feel immense pressure to provide. Despite this, many men (up to three-quarters) in recent studies report they would rather spend more time with their families and slow down their careers; 35% say they’d quit their jobs or cut their hours if their wives made more money (Tyre & McGinn, 2003). On another note, while many countries have mandated that paid parental leave must be made available to both mothers and fathers upon a birth or adoption, the United States offers no paid parental leave. Working women are expected to take time off when they have a new baby; men are often expected to take a couple of days off for the birth and then be right back at work. Men who request extended time off for family duties may be viewed with confusion by coworkers and supervisors.

            Though we have discussed plenty of work-related topics, we haven’t yet touched upon one of the most commonly discussed gender inequalities: the gender wage gap. America’s gap is larger than that of any other advanced nation (Kimmel, 2013). In the ten most common job fields for women in America, there are only two where women’s pay is over 90% of what men earn: teaching (90.0%) and nursing (90.5%). In perhaps the most prestigious of these ten most common female jobs, accounting, the gap is widest (71.3%; U.S. Census Bureau, 2012). 

Box 7.5: Gender Wage Gap

           There isn’t too much debate over whether or not the gender gap exists, but the nature of its cause is certainly contested. Some say it’s because women choose lower-paying jobs; some because they take more time off due to family concerns and therefore are less likely to be promoted; others because women are poor negotiators or simply accept salaries offered to them without pushing for an improvement; and still others because women trade higher earning potential for more flexible work hours and family-friendly policies (Furchgott-Roth, 2014; Lukas, 2014; Biggs, 2014).

            Women and men, as noted earlier in this chapter, often choose different career paths, and those that women choose tend to be lower-paying. In fact, four of the most common women’s jobs (cashier, server, maid, retail sales) do not average enough earnings to lift a full-time worker above the poverty line for a family of four; the same is true for only one of the most common male-dominated professions (Hegewisch & Matite, 2014). The question is whether women are truly choosing those paths out of a desire to do that sort of work, or whether they are resorting to those sorts of jobs because they are what is available to them.

            Is it about lower aspirations, then? Do women simply not shoot for the stars as often as men do? Well, if that were true, we’d expect women’s job satisfaction in lower-prestige jobs to be higher than men’s satisfaction in those same jobs. Spoiler alert: it's not. In fact, men at all levels of work are more satisfied with their jobs than their female counterparts, except at the lowest entry-level jobs, where dissatisfaction between men and women is equal (Covert, 2014). What’s more, “Even among extraordinarily ambitious and successful workers of both genders…research found a [wage] gap…Twice as many of the most proactive men advanced to a senior executive level as similar women” (Covert, 2014, p. 33). Could it be that women weren’t playing the game correctly? It would seem not: “When women used the same career advancement strategies as men, they advanced less” (Covert, 2014, p. 34).

            So, what about the argument that men and women are offered similar starting salaries, but men are more apt to push for more money than their female counterparts? That doesn’t seem to be the cause either. Skidmore College psychologist Carinne Moss-Racusin conducted a study that had scientists evaluate (fake) resumés of students applying for a lab manager position (Moss-Racusin, Dovidio, Brescoll, Graham, & Handelsman, 2012). The resumés were identical but for one detail: the name on top was either Jennifer or John. Over 100 professors in the science, technology, engineering, and math (STEM) fields were asked to evaluate the fictitious students’ job prospects, and their responses were telling. Jennifer was perceived as more lacking in qualifications despite having the same background as John. On average, those who were willing to hire Jennifer offered her a salary $4,000 (13%) lower than John (Moss-Racusin et al., 2012). Given data like that, it’s hard to discount the potential for gender bias to impact candidate evaluation and salary offers—and I’m sure the scientists involved in the study would be shocked to discover the results, as they almost certainly would claim their evaluations were based on merit alone.

            Interestingly, when we look at data regarding the wage gap internationally, we find some notable patterns as well. For example, as noted earlier in the chapter, dentistry is a male-dominated profession in the United States. In Europe, however, most dentists are female. If the only determining factor in workers’ pay was the job being done, we’d expect that female dentists in Europe were well-off; after all, dentists are among the most well-paid professionals in America. In Europe, despite many years of schooling, dentists earn salaries near the average salary for all jobs (Kimmel, 2013).

            Finally, something that may surprise you: when biological women undergo sexual reassignment surgery (SRS; also called gender confirmation surgery, previously known as a “sex change operation”) and legally become men, they report experiencing more respectful and prestigious treatment at work. Certain consistent differences are observed: “increases in workplace respect, authority,” and for some, even increases in pay (Schilt & Wiswall, 2006, p. 2). Conversely, when biological men transition and become legally recognized as women, they experience increased harassment, a loss of authority and pay, and in some cases, they are fired (Schilt & Wiswall, 2006). If this isn’t sexism at work, what is it?

            Overall, the most common figure reported is about 77-82%--that is, women working full-time make about 77-82% of what men with full-time jobs make (Kimmel, 2013). Some of the gap can be explained by the fact that women are more likely to be employed in low-earning jobs, but U.S. Census Bureau data (2010) also shows us that women are paid less than men in virtually every job category. It seems that when they initially enter the job market, men and women with the same education levels are nearly even—for instance, female lawyers with 4-10 years’ experience make about 96% of what their male counterparts make. However, for lawyers with more than 10 years’ experience, women make about 74% of what men make (Sterling & Reichman, 2004). This illustrates that even when women do get hired into high-prestige, high-paying fields, their opportunities to advance in those fields are limited, a phenomenon often referred to as the glass ceiling.

            Women are more likely to leave the workforce temporarily when they have children, and this impacts their earning potential as well, since when they come back they have not earned any tenure for the time they were gone, while men who have worked the whole time continue to see their status rise. Perhaps if we had more family-friendly policies that allowed women and men to take more time off for child care after a birth, this gap would shrink somewhat, but for it to disappear we’d also need to have a change in attitude about whose job it is to take care of the kids, and then we’d also need to see that attitude change impact actual behavior.

            The gender wage gap also plays a role in the disproportionate number of women who are poor; the feminization of poverty is a term that reflects this trend. Women are more likely to be single parents (who in many cases are not receiving any child support from children’s fathers), to be primary caregivers for older relatives, and to be victimized by violence (Kimmel, 2013). Add in the gender wage gap and you have a recipe for economic difficulty. Because of this, women are more likely to depend on government programs to cover some of their living expenses. When funding for these programs gets cut, women (and their children) suffer more than men, simply because men are less likely to be poor. (Naturally, single fathers are hurt by these cuts too, just not as much as the single moms who typically earn less.)

Violence

            Men are responsible for a majority of the violence in our culture. In fact, there is evidence to suggest young American men are the most violent people in the industrialized world, if crime statistics carry any meaning. Almost 20% of violence victims in the emergency room were hurt by a current or former spouse/boyfriend/girlfriend (Kimmel, 2013). Domestic violence (discussed further in Chapter 11) has been called both the top and the number two overall cause of injury to women in the United States, and the top cause of injury to women aged 15-44—and most of that violence is committed by men (Barrier, 1998). However, firm numbers can be hard to come by as much domestic violence goes unreported and categorization of incidents may muddy the statistical waters. 

Box 7.6: Gendered Crime

Crime and gender

            There has been a decrease in intimate partner violence over the last 20 years, but male victims have seen a more significant drop than females. Meanwhile, our rape rate in the United States is the highest in the industrialized world, 18 times as high as England’s (Kimmel, 2013). An estimated 20-25% of women experience rape or attempted rape during their college years, and nearly half of women say they’ve had unwanted sex in one form or another. Further, marital rape, a crime in all 50 states, is committed against an estimated 12-25% of married women during their marriages (Kimmel, 2013). Most rapes go unreported, and that is especially true when the victim knows the assailant. When a rape occurs, the victim may experience posttraumatic stress disorder (PTSD) long after the event, and can also be revictimized in the criminal justice system if the crime is reported, since rape survivors are often blamed—subtly and directly—for their victimization.

            Is there violence against men? Yes, definitely—but women’s violence toward men tends to be defensive, while men’s violence toward women is far more often offensive; female victims also suffer injuries more often and their injuries are, on average, more severe. In same-sex relationships, violence occurs as well, and seems to be about as common as it is in heterosexual relationships (Kimmel, 2013).

Social work and sexism

            Despite the fact that over 80% of social work practitioners are women, most social work clients are women, and social work (as one might expect) as a profession is a staunch advocate for women’s rights and equality—including elimination of the gender wage gap—alas, social work doesn’t fare much better than other fields of employment when it comes to opportunities and earnings. Men make up more than their equal share of supervisory and managerial roles, and even receive 14% higher salaries (a gap of about $7,000 for comparable jobs) on average than their female coworkers (U.S. Bureau of Labor Statistics, 2008; NASW, 2011). One would think that if any field would get this right, it would be social work; yet we are prone to the same biases and institutional sexism perpetrated by other career areas.

Sexual harassment

            Sexual harassment includes “unwelcome sexual advances, requests for sexual favors, and other verbal or physical harassment of a sexual nature” as well as mistreating someone on the basis of their sex—for example, making jokes about women’s intelligence in front of female coworkers (Equal Employment Opportunity Commission [EEOC], n.d., para. 1). It can be perpetrated by any gender against other people of any gender.

            Often, sexual harassment carries with it an element of unequal power—as when the perpetrator is a person in a position of relative privilege or prestige compared to the target of the harassment (e.g. boss to subordinate, teacher to student, doctor to patient). This imbalance of power can cause the individual being harassed to feel powerless to refuse the advances or to speak out about the mistreatment, because there can be significant consequences for doing so—loss of job, demotion, poor grades, etc. Therefore, even relationships that appear consensual between a boss and subordinate or a professor and student—situations in which the people involved are all adults—can be perceived as harassment since the person with less power may not truly feel free to end the relationship, and may have consented in the first place due to similar concerns.

            If someone wishes to file a charge of sexual harassment, he/she generally has 180 days from the date of the incident to do so (though state laws may go beyond that limitation) (EEOC, n.d. a). In order to prove a claim, someone must show that the harassment has “explicitly or implicitly affect[ed] an individual's employment, unreasonably interfere[d] with an individual's work performance, or create[d] an intimidating, hostile, or offensive work environment” (EEOC, n.d. b, para. 2). Not all harassment must be in the quid pro quo form—seeking sexual favors in exchange for some sort of positive treatment (e.g., a promotion). It can simply be the creation of a hostile environment, which is somewhat in the eye of the beholder. For example, a female law school intern at a firm may file a sexual harassment charge if the male lawyers at the firm put up a calendar featuring bikini-clad models in the break room and make comments about the bodies of the women in the calendar while in the presence of the intern.

Feminism

            Social work supports the philosophy of feminism. The word clearly carries some level of stigma among today’s young people, as your authors have noticed that many of our students do not claim the label themselves even though they tend to agree with feminist ideals. Defining the term has been a trickier matter than perhaps it needs to be. Estelle B. Freedman (2002), one of the founders of Stanford University’s feminist studies program, provides the following explanation:

Feminism is a belief that women and men are inherently of equal worth. Because most societies privilege men as a group, social movements are necessary to achieve equality between women and men, with the understanding that gender always intersects with other social hierarchies. (p. 7)

If we were to ask students how many of them believe that men and women have equal worth, we believe most would raise their hands, if not all of them. Yet asking “How many of you are feminists?” gets a decidedly weaker response. This may be due to the tendency some have to associate the word feminism with caricatured behaviors such as bra-burning, which seems to stem from a protest of the group New York Radical Women (NYRW) at the Miss America pageant in 1968—a protest at which no bras were actually burned, though rumors abounded to the contrary (Buchanan, 2011). Feminists are also sometimes stereotyped as man-haters or lesbians; while some feminists may hate men and some are certainly lesbians, these characterizations serve as attempts to reduce the movement to a group that can be easily dismissed due to its extremism.

In reality, most feminists do not hate men, and lesbians compose a small (but important) percentage of the whole; moreover, men can and do identify as feminists (your authors included)! Sometimes, people suggest that if the word is really just about equality, then a term like humanist should be used. Ms. Freedmen’s definition nicely explains the need to emphasize the focus on women; since women are the ones most likely to be disadvantaged, the bulk of the focus of the movement goes their way. However, most feminists would say that they support men who wish to be stay-at-home parents just as much as women who want to be CEOs. The whole idea of feminism involves rejecting the oppressive limitations of society’s prescribed gender roles, not allowing them to define what people are allowed to do. Feminists are bothered by the impact of gender roles on men and women alike—for instance, the fact that men are less likely than women to seek help for emotional difficulties, that men may feel pressure to work long hours in a job they do not enjoy in order to provide for a better lifestyle for their family, or that they may endure ridicule or shame when they are unable to handle an emotionally challenging situation without crying.

As a movement, feminism (or the women’s rights movement) has made some impressive strides in American history. Let’s discuss a few of them.

New Spider-Woman
 If you believe that whether you had a daughter or a son, your child should still be able to pursue the same avenues of self-fulfillment, have the same privileges and rights and access to the same resources, and should not be limited in their life (from work to family to self-expression) in any way simply due to their chromosomes, then you are probably a feminist!
"New Spider-Woman" by greyloch is licensed under CC BY-SA 2.0

Suffrage

            The first major push for women’s rights came with the quest for suffrage. The stage for a serious movement to gain voting rights was set when women became active in the abolitionist movement, calling for an end to slavery. Prominent women in the movement gained experience speaking in public and understanding the politics of organizing protest movements, giving them valuable experience toward being their own best advocates (Flexner, 1975).

Box Lunch Talk: On Account of Sex – Historical Society of Carroll County,  Maryland
Despite its eventual success, many people fought the movement to give women the right to vote right down to the end—The National Association Opposed to Woman Suffrage disbanded after the passage of the Nineteenth Amendment in 1920, though founder Josephine Dodge remained active in opposing the work of feminist groups. (Photo source: Library of Congress)

            The first visible step in the movement for suffrage occurred at the Seneca Falls Convention of 1848, which was covered by national media and attracted the attention of many women eager for change, as well as attracting the support of Frederick Douglass, the first man to publicly defend women’s right to vote (Terborg-Penn, 1998). Elizabeth Cady Stanton and a handful of others organized the convention to pull together support for the establishment of a truly united movement toward gaining the right to vote (Severn, 1967). This is a pattern that would continue—women united for social change of some form would also use their collective power to address their own inequality.

            Susan B. Anthony joined Stanton as pioneers of the movement in 1851 and they worked together toward this common goal until Stanton’s passing in 1902 (Rossi, 1973). Though she did not survive to see the passing of the Nineteenth Amendment, which finally gave American women the right to vote in 1920, Stanton’s diligent work nonetheless was an undeniable part of accomplishing the monumental task. It is worth noting that the 19th Amendment had really only succeeded in giving white women the right to vote--minority women still found their path blocked by local customs, racist literacy tests, poll taxes, and sometimes even laws (like those specifically prohibiting Native American voting; PBS, 2020). After the passage of the amendment, feminism died down a bit in prominence—the major goal had been achieved. However, a second wave would be coming later, concurrent with the civil rights movement.

Betty Friedan’s book The Feminine Mystique is often lauded as a major feminist text that revitalized the movement and gave more women the impetus to question their circumstances and the roles they’d been socialized to fill. According to Friedan, there were very few happy housewives; the “mystique” she spoke of was a nebulous sense of despair and uselessness that “left women asking, ‘Is this all?’” (Friedan, 1963). As one housewife said in the book, “…I’m desperate. I begin to feel I have no personality. I’m a server of food and a putter-on of pants and a bedmaker, somebody who can be called on when you want something. But who am I?” (Friedan, 1963, as cited in Collins, 2009).

Reproductive rights

“No woman is completely free unless she is wholly capable of controlling her fertility and… no baby receives its full birthright unless it is born gleefully wanted by its parents.” –Alan Guttmacher, former president of Planned Parenthood (2008)

            Taken together, the issues of abortion and birth control often are collectively referred to as reproductive rights. Margaret Sanger, early birth control pioneer and founder of what became Planned Parenthood, was arrested in 1916 for opening the first birth control clinic in New York (Buchanan, 2011). To Sanger and other feminists, the right to control one’s own reproduction should belong to everyone. The idea was prominent at the time (and is still held by some today) that women who used birth control methods were promiscuous and immoral, but Sanger wanted to fight against that sentiment; in her mind and in the views of other feminists, dominion over one’s body was a foundational human right (Buchanan, 2011).

            The birth control pill (often just called “The Pill”) went on sale in 1960 after being approved by the Food and Drug Administration (FDA), but at the time, 30 of the 50 states had legal restrictions on sale, advertisement, and promotion of anything related to birth control (Collins, 2009; Kimmel, 2013). This made it relatively difficult for poorer women who had to access medical care through public clinics, while middle- and upper-class married women had no problems quietly getting their prescriptions through family doctors. Connecticut’s Planned Parenthood League actually ran a shuttle bus for women to go across state lines to get the pill in states that didn’t restrict their access, like Rhode Island or New York. It wasn’t until 1965 that the bans on married women using birth control were struck down by the Supreme Court, and in 1972, single women were finally able to legally get birth control nationwide (Collins, 2009). Imagine if men had had to go to the same lengths to win the rights to buy and use condoms!

            Despite those decades-old, hard-won victories, women are finding today that their right to use birth control is under attack again from various corners. The Hobby Lobby Supreme Court decision has upheld the rights of companies to refuse to provide employee health insurance that provides birth control coverage if the business has a serious religious and moral objection to birth control, despite the fact that insurance companies would much rather cover birth control than the far more expensive process of pregnancy and birth. Birth control pills cost between $160 and $600 per year, while the price of a vaginal birth with no complications was between $3,300 and $37,000 in one study (Palmer, 2012; Neporent, 2014)

            Abortion is another reproductive rights battle that had feminists at the forefront. Abortion had been prohibited in every state by 1965, though some exceptions existed for the survival of the mother or in the case of fetal abnormalities. Despite the fact that abortion was illegal, the procedure was still performed, sometimes in clandestine medical settings, sometimes in homes by potentially unscrupulous people looking to make money off of people’s desperation. One thing is clear—outlawing abortion did not stop abortion from happening.

            In 1973, the Supreme Court ruled in Roe v. Wade that women had a constitutional right to abortion within some limitations. The Court determined that the state could restrict access to abortion once a woman’s pregnancy reached the point of viability, unless the woman’s health was at risk; states were free to legislate as they wished at that point. In recent years, states have devised and passed quite a few laws that can restrict a woman’s access to abortion, and the Supreme Court is likely to hear cases in the near future that may impact abortion right in the United States. 

Box 7.7: Abortion Laws

Abortion

Equal Rights Amendment

            In 1971 began an effort to pass a constitutional amendment, the Equal Rights Amendment (ERA). In reality, such an amendment had first been proposed in the 1920s, but it was finally passed by the House of Representatives in 1971, then passed the Senate by a resounding vote of 84 to 8. (Can you imagine such broad agreement in Congress now?) All that was left was for 38 of the 50 states to ratify the amendment, and it would become national law (Buchanan, 2011; Collins, 2009).

            The proposed amendment was simple enough, certainly much more so than a lot of laws. It stated that equality could not be denied or restricted by stated or the federal government based on someone’s sex; Congress could enforce the directive; and it would take effect two years after ratification. Perhaps this simplicity was what made it pass so easily through both houses of Congress, but the process struggled from there.

            It proved to be quite difficult to get the state approvals necessary to pass the ERA. By 1973, 24 states had approved the amendment, but a prominent woman opponent had begun to urge the country to rethink the proposed law (Buchanan, 2011; Collins, 2009). Attorney Phyllis Schlafly set about making speeches and hosting rallies to convince people that the ERA would cause untold social ills. Conservatives posited that the amendment would further weaken the institute of marriage, would prevent a woman from allowing her husband to provide for her, would require women to give up preferential treatment in custody cases, and would mandate they submit themselves to the military draft (Buchanan, 2011; Collins, 2009). Other arguments included that the amendment would pave the way for same-sex marriage and unisex bathrooms; Schlafly, who died in 2016, continued into her last decade to claim the ERA would deny Social Security benefits for housewives and widows (Eliperin, 2007).

            By the seven-year deadline, only 34 states had ratified the ERA. Though the National Organization for Women (NOW) managed to get the deadline extended another three years, no more states would join in ratification. The amendment died thanks to powerful opposition from certain groups and in part to one very outspoken professional woman who continued to assert that women would be happiest if they were mothers and housewives—though she certainly didn’t fit that mold herself (Buchanan, 2011; Collins, 2009).

Political power

            Women, despite slightly outnumbering men, have a considerably smaller portion of the political power in the United States. The first female Congressperson was Jeanette Rankin of Montana in 1917, while the first female Senator was Rebecca Latimer Felton (1922)—but she had been appointed rather than elected, and served for only one day. The first elected female Senator was Hattie Caraway in 1931. Women have increasingly entered political races since then, but only 13 races for Senate in history have pitted a female Republican versus a female Democrat, while literally thousands of races have seen two men face off for a seat.

Congresswoman Nancy Pelosi pays tribute to the legacy of Shirley Chisholm
Shirlye Chisholm, commemorated here on a postage stamp, was the first Black woman to serve in Congress, spending 1969-1983 in the House of Representatives. In 2021, there were 143 women (104 Democrats and 39 Republicans) in the Senate and House of Representatives, compared to 391 men.
"Congresswoman Nancy Pelosi pays tribute to the legacy of Shirley Chisholm" by Speaker Nancy Pelosi is licensed under CC BY 2.0

            The Congress that took office in 2015 was the first in United States history to feature more than 100 women among its 535 members. Twenty elected Senators and 84 members of the House of Representatives were women (76 Democrats and 28 Republicans in total). Still, only six women were governors in May 2015 compared to 44 men; twenty-three states have never had a female governor. Women held 24.2% of state legislative offices; 16 of 100 largest U.S. cities’ mayors were women, as were seven members of President Obama’s Cabinet (Center for American Women and Politics, 2015).

            How many women in government is enough? I’m not sure there’s a consensus answer to that question, but I’d say it’s pretty clear that we are lagging far behind a number of countries you might not expect. The Supreme Court at the time of this book’s publication (2021) has three female Justices out of nine—Sonia Sotomayor, Amy Coney Barrett, and Elena Kagan. Both Kagan and Sotomayor were appointed by President Obama, while Barrett was appointed by President Trump to replace the late Ruth Bader Ginsburg. They still make up just a third of the nine-person membership of the Supreme Court. The longest-serving of these three women, Ginsburg, was asked about the increased appointment of women to the country’s highest court. This was what she had to say: “People ask me sometimes…when do you think it will be enough?  When will there be enough women on the [C]ourt? And my answer is when there are nine” (PBS, 2015). 

Box 7.8: Women in Power

Women in legislatures

Which country on this list surprises you the most?

(Inter-Parliamentary Union, 2019)

 

References

Abusheika, N., Lass, A., & Brinsden, P. (2011). XX males without SRY gene and with infertility. Human Reproduction, 16(4), pp. 717-718.

Barrier, P. A. (1998). Domestic violence. Mayo Clinic Proceedings 73(3), pp. 271-274.

Belkin, L. (2008, June 15). When Mom and Dad share it all. New York Times Magazine.

Bem, S. (1975). Sex role adaptability: one consequence of psychological androgyny. Journal of Personality and Social Psychology, 31(4), pp. 634-643.

Biggs, A. (2014). Sex, workers: Gender discrimination does not explain the male-female pay gap. In N. Merino (Ed.), The wage gap. Greenhaven.

Blakemore, J. E. O. (2003). Children’s beliefs about violating gender norms: Boys shouldn’t look like girls, and girls shouldn’t act like boys. Sex Roles, 48(9/10), pp. 411-419.

Brence, M. (2015, May 19). Gay marriage marks 1 year in Oregon: A look back at best photos, stories. The Oregonian. Retrieved from http://www.oregonlive.com/politics/index.ssf/2015/05/gay_marriage_marks_1_year_in_o.html

Buchanan, P. D. (2011). Radical feminists: A guide to an American subculture. Greenwood.

Carey, B. (2011, May 21). Need therapy? A good man is hard to find. New York Times. Retrieved from http://www.nytimes.com/2011/05/22/health/22therapists.html.

Carroll, J. (2010). Sexuality now (4th ed.). Wadsworth/Cengage Learning.

Center for American Women and Politics (2015). Current numbers of women officeholders. Retrieved from http://www.cawp.rutgers.edu/fast_facts/levels_of_office/Current_Numbers.php.

Chandler, K. (2015, March 18). Alabama abortion law lets judges appoint lawyers for fetuses. MSNBC. Retrieved from http://www.msnbc.com/msnbc/alabama-abortion-law-lets-judges-appoint-lawyers-fetuses.

Colburn, D. (2008, March 27). Transgender pregnancy raises a host of issues. Seattle Times. Retrieved from http://www.seattletimes.com/seattle-news/health/transgender-pregnancy-raises-a-host-of-issues/

Collins, G. (2009). When everything changed: The amazing journey of American women from 1960 to the present. Little, Brown and Company.

Crooks, R. & Baur, K. (2014). Our sexuality (12th ed.). Wadsworth/Cengage Learning.

Covert, B. (2014). Institutional bias partially explains the gender wage gap. In N. Merino (Ed.), The wage gap. Greenhaven.

Dines, G. (2010). Pornland: How porn has hijacked our sexuality. Beacon.

Edelman, B. (2009). Markets: Red light states: Who buys adult online entertainment? Journal of Economic Perspectives, 23(1), pp. 209-220.

Eilperan, J. (2007, March 28). New drive afoot to pass Equal Rights Amendment. Washington Post. Retrieved from http://www.washingtonpost.com/wp-dyn/content/article/2007/03/27/AR2007032702357_pf.html.

Equal Employment Opportunity Commission (EEOC) (n.d. a). Sexual harassment. Retrieved from http://www.eeoc.gov/laws/types/sexual_harassment.cfm.        

Equal Employment Opportunity Commission (EEOC) (n.d. b). Facts about sexual harassment.  Retrieved from http://www.eeoc.gov/eeoc/publications/fs-sex.cfm.

Flexner, E. (1975). Women’s involvement in the antislavery movement. In B. Stalcup (Ed.), Women’s suffrage. Greenhaven.

Freedmen, E. B. (2002). No turning back: The history of feminism and the future of women. Ballantine Books.

Friedan, B. (1963). The feminine mystique. Norton.

Furchtgott-Roth, D. (2014). The gender wage gap is a myth. In N. Merino (Ed.), The wage gap. Greenhaven.

Garcia, L. (1982). Sex-role orientation and stereotypes about male-female sexuality. Sex Roles, 8, pp. 863-876.

Gibson, O. (2014, February 10). Sochi 2014: Women ski jumpers have point to prove after 90-year wait. The Guardian. Retrieved from http://www.theguardian.com/sport/blog/2014/feb/10/ski-jumping-women-winter-olympics-2014-sochi.

Guillen, E. O., & Barr, S. I. (1994). Nutrition, dieting, and fitness messages in a magazine for adolescent women, 1970-1990. Journal of Adolescent Health, 15(6), pp. 464-472.

Guttmacher Institute (2008). Alan Guttmacher 1898-1974. Retrieved from http://www.guttmacher.org/about/alan-bio.html.

Guttmacher Institute (2015). State policies in brief: An overview of abortion laws. Retrieved from http://www.guttmacher.org/statecenter/spibs/spib_OAL.pdf.

Greenberg, J. S., Bruess, C. E., & Conklin, S. C. (2011). Exploring the dimensions of human sexuality (4th ed.). Jones & Bartlett.

Hegewisch, A. & Matite, M. (2014). Women’s wages are lower due to occupational segregation. In N. Merino (Ed.), The wage gap. Greenhaven.

Hess, A. J. (2019, June 19). US women's soccer games now generate more revenue than men's--but the players still earn less. CNBC. Retrieved from https://www.cnbc.com/2019/06/19/us-womens-soccer-games-now-generate-more-revenue-than-mens.html.

Hirokawa, K., Yagi, A., & Miyata, Y. (2006). An experimental examination of the effects of sex and masculinity/femininity on psychological, physiological, and behavioral responses during communication situations. Sex Roles, 51(1/2), pp. 91-100.

Hopkins, P. (1998). How feminism made a man out of me: The proper subject of feminism and the problem of men. In T. Digby (Ed.), Men doing feminism (pp.33-56). Routledge.

Inter-Parliamentary Union (2019). Women in national parliaments. Retrieved from http://www.ipu.org/wmn-e/classif.htm.

Kimmel. M. (2013). The gendered society (5th ed.). New York: Oxford University Press.

Lindsey, L. L. (2011). Gender roles: A sociological perspective (5th ed.). Prentice Hall.

Lips, H. M. (1993). Sex & gender: An introduction. Mayfield.

Lukas, C. (2014). The “equal pay day” myth. In N. Merino (Ed.), The wage gap. Greenhaven.

McAnulty, R. D. & Burnette, M. M. (2004). Exploring human sexuality: Making healthy decisions. Pearson.

Moss-Racusin, C. A., Dovidio, J. F., Brescoll, V. L., Graham, M. J., & Handelsman, J. (2012). Science faculty’s subtle gender biases favor male students. Proceedings of the National Academy of Sciences of the United States of America, 109(41), pp. 16474-16479.

Nahom, D., Wells, E., Gilmore, M. R., Hoppe, M., Morrison, D. M., Archibald, M., Murowchick, E., Wilsdon, A., & Graham, L. (2001). Differences by gender and sexual experience in adolescent sexual behavior: Implications for education and HIV prevention. Journal of School Health, 71(4), p.153-158.

Nation Association of Social Workers (NASW) (2011). Social work salaries by gender: Occupational profile. NASW Center for Workforce Studies & Social Work Practice.

National Collegiate Athletic Association (NCAA) (n.d.). Men’s basketball championship history. Retrieved from http://www.ncaa.com/history/basketball-men/d1.

National Collegiate Athletic Association (NCAA) (n.d.). Women’s basketball championship history. Retrieved from http://www.ncaa.com/history/basketball-women/d1.

Neporent, L. (2014, January 16). Cost of giving birth varies 10-fold, study finds. ABC News. Retrieved from http://abcnews.go.com/Health/cost-giving-birth-varies-10-fold-study-finds/story?id=21547172.

O’Neil, C. (Director). (2012, February 14). Ricky Gervais [Television series episode]. In J. Stewart (Producer), The Daily Show. New York: Comedy Central.

Palmer, K. (2012, March 5). The real cost of birth control. US News and World Report. Retrieved from http://money.usnews.com/money/blogs/alpha-consumer/2012/03/05/the-real-cost-of-birth-control.

Pauletti, R. E., Menon, M., Cooper, P. J., Aults, C. D., & Perry, D. G. (2017). Psychological androgyny and children's mental health: A new look with new measures. Sex Roles, 76, 705-718.

PBS (2015). When will there be enough women on the Supreme Court? Justice Ginsburg answers that question. Retrieved from http://www.pbs.org/newshour/bb/will-enough-women-supreme-court-justice-ginsburg-answers-question/.

PBS (2020). Not all women gained the vote in 1920. Retrieved from 

https://www.pbs.org/wgbh/americanexperience/features/vote-not-all-women-gained-right-to-vote-in-1920/

Plous, S. & Neptune, D. (1997). Racial and gender biases in magazines and advertising. Psychology of Women Quarterly, 21(4), pp. 627-644.

Rathus, S. A., Nevid, J. S., & Fichner-Rathus, L. (2014). Human sexuality in a world of diversity (9th ed.). Pearson.

Reynolds, L.T., & Hermany-Kinney, N.J. (2003). The handbook of social interactionism. AltaMira.

Rossi, A. S. (1973). The working relationship of Elizabeth Cady Stanton and Susan B. Anthony. In B. Stalcup (Ed.), Women’s suffrage. Greenhaven.

Rubin, J., Provenzano, F., & Luria, Z. (1974). The eye of the beholder: Parents’ views on sex of newborns. American Journal of Orthopsychiatry, 44(4), pp. 512-519.

Sadker, M. & Sadker, D. (1995). Failing at fairness: How our schools treat girls. Touchstone.

Salsberg, E., Quigley, L., Mehfoud, N., Acquaviva, K., Wyche, K., & Sliwa, S. (2017). Profile of the social work workforce. George Washington University Health Workforce Institute and School of Nursing. Retrieved from https://www.cswe.org/Centers-Initiatives/Initiatives/National-Workforce-Initiative/SW-Workforce-Book-FINAL-11-08-2017.aspx.

Sandnabba, N. K. & Ahlberg, C. (1999). Parents’ attitudes and expectations about children’s cross-gender behavior. Sex Roles, 40(3/4), pp. 249-263.

Schilt, K. & Wiswall, M. (2006). Before and after: Gender transitions, human capital, and workplace experiences. Unpublished manuscript, Department of Economics, New York University, New York, NY. Retrieved at http://www.econ.nyu.edu/user/wiswall/research/schilt_wiswall_transsexual.pdf.

Schneider, J. P. (2000). Effects of cybersex and addiction on the family: Results of a survey. Sexual Addiction and Compulsivity, 7(1), pp. 31-58.

Severn, B. (1967). Free but not equal: How women won the right to vote. In B. Stalcup (Ed.), Women’s suffrage. Greenhaven.

Shimonaka, Y., Nakazato, K., Kawaai, C., & Sato, S. (1997). Androgyny and successful adaptation across the life span among Japanese adults. Journal of Genetic Psychology, 158(4), pp. 389-400.

Skolnick, A. (1992). The intimate environment: Exploring marriage and the family. HarperCollins.

Smith, E. J. (1982). The black female adolescent: A review of the educational, career, and psychological literature. Journal of Social Issues, 39(3), pp. 1-15.

Sterling, J. & Reichman, N. (2004). Gender penalties revisited. Colorado Women’s Bar Association.

Terborg-Penn, R. (1998). African-American women in the struggle for the vote, 1850-1920. In B. Stalcup (Ed.), Women’s suffrage. Greenhaven.

Tyre, P. & McGinn, D. (2003, May 12). She works, he doesn’t. Newsweek, pp. 45-53.

U.S. Bureau of Labor Statistics (2008). Women in the labor force: A databook (report 1011). U.S. Department of Labor.

U.S. Census Bureau (2012). Employed civilians by occupation, sex, race, and Hispanic origin: 2010. Retrieved from http://www.census.gov/compendia/statab/2012/tables/12s0616.pdf.

Williams, J. E. & Best, D. L. (1994). Cross-cultural views of women and men. In W. J. Lonner &R. Malpass (Eds.), Psychology and culture. Allyn & Bacon.

Chapter 8: Sexuality and LGBTQ+ Clients

Sexuality is an important component of our identities and day-to-day lives. Social workers, in whatever way they work with people, will almost undoubtedly deal with some aspect of clients’ sexual behavior and sexuality over the course of their careers. Believe it or not, you can go all the way through some master’s degree programs in social work without taking any classes on human sexuality. This, in your authors’ minds, is a travesty; social workers must be well-versed in issues of human sexuality and comfortable discussing such topics if they are going to be working with people in a helping capacity. It’s not unusual for issues related to sexuality to come up in counseling, for example, even if the presenting problem wasn’t a sexual one. Clients who are struggling with sexual issues (e.g., sexual dysfunctions, coming out, infertility, sexual abuse) often see significant impacts on other areas of their lives, from work productivity to relationship health to academic performance. Social workers need to be knowledgeable enough to handle these issues appropriately and must be nonjudgmental about clients’ sexual orientations, behaviors, and proclivities in order to effectively work with them. When you’ve finished reading this chapter, you should be able to:

1. Identify major contributors to the field of sexology and the focus of their research;

2. Explain the shortcomings of abstinence-only sex education;

3. Understand the meanings of trans* terminology;

4. Define sexual orientation and several orientation terms;

5. Differentiate between sexual and romantic orientation;

6. Debunk several common myths about LGBTQ+ people;

7. Discuss several aspects of life experienced by LGBTQ+ people;

8. Relate what is meant by the gender binary and evaluate the idea’s legitimacy;

9. Define gender identity and explain related terminology;

10. Identify the causes and impact of homophobia and heterocentrism.

Sexology

            Despite the fact that we’ve been having sex as long as we’ve existed as a human species, the formal study of sex, sexology, is a relatively young science, really only seriously pursued since the 1800s. Sexuality was often regarded with “untouchable” status due to religious influences, as it was felt that decent men certainly wouldn’t take it upon themselves to study such a subject—and that God certainly wouldn’t approve of a woman doing so!

            Still, some people took it upon themselves to move scientific inquiry into the realm of sex and sexuality, despite public sentiment and the disapproval of religious leaders. Let's take a look at five of them.

Richard von Krafft-Ebing. Photogravure.
"Richard von Krafft-Ebing. Photogravure." is licensed under CC BY 4.0

Richard von Krafft-Ebing (1840-1902)

            Early sex research tended to focus upon the problems of sexual behavior, and Krafft-Ebing was perhaps the most significant example of that pattern. Probably the most influential early sex researcher, Krafft-Ebing took the stance that masturbation was the root of all sexual disorder and deviance. His most famous work, Psychopathia Sexualis, was a collection of case studies of people who exhibited behaviors like fetishism, sadism, masochism, and homosexuality. (In fact, Krafft-Ebing invented the terms sadomasochism and transvestite.) Krafft-Ebing believed these acts to be perversions rather than possibly healthy variations of sexual interest and behavior (Yarber & Sayad, 2013).

Box 8.1: An excerpt from Krafft-Ebing's Psychopathia Sexualis

“Case 87. Miss X., age twenty-six…Coitus with a man she disdained…Erotic dreams were always of a homosexual nature…In mutual kissing she derived the most pleasure from biting her partner…by preference in the lobe of the ear, causing pain and subsequent swelling. X. always had leaning toward male occupations, loved to be among men as one of their own. From her tenth to her fifteenth year she worked in the brewery of a relative, if possible clad in trousers and a leather apron. She was bright, intelligent and good-natured, and felt quite happy in her perverse, homosexual existence. She smoked and drank beer. Female larynx…small, badly developed breasts, large hands and feet.” (Krafft-Ebing, 1886/1965, p. 140)

Sigmund Freud
"Sigmund Freud" by wordscraft is licensed under CC BY-NC-ND 2.0

Sigmund Freud (1856-1939)

            Freud conducted his work in the morally oppressive environment of the Victorian Era, and yet may be the person most responsible for bringing sexology into the spotlight and inspiring people to take up the mantle after him. Actually, that’s a bit misleading--it's a bit of a stretch to call Freud a sexologist. He mostly posited theories that were unprovable and based on his own best guesses derived from his work with many patients.

            Among Freud’s ideas were penis envy, the notion that girls resented that boys had penises while they did not (some have proposed that Freud saw the vagina simply as the lack of a penis); the Oedipus complex, when a boy (age 3-5) views his father as a rival for his mother’s affections and wants to eliminate his father so he can be with his mother sexually; and the belief that vaginal orgasms (those obtained from vaginal penetration) were more developed and advanced than clitoral orgasms (those obtained from stimulation of the clitoris). Again, Freud had no real proof of any of these “findings,” but he put them forward as truths rather than theories, and he built much of his work around them (Carroll, 2013; Yarber & Sayad, 2013; Gathorne-Hardy, 1998).

            However, Freud’s work cannot simply be dismissed. He did make some statements that were important and ahead of their time. For example, Freud believed that all people were essentially born bisexual—certainly a progressive idea—though he also believed that heterosexuality was the result of normal development. Still, he did not see homosexuality as a mental illness, but rather a sign that something in development went awry (Carroll, 2013; Herdt & Polen-Petit, 2014). 

            Freud also was perhaps the first prominent individual to say that sexuality was a central component of one’s identity. While at times he may have emphasized sexuality to the point of being myopic, he was correct that it’s an important part of our identities and self-concepts, as well as our relationships with others. That contribution alone was enough to ensure that further research would continue to be done in the area of sexology.

 

This image is taken from Page 244 of Havelock Ellis : a biographical and critical survey
"This image is taken from Page 244 of Havelock Ellis : a biographical and critical survey" by Medical Heritage Library, Inc. is licensed under CC BY-NC-SA 2.0

Havelock Ellis (1859-1939)   

            Often considered the “father of sexology,” Havelock Ellis significantly departed from the way Krafft-Ebing and Freud thought of sexuality, and there was good reason for this. Ellis had many nocturnal emissions as a child, and the belief among physicians at the time was that people who experienced this phenomenon regularly would lose their eyesight, become mentally ill, and eventually die from the loss of sperm in this manner (Yarber & Sayad, 2013; King, 2009). Ellis was petrified but noted that none of what was predicted occurred. He became angry at having been scared for really no good reason, and devoted his life to the study of sex so fewer people would have experiences like his, where normal, harmless behavior was pathologized to the extreme.

            As a doctor, Ellis had the ability to study sexual behavior without public condemnation. He sought to debunk a lot of myths about sexuality and did so; particularly notable was his assertion that homosexuality was neither an illness nor a perversion, and that masturbation was also normal (King, 2009; Yarber & Sayad, 2013). In fact, Ellis was an early advocate of the idea that homosexuality was congenital—that is, one was born homosexual. Ellis’s acceptance of many behaviors as within the realm of sexual health was markedly different from other sexologists of his time. He helped to influence researchers that followed him to move away from a focus on stigmatizing sexual behavior toward seeking to understand it (King, 2009; Yarber & Sayad, 2013).

File:Alfred Charles Kinsey.jpg
"File:Alfred Charles Kinsey.jpg" by Proyecto Historiador 2
 is licensed under CC BY-SA 3.0

Alfred Kinsey (1894-1956)

            Kinsey is often considered the father of American sexology, as he was the first U.S. researcher to use modern scientific methods in the study of sexuality, ushering in the era of modern sex research. Kinsey, like Ellis, had been given incorrect information about normal sexual behavior as a minor and had been led to believe he would go blind, insane, or both. While working at Indiana University as a biology professor specializing in zoology and entomology, Kinsey had an opportunity to teach in a marriage and family course (King, 2009; Gathorne-Hardy, 1998). He soon found that, much like the medical professionals with whom he spoke in his youth, his students had some major mistaken beliefs about sexual behavior and its effects. To Kinsey’s chagrin, there was little empirical information to be found on sexual behavior (King, 2009).

            Kinsey, who spent much of his early career studying insects, used his skills of data collection to design an interview method that allowed him to take in information about thousands of respondents’ complete sexual histories—their behaviors, their fantasies, their desires, their relationships, and their attractions. He started with exclusively male subjects, with a disproportionate number of them being college-educated, middle- and upper-class white males, since that was the population to which Kinsey had the easiest access (Gathorne-Hardy, 1998). (In fact, Kinsey omitted the data concerning his African-American subjects from his first book because he felt the sample size to too small to be meaningful—and he would later be criticized for not having a racially diverse sample.) Kinsey and a small group of research associates conducted face-to-face, lengthy interviews with 5,300 men, compiling the data into his 1948 book Sexual Behavior in the Human Male (often simply called The Kinsey Report; Gathorne-Hardy, 1998).

            Kinsey’s report shook up the establishment, to say the least. Though all he truly did was to report what people told him and his fellow researchers during the interview process, the public (and some people in academia) attacked Kinsey, accusing him of having an immoral agenda and hoping to undermine the fabric of American religious beliefs (Gathorne-Hardy, 1998). What had them so upset?

            Kinsey’s work brought to light to considerable discrepancies between the stated morals and values of the time and the actual behavior in which Americans were engaging. It was true that Kinsey eschewed a moral stance, but that was due to his desire as a scientist to report the findings without judgment of his participants (Gathorne-Hardy, 1998). Still, people accused him of simply manipulating his data or intentionally taking on a disproportionate number of sexually deviant subjects in order to skew his results. Kinsey continued to stand firm, and drew few conclusions other than saying that America needed to confront what was happening. People were preaching a set of values that weren’t actually being followed very much. Kinsey didn’t see the sexual behavior as a problem, but felt it was necessary to start a national conversation about the topic and stop allowing sex to be such a taboo. Kinsey followed up his initial tome with Sexual Behavior in the Human Female in 1953, interviewing nearly 6,000 women with the help of his team (Gathorne-Hardy, 1998).

            What specifics did Kinsey’s initial books reveal? There was far more diversity in sexual behavior than people were openly acknowledging, for one thing. Some men masturbated and/or had sex on a daily basis, leading to frequent orgasms; others went months between climaxing. He found that a large majority of men (92%) had masturbated to orgasm, and over half of women (62%) had done the same; about half the men and one quarter of his female subjects had same-sex sexual experiences (and a majority of those experiences led to orgasm for men, slightly less than half for women); 67% of men and nearly half of women had had premarital sex; and a sizable number of married men and women had had affairs (Greenberg, Bruess, & Conklin, 2011). He also discovered that some people’s sexual orientation and attractions seemed to shift over the course of their lifetimes (including his own; Gathorne-Hardy, 1998; Greenberg, Bruess, & Conklin, 2011).

            Perhaps the best-known contribution Kinsey made to the field of sexual research was the Kinsey scale, a continuum of sexual orientation (see below). He had come to find through his interviews that people rarely fit neatly into the categories of homosexual and heterosexual. Most people, it seemed, either had experiences with both men and women, or at the very least, attraction and fantasies. Kinsey, therefore, devised a conceptual view of sexuality as more fluid, a matter of degrees rather than an either/or proposition. On his scale, 0 represented someone who was exclusively heterosexual, and 6 denoted someone who was exclusively homosexual; a 3 was assigned to someone who was equally attracted to both men and women. It became Kinsey’s assertion that many (if not most) people were, in a way, bisexual—falling between the 0 and 6 rather than on those polar opposites (Yarber & Sayad, 2013; Bronski, 2011).

Box 8.2: The Kinsey Scale

Kinsey scale
Kinsey’s continuum of sexuality, or Heterosexual-Homosexual Rating Scale. Taking your relationships, fantasies, attractions, and sexual history into account, where would you place yourself on the scale? (Source: Kinsey Institute)

            Due to extreme public disapproval, Kinsey’s research funding was a constant struggle. He had to find new sources regularly to be sure his research could continue; it had become his life’s work. Criticized as immoral and reckless by some, Kinsey persevered where the pressure may have caused others to give up the pursuit. Thankfully, he persevered, and there remains an institute that bears his name at Indiana University today, dedicated to furthering the understanding of human sexuality (Jones, 1997).

M & J
William Masters (1915-2001) and Virginia Johnson (1925-2013)
(Source: Library of Congress)

William Masters was a gynecologist who had an interest in treating sexual functioning problems (the word dysfunction wasn’t being used in this context yet) but found, like Kinsey, that there was little empirical research on the topic he wished to know better: human sexual response. Therefore, he set about studying the topic on his own, eventually enlisting the help of Virginia Johnson, a research assistant with no college degree (who would become his research partner, his mistress, his wife, and eventually his ex-wife). If Kinsey had made waves through his process of daring to interview strangers about their sexual histories, Masters & Johnson took it a step further (Maier, 2009).

They recruited subjects to have sex in the laboratory under observation, while instruments took various sorts of measurements: strength of erection; amount of vaginal lubrication; heart rate as orgasm approached, occurred, and subsided; and much more. They were the first researchers to study what physically happened to the human body during sexual activity (both with partners and via masturbation; Maier, 2009). Like Kinsey, they were also out to disprove some long-held beliefs, and to learn new information to help those dealing with sexual issues for which there seemed to be no answer.

Masters & Johnson’s first book was Human Sexual Response in 1966, and it detailed their findings from observing nearly 700 people encounter what they came to identify as the stages of the sexual response cycle—arousal/excitement, plateau, climax, and resolution. The focus was on the physical aspects of sexual response, which led to some criticism that the emotional and psychological had been disregarded, but the book and concept were nonetheless revolutionary (Maier, 2009). Among the myths the team were able to dispel was the old Freudian assertion that vaginal orgasms were more advanced than clitoral ones; their laboratory findings showed that there were virtually no orgasms not in some way connected to clitoral stimulation, and thereby legitimized female masturbation and women who could not orgasm from vaginal penetration alone (Maier, 2009).

A second book followed, Human Sexual Inadequacy (1970), in which Masters & Johnson detailed their method for treating sexual dysfunctions. They worked as a therapy team together with the couple experiencing the dysfunction and did not attempt to pin the fault for the condition on one person or the other, instead seeing the relationship as the “client” in therapy (Maier, 2009). They were successful in their efforts to use talk therapy and at-home exercises alone to alleviate the conditions of these dysfunctions, curing approximately 80% of the people with whom they worked using intense two-week treatment periods (previously, treatment of some of the conditions had averaged years of therapy work). They never observed their clients actually performing sexual activity with each other when treating dysfunctions (Maier, 2009; Herdt & Polen-Petit, 2014).

            Masters & Johnson continued to work together until just after they divorced in 1992 (Maier, 2009). Among the things that pushed them apart, other than the divorce, was Masters’ confidence in his conversion therapy work, which Johnson allegedly opposed. We’ll discuss conversion therapy in more depth later in this chapter.

 

Sex Education

            Most Americans would agree that sex education is necessary. The average age at which Americans begin having sex is now around age 17 (Centers for Disease Control [CDC], 2011). If we do not educate our young people on sexuality, then we are leaving them to pick up information from the vagaries of current rumors among their peers, the media, and on the Internet. (Would you really want your own kids to learn everything they knew about sex from Twitter or fanfiction?) Of course, some would also make the case that it’s really the family’s job to teach their own children about sexuality, since sexual morals are a very personal topic and are often connected to religious beliefs. Since beliefs differ from family to family, opponents of school-based sex education might say, then it’s impossible to have a one-size-fits-all program that gives people the assurance their kids are learning what they would want them to know.

            Of course, leaving it up to families may not be the answer either, since many parents have misconceptions about sexuality themselves, and some families will avoid the topic altogether, leaving children to figure things out for themselves (which can become an intergenerational pattern, and a problematic one). Therefore, if we are going to have sex education programs in school, we should probably understand what works best to accomplish the goals of such programs.

            The goals of sex education may include some or all of the following:

  • Understanding of anatomy
  • Knowledge about what sex actually is
  • The potential consequences of sexual activity (including STIs, pregnancy, and emotional consequences)
  • Contraception and safer sex
  • Consent
  • Respect for others
  • Sexual orientation

In some areas, schools practice abstinence-only sex education, which focuses on encouraging students not to have sex until marriage, or at the very least, when in a committed adult relationship that is leading to marriage. No information about contraception is taught in some programs of this sort; others may simply emphasize that contraception methods provide scant protection, if any at all. Scare tactics like focusing on STIs, pregnancy risk, and the irreversibility of losing one’s virginity may be focused upon; at times, programs like this compare kids who have sex before marriage to used tissue, candy that has been in someone’s mouth already, or other soiled items. This form of sex education is still being used in many American schools, especially schools with a student body heavier in minority students (Foulkes, 2008).

This is problematic since research generally indicates that abstinence-only sex education programs, while perhaps better than not receiving any sex education at all, lag behind the effectiveness of other programs. A majority of parents would prefer their children to receive comprehensive sex education, which takes a fuller approach to educating kids about sexuality, including some of the bullet point topics noted earlier in this section (Constantine, Jerman, & Huang, 2007; Irvine, 2002). Comprehensive sex education programs have been found to have a greater impact than abstinence-only programs in reducing teen pregnancy and STI rates, all while not increasing the chance of students having more sexual partners, more frequent intercourse, or earlier onset of sexual activity (Boonstra, 2009; Irvine, 2002; Foulkes, 2008).

Science seems to be having an impact on the politics of the issue. Although the Affordable Care Act provided millions in grants for abstinence-only programs in 2013, President Obama proposed lowering their funding as he was leaving office (Glum, 2015). Under President Trump, however, lawmakers pushed for expanded governmental support for these ineffective programs, at times rebranding them "sexual risk avoidance" education (Boyer, 2018). More comprehensive sex education programs will only help keep teen pregnancy and STI rates low and may even delay the age at which students start having intercourse.

Sex education programs have also been criticized by some for being heteronormative, as they rarely (if ever) discuss same-sex sexual behavior (or do so negatively), and proceed instead from an assumption of heterosexuality. Of course, it’s predictable that if sex ed programs are already controversial to parents, including information on same-sex sexual contact would make for some new opponents. Most states don't require sex education at all; only eleven have laws requiring affirming representation of LGBTQ+ people in sex ed, and nine actually require that the topic either be excluded or only presented in a condemning manner (Quiroz, 2021). Avoiding or degrading the topic of LGBTQ+ teens and sexual behavior could be taken by some students as an indication that the school doesn’t accept their LGBTQ+ population, making children and adolescents in that group feel ostracized.

 

The Gender Binary

            We made indirect reference to this idea in Chapter 7. The gender binary is the classification of people into just two genders: male and female. More broadly, it represents a belief that everyone fits into one of those two categories. However, we can clearly demonstrate that is a false conclusion.

            For one thing, even if we speak strictly in terms of sex rather than gender, we know that not everyone is male or female—some people are intersex, as discussed in the previous chapter. Intersex (also sometimes referred to as intersexed or intersexual) individuals have some element(s) of both male and female sex organs and/or ambiguous genitalia (for instance, a very small penis that seems more like a large clitoris, and undescended testicles). People often incorrectly use the term hermaphrodite to identify people who are intersex, when that term actually means people born with both ovarian and testicular tissue—a very rare condition. The term has largely been abandoned, as it is often seen as overly stigmatized as well as misapplied.

            Intersex is an example of a nonbinary identity—one which does not fit the dichotomy of male and female. Intersex people generally have one of several conditions, like Kleinfelter syndrome or Turner syndrome, that result in a body that is not fully male or female (Viloria, 2014). Social workers should strive to remain aware of the emerging preferences of this population (and any population) when it comes to the terms they use for themselves. As for how likely you are in your career to have a client with an intersex condition, it’s more likely than you might think, but hard to pin down. Estimates range from 0.05% to 1% of the population having a variation of intersex or DSD conditions (Accord Alliance, n.d.).

            Apart from people who are intersex, other groups do not feel the gender binary applies to them. Here are a few of the terms that may be used and what they mean.

Agender: Without a gender.

Bigender: Both male and female.

Genderqueer: Another term for nonbinary. A genderqueer person may feel they are both male and female simultaneously, or part male and female and part some other category, or simply another category altogether.

Genderfluid: A genderfluid person may feel more male on some days and more female on others, and a mix of the two or an absence of the two on other days. Their gender expression may fluctuate as their identity does. The term gender flexible is also used in this way.

            Additionally, there are many cultures worldwide where more than two genders are recognized (see box below). We understand this may be a lot to try to take in if you’ve always thought of gender in binary terms. However, it is a big part of the expanding diversity of the world and the clientele with whom you will work in this field—and we’ve only gotten started.

Box 8.3: Gender Spectrum in Other Cultures

Nonbinary genders

Although most Americans would state that they believe only two genders exist, this is hardly universal around the world (or even in our own country). Here are a few examples of nonbinary genders recognized around the world—some in countries many would consider far more traditional than the United States.

Hijras in Bangalore
"Hijras in Bangalore" by Oatsandsugar is licensed under CC BY-NC-SA 2.0

Hijra (pictured): Recognized legally as their own gender in India, Nepal, Pakistan, and Bangladesh, hijra may be intersex, eunuchs, or transgender women. They are often asked to bless important events such as weddings and births, particularly in rural areas of India.

Two-spirit: A gender recognized in many Native American tribes. The two-spirit individual is considered to have both a male and female spirit dwelling within them, hence the name. In some tribes, they are deeply respected, while others do not recognize them at all. They may dress in men’s or women’s clothing and often serve important ritual roles as counselors, healers, or oral historians. In many tribes, they marry men, and those relationships are not considered homosexual.

Xanith: Considered a separate gender in Oman, xaniths are anatomically male but identify as women, and are treated as women in situations where genders are strictly segregated—for example, singing and being seated with women at weddings. They often work as servants or prostitutes. However, they retain men’s names.

Fa’afafine: A distinct gender category in Samoa, fa’afafine are anatomically male but present in stereotypically female ways. They are recognized early on by their parents as neither male nor female, and this is generally celebrated rather than a source of shame. The child is raised as fa’afafine, and may have relationships with men, women, or other fa’afafine. If they partner with a man, the relationship is not considered homosexual. Traditionally, fa’afafine are not considered trans*, but in recent years, more are electing to have sexual reassignment surgery.

Kathoey: A nonbinary gender in Thailand, where many work as performers and some as sex workers, kathoey are anatomically/genetically male but have female gender identity, names, and appearance. Some are simply effeminate gay males. They are sometimes referred to as “ladyboys,” though this term has also been seen as pejorative by some. A team of gay and kathoey volleyball players won the Thailand national men’s volleyball championship and were depicted in the documentary film Iron Ladies. While adored in some circles, kathoey are reviled in others and are a source of some degree of controversy.

(Khaleeli, 2014; Mesa-Miles, 2015; Wikan, 1991, Stryker & Whittle, 2006; Käng, 2012)

Transgender people

            Though these terms are continually evolving, it is probably most accurate to say that Transgender refers to “any and all kinds of variation from gender norms and expectations” (Stryker, 2008, p. 19). The shorthand term trans has begun to be used interchangeably with this definition of transgender. This makes it a large category with many subsets. The word is also sometimes used to refer specifically to people whose gender identity differs from their biological sex but who do not wish to have gender confirmation surgery (also called gender-affirming surgery). The opposite of transgender is cisgender

            Transgender people may live full- or part-time in accordance with their gender identity. They may feel unable to do so full-time due to societal expectations or constraints (like workplace relationships or policies), or they may simply be comfortable with differing gender expressions in different places/situations.  The term transman may be used to refer to someone who identifies as a man but was genetically assigned a female body, while transwoman may be used to refer to someone who identifies as a woman but was genetically assigned a male body, but you should generally refer to clients as their gender identity (man, woman, boy, girl) without the trans- prefix, since that is how they identify. (Remember, it’s always up to the client how they would like to be identified.)

            Transsexual people, who often prefer to use the term transgender for themselves as well, are individuals who have what has been called gender dysphoria, often described as a sense one is “trapped” in the wrong body (though some may perceive that as an insensitive characterization). The term is usually reserved for people who have had gender confirmation surgery or who wish to do so. They may undergo hormone therapy and cosmetic surgery to help them feel their body is more in line with their gender identity as well. It is much more common for someone assigned male at birth to surgically transition to female than vice versa, and the surgeries tend to be more successful in creating a body the individual finds satisfying, as it is more difficult to construct a penis than a vagina (Rathus, Nevid, & Fichner-Rathus, 2014). Christine Jorgensen was the first transsexual person to come to international prominence after she underwent what was then called a “sex change” in 1952 (Stryker, 2008). It should be noted that many now consider the term transsexual to be outdated. It places the emphasis on one's physical body and may contribute to the belief some people have that they are entitled to know whether a trans person has undergone surgery. 

            Transvestic fetishists, sometimes simply called transvestites, are people (typically heterosexual men) who dress up in the clothing not typically associated with their gender for the purpose of sexual arousal and/or gratification. They generally are cisgender and do not wish to modify their bodies or “become” a different sex or gender. This is to be contrasted with Crossdressers, who wear the clothing not associated with their gender, but do not become sexually aroused by doing so. Crossdressing is an activity that may be exhibited by transgender people as part of their gender expression, or it may be done by cisgender people for various reasons. Drag queens (sometimes called female impersonators) are men who dress as women—often very convincingly—for the purpose of performance or leisure. Drag kings are women who dress as men for similar purposes.

            Transgender people may be sexually or romantically attracted to anyone. Remember, gender identity is different than sexual orientation. A trans person’s sexual orientation is not impacted by their gender identity—a person who is assigned male at birth, attracted to women, and undergoes sexual reassignment surgery will not become attracted to men by virtue of having the surgery. However, sexual orientation can vary over the course of someone’s life—which brings us to our next topic.

Box 8.4: Gender-neutral Pronouns

'They' is now officially regarded as an appropriate gender-neutral pronoun for a single individual, and you may have noticed this book uses it regularly for that purpose. Due to the increasing acceptance of the fact that the gender binary does not apply to everyone, and some people would prefer to be known by pronouns that do not indicate a masculine or feminine gender specifically, a family of gender-neutral pronouns has developed in English over the last few decades. (Some other languages have had such pronouns for centuries.) Some nonbinary individuals prefer to use pronouns like these to refer to themselves, and some people like to use these words (or they/them) in reference to anyone whose gender as not yet been revealed.

Social work supports everyone’s right to be called by any pronoun they choose. What follows is a chart of some of the most popular gender-neutral pronouns; there are many more than we have listed here.

Pronouns

(Source: The Gender Neutral Pronoun Blog)

Sexual Orientation

            Sexual orientation is often defined in a variety of ways, and the idea of the concept has certainly shifted over time. It is generally considered to be an erotic, sexual, and often emotional attraction toward a particular gender (or genders). The outdated term sexual preference has fallen out of favor because it implies that the object(s) of one’s attractions is simply a matter of choice. However, even this is a matter of some debate, as some gay, lesbian, or bisexual people do feel they chose their orientation, even if the majority do not (and your authors would surmise most heterosexuals do not feel they could choose to be gay or lesbian). Actually, some research indicates that it is gay men who by and large see their sexual orientation as an immutable inborn characteristic, while lesbians are more apt to see their orientation as a choice (Kimmel, 2013). Regardless, the term sexual orientation is more accepted today.

            You likely are aware of the three most well-known sexual orientations, but there are more than just those three to be discussed. What follows is a listing of terms for different orientations, along with their definitions and explanations. You are likely to encounter future clients who identify with each of these terms (and perhaps some we have not yet identified).

Heterosexual

            Someone who is heterosexual is sexually attracted to a different gender. This typically means men who are attracted to women, and women who are attracted to men. The majority of people, both in America and worldwide, when asked to label themselves, identify as heterosexual.

If your attention is keen, you may have noticed we did not use the term “opposite sex.” That is deliberate. We choose not to employ that term because it is misleading in multiple ways. First of all, as we established in the previous chapter, the gender binary is flawed; the existence of intersex people alone disproves it, not to mention some of the other gender minorities we have explored in this chapter. Furthermore, men and women are not polar ends of some spectrum. There is nothing inherently opposite about men and women; in fact, the average man and the average woman are not that different in terms of their characteristics and personality traits. However, there is considerable variety of each trait within every gender; that is, the most nurturing man and the least nurturing man are far more different than a man and woman of average nurturing ability. Referring to men and women as opposite sexes does little to recognize just how much they have in common, and feeds into the idea that men and women can never truly understand each other.

At times the word “straight” is used as slang for heterosexual, by people of all sexual orientations. Some have questioned whether this term is in itself offensive, since if heterosexual people are straight, it implies that non-heterosexual people are in some way “crooked” or imperfect. However, there does not seem at this time to be a major push for changing the use of “straight” in this manner.

Homosexual

            People who identify as homosexual are sexually attracted to those with whom they share a gender. This means men who are attracted to men, and women who are attracted to women. Estimates of the prevalence of homosexuality in the population have ranged from 1 to 10%. The National Survey of Family Growth (Centers for Disease Control [CDC], 2011) found only 1.1% of women identified themselves as “homosexual or gay” compared to 1.7% of men (about 1.6% of people identified as “something else” or did not answer, while the rest identified as heterosexual). However, in the same survey, 11.2% of women and 6.0% of men reported that they had had same-sex contact at least once during their lifetimes. This illustrates a couple of important points; first, that sexual activity does not necessarily reflect sexual orientation. Secondly, that bisexuality may be more common than homosexuality (which would come as no surprise to Alfred Kinsey).

Gay Pride Parade New York City 2007
Gay pride parades now take place in most major American cities on an annual basis, as well as many smaller cities and international sites, like this parade in Madrid, Spain. Many cities have particular gay-friendly neighborhoods or districts as well."Gay Pride Parade New York City 2007" by Kevin Coles is licensed under CC BY 2.0

            Kinsey found in his own studies that about 4% of men and 1-3% of women had been exclusively homosexual from the time of puberty until they were interviewed for his research. However, some researchers have reanalyzed Kinsey’s data set in the years since his works were published and have come up with figures of up to 9.9% of the participants having extensive or exclusive homosexual experience (Kinsey Institute, 2011). Researchers often estimate the prevalence of homosexuality to be about 7% of the population. Part of the problem with trying to assess a statistic like this is that the only way to measure how many people identify with an orientation label is to ask them in surveys or interviews—and people simply aren’t always going to be honest. There may be some who would dishonestly identify as homosexual, but there are likely a higher number that would not disclose a homosexual orientation on a survey or in an interview due to confidentiality concerns and worries about how others may react, or because they have not yet accepted their sexuality themselves.

Sometimes people want to know what causes homosexuality, but it’s a flawed question, because it assumes that heterosexuality is the outcome of normal development and homosexuality must have some sort of specific cause, or gay people would be heterosexual. However, we can safely assume that whatever causes one to be homosexual is similar to what causes one to be heterosexual. The question isn’t, “Why are some people gay?” but instead “What determines a person’s sexual orientation?” (The answer, incidentally, isn’t exactly clear, though it seems genes do play a role of some kind.)

Bisexual

            Bisexual people are typically sexually attracted to both men and women, though perhaps not equally. It is not unusual for a person who identifies as bisexual to have more attraction toward men or women at a given time, or even as a consistent pattern. There is a lot of variation within the bisexual population, just as there are with other sexual orientations. Some people choose the bisexual label for themselves even though they may also be attracted to more than two genders, though they may also call themselves pansexual (discussed later in this chapter) or polysexual.

Bisexual people have expressed that they experience prejudice both from heterosexual and homosexual people; this experience of prejudice and mistreatment has been called biphobia. It may not be surprising to hear that there are heterosexual people with anti-bisexual bias, but you may not realize that same bias can be found in the homosexual community. At times, people with a bisexual orientation as treated as if they are simply confused, unwilling to admit their homosexuality, or “acting” bisexual in order to attract a heterosexual mate. Some people believe bisexuality doesn't actually exist, perpetuating bisexual erasure. Make no mistake, however; bisexuality is a legitimate sexual orientation in its own right (Burleson, 2005). Additionally, bisexual people who are currently in relationships with a member of a different gender than their own sometimes experience exclusion from LGBTQ+ circles because they are currently in what appears to be a heterosexual relationship. 

The National Survey of Family Growth (CDC, 2011) found that 3.5% of women age 15-44 identified as bisexual, compared to 1.8% of men. This remains in line with what most research over the years has found—women seem to be more likely to call themselves bisexual, while there are more self-identified gay men than lesbians.

Asexual

            People who identify as asexual are not interested in sexual activity, having no erotic desire for anyone. This is not the same as celibacy, which is a choice not to have sexual contact despite having sexual desires. Sometimes asexual people are perceived by others as having made an admirable lifestyle choice rather than having a distinct sexual orientation. Asexuality is also not the same thing as being anti-sex. Asexual people don’t have any interest in stopping sexual people from having sex; they’re simply not interested in having it themselves in the way most people are. It is also important to recognize the asexual population has some variation in sexual interest, sometimes called the ace spectrum. (Ace is a common slang term for asexual.) Some asexual people have sex under certain conditions; some asexual people are disinterested in sex and neutral toward it; some are repulsed by the idea.

            Asexual people may be interested in romantic relationships and able to fall in love, or they may be disinterested in having such connections, but are very able and interested in having friendships and other associations with people. (See the section on romantic orientation coming up later in the chapter for more information.) They may also be able to perceive other people as attractive, but still be uninterested in sexual contact with those people.

Asexual network at Stockholm Pride
Asexual people march in Stockholm, Sweden's pride parade, holding the asexual pride flag.
"Asexual network at Stockholm Pride" by trollhare is licensed under CC BY-NC-ND 2.0

            Asexual people are physically capable of having sex, at least in the majority of cases. Some masturbate, and some do not. Some may fantasize about sexual contact with someone else or use pornography as a method of arousal; still, if they had an opportunity to have sex with another person, they would not be sexually attracted to that person. Some asexual people may choose to engage in sexual activity for a variety of reasons—for example, they may be in a relationship with someone they love who is not asexual, and they may have sex with that partner as an act of love (Bogaert, 2013).

            Kinsey found that some interviewees fell nowhere on his scale, and he referred to those people as “X's.” His definition of asexuality really was dependent upon behavior, so if people did not have sex and rarely thought about it, they could have been put into the “X” category. Kinsey found about 1.5% of all males to be asexual by his definition, along with 1-3% of married women and 14-19% of unmarried women (Kinsey, Pomeroy, & Martin, 1948; Kinsey, Pomeroy, & Martin, 1953, as cited in Bogaert, 2015). One of today’s foremost researchers on asexuality, Anthony Bogaert, has come to the tentative conclusion that 1% is a reasonable estimate of the prevalence of asexuality in the population, with the majority of asexual people being women (Bogaert, 2012).

Asexual people are also sometimes perceived by others as if they have something wrong with them physically or psychologically; after all, most of us do have a drive to have sex with other people and are interested in sex to some degree. It can be very difficult for someone who is not asexual to understand how someone could have no interest in sex. However, just as we once characterized homosexuality as a mental illness in America, asexual activists would say that it would be a similar mistake to think of asexuality as a problem rather than a legitimate orientation. Asexual individuals would prefer to be recognized simply as people with a different orientation, rather than having a problem in need of a solution.

polyamory

Pansexual

            Many times, people have a difficult time understanding the difference between pansexual and bisexual. A pansexual person is attracted to people of any gender; for many of them, gender is not a key factor in determining attraction; they may also be attracted to transgender, genderqueer, and other people who do not fit into mainstream definitions of male and female. A pansexual person, therefore, does not believe in the gender binary.

            Contrary to what some may think, pansexuality is not the same as being attracted to or wanting to have sex with everyone. Just because someone is pansexual does not mean that person is indiscriminate in feeling sexual attraction. Homosexual people are not attracted to all people of the same sex; heterosexual people are not attracted to all people of another sex. Pansexual individuals do have a larger potential field of people they may find attractive, but they do not necessarily find themselves attracted to a larger number of people.

Demisexual

            This is one of the newer terms to emerge in the sexual orientation conversation; in fact, although it is fairly easy to find a lot of information about demisexual orientation online, as late as 2015 the word didn’t appear in searches of academic research databases. More personal testimonies of demisexual people are available than empirical articles.

            As said by Molly Martinson (2015), an author at XOJane.com, “I don’t feel sexual attraction to someone unless I’ve first developed a deep emotional connection to them” (para. 4). She goes on to describe how she doesn’t understand when people characterize celebrities or people they don’t know well as “hot” or “sexy” (para. 15). She doesn’t feel sexual attraction that she denies in order to be selective about her sex life; she tends to feel similar to how asexual people feel most of the time, and only after a period of growing close to someone and getting to know that person might she feel sexual attraction. In other words, it is not simply that she waits longer than most people to sleep with someone; most of the time, she simply doesn’t feel sexual attraction. It would not be unusual for a demisexual person to feel she/he is asexual if that deep bond has not yet developed with anyone.

            Demisexual people are also often considered part of the ace spectrum, and may identify as asexual at some point before they develop their first sexual attraction to an individual. They are most likely among ace spectrum identities to say that an emotional connection would be necessary for them to consider sexual activity (Hille, Simmons, & Sanders, 2019).

Box 8.5: A Demisexual Journey

            “While asexual means that someone doesn’t feel sexual attraction at all, being demisexual means that I do not feel sexual attraction to a person unless there is a strong emotional connection.

The inevitable response is generally “But I don’t think that anyone has sex unless they’re emotionally connected to the other person!”

Putting aside for now the fact that one-night stands would not be a thing if this were true (and there wouldn’t be so many songs written about taking home a stranger you met in a bar), being demisexual isn’t about the act of sex proper. It’s about sexual attraction and feelings.

It wasn’t until the tail end of college that I started suspecting that I might actually be different. I had a friend who would always complain that she was ‘soooo horny.’ I felt confused, as I was pretty sure I’d never had the experience of being horny. Sex scenes in movies had always annoyed me…

I couldn’t understand what the big deal about sex was beyond the obvious baby-making process. It just wasn’t on my radar…

About a year and a half ago, I met a wonderful man through a mutual friend. We bonded over our shared love of Doctor Who and, though I had just gotten out of a relationship and wasn’t looking for another, I found myself falling for him. And more than that, I realized I wanted to do more with him.

With him, I’ve gone further than I ever have before. He’s helped me to learn a lot about my body. I’ve figured out more of what I like sexually and what I don’t. I now understand a lot more what the ‘big deal’ is about sex. It does feel good! While I still don’t plan on having ‘traditional’ [vaginal] sex any time soon, I’ve learned that there’s a lot more out there in the realm of sexual fun.”

(Liebowitz, 2015)

Queer

            Queer has become sort of a catch-all label that applies to a variety of sexual orientations and gender identities. If you are hesitant to use the word, that is understandable, given its recognition as a gay slur for decades. However, there is a growing amount of scholarly work on queer theory, a school of thought regarding the arbitrary nature of society’s gender and sexuality labels, with a strong leaning toward feminism and LGBTQ+ rights. The word has been reclaimed by a number of people in the LGBTQ+ community, some of whom use it as a term of empowerment and/or specifically to describe themselves.

            What, then, does it mean? Queer has come to be used to mean virtually any non-cisgender identity and/or any non-heterosexual orientation. It is also associated with more revolutionary thinking in terms of sexual and gender politics, a feeling that the system of labels we currently have for sexuality and gender is fundamentally flawed and is too monolithic to be fixed; therefore, it must be eliminated in favor of a more open-minded way of looking at these identities.

            Note that for some people in the LGBTQ+ community the word “queer” continues to have a pejorative feel to it, and perhaps always will. They have a right to feel that way, as it is likely connected to their own experiences with the word. It’s not recommended that someone refer to anyone in this group as “queer” unless that person has used it to self-define, and then only if there is an existing relationship. Calling someone “queer” whom you do not know well can certainly lead to a negative reaction. 

Margaret Cho
"Margaret Cho" by jimdavidson is licensed under CC BY-NC-ND 2.0

 

Box 8.6: Margaret Cho's Take on Queer

Often people are curious about the fact that I am married to a man but call myself queer. It's because I have had sex with more than one person, and I had unmarried sex quite a few times, and roughly half the people have been men and the other half have been women, and then there were a few people in between those genders who identified in differing ways, so it's up to me to define myself, too, and so that would be queer. It's the most fitting description, short and concise, and really to-the-point. I don't know why it's a difficult concept to understand. Most of the people I know have had sex with more than one person, and many have sex outside marriage. I just happen to have had it with people all along the gender scale.

I think what I respond to is androgyny, in all its forms. It's often not obvious. Someone can look very male but then reveal himself to be a true lady. A woman can appear incredibly feminine yet be super butch inside. We are all creatures of infinite possibility, and sexuality is one aspect where our souls and bodies really collide.

(Cho, 2011)

Romantic Orientation

            Somewhat separate from the idea of sexual orientation, romantic orientation represents someone’s tendency to want to get into a relationship with people of a particular gender or genders. For most people, sexual orientation and romantic orientation seem to line up; the people with whom one is interested in partnering sexually are usually the same people with whom one is interested in partnering for relationships.

            However, for some people, these orientations are somewhat different. One could be bisexual but heteroromantic—for example, a woman who is attracted sexually to both men and women but only interested in partnering with men for relationships. Similarly, one could be asexual but biromantic—not interested in sex, but willing to have romantic relationships with either women or men (LGBTQ Center, UNC-Chapel Hill, n.d.).

            It is important to recognize that romantic orientation and sexual orientation will not be in unison for every client, because a social worker can help normalize that experience. A client may feel like something is wrong when these orientations aren’t aligned, but with proper knowledge of these issues, we can help the client to rest at ease about having one of the many diverse combinations of identities.

Common Myths About LGBTQ+ People

            You will likely serve a lot of clients who are LGBTQ+, and you will also work with their families and friends over the course of your social work career. Some people will need you to help them understand what is truth and what is myth when it comes to these groups of people.

  • A mother may be worried that her gay son was molested as a child. An adolescent girl may think that she is psychologically ill because she’s attracted to other girls.
  • A man who is happily married may worry that the fact he also enjoys gay pornography means he’s secretly homosexual and he must have somehow fooled himself into believing he was in love with his wife.
  • A father may think that there is no way his five-year-old boy could be transgender because he’s just too young to know.

You could come across any of these situations in your career; knowing fact from fiction will help you to navigate some of those difficult discussions.

Myth #1: Gay people are easy to spot.

Eddie Izzard comes to Crouch End
People sometimes have the impression that they can tell a person’s sexual orientation by appearance alone. Often, this represents an overreliance on stereotypes or being confused between the terms “gender role” and “sexual orientation.” Is there any way to know for sure what this person’s sexual orientation is based on the way she looks? What assumptions might people make about her? Why?
"Eddie Izzard comes to Crouch End" by puntofisso is licensed under CC BY-SA 2.0

            This myth relies on the stereotypes many people have about gay and lesbian individuals. Some of these include:

  • Gay men are effeminate.
  • Lesbians have short hair and masculine mannerisms.
  • Gay men walk and sit differently than heterosexual men.
  • Lesbians are more athletic and aggressive than heterosexual women.
  • Gay men have higher-pitched voices and lisps.
  • Lesbians dress more like men.

Are there lesbians and gay men who fit these stereotypes? Yes, of course! However, it is a mistake to take traits that are true of some people in a group and assume they apply to the entire group. You probably know some heterosexual couples that don’t fit into stereotypical heterosexual norms, right? Perhaps a couple where both the man and the woman are highly athletic and competitive? If heterosexuals don’t all fit stereotypes, why would we expect gays and lesbians to do so?

This is a common misconception in part because people often conflate gender identity with sexual orientation, meaning that when a man “acts feminine” or when a woman “acts masculine” it is assumed by some people that they are also gay/lesbian. Again, while this is true in some cases, it’s nowhere close to being universal. It’s incorrect anyway to assume that just because someone is masculine, he/she must be attracted to women, or that feminine people must be attracted to men.

Again, sometimes when you try to guess someone’s sexual orientation, you’re going to be right. In fact, I would imagine you’ll be right most of the time (you could ensure that just by guessing that everyone is heterosexual). But some of the time you will be wrong. Nicholas Rule, a gay psychologist, has even gone as far as to study this, giving people photographs and asking them to guess the sexual orientation of the people pictured. On average, people guess right 64% of the time when a sample is split evenly between heterosexual and homosexual people—that’s better than what random chance would yield, so we do seem to be able to pick up something that makes us right more often than simple guessing (Bronski, Pellegrini, and Amico, 2013). However, 36% is a pretty significant rate of error. Would you put money on being able to guess correctly more than 3-4 times in a row? If Rule’s results are correct, and you have average orientation-guessing ability, you’d only be right on four consecutive guesses about 17% of the time. About five times out of six, you'd be wrong about at least one person in that group of just four. There’s simply too much diversity among the people of each sexual orientation.

Myth #2: LGBTQ+ people shouldn’t be parents because their kids will suffer.

            A study of over 300 adoption agencies by the Donaldson Institute revealed that 40% were unwilling to accept applications from same-sex couples, while 39% of agencies had already completed at least one such adoption. The remaining agencies had accepted same-sex applications but rejected them for a variety of reasons (Mezey, 2015). The Supreme Court affirmed in a unanimous 2021 decision (Fulton v. City of Philadelphia) that religiously-based adoption agencies could legally exclude same-sex couples from adopting kids looking for homes (Higgins, 2021).

            Since a same-sex couple has to make a very planned and deliberate decision to become parents, they are far less likely to be surprised by and unprepared for the changes in their lives that parenting brings about. It’s estimated that without LGBTQ+ parents being involved in the foster care and adoption system, the government would lose up to $27 million caring for kids with public money (Mezey, 2015). Studies have generally indicated that children are better off in families with two parents, regardless of their gender makeup, than they are in single-parent homes or permanently in the foster care system.

            Opponents of LGBTQ+ parenting have expressed concerns about the children’s social and psychological development, the chance of kids being sexually abused, and the possibility that kids raised by same-sex parents could grow up to identify as gay/lesbian themselves. These worries are not only homophobic and transphobic, but misguided. It has been confirmed in numerous studies that children with LGBTQ+ parents:

  • Are no less likely to be gay/lesbian than kids raised by heterosexual parents;
  • Are just as likely to be cisgender as kids raised by heterosexual parents;
  • Are less likely to feel restricted to pursuing a career that traditionally matches up with their gender role, especially in the case of girls;
  • Are as happy as children raised by heterosexual parents; and
  • Are not more likely to be sexually abused (Stacey & Biblarz, 2001)

Myth #3: Gay people were sexually abused as children.

            First, this myth relies on a flawed premise: that being homosexual is a sign that something went wrong in normal development—a symptom of a problem. Next, as with our first myth, this one does apply to some people; however, we could just as easily say that heterosexual people were sexually abused as children. In the case of both groups, most were not sexually abused as children, but some were.

            There are many increased risks for adolescents and adults who were sexually abused as children—anhedonia, caretaking of others, sexual dysfunction, alcohol and drug abuse, generalized fearfulness and many others—but an increased risk of identifying as homosexual is not one of them (Herdt & Polen-Petit, 2014; Cermak & Molidor, 1996).

Myth #4: Gay men seek out young boys as sexual partners.

            One of the most nefarious myths out there, this again is an indication that some people see homosexuality as a deviant behavior. It then gets linked in their minds to another deviant behavior: pedophilia. Certainly, scandals like the one that has rocked the Catholic Church regarding priests molesting young boys do nothing to dissuade people from perpetuating this mistaken belief.

WHERE IS THE JUSTICE?
While undoubtedly reprehensible, the Catholic Church’s significant issues with priests molesting children, particularly boys, is not reflective of the nature of homosexuality. In reality, most child molestation is perpetrated by heterosexual men toward young girls.
"WHERE IS THE JUSTICE?" by RubyGoes is licensed under CC BY 2.0

            The vast majority of child molestation is perpetrated by adult men against underage girls, not boys (Murray, 2000). There are, of course, adult men who sexually abuse boys as well; they do not necessarily identify as homosexual, however. Let us leave it at this: pedophilia has no discernible connection to homosexuality; it is more commonly found among heterosexuals.

Myth #5: All religions condemn homosexuality.

            Thankfully for LGBTQ+ people who wish to practice their religious faith, there are many congregations and faiths that do not simply tolerate homosexuality, but actively welcome and even celebrate marriages of same-sex couples. The website gaychurch.org maintains a directory of over 7,500 affirming Christian churches around the world, meaning churches that do not see homosexuality as a sin and would welcome gay and lesbian attendees at services. And that’s just the Christian churches! There are many welcoming congregations in other faiths as well.

There remains a prominent idea that there are passages in the Bible that specifically prohibit homosexuality, referring to it as an abomination. However, Biblical scholars are not in agreement on the meaning of those parts of the Bible (often called the clobber passages by LGBTQ+ people of faith and their allies). For one Christian minister’s view on homosexuality, see Box 8.7 below.

Box 8.7: One Pastor's View of Biblical Commentary on Homosexuality

One of your authors was fortunate to become friends with a Presbyterian pastor named Kurt Esslinger through a friend in the Chicago area, and met with him on occasion to discuss issues of faith. Upon request, Rev. Esslinger agreed to write the following statement about his views on what the Bible has to say about homosexuality. (One note: Rev. Esslinger uses the acronym LGBTQQIA, which stands for lesbian, gay, bisexual, trans, questioning, queer, intersex, and asexual/allies. LGBTQ+ is the parallel term this book uses to cover all gender and sexual minorities.)

“I grew up in West Texas, a community mostly dominated by Southern Baptists and Evangelicals. Right away, my moderate Presbyterian tradition was at odds with many of the social prognostications of the Christian majority. I was never able to trust that Christians should not be allowed to drink or to dance at parties. Eventually my skepticism grew around my Baptist friends trying to tell me that God didn’t like gay people. Since then, after having completed a Master of Divinity degree and having received ordination in the Presbyterian Church U.S.A., the more I have learned about scripture and its interpretation, the more I am sure that a same-sex orientation is neither a sin nor a choice, and one can still be a faithful Christian in a healthy same-sex relationship. The very Spirit of God is helping to enact this change in Christian thinking.

For this conversation to make sense, we must make sure to dismantle unhealthy assumptions about Biblical interpretation. Unfortunately, many Christians continue to believe the fallacy that we can simply go to the Bible, read it, and objectively understand exactly what it prescribes for our decision making today. You can hear this misunderstanding in the idiom, ‘This is what the Bible says.’ The Bible does not say anything on its own. In order to find the meaning of stories, poems, and letters that were written in the midst of a very different cultural context than our own, we must subjectively work, search, and interpret the meaning.1 All of your understandings and interpretations of scripture arise out of your own experience, what teachers have told you, and what cultural assumptions you operate under.

For example, from our 21st century perspective, we have the privilege to look on scripture and understand that it does not claim that the sun revolves around the earth. If we lived in the 16th century, we would not have that privilege of perspective. Remember, the Bible never said that the earth revolves around the sun either. It took overwhelming scientific evidence for Christians to realize their understanding, their interpretation of scripture was wrong despite the thousands of years they believed it was right. In fact, Christians were so angry that Galileo questioned their supposed ‘objective perception of Biblical truth,’ that they sentenced him to house arrest until his death.  500 years later no one claims that Galileo was deceived by Satan or bending to the whims of liberal culture. Then later, Christians stood up on the floor of congress claiming that a clear reading of scripture supported slavery.2My denomination split into north and south churches because many believed God was okay with slavery. Then when they reunited and decided to support Martin Luther King Jr. and the Civil Rights Movement, a bunch of churches left again to form the Presbyterian Church in America (PCA) claiming that our denomination no longer respects the authority of scripture. These days we know that this interpretation was wrong. Many Christians believe an objective reading of scripture disallows women from being ordained. Many denominations, such as mine, now recognize that interpretation was wrong. They thought they were reading the Bible objectively, simply listening for what it said.  It turns out their interpretation was clouded by a Eurocentric perspective, or a male-centered sexist perspective.

So here we are now. Scientific evidence is constantly growing in support of the fact that sexual orientation is not a choice. Official organizations representing 1.5 million doctors, psychologists, psychiatrists, educators, and counselors have released statements that sexual orientation is not a choice and treating it as such, or trying to convince LGBTQ people to just ‘not act on it’ can do grave psychological harm.3If you still distrust science, you can also find the growing number of evangelical Christians that are coming to similar conclusions based on the growing recognition of the resulting spiritual harm that comes from their attempts to council LGBTQ persons to suppress their orientation.4Let’s go into the Biblical passages that people claim to read objectively as if the Bible says that sexual orientation is a choice and is a sin. We’ll break down one Old Testament text and one New Testament text to see, after searching and learning, whether scripture actually denounces a same-sex loving sexuality.

 

Sodom and Gomorrah – Genesis 18:17-19:14

God was planning on destroying Sodom and Gomorrah because an outcry against their sin had come to God. God sent two angels to check whether any righteous might be spared. The angels entered the city as foreigners. Note here that the Bible has far more commandments toward caring for strangers and foreigners who enter your land than about sexual acts with the same gender. Lot takes the angels in, but the men of the town come and ask to kidnap the angels and gang-rape them. Lot offers up his daughters to be raped instead, but the men want the foreigners. The angels help Lot and his family escape. Five Old Testament prophets and Jesus mention the sins of Sodom and Gomorrah, but none of them mention homosexuality. According to Ezekiel, ‘This was the guilt of your sister Sodom: she and her daughters had pride, excess of food, and prosperous ease, but did not aid the poor and needy.’5If you want to try to single out the same-sex sexual act, then you also have to argue why that is more important than the violence of gang rape. I don’t know many LGBTQQIA people who enjoy gang rape.

 

Natural and Unnatural – Romans 1:26-27

‘They exchanged the truth about God for a lie…. For this reason God gave them up to degrading passions. Their women exchanged natural intercourse for unnatural, and in the same way also the men, giving up natural intercourse with women, were consumed with passion for one another. Men committed shameless acts with men and received in their own persons the due penalty for their error.’

Especially for this passage, cultural context and perspective play the most important role. First, in Paul’s context, women were naturally (read customarily) understood as the property of men. Sexual acts were generally understood as acts performed between owner and property, such was the meaning and significance. To perform them with individuals outside this custom was egregious for Paul. He had no sense of sexuality as an orientation, because all sexual feelings, hetero included, were discouraged.6 Finally, Paul was referring specifically to priests and priestesses of temples to gods and goddesses of fertility, sex, and passion. They practiced self-castration, drunken orgies, and having sex with the temple boy and girl prostitutes. Paul described them as having had customary sexual relations before, but gave them up for non-customary relations including the orgies and sexual acts with the same gender. These were not people who were born with a same-gender sexual orientation. Remember, homosexuality and heterosexuality did not exist as concepts until the modern age. Sexual acts are not the same as sexual orientations. For these temples, passion, sex, and lust became their driving force rather than God’s will. It is possible for same-gender couples to be in committed relationships without passion, sex, and lust becoming more important than their relationship to God.7To assume that these sins refer generally to the entire LGBTQQIA community is an unnecessary leap in logic. We realize now, just as with Galileo, slavery, and ordination of women that this anti-gay interpretation is wrong. This interpretation is clouded by the current heterosexist perspective of our culture. It ignores God’s will and the presence of the Spirit in the lives of faithful God-loving LGBTQQIA persons.

In 500 years, will our children look back on us the same way it looks on the church that imprisoned Galileo? Or will we be seen as the community that understood the precedent set by the church in Acts when they welcomed uncircumcised Gentiles as Christians even though scripture said they were unclean?8

 

You do not have to agree with what the Rev. Esslinger wrote, of course, but his statements are included here simply as an illustration of the fact that people who have studied the Bible extensively have different opinions on what it has to say on this topic. A growing number of houses of worship and clergy are coming down on the side of tolerance and acceptance.

References:

1. Martin, Dale B. Sex and the Single Savior. Westminster John Knox Press: Louisville, KY, 2006. Pg. 1-16.

2. Tise, Larry E. Proslavery: A History of the Defense of Slavery in America. University of Georgia Press. 2004 Pg. 363-366.

3. White, Rev. Mel. What the Bible Says -and Doesn’t Say- About Homosexuality. Soulforce Website. http://www.soulforce.org/resources/what-the-bible-says-and-doesnt-say-about-homosexuality/

4. Achtemeier, Dr. Mark. And Grace Will Lead Me Home: Inclusion and Evangelical Conscience. Covenant Network of Presbyterians Website. http://covnetpres.org/2009/11/and-grace-will-lead-me-home/

5. Ezekiel 16:48-49

6. Martin. Sex and the Single Savior. Pg. 51-64

7. White. What the Bible Says -and Doesn’t Say- About Homosexuality.

8. Acts 10:1-11:18

Myth #6: One person in a same-sex relationship “wears the pants.”

            This myth is an attempt to put same-sex relationships into terms to which heterosexuals can relate, the idea that one person in the relationship acts as “the man” and one acts as “the woman.” As noted in our discussion of myth #1, many heterosexuals don’t even fit into this dichotomous gender role standard.

            What some people mean when they say this is that one member of the couple is the dominant partner and one is more passive, perhaps sexually, perhaps in general—maybe both. However, data doesn’t back that up. Same-sex couples are more likely to display affection and humor when they were having a disagreement, and they act less belligerently, less fearfully, and are less dominant over each other than patterns seen in average heterosexual couples (Gottmanet al., 2004). In other words, same-sex couples do not typically fit into neat assertive/passive or male/female gender role patterns. Compared with heterosexual couples, same-sex couples are more likely to share housework and other at-home duties more equally (Kurdek, 2010).

Myth #7: LGBTQ+ people are mentally ill.

            The American Psychiatric Association used to categorize homosexuality as a mental illness, but it was removed from the Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1973. The helping professions in the United States have come to recognize that homosexuality is not an illness, but a simple and natural variant of sexual orientation.

            Despite this fact, some practitioners continue to offer conversion therapy services that claim to be able to change one’s sexual orientation from homosexual to heterosexual. Richard Cohen is a prominent provider of conversion therapy, having once sought treatment himself for his homosexual desires. Cohen claims he has been cured of what he calls SSAD (same-sex attachment disorder), a condition not recognized by any professional treatment organization. Now married and a father, Cohen (2000) says same-sex attraction is “the result of unresolved childhood trauma that leads to gender confusion…when the wounds are healed, gender identity will be experienced and heterosexual desires will ensue;” he states further that “[t]here is nothing ‘gay’ about the homosexual lifestyle; it is full of heartaches and most often an endless pursuit of love through codependent relationships.” (p. xi)

            Regardless of Cohen’s assertions, repeated studies have found that conversion therapy not only is ineffective in changing sexual orientation, but it lacks any evidence for its continued practice and is wildly unethical, irresponsible, and harmful (Cramer, Golom, LoPresto, & Kirkley, 2008). In 2002, Cohen was expelled from the American Counseling Association for multiple ethical violations connected to his conversion therapy practices (Boodman, 2005).

            For its part, the American Psychiatric Association (2000) has said in an official position statement, “The potential risks of reparative therapy are great, including depression, anxiety, and self-destructive behavior” and it “may reinforce self-hatred already experienced by the patient” (p. 1). Homosexuality is not an illness and therefore is not a “curable” condition either; if anything, reparative therapy appears to decrease psychological well-being.

Myth #8: Children are too young to know if they’re transgender.

            We have seen an increasing number of stories in the media about children who have been recognized as transgender (Grinberg, 2015; Snow, 2015). This fact could be mistakenly taken to mean that more kids are exhibiting transgender behavior; however, it is more likely that we are just hearing about these children more often, and that the increasing presence of transgender adults in the media is giving more children an ability to recognize that they are not alone, and more parents the capacity to be supportive and understanding of their children.

            Think for a moment: when did you know what your gender was? You were likely aware of it very early on. Kids typically develop gender identity by age two, and from that point forward, it is very difficult to change that identity (though social workers might ask why we would want to change it in the first place; Carroll, 2013). If you are cisgender, no one dared to question your gender identity at a young age, as it would have been unthinkable to do so. You knew what you were! Transgender kids, we’re understanding more and more, know from an early age as well.

Jazz Jennings CC2
Transgender teen activist Jazz Jennings has written I am Jazz, a children’s book about what it means to identify as transgender—one of the first of its kind.
"Jazz Jennings CC2" by ALA - The American Library Association is licensed under CC BY-NC-SA 2.0

 

            While very young children who claimed to be transgender have probably existed far longer than we realize, it seems our response to them in the past would have likely been to keep it quiet, perhaps get the child into therapy, and do our best not to let anyone know. This would probably have two purposes: 1) to avoid embarrassment for the parents, and 2) to give the child a chance at “fitting in” and having a “normal” life. In past decades, we didn’t really have as solid of an understanding of gender nonconformity, especially in children (Bullough & Bullough, 1998).

The trend in recent years has been toward greater acceptance and understanding of gender-nonconformity (or as some have called it, gender independence) in children as a variation of diversity rather than as an illness or treatable condition. There is an increasing amount of research that takes a harsh look at treatments meant to make kids more gender-conforming and finds them problematic rather than helpful, harming their relationships with their parents and increasing the amount of shame they felt about their identities (Wallace & Russell, 2013). The DSM-5 also replaced the previous diagnosis of gender identity disorder with the less critically-named gender dysphoria, indicating unhappiness with one’s physical sex not “aligning” with one’s gender identity. Even gender dysphoria was a marked improvement over terms coined by researchers in the 1970s and 1980s, like “deviant gender identity,” “pathological sex role development,” and even “sissy boy syndrome” (Pyne, 2014).

It is clear that kids who do not conform to gender stereotypes can face teasing, bullying, and ostracism at school, and those were some of the reasons that past approaches to the issue focused on getting kids to conform to gender, to theoretically make them more socially accepted and happier as a result. However, the focus has shifted to one that sees the environment’s reaction to these children as the problem, rather than the child’s natural personality and tendencies. Instead of pushing conformity, we have moved toward encouraging tolerance, and more positively, acceptance (Pyne, 2014).

As one research team on the topic of transgender children wrote:

Although children have no choice but to live in the world that is made available to them, society does have a choice about how to treat them. With respect to gender variance, we may ask: can society, professionals and schools facilitate a child’s self-identification instead of policing conformity to gender norms? Can the stigma of gender variance be eliminated so that children whose behaviour harms no one can live in peace while embracing their differences? (Riley, Sitharthan, Clemson, & Diamond, 2013, p. 656).

Myth #9: Homosexuality is universally taboo.

            This myth used to be more difficult to disprove, before public sentiment in America really started to turn remarkably. While in 1997, only 44% of Americans in Gallup polls felt homosexual sex should be legal, as of 2020, that figure had ballooned to 69%, and a full 60% of American poll respondents believe same-sex couples should be able to marry with all the same legal rights as heterosexual couples (Gallup, 2015). In fact, a majority of Americans who describe themselves as religious support marriage equality, even 60% of Catholics, despite the official position of their faith (Jones, 2015). After dozens of states and Native American reservations had already come to have marriage equality, the 2015 Supreme Court decision in Obergefell v. Hodges struck down the remaining state laws that recognized only heterosexual marriages, allowing same-sex marriages nationwide.

              Internationally, there is a hodgepodge of various laws and acceptance levels when it comes to homosexuality in general, let alone marriage equality. France was the first country to decriminalize homosexuality, in 1791. Since then, most countries have followed suit (though most do not have marriage equality); some, like the USSR/Russia, have waffled on the issue depending on leadership and public sentiment. Today, there are a handful of countries where one can be executed for same-sex sexual acts (Iran, Mauritania, Saudi Arabia, Sudan, Yemen, and particular areas in Somalia and Nigeria), but a much greater number of countries that have marriage equality or domestic partnership recognition for same-sex couples (BBC, 2014).

 

Life Experiences of LGBTQ+ People

Coming out

            Coming out is a term commonly used to describe the process whereby LGBTQ+ people inform people in their lives about their sexual orientation or gender identity. The Cass Identity Model, developed by Vivienne Cass (1979), is one of the most well-known theories regarding this process. Identified initially as a model for homosexuals alone, the model may also hold some truth for other sexual and gender minorities.

            It should be noted that coming out is not a one-time event; members of these minority groups may be faced with the decision to come out repeatedly as they form new relationships—romantic, friendship, professional, familial—throughout their lives. There are also no absolutes. People do not have to come out to everyone in their lives. Some choose to be more selective and come out to supportive family members while choosing not to discuss the issue with others. There is no “right way” to do it—it all depends on one’s own level of comfort and personal wishes.

            Here are the stages of Cass’s (1979) model and a brief description of each. For simplicity’s sake, we will describe each stage as it relates to sexual orientation, in line with Cass’s original theory, but one can easily imagine the parallel process possibly related to gender identity.

Identity confusion: In this stage, one begins to perceive one’s behavior, desires, and/or thoughts as potentially gay or lesbian. One may repress it, feel guilty about it, or may not make the connection to one’s own identity. There may be a fair degree of inner conflict.

Identity comparison: The individual recognizes they may be gay/lesbian, and may accept or dislike it. This may be seen as temporary, or as someone else’s fault. One may begin to seek out role models in the gay/lesbian community for comparison’s sake, seeing if they “fit” one’s own emerging self-definition.

Identity tolerance: At this stage, one recognizes one is probably gay/lesbian and begins to seek out relationships more actively—both relationships and friendships in the gay community. The quality of those connections is of paramount importance. If the relationships are positive, it will help the individual to continue to proceed through the stages; if not, one may be thrown back into an earlier stage or take on a very negative view of oneself.

Identity acceptance: At this stage, one fully acknowledges one’s sexuality. People also begin selectively disclosing their sexuality (“coming out”) to friends and family, typically starting with people who are most likely to be accepting and supportive.

Identity pride: Those in this stage feel strongly positive about their own identity, immerse themselves in the gay community, and may distance themselves from heterosexual society and people. The individual is acutely aware of the rejection and outsider nature of the homosexual community as it relates to mainstream society. Sexual orientation becomes the single most important identifying factor of one’s identity.

Identity synthesis: In the final stage, individuals recognize their sexuality is important, but not the sole identity that defines them. They also come to see that sexual orientation does not define whether a person is good or bad, since there are very accepting and open heterosexuals (as well as gay/lesbian people they just don’t like). People in this stage are the most comfortable with their lifestyles and themselves, and are most likely to be open about their identity with others (Cass, 1979).

            There are other theories and conceptualizations of this process, but Cass’s remains a prominent one. As societal acceptance of sexual and gender minorities increases, some have questioned whether the model needs to be rethought, since people are coming out at younger ages on average and experiencing more positive reactions from people around them. At any rate, it would not be unusual to know a gay or lesbian individual for whom this model did not strictly apply (Degges-White, Rice, & Myers, 2000).

            It is not up to a social worker to encourage LGBTQ+ people to come out to family and friends, but to help clients discern whether that is the right decision for themselves. See Box 8.8 for some further thoughts on this.

Box 8.8: Coming Out

coming out

Homophobia, heterocentrism, and transphobia

            Though it may involve an element of fear for some, homophobia can be defined simply as a strong negative attitude toward gay and lesbian people. A motivating factor in many hate crimes, homophobia nevertheless does not always rise to the level of violence. It still can be damaging to gay/lesbian people, however, as it can manifest in various ways that impact their daily lives:

  • Refusal of service at a business
  • Refusal of membership in a religious or community organization
  • Hearing gay slurs or derogatory comments
  • Being told one is going to Hell
  • Social isolation from peers

            Homophobia may even be exhibited by gay/lesbian people themselves, especially if they were raised in a family with anti-gay bias. This is known as internalized homophobia. You may meet clients who are homosexual but have strong negative feelings about their own sexuality who may need assistance working through such feelings.
 

Box 8.9: Heterosexual Privilege

Heterosexual privilege is the term used for all the benefits automatically gained by being heterosexual that are denied to homosexuals. Here are some examples:

  • Freedom to express affection in public without negative reactions
  • No fear of being assaulted due to one’s sexuality
  • The ability to foster or adopt children in any state in America, from any agency
  • Less risk of anyone questioning if one’s sexual orientation could be changed
  • Less fear of being told one’s sexuality or relationship is immoral, or one is going to Hell
  • Expecting to be around other people who share one’s sexuality most of the time
  • Not being asked “how do you have sex?”
  • Acting, dressing, or talking as one wishes without it being seen as a reflection of one’s sexuality
  • Easy access in cases of emergency to loved ones who are hospitalized

What other examples can you identify?

Social workers are not immune to being homophobic themselves, particularly if they were raised in strictly religious environments. In fact, some research has indicated social work students are among the most homophobic in the helping professions (Cramer, 1997). This is particularly concerning since clients should rightly expect to encounter a more supportive and positive environment when they visit a social worker than they would experience in society at large. It is crucial that social workers recognize and confront homophobia in themselves and their colleagues.

Less obvious, but still problematic, is heterocentrism. Someone can display heterocentric views or behavior without being homophobic at all—in fact, one can be very much in favor of gay equality and still behave in heterocentric ways. If one assumes everyone is heterosexual until one knows otherwise, that is heterocentrism in action. It does not have to be negatively intended or mean-spirited, and yet it can still cause problems in relationships with one’s clients (and colleagues).

Imagine if you were working with a client whose daughter was preparing for her prom, and your client was musing about how happy she was that her daughter found someone to take her to the dance. If you responded with something like, “That’s great! Did she ask him or did he ask her?” then you are being heterocentric. If the date is a boy, then the conversation would continue as expected. But what if the client’s daughter’s date is a girl? Your client might simply say, “Oh no, she’s going with another girl.” That would be an embarrassing mistake to make, at the very least.

However, the client could surmise that your question indicates you are homophobic, even if you are not. This could do irreparable damage to your relationship with that client, even though the comment was not directly related to your client. You can imagine what could happen if you said something heterocentric to a client who wasn’t heterosexual themselves. Not only might you damage your social worker-client relationship, you might give the client the impression that social workers are not as open-minded as people claim.

The best strategy is to be aware of your language and not to make any assumptions about anyone. Don’t use gender-specific language if it’s unnecessary. Always leave the door open for your clients to educate you about themselves, and do your best always to give the impression that you will be open to whatever they have to say.

Transphobia is a strong negative attitude about trans people, and this is a considerable problem if hate crime statistics are any indication. The final section of this chapter addresses this further.

Hate crimes

            There are a lot of laws in place to punish hate crimes, including the 1964 Federal Civil Rights Law; the Violent Crime Control and Law Enforcement Act; and the Matthew Shepard and James Byrd, Jr. Hate Crimes Prevention Act, which included “a victim’s actual or perceived gender, gender identity, sexual orientation, or disability” as categories against which people could be prosecuted for committing hate crimes (Cheng, Ickes, & Kenworthy, 2013, p. 762).

Evidence suggests that LGBTQ+ people are more likely on an individual basis to be the targets of hate crime than members of racial minorities: 2.4 times as often as Jews, 2.6 times as often as Blacks, and 4.4 times as often as Muslims (Beirich, Schlatter, & Steinbeck, 2010). Additionally, hate crimes committed on the basis of sexual orientation are more likely to be crimes committed against the people themselves rather than their property, and the crimes are also more likely to be severe (simple or aggravated assault versus intimidation and property damage). Gay men are particularly likely to be targeted, at a rate four to five times that of lesbians. The perpetrators of these hate crimes are often “males with a strong masculine ideology” (Cheng, Ickes, & Kenworthy,2013, p. 789). As racial minorities are also potential targets of hate crimes, LGBTQ+ people who are also racial minorities are at even higher risk of victimization.

Recent years have brought about a more specific focus on tracking anti-trans hate crimes, and the numbers are staggering. One researcher discovered that 60 out of 86 transgender individuals reported having experienced a violent or abusive incident due to their gender identity before the age of 18. Perhaps even more disturbing were the people most likely to have carried out the violence or abuse (in order): their father, another adult, a relative, their mother, and a peer. Other research studies determined that about 60% of transgender people had been victimized by violence and/or harassment (Kidd & Witten, 2007/2008). One may conclude that being transgender perhaps puts people at higher risk of hate crime victimization than membership in any other group, and transgender women who are racial minorities are at particular risk—in 2012, “73% of all anti-LGBTQ homicide victims were people of color” and “53% of anti-LGBTQ homicides were transgender women” (Giovanniello, 2013, para. 1). 

Stonewall Inn, West Village
Stonewall Inn, Greenwich Village, N.Y. The site of the beginning of the Stonewall Riots, often considered the beginning of the gay liberation movement. 
"Stonewall Inn, West Village" by InSapphoWeTrust is licensed under CC BY-SA 2.0

 

Box 8.10: The Gay Liberation Movement: A Timeline of Selected Major Events in the Gay Rights Battle in America

1950: The Mattachine Society, America’s first gay rights organization, is founded

1953: President Dwight Eisenhower signs an executive order banning all homosexual people from working for the federal government or any companies contracted with the government, deeming them a security risk

1955: The Daughters of Bilitis, the country’s first lesbian rights organization, is formed

1956: Evelyn Hooker publishes “The Adjustment of the Male Overt Homosexual,” with its evidence that there are no discernible personality or adjustment differences between homosexuals and heterosexuals

1962: Illinois repeals its anti-sodomy laws, becoming the first state to do so

1969: The event often considered the birth of the gay rights movement, the Stonewall Riots, occurs when police aggressively barge into a gay bar known as the Stonewall Inn in Greenwich Village, New York, attempting to arrest many patrons—a practice that had been occurring for at least two years. On this particular night, the crowd fights back, setting off a three-day-long series of riots and spontaneous marches and energizing the LGBTQ+ community to stand up for their rights more vociferously than many had in the past

1973: Homosexuality is removed from the Diagnostic and Statistical Manual, the American Psychiatric Association’s official book of mental illness

1974: The first openly gay American is elected to public office when Kathy Kozachenko wins a seat on the Ann Arbor City Council in Michigan

1977: Harvey Milk is elected to the San Francisco Board of Supervisors and goes on to help enact a key anti-discrimination ordinance protecting gays and lesbians from being fired on the basis of their sexual orientation; Milk is assassinated in 1978

1980: The Democratic Party becomes the first major political party to come out in favor of homosexual rights

1982: Wisconsin becomes the first state to ban sexual orientation discrimination

1993: The policy commonly known as “Don’t ask, don’t tell” is instituted by the U.S. Armed Forces, prohibiting the refusal of applicants on the basis of sexual orientation; service members are still barred from committing homosexual acts or admitting homosexuality

1996: The Defense of Marriage Act is signed into law, confirming states’ rights to choose whether or not to recognize gay marriage and denying federal benefits to same-sex couples and same-sex partners

2000: Vermont becomes the first state to give same-sex couples the opportunity to have a civil partnership recognized by the state

2003: The Supreme Court rules all remaining anti-sodomy laws in the U.S. unconstitutional

2004: Massachusetts becomes the first state to legalize same-sex marriage

2007: The LOGO cable channel hosts the first Presidential candidate debate on LGBTQ+ issues, inviting all Republican and Democratic candidates; six Democrats participate (including future President Obama and Hillary Clinton) while all Republican invitees choose not to attend

2009: President Obama signs an order allowing some benefits to be extended to same-sex partners of people employed by the federal government

2010: “Don’t ask, don’t tell” is repealed, allowing gays to openly serve in the military

2011: President Obama determines the government will no longer defend the Defense of Marriage Act in court cases

2013: The Supreme Court rules Section 3 of the Defense of Marriage Act (prohibiting federal recognition of same-sex marriages recognized by the states) is unconstitutional

2015: The Supreme Court is poised to announce a decision on four marriage cases that will effectively decide the constitutionality of same-sex marriage bans nationwide.

2021: Laws allowing employers to fire LGBTQ+ people due to their sexual orientation or gender identity are ruled unconstitutional by the Supreme Court.

(PBS, n.d.; Schwartz, 2013)

 

References

Accord Alliance (n.d.). FAQs: How common are these conditions? Retrieved from

http://www.accordalliance.org/learn-about-dsd/faqs/.

American Psychiatric Association (1998). Position statement on psychiatric treatment and sexual

orientation. Retrieved from http://www.psychiatry.org/File%20Library/Advocacy%20and%20Newsroom/Position%20Statements/ps1998_TreatmentSexualOrientation.pdf.

BBC (2014, February 24). Where is it illegal to be gay? Retrieved from

http://www.bbc.com/news/world-25927595.

Beirich, H., Schlatter, E., & Steinback, R. (2011). The anti-gay lobby: The Family Research

Council, the American Family Association, and the demonization of LGBT people. The Southern Poverty Law Center.

Bogaert, A. F. (2012). Understanding asexuality. Rowman & Littlefield.

Bogaert, A. F. (2013). The demography of asexuality. In A. Baumle (Ed.), International

handbook on the demography of sexuality (pp. 275–288). Springer Press.

Bogaert, A. F. (2015). Asexuality: What it is and why it matters. Journal of Sex Research, 52(4),

pp. 362-379.

Boodman, S. G. (2005, August 16). A conversion therapist’s unusual odyssey. The Washington

Post.

Boonstra, H. D. (2009). Advocates call for a new approach after the era of ‘abstinence-only’ sex

education. Guttmacher Policy Review, 12(1), pp. 6-11.

Boyer, J. (2018). New name, same harm: Rebranding of federal abstinence-only programs. Guttmacher Institute. Retrieved from https://www.guttmacher.org/gpr/2018/02/new-name-same-harm-rebranding-federal-abstinence-only-programs#.

Bronski, M. (2011). A queer history of the United States. Beacon.

Bronski, M., Pellegrini, A., & Amico, M. (2013). “You can tell just by looking” and 20 other myths about LGBT people. Beacon.

Bullough, B. & Bullough, V. L. (1998). Transsexualism: Historical perspectives, 1952 to present. In D. Denny (Ed.), Current Concepts in Gender Identity. Garland Press.

Burleson, W. E. (2005). Bi America: Myths, truths, and struggles of an invisible community. Harrington Park Press.

Carroll, J. L. (2013). Sexuality now: Embracing diversity (4thed.). Cengage.

Cass, V. C. (1979). Homosexual identity formation: A theoretical model. Journal of Homosexuality, 4, pp. 219-235.

Centers for Disease Control (2011). Sexual behavior, sexual attraction, and sexual identity in the United States: Data from the 2006-2008 National Survey of Family Growth. National Health Statistics Reports, 36, pp. 1-36.

Cermak, P. & Molidor, C. (1996). Male victims of child sexual abuse. Child and Adolescent Social Work Journal, 13(5), pp. 385-400.

Cheng, W., Ickes, W., & Kenworthy, J. B. (2013). The phenomenon of hate crimes in the United States. Journal of Applied Social Psychology, 43, pp. 761-794.

Cho, M. (2011). “Queer.” Retrieved from http://www.huffingtonpost.com/margaret-cho/queer_b_984123.html.

Constantine, N. A., Jerman, P., & Huang, A. X. (2007). California parents’ preferences and beliefs regarding school-based sex education policy. Perspectives on Sexual and Reproductive Health, 39(3), pp. 167-175.

Cramer, E. P. (1997). Strategies for reducing social work students’ homophobia. In J. T. Sears & W. L. Williams (Eds.), Overcoming heterosexism and homophobia: Strategies that work. Columbia University Press.

Cramer, R. J., Golom, F. D., LoPresto, C. T., & Kirkley, S. M. (2008). Weighing the evidence:

Empirical assessment and ethical implications of conversion therapy. Ethics & Behavior, 18(1), pp. 93-114.

Degges-White, S., Rice, B., & Myers, J. (2000). Revisiting Cass’ theory of sexual identity formation: A study of lesbian development. Journal of Mental Health Counseling, 22(4), pp. 318-333.

Foulkes, R. K. (2008). Abstinence-only education and minority teenagers: The importance of race in a question of Constitutionality. Berkeley Journal of African-American Law and Policy, 10(3).           

Gallup (2015). Gay and lesbian rights [Data set]. Retrieved from

http://www.gallup.com/poll/1651/gay-lesbian-rights.aspx.

Gathorne-Hardy, J. (1998). Sex the measure of all things: A life of Alfred C. Kinsey. Indiana University

Press.

Giovanniello, S. (2013, June 4). NCAVP report: 2012 hate violence disproportionately target transgender women of color. Retrieved from http://www.glaad.org/blog/ncavp-report-2012-hate-violence-disproportionately-target-transgender-women-color.

Glum, J. (2015, February 4). States reconsider abstinence-only sex ed programs as Obama, Congress battle over teen pregnancy prevention funding. International Business Times. Retrieved from: http://www.ibtimes.com/states-reconsider-abstinence-only-sex-ed-programs-obama-congress-battle-over-teen-1804460.

Gottman, J. M., Levenson, R. W., Gross, J., Frederickson, B. L., McCoy, K., Rosenthal, L., . . . Yashimoto, D. (2003). Correlates of gay and lesbian couples’ relationship satisfaction and relationship dissolution. Journal of Homosexuality, 45(1), pp. 23-43.

Greenberg, J. S., Bruess, C. E., & Conklin, S. C. (2011). Exploring the dimensions of human sexuality (4th ed.). Jones & Bartlett.

Grinberg, E. (2015, March 19). Why transgender teen Jazz Jennings is everywhere. CNN. Retrieved from http://www.cnn.com/2015/03/16/living/feat-transgender-teen-jazz-jennings/.

Guerra, C. (2015, May 25). Families with a transgender child learn, change. The Boston Globe. Retrieved from http://www.bostonglobe.com/lifestyle/2015/05/25/parents-transgender-children-acceptance-support-and-new-beginnings/EQGZ0SPU7U9rAkujCKCiLL/story.html.

Herdt, G. & Polen-Petit, N. C. (2014). Human sexuality: Self, society, and culture. McGraw-Hill.

Higgins, T. (2021, June 17). Supreme Court sides with Catholic adoption agency that refuses to work with LGBT couples. MSNBC. Retrieved from https://www.cnbc.com/2021/06/17/supreme-court-

            sides-with-catholic-adoption-agency-that-refuses-to-work-with-lgbt-couples.html.

Hille, J. J., Simmons, M. K., & Sanders, S. A. (2019). "Sex" and the ace spectrum: Definitions of sex, behavioral histories, and future interest for individuals who identify as asexual, graysexual, or demisexual. The Journal of Sex Research, 57(7), 813-823.

Human Rights Campaign (n.d.). Marriage Center. Retrieved from http://www.hrc.org/campaigns/marriage-center.

Irvine, J. M. (2002). Talk about sex: The battles over sex education. University of California Press.

Jones, J. H. (1997). Alfred C. Kinsey: A public/private life. Norton.

Jones, R. P. (2015, April 28). Religious Americans support gay marriage. The Atlantic. Retrieved from http://www.theatlantic.com/politics/archive/2015/04/religious-americans-support-gay-marriage/391646/.

Käng, D. B. (2012). Kathoey “in trend:” Emergent genderscapes, national anxieties and the re-signification of male-bodied effeminacy in Thailand. Asian Studies Review, 36, pp. 475-494.

Khaleeli, H. (2014, April 16). Hijra: India’s third gender claims its place in law. The Guardian. Retrieved from http://www.theguardian.com/society/2014/apr/16/india-third-gender-claims-place-in-law.

Kidd, J. D., & Witten, T. M. (2007/2008). Transgender and trans sexual identities: The next strange-fruit hate crimes, violence and genocide against the global trans-communities. Journal of Hate Studies, 6(1), pp. 31-63.

Kimmel. M. (2013). The gendered society (5th ed.). Oxford University Press.

King, B. M. (2009). Human sexuality today (6thed.). Pearson.

Kinsey, A. C., Pomeroy, W. B., & Martin, C. E. (1948). Sexual behavior in the human male. W. B. Saunders.

Kinsey, A. C., Pomeroy, W. B., & Martin, C. E. (1953). Sexual behavior in the human female. W. B. Saunders.

Kinsey Institute (2011). Prevalence of homosexuality: Brief summary of U.S. studies. Retrieved from http://www.kinseyinstitute.org/resources/bib-homoprev.html.

Krafft-Ebing, R. v. (1965). Psychopathia sexualis (F. S. Klaf, Trans.). Arcade Publishing. (1886).

Kurdek, L. A. (2010). The allocation of household labor in gay, lesbian, and heterosexual married couples. Journal of Social Issues, 49(3), pp. 127-139.

LGBTQ Center, University of North Carolina at Chapel Hill (n.d.). Asexuality, attraction, and romantic orientation. Retrieved from https://lgbtq.unc.edu/asexuality-attraction-and-romantic-orientation.

Liebowitz, C. (2015). Let them eat cake: On being demisexual. Retrieved from http://thebodyisnotanapology.com/magazine/let-them-eat-cake-on-being-demisexual/.

Maier, T. (2009). Masters of sex: The life and times of Williams Masters and Virginia Johnson, the couple who taught America how to love. Basic Books.

Martinson, M. (2015). It happened to me: I’m a demisexual. Retrieved from http://www.xojane.com/it-happened-to-me/demisexuality.

Mesa-Miles, S. (2015, January 13). Two spirit: The trials and tribulations of gender identity in the 21st century. Indian Country Today Media Network. Retrieved from http://indiancountrytodaymedianetwork.com/2015/01/13/two-spirit-trials-and-tribulations-gender-identity-21st-century-158686.

Mezey, N. J. (2015). LGBT families. Sage.

Murray, J. B. (2000). Psychological profile of pedophiles and child molesters. Journal of Psychology, 134(2), pp. 211-224.

PBS (n.d.). Timeline: Milestones in the American gay rights movement. Retrieved from http://www.pbs.org/wgbh/americanexperience/features/timeline/stonewall/.

Pyne, J. (2014). Gender independent kids: A paradigm shift in approaches to gender non-conforming children. Canadian Journal of Human Sexuality, 23(1), pp. 1-8.

Quiroz, L. (2021). Sex ed often leaves out queer people. Here's what to know. NPR. Retrieved from https://www.npr.org/2021/04/22/989826953/sex-ed-often-leaves-out-queer-people.

Rathus, S. A., Nevid, J. S., & Fichner-Rathus, L. (2014). Human sexuality in a world of diversity (9th ed.). Pearson.

Riley, E. A., Sitharthan, G., Clemson, L., & Diamond, M. (2013). Recognising the needs of gender-variant children and their parents. Sex Education 13(6), pp. 644-659.

Savin-Williams, R. C. (2001). Mom, Dad. I’m gay. How families negotiate coming out. American Psychological Association.

Schwartz, J. (2013, June 26). Between the lines of the Defense of Marriage Act opinion. The New York Times. Retrieved from http://www.nytimes.com/interactive/2013/06/26/us/annotated-supreme-court-decision-on-doma.html.

Snow, K. (2015, April 21). Jacob’s journey: Life as a transgender 5-year-old. MSNBC. Retrieved from http://www.msnbc.com/msnbc/jacobs-journey-life-transgender-5-year-old.

Stacey, J., & Biblarz, T. J. (2001). (How) does the sexual orientation of parents matter? American Sociological Review, 66(2), pp. 159-183.

Stryker, S. (2008). Transgender history. Seal Press.

Stryker, S. & Whittle, S. (Eds.) (2006). The transgender studies reader. Routledge.

Viloria, H. (2014, May 14). Op-ed: What’s in a name: Intersex and identity. Advocate. Retrieved from http://www.advocate.com/commentary/2014/05/14/op-ed-whats-name-intersex-and-identity.

Wallace, R., & Russell, H. (2013). Attachment and shame in gender-nonconforming children and their families: Toward a theoretical framework for evaluating clinical interventions. International Journal of Transgenderism, 14(3), pp. 113-126.

Wikan, U. (1991). Behind the veil in Arabia: Women in Oman. University of Chicago Press.

Yarber, W. L. & Sayad, B. W. (2013). Human sexuality: Diversity in contemporary America (8thed.). McGraw-Hill.

Chapter 9: Poverty and Financial Assistance

If there is a signature issue associated with social work, it is poverty. Perhaps no other single factor is as connected to social injustice and inequality. Regardless of one’s race, religion, family composition, sex, sexual orientation, political stripe, or any other identifying factor, poverty has a pernicious impact on everything in one’s life, from housing to education to life expectancy. Despite a number of programs intended to help alleviate the suffering of those in poverty, it seems at times like we are doing nothing more than treating a symptom of a larger problem, since the scope of poverty itself continues to be fairly unabated. Social workers who work in the public assistance system obviously deal with poverty every day, but social workers in any area of practice will be confronted with the impact of substandard incomes on a range of client issues.

When you have finished reading this chapter, you should be able to:

1) Compare and contrast the residual and institutional views as they pertain to poverty;

2) Explain different ways of conceptualizing poverty and how the United States determines its poverty line;

3) Relate the degree to which poverty is a problem in the United States today and compare it to historical levels;

4) Identify which populations are more at risk for poverty in the United States;

5) Discuss several harmful impacts that poverty has on the poor and on the nation as a whole;

6) Analyze the degree of income inequality in America;

7) Comprehend and evaluate the validity of the culture of poverty theory;

8) List several benefits that the existence of poverty provides to the rest of society;

9) Recall the major public assistance programs in the United States and explain the benefits they provide;

10) Recall the major social insurance programs in the United States and explain the benefits they provide;

11) Assess the usefulness of various proposals to reform the social welfare system.

Homeless Shelter Stays Open in Preparation for Storm
Beds await clients in a homeless shelter.
"Homeless Shelter Stays Open in Preparation for Storm" by KOMUnews is licensed under CC BY 2.0

 

Social justice and poverty

            As you may remember from Chapter 3, social justice is the belief that all people deserve equal rights, opportunities, and access to economic and political resources. Obviously, the existence of widespread poverty is practically the antithesis of social justice, so it only makes sense that it is a major focus of social work efforts today. There are some who would say that anyone in the United States is capable of rising above poverty, and others would assert that there are too many structural barriers preventing people from moving out of difficult circumstances. Let’s review how the residual and institutional views perceive the issue.

The residual view of poverty

            Adherents to the residual view of social welfare are apt to see poverty as a problem of the individual. They see each person’s circumstances as a product of their own traits and actions, rather than a result of the many complex factors that determine one’s opportunities for success. If a person is born into difficult circumstances, in the eyes of someone holding the residual view, that person simply needs to work hard—positive results will come their way. People are poor not because the odds are stacked against them, but because they’re looking for an easy way out and/or they simply haven’t given it their best effort. Obviously, people sometimes have bad luck, the residual view says, but hard work and determination can always trump it.

The biggest contention aid recipients have with the way the general public seems to perceive them may be that they believe they deserve public assistance; they don’t care to be seen as bad parents, morally lacking, lazy, or out to manipulate the system (Morgen, Acker, & Weigt, 2010). Given that they subscribe to this view, it only makes sense to residualists that public assistance programs should be rather limited in scope. They see any attempt by the government to give people financial assistance as ideally temporary and as small as possible. In their view, these programs are handouts, and not something to which anyone should feel entitled. The residual view holds that these programs are more likely to lead to people being dependent upon their government, eliminating their desire to provide for themselves. At times, people holding this view will refer to the government’s set of public assistance programs as a “welfare state” or “nanny state,” implying the government takes care of its citizens so much as to prevent them from growing up and taking responsibility for themselves.

Finally, the residual view believes that many welfare benefits that do exist should be as unpleasant as possible to obtain. If these programs are accessed too easily, the thinking goes, then people will not have an incentive to work toward being more self-sufficient. By making benefits difficult (or even dehumanizing) to obtain, the government can save money, thereby saving the taxpayers money (in theory). Residualists tend to believe there are many people bilking the system by using welfare benefits to pay for expensive foods, making poor decisions like getting expensive cell phones or using drugs, and even driving expensive cars while living on the government’s dime. Republican presidential candidates Newt Gingrich and Rick Santorum made comments leading into and during the primaries for the 2012 election that “accused those on food stamps of no longer possessing the American will to [succeed],” and Gingrich even suggested that making child labor laws less restrictive could help poor kids get jobs as janitors so they could rise out of poverty (Abramsky, 2013, p. 45-46). We saw residual thinking during the covid-19 pandemic as well, as Republican politicians pushed to end enhanced unemployment benefits because they believed people were taking the benefits rather than seeking work, causing a shortage of workers in some industries (e.g., restaurants and hospitality).

The residual view is very much in line with individualism—the idea that people are masters of their own fate and should take care of themselves without assistance or interference. They would say that government intervention has gone too far and actually causes more problems than it solves. They have some fair points—some realities and policies in particular programs actually discourage people from getting off welfare, at least in the short term, or even put more roadblocks in the path to personal financial success. (Ironically, though, some of those same policies have been pushed by leaders with more residual views themselves, as with the Personal Responsibility and Work Opportunity Reconciliation Act of 1996, which will be discussed later in this chapter.)

Although the two sides differ very much in their view of social welfare, residualists often want the same thing that institutionalists do—they want to see a prosperous and healthy economy and fewer people dependent upon government programs for survival. It’s just that these opposing views differ greatly on how to bring that about.

The institutional view of poverty

In contrast, the institutional view sees people’s poverty as the consequence of a lot of factors that are beyond of their control. (Remember, this is the view that is part of social work’s belief system.) This view acknowledges that racism and the intergenerational nature of poverty, among other macro factors, have a significant impact on people’s earning potential. They point out that many events happen to people through no fault of their own which have a huge effect on their lives (e.g. companies outsourcing jobs, major medical problems, getting laid off at age 58, the collapse of the housing bubble). In the mind of an institutionalist, there are many hard-working, intelligent, motivated people who end up poor and simply need help to get through a difficult time.

Someone who holds the institutional view would say it benefits the government and the economy if we can give people a chance to get on their feet in difficult circumstances. They see the benefits provided through public assistance programs as rights, believing that every citizen is entitled to a basic standard of living and that society has a duty to take care of the poor rather than letting them suffer. (This is in line with the philosophy of collectivism.) They believe the programs in place are legitimate and should be permanent—not that they need to continue to pay each client forever, but that the programs that exist will always be needed by someone. They see welfare programs not as “handouts,” but as an investment. Since so many people using public assistance have families, institutionalists would say, it only makes sense to help them—at the very least, the children should have basics like food, clothing, and medical care.

Finally, the institutional view would agree with the idea that welfare benefits should be easy to obtain for those who qualify. People have already been suffering, in most cases, before they even walk into a welfare office—why make them feel even more negatively about themselves and their situation? It is not easy for most people to come in and ask for help, and making the process difficult seems mean-spirited and pointless to someone on the institutional side. All clients have stories behind how they ended up in their predicaments, and institutionalists are more likely to give those welfare recipients the benefit of the doubt.

This does not mean the institutional view believes there should be no regulations or limits, either. You will find that people on both sides can agree on some of the requirements and exceptions for receiving benefits in some cases, but that adherents to the institutional view are less likely to believe that there are many people taking unfair advantage of the system as it stands. They would say that those who are manipulating the system to their advantage are a tiny minority, and that the government disqualifies a lot of people who truly need assistance, so the number of benefit recipients who do not need the help is negligible.

 

Defining Poverty

As with any problem (and as the social work change process discussed in Chapter 4 taught you), in order to discuss the different ways to approach poverty, we first have to define what the problem is. With poverty, that can be rather complicated, as there are multiple ways to think about the word itself. What would tell you someone is living in poverty? How does a poor person’s (or poor family’s) day-to-day life look? How much can a poor person own before he or she is no longer poor? (See Box 9.1 for one approach to that question.)

Box 9.1: Are the Poor Allowed to Have Some Nice Things?

It is not difficult to find some people saying that most Americans living in poverty “don’t really have it that bad.” Perhaps that is an honest belief; perhaps they simply have been fortunate enough not to see poverty up close very often in their lives. One news program noted the following statistics from The Heritage Foundation (a conservative think tank) to claim that people in poverty are not really suffering all that much:

  • 99.6% of poor families own a refrigerator
  • 81% own a microwave
  • 78% have air conditioning
  • 65% have a DVD player
  • 32% have more than two TVs
  • 25% have a dishwasher
kitchen
"kitchen" by zloizloi is licensed under CC BY-NC 2.0

What do these numbers say to you? Is this enough information to know whether those families are poor? Why or why not? What circumstances could lead a poor family to have some valuable possessions?  (Shere, 2011)

We will start by taking a look at two major definitions which endeavor to identify who qualifies as poor using somewhat different approaches.

The relative approach to defining poverty

According to Zastrow (2010), the relative approach would consider a person poor when her/his income is much lower than the typical income in that population. Mangum, Mangum, and Sum (2003) agree, saying the “relationship to the median income could be called relative poverty” (p. 9). This means that if we find what the income is for the most average family—in other words, a family that has more income than 49.999% of the population and less income than 49.999% of the population—we could decide, for example, that anyone whose family made one third (⅓) that income level or less was officially poor. This means that the poverty line for that population would shift as the median income shifts (in other words: constantly).

There are good and bad points to the relative approach to defining poverty. First of all, we’re comparing people to others around them to get an idea of how badly they are doing in comparison to others (hence the term relative approach). That means that different income levels could apply in different states, or even different counties or towns within the same state. These people represent the most in need in their various communities.

From a social justice perspective, this approach would help us to focus upon moving toward equality. The more people are poor under a relative definition, the more we know inequality is a problem. The closer we get to a fair distribution of income and resources, the fewer people there would be below the poverty line using this approach.

However, this can also be a fairly arbitrary definition. Who decides whether it’s half, or one third, or one quarter of the median income? While half is a common standard, it could easily be changed by policymakers if it fit their needs to do so. Another question is whether a family’s presence below the relative poverty line can actually tell us how that person or family is living. Can we assess if their quality of life is adequate? Furthermore, if we do take the relative approach from state to state, what if one state is quite a bit richer than the others? We may end up defining some people in that rich state as poor who don’t really seem to be in need, while in other states we could have a lot of people who are in fairly dire situations but don’t qualify as poor under the relative approach because most of the state is in a similarly difficult predicament.

The absolute approach to defining poverty

The angle the American government prefers to take in defining poverty is the absolute approach. To put it simply, the absolute approach designates a basic subsistence income level (the absolute version of a poverty line) and anyone who falls below that line is considered poor. This is the approach that most of us know better, as it is a fairly straightforward thought: a family is poor if their income is below (x) dollars. This basic approach does not require a lot of explanation on the surface.

However, what remains unclear with that definition (and often goes unasked) is just exactly how that subsistence level of income is calculated. A 1955 survey by the Department of Agriculture determined that Americans spent about a third of their total income on food. This didn’t tell anyone how much of their income poor families spent on food, just that the typical American family budget was one third for food, two thirds for everything else. Taking that approach, the government identified the most frugal diet among the many options that the Department of Agriculture had recently recommended as potential bases for family food budgets and multiplied it by three. Essentially, they took the minimum cost of feeding an average family and used that to determine how much money a family should need to get by as long as they were also being as frugal as possible in every other area of their budget. Then, as now, the poverty line varied based upon the size of one’s family, since the amount of food necessary to feed a family increased with the size of the family (Katz, 1996; Mangum, Mangum, & Sum, 2003)

Both conservatives and liberals would agree it’s important for poor and even middle-class families to be frugal, so establishing a minimum income that would require careful spending doesn’t seem too bad on the surface. This approach has been called the market basket concept, and although it was implemented in the 1950s, this is the same basic method being used today. The only reason the poverty line increases each year is because there is a cost-of-living adjustment due to inflation and increasing prices.

Walmart Grocery Checkout Line in Gladstone, Missouri
The government still uses an outdated calculation method invented in the 1950s to determine the poverty line, based on a family’s food budget being one third of their total budget.
"Walmart Grocery Checkout Line in Gladstone, Missouri" by Walmart Corporate is licensed under CC BY 2.0

 

Obviously, the cost of living in the 1950s isn’t in line with today, as there are additional expenses that didn’t exist at the time, while other costs have risen more sharply than the cost of food, rendering the multiplier of three obsolete. Additionally, establishing a national poverty line seems a bit absurd when one considers the vastly divergent costs of living in different places. For instance, in 2013, the median apartment rent in America was about $1,230, but one could get a one-bedroom, one-bathroom apartment for about $1,000/month in Kansas City; the same apartment in San Diego would run $1,700 (Glink, 2013). And if you’d like to compare extremes, consider the median monthly rent in a city like Wichita, Kansas ($623) in relation to San Francisco ($4,000) (Glink, 2013).

Box 9.2: How Much Does a Full-time Worker Have to Make per Hour to Afford a Two-Bedroom Rental?

Hourly wage needed

Note that a full-time minimum-wage ($7.25/hour) job doesn't come close, anywhere.
Source: National Low Income Housing Commission, 2018

It’s probably safe to bet that poor families in San Francisco aren’t looking to live in $4,000 apartments, but it costs a lot more to live there than it does in a smaller Midwestern city, not just in rent but in other daily costs; jobs in these places are also likely to pay differently, though the low-end jobs are still going to be hovering around the minimum wage ($9 in California, $7.25 in Kansas) (National Conference of State Legislatures [NCSL], 2015). Applying an absolute poverty line seems a bit absurd when we start looking at these tremendously different rents, and while food is not going to cost six times as much in California, it’s fair to conclude that food costs are lower in Kansas.

Box 9.3: The Poverty Line

Poverty lines

Beyond the issues with varied costs of living, the absolute approach also falls short in determining how a family is actually living. A healthy family of four with two young parents who are nonsmokers and nondrinkers is likely to have very few medical expenses. A different family of four could have two special needs kids and a father with diabetes, incurring much higher medical expenses. That family could have an income well above the poverty line but be struggling worse than some families below it due to their higher everyday expenses that have nothing to do with subpar budgeting skills.

In the end, there probably isn’t a perfect way to define poverty that addresses all of these issues and still can be calculated easily enough to make the government’s job of determining benefit eligibility less cumbersome. Social scientists tend to favor the relative approach since it gives a snapshot not only of the number of families who need assistance, but also an idea of the overall inequality among the economic classes.

Another measure of that inequality is called the poverty gap, which goes beyond just telling us how many families fall below the poverty line. The poverty gap measures the difference between the poverty line and the actual income level of the average poor family (Mangum et al., 2003). The United States has one of the worst poverty gaps among economically advanced nations, hovering around 18%, while countries like Finland, Czechia, and Denmark are between 5 and 7% and the average is about 11% (Organisation for Economic Cooperation and Development [OECD], 2016).

 

Income Inequality

By almost any measure, income inequality in the United States is at levels that rival the country’s status right before the Stock Market Crash of 1929. The top 10% of the country makes an average of $109,000 per household per year. The top 1%--the symbolic opponents of movements like Occupy Wall Street—make over $368,000 per year. The top tenth of that top 1%—about 84,000 households in the country—make $1.7 million per year or more (Noah, 2012).

Since 1973, in fact, the median income for full-time working men in the United States has declined if we take inflation into account. Interestingly, since 1979, women’s median income has actually increased by 22%, though they still lag considerably behind men, as noted in Chapter 7 (Noah, 2012). The year 1979 marked the beginning of what Princeton economic professor Paul Krugman called The Great Divergence (2007), an ever-widening gap between the rich and poor, with a vanishing middle class. Even though American workers’ productivity had increased considerably over three decades, by the 2000s, their share of the economic profits being derived from that improved work efficiency was notably absent. Though the total income of U.S. workers was increasing from 1980-2005 (even after adjusting for inflation), the top one percent of the country received eighty percent of the total increase (Noah, 2012).

In fact, while in 1979 the richest 1% of Americans had about 9% of the total income, by the year 2007 that had ballooned to 21-24% (Noah, 2012; Wolff, 2013). That made it eerily parallel to the level of economic inequality (24%) in 1928 right before the biggest economic crisis in American history, the Great Depression (Noah, 2012). This led some to speculate that the United States could be on the verge of another major crash, or even a revolution (Judson, 2009).

It’s not just that the top one percent’s share of the income pie has been increasing; the top twenty percent have all been enjoying gains, while the bottom 80% have all been experiencing losses, in both income and overall wealth. Obviously, the more income one has, the more chance there is to increase one’s wealth. However, wealth (or the lack of it) also tends to get carried over from generation to generation.

Box 9.4: The Haves and Have-nots

Wealth and income distribution

(Wolff, 2013, p. 41)

            As the chart illustrates, the rich take up an even greater share of the overall wealth and income than people might imagine they do; when the bottom 40% only has 0.2% of the wealth and makes only 9.6% of the new income, there is no wonder that they struggle to do anything to rise out of poverty. Has it gotten better since 2007? Unfortunately, no. The Gini coefficient, a measure used to compare income equality across nations, shows that the United States has more profound inequality than any other G7 nation (UK, Italy, Japan, Canada, Germany, France) or Russia. In fact, by 2016, the richest 5% of American households had 248 times as much as the median household (Schaeffer, 2020). 

            Still, most Americans still believe that social mobility is a realistic possibility in their country. A survey of 27 nations’ citizens at the turn of the 21st century asked people to say whether they agreed with the following statements:

  • “People are rewarded for intelligence and skill.”
  • “People get rewarded for their effort.”
  • Coming from a wealthy family is “essential” or “very important” to one’s chances at success (Noah, 2012, p. 28-29).

How would you respond to those statements? About 70% of Americans agreed with the first, 60% with the second, and less than 20% with the third, giving a clear indication that most citizens believe our system is a meritocracy, much more so than most other nations (Noah, 2012). Another poll by Pew Charitable Trusts in 2009 found 39% of Americans said it was “common for someone in the United States to start out poor and become rich” (Noah, 2012, p. 29).

However, the realities of our country do not bear that out. Out of the people born into the bottom fifth of the population (making $25,000 or less per household), only six percent—that’s not six out of twenty, but six out of one hundred—make it to the top 20% ($100,000 or more per household) (Noah, 2012). Overall, more than 65% of people born into the poorest 20% of families will never rise out of the bottom 40% (Hertz, 2005).  In fact, one’s “[p]arentage” is a bigger factor in determining one’s future income than it is in determining one’s height and weight—in other words, economics kind of trump genetics (Noah, 2012).

The residual view would say that the reason most people who are born into poverty don’t leave it is because they haven’t been taught the way to succeed, or perhaps more hardline residualists would say it is because most poor people don’t have the skills or desire it takes to make it. Institutionalists—and social workers—would point out that there are a lot of hardworking people—in fact, most people receiving public assistance are actively working but cannot make enough to rise out of poverty due to factors beyond their control.

What do you believe? Could it really be possible that people who remain poor just aren’t trying, or don’t know what to do? Could most of the hardworking people really be concentrated in the top 20%, or the top 1%? Before you answer that, let us take a look at some of the populations that are at greater risk for poverty in the United States.

 

Who Are the Poor?

More than one out of ten Americans (10.5%) lives in poverty (U.S. Census Bureau, 2020). Despite the belief some maintain that poverty is due to poor choices made by many individuals, according to Blank (2009), these are the most common ways people end up living in poverty:

  • Earnings of head of household dropped (42.8%)
  • Married couple splits up (12.6%)
  • Second income dropped (12.0%)
  • Child moves out and forms a new family (11.3%)
  • Other changes in the makeup of the family (10.9%)
  • Birth (born into a poor family) (8.9%)

There are many populations more affected by poverty than others—populations that carry a higher risk of ending up poor due to structural and societal factors that create greater difficulties in reaching economic self-sufficiency. By no means is being a member of one of these groups a sentence to a destitute life, but it does mean for a tougher road in a lot of cases. If someone is a member of more than one of the following groups, that increases their risk even more.

Children

            Sadly, being a child puts one at greater risk for poverty; kids are the highest-risk age group for poverty in America. This is especially true since the larger a family gets (i.e., the more kids they have), the greater the risk. Families with five kids are more likely to be poor than families with two, simply because there are fewer resources to go around. The chance of being poor decreases as age increases; about one-fifth of kids under age 5 are poor, compared to about one-seventh of children overall. Nearly three-quarters of all poor children are racial minorities (Reese, 2005; Children's Defense Fund, 2021).

               In fact, America has the highest child poverty rate of any industrialized nation in the world—this is likely due in part to the fact that many other advanced countries provide “universal allowances, national health insurance” (typically more comprehensive than the Affordable Care Act), “subsidized child care, and paid family leave” (Reese, 2005, p. 199). Only about 10 to 20 percent of American families that qualify for child care subsidies from the government receive them, and only the poorest can qualify (Reese, 2005). Additionally, half of all poor children live in extreme poverty--in households where the income is less than half of the poverty line (Children's Defense Fund, 2021).

End Child Poverty - Keep The Promise
Nearly one in five children in America lives in a poor household, which can make healthy eating a struggle, leading to potential health problems down the line.
"End Child Poverty - Keep The Promise" by RMLondon is licensed under CC BY-NC 2.0

 

Women

We discussed the feminization of poverty in Chapter 7, so you are already familiar with problems like the gender wage gap. You may be surprised, however, to learn that the gap between male and female poverty in America is greater than any other country in the Western Hemisphere, and over half our nation’s total poor population, and 70% of the world’s impoverished people, are adult women (Cawthorne, 2008; Lefton, 2013).

The Center for American Progress (Cawthorn, 2008) notes the following economic challenges faced by women:

  • Women are more often employed in lower-paying fields, and are encouraged to pursue careers in such fields more than lucrative careers;
  • Although most poor women are childless, when parents split up, women take on a disproportionate amount of the economic burden of child care, if not all of it; 80% of single parents with custody are mothers, and they are “twice as likely to be poor as custodial fathers” (para. 13);
  • Pregnancy affects women’s work more than men’s, as they are often forced to take more time off or cut hours without being compensated for the lost time;
  • Domestic and sexual violence are far bigger risk factors for women, and two major causes of homelessness, as well as risk factors for losing one’s job (Davis, 2006).

Box 9.5: Racial and Gender Disparities

            Since poor women more often saddled with child care duties or expenses than poor men, and most employers do not provide child care benefits, women often have to make a difficult choice: work, spend very little time with their kids, and spend a large portion of their earnings on the child care they only need because they are working; or stay home, live off of government benefits, and spend time with their children while they still can—typically enjoying an equal or even improved quality of life compared to the money they’d have left over from their job after paying for child care (Dáil, 2012).

Single-parent families

Over a quarter (27%) of single-parent families live in poverty compared to 16% of two-parent families (Livingston, 2018). The risk is unsurprisingly higher for single mom-headed families. While 30% of families led by a single mother are below the poverty line, 17% of single father-headed families (Segal, Gerdes, & Steiner, 2013; Livingston, 2018). 

Older adults

            Though the percentage of elderly who are poor has fallen over the last few decades, the number of elderly people in poverty has actually grown as our older adult population has been undergoing considerable growth (as you will read in Chapter 16). Their ability to stay out of poverty is in large part due to benefits paid out through Social Security, which average close to $1,550 per month (Social Security Administration, 2021a). Without those benefits, nearly 45% of elderly people would be below the poverty line; with it, only 9.1% are (Van de Water, Sherman, & Ruffing, 2013).

Nonwhites

There can be no doubt that poverty and race are linked. Not only are nonwhites more likely to be below the poverty line, they are more likely to stay there for a longer period of time (Blank, 2009). According to the U. S. Census Bureau statistics of 2010, 22% of Black families and 21.3% of Hispanic families were poor, compared to 9.8% of Asian-American families and 8.4% of white families. However, lest you think of poverty simply as a minority problem, it is worth noting that despite the lower rate of poverty among whites, the number of White families in poverty (approximately 5.4 million) still exceeds the number of poor Black and Hispanic families combined (4.3 million) (U.S. Census Bureau, 2010).

When the economy is suffering, as it has in recent years due to the effects of the Great Recession, minority Americans also find themselves disproportionately impacted. The national unemployment rate hit its recession peak at 10.1% in October 2009, but unemployment among Black people continued to increase beyond that, eventually capping off at 16.5% in 2010; by 2011, the overall unemployment rate had improved to 9.2% while the Black unemployment rate remained over 16% (Martin, 2013). This gap existed between Blacks and Whites of similar educational levels as well, at each level measured:

  • High school diploma: 22.5% Black unemployment, 13.9% White unemployment
  • Some college: 12.4% black unemployment, 7.6% White unemployment
  • Bachelor’s degree or higher: 7.9% black unemployment, 4.3% White unemployment (Martin, 2013).

Although not separately addressed in the Census data we’ve discussed, it is noteworthy that Native Americans and Alaskan natives have long been suffering disproportionately from poverty as well. Every Census year from 1970-2000, the percentage of Native Americans and Alaskan natives living in poverty on reservations was at least double the rate of the American population in general (Dewees & Foxworth, 2013); though this improved with the 2010 Census, there is still a large gap. Over 28% of Native Americans fell below the poverty line, as compared to 15.3% of the United States as a whole (U.S. Census Bureau, 2011)

People with disabilities

Many people have seen a homeless person with an apparent disability on the street and felt something stir within them, perhaps given them a dollar or two as they passed by. People with disabilities are more likely to be chronically homeless than other groups (Hombs, 2011). An estimated 28.4% of adults with disabilities (aged 21-64) who were not housed in institutions in 2012 fell below the poverty line (Erickson, Lee, & von Schrader, 2014).

Robin Wathen - Part 1
Having a disability is a major risk factor for poverty, nearly doubling one’s chances of being poor.
"Robin Wathen - Part 1" by EX22218 - ON/OFF is licensed under CC BY-NC-ND 2.0

 

Many of us have also seen people on the street asking for donations with signs and even decorations denoting their military service. Interestingly, though the poverty rate for American military veterans is lower than the overall poverty rate, that pattern becomes reversed when comparing veterans with disabilities to non-veterans with disabilities. Among Americans aged 35-54, 33.8% of veterans with a disability are below the poverty line, compared to 25.4% of non-veterans with disabilities (U.S. Department of Veterans Affairs, 2015).

LGBTQ+ people

“Annual earnings are approximately 10 percent lower for gay households and 24 percent lower for lesbian households compared to heterosexual households” (Martell, 2013, p. 261). Many studies have shown that while lesbian women appear to earn slightly more than heterosexual women, gay men earn less than heterosexual men (Martell, 2013). Given that legal recognition of marriage confers an economic benefit, it will be interesting to see if this statistic evens out somewhat as we study the impact of same-sex marriage equality.

There remains considerable evidence, however, that discrimination plays a part in the wage differentials of LGBTQ+ workers and heterosexual cisgender workers (Martell, 2013). Until 2021, in most states, LGBTQ+ people could be fired simply on the basis of sexual orientation or gender identity, irrespective of their talents or job performance. One recent study found that nearly “30 percent of bisexual women and 23 percent of lesbian[s]” were below the poverty line, compared with 21% of all American women (Caiazza, 2015). The news was even worse for trans women, who are four times as likely as other Americans to be living on $10,000 or less per year (Caiazza, 2015).

 

Impacts of Poverty

It should be clear that poverty’s primary harmful effects are economic, but it will surprise no one that the economic struggles bring about many other problems.

Homelessness

This is notoriously difficult to measure, since it can be challenging or impossible to count the homeless. By its very nature, homelessness is something that its sufferers try to keep hidden. The Annual Homeless Assessment Report (AHAR) attempts to provide some numbers on both chronic homelessness and the number of people who are homeless on a given night. In 2009, an AHAR count found 643,067 homeless individuals, both in and out of shelter settings; there were an estimated 110,917 chronically homeless people (homeless for a year or more, or temporary homeless four or more times in a three-year span) among that count (Hombs, 2011). The National Alliance to End Homelessness (2021) estimated about 580,000 people in the homeless population, including over 110,000 chronically homeless, showing that while there has been an improvement in overall numbers, chronic homelessness remains relatively unchanged.

Homelessness brings with it a myriad of problems that add to the misery of poverty. Homeless people are more likely to be victimized by crime (Fish, 2014); more likely to suffer from untreated health problems; more likely to suffer from mental disorders (20-25% compared to 4% of all Americans); and have a much shorter life expectancy—42 to 52 years, as opposed to 78 for the general population (Ambrosino, Heffernan, Shuttlesworth, & Ambrosino, 2012; National Coalition for the Homeless, 2009). Furthermore, it is very difficult for homeless individuals to get a job, as they have a harder time finding a way to look presentable for interviews, have no address to put on an employment application, and likely have no phone where a prospective employer can reach them. This makes escaping from homelessness, and poverty, all the more difficult.

Still hungry. Still homeless. Still need help.
Surviving day to day is a significant enough challenge for the homeless. More cities in recent years have even been criminalizing the act of feeding the homeless in public.
"Still hungry. Still homeless. Still need help." by Ed Yourdon is licensed under CC BY-NC-SA 2.0

 

Mental and physical health

Poverty impacts the quality of health care one can receive, as it is not unusual for poor individuals to be uninsured or underinsured. If they can qualify for Medicaid, that is much better than nothing; but many adults in need do not receive Medicaid benefits and are forced to get whatever affordable healthcare they may be, or to resort to emergency rooms in dire situations.

Not only can poor health and high medical expenses lead to homelessness, but homelessness can certainly harm one's health. Compared to people with a household income of $70,000 or more, those with an income blow $19,000 have significantly higher risk of developing depression, an anxiety disorder, or a substance use disorder during their lifetimes (Mossakowski & Gibson, 2013). Regarding dental health, “[m]ore than 54% of children living at or below the poverty line have experienced primary tooth decay, compared with 32% of those over 200% of the poverty line” (Kahn, 2013, p. 58). The disparity is even greater for younger children—34% of poor children age 2-4 had tooth decay in a five-year span, more than double the number of non-poor kids (Kahn, 2013). Poverty is also strongly linked with higher risk of AIDS and other sexually transmitted infection transmission (Kposowa, 2013).

Education

Many schools in the United States are funded largely by local property taxes, which means that school districts with more expensive land and wealthier residents get more tax revenue to build their facilities, hire the best teachers, and train their administrators, support staff, and educators to do the best job possible. Meanwhile, schools in low-income areas have to make do with teachers that will take lower-paying positions, sometimes using textbooks that are outdated. This puts the poorer students in more cash-strapped school districts at an even greater disadvantage than they were before school.

Children in poverty are also less likely to stay in school, in part because they are more apt to find it irrelevant, tedious, and devaluing of their humanity (Brown, 2015). It has also been found that although kids from poor households are more likely to be truant, nearly a quarter of poor kids were frequently missing school in order to care for a sick relative at home; 30% were “bullied so severely they were too scared to return to school,” and nearly half succumbed to peer pressure to skip classes (Brown, 2015, p. 24-25).

As if that were not enough, students who live in poverty are already educationally disadvantaged before they even get to kindergarten. Those differences that have them on unequal footing at the beginning of their scholastic career will only widen over the course of their education. “Time after time, sociological research has demonstrated that a person’s social class and not education is a bigger predictor of their occupation and income…education can lead to a perpetuation of the social class system” (Ansalone, 2009, p. 34).

Box 9.6: Poverty and School Preparedness

Beginning Kindergarten Students’ School Readiness Skills by Socioeconomic Status (SES)
Readiness stats           
(Neuman, 2009, p. 19)

The Culture of Poverty

Anthropologist Oscar Lewis, in a controversial article published in Scientific American in 1966, proposed (based upon his observations of low-income communities) that there was a culture of poverty—that is, a set of behaviors and attitudes exhibited by the poor in reaction to their difficult circumstances. These actions and mindsets, Lewis said, were adaptive responses to the troublesome situations in which the poor found themselves. Unfortunately, the same behaviors served to keep the poor at the lowest rung of the society—their own adaptations prevented them from rising above their circumstances. Lewis’s theory has been roundly criticized by many; decide for yourself what you think of it after reading a few of the traits he considered to be signatures of the culture of poverty.

  • Social isolation: The poor tend to prefer to keep to themselves, away from the upper and middle classes, socializing mostly with other poor people.
  • Instant gratification: If they get a little extra money, the poor are prone to spending it immediately rather than saving it up to eventually help themselves move out of poverty. They don’t save because they don’t necessarily believe anything good could come from it; poverty seems insurmountable. However, they know they can enjoy themselves now.
  • Rejection of the dominant class: Though the upper class and the government could conceivably help the poor to escape poverty, or at least illustrate some skills that could be useful to them, the poor often choose to reject their help. They do not want to be associated with the upper class, who are seen as colder and less human. This may even mean behaviors like rejecting participation in the educational system or refusing to follow laws.
  • A lack of value placed on childhood: The poor do not see childhood as a time of innocence and leisure but a time to prepare for the tough futures they will face. Children are more likely to be more significantly restricted in their behavior when they grow up in poor homes (Lewis, 1966).

As noted, the culture of poverty theory has not been uniformly popular with sociologists and theorists. Some see this as Lewis blaming the poor for staying poor, while Lewis himself would likely claim he does not blame the poor at all for their circumstances and understands how these behaviors and attitudes have developed in order to give people some sense of identity and control over their own happiness.

 

The Functions of Poverty

If you’ve taken a sociology class, you may remember learning about a school of thought called the functionalist perspective. According to that view, every part of a society serves some purpose to the overall functioning of the society. If one part did not serve a purpose, this perspective argues, then that element of society would cease to exist. Obviously, that is not happening with poverty! If anything, poverty is becoming more omnipresent in America. From a functionalist way of thinking, that must mean that it serves a purpose: it provides some benefits to society.

Gans (1972) identified a number of functions of poverty for the rest of society. We are going to review several of them here.

  • Poor people do the “dirty work”—“physically dirty or dangerous, temporary, dead-end and underpaid, undignified, and menial jobs” (p. 278) that must nevertheless be done in order for society to function—e.g., janitorial work, food service, groundskeepers.
Janitor
Low-paid jobs keep our society moving. How quickly would your community shut down if all the minimum-wage workers decided not to show up for work one day? How many low-paid workers were suddenly recognized as essential when the covid-19 pandemic hit?
"Janitor" by kptice is licensed under CC BY-NC-SA 2.0
  • The poor purchase cheaply-made, low-cost goods that the middle class and upper class would not bother to buy. They also buy second-tier goods like “day-old bread” and aging produce (p. 279).
  • Upward mobility is more possible for others because the poor exist. The poor, by taking up a smaller portion of the overall resources in a society, enable the rich to have more than their equal share and (theoretically) to invest it into the economy, helping produce income for others. One large portion of the populace having much less than their equal share means more money is free to exchange hands among the middle and upper classes, giving them the opportunity to have social mobility.
  • The existence of the poor creates jobs: police officers, pawnbrokers, payday loan operators, even (ahem) social workers.
  • The poor serve as examples of what can go wrong if one behaves lazily or in a deviant fashion, giving parents and authority figures the opportunity to guide children’s behavior to stay in line with expectations. (It doesn’t matter if the poor really did anything to deserve their plight; their existence can still be used as a warning.)
  • The rich have an opportunity to be charitable to the poor, thereby alleviating any potential risk of feeling guilty about their wealth and attracting positive attention for their generosity.
  • The poor, inspired by their struggles, create forms of art that get appropriated by the middle and upper classes.
  • They add strength in numbers to one political party while acting as an opponent for the other. In the case of modern-day America, it could easily be argued that the poor help give voting clout to the Democratic Party while looming as a problem the Republican Party can make into a part of their political platform.
  • Importantly, the poor “absorb the economic and political costs of change” (p. 283). Major changes in policies, technology, and cultural shifts tend to have a disproportionate impact on the poor, which clears the way for other groups in society to benefit from the changes.

This list of functions may not make you feel better about poverty (nor should it), but it does help explain—at least from a functionalist perspective—why poverty continues to exist in record amounts across the country. The existence of the poor inarguably serves some very convenient purposes for the middle and upper classes.

 

Public Assistance Programs

The government has developed several programs to both combat and prevent poverty over the last 85 years or so since the Great Depression. The following programs fall under the category of public assistance. Remember, this group of programs is meant to alleviate the effects of poverty, and applicants must pass a means test in order to receive benefits. The benefit levels are determined by factors within each individual case and dependent upon the program.

Supplemental Security Income (SSI)

            SSI is a federal program that serves low-income Americans who are aged (over 65), blind, and/or have a disability. It is funded by general tax revenues rather than Social Security payroll taxes. The benefits provided under SSI are intended to help recipients pay for food, clothing, and shelter—the basic necessities (Social Security Administration, 2015a). The income level at which one qualifies is the same nationwide. Although it is a federal program, some states supplement the payments made to recipients (Social Security Administration, 2009). The maximum federal benefit payment in 2015 for SSI was $1,191 for an eligible couple and $794 for an eligible individual (Social Security Administration, 2021b). The more income one has, the lower the benefit she/he will receive from SSI; adult recipients will also receive lower benefits if they live with someone else (other than a spouse) who takes care of their living expenses (Social Security Administration, 2015b).

General Assistance (GA)

Poor adults who have no children but do not qualify for SSI have little available in the way of federal assistance to help them.  Twenty-one states have a program for these adults called General Assistance which provides some cash assistance. Many states have done away with General Assistance in order to budget more money elsewhere, as there is a perception among some governments that recipients of GA are undeserving since they do not qualify for other assistance programs; in other states, benefits may be offered in some municipalities or counties and not others, and payment amounts can vary widely, since the state or local municipality is funding the program itself (Schott & Cho, 2011). Currently, some states deem only people who are considered "unemployable" due to a health condition eligible for GA.

Medicaid

            Established as an addition to the Social Security Act in 1965 under President Lyndon B. Johnson, Medicaid came into existence simultaneously with Medicare. People often get the names of these programs confused with each other; an easy way to remember the difference is to say “Medicaid is public aid.” That is, Medicaid is health insurance available for the poor. Generally speaking, if one qualifies for SSI, one also qualifies for Medicaid, but it is not necessary to receive SSI if one wants to apply for Medicaid assistance (Olson, 2010). Along with the Children’s Health Insurance Program (CHIP), Medicaid provides insurance to 72.2 million Americans who might otherwise not be able to afford doctor’s visits, emergency room visits, hospital stays, or medications (U.S. Department of Health and Human Services, n.d.). Medicaid is funded through a combination of state and federal monies and is administered entirely by the states in accordance with some federal guidelines (Cox, Tice, & Long, 2016; Matthews, 2015). (Both Medicaid and CHIP are covered in greater depth in Chapter 12.)

Housing Choice Voucher Program                              

            Commonly known as Section 8, the Housing Choice Voucher Program provides funding assistance to low-income families looking to obtain housing. There are two kinds of vouchers: a project-based voucher and a tenant-based voucher. To receive either kind of voucher, an applicant must qualify through the completion of a means test. Different housing authorities have different income maximums for people to be eligible to receive assistance in these programs.

A project-based voucher gives an applicant approval to take residence in public housing, which can take the form of standalone houses, duplexes, or apartments. There are approximately 1.2 million public housing households in the United States, and long waiting lists to get into one are common; in some areas, waiting lists get closed when there are more families on them than can be realistically housed in the near future (U. S. Department of Housing and Urban Development, n.d. a). Residents must be approved by the local housing authority in order to move in, and once they move out of public housing, they may have to go back onto a waiting list to move back into a housing project. If residents’ income increases past the maximum allowed for public housing residents, they are supposed to notify the housing authority, who will reassess whether the family can stay in public housing (U. S. Department of Housing and Urban Development, n.d. a).

A tenant-based voucher (sometimes referred to as a housing choice voucher) allows the individual who receives it to use the voucher on the private market to get a home or apartment anywhere in the United States with homes approved by the local housing authority. The beneficiary can use the voucher at any home where it is accepted by the landlord, and then the housing authority will directly pay the landlord a share of the rent while the tenant pays the remainder (U. S. Department of Housing and Urban Development, n.d. b). When tenants choose to move to a different home, the vouchers stay with them—they do not need to reapply and get put back on a waitlist.

Duluth, MN Public Housing Project
While there is a stereotype of public housing projects as dilapidated, dangerous, and ugly, many look like typical housing developments, like this one in Duluth, Minnesota.
​​​​"Duluth, MN Public Housing Project" by tvdxer is licensed under CC BY 2.0

Recipients of both kinds of vouchers still have to pay a portion of their rent every month, referred to as the total tenant payment (TTP). The TTP is determined by the highest of the following:

  • 30% of monthly adjusted income (income minus certain allowed deductions based on medical costs, the number of dependents in the home, and the number of elderly people and/or people with disabilities in the home)
  • 10% of monthly income
  • Welfare rent, if applicable
  • A $25 minimum rent (or a higher amount set by the local housing authority, up to $50) (U.S. Department of Housing and Urban Development n.d. a).

A tenant-based voucher is approved for a maximum monthly rent amount, but one can choose a home with more expensive rent as long as one is willing to pay the difference and the TTP does not exceed 40% of the recipient’s income (U.S. Department of Housing and Urban Development, n.d. b). In order to qualify to receive either kind of voucher, a family’s income generally can’t be higher than 50% of the median income in the area governed by the local housing authority; in fact, the authority is typically required to award at least three-quarters of its vouchers to families with an income no more than 30% of the median for that area (U.S. Department of Housing and Urban Development, n.d. b).

Living in public housing is better than living on the street by virtually any measure. However, some public housing projects are plagued by crime and gang activity (Bowly, 2012; Husock, 2004), making them far less than ideal places to bring up a family.

Supplemental Nutrition Assistance Program (SNAP)

            Formerly known as food stamps, the Supplemental Nutrition Assistance Program provides financial assistance for low-income people to purchase food. Similarly to the way the poverty line is designated, SNAP benefits are based upon a frugal but healthy meal plan. However, that plan (which the USDA calls “nutritionally adequate”) requires nutrition knowledge, storage space, access to affordable markets, and equipment that may not be available or possessed by the poor (Levitan, Mangum, & Mangum, 1998).

            Food Stamps began as a pilot program in several states thanks to an executive order by President John F. Kennedy, and they were made permanent by his successor, President Lyndon B. Johnson, in 1964 (Edelman, 2012; U. S. Department of Agriculture, 2014).  By 1974, all counties in every state had to adopt a Food Stamps program, which made it “the country’s single most effective intervention against poverty” and “unquestionably a successful public policy story” (Abramsky, 2013, p. 74; Edelman, 2012, p. 12). Even conservative-leaning President Richard Nixon helped the program to expand, though at the time families had to pay a fee to begin receiving Food Stamps benefits; this requirement was finally eliminated by Congress in 1977 (Abramsky, 2013), putting the full burden of funding the program on the federal government. In 2019, 38 million Americans used SNAP benefits (Hall, 2021).

Buying food with the EBT card
SNAP benefits are now disbursed in all states via electronic benefit transfer (EBT), so people accessing their public assistance funds are virtually indistinguishable at the register from any other customer paying with a credit or debit card.
"Buying food with the EBT card" by Bread for the World is licensed under CC BY-NC-ND 2.0

The benefits were originally known as Food Stamps because they were literally stamps or coupons that people exchanged for food. When paying at the register, the individual would use the number of stamps necessary to cover the cost of the food. Obviously, this caused a bit of a stigma because it was clear to see who was paying for their food with stamps, so everyone in line and the cashier would know the customer was poor. By 2004, however, all Food Stamp Program recipients had been transitioned to the use of an EBT (electronic benefit transfer) card, which helped to lessen the attention they drew at stores and made them less likely to be embarrassed about the reaction of others. This also led to the renaming of the program to SNAP in 2008 (U. S. Department of Agriculture, 2014).

SNAP benefits are enough to give five million Americans an income boost that brings them above the poverty line, according to the Department of Agriculture (2014). SNAP benefits vary widely by state, with 2014’s average monthly benefit per household of $463 in Hawaii at the high end and New Hampshire's $193 bringing up the rear; the average payment per household across all states in 2014 was $239 (or $139.50 per person, since the average SNAP household has 2.0 people; U. S. Department of Agriculture, 2018). You may have heard stories of food stamp recipients buying steak and lobster with their benefits, but you might want to walk around a local grocery store and investigate just how much steak and lobster you could afford to eat with $139.50 a month—that’s about $4.65 a day, or about $1.55 per meal, per person. There is not a lot of wiggle room there for luxury items. Most adult SNAP recipients who are not disabled cannot receive these benefits for any more than three months in a three-year period if they are not employed (U. S. Department of Agriculture, 2018).

There is also an impression that people on SNAP simply make bad diet choices, but the evidence doesn’t support that assertion either. SNAP participants are less likely to have excessive sodium in their diet, less likely to exceed recommended maximum intake of saturated fats, and just as likely to have adequate intake of vitamins and minerals (U.S. Department of Agriculture, 2015b). There are undoubtedly some people making unhealthy food choices, but they are not representative of most SNAP recipients.

Healthy Meals for Healthy Americans

            Formerly known as WIC (Special Supplemental Nutrition Program for Women, Infants and Children), Healthy Meals for Healthy Americans provides food, nutrition services, and access to health care for eligible women (typically pregnant women or new mothers), infants, and children up to age five who are considered to be at nutritional risk (U.S. Department of Agriculture, 2015a). Though the official title of the program is no longer WIC, that name continues to be used even on a number of government websites, and you may have seen food for sale at your local grocery store on shelves labeled “WIC item.” Families with an income up to 185% of the poverty line (for instance, $49,025 for a family of four in 2021) are eligible to receive benefits (U.S. Department of Agriculture, 2021).

Temporary Assistance to Needy Families

Under the Social Security Act, one of the public assistance programs founded was Aid to Dependent Children (ADC). At the time, you may recall from Chapter 3, the program was designed to provide financial support to poor single mothers, often widows. The prevailing social sentiment of the day was that a mother’s place was in the home, so the government provided ADC so these single mothers could care for their children at home with the help of public assistance (Levitan et al., 1998).

From the beginning, however, the program’s delivery has had an element of institutional racism to it. Several states implemented policies after the founding of ADC that gave state employees administering the program the ability to deny benefits to any applicants that were deemed not to have “suitable homes;” in practice, this meant nonwhites and families with children born out of wedlock were disproportionately denied benefits (Levitan et al., 1998; Morgen et al., 2010; Schorr, 2001). Ideologically, the thinkers behind the expansion of welfare recognized that racism had contributed to income inequality and poverty; sadly, the programs they succeeded in putting into place served as yet another part of the problem (Morgen et al., 2010)

The program was rechristened Aid to Families with Dependent Children (AFDC) in the 1960s, as it expanded to provide financial assistance to two-parent families rather than just households headed up by single parents. Half the states elected to expand coverage to two-parent families with fathers who couldn’t find work (Mangum at al., 2003). The demographics of the recipients of benefits under the program continued to shift as a result. By the 1990s, a program that had originally been designed to care mostly for widowed mothers was more likely to be taking care of mothers who had never been married (Schorr, 2001).

Family of Three.
Despite ample evidence to the contrary, many Americans still think parents receiving public assistance intentionally have more children in order to increase their benefit; in reality, the average family on welfare is 30% smaller than in the 1960s.
"Family of Three." by iMorpheus is licensed under CC BY 2.0

The social climate began to favor more women, including single mothers, entering the workforce. However, the AFDC rules until the mid-1960s required AFDC mothers to report any income they made so it could be deducted from their benefits. Therefore, unless they found a job that could pay them more than their AFDC benefits plus the cost of child care, it simply made more sense to stay at home. They got no further ahead by working a low-paying job; they would be less financially stable and spending less time with their kids. (Schorr, 2001).

Congress attempted several formulas that would give AFDC parents an incentive to work by allowing them to keep more of their welfare benefits when they started working, but this did not dramatically improve the situation. They started resorting to slashing benefits in order to make low-paying jobs more appealing than a meager welfare check (Mangum et al., 2003). By 1993, twelve states had cut their maximum monthly AFDC payments by more than 50% (adjusted for inflation) since 1970; the only state that paid more than a maximum of $200 per person per month was Alaska (Levitan et al., 1998). Thirty-seven of the fifty states had maximum benefit payments below 50% of the poverty line (Levitan et al., 1998).

Families were also getting smaller, despite popular belief that unmarried mothers on welfare were simply having as many kids as possible to maximize their benefits. While a third of AFDC families had four or more kids in 1969, that was true for only about 10% in 1987; by 1995, the average size of a family on AFDC had fallen from 4.0 to 2.8 (Levitan et al., 1998; Schorr, 2001).

This all led up to the elimination of AFDC in the 1990s under President Bill Clinton. Clinton had promised during his campaign to “end welfare as we know it,” but before he could put his vision into place, Republicans took both houses of Congress and had a lot of power to dictate some of those changes the party had wanted to see in AFDC for some time (Morgan, Acker, & Weight, 2010). Congress passed the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) in 1996 and Clinton signed it into law, completely replacing AFDC with a program whose name rang a bit ominously: Temporary Assistance for Needy Families (TANF) (Morgan, Acker, & Weigt, 2010).

That first word is the key: temporary. The belief was that the vast differences between AFDC’s and TANF’s rules would push poor parents off the couch and into the workforce, if for no other reason than the benefits would run out. Some of those reworked rules and policies included the following (Levitan et al., 1998; Schorr, 2001):

  • States receive block grants and determine their own eligibility criteria: The federal government gives each state a block grant of funding for TANF, and it is up to the state to set “objective criteria for delivery of benefits and determining eligibility” (Levitan et al., 1998, p. 81). Previously, the federal government determined eligibility requirements and benefit levels. Now all of that is under the states’ purview.
  • Lifetime limit of 5 years: Under TANF, families’ benefits are capped at five years. After that, even if their financial situation has stayed the same (or gotten worse), they are no longer eligible for TANF benefits (Schorr, 2001; Zastrow, 2010). However, states have some leeway: they can actually cut families off earlier, or they can exempt up to 20% of families (ostensibly the neediest recipients) from this limit (Levitan et al. , 1998; Schorr, 2001). Both decisions are up to the state and their state policy can be changed at any time. If a state that exempts 20% of families from the five-year limit finds itself in a budget crisis, it can put that limit back in place, or even decide to cut it to a three-year limit if they wish.
  • Teenage recipient rules: Teen parents may not receive benefits unless they live with an adult relative, are going to high school, or have a diploma already (Levitan et al., 1998; Schorr, 2001).
  • Community service and work requirements: Parents receiving benefits must “perform community service after two months” of receiving TANF payments, and must be employed within two years of the start of payments (Schorr, 2001, p. 7). States can choose to opt out of the community service requirement (Zastrow, 2010).
  • State contributions: States must continue to contribute funds to the cost of TANF in their state. Their portion must be at least 75%-80% of what they were paying in 1994 (Levitan et al., 1998; Schorr, 2001).
  • Child care funding: Funding is provided by the federal government, with mandatory state contributions, to help cover the costs of child care. While child care coverage is not a guaranteed TANF benefit, single parents who cannot find child care for children under 6 years of age in their home cannot be penalized for failure to work (Levitan et al., 1998; Schorr, 2001).
  • Drug crimes: TANF recipients convicted of drug crimes become benefit-ineligible for life (Levitan et al., 1998).
  • Paternity: Mothers who choose not to identify a father or cooperate with efforts to do so can have their benefits reduced by 25% or more (Katz, 1996; Zastrow, 2010).
  • Child nutrition cuts: About $3 billion was cut from funds to subsidize child nutrition through home day care providers, summer food programs, and legal aliens (Levitan et al., 1998).

There were further provisions put into place as well; these were major changes, to say the least. While under AFDC one could stay on benefits until the youngest child turned 18 and/or moved out, there is no such open-ended eligibility with TANF. Additionally, AFDC didn’t require work, but TANF cut off benefits after two years in most cases if a recipient wasn’t working. The big question is, “Did it work?”

While there were some signs of success, like decreasing caseloads for TANF caseworkers and fewer overall people receiving benefits since TANF was instituted, we have also had a significant recession, and a greater number of people likely in need of the program (Morgan, Acker, & Weigt, 2010). The fact that TANF rosters did not increase during that time is a cause for concern, because it means there was less of a safety net there for people who desperately needed it.

During the same time that TANF recipients decreased, there were significant increases in the numbers of recipients of SNAP and Unemployment Insurance, home foreclosures soared, and food banks also struggled to meet the increased need of their communities (Morgen et al., 2010). Making TANF’s rules stricter may have simply pushed clients to other programs. Their needs didn’t change. Some did find jobs, but they were generally low-paying jobs with little chance of facilitating a rise in economic status (Morgen et al., 2010). Reducing the number of clients receiving benefits is not the same thing as reducing poverty.

 

Social Insurance Programs

Social Security Disability Insurance (SSDI)

SSDI covers individuals who have worked enough years to qualify for Social Security payments if they become disabled with a condition that “is expected to last at least one year or result in death” (Social Security Administration, 2014, p. 4). Since this is not a public assistance program, applicants do not need to pass a means test. Benefits can also extend to some family members:

  • a spouse age 62 or older
  • a spouse of any age caring for one of the recipient’s children under the age of 16, or caring for a recipient’s child who has a disability
  • a child under 18, or a child who is age 18 but a full-time elementary or high school student
  • an unmarried child over age 18 with a disability that started before age 22 (Social Security Administration, 2014).

After receiving SSDI benefits for two years, one automatically becomes eligible for Medicaid benefits as well. (Social Security Administration, 2014).

Box 9.7: Work requirements for SSDI eligibility

eligibility ages

 

(Source: Social Security Administration, 2014, p. 6)

Medicare

            Medicare is a program, funded by tax revenues, which provides financial assistance for medical care for the nation’s elderly, retired, and some people with disabilities. Much more complex than Medicaid, Medicare’s benefits come in various forms (Part A, Part B, Part C, Part D). Part A (inpatient hospital coverage) is free, with the remaining optional components requiring the payment of a premium. Medicare is addressed in greater depth in Chapter 12.

Social Security (OASDI)

            Old Age, Survivors, and Disability Insurance is the formal name for the program we more typically call Social Security. It provides an income to “qualified retired and disabled workers and their dependents and to survivors of insured workers” (Social Security Administration, 2011). Over 50 million Americans receive benefits, including over 85% of those aged 65 or older (Social Security Administration, 2011). Although it was never designed to be the primary source of income for the elderly, it is at least 90% of the income for 22% of married couples and 43% of other individuals 65 or older (Social Security Administration, 2011).

Under OASDI, the path to guaranteeing a retirement benefit is somewhat complex, but in most cases, a person who has worked even somewhat steadily during adulthood will qualify for retirement benefits at age 66, though that age is inching toward 67 in 2027 (Biggs, 2011). In essence, one needs about ten years of work in order to be eligible for retirement benefits, which will be paid out at a level reflective of the earnings one made while working—that is, the more one makes, the higher her/his Social Security benefit check will be (Biggs, 2011). If one can delay retirement until a later age, then the benefit received will be higher than if the individual retired at 66 or 67 (an 8% increase per year up to age 70) as a reward for saving the system money while one was still working (Social Security Administration, 2015d).  One can also opt to retire and start receiving reduced benefits as early as age 62 (Social Security Administration, 2015d; Baker & Weisbrot, 1999).

Box 9.8: Social Security eligibility ages

eligibility(Source: Social Security Administration, 2015d)

Additionally, people who haven’t worked enough to qualify for Social Security but have a spouse who did can get up to half of the full benefit of a retired worker; child dependents of people receiving Social Security retirement or disability benefits can also get a smaller benefit (Social Security Administration, 2015d). The total amount paid to all family members of someone receiving OASDI payments cannot exceed 150-180% of that person’s benefit amount (Social Security Administration, 2015d).

There is some concern about the long-term viability of Social Security due to the increasing average age and life expectancy of Americans, coupled with the trend of companies encouraging older workers to go into early retirement (Baker & Weisbrot, 1999).  Though you will (or perhaps already do) pay Social Security taxes throughout your working career, that money doesn’t go into an account with your Social Security number on it—the money paid into the system by today’s workers is used to pay benefits to today’s retirees (Levitan et al., 1998). That was a very feasible system in 1950, when there were 16 working Americans for every person drawing Social Security benefits; however, that dependency ratio is now around 3 to 1, and will be 2 to 1 by 2040 (Biggs, 2011). In order to keep up Social Security benefits at their current levels, changes would have to be made, and a simple payroll tax raise wouldn’t likely work, since it would have to be hiked to 18% of workers’ wages—not a very popular idea to float politically (Biggs, 2011).

Some people will never see a penny of return on their Social Security tax payments, while others will draw much more out of the system than they put into it. The maximum benefit payable to a retired worker in 2021 is $3,148, but they can only collect that much if they have earned $142,800 or more each year over a 35-year working career. The average retiree's monthly Social Security payment in 2021 was $1,543/month (Brandon, 2021).

Box 9.9: How to Stabilize the Future of Social Security

  • Encourage people to work longer and retire later, and enact workplace policies that will change the culture around early retirement
  • Decrease the benefits being paid out to workers
  • Increase the tax rate for current workers
  • Eliminate the Social Security tax cap ($142,800 in 2021)
  • Tie the retirement age to the current life expectancy, so they increase at the same rate
  • Increase investment in workplace pension plans

 Each of these options has its benefits and drawbacks. What would you choose?

(Source: Biggs, 2011)

 

Unemployment Insurance (UI)

            A program that was very heavily in use during the Great Recession, Unemployment Insurance (UI) is aimed at preventing recently unemployed workers from slipping into economic despair while they search for a new job. There is no means test, and benefits paid out are based on earnings from one’s previous job. The program is funded by tax paid by employers rather than employees (Conrad, 2008). Workers can generally apply only if they’ve been laid off, but in some cases people who have been fired are eligible (Kirst-Ashman, 2013; Zastrow, 2010). In order to continue to receive benefits, one must also be actively looking for work and be able to furnish proof of that fact (Stone & Chen, 2014).

Each state runs its UI program quite differently. Workers must have been employed a minimum amount of time over the last 12-18 months to receive UI, and each state also designates a minimum income one must have earned in the previous year in order to be eligible for benefits; that income ranges from under $200 to over $5,000 (Levitan et al., 1988). The maximum benefit that a state will pay out also varies; for example, in Alabama, the weekly maximum is $275, while in Hawaii it is $648 (Alabama Department of Labor, n.d.; Guerin, 2021).  Payment levels are determined by how much the worker earned while working and what the average income is in that state, and benefits are often capped at around half the worker’s previous earnings (Levitan et al., 1998). During the COVID-19 pandemic, the federal government also provided additional payments beyond state unemployment payouts, adding $300 per week for many people in need (Guerin, 2021).

In most states, the limit on receiving UI benefits is 26 weeks (6 months), but that can be extended in times of financial crisis; during the Great Recession, 49 states extended their benefits limits to anywhere from 40-73 weeks (North Carolina was the lone holdout; Vinik, 2014). Since the Great Recession, however, several states that were unprepared for the high amount they had to pay out during that crisis tightened their UI limits to as little as 12 weeks (Leachman, 2015), leaving many people in dire need of assistance in difficult times. Benefit extensions and expansions during the COVID-19 pandemic were also initially popular bipartisan moves, but an ideological divide became more apparent as the pandemic wore on and some employers struggled to find workers willing to accept the low wages they were once paid.

Workers’ Compensation

            Like UI, Worker’s Compensation is meant to help people stay out of poverty during temporary loss of income—in this case, due to an injury or disease sustained on the job. Workers’ Compensation is designed to cover lost wages, medical treatment for the condition, possible rehabilitation, and to compensate one’s family in the event of a workplace-related death (Levitan et al., 1998; Matthews, 2015). However, the total of an individual’s disability benefit payment (if any) and Worker’s Compensation payment cannot exceed more than 80% of his/her working income (Matthews, 2015).

 

Final Thoughts

Earlier in the chapter, we asked you: could most of the hardworking people really be concentrated in the top 10%, or the top 1%? We’d like to share a personal story that, to us, illustrates vividly the relative lack of connection between hard work and economic success.

Our father was laid off several years ago after over three decades as a mechanical engineer. He was in his mid-50s at the time, making close to $100,000 a year, and had started working on his master’s degree in business administration (MBA). He continued to go to school after being laid off and finished that degree, all while struggling to find new work in his field. With multiple patents to his name, managerial experience, and decades of knowledge—plus now an advanced degree—one would think that it would be easy for him to find another job. Well, he did find a new job—assembling bicycles at a bike shop for a few months, before he left because of the shop owner’s racist views. Then he was a shelf stocker at a grocery store’s liquor section (which we found particularly ironic, given that he never drinks). Then he took a job as a school bus driver. Over those years, he put out dozens, perhaps hundreds of resumés, and scored many interviews, but never an offer that would put him back into engineering or management.

Why couldn’t he find a well-paying job? Why did he often have to settle for low-wage manual labor? Well, a lot of factors led to his predicament. His decades of experience and his advanced degree have, in some ways, made him more difficult to hire because he legitimately would have commanded a high salary. When he applied for jobs that paid less but for which he was overqualified, he would not get offers, because the employers were afraid he’d leave once he got something better. Some people in the industry even recommended he take his MBA off his resumé, so human resources managers didn’t see him as too expensive to hire.

This isn’t a sob story. Our father never expected anyone to feel sorry for him, and he was a lot more fortunate than most since he had a well-paying career before his years of unemployment and underemployment. However, if the system favored those who got educated and worked hard, he would have had a lot more success in his job hunt. Though he has since become disabled, at age 64 now, he would have almost no chance of getting a job in his field since people will just see him as a soon-to-be retiree. We are sure that many of you know people with similar stories in recent years.

There are many factors that people cannot control that cause them to be unemployed, to file for bankruptcy, to apply for public assistance. It is our job as social workers to know that what our clients really need is not judgment—they need someone to recognize that they are people who have a story and deserve an opportunity to get on their feet, regroup, and keep fighting against a powerfully unequal system.

 

References

Abramsky, S. (2013). The American way of poverty: How the other half still lives. Nation Books.

Alabama Department of Labor (n.d.). Claims and benefits FAQ. Retrieved from http://www.labor.alabama.gov/uc/claims.aspx.

Ambrosino, R., Heffernan, J., Shuttlesworth, G., & Ambrosino, R. (2012). Social work and social welfare: an introduction. Brooks/Cole Cengage Learning.

Ansalone, G. (2009). Exploring unequal achievement in the schools: The social construction of failure. Lexington Books.

Biggs, A. G. (2011). Social Security: The story of its past and a vision for its future. AEI Press.

Blank, R. (2009). The changing face of poverty. In J. Manza & M. Sauder (Eds.), Inequality and society: Social science perspectives on social stratification, pp. 279-295.

Bowly Jr., D. (2012). The poorhouse: Subsidized housing in Chicago (2nd ed.). Southern Illinois University Press.

Brandon, E. (2021, January 11). How much you will get from Social Security. U.S. News and World Report. Retrieved from https://money.usnews.com/money/retirement/social-security/articles/how-much-you-will-get-from-social-security

Brown, C. (2015). Educational binds of poverty: The lives of school children. Routledge.

Caiazza, T. (2015). Release: LGBT women are among most at risk of poverty in America. Center for American Progress. Retrieved from https://www.americanprogress.org/press/release/2015/03/13/108650/release-lgbt-women-are-among-most-at-risk-of-poverty-in-america/.

Cawthorne, A. (2008, October 8). The straight facts on women in poverty. Center for American Progress. Retrieved from https://www.americanprogress.org/issues/women/report/2008/10/08/5103/the-straight-facts-on-women-in-poverty/.

Children's Defense Fund (2021). The state of America's children 2021. Retrieved from https://www.childrensdefense.org/state-of-americas-children/soac-2021-child-poverty/

Conrad, D. (2008, December 27).  A look at how unemployment benefits are funded. Tampa Bay Times. Retrieved from http://www.tampabay.com/news/business/workinglife/a-look-at-how-unemployment-benefits-are-funded/948526.

Cox, L E., Tice, C. J., & Long, D. D. (2016). Introduction to social work: An advocacy-based profession. SAGE.

Dáil, P. W. (2012). Women and poverty in 21st century America. McFarland & Company.

Davis, D. (2006). Battered black women and welfare reform: Between a rock and a hard place. State University of New York Press.

Edelman, P. (2012). So rich, so poor: Why it’s so hard to end poverty in America. The New Press.

Erickson, W., Lee, C., von Schrader, S. (2014). Disability Statistics from the 2012 American Community Survey (ACS). Ithaca, NY: Cornell University Employment and Disability Institute (EDI). Retrieved May 28, 2015 from www.disabilitystatistics.org.

Fish, S. (2014, August 25). Violence grows against the homeless, sparking push for hate crime status. Al Jazeera America. Retrieved from http://america.aljazeera.com/articles/2014/8/25/violence-againsthomeless.html.

Gans, H. J. (1972). The positive functions of poverty. American Journal of Sociology, 78(2), pp. 275-289.

Glink, I. (2013, July 20). Top 10 cheapest U.S. cities to rent an apartment. Retrieved from http://www.cbsnews.com/media/top-10-cheapest-us-cities-to-rent-an-apartment/.

Guerin, L. (2021).Collecting Unemployment benefits in Hawaii. NOLO. Retrieved from https://www.nolo.com/legal-encyclopedia/collecting-unemployment-benefits-hawaii.html.

Hall, L. (2021). A closer look at who benefits from SNAP: State-by-state fact sheets. Center on Budget and Policy Priorities. Retrieved from https://www.cbpp.org/research/food-assistance/a-closer-look-at-who-benefits-from-snap-state-by-state-fact-sheets.

Hertaz, T. (2005). Rags, riches, and race: The intergenerational economic mobility of black and white families in the United States. In S. Bowled, H. Gintis. & M. Osborn (Eds.), Unequal chances: Family background and economic success (pp. 165-191). Princeton University Press.

Hombs, M. E. (2011). Modern homelessness. ABC-CLIO.

Husock, H. (2004). Housing vouchers do not benefit low-income families. In L. I. Gerdes (Ed.), The homeless: Opposing viewpoints, pp. 129-137.

Judson, B. (2009). It could happen here: America on the brink. HarperCollins.

Kahn, P. (2013). Oral health and poverty. In K. M. Fitzpatrick (Ed.), Poverty and health: A crisis among America’s most vulnerable. Volume 1: Risks and challenges, pp. 55-88. Praeger.

Katz, M. B. (1996). In the shadow of the poorhouse: A social history of welfare in America. BasicBooks.

Kirst-Ashman, K. K. (2013). Introduction to social work and social welfare: Critical thinking Perspectives (4th ed.)Cengage Learning.

Kposowa, A. J. (2013). Poverty, HIV, and sexually transmitted diseases. In K. M. Fitzpatrick (Ed.), Poverty and health: A crisis among America’s most vulnerable. Volume 1: Risks and challenges, pp. 89-104. Praeger.

Krugman, P. (2007). The great divergence. In J. Manza & M. Sauder (Eds.), Inequality and Society (pp. 943-959). Norton.

Leachman, M. (2015, May 28). States cutting jobless benefits hadn’t adequately prepared for recession. Center on Budget and Policy Priorities. Retrieved from http://www.cbpp.org/blog/states-cutting-jobless-benefits-hadnt-adequately-prepared-for-recession.

Lefton, R. (2013, March 11). Gender equality and women’s empowerment are key to addressing global poverty. Center for American Progress. Retrieved from https://www.americanprogress.org/issues/poverty/news/2013/03/11/56097/gender-equality-and-womens-empowerment-are-key-to-addressing-global-poverty/.

Levitan, S. A., Mangum, G. L., & Mangum, S. L. (1998). Programs in aid of the poor (7th ed.). The Johns Hopkins University Press.

Lewis. O. (1966). The culture of poverty. Scientific American, 215(4), pp. 19-25.

Livingston, G. (2018). The changing profile of unmarried parents. Pew Research Center. Retrieved from https://www.pewresearch.org/social-trends/2018/04/25/the-changing-profile-of-unmarried-parents/.

Mangum, G. L., Mangum, S. L., & Sum, A. M. (2003). The persistence of poverty in the United States. The Johns Hopkins University Press.

Martell, M. E. (2013). Are gays and lesbians “mainstream” with respect to economic success? In R. S. Rycroft (Ed.), The economics of inequality, poverty, and discrimination in the 21st century, pp. 254-271. Praeger.

Martin, L. L. (2013). Black asset poverty and the enduring racial divide. FirstForumPress.

Matthews, J. (2015). Social Security, Medicare & government pensions: Get the most out of your retirement & medical benefits. Nolo.

Morgen, S., Acker, J., & Weigt, J. (2010). Stretched thin: Poor families, welfare work, and welfare reform. Cornell University Press.

Mossakowski, K. N. & Gibson, N. (2013). Poverty and mental illness in America. In K. M. Fitzpatrick (Ed.), Poverty and health: A crisis among America’s most vulnerable. Volume 1: Risks and challenges, pp. 31-54. Praeger.

National Alliance to End Homelessness (2021).State of homelessness: 2021 edition. Retrieved from https://endhomelessness.org/homelessness-in-america/homelessness-statistics/state-of-homelessness-2021/.

National Coalition for the Homeless (2009). Health care and homelessness. Retrieved from http://www.nationalhomeless.org/factsheets/health.html.

National Conference of State Legislatures (2015). State minimum wages: 2015 minimum wage by state. Retrieved from http://www.ncsl.org/research/labor-and-employment/state-minimum-wage-chart.aspx.

Neuman, S. B. (2009). Changing the odds for children at risk: Seven essential principles of educational programs that break the cycle of poverty. Teachers College Press.

Noah, T. (2012). The great divergence: America’s growing inequality crisis and what we can do about it. Bloomsbury Press.

Organisation for Economic Cooperation and Development (OECD) (2016). Poverty rates and poverty gaps, 2012 or latest available year. OECD Factbook 2015-16: Economic, Environmental, and Social Statistics. Retrieved from https://www.oecd-ilibrary.org/sites/factbook-2015-table45-en/index.html?itemId=/content/component/factbook-2015-table45-en

Olson, L. K. (2010). The politics of Medicaid. Columbia University Press.

Reese, E. (2005). Backlash against welfare mothers: Past and present. University of California Press.

Schaeffer, K. (2020). 6 facts about economic equality in the U.S. Pew Research Center. Retrieved from https://www.pewresearch.org/fact-tank/2020/02/07/6-facts-about-economic-inequality-in-the-u-s/.

Schorr, A. L. (2001). Welfare reform: Failure & remedies. Praeger.

Schott, L. & Cho, C. (2011). General Assistance programs: Safety net weakening despite increased need. Center on Budget and Policy Priorities. Retrieved from http://www.cbpp.org/research/general-assistance-programs-safety-net-weakening-despite-increased-need.

Segal, E. A., Gerdes, K. E., & Steiner, S. (2013). An introduction to the profession of social work: Becoming a change agent (4th ed.). Brooks/Cole Cengage Learning.

Shere, D. (2011, July 22). Fox cites ownership of appliances to downplay poverty in America. Retrieved from http://mediamatters.org/research/2011/07/22/fox-cites-ownership-of-appliances-to-downplay-h/148574.

Social Security Administration (2009). State supplementary payments. Social Security handbook. Retrieved from http://www.socialsecurity.gov/OP_Home/handbook/handbook.21/handbook-2181.html.

Social Security Administration (2011). Social Security (Old-Age, Survivors, and Disability Insurance). Retrieved from http://www.socialsecurity.gov/policy/docs/statcomps/supplement/2011/oasdi.pdf.

Social Security Administration (2014). Social Security Disability benefits. Retrieved from http://www.ssa.gov/pubs/EN-05-10029.pdf.

Social Security Administration (2015a). Supplemental Security Income home page—2015 edition. Retrieved from http://www.ssa.gov/ssi/.

Social Security Administration (2015b). Spotlight on living arrangements—2015 edition. SSI spotlights. Retrieved from http://www.ssa.gov/ssi/spotlights/spot-living-arrangements.htm.

Social Security Administration (2015c). Retirement benefits. Retrieved from http://www.ssa.gov/pubs/EN-05-10035.pdf.

Social Security Administration (2021a). Fact sheet. Retrieved from https://www.ssa.gov/news/press/factsheets/basicfact-alt.pdf.

Social Security Administration (2021b). SSI federal payment amounts for 2021. Retrieved

           from https://www.ssa.gov/oact/cola/SSI.html.

Stone, C & Chen, W. (2014, July 30). Introduction to Unemployment Insurance. Center on Budget and Policy Priorities. Retrieved from http://www.cbpp.org/research/introduction-to-unemployment-insurance.

U. S. Census Bureau (2020). Income, poverty, and health insurance coverage in the United States: 2019. Retrieved from https://www.census.gov/newsroom/press-releases/2020/income-poverty.html

U. S. Census Bureau (2011). Profile America facts for features: American Indian and Alaska Native Heritage Month: November 2011. Retrieved from https://www.census.gov/newsroom/releases/archives/facts_for_features_special_editions/cb11-ff22.html.

U. S Department of Agriculture (2014). 50 Years of SNAP [Infographic]. Retrieved from http://www.fns.usda.gov/sites/default/files/snap/SNAP-infographic-banner.pdf.

U. S. Department of Agriculture (2015a). Women, Infants, and Children (WIC). Retrieved from http://www.fns.usda.gov/wic/women-infants-and-children-wic.

U. S. Department of Agriculture (2015c). Diet quality of Americans by SNAP participation status: Date from the National Health and Nutrition Examination Survey, 2007-2010—Summary. Retrieved from http://www.fns.usda.gov/sites/default/files/ops/NHANES-SNAP07-10-Summary.pdf.

U. S. Department of Agriculture (2018). SNAP household state averages for SNAP benefits. Retrieved from https://www.fns.usda.gov/SNAP-household-state-averages#.

U. S. Department of Agriculture (2021). Income eligibility guidelines. Retrieved from https://www.fns.usda.gov/wic/2021-2022-income-eligibility-guidelines.

U. S. Department of Health & Human Services (n.d.). Medicaid: Overview. Retrieved from http://medicaid.gov/medicaid-chip-program-information/medicaid-and-chip-program-information.html.

U. S. Department of Health and Human Services (20121). Annual update of the HHS poverty guidelines. Retrieved from https://www.federalregister.gov/articles/2015/01/22/2015-01120/annual-update-of-the-hhs-poverty-guidelines#t-1.

U. S. Department of Housing and Urban Development (n.d. a). HUD’s public housing program. Retrieved from http://portal.hud.gov/hudportal/HUD?src=/topics/rental_assistance/phprog.

U. S. Department of Housing and Urban Development (n.d. b). Housing Choice vouchers fact sheet. Retrieved from http://portal.hud.gov/hudportal/HUD?src=/program_offices/public_indian_housing/programs/hcv/about/fact_sheet.

U. S. Department of Labor Bureau of Labor Statistics (2015). Labor force statistics from the current population survey [Data set]. Retrieved from http://data.bls.gov/timeseries/LNS14000000.

U. S. Department of Veterans Affairs (2015). Veteran poverty trends.  National Center for Veterans Analysis and Statistics. Retrieved from http://www.va.gov/vetdata/docs/SpecialReports/Veteran_Poverty_Trends.pdf.

Van de Water, P. N., Sherman, A., & Ruffing, K. (2013, October 25). Social Security keeps 22 million Americans out of poverty: A state-by-state analysis. Center on Budget and Policy Priorities. Retrieved from http://www.cbpp.org/research/social-security-keeps-22-million-americans-out-of-poverty-a-state-by-state-analysis.

Vinik, D. (2014, January 15). Here’s how long unemployment benefits now last in each state. Business Insider. Retrieved from http://www.businessinsider.com/heres-how-long-unemployment-benefits-now-last-in-each-state-2014-1.

Wolff, E. N. (2013). The distribution of wealth in the United States at the start of the 21st century. In R. S. Rycroft (Ed.), The economics of inequality, poverty, and discrimination in the 21st century (pp. 38-56). Praeger.

Zastrow, C. (2010). Introduction to social work and social welfare (10th ed.). Brooks/Cole Cengage Learning.

Chapter 10: School Social Work

Schools are a specific setting in which social work is practiced, and they are more than just teaching kids the three Rs.  The school setting is a microcosm of society in which students can gain practice on skills needed as adults.  School social workers are there to help students navigate this world and all the issues that may arise.  This chapter will help you:

  1. Understand the history of school social work;
  2. Describe school social work’s foundational values;
  3. Identify the client systems with which school social work practices and its constituents;
  4. Analyze how current trends impact school social work;
  5. Recognize what barriers to education exist and assess how to address them.

education, people, school, child, group, boy, class, classroom, sitting, men, males, student, childhood, eyeglasses, group of people, offspring, glasses, boys, learning, portrait, table, studying, pre-adolescent child, 1080P

 

Social Work in a School Setting

            Historically, social work in the school setting can be seen as one of the foundational roles of social work in the United States.  Starting with the settlement movement in the early 1900’s as visiting teachers, moving into student case management, and continuing today to include working with students, families, communities, teachers, administrators, and the school system itself, school social workers are uniquely positioned to impact students in one of the most influential settings of their lives.  As we will see, school social work is a specialty practice area that requires a generalist approach to the many different concerns and functions of students in a school setting.  In chapter 4 we discussed the goal of school social work as creating an effective environment of learning and growth in various institutions.  While there are social workers in many different educational settings, for our purposes we will focus the discussion on school social workers that work in a K-12 setting.  However, the strategies and concepts highlighted are still useful for those working in colleges and universities or in outside agencies who provide services within the school, and should not be considered unique to work done by professionals based in a primary or secondary school setting.  In this chapter, the focus will be on a historical look at school social work, what sets it apart, where and for whom they direct their practice efforts, trends in school practice, as well as current issues of focus.

 

History

As we will see at various points in this chapter, the school social worker of today has to tailor services to fit with legislation, school policies and environment, and societal demands of families and children.  This has been a very common theme since the beginning of the school social work movement.  However, the fundamentals of school social work have been constant throughout its history.  Massat, Constable, McDonald, and Flynn (2009) stated, “In many ways these early diverse programs contained in rough and in seminal form all the elements of later school social work practice.” (p. 13).  In reference to Johnson’s definition of the primary role of early school social workers, Stanley (2011) also writes, “This approach coincides with the preventive concepts of today as school social workers aim to prevent academic failure,” (p. 170).  These elements address the needs of the students in various environmental settings to allow for greater academic achievement.  While some of the methods of today may look different than those from when school social work first began, it is clear that these elements are still present in the work school practitioners do now.

            Although the 1975 Education for All Handicapped Children Act (EAHCA)—which was later renamed the Individuals with Disabilities Education Act—was the first time the federal government recognized the importance of social workers in working with the educational and emotional needs of students in the school setting (Morrison, 2006), school social work itself had already been around for almost 70 years, since 1906 (Allen-Meares, 2010).  Visiting teachers, as school social workers were originally referred, had been established in New York, Boston, Chicago, and Hartford around the same time (Shaffer, 2006).  Initially related to addressing the needs of the “so-called underprivileged” (Allen-Meares, 2010), visiting teachers worked for settlement houses, civic groups, and other agencies outside of the school (Costin, 1969; Massat et al., 2009; Stanley, 2011).  The demand for visiting teachers increased with the mandatory attendance laws for school-aged children in all states by 1918 (Shaffer, 2006).  These early school social workers were a means of mediating between families and schools in order to address attendance and behavior (Phillippo & Blosser, 2013) by helping students and their families deal with home environment concerns that impacted the child’s education.  The first professional organization of visiting teachers, the National Association of Visiting Teachers, started in 1920 (McCullagh as cited in Massat et al., 2009) , and set the groundwork for the legitimacy of the field of school social work.  A year later, the Commonwealth Fund of New York provided for three-year demonstrations of visiting teachers in 30 communities throughout the country as part of their Program for the Prevention of Juvenile Delinquency (PPJD) (Allen-Meares, 2010; Shaffer, 2006).  The mental hygiene movement was also an influence during this time and helped to further enhance the role of visiting teachers by paving the way for social casework as a function of working with students and their families (Phillippo & Blosser, 2013).

The PPJD demonstrations would later result in a total of 244 visiting teachers in 31 different states by 1930.  However, the Great Depression brought cuts in visiting teachers throughout the country.  As a result, the field continued to evolve and become more specialized, leaning on the focus of social casework and treating mental health concerns, so to be seen as a legitimate profession (Allen-Meares, 2010; Peckover, Vazquez, Van Housen, Saunders, & Allen, 2013; Phillippo & Blosser, 2013).  Social casework with individual students became the standard activity for visiting teachers into the 1960s, where the focus was not only on behavioral issues but on providing social and emotional treatment as well (Peckover et al., 2013).  Oftentimes, this meant school social workers needed to interact with parents, teachers, and administrators in order to fully address student needs, but these were not really recognized as concrete aspects of casework (Massat et al, 2009).

From the 1940s to the 1960s, school social work built a body of knowledge and practice standards, and became more affiliated with general social work.  This was illustrated by the merging of visiting teachers national organization with other social work organizations to become the National Association of Social Work (NASW) in 1955 (Phillippo & Blosser, 2013).  In the 1960s, there was an increased call to refocus school social work and incorporate methods of addressing broader issues in the school system itself, instead of just providing individual casework (Allen-Meares, 2010; Peckover et al., 2013).  As Peckover et al. (2013) further discussed, this added to confusion about what social workers’ roles were in a school setting.  As the profession grew, the need to understand and standardize the role of school social workers became more evident.

In 1970, a few people devised various models of school social work designed to direct school social work activities.  In 1972, Alderson provided four models of practice that classified the various functions of school practitioners.  The clinical model was the traditional model of social casework which had been the prevailing function of school social workers for decades.  The school change model directed services to addressing issues within the school system as a whole.  The community-school model underlined the importance of building relationships between the school system and community members.  Finally, the social interaction model looked at creating quality interactions between people (students, parents, administrators) and environments (family, school, community) in order to best address the needs of the students.  This last model focused on the ecosystems perspective, also called the person-in-environment approach, that has become an important mainstay of school social work today (Massat et al., 2009).  Similar to Alderson’s fourth model, Costin’s 1973 school-community-pupil relations model emphasized the importance of interactions between these parts and the need to address various aspects of each part that may negatively contribute to interactions among the three.  These various models demonstrate the growth in structured form and function of school social from within.  In addition, the late 1970s saw the creation of three professional journals specifically focused on school social work, School Social Work Journal, Social Work in Education, and School Social Work Quarterly, that published the growing number of scholarly articles and continued to expand the depth and breadth of knowledge of school social work (Phillippo & Blosser, 2013).

Outwardly, federal legislation was also adding to this figurative and literal growth of the field.  The 1970s and 1980s saw an increase of social workers, often related to laws that passed to not only increase and fund school social work positions, but also validate and impress the importance of school social workers in meeting the educational needs of children.  Arguably, the biggest of these being EAHCA in 1975 (Morrison, 2006).  Allen-Meares (2010) stated that by the mid-1970s, all 50 states employed social workers in district.  What is interesting about these pieces of legislation is that they are focused on educational improvement, but very directly indicate the importance of school social workers in contributing to the change.  In the mid-1990s, as a result of a perceived lack of attention by the NASW, a group of school social workers once again developed an independent national organization, the School Social Work Association of America (SSWAA), which is still an active force in organizing and supporting school social work today (Phillippo & Blosser, 2013).

            In 1990, the EAHCA was revamped as the Individuals with Disabilities Education Act (IDEA).  It required schools to provide for the educational achievement of students with a diagnosed disability.  This includes providing reasonable accommodations for the student based on the disability, as well as inclusion in general classrooms as much as possible. IDEA allows students who were previously neglected and limited in their academic growth to be given access to proper education and a chance to reach their full potential in school and life.  No Child Left Behind (NCLB), is an additional educational policy implemented in the early 2000s by President George W. Bush.  It looked to improve educational opportunities for children from lower-income families and areas.  This policy graded schools based on achievement test results of all the students in the school.  Schools that did not score well were required to make changes that would help address the academic needs of the students.  Those that continued to do poorly, or did not meet Annual Yearly Progress, were subject to increasing degrees of improvement each year they fall short of the goal.  The idea was to make schools accountable for the education they provide to all students.  In 2015, President Obama implemented the Every Student Succeeds Act (ESSA) that took the best parts of NCLB and provided for oversight at the state level, eliminating the one-size-fits all mandates of the federal government.  In this way, "state, districts, and schools will not decide what support and interventions are implemented, providing them with a great degree of flexibility and responsibility." (Center for Parent Information & Resources, 2021).

ESSA and the update to the IDEA at the beginning of the 21st century have directed school social work practice even further.  The push for providing for all students in the general education classroom and the use of evidence-based practices to prevent educational problems before they start is making school practitioners reformulate their service methodologies.  As we will see later in the chapter, Response to Intervention and Positive Behavioral Interventions and Support are two strategies many schools are incorporating to address the needs of everyone in the student population.  The result is an increase in what could be considered macro level practices, including school policy evaluation and revision, committee formulation, and school-wide training facilitation to name a few.  In 2005, Frey and Dupper developed their Clinical Quadrant model as a way to diagram the interventions used to address various needs (Massat et al., 2009).  This quadrant breaks down the work school practitioners do based on size of the target system and client system (see Chapter 1). Both range from individuals to entire systems, demonstrating the various ways in which school social workers can affect change for student needs.   This is a much more holistic and systems perspective focus to working for students.

While school social work has grown from the narrow focus of the visiting teacher role when it first began, it has once again returned to addressing issues within the school system to help meet student need.  However, it has matured along the way and incorporated many different practice techniques and methodologies, targeting various client systems (in an educational setting) to more effectively work with students at risk of underachieving.  School social workers are more qualified than ever to confront the barriers students may encounter to their educational attainment.

Black and white picture of a classroom with a young student off not paying attention to his work and looking sullen.
School practice is a specialty field in social work because it is more than just being able to work with students.  Though the school is the hub of the work we do, we must be ready to deal with a number of different collaborators in a number of different settings if we are going to help meet students’ needs.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Box 10.2 – School Social Work Standards

  1. Ethics and values: School social workers shall adhere to the ethics and values of the social work profession and shall use the NASW Code of Ethics as a guide to ethical decision making, while understanding the unique aspects of school social work practice and the needs of the students, parents, and communities they serve.
  2. Qualifications: School social workers shall meet the provisions for professional practice set by NASW and their respective state department of education and possess knowledge and understanding basic to the social work profession as well as the local education system.
  3. Assessment: School social workers shall conduct assessments of individuals, families, and systems/organizations (namely, classroom, school, neighborhood, district, state) with the goal of improving student social, emotional, behavioral, and academic outcomes.
  4. Intervention: School social workers shall understand and use evidence-informed practices in their interventions.
  5. Decision making and practice evaluation: School social workers shall use data to guide service delivery and to evaluate their practice regularly to improve and expand services.
  6. Record keeping: School social workers shall maintain accurate data and records that are relevant to planning, implementation, and evaluation of school social work services.
  7. Workload Management: School social workers shall organize their workloads to fulfill their responsibilities and clarify their critical roles within the educational mission of the school or district in which they work.
  8. Professional development: School social workers shall pursue continuous enhancement of knowledge and skills to provide the most current, beneficial, and culturally appropriate services to students and their families.
  9. Cultural competence: School social workers shall ensure that students and their families are provided services within the context of multicultural understanding and competence.
  10. Interdisciplinary Leadership and Collaboration: School social workers shall provide leadership in developing a positive school climate and work collaboratively with school administration, school personnel, family members, and community professionals as appropriate to increase accessibility and effectiveness of services.
  11. Advocacy: School social workers shall engage in advocacy that seeks to ensure that all students have equal access to education and services to enhance their academic progress.

NASW 2012

 

School Social Work Foundation

            While school social work is not too different from general social work in terms of values, integrated perspectives, or practice methods, it is clear to see that it has distinguished itself as a specialty within the general field.  In the NASW (2012) Standards of School Social work, it states, “School social work is a complex and specialized field of practice that is affected by changes in education policy, research, and practice models that continue to evolve” (p. 1).  As a result of the changes taking place, the NASW (2012) outlined 11 standards that define school social work services and that follow three guiding principles of (1) reforming educational/school environments, policies, and practices; (2) working to ensure fair educational opportunity for all students, specifically addressing the needs of those who are at risk; (3) leveraging services in a multi-tiered approach at the school-wide, small group, and individual levels.  In addition to these guidelines, it is important to be aware of some of the themes of contemporary school social work that are demonstrated in the standards. Professional competency is necessary as a school social worker.  Starting with a strong educational foundation and continued professional development, school social workers use this in their ethical, value-driven practice that is culturally aware (Standards 1, 2, 7, 8, and 9).  The evidence-based nature of school social work services is another important aspect of school social work.  Practitioners need to use data to drive, change, and validate prevention and intervention strategies (Standards 3, 4, 5, 6, and 7).  Utilizing the ecological perspective in order to deliver informed, professional services in a school setting is a must, and social workers in schools need to understand the intricate interactions between the different levels of client systems and how these interactions impact students.  As a result, services need to be directed at addressing issues at all levels and in all possible client systems, allowing all students access to a nurturing educational environment (Standards 4, 5, 10, and 11).

Even though these three themes incorporate all 11 standards, there is one standard that needs to be addressed separately, as it has been at the crux of school social work since its inception in the visiting teacher role.  Standard 11, Advocacy, encapsulates the heart of school social work, which is providing for the needs of students to ensure everyone has fair access to education.  Frey et al. (2012) incorporated this basic tenet, along with the other three themes described above, in a proposed Practice Model for Comprehensive and Integrated School Social Work Services in order to better conceptualize the basis for what school social workers should be doing.  The model included four key constructs – a social justice perspective, an ecological approach, ethical-legal practice, and data-informed practice.  The team continued to develop the model (which was later accepted by the SSWAA in 2013 as the national model for school social work), renaming the constructs as education rights and advocacy, home-school-community linkages, ethical guidelines and educational policy, and data-based decision-making (Frey et al., 2013).  Despite the change, the same core ideas of social justice in the educational setting, the ecological perspective, ethical practice in schools, and data-informed practice persist and can be used to explore the foundational principles for school social work.

 

Social Justice in the Educational Setting

            As was discussed in Chapter 5, social justice is the driving force behind social policy reform and, as a result, the impetus behind educational reform as well.  When we talk about the social justice perspective as it applies to school social work, we can adapt Steele’s (2008) definition of social justice advocacy to an educational context where school practitioners work to understand, identify, and confront barriers to equitable educational attainment for all students.  These barriers may be in the community, school environment, family setting, or individual students themselves, and may take the form of lack of adequate transportation to school, family financial need, bullying, even dyslexia, just to name a few.  There are numerous issues that may impede a student’s academic progress in many different ways.  However, it is key for school social workers to understand their student populations, what barriers might be present for a student or group of students, and how to best address those.  In addressing social justice as a school practitioner, we want to make our top priority that of providing for equitable educational and personal growth opportunities for the students we serve.

 

Ecological Perspective

            Originally put forth in 1973 by Carel Germain, the ecological approach is a figurative application of ecology’s focus on organism-environment relations (Germain & Gitterman, n.d.).  “Ecological concepts emphasize the reciprocity of person-environment exchanges, in which each shapes and influences the other over time.” (Mizrah & Davis, 2008, online).  Using an ecological perspective enables a practitioner to understand the importance of the environment in addressing a client’s needs with intervention strategies that can focus on the client, the environment, or both.  As a result, school social work services are best suited to be provided using this approach (Allen-Meares, 2010).  Workers can evaluate the needs of the student or students and see the best area in which to effect change, whether it is with the individual or individuals, at home, within the school system itself, or in the greater community.  Although historically school social workers have always been concerned with students in the educational environment (Jozefowicz-Simbeni & Allen-Meares, 2008), much of the work had been focused on working for change in the individual.  As recent federal mandates have called for more empirically based interventions school-wide, the ecological approach is becoming more important in terms of framing prevention and intervention strategies designed to address issues at multiple system levels (Peckover et al., 2013).

Photo of the word Ethics on a frosted glass wall.
Although they work in a school setting, school social workers still follow the same code of ethics as any other social worker.  However, there are a few additional ethical concerns other social workers don't encounter when working in more traditional service settings. "Ethics" by masondan is licensed under CC BY-NC-SA 2.0.

 

 

Ethical Practice in Schools

            Generalist social workers are guided by the NASW Code of Ethics.  It is taught in undergraduate social work classes and utilized by the field as a guide to ethical practice and decision making.  However, because this code is a guide for generalist work, it may not always be specific enough for specialized settings, like in the case of school social work.  As a result, the SSWAA has supplemented the NASW code with their own Ethical Guideline Series that addresses issues unique to school social work that may not be present in other social work settings.  The series includes topics focused on dealing with privacy and confidentiality rights of clients who are not of the age of majority versus rights of custodial parents (Dibble, 2008), who the client in a school setting is and how to interact with non-social work colleagues (Frey & Lankaster, 2008), as well as guidelines for working with therapeutic and nontherapeutic groups (Raines, 2008).  As these documents point out, the goals of social workers in a school setting center on minor students, in a non-traditional social work setting, with other professionals who are not social workers.  At times it can be difficult to navigate some of the issues that arise when there are competing goals, collaborative expectations, and multiple possible client systems with which to work.  Therefore, it is important for school social workers to not only follow the same code that guides all social workers but also to be mindful of the situations that may stand out working in a host setting such as a school.

 

Data-Informed Practice

            As we have seen, contemporary school social work is being influenced by two important pieces of legislation, ESSA and IDEA.  Both mandate utilizing scientifically research-based practices and interventions, or data-informed practice, in identifying, addressing, and evaluating student needs.  RtI and PBIS strategies are being implemented in more and more schools across the country because of how they direct the services provided by all school personnel, including social workers.  Bloom, Fischer, and Orme (2009) created a six-step approach for evidence-based practice that does a great job of outlining how school social workers can use data to inform their services:

  1. Develop a question.
  2. Find the evidence.
  3. Analyze the evidence.
  4. Combine the evidence with your understanding of the client and situation.
  5. Application to practice.
  6. Monitor and evaluate results.

As we can see, data and research-based strategies can and should be incorporated throughout the service delivery of school practitioners.  It is not enough to know what problem to address, but one needs to know how to best address it, if the strategies are being implemented correctly, and ultimately if they are working.  Utilizing evidence-based interventions, appropriate to need, and evaluating those strategies helps to provide students with effective and efficient service.

 

Practice Areas

            Not all school social workers serve the student population in one specific school.  Depending on the state, the district, and financial resources, some practitioners may work within one specific school, between schools in the same district, or across districts with in the same area.  Some school social workers are part-time, working with specific programs or certain student populations, while others are full-time, meeting needs of many different client systems.  No matter what, the focus of all school social workers is to work on the students’ behalf, no matter how that may look.  Alvarez, Bye, Bryant, and Mumm (2013) discussed the importance of having a multi-level intervention approach to obtain better educational outcomes.  The School Social Work Association of America (n.d.), a non-profit organization that “empowers school social workers and promotes the profession of school social work to enhance the social emotional growth and academic outcomes of all students,” (para. 1) outlines several areas of practice for this multi-level approach of school social workers.   In a document titled School Social Work Service, Kontak, SSWAA’s Director of Communications, states school social workers provided services to the following groups: students, parents/families, school personnel, districts, and communities.  Using this as a guide, we will look at how school social workers interact with these different systems in order to meet their ultimate goal of providing the best educational environment for all students.

 

Serving Students

            To reiterate the point, all the activities school social workers do in the school is for the service of the student body or bodies with which they work.  Even if they are working with parents of the students, teachers, or the school administration, the overall goal is the same and that is to provide a positive learning environment and eliminate distractions or barriers that inhibit a student’s education achievement.  Work involving direct contact with students is one way in which school practitioners advance toward this goal.  In this section we want to highlight how school practitioners do that through direct work with the students.

            The most basic role a school social worker performs is that of working with students on a one-to-one basis.  Peckover et al. pointed out how the traditional clinical casework model is still a primary emphasis in school social work.  Others have also mentioned how past and current studies demonstrate the persistence of student-centered, individualized case management as a function of school-based social work (O’Brien et al., 2011; Phillippo & Blosser, 2013), despite educational trends toward more broad prevention and intervention strategies.  While strategies that are far-reaching have their usefulness, meeting with single students allows social workers to address unique concerns in a student’s life that may not be met by these larger programs or with which few other students are dealing.  It addresses educational concerns on the most basic level of client systems and will likely continue to play a significant role in providing for the needs of students.

            As with any casework, there are times school social workers are helping link students with various academic resources, programs that address social-emotional concerns, or outside agencies that can better serve the student’s needs.  Workers may have to advocate on behalf of students with teachers, parents, or the administration.  Practitioners also often teach students life skills that will help them be more successful academically such as time management, how to be organized for class, and even how to have a conversation with another student.  Utilizing their generalist skills and assessing need is a huge part of working with individual students.  

 

Box 10.3 – IDEA and IEPs

IDEA was implemented as a means to provide students with disabilities the access to a quality education, which they have the right to receive. One of the main tools to providing that education is to create an individualized education program, or IEP, that describes how exactly this will be done. Here’s what IDEA requires the content of the IEP to include:

  • A statement of the child’s present levels of academic achievement and functional performance . . .
  • A statement of measurable annual goals, including academic and functional goals designed to:
    • Meet the child’s needs that result from the child’s disability to enable the child to be involved in and make progress in the general education curriculum; and
    • Meet each of the child’s other educational needs that result from the child’s disability;
  • For children with disabilities who take alternate assessments aligned to alternate achievement standards, a description of benchmarks or short-term objectives;
  • A description of
    • How the child’s progress toward meeting the annual goals will be measured; and
    • When periodic reports on the progress the child is making toward meeting the annual goals (such as through the use of quarterly or other periodic reports, concurrent with the issuance of report cards) will be provided;
  • A statement of the special education and related services and supplementary aids and services, based on peer-reviewed research to the extent practicable, to be provided to the child, or on behalf of the child . . .
  • A statement of any individual appropriate accommodations that are necessary to measure the academic achievement and functional performance of the child on State and districtwide assessments . . .

Adapted from Idea Regulations for Individualized Education Program, Retrieved from http://idea.ed.gov/explore/view/p/%2Croot%2Cdynamic%2CTopicalBrief%2C10%2C.

One of the ways in which this is clearly evident is when working with students who have individualized education programs (IEPs) or 504 plans.  School social workers are an important part of the team that creates these plans for students with documented disabilities need, what accommodations are necessary and how to implement them, as well as monitoring the students’ progress while using these plans.  Parents are also involved in the child’s educational team, and practitioners will need to work with them and, in a way, for them, but we will touch on that when we talk about service to parents of students.  Both types of plans are mandated by the federal government through IDEA and Section 504 of the Rehabilitation Act.  As a result, school social workers are well positioned to be an integral part of facilitating the school’s provision of the necessary accommodations for the student.  Often, they are also a part of the plan by being able to work with students on social-emotional concerns and mental health issues in a counselor role.

One aspect of school social work on the micro level that needs to be singled out is that mental health counselor.  A study by Bye, Shepard, Patridge, and Alvarez (2009) had providing mental health services to students, rated by both school social workers and administrators, as the greatest benefit of social workers in the school setting.  Whether it is with students on IEPs, those dealing with depression or anxiety, or all those affected by the sudden death of a classmate, social workers in a school setting deal with wide variety of mental health concerns presenting in the student body of the school or schools with which they work.  O’Brien et al. (2011), cited Hoagwood et al. and Hennessey and Green-Hennessey to say that schools are main settings for helping students address these matters.  This is one of the reasons most states require school social workers to hold an MSW degree at minimum (Sabatino, Alvarez, & Anderson-Ketchmark, 2011), which we will talk about later on in the chapter.  For students who have any level of mental health distress, schoolwork and educational success can easily be adversely affected by that with which they are dealing.  School social workers need to know how to address students’ needs with effective interventions so that students can better direct their energy to their schoolwork.

Aside from the one-on-one help school practitioners provide students, an effective strategy that is often utilized is that of the small group.  Kelly et al. (2010) reviewed data from the National School Social Work Survey that identified small group work as a practice modality only 31% of school social workers used occasionally or rarely.  This work can take the form of task groups, psychoeducational groups, counseling groups, or psychotherapy groups and can address issues such as death and loss, anger management, changing the school climate, social skills development, and teen pregnancy.  Box 10.4 describes the purpose of each group further. These groups can also be co-facilitated with other mental health professionals in the schools, such as school counselors and psychologists, or may even be done as a collaborative effort with workers from outside agencies.  While not necessarily based on a social worker-student dichotomous relationship, students’ needs are still being met through direct work with a social worker.

Elementary students sitting around a desk doing group work with their instructor.
Group work is an effective intervention in the school setting and can cover a variety of topics in different ways.  it is an oft-used second-tier RtI and PBIS strategy, requiring school practitioners to have strong group facilitation skills. "First grade reading - small group breakout" bywoodleywonderworks is licensed under CC BY 2.0.

 

 

Box 10.4 – Small Groups in Schools

In their text, Groups: Process and Practice, Corey, Corey, and Corey (2010) discussed the usefulness of groups in school settings at being able to prevent and remediate student issues. The following is a list of the various groups a school social worker might facilitate in the school environment:

  • Task: Group members have identified the specific goals that they want to accomplish. The school social worker can help them build their interpersonal skills and understand the importance of healthy group dynamics in helping to complete their task. Examples can include gay-straight alliances (GSAs), study groups, student council, and student activities committees.
  • Psychoeducational: These groups are designed to develop cognitive, affective, and behavioral skills of students who may be lacking such skills. The practitioner provides the opportunity for students to learn, discuss, and practice some of these skills. Topics for these groups include stress and anger management, managing relationships, and assertiveness.
  • Counseling: Group members rely on an interactive group process, including feedback and support from other members to help them deal with transitional, interpersonal, or personal life issues. Social workers help members process their feelings and thoughts with each other. Work can focus on death and loss, adjusting to a new environment, and making personal behavioral and attitudinal changes.
  • Psychotherapy: These groups are focused on addressing psychological and interpersonal problems of living for students with significant mental or emotional needs or concerns. The intensity of and level of training needed to run these groups may not be appropriate for all school settings or for school social workers.

 

Parents and Families

            In K-12 schools, families can have a large role in their student’s education.  Teachers instruct students in the classroom, but learning is not restricted to the confines of the school itself.  Indeed, parents, as well as the family system as a whole, are integral in the learning that takes place outside of school.  In a similar manner, learning done inside the classroom setting can be greatly impacted by what is going on within other settings in a student’s life.  Poverty, divorce, bullying, alcoholism, and depression are all issues that happen within a family system, creating a less-supportive environment for learning.  By viewing the parents and families as an area in which services can be provided, the struggles present outside the classroom can be alleviated so students can focus more on their education.

            Understanding the needs of the family is essential in understanding the needs of the individual student.  As a result, helping to address the needs of the family system as a whole, will ultimately provide for needs of the student.  Social workers can connect families with outside resources or programs.  They can be an advocate for the family in terms of obtaining the needed assistance from the school itself.  They can also mediate between parents and teachers in order to get the best solution for the student.  Addressing the needs of the family can provide a more nurturing home environment that will allow for more concentration on school work when needed.

School social workers involve parents in particular in a number of interventions to address the SEL and mental health concerns of students.  The positive impact of supportive parents when it comes to a child’s educational attainment has been documented in various studies (Estell & Perdue, 2013).  One in particular suggests that significant parental involvement in mathematics homework assignments can increase student’s achievement in that subject (Sheldon & Epstein, 2005).  The study also stated the results, evaluated in conjunction with others done by Epstein, Sheldon and Epstein, Simon, and Van Voorhis, indicate that family-involvement in homework for specific subjects will can increase achievement in that subject area.  This can be applied to social-emotional well-being and mental health concerns in students.  School social workers need to include parents in the planning and implementing strategies, interventions, or resources that will help their children strengthen life and academic skills, increase self-efficacy and self-esteem, and build resilience to outside factors.

Along this line, parents should be included in the educational team for any child that needs additional help in the school itself.  As noted earlier, schools are legally required to provide certain services or accommodations to students with a documented need.  In order to do so, social workers, teachers, school psychologists, school counselors, parents, and the student come together as a team of experts to evaluate the student’s needs and put forth a plan to help give the student equal footing to her or his classmates.  This may take the form of a sign-language interpreter for a student who is deaf or hard of hearing, a proctor who reads tests for a student who is dyslexic, or extra time for tests if a student has attention deficit hyperactivity disorder (ADHD).  Although there are some standard strategies for specific needs, the educational team will evaluate these on an individual basis to make sure that they adequately serve the student.  Even if students do not have a documented need, school social workers can still include parents in the work done with students if it is deemed appropriate.  No matter what, involving parents and families in helping students succeed is a great way of addressing student need (D’Agostino, 2013).

Teachers sitting in a circle having a meeting.
Working in a school setting, social workers must collaborate with other personnel in helping the school provide for the educational achievement of all students.  Teachers, principals, school resource officers, teacher's aides, coaches, school counselors, nurses, and maintenance workers all interact with students and influence the school climate.  What skills will help bring these people together for a common goal? "Taichung ANL English Teachers Meeting 2008" by ANL 艾而歐語 is licensed under CC BY-NC-ND 2.0.

 

School Personnel

            It was stated earlier that parents are an important part of the education process outside of the classroom, but that teachers have the primary function of educating students while they are in class.  Aside from just the subject teaching done in the classroom, teachers and other school personnel can have an impact on the student that reaches beyond the physical classroom or school, often having more direct contact with a student during a week than a school social worker may have.  As a result, school social workers need to be able to provide services to teachers and other school personnel in order to promote the positive connection they have with students, as well as families of the students.

            One of the most basic ways in which school social workers can work for teachers, administrators, and other school staff and faculty is to provide various trainings that can benefit all school employees.  These trainings can include how to work with students on IEPs, effective strategies for dealing with disruptive behavior, and characteristics of various mental disorders in children, to name a few.  D’Agostino (2013) also mentioned training employees to understand how the connections they build with students and their families can help students succeed.  Indeed the connections employees, especially teachers who see students on a regular basis, build with students can go a long way to helping those students feel comfortable in the educational setting.

            Beyond general trainings for school personnel, working with teachers specifically on an individual basis can allow them to better meet the needs of the student in the classroom.  Students can provide challenges that teachers may not be equipped to address, and a social worker may be contacted when the student and the behavior the student is presenting with in class necessitates a referral.    Teachers also contact school practitioners as a resource when trying to figure out how to deal with certain students or to better understand individual student needs.  In the same sense, teachers may be well positioned to implement specific intervention strategies with students in the learning setting.  School social workers, therefore, need to work with and for teachers to make sure student needs are being met.  As a study by Berzin et al. (2011) points out, school practitioners need to utilize the primary role teachers have in providing for the needs of students through collaboration and training.

 

Box 10.5 – Climate Change

The National School Climate Council stated, “School climate refers to patterns of people’s experiences of school life; it reflects norms, goals, values, interpersonal relationships, teacher, learning and leadership practices, as well as the organizational structures that comprise school life” (p. 20). In partnership with many other school leaders from across the country, they developed the following National School Climate Standards:

  1. The school community has a shared vision and plan for promoting, enhancing, and sustaining a positive school climate.
  2. The school community sets policies specifically promoting
    1. the development and sustainability of social, emotional, ethical, civic and intellectual skills, knowledge, dispositions, and engagement, and
    2. a comprehensive system to address barriers to learning and teaching and reengage students who have become disengaged.
  3. The school community’s practices are identified, prioritized, and supported to
    1. promote the learning and positive social, emotional, ethical, and civic development of students;
    2. enhance engagement in teaching, learning, and school-wide activities;
    3. address barriers to learning and teaching and reengage those who have become disengaged; and
    4. develop and sustain an appropriate operational infrastructure and capacity building mechanisms for meeting this standard.
  4. The school community creates an environment where all members are welcomed, supported, and feel safe in school: socially, emotionally, intellectually, and physically.
  5. The school community develops meaningful and engaging practices, activities, and norms that promote social and civic responsibilities and a commitment to social justice.

Understanding these standards, think about the roles school social workers take in creating a positive school climate for each of the following groups of students who:

  • Have disabilities
  • Are racial or ethnic minorities
  • Identify or are identified by others as lesbian, gay, bisexual, transgender, queer, or questioning (LGBTQ)
  • Are high achievers
  • Come from low-income families
  • May be identified as different

 

School Districts

It should not seem odd that some of the client systems school social workers provide services to are the school districts in which they work.  As with any social worker, school social workers need to work with client systems at the different levels of practice.  In fact, based on this multi-level approach and their understanding of the interplay between the school environment and the student, school social workers have a unique understanding of the needs of the students and the needs of the school, and should be a part of the leadership in implementing effective programs and policies (Hopson & Lawson, 2011).  Aside from the individual work they do with students, utilizing parents, and working with teachers, school practitioners need to work with school administrators to address issues on a school-wide, or even district-wide approach.

School administrators have a lot of pressure to intensify their efforts when it comes to academic achievement and proving student learning (Hopson & Lawson, 2011).  With government mandates, such as NCLB, schools are being pressured to address achievement gaps between certain student populations (Lagana-Riordan & Aguilar, 2009).  Administrators are, therefore, looking to make the biggest impact in the shortest amount of time, at the lowest cost.  This is where school social workers can contribute.  It is still critical to view students as individuals and address many needs in the same manner.  However, being able to target a greater number of students with programs or policies focused on the various issues that may be contributing to students being at risk for school failure should be the first-line defense for school social workers.  Lagana-Riordan and Aguilar (2009) identified ways in which school social workers can target their school- and district-wide efforts in addressing barriers to learning, including establishing committees to address student needs, implementing bullying prevention programming, providing in-service trainings, revising curriculum to include cultural competence and SEL components, evaluating policy, and gathering data on effectiveness of these efforts.  

Of course, any discussion on services to schools and school districts would be incomplete without mentioning RtI and PBIS, two trending topics when it comes to large-scale intervention services in schools.  Both of these strategies provide guidelines for addressing school interventions at three distinct levels, similar to the macro, mezzo, and micro levels of social work practice.  The main idea is to address student need as much as possible with school-wide efforts in order to minimize the number of students who ultimately need help at the group or individual levels.  While the interventions resulting from these strategies are provided at the three different levels, the strategy itself is implemented at the largest, or school level.  Oftentimes school social workers are a part of the team, if not the main constituent, deciding how to use these strategies.

View of a city skyline with several tall buildings.
School social workers understand the demographics and needs of the communities their schools serve.  They are also aware of any other entities in the community that may impact the students, such as churches, social services, park districts, and businesses.  This allows them to better serve the students and, ultimately, the community. "city" by barnyz is licensed under CC BY-NC-ND 2.0.

 

Communities

            The services school social workers provide to communities is the last area, and arguably the area of least focus, when it comes to intervention services.  Nevertheless, important work can be done when viewing the community in which the school is located as a client system.  The ecological perspective speaks to the impact all environments have on an individual.  Despite the school setting in which a school social worker primarily functions, the community in which students live is an area in which services can be directed.

            When we are talking about services to communities, we need to include all the different systems within that community that might have an influence on students.  School social workers should already have a connection with local social service agencies that can help address student and family mental, emotional, and physical needs, along with basic needs of food, shelter, and safety (Hopson & Lawson, 2011; Lagana-Riordan & Aguilar, 2009).  School practitioners can also collaborate with these agencies to provide services within the school setting.  However, the school social worker can be much more than just a link between the school and these agencies.  When a community is lacking adequate resources outside of the school setting, school social workers can provide assistance.  Being the mental health expert of the school, school social workers can relate the needs of the students to agencies in the community or the community itself in order to create a plan to address these concerns. Of course, school social workers can also leverage their expertise on working with at-risk students as a means of serving client systems larger than the home communities of students.  Being able to help shape and reform policies at the state and federal levels, created by lawmakers who are not on the frontline of mental health care in a school setting, is vital in making sure policies include addressing student social, emotional, mental, and physical needs.

 

Response to Intervention and Positive Behavioral Interventions and Support

            In the discussion about school social work services provided to school districts, both Response to Intervention (RtI) and Positive Behavioral Interventions and Support (PBIS) were briefly addressed.  Here we want to expand on these two strategies to address student need.  These two models have very similar core components, but it is important to first understand each model on its own footing. 

            While the coining of the term “Response to Intervention” is most closely related to the reauthorization of IDEA in November of 2004, RtI’s foundational concepts grew out of a model of problem solving based on the scientific method that has been around a lot longer and was not necessarily focused on addressing educational needs (Wedl, 2005).  Ehren (n.d.), provided the National Center for Learning Disabilities definition of RtI:

The RTI process is a multi-step approach to providing services and interventions to students who struggle with learning at increasing levels of intensity. The progress students make at each stage of intervention is closely monitored. Results of this monitoring are used to make decisions about the need for further research-based instruction and/or intervention in general education, in special education, or both. (para. 2).

This definition not only demonstrates the scientific foundations of RtI by using data-driven interventions as well as evaluation data to assess those interventions, but it also touches on utilizing varying levels of service to address student concerns. What should be pointed, and probably the main difference between RtI and PBIS, is that RtI, in its inception, was an alternative to IQ testing used to identify students with significant learning needs (Wedl, 2005). Thus, those students who are a part of the special education program can be in general education classrooms and those students in general education classrooms that need additional academic help can get it. PBIS, on the other hand, target the behavioral needs of all students, as opposed to the educational needs addressed by RtI. PBIS, at times used synonymously with terms like Positive Behavior Support (PBS) and School-Wide Positive Behavior Support (SWPBS) depending on the state and the school district, is the direct opposite approach to 1990s zero-tolerance approaches schools took toward unwanted student behavior, which were not effective at creating change in student’s behavior (Bradshaw, Waasdorp, O’Brennan, & Gulemetova, 2013; Nocera, Whitbread, & Nocera, 2014). Along with RtI, it was a response to the directives of IDEA in finding a more preventative way of addressing student needs (Fitzgerald, Geraci, & Swanson, 2014) and provides a framework to do so in a systematic and evidence-based approach.

            Sandomierski, Kincaid, and Algozzine (2007) outlined a number of underlying principles the two strategies share that will allow for a more thorough understanding of both:

  1. Preventative in nature
  2. Three tiers of intervention at the universal, targeted group, and individual levels
  3. Quality curriculum and instruction from the beginning
  4. All interventions are evidence based and carried out with fidelity
  5. Gather data to monitor and assess students, and inform decision making.
  6. Use additional resources and services for students demonstrating need

These foundational tenets guide school personnel, including school social workers, to be proactive in their approach to student behavioral and educational needs.  Instead of waiting for students to fail academically or act out behaviorally and then intervene, possibly on a much smaller scale, RtI allows schools to provide a more nurturing educational environment, and PBIS creates an environment that fosters positive social and emotional growth.  In fact, it is through a combined use of the models that outcomes for both foci can be realized for all students (Sandomierski et al. 2007).

Borrowing from Carr et al. (2002), we need to be aware that while PBIS and RtI do require the utilization of empirical data, the implementation, and evaluation of interventions needs to also have a strong values background in order to maintain a person-centered approach.  It is this humanistic view that aligns these approaches with the person-in-environment perspective that directs school social work.  Adding the multi-level service delivery, which mirrors the macro, mezzo, and micro levels of social work practice, clearly demonstrates how these models can perfectly fit in with the generalist foundation social workers apply even in the school setting.

 

Barriers to Educational Attainment

When visiting teachers first entered schools, their primary concern was to help those students identified as having difficulties in school, whether they were not attending regularly, not completing the work, or not even grasping what was being taught.  As we discussed earlier, federal legislation created an influx of students into the school system.  This new population growth included students from low-income areas, immigrants, and those with disabilities, who were often referred to visiting teachers for services.  Today’s school social workers deal with a wide variety of issues students face, from truancy to academic underachievement to ADHD to teen parenting, while still addressing those same concerns from the field’s inception.  We are going to discuss a few of the populations and areas of concern that are faced or uniquely experienced in the school setting today.  It is important to keep in mind that these categories and situations can overlap, exacerbating the barriers students face in obtaining their education.

 

Box 10.6 – Students Dealing with Many Barriers

Obviously, certain life situations or group membership can present barriers to functioning well in school, thus affecting one’s educational attainment. But if you are a student dealing with several of these issues, it can be exponentially more difficult to maintain one’s mental and physical health. Before you read about some of the issues pertinent to these groups, think about what school-related issues might come up for students that fit these categories:

  • Neuroatypical and undocumented
  • Gay and experiencing homelessness
  • Has a behavioral concern and is bullied
  • From a low income area and depressed
  • Is experiencing an eating disorder and is new to school

 

Students with Disabilities and Behavioral Concerns

            As current federal legislation dictates, students with disabilities, whether physical, cognitive, or developmental, all have the right to fair educational attainment.  IDEA even specifies that schools must evaluate students for all suspected disabilities for the purpose of providing for each of the students' needs in an educational context (Weber, 2013).  More recently, this has been demonstrated through the reintegration of students in this population, some of whom would have been termed LD (learning disabled) or BD (behaviorally disabled), into general education classrooms.  Often following an inclusion model, this is considered to be in the best interest of all students (School Social Work Association of America, 2001).  As a result, school social workers will often have to work with students facing these concerns.  The most recent numbers from the National Center for Education Statistics (2020) state that almost 7.3 million students in kindergarten through 12th grade were served under IDEA in the 2019-2020 school year; which equates to over 14% of the total school-aged population in the United States.  The data also shows that 33% of the total number of students with disabilities had a specific learning disability.

However, even with the legislative push to address the educational needs of all these students, they still do not achieve educationally, nor are expected to, as much as other students (Aron & Loprest, 2012).  This makes it so much more important for social workers to engage in practice specific to this population of students.  From integrating school-wide intervention strategies to working on the educational planning team that formulates a student’s IEP or educational plan based on a Functional Behavioral Assessment, school social workers are well suited for addressing the needs of these students.  Relying on their data-driven practice, they can evaluate the school’s and the student’s needs to plan and implement the most effective educational and behavioral prevention and intervention strategies to make sure students are meeting their educational goals and receiving an equitable education.

            Collaboration with parents and teachers is an important part of working for students with a disability.  Parents of children with disabilities can fall anywhere on a continuum of being very well informed about their child’s disability to being told for the first time with what their child is dealing.  School social workers need to be there to advocate for the student and the student's parents, provide parent education on disabilities and strategies, and help families navigate the school and community systems.  Teachers may also need help from school social workers when it comes to working with this population of students.  Strong collaboration is essential in addressing classroom behavior with appropriate interventions, sometimes even through school-wide trainings and skill-building.  Often, both parents and teachers are called to be a part of the child’s educational planning team.  Being able to engage everyone to work for the student is a necessary part to ensure the school is providing for the educational needs and rights of students with disabilities.

Red F grade in a circle.
Students who may be dealing with a learning disability can often feel like they are just dumb. School social workers are an integral part of helping these students receive the appropriate accommodations that will help them receive the education they deserve. "Bad Grade" by Robert Hruzek is licensed under CC BY-NC-ND 2.0.

 

Bullying & School Violence

It has been said that being bullied in school is a normal part of growing up that everyone will experience and is harmless, making it seem almost like a rite of passage.  In their Indicators of School Crime and Safety: 2020 report, the National Center for Education Statistics (2021) reported that 22.2% of students in 6th through 12th grades were victims of school bullying.  A study done by Bradshaw, Sawyer, and O’Brennan (2007) further indicated that just over 70% of both students and staff have witnessed bullying taking place in the school setting.  However, Stopbullying.gov (n.d.), a project form the U.S. Department of Health and Human Services, defined bullying as:

[An] unwanted, aggressive behavior among school aged children that involves a real or perceived power imbalance. The behavior is repeated, or has the potential to be repeated, over time. Both kids who are bullied and who bully others may have serious, lasting problems. (Bullying Definition, para. 1)

This points out that bullying is not harmless.  A look at the literature will echo how bullying has negative, and sometimes deadly, effects on students’ social, emotional, and physical well-being.  These include increased risk for headaches, feelings of loneliness, depression, sleep disturbances, anxiety, suicidal thoughts and behaviors, and school-wide violence (Albertson, 2014; Bradshaw et al., 2007; Healy, Sanders, & Iyer, 2015Ramirez, 2013; Tsiantis et al., 2013).  While it seems true that bullying is a regular occurrence for more than one-fourth of students in middle and high schools and something most people in the school setting witness on a daily basis, it is equally as true that bullying is damaging to students.

In providing for a safe and nurturing educational environment, it is paramount that school social workers work to address bullying and violence in a school setting.  School practitioners are at the forefront of addressing school bullying and violence through data-driven prevention programs and intervention strategies (Cawood, 2010).  With the push for evidence-based practices, many school social workers are helping schools initiate school-wide bully prevention programs aimed at educating students about the behavior and how to combat it.  However, focusing on the students is not enough.  As Bradshaw et al. (2013) discussed, teachers and other school personnel do not understand the danger of school bullying and often underestimate how many students are victimized.  School social workers can provide training for their colleagues in preventing, recognizing, and understanding how to intervene with bullying situations.  They can also work with administrators to create school policies that will protect potential victims.  These efforts are an important part of addressing the climate of the educational setting to better provide for the physical and mental safety of all students.

It is clear that there are times in which bullied students will end up in the social worker’s office.  Services for victims may include small group work or individual meetings with a school counselor.  However, most victims, a little more than 45% (National Center for Educational Statistics, 2020), may never tell an adult at school what is happening, even when it may be clear to school personnel.  As a result, school social workers need to be visible throughout the school so students can identify them and feel more comfortable initiating contact with them.  Working with parents through large group bullying training, getting involved with the parent teacher organization, or individual meetings, can also help address the issue if students do not seek help.

It is important to address the fact that certain types of students, such as those who are perceived as overweight, have a disability, belong to a racial or ethnic minority (Bradshaw et al., 2013), or identify as LGBTQ (Hong & Garbarino, 2012) get singled out more than others when it comes to school bullying.  Anyone perceived as being different from what is believed to be the norm, whether the perception is accurate or not, can become a target for bullying.  On the individual level, services for someone who has been bullied should not necessarily just focus on the bullying.  It can also address the reason for the bullying, if it is of concern to the student, and the school social worker can process this separately with the student in order to build strategies to tackle this concern in its own right.  Of course, this can be true of the school system itself; the need to educate and build a more accepting environment for students who are different.  School social workers can work to tackle a number of different issues school-wide that can all contribute to a safer environment when it comes to bullying.

Students who are victims of bullying are not the only ones with which school social workers may work.  Just as it is necessary to address the mental health of those who have been bullied and help them develop coping strategies, school social workers can help address the underlying causes of the bullying behavior with students who are seen as the perpetrators.  Often bullies are dealing with their own mental health concerns or problems at home.  Again, inclusion of parents in the process can help deal with the bullying incident.  Collaboration between parents and the school can provide a consistent message about bullying (Whitted & Dupper, 2005), working to reduce the behavior and the negative effects for victim and bully.  School social workers address the needs of all students who are not getting the most out of their educational experience, despite the role they may have played in a bullying situation.

Boy crying with six hands in a circle around his head pointing at him.
Bullying in schools can happen at any age and can take many forms, including physical, verbal, and virtual.  School practitioners will work with victims, bullies, and school personnel in addressing this problem.

 

LGBTQ+ Students

            It is understood that students who identify as LGBTQ are targets for bullying behaviors more often than their straight counterparts (Hong & Garbarino, 2012).  This, undoubtedly, contributes to the higher levels of depression, low self-esteem, and suicidal ideation among students who identify as LGBTQ+ (Almeida, Johnson, Corliss, Molnar, & Azrael, 2009; Kosciw, Greytak, Palmer, & Boesen, 2013).  However, bullying is not the only factor impacting the mental health concerns of LGBTQ+ students.  Living as an individual who is LGBTQ+ in an environment that has determined heterosexuality and cisgender identity as the norm can be quite difficult, especially for students who are still trying to understand who they are and where they fit in the world.  Since school environments greatly mimic society at large, this heteronormativity is played out in the daily interactions students who are LGBTQ+ have with their peers, school employees, and the school system itself.  While verbal and physical bullying is a very overt way in which people who are LGBTQ+ experience discrimination based on their sexuality, there are also many unintentional acts that add to the depression, anxiety, self-esteem, and ultimately lower academic success of these students.

            In their study on the effects of homophobic bullying and school climate, Birkett, Espelage, and Koenig (2009) looked at school climate as, “how much students feel that they are getting a good education at their school and are respected and cared about by adults at their school.” (p. 993).  A positive environment for LGBTQ+ youth can thus be thought of as one in which these students feel their education is nurtured and they are supported by school employees.  However, all too often this group of students encounters a negative, often hostile, environment that is not affirming.  Aside from the bullying, by peers as well as teachers or other school staff, LGBTQ+ students encounter heteronormative language when interacting with others in the school, unfair policies that do not protect them and may specifically target them, assumptions of sexuality and gender identity, and a lack of LGBTQ+ presence in the curriculum.  All of this encourages conformity through the rejection of one’s identity and creates a school climate that is not safe or nurturing for these students.

            School social workers need to work to ensure these issues are addressed properly.  It starts with having an understanding of these students and the concerns they are faced with on a daily basis living in a heteronormative world.  One that often tells them they should be ashamed of who they are.  In interactions with students, as well as other school personnel, it is important to be aware of biased language that assumes a student’s sexual orientation or gender identity, including preferred pronouns.  LGBTQ+ students should be able to identify school social workers as someone they can talk to about any problem they may be having, including those related to sexuality.  Teachers, administrators, and other school personnel should also have a working knowledge of the LGBTQ+ population.  Teachers may be untrained and uncomfortable when it comes LGBTQ-related topics, and may avoid talking about, teaching about, or addressing these in their interactions with students in and out of the class (Hanlon, 2009).  Supplemental training led by social workers, such as Safe Zone, can help alleviate these concerns for teachers, as well as other adults in the school, allowing for a more inclusive environment.  Supportive educators was just one of the LGBT-inclusive supports Kosciw et al. (2013) outlined as a way schools can make a difference.

Gender and sexualities alliances (GSAs), LGBTQ-inclusive curricula, and comprehensive anti-bullying policies are the other ways in which schools can provide for an accepting school climate.  GSAs, in particular, have been addressed in numerous studies as being able to combat the negative effects of a hostile school environment, allowing for better mental health and academic achievement of LGBTQ+ youth (Kosciw et al., 2013; Kosciw, Greytak, &Diaz, 2009; Poteat, Sinclair, DiGiovanni, Koenig, & Russell, 2013) and school practitioners have the skill and background to advocate for and facilitate such groups.  They can be a place to process what students deal with and find support from others who may have gone through similar experiences.  GSAs allow students to connect with others who are accepting and affirming of their identity, and can be an agent of change when it comes to the school climate.

 

Box 10.7 – Heteronormativity

Educators too often assume that students are straight or identify as the gender they were assigned at birth. We may make these assumptions without realizing it and have it come out in what we say or how we interact with our students. Most likely, these things have become natural to us because we have been socialized to be this way. When we work with all students, we cannot make assumptions about them or their experiences. We can have an idea of what they might be going through or be aware of the issues students who similarly identify deal with, but we cannot label them and fit them into a nice, neat box. The following is a short list of actions or verbalizations that can block a therapeutic connection with a student who is LGBTQ.

  • Asking a male student if he has a girlfriend.
  • Being surprised in body language, action, and speech when a student discloses that she is a lesbian.
  • Saying, “Hi, guys.” to a group of mixed gender students.
  • Asking a male student if he likes sports; telling a female student that her outfit looks nice.
  • Referring to a student in group as a “he” when that student has not provided preferred pronouns.
  • School forms only having male and female options for gender.
  • Not addressing a colleague’s assumptive actions in front of a student who identifies as LGBTQ.

 

Racial and Ethnic Minority & Low-Income Students

            The main goal of the No Child Left Behind legislation was to close the achievement gap between academically achieving students and those who have traditionally been denied equal access to education, or as Lagana-Riordan and Aguilar (2009) put it, “between white, economically advantaged students and those considered at risk for school failure,” (p. 135).  Those at risk can be further defined as African American, Native American, Latinx, certain Asian American (Howard, 2010), and low-income white students (Lagana-Riordan and Aguilar, 2009).  Even though NCLB relates the difference between these groups as an academic issue and rely on academic assessment scores to determine success or lack of it (Orlich, 2004), there are many other non-academic influences that can contribute to this variance as well.  Often these influences go beyond teaching and curriculum, are out of the reach and control of students and educators, and can take a larger-scale effort to address.  As a result, Pitre (2014) references the idea of using the term “opportunity gap” instead of achievement gap because it brings to light the disproportionate opportunities between the advantaged and the at-risk.  This shifts focus from schools not being able to educate students to society not providing equal access for all students.  The newer Every Student Succeeds Act is trying to address this issue specifically by giving more local control over what interventions and supports are made available to students that need them.

            Schools that primarily serve minority students and low-income students, which are disproportionately the same group of students, do not have the same resources as schools in white, middle-class areas.  These students do not have the same access to high-quality instruction and curriculum; extra-curricular, after school programs, and summer programs; or funding to provide for quality educational materials (Lagana-Riordan and Aguilar, 2009; Amatea & West-Olatunji, 2007).  In addition, resources within the community are scarce or underfunded, including mental health care, further disenfranchising these students.  Even when socioeconomic status is removed, other concerns such as racism, prejudice and discrimination, and language barriers can all play a role in working to maintain the opportunity gap.

            Working with these students embodies the idea of social justice.  Systemically, school social workers need to have input into policies, such as NCLB, to better direct how the government and society address the opportunity gap.  Legislators usually have good intentions, but may lack the foundational knowledge or direct experience to understand how to best address problems.  School social workers have both and need to leverage this awareness to better inform policy.  School practitioners can also work at the school level by educating teachers and administrators about how to better address the needs of these students, helping the school become culturally competent, and implementing school-wide programs to build resource and resilience for students (Jozefowicz-Simbeni & Allen-Meares, 2002; Lagana-Riordan & Aguilar, 2009).  In this way, they can take a leadership role in providing for these underserved students.

            Services for individual students are equally as important in addressing the educational discrepancies.  Working from an ecological perspective, school practitioners can identify all the various barriers students are dealing with and can work with students to implement strategies to affect change, either within the student themselves, or within the various systems of the student.  This can be providing for physical needs like lunch or clothing, building resiliency skills, or connecting students with outside agencies that can help address family needs of income or housing assistance.  School social workers may not be the ones implementing teaching and curriculum changes to bridge the opportunity gap, but they certainly provide a multitude of services that can have a greater impact.

 

Conclusion

            Schools are a microcosm of society, complete with all the problems and inequities present in the American life, played out as young humans grow into adults.  Although a big focus of the time students spend in school every day is on academic learning, schools do much more than that.  They are also a place to learn how to learn and grow in a social-emotional manner as well.  With so much emphasis on academic achievement, society can lose sight of the need for mental health achievement.  It is up to school social workers, through their special skill set, to help students navigate and interact with the various systems in their lives in an effective manner, conducive to educational, behavioral, and personal growth.  In the same respect, school practitioners can also turn their abilities to work with these systems into another means of taking on student needs and breaking down barriers to equal access for everyone.  Addressing all areas of the students’ lives, and not just focusing on teaching and curriculum, will allow for success of the whole person.

 

Chapter 10 References

Albertson, A. K. (2014). Criminalizing bullying: Why Indiana should hold the bully responsible. Indiana Law Review, 48(1), 243-271.

Allen-Meares, P. (2010).  Social work services in schools. Allyn & Bacon.

Almeida, J., Johnson, R. M., Corliss, H. L., Molnar, B. E., & Azrael, D. (2009). Emotional distress among LGBT youth: The influence of perceived discrimination based on sexual orientation. Journal of Youth and Adolescence, 38(7), 1001-1014. doi:http://dx.doi.org/10.1007/s10964-009-9397-9.

Alvarez, M. E., Bye, L., Bryant, R., & Mumm, A. M. (2013). School social workers and educational outcomes. Children & Schools, 35(4), 235-243.

Amatea, E. S., & West-Olatunji, C. A. (2007). Joining the conversation about educating our poorest children: Emerging leadership roles for school counselors in high-poverty schools. Professional School Counseling, 11(2), 81-89.

Aron, L., & Loprest, P. (2012). Disability and the education system. Future of Children, 22(1), 97-122.

Berzin, S. C., O’Brien, K. H. M., Frey, A., Kelly, M. S., Alvarez, M. E., and Shaffer, G. L. (2011) Meeting the social and behavioral health needs of students: Rethinking the relationship between teachers and school social workers. Journal of School Health, 81(8), 493-501. Doi:10.1111/j.1746-1561.2011.00619.x

Birkett, M., Espelage, D. L., & Koenig, B. (2009). LGB and questioning students in schools: The moderating effects of homophobic bullying and school climate on negative outcomes. Journal of Youth and Adolescence, 38(7), 989–1000.

Bloom, M, Fischer, J. & Orme, J. (2009), Evaluating practice: Guidelines for the accountable professional (6th Ed.). Boston: Allyn and Bacon. Retrieved from http://lyceumbooks.com/pdf/Toward_Evidence-Based_Chapter_21.pdf

Bradshaw, C. P., Sawyer, A. L., & O'Brennan, L. M. (2007). Bullying and peer victimization at school: Perceptual differences between students and school staff. School Psychology Review, 36(3), 361-382.

Bradshaw, C. P., Waasdorp, T. E., O'Brennan, L. M., & Gulemetova, M. (2013). Teachers' and Education Support Professionals' Perspectives on Bullying and Prevention: Findings from a National Education Association study. School Psychology Review, 42(3), 280-297.

Bye, L., Shepard, M., Patridge, J., & Alvarez, M. (2009). School social work outcomes: perspectives of school social worker and school administrators. Children & Schools, 31(2), 97-108.

Carr, E.G., Dunlap, G., Horner, R. H., Koegel, R. L., Turnbull, A. P., Sailor, W., … Fox, L. (2002). Positive behavior support: Evolution of an applied science. Journal of Positive Behavior Interventions, 4(1), 4.

Cawood, N. D. (2010). Barriers to the use of evidence-supported programs to address school violence. Children & Schools, 32(3), 143-149.

Center for Parent Information and Resources (2017).  Everything you need to know about the Every Student Succeeds Act. Retrieved on August 6, 2021, from https://www.parentcenterhub.org/everything-about-essa/.

Costin, L. B. (1969) An historical review of school social work. Social Casework, 50, 439-453.

Cowan Pitre, C. (2014). Improving African American student outcomes: Understanding educational achievement and strategies to close opportunity gaps. Western Journal of Black Studies, 38(4), 209-217.

D'Agostino, C. (2013). Collaboration as an essential school social work skill. Children & Schools, 35(4), 248-251.

Dibble, N. (2008). School social work & the privacy of minors. Retrieved from http://c.ymcdn.com/sites/sswaa.site-ym.com/resource/resmgr/imported/School%20Social%20Work%20and%20the%20Privacy%20of%20Minors.pdf.

Ehren, B. (n.d.) Response to Intervention in secondary schools: Is it on your radar screen? Retrieved from http://www.rtinetwork.org/learn/rti-in-secondary-schools/response-to-intervention-in-secondary-schools.

Estell, D. B., & Perdue, N. H. (2013). Social support and behavioral and affective school engagement: The effects of peers, parents, and teachers. Psychology In the Schools, 50(4), 325-339. doi:10.1002/pits.21681

Fitzgerald, C. B., Geraci, L. M., & Swanson, M. (2014). Scaling up in rural schools using positive behavioral interventions and supports. Rural Special Education Quarterly, 33(1), 18-22.

Frey, A., and Lankaster, F. (2008). School social work in host settings. Retrieved from http://c.ymcdn.com/sites/sswaa.site-ym.com/resource/resmgr/Res_Statements/School_Social_Work_in_a_Host.pdf.

Frey, A. J., Alvarez, M. E., Sabatino, C. A., Lindsey, B. C., Dupper, D. R., Raines, J. C., … Norris, M. P. (2012). The Development of a National School Social Work Practice Model. Children & Schools. pp. 131-134. doi:10.1093/cs/cds025.

Frey, A.J., Alvarez, M.E., Dupper, D.R., Sabatino, C.A., Lindsey, B.C., Raines, J.C., … Norris, M.A. (2013). School social work practice model. Retrieved from http://sswaa.org/displaycommon.cfm?an=1&subarticlenbr=459.

Germain, C. A., & Gitterman, A. G. (n.d.). Ecological perspective. Retrieved from http://www2.uncp.edu/home/marson/348_ecological.html.

GLSEN (2013). The 2013 National School Climate: The experiences of lesbian, gay, bisexual and transgender youth in our nation’s schools. Kosclw, J. G., Greytak, E. A., Palmer, N. A., & Boesen, M. J. Retrieved from http://www.glsen.org/sites/default/files/2013%20National%20School%20Climate%20Survey%20Full%20Report_0.pdf.

Hanlon, J. (2009). How educators can address homophobia in elementary schools. Encounter, 22(1), 32-45.

Healy, K., Sanders, M., & Iyer, A. (2015). Parenting practices, children's peer relationships and being bullied at school. Journal of Child & Family Studies, 24(1), 127-140. doi:10.1007/s10826-013-9820-4

Hong, J., & Garbarino, J. (2012). Risk and protective factors for homophobic bullying in schools: An application of the social-ecological framework. Educational Psychology Review, 24(2), 271-285. doi:10.1007/s10648-012-9194-y

Hopson, L., & Lawson, H. (2011). Social Workers' leadership for positive school climates via data-informed planning and decision making. Children & Schools, 33(2), 106-118.

Howard, C.T. (2010).  Why race and culture matters in schools.  Teachers College Press.

Individuals with Disabilities Education Act (2007). Questions and answers on Response to Intervention (RTI) and Early Intervening Services (EIS). Retrieved from http://idea.ed.gov/explore/view/p/%2Croot%2Cdynamic%2CQaCorner%2C8%2C

Jozefowicz-Simbeni, D. H. (2008). An ecological and developmental perspective on dropout risk factors in early adolescence: Role of school social workers in dropout prevention efforts. Children & Schools, 30(1), 49-62.

Jozefowicz-Simbeni, D. H., & Allen-Meares, P. (2002). Poverty and schools: Intervention and resource building through school-linked services. Children & Schools, 24(2), 132.

Kelly, M. S., Frey, A. J., Alvarez, M., Berzin, S. C., Shaffer, G., & O'Brien, K. (2010). School social work practice and response to intervention. Children & Schools, 32(4), 201-209.

Kosciw, J. G., Greytak, E. A., & Diaz, E. M. (2009). Who, what where, when, and why: Demographic and ecological factors contributing to hostile school climate for lesbian, gay, bisexual, and transgender youth. Journal of Youth and Adolescence, 38, 976–988.

Lagana-Riordan, C., & Aguilar, J. P. (2009). What's missing from No Child Left Behind? A policy analysis from a social work perspective. Children & Schools, 31(3), 135-144.

Massat, C. R., Constable, R., McDonald, S., & Flynn, J. P. (Eds.). (2009). School social work: Practice, policy, and research (7th ed.). Lyceum Books, Inc.

Mizrah, T., & Davis, L. E. (Eds.). (2008). Ecological Framework. Encyclopedia of social work (20th ed.). doi:10.1093/acref/9780195306613.001.0001.

Morrison, V. (2006). History of school social work: The Illinois perspective. School Social Work Journal, 30, 1-23.

NASW. (2012) NASW Standards for school social work services. Retrieved from http://www.socialworkers.org/practice/standards/NASWSchoolSocialWorkStandards.pdf.

National Center for Education Statistics. (December 2020). Among students ages 12-18 who reported being bullied at school during the school year, percentage reporting various frequencies of bullying and the notification of an adult at school, by selected student and school characteristics: 2019. [Table]. Retrieved on August 6, 2021, from https://nces.ed.gov/programs/digest/d20/tables/dt20_230.60.asp

National Center for Education Statistics. (June 2020). 3-21 years old served under Individuals with Disabilities Education Act (IDEA), Part B, by type of disability: Selected years, 1976-77 to 2018-2019 [Table]. Retrieved on August 6, 2021, from https://nces.ed.gov/programs/digest/d20/tables/dt20_204.30.asp.

Nocera, E. J., Whitbread, K. M., & Nocera, G. P. (2014). Impact of School-wide positive behavior supports on student behavior in the middle grades. Research in Middle Level Education Online, 37(8), 1-14.

O'Brien, K. M., Berzin, S. C., Kelly, M. S., Frey, A. J., Alvarez, M. E., & Shaffer, G. L. (2011). School social work with students with mental health problems: Examining different practice approaches. Children & Schools, 33(2), 97-105.

Orlich, D. C. (2004). No Child Left Behind; An illogical accountability model. Clearing House, 78(1), 6-12.

Peckover, C. A., Vasquez, M. L., Van Housen, S. L., Saunders, J. A., & Allen, L. (2013). Preparing school social work for the future: An update of school social workers' tasks in Iowa. Children & Schools, 35(1), 9-17. doi:10.1093/cs/cds015

Poteat, V. P., Sinclair, K. O., DiGiovanni, C. D., Koenig, B. W., & Russell, S. T. (2013). Gay-straight alliances are associated with student health: A multischool comparison of LGBTQ and heterosexual youth. Journal of Research on Adolescence (Wiley-Blackwell), 23(2), 319-330. doi:10.1111/j.1532-7795.2012.00832.x

Raines, J. (2008). School social work and group work. Retrieved from http://c.ymcdn.com/sites/sswaa.site-ym.com/resource/resmgr/imported/SSW%20&%20Group%20Work.pdf.

Ramirez, O. (2013). Survivors of school bullying: A collective case study. Children & Schools, 35(2), 93-99

Sabatino, C. A., Alvarez, M. E., & Anderson-Ketchmark, C. (2011). "Highly qualified" school social workers. Children & Schools, 33(3), 189-192.

Sandomierski, T., Kincaid, D., & Algozzine, B. (2007). Response to Intervention and Positive Behavior Support: Brothers from different mothers or sisters with different misters? Retrieved from https://www.pbis.org/common/cms/files/Newsletter/Volume4%20Issue2.pdf.

School Social Work Association of America. (n.d.). Mission & Vision. Retrieved from http://sswaa.site-ym.com/?51.

School Social Work Association of America. (2001). Functional behavioral assessments and behavioral intervention plans.  Retrieved from http://c.ymcdn.com/sites/www.sswaa.org/resource/resmgr/imported/Functional%20Behavioral%20Assessments%20and%20Behavioral%20Intervention%20Plans.pdf

Shaffer, G. L. (2006). Promising school social work practices of the 1920s: Reflections for today. Children & Schools, 28(4), 243-251.

Sheldon, S. B., & Epstein, J. L. (2005). Involvement counts: Family and community partnerships and mathematics achievement. Journal of Educational Research, 98(4), 196-206.

Stanley, S. G. (2011). Visiting Teachers and Students with Developmental Disabilities. Children & Schools, 33(3), 168-175.

Steele, J. M. (2008). Preparing counselors to advocate for social justice: A liberation model. Counselor Education & Supervision, 48(2), 74-85.

Tsiantis, A. J., Beratis, I. N., Syngelaki, E. M., Stefanakou, A., Asimopoulos, C., Sideridis, G. D., & Tsiantis, J. (2013). The effects of a clinical prevention program on bullying, victimization, and attitudes toward school of elementary school students. Behavioral Disorders, 38(4), 243-257.

Stopbullying.gov. (n.d.). What is bullying? Retrieved from http://www.stopbullying.gov/what-is-bullying/definition/index.html.

Weber, M. C. (2013). All areas of suspected disability. Loyola Law Review, 59(2), 289-322.

Wedl, R.J. (2005). Response to Intervention: An alternative to traditional eligibility criteria for students with disabilities. Retrieved from http://www.educationevolving.org/pdf/Response_to_Intervention.pdf.

Whitted, K. S., & Dupper, D. R. (2005). Best practices for preventing or reducing bullying in schools. Children & Schools, 27(3), 167-175

Chapter 11: Families and Children

Families are the foundational unit for love, support, and socialization in the United States.  However, not all families are able to provide such an environment for all of its members.  There are many different situations in which social workers need to provide family or child-related services in order to meet the needs of the family system as the client, the individual family members as the clients, or both.  Social workers need to understand family styles and the issues that can prevent them from being a positive safe environment.  This chapter will discuss information about families and children so students will be able to:

  1. Define family and the various structures it takes in the U.S.;
  2. Describe how systems theory applies to families;
  3. Recognize common concerns for families and what level of need they fit into;
  4. Understand the different child welfare efforts;
  5. Identify the unique problems facing children as they transition into adulthood.
Multigeneration Indian family at a celebration.
"Multi-generational.jpg" by ToreaJade is licensed under CC BY-NC-SA 2.0.

 

Working with Children & Families

When the Hull House opened its doors in 1889, its core purpose was to help families navigate the community in which they lived.  Serving families, the Hull House, and other settlement houses like it were the beginning of social work practice in the United States, especially social work practice with children and families.  Currently, the National Association of Social Workers (2015) estimates that a combined 28 percent of all social workers provide services specifically catered to children and to families.  It only makes sense that more than a quarter of all those in the field would be focused on working to improve one of the most basic structures underlying our humanity.

Biologically, all living animals have parents from which they received the two halves of their DNA.  Reproduction in the animal kingdom is sexual, meaning that it takes two parents to create a new member of the species.  Socially, families can function as a means to protect young individuals of the species from predators or other dangers that could end the creature’s existence.  The parent or parents of the group teach the younger members how to endure, by educating them on how to move, behave, find nourishment, and avoid those organic and inorganic threats to life.  Without the family, certain species would not be able to protect their young and continue their genetic code.  Human families in the United States are still meant to perform these functions.  They are supposed to be a place of safety, upbringing, and socialization, helping children grow into adults who will be able to navigate and survive in the environment in which they live.  When they do not or cannot provide the proper environment for these things to happen, social workers are often the ones who step in to try and help the family function in a positive way for all the individual systems involved.  From connecting families experiencing poverty with public welfare programs to reporting suspected child abuse, to helping families grieve after the loss of one of its members, social workers help families address the plethora of issues they may face.

 

The American Family

A working definition of what we mean by family should be addressed if we are going to talk about the concept and how to best work with family systems.  The problem becomes finding an adequate way of describing what exactly should be considered a family that satisfies everyone.  While biologically related parents and children all living under one roof are the typical representation of a single family unit, the way people define their current functioning “family” does not always fit this structure.  For instance, some people prefer to include friends or religious groups in the self-held definition of their family because they spend more time with, have a stronger connection to, or receive more support from these people.  These familial assemblages really can function much like the biological necessity that lead to family groupings in the first place.  Friends help each other become socialized in their peer group environment or the church family can provide financial, spiritual, and social support.  These configurations can help people meet the varying needs that may not be fulfilled by their biological families.

A father and mother with their two young children, reading a book together.
The “typical” American family consists of married heterosexual cisgender parents and their biological children.  The problem is the ‘typical family’ is that it's an atypical family form in the United States.  "African American family" by pennstatenews is licensed under CC BY-NC-ND 2.0.

An effective social definition of family could then be a group of two or more people connected by a commonality, such as ancestry, household, or even interests, that also define themselves as a family.  This allows for multiple organizations of people and brings subjectivity to the concept for those who do not have a relationship or strong connection to their blood relatives.  A great example would be a child who has never known her biological father because he abandoned her and her mother when the child was an infant.  It is not hard to see why the child may not feel like she can or wants to consider him family.  In fact, the official definition of family according to the U.S. Census Bureau (2013a) is, “a group of two people or more (one of whom is the householder) related by birth, marriage, or adoption and residing together; all such people (including related subfamily members) are considered as members of one family.” (Family definition, para. 1).  By this meaning, the biological father in our case would be excluded as an official family member for the purpose of the census.

What this definition does not account for are those divorced parents who are still very much involved in a child’s life, despite the fact they are not living under the same roof.  While these parents are not part of their child’s household family, their children can still count them as a family member.  The Current Population Survey for which the definition is used provides statistics related to the labor force and the population of the U.S., including the economic situation of households.  It is not concerned with understanding the complex and intricate dynamics of families and family members.  Even if you tried to define families in a legal manner to indicate who has responsibility for whom or what in the eyes of the law, it still may not be able to encapsulate all the variations on family that exist in the United States today.  For social work’s consideration, discussing practice done with families will be geared toward helping all the assorted biological, marital, and adoptive – both legal and social – relationships work together to function as best as possible as a family, provide a nurturing environment for children to grow, and address any unmet needs.  However, as is natural with the person-centered approach common in social work, we need to rely on the families we are working with to explicitly (or implicitly) define their own membership.  We cannot expect to build an effective helping relationship with our client systems if we are not willing to meet them where they are.  As a result, this provides us with an inordinate amount of family types and, though we cannot cover them all, it is important for us to look at some of the more common forms families take in America, with the help of popular television shows.

 

Box 11.1: Defining Family

When one of your authors was an undergrad, one of his class discussions revolved around creating a working definition of family that was inclusive of all variations.   His class was not able to come to a consensus by the time they had to move onto the next topic.  Think you can do it?  Try it.  Discuss with your classmates an acceptable definition of family or come up with one on your own.  See if it still makes sense for you after you read the chapter.  To get you started, here are some definitions of family found on the Internet:

  1. Merriam-Webster - The basic unit in society traditionally consisting of two parents rearing their children.
  2. Dictionary.com - A basic social unit consisting of parents and their children, considered as a group, whether dwelling together or not.
  3. YourDictionary.com - A specific group of people that may be made up of partners, children parents, aunts, uncles, cousins and grandparents.
  4. BusinessDictionary.com - Social unit of two or more persons related by blood, marriage, or adoption and having a shared commitment to the mutual relationship.

What do these definitions have in common?  How is each unique?  What are they all missing?

 

The Cleavers – Traditional Families

The TV show Leave It to Beaver centered on a young boy, Theodore “Beaver” Cleaver and his family, which consisted of his father Ward, his mother June, and his brother Wally.  The show, which began in 1957, represented what is known as the traditional family, one in which the father was the breadwinner and disciplinarian, and the mother was the housewife who would clean, cook, and care for the children.  Today, more than 50 percent of all children are growing up in a family that does not fit the definition of the traditional nuclear family – two parents and their children (National Association of Social Workers, 2015).  In fact, during the Cleavers time, 57 percent of families did not fit this family structure (Kimmel, 2013).  Yet there is still a belief that the “ideal” family, described as consisting of heterosexual, cisgender parents who conceive and rear their biological children (Parke, 2013), is the cornerstone of American society.  In section six of the Republican National Committee’s 2012 platform, they discuss the benefits of the traditional family and how decreased freedom can result from single-parent and nontraditional family structures.  This inflexible definition helps perpetuate the stereotype that the traditional family, with its gender roles, is the prevailing form in the United States.  However, gender roles are one of the ways in which the “traditional” family is changing.  Even for families consisting of a father, mother, and children, the Cleavers are no longer the mold for the traditional family.

Gone are the days when only the husband went to work and the wife stayed home to clean the house, take care of the children, and have a nice hot meal waiting on the table when father came home.  Today, the majority of families with heterosexual married parents require both husband and wife to work outside of the home to make ends meet.  This does not mean that men are necessarily helping out at home more.  A study by Cook, Brashier, and Hughes (2011) replicated other findings in stating that women tend to have a disproportionate amount of responsibilities at home than men.  They demonstrated how this inequality at home added stress to the marriage and the family.  One way other traditional parenting teams are handling this is by having the mother take on the role of breadwinner and the father being a stay-at-home dad.  Boushey even identified that more than one-third of wives – 38 percent – earn as much or more than their husbands (as cited in Fischer & Anderson, 2012).  These role changes are becoming more and more common as financial need trumps conforming to societal gender norms.  When parents are able to move past traditional parental roles to better address family issues, they can provide a healthier environment for their children.

 

The Bings – Adoptive Heterosexual Families

            Monica and Chandler Bing, two of the six main characters on the popular TV show Friends are a great example of the adoptive heterosexual family.  In the show, Chandler and Monica were trying to have a baby through natural conception but were unsuccessful.  After taking fertility tests and finding out there were some health issues complicating the situation, they decided adoption would be their best choice.  In the end, the Bings ended up with twins from an adoptive mother who chose them as the new parents for her children.  Though the twins are not biologically theirs, the adoptive family can take on a similar form to that of the traditional family.  Like Monica and Chandler, there are a number of parents who opt for adoption because they could not have children of their own.  The U.S. Census Bureau (2014) estimated the number of adopted children in the United States was about two million, or roughly two percent of all children in the country.  This accounts for both domestic and international adoptions by various parental configurations, including single parents, heterosexual parents, and parents who are LGBTQ, though married heterosexual parents are the most common type of adopting group.  The Bings' family arrangement most resembles the ideal nuclear family and may not appear any different in the social environment unless the adoption is interracial.  Even then, these families are a wonderful option if a couple cannot have children of their own.

Family lying on their stomachs in the grass in a line smiling for the photo with their eyes closed.
Blended families can consist of parents bringing children from a previous relationship to the family as well as having children of their own.

 

 

 

The Bradys – Blended Families

The Bradys, from 1970s sitcom The Brady Bunch, were the perfect example of a blended family, or a family in which one or both of the parents bring children from a previous marriage or relationship to help create the new family.  The premise of this show was that Mike and Carol met, got married, and each brought their three children to live together in one household.  In the beginning of the show, it focused on issues the individuals had in adjusting to their new family situation, which can be typical of blended families.  While the storyline framed Mike as a widower, Carol's marital background was never discussed.  She may well have been divorced but fear of public disapproval could have caused the producers from specifically mentioning divorce.

Nowadays, it is not unlikely for children to have stepmoms and stepdads living at home with them, sometimes with children from a previous parenting partnership living with them as well, much like the Bradys.  There are an estimated 3.8 million children living in a household with a biological parent who is married to a stepparent (U.S. Census Bureau, 2014).  Although this marital union can happen as the result of the death of one parent, the majority of these children’s biological parents divorced, or broke up and one or both remarried. This statistic, however, does not include those children who were adopted by stepparents, indicating the number of blended families may be larger than it was initially thought to be.  Still, blended families are not viewed as the ideal situation, especially if the parents had been through a divorce or the children being brought to the relationship were born out of wedlock.

 

The Winslows – Extended Families

            The 1990s sitcom Family Matters centered on the life of the Winslow family which included husband Carl, his wife Harriette, his children Judy, Laura, and Eddie, Carl’s mother Estelle, Harriette’s sister Rachel, and Rachel’s son Richie.  There were a number of family dynamics at play with the eight of them living under one roof, but they were indeed all one family.  They all contributed to the financial, emotional, and social needs of the household in some form.  A great example of an extended family, Carl’s family combines immediate family member roles, such as parent, child, sibling, with other roles that are not found in nuclear families, such as grandmother, aunt, and cousin.  Although this family structure is not uncommon in the United States, it is not representative of the individualistic viewpoint prevalent in American society today, one in which children feel the need to move out of their parents houses as a demonstration of independence.

Extended families often fill a need for the members who are a part of them.  In Family Matters, Rachel and her son move in with her sisters’ family because Rachel’s husband and Richie’s father passed away.  Estelle also lives in the house because her children had moved out of her house and her husband had passed away.  Instead of living alone, Estelle, Carl, and Harriette may have all decided that the best option was for Estelle to move into Carl and Harriette’s house.  It should be stated that there does not have to be a family trauma or financial instability reason for extended family members to live together.  Sometimes it can be just a matter of preference and comfort rather than dire straits.

 

The Parkers – Single-Parent Families

            Nikki Parker and her daughter Kim are a single-parent family from the show The Parkers who attend college together.  The backstory of the family had Nikki as a teenager when she had her daughter and decided to drop out of high school in order to take care of Kim. Although Nikki later married Kim’s father, they eventually divorced and Nikki had custody and was the custodial parent for the majority of Kim’s life.  The single-parent household, like the one in The Parkers, is not an unusual one.  In 2013, there were about 1.6 million births to unmarried women, which actually represented a slight drop in percentage as compared to 2012 (Martin, Hamilton, Osterman, Curtin, & Mathews, 2015).  While this statistic may not take into consideration the number of children given up for adoption by single mothers, it also does not account for the single-parent families in the U.S. who have custody of their children as the result of divorce or death either.

This statistic does give us a general idea of how commonplace the number of single-parent households is in the United States.  Unfortunately, this form of family is definitely not seen as ideal in society, with never-wed single mothers often being seen as one of the main contributors to the downfall of the traditional family.  Without having a consistent, committed father-figure in the child’s life, many believe the child will struggle more, face more adversity, and will not have the best upbringing.  Of course, when a single father is raising children, the situation takes on a different twist and many feel sympathy for the father for being forced into such a situation.  Single fathers are too often viewed as needing help raising children because they are seen as less capable of raising children on their own than mothers are.

 

The Disick-Kardashians – The Cohabiting Family

            Unlike the other families portrayed in this chapter, Kourtney Kardashian and her ex-boyfriend, and father of her children, Scott Disick are real people from the reality TV show Keeping Up with the Kardashians.  Scott and Kourtney have three children but never married and had made no plans to walk down the aisle together.  They were, however, committed to each other and lived together with their children in a house in California.  The family framework they had is very similar to that of a traditional family, minus the married parents, but is just not as socially accepted as the ideal nuclear family.  For those who believe that the traditional family is the cornerstone of American society, this family makeup is considered a direct threat to the stability of the U.S.  Deciding not to get married but purposefully having children is considered by many to be taking the role of parenting too lightly, thinking that it is more important to be sure of marriage than it is to be sure of bringing a child into the world.

            One of the problems with this line of thinking is that is assumes the couple who is not married is not committed to one another, which is not necessarily true.  From 1997 to 2017, the percent of unmarried, cohabiting parents rose by 15%, making up more than a third (35%) of unmarried parents living with a child (Livingston, 2018). Today, more couples are postponing the formal wedding ceremony despite being committed.  Oftentimes it is a financial concern with not being able to afford the wedding they want.  Yet if they wait until they can afford the wedding, they may be older than they want to be when raising children.  For gay couples, it can come down to a matter of not being able to legally get married but wanting to establish a family with children.  Still some couples do not see a need to formally or legally recognize their love and commitment to each other and choose to never marry.

A gay couple walking during a pride parade with their young daughter in a stroller.
Gay and lesbian couples wanting to have kids is a relatively new family structures in American society.  This type of family is seen by some as a threat to American families, to the point that it can be politically polarizing.  "parents" by nerdcoregirl is licensed under CC BY-SA 2.0.

 

Pritchett-Tuckers – The Gay Parent Family

            One of the nuclear families in the show Modern Family features a gay couple, Mitchell Pritchett and Cameron Tucker, and their adopted child, Lily Tucker-Pritchett.  In the show, Mitchell and Cameron adopt Lily together after they had already been established as a couple but before they married in a later season of the show.  Both gay men and lesbian couples can have a child that is biologically related to one of the two of them, though it may be easier and require less paperwork for the lesbian couple.  However, if both partners want to have parental rights, they must go through the adoption process, something which not all states allow for gay couples or individuals.  In fact, 35 states plus Washington D.C. allow LGBT parents to petition for joint adoption, while the other 15 either have legal restrictions against it or do not have specific legislation for or against it (Family Equality Council, 2015).

Currently, this family unit may be considered the biggest threat to the traditional family in American society because of the nontraditional marriage or committed union the parents have.  Complaints about gay couples as parents range from not being able to provide a strong role models of both genders, to the children being disproportionately targeted for bullying, causing undue mental distress, to the parents turning their children gay.  However, none of these beliefs have any factual basis, with numerous studies providing evidence that they are inaccurate (Cullen, 2001).  What is true, however, is that children of gay and lesbian parents usually grow up in a much more understanding and accepting environment in terms of differences between people.

 

Immigrant Families

            Immigrant families are not necessarily different in structure than the families we have discussed so far, but should be highlighted as a unique family representation.  Sometimes nuclear families come to the United States as a means of finding better opportunities for education, economic stability, or healthcare.  Yu, Lin, and Adirim (2013) categorize U.S. immigrant families into three groups – those in which the parents and the children were born in another country, the ones that have foreign-born parents but native born children, and the families that have one foreign-born parent while the other parent and the children are native born.  In addition, extended family members may be living in the same household as the nuclear family unit and should be considered one whole family group.

The form these families have here in America may not have been the form they had in their homeland nor the form the families will have in the future.  Sometimes, the family will be living as an extended family in one household in order to help some of the members get established in the community.  Other times, immigrant families may be leaving extended family households in their country of origin and establishing a nuclear family here in the States.  Still some immigrant families that take on a single-parent makeup may well be a part of a nuclear family that could not all come at once.  One parent may have brought the children first to establish a residence, find a job, and get the children in school while waiting for the other parent or other family members.  In any form, immigrant families should be identified as possibly needing additional services in order to deal with the adjustment to life in the U.S., conflicting cultural values and norms, and navigating the community and American institutions.  While many immigrants rely on ethnic communities and resources in certain areas to aid them in the transition, these communities may not be available everywhere.  Social workers need to identify the gap in services in order to better serve these families.

 

Family Systems Theory

            An integral part to understanding families, assessing need, and identifying appropriate intervention strategies is the application of systems theory to the family as a whole.  As was previously discussed, systems theory is a basic approach used in social work when working with clients to get a better understanding of how they interact with different systems and the impact those systems and the interactions have on our clients.  However, another significant part of systems theory is that all systems are made up of smaller systems, thus individual clients are considered to be made up of different body systems that have their own processes for healthy functioning as a human being.  Using the family systems theory to view families as client systems, not only can one identify and assess the various systems with which they interact, but also view the family as more than just a collection of individuals.  Instead the individual systems can be thought of in terms of how their interactions and “processes” help the family function in a healthy and effective manner.  Lambie (2008) discussed three guiding principles of the family system that allow us to better understand them:

  1. No individual can be understood without looking at how [they fit] into the whole of the family – Again it is not about the individual but about how the individual interacts with the other people – parts of the system – within the family.  Family members do not live in bubbles and their circumstances, behavior, and cognitions are influenced by the other systems with which they come in contact.  Moving up to the family as a whole, the same holds true at this system level.  Families are not solitary systems and need to be understood in the context of the systems with which they interrelate.
  2. Families need rules for structure and rules for change – All families have an innate structure that guides their day-to-day functioning.  This structure lets the different family members know how they should behave and guides the interactions of the group.  Rules for change, on the other hand, direct members in times when the family’s homeostasis or current way of functioning is disrupted and requires the family members to adjust until equilibrium is returned or until a new structure is established.
  3. Interaction of the family with the school, community, extended family, and friendship circle is essential to the life of the immediate family – In our society today, families cannot get all their needs met by themselves.  It is essential that the family and its members interact with other systems in order to provide for a healthy nurturing environment for everyone.  Other than the systems the principle mentioned, families connect with habitat, work, religious or spiritual, healthcare, protective (law enforcement), and entertainment systems to name a few.  All systems with which the family and its members interact serve some function to the quality of life of the family. (pp. 10-11)

When working with families through the lens of systems theory, we can assess each of these three areas to have a better understanding of what issues are present and where the need is.  No matter their level of functioning, these three aspects hold true for all families.  Some families address them in a very positive and healthy way while others are quite the opposite.  Where families’ needs are not being met can influence how the principles of families as systems manifest.  When a family lacks housing and food, we can better understand how a child from this family has a flat affect, is not interacting with other children in school, and does not focus in class.  Families with a member who is experiencing alcoholism have a structure to them that may require other members to compensate in areas of work, child care, or providing for basic needs like food.  While this structure may guide the family’s day-to-day life, it is not a healthy environment for all members, because it does not provide a safe environment that fosters positive development.  Since social workers need to know how the family system works and why it works that way, family systems theory gives a great outline on how to determine the answers to these questions.

 

Box 11.2: Interacting with Other Systems

Families impact and are impacted by many different systems.  In our work with family systems and their individual member systems, we will gain an understanding of the many outside systems that impact our client family.  As you read this list, come up with ways each system can have a positive and negative impact on the functioning of the family system.

  • Parents’/guardians’ place of employment
  • Children’s school
  • Parent’s/guardian’s school
  • Extended family living outside of the household
  • Church
  • Law Enforcement
  • Neighborhood or community of residence
  • Social welfare system
  • Group of friends
  • Racial/Ethnic group involvement

What other groups can you think of?

 

Levels of Family Need

            Families are not static systems.  They are growing throughout their lifecycles and the family structure undergoes a number of changes.  Children mature, family members pass on, individuals change or lose jobs, parenting teams encounter problems and may end the partnership, and members can even go through a traumatic event.  Work with families is not necessarily a one-time event or short-term process.  Depending on what the family is experiencing within its system or as a result of the systems with which it interacts, the level of needs they come in for can change.

Kilpatrick (1999) focused on four levels of family need, based on Maslow’s hierarchy of needs, which range from basic survival and persistence needs to existential, self-actualizing needs.  It would be easy to think the role we play in the work we do with family client systems will dictate what level of need we are helping families meet.  For instance, it might be assumed that social workers doing case management are going to be much more likely to address those lower level, basic needs while the higher level of needs are going to be met by private practice therapists.  However, all social workers, no matter what their position is or level of service they provide, have the potential to deal with any family need at any time.  While certain demographics, such as family structure, race or ethnicity, socioeconomic status, and age may make certain groups statistically more likely to encounter a specific level of need, we need to understand that any of these needs can be present in any family at any time, regardless of who they are, where they come from, or what they do.  By assessing for family level of need, practitioners gain a better understanding of how the issue(s) can be addressed and what type of intervention approach should be taken to alleviate family constraints.

Couple in their bedroom sitting and looking away from each other, looking sullen.
Understanding the different levels of family needs will help us direct how we provide services to the families.  Sometimes the services we provided to one family will address needs on different levels. "argument." by smile_kerry is licensed under CC BY-NC 2.0.

 

 

 

 

Level I Needs

This level addresses those basic resources we need for survival.  For families, examples of these needs would be shelter, food, clothing, basic medical care, and family connection.  Many of the families that come into contact with social service agencies at this level do not have the financial stability to afford things like rent, groceries, or regular doctor visits.  Not necessarily dependent on financial stability, but often correlated to it, some families lack a personal and loving connection between members and thus no connection to the family as a whole.  Both of these dynamics cause families to fail at their intended purpose of providing a protective nurturing environment for all members.  Social work practice to address this level is about helping families establish a basic foundation off which to build.  Without this families are going to be more destructive to the individual systems that make up there whole.

Case management services are the prevailing mode of practice for both level I and level II needs.  Practitioners will often identify resources within the community that will help them with income to pay bills, job services to find gainful employment, and welfare programs for food or healthcare.  Some of the community resources are less formal, such as friends, extended family members, and ethnic, social, or church groups.  While community resources address physical needs, informal resources can provide the support network to help with emotional needs for family members (Harper-Dorton & Herbert, 1999).  Families dealing with lack of cohesion benefit from skill-building for parents in caring for their children or partnering with each other to become leaders in the household.  Social workers can provide some basic instructional opportunities for parenting skills or other relevant life skills; however, community agencies can provide small group workshops and trainings for basic parenting skills.

When working with families at any level, though especially at this level, social workers need to utilize their strengths-based perspective in helping families identify what strengths they already possess, both as individual members and as a family system, and using that to build their capacity to operate effectually.  Not only is this approach important to empowering clients, in family services it allows members to have a greater sense of connection to the whole and a desire to work for improvement.  The work at this level is focused on creating a strong baseline of family functioning on which to build at a later point with higher level needs.

 

Level II Needs

Here we are more concerned with establishing a positive structure, including setting limits and maintaining authority in the system.  Thinking in terms of family systems theory, all family members have a specific role they play within the family structure itself.  At this level, we are concerned with members taking on the proper role, especially parents, and allowing others to do the same.  These roles guide the interactions between the individual systems and give members the opportunity to contribute to the positive functionality of the family system.  The roles of parents are to be the authority figure in the family.  They set the rules and limitations, they care for the children, and they provide safety and protection for the family.  Children also have a role to play, but it is one of development and allowing the parents to have the authority.  When family members are not fulfilling their role properly, the family is left imbalanced, like when one of the parents is experiencing alcoholism.  Often in this situation, someone else will take on these parenting responsibilities, such as the other parent, one of the children themselves, or an extended family member, in order to keep the family functioning even at a minimal level.  If no one takes on this role, the family will eventually be thrown into a state of chaos which can have devastating and lasting effects on the system.  It is also detrimental to the individuals, especially in cases when children have to take on a parenting role.  The authoritative role is never something children should have to take on as it forces them to grow up quicker than they should and can have long-term effects on their mental health.  It is clear in situations like these the family system is not working as it should.

The work done with families at level II is focused on helping parents gain leadership and authority in the family.  Skill-building opportunities work at this level as well, especially when it comes to assertiveness, communication, discipline, and confidence for parents.  Children can also benefit from skill-building at this level, especially communication and behavioral.  However, as the level of needs increases, the social workers tend to turn more to therapeutic roles in working with family members individually, as a dyad, or as a family system, all trying to help address the needs of the family.  In therapy, at this level, families can work on addressing issues and their underlying causes.  Helping parents analyze the current environment and recognizing what needs to be implemented in the family system in order to help it run more effectively.  Sessions can also look at any events in the family history that have had an effect on the system and help the family members process the past so they can move forward and change the present state of functioning.  The therapy done with families in this arena is going to be directed at helping the family meet its needs, even in individual work, by viewing individuals as parts of the family system.  Social workers need to help the family avoid prescribing one member’s behavior as the “problem” and work to find a family-based solution (Dubois & Miley, 2011).

 

Level III Needs

  Unlike the previous two levels, families with this level of need appear to be working just fine from the outside.  Basic needs are being met and a hierarchy of parent-child roles is established, however, the family identity is more rooted in cultural, ethnic, and familial ancestry than to the individual family members. If level II needs are about being a group, level III needs are about family members differentiating from the family identity and being recognized as individuals.  Families need to allow individual members their own boundaries, providing them with their own private space.  Of course at first glance this can be seen as very ethnocentric, especially because the United States is a very individualistic society.  However, it is not that culture and the importance of family need to be ignored or negated just to make room for individuality.  Oftentimes, acknowledging individual members helps them feel more connected to the family and better understand how and why they contribute to the family.  Family members are more than just parts of a whole; they themselves are complete systems that need to be nurtured.

As with the last stage, social work strategies at this level are going to be more therapeutic than anything else.  Families can benefit from a number of different therapeutic interventions that can help them better understand the dynamics and communication patterns between individual family members.  Individuals can also benefit from the introspection that can accompany therapy in understanding their role in the family as well as their identity as a complete system themselves apart from the family unit.  Marital counseling can also help parents build their relationship as a couple and their identity separate from their children.  In working with families at this and the two previous levels, it can be helpful if meeting with the social worker can take place in the family's natural environment.  Observing a client system in its natural setting can highlight patterns or behaviors of which the family members might not be aware.

 

Level IV Needs

            The difference between level III and IV needs can seem blurred.  The best way of looking at it is through the metaphor Kilpatrick (2008) used when outlining these levels.  It was said that level III needs can be thought of as the building of walls to create rooms in a house and level IV needs are the furniture and decorations with which we fill those rooms.  Being able to recognize the parts of the family as distinct systems is just the start.  Level IV needs are related to the individual family members being able to establish their own identity that includes but is not limited to their role as a family member.  Work at this level is focused on helping individuals and the family have a high quality of and satisfaction in life.  The strategies used at this level are working on helping family members build deeper connections to each other and with themselves.  The family itself seems to be functioning well, but the members are looking for something more profound.  They want more enjoyment from their life and their place in the family.  Social workers can again work with individual family members, subsets of family members, or the entire family.  This level of work usually involves dyad or individual sessions as a means of beginning the change process.

 

Policy Need

            Work with families does a lot to help them make changes in their current state of being in order to better fulfill their purpose.  One activity social workers take on when working with families is that of policy practice.  Through dealing with families in various social work agencies and programs, social workers can identify the societal needs of families and work to create or increase policies that support all the various forms of the family in the United States.  Predominant values in the U.S. that the traditional family should be promoted through policy over all others does a disservice to helping all non-traditional family structures provide the necessary environment for carrying out the roles and functions of a family (Furstenberg, 2004).  As helpers, we need to understand that each family is unique and may not benefit from the same solution another family would.  In the same sense, we understand that some family systems will better serve family members if they alter their structure in some way.  Our policy practice for families must be dedicated to working with them as unique systems, meeting them where they are instead of forcing them to conform to an ideological view of what a family should look like.

 

Box 11.3: Level of Need

As we move into discussing different family concerns, it is important to realize that some of these issues can impact needs of varying levels and may present in a family at the same time.  While some of the needs are pretty clear others we may not see until we build a relationship with the family and understand their situation better.  As a child welfare worker, we might be called in to investigate a child neglect claim in which a 10 year-old boy is left to take care of his six month-old sister after school by himself.  Clearly the role the boy is taking is more responsibility than he should have and parenting skills training may be appropriate.  In working with the family, however we realize they are also experiencing poverty and need to connect them with resources for help with food, housing, and child care.  What other needs might we help this family address?  What type of work can we do with them?  As you read about some of these family concerns, think about what levels of need these issues alone can cause.

 

Common Family Concerns

            Now that we have an understanding of the varying levels of family needs, we will take a quick look at some of the more common concerns that direct families to seek, be referred to, or be mandated to connect with social services for families.  These issues can also cause a lot of emotional distress at both the family and individual level.  Some of these concerns are internal, in terms of originating within the system, while others are outside the family’s locus of control.  Generalist social workers should know when they need to help families improve their own situation and when they need to help them adjust and work through those things that happen to them of which they have no control.

Family in front of a home that seems to be falling apart.
Poverty can cause a lot of different issues for families.  However, it may be hard to address some of the deeper issues when you don’t know where the next meal is coming from or where your family is going to sleep at night. "family" by simaje is licensed under CC BY 2.0.

 

 

 

Poverty and Families

            Although we often equate poverty more to single-parent families, the estimated 4 million single-mother families experiencing poverty is less than half the total number of almost 9 million families that live below the poverty level, with married-couple families counting around 3.25 million (U.S. Census Bureau, 2013b).  There are a number of reasons families end up in this socioeconomic level that have less to do with type of family and more to do with environmental factors, including job loss or lack of income, divorce or ending of a relationship, and unexpected financial obligation such as healthcare costs.  Events like these can cause undo hardships on families that may not have the resources to handle the change financially let alone emotionally.  Of course, families who are a part of any racial or ethnic minority group are much more likely to experience poverty than their white counterparts.  However, no matter who is dealing with it, poverty is one of the most crippling problems facing American families today.

There are a number of different issues created for families as a result of experiencing poverty.  The triggering event itself will affect all the family members on an emotional level, but emotional distress can be exacerbated for the parents with the realization that they cannot provide well enough for their family, especially their children.  Lack of adequate income can result in level I needs for families, including substandard housing options or homelessness.  Children specifically can suffer effects of poverty that are more developmental in nature.  Poor nutrition, lack of proper healthcare, and lower levels of educational readiness are not uncommon among children living in poverty (Newman & Grauerholz, 2002) and can interrupt or delay their physical, mental, and emotional growth.  Social work with families dealing with poverty absolutely must focus on connecting them with resources for physical needs, but should incorporate resources for emotional needs and situational adjustment.  One issue that may come up for the family is that of child neglect.  If it is determined that a family is not able to properly provide for any children in the family, social services may remove the child from the household until the family can improve their ability to care for the child.  This will be discussed further in the section on child welfare, suffice it to say social workers can still be involved in helping the parents regain full custody of their children if it is deemed appropriate.

 

Box 11.4 Child Welfare and IPV

In grad school, one of your authors had a group of practitioners from an agency that dealt with domestic violence present to the class and lead in a class discussion about domestic violence in a household with children.  The course was on child welfare and the agency workers were discussing how wrong it was for mothers who were being abused by their partner to have their children taken away because the mother would not leave the home.  The argument was that because those experiencing domestic violence can feel powerless to leave and get caught in the cycle of abuse, they are not at fault for what happens to their children.  Child welfare workers may want to remove the children because they feel the mother is choosing to stay with the abuser, despite the impact it has on her kids.  The presenters’ argument was that it is not a choice and that removing the child is further stigmatizing the woman.  They also argued that removing the child was taking away a protective factor for the mother, who could suffer more emotional distress because the children that she loved and cared for would not be there.  Think about the situation and answer the following questions:

  • Do you think children in this situation should be removed from the household?
  • Who is at fault for what happens to the children?
  • What responsibility do we have to the mother and the children in this situation?
  • What is our responsibility to the abuser in the situation, especially if he is the father?
  • What can we do to help families in this situation function better?

 

Intimate Partner Violence

            According to the 2010 National Intimate Partner and Sexual Violence Survey, one out of four women and one out of seven men have been the target of severe physical abuse by an intimate partner (Centers for Disease Control and Prevention, 2011).  This of course does not account for those who have experienced emotional and verbal abuse as well.  The Centers for Disease Control and Prevention (2011) defined intimate partner violence as:

Physical, sexual, or psychological harm by a current or former partner or spouse.  This type of violence can occur among heterosexual or same-sex couples and does not require sexual intimacy...IPV can vary in frequency and severity.  It occurs on a continuum, ranging from one hit that may or may not impact the victim to chronic, severe battering. (para. 1&4).

Box 11.5, the power and control wheel, is used by those doing domestic violence work and provides a good framework for understanding how domestic violence, or IPV, is manifested in its various forms.  While violence congers up an image of physical battery, IPV can present in various types of abuse tactics, including:

  1. Coercion and threats
  2. Intimidation
  3. Emotional abuse
  4. Isolation
  5. Minimizing, denying, and blaming
  6. Using children
  7. Economic abuse
  8. Male privilege

These tactics really do represent the physical and psychological forms IPV can take and one can imagine the type of toll these take on those who are experiencing domestic violence.

 

Box 11.5: Power and Control Wheel

The National Center on Domestic and Sexual Violence has this PDF that explains the various abuse tactics that perpetrators use against their targets.  This power and control wheel is used by social workers who work with survivors of IPV.

            One of the most disruptive and traumatic experiences a family can have is that of domestic violence.  Intimate partner violence is damaging in any relationship, but when it is done in families, more than just one’s partner is hurt.  Wortham (2014) discussed surveys that showed children were witnesses, whether by seeing or hearing the abuse, in at least 50 percent of reported violent events.  It is pretty obvious that this, like any of the other family issues discussed here, can have significant emotional effects on survivors of IPV and can affect their ability to be a parent.  Children who witness the abuse can also be traumatized emotionally, with boys more likely to display hostility and girls more likely to worry (Blair, McFarlane, Nava, Gilroy, and & Maddox, 2015).  In addition, studies indicate these children are being socialized to accept violence as a way to resolve conflict, see it as a normal part of a romantic relationship, and fulfill gender roles of men being aggressive and woman being submissive (Blair et al., 2015).  When social work is helping families that are confronting IPV, strategies to keep family members safe are first and foremost.  We want to connect them with the appropriate resources, such as safe houses, shelters, and social services, advocate with the police, and help them utilize their support network.  However, in order to help them overcome it and quell any long term effects, interventions that build resilience and strength are important (Wortham, 2014).

Of course, if we are working with the whole family, we also want to provide services for batterers, though these services are aimed at protecting the family by working with the batterer to process and change abusive behaviors.  Although batterer intervention programs are increasing in number and can decrease re-assault rates, studies have shown there is a lot of room to grow these programs (Scott, King, McGinn, & Hosseini, 2011).  Still, batterers are a part of the family and in working to improve the family situation, this is an area that needs to be addressed as well, even if it is decided that leaving the batterer was the best option for the family.

Mother consoling her young daughter who is crying.
Divorce can be hard for a family, especially the children.  But it may be the healthiest option for the family as a unit in the long run, depending on how the parents handle their relationship after the divorce.

 

 

 

Marital Discord and Divorce

            It is not uncommon at all for married couples to deal with marital distress at some point in the relationship.  Financial disagreements, poor communication, emotional disconnection, and even infidelity are just a few of the reasons married couples do not get along.  When there are problems in the marriage, it is recognized that there are going to be problems in the family system as well.  Recalling what was discussed about family systems, we must consider that a conflict between two parts of the system is going to disturb the homeostasis of the whole system and impact the other parts as well.  Even if the parents do not get divorced, other individual family members can experience stress that can be disruptive to their individual system, resulting in an upset family system.  If the conflict is not addressed, either by the family themselves or by seeking help, increased stress and negative interactions with other systems can occur.  One of the ways in which families resolve conflict is through divorce.  While couples counseling is often an attempt to avoid the ending of a relationship, getting a divorce, or breaking up may be a valid, effective option.

In 2020, the average age for men and women to get married the first time is 30 and 28 respectively (U.S. Census Bureau, 2020).  What should be pointed out about the statistic is not that the age for both genders has been increasing but that there is even a need for the stat to specify “first time”.  In the United States, it is said that half of all marriages end in divorce.  When it comes to social work with families, we might want to view divorce as the result of a failing effort to make things work, but the truth is divorce can actually help prevent a lot of negative, more harmful issues from rising up.  Although children experiencing divorce in their family are more likely to have behavioral and emotional issues present in a number of the systems with which they interact (Parke, 2013), this does not mean divorce is always going to make things worse.  The fact is some children’s negative behavioral concerns begin before a divorce and can improve after a divorce (Li, 2010).  Conversely, children whose parents are in a distressed union but never get divorced are more likely to deal with social-emotional distraction (Rutter, 2010).  The idea, of course, is that divorce may be the solution to the conflict between the parents and that tension and animosity can end when the romantic relationship ends.  Thus children whose parents get along after a divorce will eventually be better off than those children whose parents continue to clash even afterwards.  When our interventions with families dealing with divorce help promote a positive relationship between both parents and between parents and the children it helps to build their resiliency to deal with the breakup of their parents on an emotional level (Kelly & Emery, 2003).

 

Child Welfare

            Since families are the key socializing agent for children, one of their most important functions is to provide a safe and physically and mentally nurturing environment for children to learn to become and grow into adults.  As we have seen, there are a number of different structures for families.  Similarly, there are many different beliefs about how families can best raise children.  That being said, child-rearing is influenced by several factors, including but not limited to ethnicity, socioeconomic status, religious orientation, family makeup, and even personality types of parents and child.  There is no universally accepted way in which all children should be raised and often families also have to deal with outside influences affecting the child that they have no control over.  For the most part, parents are allowed to raise their children in the way they best see fit.  This can become an issue when parents have level I and possibly level II needs.  When they are not able to parent their children, providing them with the necessary affection, nutrition, or safety with which to grow physically or emotionally, change needs to happen in order for the children and the family to function more effectively.  The Federal government first created the Child Abuse Prevention and Treatment Act, or CAPTA, in 1974 based on the idea of parens patriae, which roughly translates into parent of the country and refers to the legal responsibility of the government to protect all children when parents fail to look out for their best interests (U.S. Department of Health and Human Services, 2011).  When it comes to physical and emotional treatment of a child, parents are held to legal definitions of harm and neglect; thus parental choice in caring for a child is overruled.  When children are maltreated, specifically by parents, guardians, or caretakers, those who are supposed to be watching out for them are not, so the government is the last line of defense.

Origami cranes on a line with a billboard in the background that says "Stop Child Abuse."
Families are supposed to provide a safe, nurturing environment for their children.  When parents can’t, don’t, or won’t, the government intervenes.  Child welfare workers are called in to assess the situation and provide recommendations and services to help the family function better. "A Crane for Each Child; Students Seek End to Child Abuse" by CT Senate Democrats is licensed under CC BY-NC-ND 2.0.

 

 

Child welfare is generally regarded as an issue in which the immediate protection of a child takes precedence over the needs of the family.  However, in protecting the child we are not saying that family needs are not a concern, especially if you remember to apply family systems theory to the situation.  When children are maltreated, there are at least two individual systems being disrupted: one is a parental system that is not doing what it should and the other is the child system that is not receiving what it should.  Since the family is made up of individual parts, the disturbance in even one part throws off the equilibrium of the whole family.  By being able to meet the needs of the child we will also meet the needs of the family.  Depending on the situation, this can take a long time and a lot of work, require the participation of any number of family members and community resources, and may change the structure of the family in the end.  Yet it will improve the ability of the family to provide the necessary setting and surrounding for growth into adulthood.

 

Box 11.6: Know Your Limits

All students earning a Bachelor of Social Work or similar degree will go through an internship during the final year of their coursework.  In his training, one of your authors worked for a state child welfare agency dealing with child abuse and neglect.  As a part of his job, he would collect information from callers reporting the abuse and neglect; shadow workers investigating these calls; interview teachers, parents, and children - while being supervised, sit in on family mediations and parental rights trials, and provide supervision for parent visits.  The first week of his internship, he observed a trial against parents who were accused of abusing their six month old son, causing him multiple bruises on his buttocks and legs as well as a spiral fracture of the femur.  Pictures of these were presented during the trial, along with testimony from the child welfare worker who investigated the case.  Your author was okay with the experience and had no problem going to his internship every day.  But when his classmates heard his stories, many of them cringed and said they would not be able to do it.  Everyone has their boundaries and we should all understand what ours are.  Your other author was a therapist at a residential facility for adolescent male sexual offenders, a job which his brother could not to do.  Would you be able to work in child welfare?  Think about how you would cope with the following situations:

  • Seeing deep, dark bruises on a baby’s butt
  • Hearing the accusations of the physical harm a parent has caused a child
  • Visiting a house with so much trash throughout  you couldn’t step on the floor
  • Listening to the details of acts of sexual abuse
  • Seeing the fear in the face of child when talking about his parents
  • Going to a house with a police escort because the accused parent has a registered gun

 

Child Abuse & Neglect

Aside from the physical injuries or problems that result from child abuse and neglect, children can also have long-lasting emotional and mental injuries that impact their growth into and lives as adults.  It is paramount that children are protected from being treated poorly by parents, guardians, or caretakers through prevention and intervention services.  With the creation of the original CAPTA, the United States government was able to establish guidelines in order to identify when parents are failing to do their job providing for the well-being of their children and when the state needs to take action.  The most recent reauthorization of CAPTA describes child abuse and neglect as:

Any recent act or failure to act on the part of a parent or caretaker which results in death, serious physical or emotional harm, sexual abuse or exploitation; or an act or failure to act which presents an imminent risk of serious harm. (as cited in Definitions of Child Abuse and Neglect, 2019, p. 1).

It is the responsibility of the individual states to provide for a child welfare system that interprets and enforces CAPTA.  Box 11.7 lists some of the general types of child abuse and neglect states consider child maltreatment.  State governments thusly have a department that oversees the receipt, investigation, and validation of all abuse and neglect claims.  Each state has a hotline professionals and community members can call to report suspected acuse or neglect.  Many professionals who have contact with children and adolescents, such as educators, child care workers, social workers, and medical staff, are mandated reporters.  These professionals are required by law to report any suspected child abuse and neglect to the proper authorities.  However, community members can also file reports of maltreatment if they believe a child is not safe or being harmed.  If the report fits the state’s requirements for abuse and neglect, it will be investigated.  The investigation will look for and gather any evidence of the abuse or neglect to make a determination if the claim is supported.  This can include interviewing children, parents, or witnesses and collecting data through medical reports, home inspections, or observation of the child.  Supported claims are then moved forward with the appropriate action being taken, whether it is arresting the abuser or removing the child from the home.

 

Box 11.7: Common Types of Abuse and Neglect Considered Maltreatment by States

Type of Abuse/Neglect

Description

Physical abuse

Nonaccidental physical injury (ranging from minor bruises to severe fractures or death) as a result of punching, beating, kicking, biting, shaking, throwing, stabbing, choking, hitting (with a hand, stick, strap, or other object), burning, or otherwise harming a child, that is inflicted by a parent, caregiver, or other person who has responsibility for the child.

Emotional/Psychological abuse

A pattern of behavior that impairs a child’s emotional development or sense of self-worth.  This may include constant criticism, threats, or rejection, as well as withholding love, support, or guidance.

Sexual abuse

Activities by a parent or caregiver such as fondling a child’s genitals, penetration, incest, rape, sodomy, indecent exposure, and exploitation through prostitution or the production of pornographic materials.

Physical neglect

Failure to provide necessary food or shelter, or lack of appropriate supervision.

Medical neglect

Failure to provide necessary medical or mental health treatment, excluding for religious reasons.

Educational neglect

Failure to educate a child or attend to special education needs.

Emotional neglect

Inattention to child’s emotional needs, failure to provide psychological care, or permitting the child to use alcohol or other drugs.

Abandonment

Leaving a child alone in circumstances where the child suffers serious harm or the parent has failed to maintain contact with the child or provide reasonable support for a specified period of time.

(Source: Adapted from Child Welfare Information Gateway, 2019.)

The Child Welfare Gateway (2013), a service under the umbrella of the U.S. Department of Health and Human Services, breaks down substantiated child and abuse claims into three levels of risk:

  1. No or low risk – when the child is not in danger, if the incident was a one-time occurence, and if the abuse or neglect is unlikely to happen again in the future.
  2. Low to moderate risk – it is clear that services will improve the safety of the child in the present and future.
  3. Moderate to high risk – families that need to be referred to juvenile dependency court for interventions including possibly removing the child from the home because of the high risk or immediate threat of harm.

             The risk level drives the type of services provided to the families, parents, and children involved in the case.  Help given to families that includes wraparound services in which families are connected with a number of different resources in the community and school, in-home services provided by child welfare or other community-based agencies, counseling, or child placement out of the family home.  All these sevices are designed to address family needs and eliminate future harm to the child.  Again, immediate danger may require us to take care of the child in the short-term, but the long-term aim of child welfare workers is to build up the family to be a functional entity for all the members, including the children.  This is the foundation for family-centered practice (FCP), which includes family preservation services - which is the idea that families of origin should be kept intact and are the best places for children to become socialized and mature.  This perspective is designed to build on the assets of families to increase their capacity, strengthen connection to the family and each other, ensure positive outcomes for children, and empower families to be self-determined (Child Welfare Information Gateway, n.d.; Madsen, 2009; National Association of Social Workers, 2015).

 

Child Placement

            Family preservation services are aimed at preventing children from being removed from the household by providing in-home services and support to the parents and family, with the overall understanding that removal of a child from a family can be devastating to the individual system and the overall family system (Mullins, Cheung, & Lietz, 2012).  Despite the best efforts of these services, removal of a child may still be necessary.  Family-centered practice has not necessarily failed at this point and can still be implemented in the placement of a child.  In incorporating FCP, best placement options are with an aunt and uncle, a grandparent, an older sibling who lives outside the family household, or any number of other extended family members that would be able to take care of the child.  Hopefully this foster care placement is only temporary while families receive help from social service agencies in improving their parenting skills, establishing a long-term adequate residence, or helping parents resolve their own personal issues.  Foster care is designed as a temporary placement for a child until the family is ready to regain custody or a permanent placement for the child is found outside the house.  In extreme cases of child abuse or neglect, like when the case is referred to law enforcement for criminal prosecution, parents may have their parental rights terminated and the child is permanently removed from the family household.  Whether permanent or temporary, out of home placements can vary depending on aavailable personal and public resources.  What follows is a list of placement options, from most to least desirable in terms of FCP:

  1. Non-custodial parent – if a child’s biological/adoptive parents are no longer together, the non-custodial parent should be the first option explored.
  2. Kinship care – placing the child with a family member outside of the household, this can include adult siblings who no longer live at home.
  3. Foster care – the child goes to a foster home with parents who are not necessarily connected to the family of origin.
  4. Specialized foster care – children with specialized behavioral, emotional, or medical needs are placed with foster parents who have been specially trained to meet with the needs of the children in their care.
  5. Group home – a home environment in which several non-related children are living together with foster parents or professional staff.
  6. Private child welfare institution – this large residential facility is run by an agency with trained staff.
  7. Shelter – a temporary placement for children needing to be removed from a home when no immediate placements with a family were available.  Depending on the state, these shelters can be homeless shelters, abuse survivor shelters, or temporary shelters for juvenile justice wards.
  8. Residential treatment facility – similar to specialize foster care, children who need specialized behavioral or emotional treatment may be placed in a residential facility if their needs require highly specialized training.
Photo of parents and their children in the background watching the sunset over a field with a large leafless tree to the right.
Adoption is a great option for a those who can’t or don’t want to have biological children.  It not only allows people the opportunity to become parents and love a child, it also allows children who don’t have parents to be loved and be a part of a family.

 

 

 

Adoption

            Adoption is a desired option for children permanently removed from their parents, those who have lost their parents, and those given up by the birth mother and father.  There are many agencies that provide adoption services both for parents who are looking to adopt and for foster parents wanting to adopt the children in their care.  All parents wanting to adopt, as well as wanting to be foster parents, have to go through an evaluation of their home environment and their character as a means of ensuring their ability to be good parents.  Excluding step-parent adoptions, private domestic adoptions make up about 38 percent of all adoptions by U.S. citizens, adoptions of foster care children are about 37%, and international adoptions are at a quarter of all adoptions (U.S. Department of Health and Human Services, 2009).  Adoptions provide a legal bond between parents and non-biological children, but have a greater purpose of providing children who were abandoned, were abused or neglected, or lost their family with a system in which to learn, mature, and be cared for like all children need to be.

 

Adolescence and Young Adulthood

            Caring for teenagers can be a tough job for parents.  Beginning with middle school and moving into high school, children are making a transition from childhood into full grown adults.  This period of time can become extra stressful for parents because puberty and the big changes that happen in the human body can make their children feel awkward in their own skin.  This is also a time when youth start to develop their own identity apart from the family and move into greater personal responsibility as an independent adult.  Parents often feel as though they have less influence over their children, as they compete for attention with friends, significant others, school, and any extracurricular activities.  Yet the family system has tremendous influence on children at this stage in their lives.  Like we said earlier in the chapter, we cannot understand any single person – or system – without understanding the family system as well.  In the same sense, it is true that the other systems in a teen’s life are gaining more influence and can have a bigger impact than they did before.  In the United States, the family system influence may change and get smaller, as adolescents become adults and move out.  However, this does not mean the family system has no influence at all and can still make an impact at this transitional phase.

            In the same sense, the struggles or problems encountered by adolescents impact the family.  This is often manifested in the frustration parents of teenagers feel when they do not know what to do.  Social workers can help families address many issues related to what is going on in their children’s lives.  Working with the parents to help them gain the skills and understanding needed to more effectively interact with their child, providing individual case management or counseling services to the youth themselves, or practice at the family system level are all ways in which the social work field can help manage troubling issues experienced during the teen years.  What follows are brief discussions about some issues that can have a big, negative impact on the quality of life for a family as well as the adolescent.  Some of these issues themselves are a direct result of family troubles, indicating they should be addressed within the family system context.

 

Pregnancy

            Sexual activity among teenagers is not uncommon.  In 2013, one survey found that 46.8 percent of high school students had sex at least once in their life already(Centers for Disease Control and Prevention, 2013), despite abstinence-based sexual health education programming.  In 2013, the birthrate for this same group of 15-19-year-olds was 26.5 births for every 1,000 adolescent girls, though this was a 10 percent drop from the previous year (National Center for Health Statistics, 2015).  If you add in those that were pregnant, but did not carry to term, the statistic grows.  The number of those impacted by teen pregnancy is even greater, however.  Pregnant teen girls, the boys who are fathers to the children, and both of their families will have to adjust as a result of the pregnancy.  Although adolescent girls clearly have the potential to be affected to a much greater degree.  Patel and Sen (2012) cite research that teen moms may have a poor education, be underemployed, live in a lower socioeconomic status, and experience depression – though some of these may also be a contributing factor to the pregnancy itself.  Many teenage girls are not ready for the responsibility of a baby which can take an emotional, physical, and economic toll on them and their bodies.  Boys too are not necessarily ready to be fathers or supporting partners and have greater stressors as a result of teen parenting.  Families and their pregnant children can face changes in the structure of the family with the addition of a baby, economic constraints with the new grandparents having to help or being unable to pay for the needs of the mother and baby, and possible social reaction to a child that may be born out of wedlock.  If the baby is the result of sexual abuse by a parent or caretaker, the emotional impact increases exponentially for the teen as well as the family.

Young woman's hands holding a pregnancy test and the instructions for the test.
Teenage pregnancy doesn’t just affect the young girl who is pregnant, it also affects her partner, and both their families.  Family social workers need to use a family systems approach to effectively work with all those affected. "First Pregnancy Test" by super-structure is licensed under CC BY-NC-SA 2.0.

 

 

 

Substance Use

             Substance use and abuse in adolescence can be an indicator of any number of troubling factors in a youth’s life.  The National Institute on Drug Abuse (2003) stated that factors in five domains of a youth’s life-individual, family, peer, school, and community-can impact whether or not a youth uses.  However, the factors in each of these domains can be impacted by issues in the other domains, recalling that individuals cannot be understood without understanding the systems of which they are a part.  While reasons teens use drugs can include peer pressure and curiosity, a large number of adolescents turn to drug use as a way of coping with or escaping emotional pain they are dealing with at school because of peers or grades, or at home as the result of economic forces or abuse and neglect.  Whether a teen is using drugs because of social influences or in order to deal with something being experienced in one of the five domains, it can result in major disruptions in their educational attainment, their physical health, and their family and social interactions.  Social work done with families should address the underlying individual and familial factors of the substance use whether it is changing family functioning or changing individual behavior.  Practitioners should also help families build up protective factors, such as creating a strong parent-child relationship, parental monitoring of and involvement in a youth’s life, setting limits and boundaries, promoting interest in school and healthy extracurricular activities (National Institute on Drug Abuse, 2003).

 

Runaway Youth

            Running away from home is considered a status offense in many states, meaning it is illegal to run away from home if you are a minor.  However, this juvenile justice view of runaways does not speak to the hardships or dangerous situations these youth have to face at home which makes running away seem like the only option.  In fact, some youth – called throwaways – have it so bad at home that they are kicked out by a parent or other adult, rather than running away on their own, and are not provided with a safe alternative housing option.  Conflict with parents is often given as the biggest reason youth run away or are thrown away, though there are a number of other reasons as illustrated in Box 11.8.  Of the 1.3 million youth who leave their home each year, about 71 percent of them are considered endangered because of substance use and dependency, sexual activity, proximity to criminal activity, or because they are 13 years old or younger and considered extremely young (Office of Juvenile Justice and Delinquency Prevention, 2002).  Aside from the physical threats living on the street poses, many runaway, throwaway, and homeless youth are at greater risk for mental health concerns such as depression and suicidal ideation.  Social work practice with runaways/throwaways and their families can first address the immediate needs of the youth and family such as shelter, food, and safety, and then focus on the precursors that led to the youth leaving the house.

 

Box 11.8: Reasons Runaway/Throwaway Youth Give for Leaving Their Household

The National Runaway Safeline’s 2017 caller statistics related the reasons youth runaway or contemplate running away from home.  The top four reasons given were:

  1. Family dynamics – 33%
  2. Any type of abuse – 24%
  3. Social issues – 10%
  4. Mental health – 8%

You can read this complete report with all the reasons callers give, as well as a lot of other data on their callers and trends for runaway youth in the U.S.

(Source: National Runaway Safeline, 2020, Chart 18)

 

LGBTQ Issues

            While Chapter 8 went into depth about concerns and issues for LGBTQ clients, we should reiterate the impact being LGBTQ has on a youth and the youth’s family.  We have already seen that youth who identify as LGBTQ are at higher risk for depression, suicide, substance abuse, and self-injury behavior because of the lack of acceptance they find in themselves, friends, and family.  However, these youth are also more at risk of being homeless than their heterosexual and cisgender counterparts.  Too often  thess youth become either because they are runaways or throwaways trying to avoid a physically or emotionally abusive relationship with their family (Durso & Gates, 2012).  Since the family environment is such an important factor in having a positive life experience for any youth, the impact of acceptance of LGBTQ youth by family members can greatly reduce the likelihood of emotional distress for these youth.  Of course reactions of parents who learn their child is LGBTQ can vary from immediate and complete acceptance to hatred and disownment of the child.  Practitioners can help all family members, including any that identify as LGBTQ, work through any struggles they may be having with the situation and find solutions that will be protective, foster acceptance, and provide for positive quality of life for the LGBTQ youth.

 

Conclusion

            In the United States, families are seen as the foundation for a healthy society and the future to America’s continued success.  However, families in the U.S. are far from consistent in structure or the problems they face.  By treating families as unique systems, social workers need to meet them where they are in order to best help them provide a safe, nurturing, and supportive environment for all their members.  We understand they are not standalone entities that function independently in society and are therefore influenced both by the systems with which they interact and the systems from which they are built. Practitioners need to view families both as a whole system and as a collection of individual systems, understanding the strong influence they have on individual’s lives.  Identifying their level of need will help drive the type of intervention we use and the level of system: society, family, or individual. Child welfare is a big part of family work, and protecting children while improving family functioning as a positive atmosphere for child growth is an essential skill in the family-centered approach social workers often take.  By helping families address issues that impact individuals as well as the complete system, social workers are able to provide for the positive quality of life of America’s future.

 

References

Blair, F., McFarlane, J., Nava, A., Gilroy, H., & Maddoux, J. (2015). Child witness to domestic abuse: Baseline data analysis for a seven-year prospective study. Pediatric Nursing, 41(1), 23-29.

Centers for Disease Control and Prevention. (2011). National data on intimate partner violence, sexual violence, and stalking. Retrieved from http://www.cdc.gov/violenceprevention/pdf/nisvs-fact-sheet-2014.pdf.

Centers for Disease Control and Prevention (2013). Ever had sexual intercourse: High school youth risk behavior survey, 2013 [Table]. Retrieved from http://nccd.cdc.gov/youthonline/App/Results.aspx?TT=B&OUT=0&SID=HS&QID=H59&LID=LL&YID=2013&LID2=&YID2=&COL=S&ROW1=&ROW2=&HT=&LCT=LL&FS=S1&FR=R1&FG=G1&FSL=&FRL=&FGL=&PV=&TST=False&C1=&C2=&QP=G&DP=1&VA=CI&CS=Y&SYID=&EYID=&SC=DEFAULT&SO=ASC.

Child Welfare Information Gateway. (n.d.). Family-centered practice across the service continuum.  Retrieved from https://www.childwelfare.gov/topics/famcentered/service-continuum/.

Child Welfare Information Gateway. (2013). How the child welfare system works. Washington, DC: U.S. Department of Health and Human Services, Children’s Bureau.

Child Welfare Information Gateway. (March 2019). Defining child abuse and neglect. Washington, DC: U.S. Department of Health and Human Services, Children’s Bureau.  Retrieved on August 6, 2021, from https://www.childwelfare.gov/pubPDFs/define.pdf.

Cook, R. E., Brashier, E., & Hughes, J. L. (2011). Gender differences in the psychological impact of the dual-income lifestyle. Psi Chi Journal Of Undergraduate Research, 16(3), 129-133.

Cullen, M. E. (2001).  The adoptive rights of gays and lesbians. Unpublished manuscript.

Durso, L.E., & Gates, G. J. (2012). Serving our youth: Findings from a national survey of service providers working with lesbian, gay, bisexual, and transgendered youth who are homeless or at risk of becoming homeless. Retrieved from http://williamsinstitute.law.ucla.edu/wp-content/uploads/Durso-Gates-LGBT-Homeless-Youth-Survey-July-2012.pdf.

DuBois, B, & Miley, K. K., (2011). Social work: An empowering profession (7th ed.). Allyn & Bacon.

Family Equality Council. (2015). Joint Adoption Laws [Map]. Retrieved from http://www.familyequality.org/get_informed/equality_maps/joint_adoption_laws/.

Fischer, J., & Anderson, V. N. (2012). Gender role attitudes and characteristics of stay-at-home and employed fathers. Psychology of Men & Masculinity, 13(1), 16-31. doi:10.1037/a0024359

Furstenberg, F. F. (2004). Values, policy, and the family. In D. P. Moynihan, T. M. Smeeding, & L. Rainwater  (Eds.), The future of the family (pp. 267-275). Russell Sage Foundation.

Harper-Dorton, K. V., & Herbert, M. (1999). Working with children and their families (Revised ed.). Lyceum.

Kelly, J. B., & Emery, R. E. (2003).  Children’s adjustment following divorce: Risk and resilience perspectives. In A. J. Cherlin (Ed.), Public and private families: A reader (pp. 269-276). McGraw-Hill.

Kimmel, M. (2013). The gendered society (5th ed.). Oxford University Press.

Lambie, R. (2008). Family systems within educational & community contexts (3rd ed.). Love Publishing Company.

Li, J. A. (2010). Briefing paper: The impact of divorce on children’s behavior problems. In Risman, B. J. (Ed), Families as they really are (pp. 173-177). W. W. Norton & Company, Inc.

Livingston, G. (2018). The changing profile of unmarried parents. Pew Research Center. https://www.pewresearch.org/social-trends/wp-content/uploads/sites/3/2018/04/Unmarried-Parents-Full-Report-PDF.pdf

Madsen, W. C. (2009). Collaborative helping: A practice framework for family-centered services. Family Process, 48(1), 103-116. doi:10.1111/j.1545-5300.2009.01270.x

Martin, J. A., Hamilton, B. E., Osterman, M. J. K., Curtin, S. C., & Mathews, T. J. (2015). Births: Final data for 2013. National Vital Statistics Reports, 64(1). Retrieved from http://www.cdc.gov/nchs/data/nvsr/nvsr64/nvsr64_01.pdf.

Mullins, J. L., Cheung, J. R., & Lietz, C. A. (2012). Family preservation services: incorporating the voice of families into service implementation. Child & Family Social Work, 17(3), 265-274. doi:10.1111/j.1365-2206.2011.00777.x

National Association of Social Workers. (2015). Children and families. Retrieved from https://www.socialworkers.org/pressroom/features/issue/children.asp.

National Center for Health Statistics. (2015). Births: Final Data for 2013. National Vital Statistics Reports, 64(1). Retrieved from http://www.cdc.gov/nchs/data/nvsr/nvsr64/nvsr64_01.pdf.

National Institute on Drug Abuse. (2003). Preventing drug use among children and adolescents: A research-based guide for parents, educators, and community leaders [NIH Publication No. 04-4214(A)].  Bethesda, MD: U.S. Department of Health and Human Services. Retrieved from https://d14rmgtrwzf5a.cloudfront.net/sites/default/files/preventingdruguse_2_1.pdf.

National Runaway Safeline. (2020). National trends on youth in crisis in the United Stateshttps://cdn.1800runaway.org/wp-content/uploads/2020/11/NRS-2018-Trend-Report-FINAL.pdf.

Newman, D. M., & Grauerholz, L. (2002). Sociology of families. Pine Forge Press.

Office of Juvenile Justice Delinquency and Prevention. (2002). Runaway/throwaway children: National estimates and characteristics [Publication NCJ 196469]. U.S. Department of Justice. Retrieved from https://www.ncjrs.gov/pdffiles1/ojjdp/196469.pdf.

Parke, R. D. (2013). Future families. Wiley Blackwell.

Patel, P., & Sen, B. (2012). Teen motherhood and long-term health consequences. Maternal & Child Health Journal, 16(5), 1063-1071. doi:10.1007/s10995-011-0829-2

Republican National Committee. (2012). Renewing American values.  In We believe in America: Republican platform 2012. Retrieved from https://www.gop.com/platform/renewing-american-values/.

Rutter, V. E. (2010). The case for divorce. In B. J. Risman (Ed), Families as they really are (pp. 159-169). W. W. Norton & Company, Inc.

Scott, K., King, C., McGinn, H., & Hosseini, N. (2011). Effects of motivational enhancement on immediate outcomes of batterer intervention. Journal of Family Violence, 26(2), 139-149. doi:10.1007/s10896-010-9353-1

U.S. Census Bureau. (2013a). Family in Current Population Survey (CPS) – definitions. Retrieved from http://www.census.gov/cps/about/cpsdef.html.

U.S. Census Bureau. (2013b). Poverty status in the past 12 months of families by family type by presence of related children under 18 years by age of related children [Table]. Retrieved from http://factfinder.census.gov/faces/tableservices/jsf/pages/productview.xhtml?pid=ACS_13_1YR_B17010&prodType=table.

U.S. Census Bureau. (2014). Adopted children and stepchildren: 2010. In Current population reports (Publication No. P20-572). U.S. Government Printing Office.

U.S. Census Bureau. (2020). Estimated median age at first marriage, by sex: 1890 to the present [Table]. Retrieved on August 6, 2021, from https://www.census.gov/content/dam/Census/library/visualizations/time-series/demo/families-and-households/ms-2.pdf.

U.S. Department of Health and Human Services. (2009). Adoption USA: A chartbook based on the 2007 National Survey of Adoptive Parents. Retrieved from http://aspe.hhs.gov/hsp/09/NSAP/chartbook/index.pdf.

U.S. Department of Health and Human Services. (2011). The Child Abuse Prevention and Treatment Act as amended by P.L. 111-320, the CAPTA Reauthorization Act of 2010. Retrieved from http://www.acf.hhs.gov/sites/default/files/cb/capta2010.pdf.

Wortham, T. T. (2014). Intimate partner violence: Building resilience with families and children. Reclaiming Children & Youth, 23(2), 58-61.

Yu, S. M., Lin, S. C., & Adirim, T. (2013). Selected health status measures of children from US immigrant families. ISRN Pediatrics, 1-8. doi:10.1155/2013/164757

 

Chapter 12: Healthcare and Disabilities

Introduction

So often in social work we are fighting for our clients basic needs for survival.  In healthcare settings or when working with those with disabilities, social work practitioners are helping client systems get the necessary care for the highest possible quality of life.  To do so, they must understand the healthcare system as it functions in the United States, America’s perception of the issues at hand, and what we need to do to improve them.  Upon completion of this chapter, students will:

  1. Understand major policies and ways in which we pay for healthcare in the United States;
  2. Identify the current issues facing healthcare;
  3. Apply social work roles to various healthcare settings;
  4. Understand the Affordable Care Act and various forms of health insurance.
  5. Explain how the U.S. has progressed in our treatment of those with disabilities;
  6. Identify different types of disabilities and what the needs of those with disabilities are;
  7. Recognize ways in which social workers help those with disabilities.

Photo of the Sapporo Medical University buildings on a sunny day.Physical Health & Well-Being

            Current longevity in the United States has been greatly impacted by the advances in medicine that have been and continue to be made.  We have come a long way from the days of blood-letting and using bottled flatulence to ward off the Black Death.  It seems that every day there is a new study, revolutionary drug, or innovative procedure that is decreasing mankind’s risk of, and increasing the age that defines, premature death.  Healthcare services, therefore, can still greatly improve someone’s quality of life, whether they get cured, their illness is managed, or they are made comfortable as they approach the end of their life.  However, Americans lag behind their counterparts in other countries around the world when it comes to our health.  Compared to our peers in 16 similar high-income nations, such as Japan, China, Britain, and Australia, the U.S. is worse in several areas, including infant mortality, injuries and homicides, heart disease, and disability (Institute of Medicine of the National Academies, 2013).  The same report identified inaccessible and unaffordable healthcare, poor diet and lifestyle choices, poverty, and convenience as factors to the disparity between the U.S. and similar countries.

Whether it is addressing the problems inherent in our system of healthcare or we are working with clients to navigate medical services, social workers are an integral part of clients’ overall health.  Social worker practitioners definitely do not have the medical expertise that nurses and doctors, but they can still greatly help clients in the area of healthcare.  At this point it should be clear to us that social workers can provide assistance in every area of a client’s life, especially when it comes to a gap in needs and resources available to the client.  When dealing with physical illnesses or disabilities, social workers may not be performing surgery, prescribing drugs, or recommending treatment, but they are there to help clients and their families connect to the proper medical services, logistically plan for their situation, and deal with any illness, injury, or disability on a psychosocial level.  A social work practitioner may not be the primary professional dealing working with a patient, but they are often using their expertise in brokering, advocacy, and counseling as a part of the treatment team to make sure the patient is receiving the proper care in all areas of life.  Generalist social workers can utilize their biopsychosocial perspective to more effectively evaluate a client’s needs and help them address them efficiently, even when it comes to health concerns and disabilities.

 

Box 12.1: Language Use

As with many other chapters and populations in this text, you might notice that we use consumer, client, or the insured to refer to someone obtaining healthcare or utilizing the services of a healthcare provider, instead of patient.  This is coming from a strengths-based perspective as patient can conjure an image of a helpless sick person in a gurney waiting for help from the doctors and nurses who are the experts.  Thinking of our clients as consumers of healthcare treatment as opposed to passive receivers helps remind us that they have the right to make decisions about their bodies and their health.  Doctors are the experts when it comes to medicine, but clients know themselves better and know what is right for them.  As social workers, we must always keep our client’s interests and personal choices at the forefront.

 

Financing Quality Healthcare

Tahir is a 53-year-old man, struggling with back problems he has had for many years.  Tahir was a seasonal employee and found work when he could, though this did not provide him with any health insurance benefits through his work.  So when he was in a car accident at age 44, he had to rely on his car insurance to cover any medical costs.  Though the accident was not his fault, the other driver had no insurance and Tahir’s insurance had to cover the initial hospital bills.  Not having a lot of money, he opted for the cheapest insurance he could get and his policy did not cover follow-up visits to the doctor.  Making too much to receive Medicaid benefits, Tahir would have to pay out-of-pocket for any additional services he needed, and ended up not being able to afford it.  He was slowly recovering and was still able to work, though often in pain.  One day while on the job, he had an accident which caused further injury to his back.  Since it was determined to be a preexisting condition, workers’ compensation at his job refused to cover any care.  Tahir could no longer perform his duties and was fired.  He has since spent the last ten years taking odd jobs that did not last very long or in which he could not continue working at the level needed.  When his back problems become so bad and the pain so unbearable, Tahir's only option is to go to the emergency room.  Since he is without insurance, the hospital reduces and stabilizes his pain, but never provides any treatment beyond that.  Tahir’s back issues are only temporarily relieved and he knows he will end up back in the hospital when things become intolerable again.

A stethoscope on money and surrounding a piggy bank.
For a long time, the costs of healthcare where way too high.  The Affordable Care Act is trying to provide access to affordable quality healthcare to everyone, especially individuals like Tahir. "Health Care Costs" by 401(K) 2013 is licensed under CC BY-SA 2.0.

 

 

Tahir is not alone.  Unfortunately this happens too often in the United States to people like Tahir who have no insurance or cannot afford the care that will alleviate their illness.  Despite the fact that everyone can benefit from quality healthcare, there is a cost to staying healthy, and it is not cheap.  In the United States, we spend more per capita on healthcare than any other country in the world, partly because healthcare costs are so high (Rice et al., 2014).  This means that medical services can cause a serious budget concern for those lacking quality health insurance.  In the past, the options for paying for your medical bills were through medical insurance you received as a benefit from you employer, private insurance you had to purchase on your own, social welfare programs such as Medicare and Medicaid, or out of pocket if you didn't have any of the above.  As a result, low socioeconomic status was, and still is, a barrier to quality effective healthcare.  In Tahir’s situation, Medicaid would only cover the necessary treatment to address the immediate concern; it was a quick fix to a chronic condition.  Prior to the Affordable Care Act (ACA), those who were poor or experiencing poverty were much more likely to be uninsured, less likely to seek out financially demanding care, and more likely to have poor health, prior to the Affordable Care Act.  Unlike many other developed countries, the United States did not provide universal healthcare for all its citizens.  While the ACA, signed into law in 2010, brought us closer to making good medical care affordable and accessible for the country, it is not truly provided by the state, unlike other countries’ universal healthcare programs.  In essence, we are still requiring people to pay for their medical treatment which, at any price, can be out of range for those who have little or no money.  Even if one is fortunate enough to be provided insurance through work, high premiums, deductibles, and chronic or terminal illnesses can bring one to one’s financial knees. 

Obviously how we finance our healthcare has huge implications for how we experience that care.  The more money or resources we have, the better care we are provided, and the more likely we are to be cured or made comfortable.  The less we have, the harder it is to find highly qualified physicians, the worse treatment and care we receive, and the poorer our overall health and quality of life will be.  Tahir could not afford the rehabilitation or regular doctor visits after his accident that would have prevented his condition from becoming chronic.  Had he had insurance or been able to afford to pay out-of-pocket, he would have been in a much different place in his life at 53.  In the work we do with clients, social workers have to be aware of the various methods for addressing healthcare costs and how it can impact the future of our clients, especially when an illness or disability becomes, or has the potential to become, a much more complicated situation.  If we are striving to connect our clients with appropriate services, we need to understand the interplay between insurance programs, what is needed to take care of our client’s situation, and how it will affect them in the long run.

Screenshot of the homepage of HealthCare.gov
The ACA created the Health Insurance Marketplace with affordable insurance options for everyone who did not have it or wanted to switch.  Everyone in the U.S. either has to have insurance or pay a fee at tax time for the number of months they were without coverage. "Healthcare.Gov" by danxoneil is licensed under CC BY 2.0.

 

Affordable Care Act

            Officially titled the Patient Protection and Affordable Care Act, though often referred to as Obamacare, the Affordable Care Act (ACA) is designed to provide everyone in the United States with health insurance that they can use to cover necessary medical treatment.  The act, of course, is not without controversy, with many arguing the basic premise of the ACA implementing mandatory insurance.  One specific argument is that some people feel their rights are being infringed upon by being forced to purchase insurance.  While the law gives people the choice to either purchase coverage or pay an extra tax, many view the tax as a fine rather than a choice.  The argument is that if they are young and living a healthy lifestyle, with little risk of needing insurance, they should not have to pay for services they will not use.  The concern with this argument is that when the unexpected happens and those people who are young and healthy are involved in some sort of accident or develop a condition despite their lifestyle, they can become a drain on the system if they can't afford to pay.  This just ends up increasing the cost of healthcare in the United States and further disadvantaging those who already cannot afford basic necessary healthcare.  Yet the ACA is much more than a governmental assurance of coverage for all.  From a social work perspective, the ACA is a policy that addresses a large gap in services and resources when it comes to quality healthcare, doing so much more than trying to provide everyone with care when they need it.  Its emphasis on providing affordable, patient-centered care in which providers are accountable  not only makes healthcare more cost effective, but can also lead to improved care coordination and a reduction in unnecessary service use (Andrews, Darnell, McBride, & Gehlert, 2013).

Prior to the signing of the ACA, there were 38-48 million Americans uninsured (Martin, 2013).  When these people needed treatment or medical care, their costs were absorbed by providers who would then raise their fees, driving up the price of quality healthcare.  Inception of the ACA has made great strides in closing the care gap through the Patients’ Bill of Rights, with the following key features:

  1. Coverage – Children can no longer be denied coverage based on pre-existing conditions, young adults can remain covered under their parent’s health plan until they are 26, companies can no longer arbitrarily cancel insurance coverage, and consumers have the right to appeal when the company denies payment.
  2. Costs – Lifetime limits on coverage are banned for all new plans, insurance companies cannot raise premiums without justifiable reasons, and most of the premium paid by the consumer needs to cover healthcare costs as opposed to administrative costs.
  3. Care – Preventative care costs nothing, consumers can choose whichever doctor they want from their plan’s network instead of having one given, and those needing emergency treatment can go to hospitals outside their network without delay. (U.S. Department of Health and Human Services, 2014, para. 3-6).

These provisions emphasize the patient-centered care that was a focus prior to the legislation.  Insurance companies are businesses and their ultimate goal is to make money.  Before the ACA, they were not as accountable to the consumer.  In addition, the ACA provides incentives to healthcare providers to allow them to cater to consumers and provide higher quality care, rather than limiting their ability to meet the needs of patients by only funding immediate care concerns.  Overall, the driving force behind the ACA really is to create a more effective and efficient healthcare system that everyone can utilize.

Aside from those who just choose not to get insured, many continue to be neglected by the system because they still cannot afford insurance, they are undocumented, or options for care are not supportive enough for their situation, leaving a large number of those living in the U.S. uninsured and unable to access healthcare when they need it (Andrews, Darnell, McBride, & Gehlert, 2013).  Even though it will not catch everyone, the ACA will definitely increase the number of insured Americans, including through the changes made in Medicaid eligibility and service coverage.  Of course, this does not mean social workers should be content with where we currently are. 

 

Box 12.2: Obamacare

Last year, the Affordable Care Act (ACA) turned 10 years old.  Despite the attempts by Donald Trump during his presidency to dismantle the program, the Supreme Court upheld its constitutionality. In June, 2021, the U.S. Department of Health and Human Services (HHS) released a brief titled “Trends in the U.S. Uninsured Population, 2010-2020” that shared approximately 274 million Americans had health insurance. Here are some of the key points the HHS outlined:

  • 30 million U.S. residents didn’t have health insurance in the beginning of 2020 - a sharp decline in the number of uninsured Americans since 2010, before ACA.
  • The ACA produced particularly large coverage gains for Blacks, Latinos, Asian Americans, and Native Americans, as well for lower-income families.
  • The uninsured rate increased from 2017-2019 by 1.7 percentage points, most likely due to policy changes by Trump.
  • Estimates from the NHIS show no significant change in uninsured rates during the early months of the COVID-19 pandemic, though the pandemic itself created challenges in conducting the survey.
  • Compared with other Americans, the uninsured are disproportionately likely to be Black or Latinx; be young adults; have low incomes; or live in states that have not expanded Medicaid.

Based on this information, and the above section of this chapter, what can we say about the success of Obamacare?  What else do we need to know?  How does this policy significant for various populations social workers serve?

Adapted from Finegold et al. (2021).

 

Medicaid & CHIP

One of the healthcare coverage options available is provided through Federally mandated, state supported and run Medicaid and Children’s Health Insurance Program (CHIP).  With the ACA being passed, Medicaid still offers a healthcare coverage solution for low-include individuals and families, including children, those who are pregnant, people experiencing a disability, and those older adults the government considers “seniors.”  However, otherwise uninsured healthy women and children have historically made up the majority -70%- of those enrolled in Medicaid programs (Kongstvedt, 2009).  Medicaid is a fee-for-service coverage program, limiting how much state governments pay directly to providers for specific services.  Many states even work with managed care organizations to provide care through a network of various providers, which is how the vast majority of Medicaid recipients are served (Centers for Medicare & Medicaid Services, n.d.).  In addition, CHIP provides insurance for children from Medicaid eligible families, children from lower income families that earn too much to be eligible for Medicaid, and, in certain instances, pregnant women.  Both Medicaid and CHIP have been expanded by the ACA to allow more Americans to utilize these programs and provide options for states to further increase eligibility requirements as they see fit.  Of course states still have much say in how they implement these programs.  However, the passing of the ACA has allowed the federal government to increase eligibility, expand coverage, and adjust minimum regulatory drivers behind the program to reduce the number of uninsured Americans that are not receiving the care they deserve or require.  The changes made to these programs align with the new legislation's foundational ideas by improving quality of care and expanding treatment, especially for those who have historically received lower levels of service from healthcare providers.  Those covered under these programs may still have nominal copayments, coinsurance requirements, deductibles, and premiums –including for prescription medication and emergency room visits – but how much they pay out-of-pocket is limited by federal mandate.

In addition to trying to increase those with adequate insurance, Medicaid and CHIP, similarly to the ACA, are working to reduce those actions taken by insurance companies, healthcare providers, and patient consumers that add to the increasing medical care costs.  For instance, going to the emergency room for non-emergency purposes is one thing directly addressed by Medicaid.  If you recall our vignette with Tahir, he would go to the ER when his pain was too intense because he had no other option.  Those with low income and no insurance who cannot afford to go to the doctor for what many people see as a minor health issue, such as a cold, have few options for care.  Since emergency rooms cannot turn anyone away, an individual can go to the ER for antibiotics or other treatment and care that should be done in a physician’s office.  Medicaid charges premiums for non-emergency use of emergency rooms as a means of trying to curb this behavior and help lower costs for care overall.

 

Medicare

            While Medicaid is designed specifically for the most financially disadvantaged individuals of varying age and ability level, Medicare is specifically for older adults and is not limited by income level.  One way to remember the difference between the two programs is that aid is given to anyone who needs help because they cannot do it on their own; care is given to those who need more regular healthcare assistance.  Thus Medicaid is for lower income individuals who need help covering their health needs and Medicare is for older Americans who utilize care more often.  Technically, Medicare is for anyone 65 years of age or older, people of any age who have certain disabilities, and those with permanent kidney failure, all of whom may need much more care than the general population.  With how much older Americans utilize medical services, Medicare has become the largest contributor to healthcare coverage in the United States.  Since it is not an insurance program for those experiencing lower income and poverty, it is not as integral in helping those without insurance become insured and, thus, has had few major structural changes with the implementation of the ACA.  There are four major parts to Medicare:

  1. Part A – Known as hospital insurance, this covers inpatient care in hospitals and can cover hospice and some forms of home healthcare.  Workers pay into this through income tax and have no premium.
  2. Part B – This is medical insurance that covers outpatient services, physician services, and some home healthcare not covered under Part A.  It also pays for supplies that are medically necessary.  People enrolled in this part of Medicare pay a monthly premium like they would for private insurance.
  3. Part C – Managed care organizations work with the government to provide Medicare Advantage Plans through this part of Medicare.  These plans cover both Part A and B benefits in order to give consumers choice in overall coverage and is similar to having private insurance.  Many of the insurance providers also cover medication.
  4. Part D – This more recent addition is the Prescription Drug Coverage of Medicare and is insurance only for prescription medication.  Like Part C, this is provided by private companies and consumers incur a monthly premium.  However, it can help reduce costs for medications that would normally have to be paid out-of-pocket.

Medicare is by no means perfect, as the various parts of the program are coordinated differently and can be confusing for those utilizing the benefits, specifically Parts C and D (Kronenfeld, 2011).  It also does not cover treatment in long-term care facilities, which is of important concern for some of those eligible for Medicare (Austin & Wetle, 2012).  However, it is still a prominent piece in the continued coverage of people who have reached retirement age and may have lost their insurance when they stopped being employed.  As our older adult population only gets bigger, Medicare figures to continue playing an important role in how this group pays for their medical needs.

Where policy fails, social work has a responsibility to intervene on behalf of all those who live in the United States and do not have that access to affordable healthcare.  We need to still be aware of those community resources that are available to client systems that have little or no coverage.  In policy practice, we need to help evaluate the implementation and effects of the ACA, recommend and work for any needed positive changes, and assist state and local governments and agencies to ensure the law is being implemented correctly.

 

Private Insurance & Managed Care

            Most of the time medical insurance can be viewed as a security net to cover our expenses in the off chance we experience a situation for which we are otherwise financially unprepared.  As we get older and may begin to require more healthcare, insurance is no longer a safety net but a necessary way to reduce the costs of medical care we receive.  No matter what, insurance is provided by what is referred to as a third-party payer, an entity or organization other than the patient or the provider that is involved in the exchange of services.  Private companies are usually the third piece to this equation, though states can play this role at times as well.  Many Americans who work full-time receive insurance benefits through their employer, for which both the employer and employee have to pay a premium.  This type of insurance plan can also cover the worker’s spouse/domestic partner and any dependents.  Older Americans who are retired may also receive insurance from their former employer as a part of their pension from that company.  More recently, however, there has been a shift away from companies providing pensions as workers no longer stay with one company for the majority of their career.  Since Medicare only covers about 60 percent of medical costs, retirees without pensions are left to either pay for care on their own or pay for insurance on their own, both of which can become expensive burdens (Hoffman & Jackson, 2013).  Of course, with the passage of the ACA, all Americans, regardless of retirement status, are required to secure personal insurance if they are not receiving this benefit from another source.  Private insurance companies thus fill this need.

            Health insurance can be very complicated, dictating how much companies will pay for certain services, how much of the cost the consumer is responsible for, and which providers consumers in their plans can receive care from to get their full benefits.  Though companies may provide their own requirements and restrictions for services, types of third-party payers are identified by how they pay for healthcare as opposed to what they pay and to whom.  Austin and Wetle (2012) outline a number of different third-party payers:

  • Indemnity insurers are the most classic form of insurance.  Simply put, indemnity insurers reimburse the covered individual for the payments they have already made to the service provider or make payments directly to the provider, but at a preset amount.  The insured can choose any provider they want.
  • Self-insurers are companies that take on the risk of loss for medical costs their employees incur.  Instead of going through an insurance company, the employer uses its own revenues to make payments.
  • Prepay insurers, such as Blue Cross/Blue Shield, pay providers for medical expenses in advance much like individuals “prepay” insurance companies for their own healthcare costs.
  • Managed care organizations are different from the previous types of insurers because they involve both the payment for services as well as the provision of these services.  These insurance companies contract with providers to give consumer access to healthcare at a lower rate. (pp. 35-36).
Picture of an outstretched hand, palm up, with an image of a heart surrounded by various healthcare related icons.
Managed care organizations are created when insurance companies and healthcare providers contract together to provide a network of doctors and services at lower costs to the consumer.

 

 

Managed care is by far the most popular form of insurance provided to workers, with about 99 percent of employees being enrolled in some sort of managed care plan (Henry J. Kaiser Family Foundation & Health Research & Educational Trust, 2014).  Those insurance companies that provide managed care plans contract with networks of providers to negotiate what fees will be paid for what services.  With different plans, they negotiate different contracts and can offer these with varying premium rates, deductibles, and coverage options.  While it is beyond the scope of this text to talk about all the intricate details of the varying types of plans, we will briefly discuss three main plan types and the basics of how they function.

            Health maintenance organizations, or HMOs, were the earliest form of managed care and can actually be thought of as a type of prepay insurance (Austin & Wetle, 2012).  Basically, the consumer pays a regular fee to the insurance company based on an estimated amount of healthcare services a person might typically need over the month or year.  No matter what amount of services the consumer actually uses, the fee is always the same.  Use less than the set amount and the insurance company gets to keep the difference, more than the set amount and the insurance company has to pay the extra cost.  Therefore it is more beneficial if the consumer uses as few services as possible, and HMOs have been known to try and limit the number of services their insurers take advantage of.  One aspect that is foundational for HMOs is the primary care physician as the initial point of contact for any healthcare concern.  No matter what kind of illness or injury they are dealing with, those with HMOs must first visit their primary care physician and get a referral before they can see any kind of specialist.  This allows professionals to determine if the course of action the consumer wants to take is necessary or if there is a different issue at hand.  However, it also allows the physician to limit the amount of services a consumer receives, benefitting the HMO, and possibly prolonging the health issue of the consumer.  This managed care option is best for young, healthy adults with little need for care and for individuals and families that cannot afford a lot of out-of-pocket expenses for healthcare.

            Preferred provider organizations (PPOs), on the other hand, do not have that same “gatekeeper” physician.  Consumers with PPOs can visit any generally physician or specialist from the preferred provider network without penalty.  The network for PPOs is the important aspect.  PPOs contract with a number of different provider groups to establish the preferred provider network for their consumers and negotiate a lower fee rate that they can then pass on to their customers.  The fee for specific services is predetermined and is paid by the insurance company once the service has been utilized by the consumer (Phelps, 2003).  PPOs are a more expensive choice than HMOs because PPOs require consumers to pay monthly premiums and a yearly deductible for their coverage.  Initially, consumers take on the total cost of their healthcare needs until their deductible is met.  Once that happens, the consumer may still have to payfor a smaller percent of the services they utilize, based on the terms of their plan, with the insurance company paying the rest.  However, this allows PPOs and their providers to give more effective and better quality care to the consumer.  Consumers with PPOs also tend to have more control over their healthcare by being able to find the option that is right for them based on their needs.  PPOs tend to be the best option for healthcare, which may explain why this plan was chosen more often by employees in 2014 (Henry J. Kaiser Family Foundation & Health Research & Educational Trust, 2014).

            The last--and one of the least popular managed care plan types--is that of point of service (POS) plans.  Very similar to HMOs, consumers pay a flat fee in return for their yearly medical services.  Unlike HMOs, and similar to PPOs, consumers do not have to choose a primary care physician and can choose the doctor they want to go to once they need the service, as long as the doctor works with the POS plan.  Use of doctors outside of the plan, and without a referral, can result in high copayments or in the consumer being responsible for the whole cost of the service.  Seen as “HMOs without walls” (Phelps, 2003, p. 368), these plans can offer more freedom to consumers with less personal financial commitment.

 

Social Issues in Healthcare

            Any issue in healthcare that has a potential impact on the clients social workers help can be seen as a concern the social work profession should address.  From high costs of healthcare to insurance companies denying claims, from the impact of malpractice suits on the healthcare system to the infant mortality rate, social workers have a duty to fight for our clients.  No matter what area within social work we practice, generalist social workers can identify various systemic influences on the quality of life for our clients and utilize our skills and knowledge base to address the problem for a resolution.

 

Affordable Quality Healthcare

            By the time the Affordable Care Act was signed into law, it was clear the healthcare system and policy in the United States needed an overhaul.  It is true that we have made great strides in healthcare in the last 200 hundred years; life expectancy testifies to this.  Someone born in 1800 could not reasonably expect to live past their thirties while someone born in the beginning of our twenty-first century can expect to live to be nearly 80 years old (Veit, 2012).  Yet the United States is among the worst of developed nations in terms of life expectancy, with this age being skewed by the number of people who do not live past their fifties – though Americans who make it to 75 tend to live longer than their peers in other countries (Institute of Medicine of the National Academies, 2013).  When it all boils down to it, there is a clear difference between those who can afford healthcare, or longer life, and those who do not have the means or resources for proper medical treatment.  Sure we have grown our knowledge base, techniques, and technology for combating illness and disease.  However, these advancements come with a price tag that many cannot afford, causing the variability in health status between the haves and the have-nots (Barr, 2008).  This definitely plays a part in a lower life expectancy in the United States, and while other countries deal with poverty, their healthcare system provides more accessible quality healthcare to all of their citizens.

The ACA was one of the ways in which we started to address this by improving access, quality, and costs of healthcare for all those in the United States.  Requiring everyone to have insurance but providing more financially viable solutions better serves the previously uninsured in lower socioeconomic statuses.  However, minority groups, including those experiencing poverty, have to deal with prejudiced and discriminatory practices, often resulting in the “treat ‘em and street ‘em mentality” similar to that experienced by Tahir.  Prejudice beliefs about a patient based on physical or demographic information can impair a provider’s ability to make a sound professional decision.  In Tahir’s case, if he went to the emergency room complaining about back pain, was dressed in worn out clothes, and presented as unkempt, the doctor may assume Tahir was an addict looking for his next fix.  The doctor may well have helped him manage his pain, but discharged him at the first sign of improvement, without getting to the underlying cause.

One of the biggest topics when it comes to quality of care and prejudice of providers has to do with old age care.  This text will discuss health concerns of older Americans later on in Chapter 16, including the disparity in quality effective care based on age.  Pain, illness, and disease are often assumed, though incorrectly, to be a natural part of growing older.  Doctors and nurses may consider these “elderly” patients as experiencing the aging process, senile, weak, or close to death anyway, impacting what treatment options are offered, how they are cared for, and how serious their situation is (Nolan, 2011).  As our older adult population continues to get bigger, this will become an even more pressing issue.  Quality care is clearly available, just not to everyone.  Healthcare is one of those things in society that is much more accessible when you fit the correct demographic – in other words, are part of the majority.

Doctor using a stethoscope to listen to the heart of her patient.
More recently there has been a stronger push for preventative care, which is also supported by the ACA.  The medical model traditionally views healthcare as a reactionary treatment of illness as it presents.

 

 

 

Treatment vs. Preventative Care

            In the quest for quality care, one of the issues currently being discussed is that of the focus on treating problems as they appear instead of working to prevent the problems in the first place.  This is better known as the medical model versus wellness model of healthcare.  In the medical model, providers address the needs of the consumer when problems are presented.  The University of Ottawa (n.d.) equates this, which was the dominant viewpoint in the United States during the 20th century, to fixing a machine when it breaks down.  This reactive approach is dedicated to diagnosing and treating illness when a patient presents with a problem.  The wellness model, on the other hand is focused on helping consumers maintain their health, preventing illness, and working with sick patients to make long-term improvements to their health.  In 1984, the World Health Organization (WHO) proposed moving away from the medical model, viewing health more as a dynamic way of being instead of a specific goal to achieve (University of Ottawa, n.d.).  Today, we use the wellness model of healthcare to better understand how daily habits and regular preventative care can add to the positive health of an individual.

            In striving to keep healthcare costs lower, it is the wellness model that fares far better than the medical model any day.  Using influenza as an example we can see the varying costs of these two models in battling the illness.  In the medical model, an individual presents at the doctor’s office feeling sick.  The patient may have taken the day off work to come in and see the physician.  After some questions, taking the patient’s vital signs, and possibly running some tests, it is determined the patient has the flu.  If the patient is like the majority of workers in the United States with PPOs, they may have to cover a copay, pay part of their deductible, miss work for another day or so, and purchase any medication, over-the-counter or otherwise that the doctor prescribed.  On the other hand, with a wellness model the patient could take preventative measures against the flu by getting a flu shot.  Flu shots are regularly inexpensive, or free depending on one’s insurance plan, which is the only cost for the wellness model.  The other activities, getting enough sleep, eating right, and washing one’s hands are all important preventative measures that can assist the immune system and prevent viral or bacterial illnesses.

            While the healthcare system in the U.S. is moving away from a strict medical model and into a more wellness focused approach to health, consumers may not buy into this ideology as much.  We will discuss this more in-depth a little later on in this chapter, though we should mention that social work has a responsibility to help educate the community about the benefits of preventative care and to teach them how to get and stay healthy.  It is not entirely up to healthcare providers.

 

Box 12.3: Patient’s Rights

Aside from the ACA’s Patients’ Bill of Rights that focused on insurance and healthcare, the American Hospital Association previously came up with a Patient Bill of Rights of their own.  This link outlines the rights as Johns Hopkins Hospital has interpreted them.  As you read through the rights, can you identify how they acknowledge diversity, promote inclusion, and respect the right of self-determination of their patients?

 

Respecting Consumers’ Rights to Self-Determination

            Doctors and nurses are the experts when it comes to medical care.  We rely on their training and judgement in effectively diagnosing and treating our healthcare concerns.  However, as consumers, we get to provide consent for doctors and nurses to provide any treatment they suggest.  If we do not want the help and are of sound mind, we do not have to give the okay.  The American Medical Association (2006) addressed informed consent in their code of ethics by stating that patients should decide the course of treatment taken, after the doctor has shared all relevant information about the illness, the treatment options, and the consequences.  Consumers than have the right to choose which treatments they want, based on what they are willing to risk and what they want for their life after treatment.  If a person wants to try every possible treatment option, no matter what the risks, until they find one that works, that is their choice.  In the same vein, if one does not want any treatment and prefers to allow one’s body to succumb to the illness, they are allowed to do that.  The Patient Self-Determination Act (PSDA) of 1990 addresses the two sides of this coin by requiring all medical facilities to honor a consumer’s living will and power of attorney (American Cancer Society, 2015).  While the power of attorney allows a consumer to designate another individual to act and make decisions on the consumer’s behalf in instances of incapacitation, the living will is documentation of a consumer’s wishes for or refusal of life-saving measures in the case the consumer can no longer make sound, medical decisions.  The PSDA allows us to advocate for ourselves and our wishes for the extent of healthcare we are provided.  For people with chronic or terminal conditions, the ability to make these decisions can prevent forced treatment that may prolong pain and suffering.

 

Box 12.4: Euthanasia

 When your authors were younger, the first time they heard the term Euthanasia, they thought it was referring to squalor conditions for the youth in Asia.  They soon found out it was actually referring to the intentional ending of life, usually in order to relieve pain and suffering.  Most commonly, we hear of family pets being euthanized because they are old or in too much pain.  But when it comes to people, euthanasia is a hotly debated topic in the United States.  Also referred to as physician-assisted suicide, dying with dignity, and mercy killing, euthanasia comes from the Greek words for "good death" and is only legal in Washington, D.C. and ten U.S. states--Washington, Oregon, Vermont, California, Colorado, New Mexico, Maine, Vermont, New Jersey, and Montana.  Doctor Jack Kevorkian was famous--or infamous depending on who you talk to--for assisting people in ending their lives.  He served time in prison for second degree murder because of it.  In considering a patient's’ right to self-determination, where does the choice to die fit in?  Debate in class or answer the following questions for yourself regarding euthanasia:

  1. What is social work’s responsibility in terms of patient rights and euthanasia?
  2. In what instances, if ever, is it okay for someone to decide to end their life? 
  3. Under what circumstances is it not okay for someone to end their life?
  4. If a person can decide when to end their life, who should be the one to actually administer the medication, the doctor or the person themselves.
  5. What is the difference between euthanasia and dying by suicide?
  6. How will you work with a patient who wants to die with dignity?

Social work should always be concerned with protecting the rights of consumers when it comes to their healthcare, and self-determination is a big part of that.  In the work we do with clients on an individual basis, we respect their right to choose how they want to change and the methods they use to make that change, as long as it is not directly harmful to themselves or others.  We continue this view into how we help clients understand, plan, and implement their healthcare.  This includes processing end-of-life care options and helping them create a living will if they so choose.  As advocates, we also understand how much influence culture and values have on a client’s self-determination and must help convey this to medical personnel who may be more concerned with curing the disease than with respecting the individual (Tham & Letendre, 2014).  For instance, Jehovah’s Witnesses do not agree with blood transfusions, believing they are not supposed to have anyone else’s blood in their body.  Indeed this may prove difficult for some medical emergencies, but protecting their decision in the moment can prevent a lifetime of depression, self-loathing, and possible suicide.

Another area in self-determination of which we need to be aware deals with doctors’ responsibility to provide information.  Doctors may believe they are the best person to make decisions on healthcare for an individual and may withhold information about risks or treatment options based on faulty assumptions.  Doctors can withhold certain information based on “therapeutic privilege” if they feel it will cause harm to or suffering for the patient, though there has to be significant reasoning and evidence in order to make such a claim (Johnston & Holt, 2006).  However, there are times when doctors may not offer options for treatment to patients because they do not feel these patients’ bodies will be able to handle them.  An example of this is when a doctor believes a procedure would be too risky for a man in his 80s because he believes the man is frail.  Doctors may be experts in the physical effects and risks of care, but mental health professionals, such as social workers, are the experts on the psychosocial impact for the individual.  Not all treatment affects consumers the same.  Social workers should be recruited to help doctors make the best decisions for overall harm reduction and respect consumers’ expertise and rights to choose what is in their best interests.

Social Work in Healthcare

            One way to affect the lives of our clients who are negatively impacted by healthcare issues is to work as part of the healthcare system itself.  While it is true that we have to help our clients address medical concerns when working in any social work setting, being employed within the very environment that acts on the psychosocial well-being of a person can allow us to make a regular difference in how our clients experience their healthcare.  With the push to care for the whole person, including addressing behavioral health needs, social work is becoming an even more integral part of the healthcare system in the United States (Allen, 2012; Balasubramanian et al., 2015).

Two people talking, one with their head in their hands and the other actively listening.
Social workers in healthcare settings spend a lot of time working with consumers and their families as they deal with or adjust to the impact of illness or injury on their lives. "PNG counselling service for women. PNG 2008. Photo: AusAID" byDFAT photo library is licensed under CC BY 2.0.​​​​​​

 

 

 

Primary Care

In the concept of addressing the whole person, mental healthcare is necessary for all around well-being.  Community mental health agencies do a great job of focusing more specifically on the psychosocial aspect of health.  Even when these agencies have outpatient treatment programs for dual diagnoses, their specialty and expertise is generally on helping clients deal with their problems from a mental health point of view.  Doctors in primary healthcare settings treat the client’s physical symptoms, prescribe them medication, or give them advice on how to stay healthy and care for their illness.  However, in coming to terms with how the illness or situation will impact their life, social workers (and other mental health professionals) take the lead.  Just like you would not want to go see a social worker to diagnose stomach pain, a medical doctor is not necessarily the right choice for dealing with depression.  Psychiatrists can prescribe medication AND provide mental health treatment to an extent, but they are much more likely to see patients with severe clinical mental illness like schizophrenia.

Unlike these behavioral health settings, social workers in hospitals and long-term care facilities are going to address needs in a medical model type of perspective, treating the patient for whatever may be making the illness worse or getting in the way of healthy recovery.  While primary care facilities and hospitals can even vary in how much time social workers spend doing various activities, the NASW (2011) described social workers in healthcare settings as needing to perform many generalist social work duties in order to connect primary care with behavioral healthcare.  They also outlined key functions of social workers in outpatient healthcare settings:

  1. Identification, assessment, and treatment of mental health conditions, such as depression and anxiety;
  2. Case management/care coordination, particularly for individuals with chronic and/or complex medical conditions;
  3. Patient navigation, especially for patients moving among different healthcare levels (e.g., inpatient, outpatient, home health, or long-term care);
  4. Identification and referral for specialized services, such as drug and alcohol treatment, legal services, financial and employment counseling, and housing support;
  5. Education and support programming (e.g., diabetes education, parenting classes, domestic violence support programs) for individual and groups;
  6. Assistance with entitlements, medications, transportation, and advance directives;
  7. Assessment and intervention in domestic violence and child abuse situations;
  8. Counseling on end-of life issues;
  9. Outreach and coordination with other community resources and agencies; and
  10. Community-level advocacy on behalf of patients and families.

Battling disease and illness, especially chronic or terminal conditions, requires change in one’s life.  Some physical health conditions may even have permanent life-changing effects.  By utilizing these functions, social workers help clients and their families have a smoother transition by guiding them as they adjust to their new lives.

Let us revisit Tahir.  He has just found out that he has lung cancer.  After talking with Tahir about his illness, the doctor has one of the social workers in the hospital visit Tahir and speak with him and his family about the next steps in the process, what to expect, and how to prepare for the changes.  The worker also wants to evaluate how Tahir is coping and set up any kind of follow up care if Tahir is having a hard time dealing with what he is going through.  When Tahir is cleared to be discharged, the social worker helps the family create a plan for aftercare and refers the family to resources in the community that may help them with food and rent while they deal with the financial strain of medical bills.  If Tahir’s condition was too far advanced and he only had days to live, the social worker would help him and his family understand and work through the death and grieving process in the short-term, with referrals for his family to resources in the community to continue dealing with the loss of Tahir once he passed.  In an outpatient primary care setting, the activities of the social worker take on more of the family mental health counseling and therapy aspect than that of a practitioner in a hospital setting, where the responsibilities are more task oriented (Greene & Kulper, 1990).  Still, both environments can allow for a helping relationship that provides psychosocial treatment for consumers’ illnesses.

Picture of young hands hold an older patient's hand while the patient lies in bed.
Social workers are an integral part of the team to help provide palliative care for those experiencing chronic or terminal illness.  This care can help clients have a positive quality of life, in a setting they choose.

 

 

 

Palliative and Hospice Care

            People who are chronically or terminally ill will have contact with social workers while in the hospital.  If they choose to spend their remaining days in that setting, practitioners will also take the opportunity to meet with any family or close friends who visit and are impacted by the client’s situation.  However, many people with these health conditions may elect to finish their lives in a comfortable place, such as their own house or that of a close relative.  Either setting provides consumers with the option of receiving palliative care, where a team of healthcare professionals provide comprehensive wellness services, including physical and mental healthcare, to those with chronic and terminal illnesses.  In fact, they can receive this specialized care in nursing homes and other long-term care facilities as well.  Palliative care is, “an approach that improves quality of life for patients and their families facing the problems associated with life-limiting illness.” (NASW, 2004, p. 10).  Hospice is a form of palliative care specifically for those who have a terminal illness, with the same goals and care team foundation.  The main idea of this treatment option is to provide respectful and compassionate care for patients in order to have as positive an outlook as possible on the life they have remaining.

            Since palliative care is a team approach, each member of the team can have a unique set of functions based on their area of expertise.  Doctors may prescribe treatment plans, nurses can help the client with monitoring and medical care for the illness, and volunteers can help with activities of daily living (ADLs) as needed, just to list a few.  Social work practitioners’ duties revolve around meeting the psychological, emotional, and social needs of clients and their families (Fine, 2012).  Social workers definitely take on a case management role with clients and will advocate for personalized treatment plans, broker with community resources, teach clients about the treatment process and options, and counsel clients in understanding death as a natural part of life.  These are all skills that other healthcare professionals are not properly trained or qualified to provide.  With the impact emotional well-being can have on the physical health of a client, social workers are such invaluable members of the treatment team that Medicare requires them for hospice certification (Reese, 2013).  However, as Reese (2013) illustrated, other professionals may not fully understand or value their unique ability or expertise in providing such services, and rely on them only when the situation is critical.

 

Community Health & Prevention

            When it comes to healthcare, macro level social work does a lot of social welfare policy practice at the national or state level that can improve access to quality care for those marginalized in society.  One aspect of macro practice in terms of healthcare is that of community health and prevention.  This strategy focuses on community resources, many of which are non-profit agencies, addressing behavioral aspects contributing to overall health.  The Centers for Disease Control and Prevention (2014) actually have a Division of Community Health with the main goal of promoting disease prevention and healthy living in communities throughout the U.S.  This division’s guiding principles for community health and prevention efforts are to:

  1. Make the greatest public health impact through far reaching prevention efforts;
  2. Achieve health equity by breaking down barriers in areas most affected by chronic illnesses;
  3. Use and build the evidence base to promote healthy behaviors, evaluate current programs, and plan future strategies (Center for Disease Control and Prevention, 2014, DCH Core Principles).

Community social workers are key constituents in implementing these efforts.  While programs and strategies might vary, social work practice in community health and prevention can focus on a wide variety of topics, including smoking, family nutrition, teen pregnancy, drunk driving, and sexual health to name a few, that can impact the overall physical and mental health of the community and its members quality of life.  Unlike primary care and mental health settings addressing healthcare concerns that align more with the medical model, community health and prevention follows the wellness model by working to identify and prevent physical and mental health problems, and does so on a broad scale.

 

Working with People with Disabilities

            One population social work practitioners in healthcare settings, as well as other social work settings, will encounter are those who are dealing with a disability.  Primary care, hospitals, and other long-term medical care facilities interact with people with disabilities on a regular basis.  These individuals seek out rehabilitation and treatment for chronic conditions, new disabilities, and disabilities that have been a part of their life since birth.  In the community, social workers may encounter people with disabilities in practice that may be geared toward community health, education, or even family counseling, presenting as a client or a member of a family system needing services.  They may also work with people with disabilities in agencies that specifically meet the needs or provide services for those experiencing a disability.  No matter where we work, the chances we will build a helping relationship with a person who has a disability is almost a given.  The prevalence of people in the United States who have some type of disability is 56.7 million, or almost one-fifth of the population (Census Bureau, 2012).  Obviously, some of them are more severe than others, and certain disabilities are more noticeable than others, like not being able to walk as opposed to someone with Autism.  However, all of those with disabilities can run into having to perform ADLs in ways that are not typically representative of the other 80% of Americans.  People with a visual impairment might read with their fingers, people who are deaf or hard of hearing might communicate with their hands, and a student with Down syndrome may need an instructional aide to help with class work.  Social work has a place in helping these individuals find effective strategies to meet the demands of a world that may not be structured in a manner that fits with how they function, as well as advocating for their rights in a world that oftentimes sees them as less capable and damaged.

 

Box 12.5: What to Say & What to Do

Many people who do not have a lot of experience being around others who have disabilities are unsure how to act or what to say.  They may even feel uncomfortable as a result.  As social workers, we will inevitably have clients with disabilities who are different than us.  Here are some tips from Henry (2007) on what to keep in mind to help them feel more comfortable around us and for us to remain respectful to our clients.

  • Don't make assumptions about people or their disabilities. Don't assume you know what someone wants, what [they feel], or what is best for [them].
  • Ask before you help. Before you help someone, ask if [they] would like help. In some cases a person with a disability might seem to be struggling, yet [they] are fine and would prefer to complete the task on [their] own.
  • Talk directly to the [client], not to the interpreter, attendant, or friend. You don't need to ignore the others entirely; just make sure to focus your interaction with the [client].
  • Speak normally. Some people have a tendency to talk louder and slower to people with disabilities; don't. Don't assume that because a person has one disability, that [they] also [have] a cognitive disability or is hard of hearing. Also, use normal language including "see" and "look."
  • Use "people-first" language when referring to people with disabilities. People-first language means put the person first and the disability second. For example, say "a woman who uses a wheelchair" instead of "a wheelchair-bound woman." Keep in mind, however, that not all people prefer person-first language. It's a good place to start as a default, but we should always use language the client prefers.
  • Avoid potentially offensive terms or euphemisms. Many people find annoying or offensive: restricted to a wheelchair, victim of, suffers from, retarded, deformed, crippled, and euphemisms such as physically challenged. If you are unsure, ask the person with a disability what terminology [they] prefers.
  • Be aware of personal space. Some people who use a mobility aid, such as a wheelchair, walker, or cane, see these aids as part of their personal space. Don't touch, move, or lean on mobility aids. This is also important for safety.

Retrieved from http://www.uiaccess.com/accessucd/interact.html

Past treatment of those with disabilities devalued them as humans and was the result of negative beliefs about the cause of the disability, the effects of the disability on society, and the abilities – or lack thereof – of these individuals.  Some early societies viewed disability as the result of a supernatural force and would sacrifice those with disabilities as an offering to the gods (Pardeck, 1998).  History of how the United States has approached disabilities did not include sacrificial offerings.  Still it has not been, and to some extent continues not to be, an accepting and affirming atmosphere for those who have some form of disability.  Munyi (2012) discussed the impact of culture on attitudes of societies toward disabilities and individuals who have them, from being respected and participating members of society to needing to be castaway and forgotten.  Historically in the United States, there have been four main approaches that have guided how disabilities are framed and approached in terms of social and medical service:

  1. Utilitarianism – People are valued for how useful they are to their society.  While one person may be useful to one society, their abilities may not translate over to another if they cannot actively contribute to that society’s success.  For those with disabilities in the United States, they have been viewed as not being productive members of society on their own, with some even requiring additional assistance just to exist on a daily basis.  Darling (2013) discussed how people who had a disability were seen as a threat to social order and were thusly institutionalized in mental hospitals, almshouses, and prisons so society did not have to see them, deal with them, or take care of them, a shift from families taking on this burden.
  2. Humanitarianism – Renaissance influences and Christian views of the sacredness of all life contributed to the focus on the well-being of all people in society.  This movement found its footing with the growth of wealth, knowledge, and resources in the late nineteenth century.  This view conflicts with that of utilitarianism by giving those with disabilities value as people.  It resulted in schools and educational programs dedicated to those with disabilities, who were otherwise viewed as incapable or unworthy of being educated or socialized.
  3. Social Darwinism – The philosophy of humanitarianism had direct conflict during the late nineteenth century by those who adhered to Social Darwinism.  This view related survival of the fittest to a social perspective.  Those who were weak physically, needing extra attention, or socially destructive – which included those with disabilities, the poor, and racial or ethnic minorities – should not be helped, leaving them and their genes to die off.  Social Darwinism was accepted enough in society that it was used to justify the sterilization of individuals with disabilities through the belief they were genetically inferior.
  4. Human Rights Philosophy – In conjunction with the civil rights movement, this philosophy grew to validate the equality in worth and value of all people to and in society.  Similar to the Humanitarian view which moved people to provide services and education to those with disabilities, the human rights movement refers to the legal mandate of sameness for all Americans in healthcare, social services, access, and education.  This philosophy is the underpinning for the move to deinstitutionalization and training and rehabilitation programs. (Darling, 2013; Newman, 1991; Pardek, 1998; Zastrow, 2008)
Group of people posing for a picture in front of a banner that says, "Welcome to Members of the Pacific Disability Forum.
Like with any other group that is viewed as different, those with disabilities were marginalized by society in the past - and still are to some extent today.  Social work embodies the human rights philosophy when it comes to advocating for our clients with disabilities. "The first Pacific Disability Forum Women With Disabilities Conference, in Port Vila, Vanuatu, 20 April 2009." by DFAT photo library is licensed under CC BY 2.0.

 

 

 

Legislative Protection

Today’s treatment of those with disabilities is still influenced by all four of the above views, though the utilitarian philosophy and Social Darwinism continue to become less and less of a factor in society.  The human rights movement can be seen as directly responsible for federal mandates requiring a protection of rights and provision of accommodations for people with disabilities.  Social Security legislation from the 1930s, as discussed in previous chapters, was the first piece of legislation to provide public assistance to the disabled.  In 1973, section 504 of the Rehabilitation Act directly prohibited any program, activity, or service receiving federal monies to discriminate against people who were disabled.  The Americans with Disabilities Act (ADA) of 1990 would later build upon section 504, applying to both public and private entities.  It specficied the types of accommodations that need to be made, opening up educational and employment opportunities for people with disabilities (Adams, Bell, & Griffin, 2007).  The 1975 original Individuals with Disabilities Education Act (IDEA) – first called the Education of All Handicapped Students Act – gave all students with any form of disability the right to receive a free education in the same public institutions that serve students who do not have any disabilities.  The most recent reauthorization of IDEA, combined with No Child Left Behind, is dedicated to making sure students are benefitting in public schools, “mainstreaming” students to be in general classrooms, as opposed to special education settings, and ensuring accommodations or more effective classroom learning environments when appropriate.

 

Defining Disability

The ADA and IDEA are the two most directive pieces of legislation protecting the rights of individuals with disabilities.  The ADA gives a useful definition of who the target population is for the regulations it provides, stating someone who is disabled has:

  1. a physical or mental impairment that substantially limits one or more major life activities of the individual;
  2. a record of such an impairment; or
  3. is regarded as having such an impairment

By not listing specific disabilities, the ADA allows for situations in which certain physical or mental characteristics not normally associated with impairment can be a barrier to utilization of a service or getting one’s needs met.  However, for a general understanding of what is included when we refer to disabilities, we can look to the U.S. Census Bureau’s report on Americans with disabilities.  The report outlines three different categories of disabilities but state that it is only as a means to group people with common experiences and that there are some people have a disability that may not fit into a defined domain (U.S. Census Bureau, 2012).  These disability domains are:

  1. Communicative – People with communicative disabilities can be visually impaired, be deaf or have difficulty hearing, and/or experience difficulty having their speech understood.
  2. Mental – This domain includes those with a neurodevelopmental disorder or neurocognitive disorder  and those with another mental or emotional condition that seriously interferes with everyday activities.  Common disabilities in the mental domain include learning disabilities, autism spectrum disorder, ADHD, dyslexia and dyscalculia, major depressive disorder, Down syndrome, Alzheimer’s, and traumatic brain injury.
  3. Physical – Those with physical disabilities use a wheelchair, cane, crutches, or walker; have difficulty walking a quarter of a mile, climbing a flight of stairs, lifting ten pounds, grasping objects, or getting in or out of bed; or can contribute arthritis, back problems, broken bones, cancer, cerebral palsy, diabetes, epilepsy, head injury, heart and circulatory conditions, hernia, hypertension, kidney problems, lung or respiratory problems, missing limbs, paralysis, stiffness or variously formed limbs, gastrointestinal problems, stroke, thyroid problems, or tumor/cyst/growths to a reported activity limitation. (p. 2)

 

Box 12.6: Term Discrepancies 

In talking about the mental domain of disabilities, the CDC differentiates between learning, intellectual, and developmental disabilities.  The American Association on Intellectual and Developmental Disabilities describes intellectual disability as falling under the umbrella term of developmental disabilities that are cognitive, physical, or both.  And IDEA lists the 13 specific disability categories that are eligible for services through the legislation as autism, deaf-blindness, deafness, emotional disturbance, hearing impairment, intellectual disability, multiple disabilities, orthopedic impairment, other health impairment, specific learning disability, speech or language impairment, traumatic brain injury, and visual impairment including blindness.  However, the DSM 5 (American Psychiatric Association, 2013)- what social workers refer to in providing formal diagnoses - has two umbrella categories for diagnosing these disabilities:

  1. Neurodevelopmental disorders - a group of conditions with onset in the developmental period.  The disorders typically manifest early in development...and are characterized by developmental deficits that produce impairments of personal, social, academic, or occupational functioning.  This category includes:
    1. intellectual disability
    2. communication disorders
    3. autism spectrum disorder
    4. ADHD
    5. motor disorders
    6. specified learning disorders like dyslexia. (p. 31)
  2. Neurocognitive disorders (NCDs) - the group of disorders in which the primary clinical deficit is in cognitive function and that are acquired rather than developmental...The NCDs are those in which impaired cognition has not been present since birth or very early life, and thus represents a decline from a previously attained level of functioning.  The major or minor subtypes are:
    1. NCD due to Alzheimer’s disease
    2. vascular NCD
    3. NCD with Lewy bodies
    4. NCD due to Parkinson’s disease
    5. frontotemporal NCD
    6. NCD due to traumatic brain injury
    7. NCD due to HIV infection
    8. substance/medication-induced NCD
    9. NCD due to Huntington’s disease
    10. NCD due to prion disease
    11. NCD due to another medical condition
    12. NCD due to multiple etiologies
    13. Unspecified NCD

In addition to these domains, it is also important to be aware of the fact that not all disabilities are congenital.  While certain disabilities can only exist since birth, such as Autism or Down syndrome, others can happen at any point in a person’s life, such as losing one's sight or experiencing a traumatic brain injury.  Some would even say it is more difficult adjusting to life with a disability the older you are when you acquire it.  No matter when it happens, however, disabilities can still put a person at a disadvantage in this country.  Social workers are there to help those with any disability navigate life in a world that is built around people that do not have disabilities.  The ADA and IDEA both do a good job of guiding the why and how of what we do with individuals with disabilities, much of which is about teaching strategies for adjusting one’s functioning with consideration of one’s disability.  These strategies can include how to comlpete ADLs, meeting personal and social needs, and processing the situation from a psychological aspect.  Children who are neurodivergent may learn strategies to better manage their behavior in a social setting, a person who can no longer walk may need personal counseling to deal with emotional adjustment to the disability, and someone born with a limb that is proportioned differently than the rest of their body will obtain and learn tools and strategies to complete ADLs in a way that works for them.  In addition, social workers help advocate for these clients in the various systems of which they are a part.  We can help educate families and communities on the specifics of different disabilities.  We should broker to provide the necessary accommodations for school and work when they are absent from those environments.  We can also work to give them opportunities for recreational activities they may not be able to regularly enjoy.  Our responsibility to these clients is to help them have the quality of life available to everyone without a disability.

Picture of Kari Miller, Paralympic volleyball gold medalist, posing with a volleyball and her prosthetic legs.
Many people equate having a disability with having a deficiency.  But the two are not equivalent.  People with disabilities might function different than the majority group in society, but they still function just fine.  We need to stop viewing disabilities as a problem for those who have them. "Kari Miller- paralympic Amputee" by TORCH MAGAZINE is licensed under CC BY-NC-ND 2.0.

 

 

Normalization of Disabilities

            One of the most important things that should direct social work practice with those with disabilities is the normalization of having a disability.  Historically, societies have, for the most part, viewed having a disability as an abnormal condition.  If people were born with, or developed, a disability and could not function “normally”, there was a justification for discriminating against them (Baynton, 2001).  The inability to conform to society’s ideals in behavior or appearance brings on the stigma of being different, of being abnormal (Darling, 2013).  Utilitarian viewpoints revolved around their ability to contribute without accommodations and social Darwinism used it to try and rid the “bad genetics” from the population.  Assumptions of inability, of uselessness, of being a strain on society instead of a benefit, or even that those with disabilities have unfortunate life situations and need our pity should be seen as an error in societal classification of normality (Brashler, 2012).  Society’s view of disability should not follow the medical model in that it is a physical condition that needs a cure.  Like any other difference, it should be seen as part of the wonderful salad bowl experience of American society.  Those with disabilities are taking pride in their disability being a part of their identity – not the entirety of it, with some people embracing their “disability” as a matter-of-fact.  A good example of this can be seen in the deaf community.  While those of us who are not deaf or hard of hearing may relate being able to sense sounds aurally as normal, those who are deaf may view their not being able to hear as normal (Hladek, 2009).  There is no reason for us not to think of disabilities as a cultural difference as opposed to a deficit in living.  Individuals with disabilities can - and should - be able to participate fully in all aspects of society, and social work needs to be the field to continue to work toward the realization of this.

 

Veterans

            In a chapter on healthcare and disabilities, it would be grave injustice if the veteran population was not acknowledged as a part of the discussion.  In our current political climate and the involvement of America’s armed forces in war zones around the world, it is critically that we recognize the impact fighting can have on our soldiers.  Through being caught in gunfights or explosions, witnessing the death of others while serving, or having to shoot at another human in order to protect yourself or your battle buddy, veterans may have any number of disabilities.  Traumatic brain injuries, chronic back problems, amputations, even PTSD can all have a strong impact on daily functioning.  The Wounded Warrior Project (2015), a non-profit agency serving veterans wounded in military service, estimates the number of soldiers who were severely physically wounded at 52,336, those with traumatic brain injuries at 320,000, and those with PTSD at 400,000.  Those of the armed forces, and their families, are eligible for services through the Veterans Administration, but may very well seek help or treatment outside of the VA for any number of reasons.  At the same there is still enough demand that the VA is recruiting social workers to counsel and facilitate the adjustment of these veterans to life with their disabilities.

 

Conclusion

            Being able to stay in good physical health can have a huge impact on a person's quality of life, and the ability of the healthcare system to help people maintain a high quality of life is dependent on a number of factors.  Social workers can play a role in making sure consumers are receiving the quality of care they deserve.  In social work in the healthcare arena, we truly rely on our generalist social work foundation to address the number of responsibilities we have to our clients at all levels of practice.  Even though we do not provide medical services to consumers, we do have an important function helping our clients, their families, and society meet the psychosocial aspect of the client's current situation.  Whether it is the result of prejudice and discrimination, lack of access to quality treatment, or interaction with personnel who cannot relate to the client, we always have to put our clients, their right to self-determination, and their right to meet basic physiological needs at the forefront of medical social work.

 

References

Adams, M, Bell, L. A., & Griffin, P. (Eds). (2007). Appendix 14C: Perspectives on the historical treatment of people with disabilities. In Teaching for diversity and social justice (2nd ed.). New York, NY: Routledge. Retrieved from http://www.life.arizona.edu/docs/ra-section/ability-hist.pdf.

Allen, H. (2012). Is There a Social Worker in the House? Health Care Reform and the Future of Medical Social Work. Health & Social Work, 37(3), 183-186.

American Cancer Society. (2015). The Patient Self-Determination Act (PSDA). Retrieved from http://www.cancer.org/treatment/findingandpayingfortreatment/understandingfinancialandlegalmatters/advancedirectives/advance-directives-patient-self-determination-act.

American Medical Association. (2006). Opinion 8.08 – Informed consent. In AMA code of medical ethics. Retrieved from http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/opinion808.page.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). American Psychiatric Publishing.

Americans with Disabilities Act of 1990 (ADA), 42 U.S.C. §§ 12101-12213. Retrieved from http://www.ada.gov/pubs/adastatute08.pdf.

Andrews, C. M., Darnell, J. S., McBride, T. D., & Gehlert, S. (2013). Social work and implementation of the Affordable Care Act. Health & Social Work 38(2), 67-71.

Austin, A., & Wetle, V. (2012). The United States health care system: Combining business, health, and delivery (2nd Ed.). Pearson Education, Inc.

Balasubramanian, B. A., Cohen, D. J., Davis, M. M., Gunn, R., Dickinson, L. M., Miller, W. L., & ... Stange, K. C. (2015). Learning Evaluation: blending quality improvement and implementation research methods to study healthcare innovations. Implementation Science, 10(1), 1-11. doi:10.1186/s13012-015-0219-z

Barr, D. A. (2008). Health disparities in the United States: Social class, race, ethnicity, and health. The John Hopkins University Press.

Baynton, D. C. (2001). Disability and the justification of inequality in American history. In P. K. Longmore & L. Umansky (Eds), The new disability history: American perspective. New York University Press.

Brashler, R. (2012). Social work practice and disability issues. In S. Gehlert & T. Browne (Eds.), Handbook of health social work (2nd ed.). John Wiley & Sons, Inc.

Centers for Disease Control and Prevention. (2014). About DCH. Retrieved from http://www.cdc.gov/nccdphp/dch/about/index.htm.

Centers for Medicare & Medicaid Services. (n.d.). Financing & reimbursement. Retrieved from http://medicaid.gov/medicaid-chip-program-information/by-topics/financing-and-reimbursement/financing-and-reimbursement.html.

Darling, R. B. (2013). Disability and identity. Lynne Rienner Publishers, Inc.

Finegold, K., Conmy, A., Chu, R.C., Bosworth, A., & Sommers, B.D. (2021) Trends in the U.S. uninsured population, 2010-2020. Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services. Retrieved from https://aspe.hhs.gov/sites/default/files/migrated_legacy_files//198861/trends-in-the-us-uninsured.pdf.

Greene, G. J., & Kulper, T. (1990). Autonomy and professional activities of social workers in hospital and primary health care settings. Health & Social Work, 15(1), 38-44.

Henry, S. L. (2007). The basics: Interacting with people with disabilities.  In Just ask: Integrating accessibility throughout design. ET/Lawton. Retrieved from http://www.uiaccess.com/accessucd/interact.html.

Hladek, G. (2009). Cochlear implants, the deaf culture, and ethics: A study of disability, informed-surrogate consent, and ethnocide. The Institute for Applied & Professional Ethics Archives. Retrieved from http://www.ohio.edu/ethics/tag/deaf-culture/index.html.

Hoffman, A. K., & Jackson, H. E. (2013). Retiree out-of-pocket healthcare spending: A study of consumer expectations and policy implications. American Journal of Law & Medicine, 39(1), 62-133.

Institute of Medicine of the National Academies. (2013). U.S. health in international perspective: Shorter lives, poorer health. National Academy of Sciences. Retrieved from http://www.iom.edu/~/media/Files/Report%20Files/2013/US-Health-International-Perspective/USHealth_Intl_PerspectiveRB.pdf.

Johnston, C., & Holt, G. (2006). The legal and ethical implications of therapeutic privilege – is it ever justified to withhold treatment information from a competent patient? Clinical Ethics, 1(3), 146-151.

Kongstvedt, P. R. (2009). Managed care: What it is and how it works (3rd Ed.).  Jones and Bartlett Publishers.

Kronenfeld, J. J. (2011). Medicare. Greenwood.

Martin, E. J. (2015). Healthcare policy legislation and administration: Patient protection and affordable care act of 2010. Journal of Health & Human Services Administration, 37(4), 407-411.

Munyi, C. W. (2012). Past and present perceptions towards disability: A historical perspective. Disability Studies Quarterly, 32(2). Retrieved from http://dsq-sds.org/article/view/3197/3068.

National Association of Social Workers. (2004). NASW standards for palliative & end of life care. Retrieved from https://www.socialworkers.org/practice/bereavement/standards/standards0504New.pdf.

National Association of Social Workers. (2011). Social workers in health clinics & outpatient health care settings: Occupational profile. Retrieved from http://workforce.socialworkers.org/studies/profiles/Health%20Clinics.pdf.

Nolan, L. C. (2011). Dimensions of aging and belonging for the older person and the effects of ageism. BYU Journal of Public Law, 25(2), 317-339.

Pardeck, J. T. (1998). Social work after the Americans with Disabilities Act: New challenges and opportunities for social service professionals. Auburn House.

Phelps, C. E. (2003). Health economics (3rd Ed.). Addison Wesley. Retrieved from http://www.aw.com/info/phelps/Chapter11.pdf.

Reese, D. J. (2013). Hospice social work. Columbia University Press.

Rice, T., Unruh, L. Y., Rosenau, P., Barnes, A. J., Saltman, R. B., & van Ginneken, E. (2014). Challenges facing the United States of America in implementing universal coverage. Bulletin of the World Health Organization, 92(12), 894-902. doi:10.2471/BLT.14.141762

Tham, S. J., & Letendre, M. C. (2014). Health care decision making. New Bioethics, 20(2), 174-185. doi:10.1179/2050287714Z.00000000051

The Henry J. Kaiser Family Foundation, & Health Research & Educational Trust. (2014). Employer health benefits: 2014 annual report (Publication #8625). The Henry J. Kaiser Family Foundation. Retrieved from http://files.kff.org/attachment/2014-employer-health-benefits-survey-full-report.

University of Ottawa. (n.d.). Definitions of health. Retrieved from http://www.med.uottawa.ca/sim/data/Health_Definitions_e.htm.

U. S. Census Bureau. (2012). Americans with Disabilities: 2010 [Publication P70-131]. U.S. Census Bureau.

U.S. Department of Health and Human Services. (2014). About the law. Retrieved from http://www.hhs.gov/healthcare/rights/index.html.

Veit, H. Z. (2012). "Why Do People Die?" Rising life expectancy, aging, and personal responsibility. Journal of Social History, 45(4), 1026-1048. doi:10.1093/jsh/shr155

Wounded Warrior Project. (2015). Who we serve. Retrieved from http://www.woundedwarriorproject.org/mission/who-we-serve.aspx.

Zastrow, C. (2008). Introduction to social work and social welfare (10th ed.). Thomson Brooks/Cole.

Chapter 13: Drugs and Addiction

Many clients we come across in social work have faced harsh judgment from others regarding particular aspects of their lives. Many people tend to look at the misfortunes of others and blame them for their circumstances, saying they must have done something to bring it upon themselves. Not many look at someone in dire straits and recognize they could just as easily be there themselves. This is especially true when it comes to substance abuse. People who struggle with drug abuse and dependence are often judged by those around them—seen as weak-willed, selfish, worthless. The public tends not to recognize that addiction is a disease, and they blame the user for the effects of the disease. We lock up our drug-using population in jail or prison repeatedly and  give them a chance at rehabilitation. Instead of treating the disease, we punish the person suffering from it. While drug users are not incapable of making changes, our collective lack of understanding of the nature of addiction means that they often do not get the empathy and help that will assist them in their recovery.

When you have finished reading this chapter, you should be able to:

1. Summarize several key events in America’s drug use history;

2. Examine the effects drug use has on a micro, mezzo, and macro level;

3. Understand the DSM-5 diagnoses for substance use disorders;

4. Evaluate various theories about the causes of drug use;

5. Categorize drugs based on similar effects they have on the user;

6. Explain how the government currently handles drugs from a legal standpoint;

6. Describe the various levels of care involved in substance use and mental health treatment;

7. Differentiate between abstinence and harm reduction strategies;

8. Identify risk factors for substance use and abuse;

9. Explain and give examples of process/behavioral addictions.

Cocaine
Cocaine seized during a drug bust on a yacht.
"Cocaine yacht" by National Crime Agency is licensed under CC BY 2.0

A Brief History of the War on Drugs

There was a time when we did not have any illegal drugs in America—not because there were no drugs, but because there were no laws. Our first drug prohibition laws were passed by states and local municipalities in the late 1800s and were largely motivated by racism, as many of our future drug laws would also be (Gray, 2012). However, this meant there was only a patchwork of various limited laws and no sort of national policy. People bought and sold patent medicines that contained opium, alcohol, cocaine, and all sorts of substances we now recognize as dangerous, addictive, and/or illicit drugs. Coca-Cola, as you have probably heard, contained cocaine in its formula (hence the first half of its name) until 1900—and the original formula also contained alcohol before it became a caffeinated drink. Many drugs we would later come to recognize were potentially dangerous were still legally and freely available at the beginning of the 20th century black market.

Pure Food and Drug Act

The first national law to be passed regarding drugs was the Pure Food and Drug Act in 1906. Corrupt or unknowing entrepreneurs were selling their pharmaceutical miracle substances without honestly labeling their contents, causing a serious health concern. The government finally felt it had to step in for public safety (Faupel, Horowitz, & Weaver, 2010). Note that it was not the user of the substances who was seen as the problem—it was the seller. The first national law on drugs was about protecting buyers from sellers. Use was not criminalized; selling people incorrectly labeled drug products was the crime. The Pure Food and Drug Act required sellers to disclose the ingredients in their concoctions, and as a result, sales of many patent medicines dropped precipitously. It was too reckless for most sellers to risk a prison sentence.

Harrison Act

However, the Harrison Narcotics Act of 1914 quickly undid a lot of the good that had been done by the Pure Food and Drug Act by making it practically impossible to legally distribute certain drugs (Gray, 2012). Even doctors were arrested and imprisoned for providing drug-addicted patients with prescription access to their substances of choice (Faupel et al., 2010). This law—still focused on the distributors rather than the users—led people with serious addictions no other option but to find illegal ways to secure their drugs, and that was an impetus for the development of the black market for drugs in America. The other impact of the Harrison Act was a major expansion of the pharmaceutical industry, which was already in existence but now had the potential additional client base of drug users who were no longer able to obtain their substances legally (Gray, 2012; Faupel et al., 2010; Levinthal, 2014). If drug manufacturers could create and sell legal drugs that had similar effects on users, they stood to make a mint.

Prohibition

The 18th Amendment to the Constitution outlawed alcohol sale, transportation, and manufacture in 1920. However, use was not outlawed, so alcohol obtained prior to the enforcement of the law could still be consumed legally (Royce & Scratchley, 1996; Kyvig & Jeffers, 2000). Prohibition had unintended negative impacts on the economy, however, and the country’s financial struggles during the Great Depression were part of what hastened the repeal of the amendment, allowing states to choose for themselves whether to “relegalize” alcohol within their borders. Every state eventually did, with Mississippi finally relenting in 1966 (Levinthal, 2014).

Secret Liquor Cellar
Though Prohibition did result in lower levels of alcohol consumption, hospital admissions related to alcohol, and deaths from cirrhosis, many Americans were unhappy about the law from the very start. Secret bars (speakeasies) and stashes of alcohol abounded.
"Secret Liquor Cellar" by mikepmiller is licensed under CC BY-NC-ND 2.0

Marihuana Tax Act & the Boggs Act

Following a huge anti-marijuana propaganda campaign driven by U.S. drug czar Harry Anslinger, who called the drug the “assassin of youth,” the Marihuana Tax Act was passed, effectively making marijuana a restricted substance much as the Harrison Act had done to opium and cocaine (Inciardi & McElrath, 2011; Anslinger, 1937; Miller, 2015). There were also penalties against possessing marijuana for nonmedicinal purposes, the first truly national drug law that punished the user. Mandatory minimum sentences for drug offenders were first instituted under the Boggs Act in 1951 (Gray, 2012).

The War on Drugs and the Controlled Substances Act

The emergence of LSD and the drug-friendly culture of the 1960s set the stage for Richard Nixon to become the first sitting President to take an active role in drug policy, as within his first year in office he declared that public enemy number one was dangerous drugs—an approach which broadly came to be called the War on Drugs. Under Nixon, the legislature passed a sweeping law that totally changed the way we approached drugs from an enforcement standpoint (Davenport-Hines, 2002). The Controlled Substances Act of 1970 put all drugs on what were called Schedules, based upon their potential medical use and the possible dangerous effects (overdose, addiction) stemming from their use. The focus fell heavily on users and distributors alike, though the Act did repeal the mandatory minimum sentences in place since the Boggs Act.

Box 13.1: Drug Schedules

The Controlled Substances Act of 1970 established five “Schedules” for the classification of drugs, based on their level of danger and their medical usefulness. Drugs placed on Schedule I are designated by the government as having no approved medical uses and high potential for abuse. Schedule II drugs have very limited approved medical uses and are recognized as dangerous and highly addictive, so they must be tightly controlled. This pattern continues until Schedule V, where drugs have little significant risk and may have multiple approved medical uses, but may contain small amounts of certain opioid substances. Here are some examples of drugs on each Schedule today.

schedules

You may reasonably wonder how in the world marijuana is on Schedule I when so many states have legalized medical (and even recreational) marijuana. There truly isn’t scientific justification for it being there, as there is virtually no overdose risk and many proven medical uses for the plant. However, federally, marijuana remains prohibited. Its placement on Schedule I is due to political reasons, not pharmacological ones.

(Source: U.S. Drug Enforcement Administration, n.d.)

From the 1980s until Today

In 1984, Congress passed a law that effectively raised the drinking age to 21 nationally; it had previously been 18 in some states and 21 in others, setting up dangerous situations where adults age 18-20 had incentive to drive across state lines (from Illinois to Wisconsin, for instance) to drink legally, then drive back home (Vander Van, 2011). This was followed by the Anti-Drug Abuse Act of 1988, bringing back the death penalty for major drug kingpins and establishing stiffer penalties for selling drugs close to schools or other places children were likely to be. In a policy decision social workers have criticized, under the 1998 Higher Education Act, college students and applicants were banned “from receiving federal aid for college if they had ever been convicted of marijuana possession, even though no such disqualification applies to convictions for offenses like robbery, rape, or manslaughter” (Faupel et al..; Gray, 2012, p. 27). The provision remains in place today despite the fact that many states have legalized medical or recreational use of marijuana, resulting in over 200,000 students losing an opportunity to receive federal student aid (American Civil Liberties Union, n.d.).

There are, of course, additional laws that we have not covered, but this gives a pretty clear picture of the foundation for our War on Drugs. We see drug use as a social ill, and not entirely without reason; still, our strategies for addressing it seem to do far more on the punitive side than the rehabilitative, and that does not appear to be having the effect of reducing drug use or crime. So why the strict, sometimes draconian anti-drug measures? What are the major problems that drug use is causing for our society?

Social and Economic Costs of Drug Abuse

It can be difficult to quantify the impact of drug misuse and drug abuse on America as a whole, but there are various data sets out there that attempt to do the job. It is clear that drugs have a widespread social impact, but what do people mean when they say drugs are a problem? Here are some items that may help you to understand a bit more clearly.

Health

According to the Drug Abuse Warning Network (DAWN), about 2.5 million emergency room visits in 2011 were related to drug abuse or drug misuse, more than a 50% rise over the numbers from 2004. In fact, after a slight dip in 2005, the number of emergency room visits related to drug use or misuse rose every single year until the most recent DAWN data available (U. S. Department of Health and Human Services, 2011). DAWN has since been discontinued, with various other measures used to track this data. Despite our intense governmental focus on arrests, prosecution, and incarceration for drug offenses, actual medical emergencies related to drugs are not decreasing or staying the same—they seem to be increasing.

Box 13.2: Drug Abuse Warning Network (DAWN) data, 2011

     

(Source: Substance Abuse and Mental Health Services Administration, 2014)

Other health concerns associated with drug use have to do with the high risk of the spread of blood-borne diseases like HIV, or hepatitis B and C. One study of people in six cities who used drugs via injection found that HIV infection ranged from three to 30 percent (compared to a national rate of 0.37%), hepatitis B infection from 50 to 80 percent, and hepatitis C 66 to 93 percent. The older the individual, the higher the infection risk, since that person had typically been injecting drugs for a longer time (Ksir, Hart, & Ray, 2006; U.S. Census Bureau, 2015; Centers for Disease Control, 2015).

Overdoses and driving while intoxicated are certainly scary impacts of use; these are both examples of acute toxicity—a drug’s capacity to do immediate damage due to its chemical composition, its method of use, or both. Drugs also have the potential for chronic toxicity (for example, lung cancer from smoking). Some drugs have greater toxicity risk than others; their specific risks will be discussed as we cover each drug later in this chapter.

Overall, the impact on public health is perhaps the most discussed element of our concerns about drug use. However, there are other impacts to consider as well.

Economic impact

The health impact of drugs has a serious economic effect. The world’s economy takes a hit of nearly $900 billion annually from alcohol-related health problems and another $900 billion from the use of all other drugs (Doweiko, 2012). The estimated cost to the United States alone from alcohol, tobacco, and other drugs is $559 billion, nearly one third of the world’s total economic expense (National Institute on Drug Abuse, 2008). These costs come from medical expenses, lost productivity at work, crime and enforcement expenses, and the costs of keeping drug crime offenders incarcerated, which is considerable.

DRUG DEAL
Caption: We often hear about how much drug use costs the economy, but do not stop to think about the fact that the drug market is actually a thriving part of our economy, underground or not.]
"DRUG DEAL" by marc falardeau is licensed under CC BY 2.0

Of course, it can also be convincingly argued that the drug trade makes an economic contribution. Firstly, the massive numbers of people incarcerated for drug crimes create jobs—correctional officers, police officers, social workers, judges, wardens, and so on. Imagine all the jobs that might be lost if we were more lenient on drug crime. While your authors are not suggesting to keep drugs illegal in order to produce jobs, there would certainly be an adjustment to make in many local economies and our society overall if we were to decriminalize or legalize many drugs. (In some towns in the United States, correctional facilities are the #1 employer, and drug laws help keep those cells full.) The illegal drug trade contributes jobs to the economy as well, from the “CEOs” of these black market organizations down to the street-level seller. As for alcohol, prescription drugs, and tobacco, it’s clear they create thousands upon thousands of jobs, with distillers, liquor store employees, chemists, salespeople, truck drivers, and bartenders just a few of those we could mention. “The economy sees no moral or legal distinctions between and among products or…laws. The sale and purchase of all products—whether alcohol, cigarettes, pornography, candy bars, cars, or Bibles—entail plusses and minuses for the economy” (Goode, 2012, p. 384). That economic boon from the War on Drugs leads us into the next impact of drug use.

Crime

There is little doubt that crime is a huge part of the picture when it comes to the impact of drugs, and it probably would have a major impact even if drugs themselves were legalized—there would still be arrests for driving while intoxicated, violence committed by people under the influence, and violent crimes and property crimes committed by people with addictions who needed to obtain money in order to fund their habit. Of course, the single drug most likely to be connected to crime is a legal one: alcohol (Ksir et al., 2006). “In a majority of homicides, aggravated assaults, sexual crimes against children, and sexually aggressive acts against women, the offender had been drinking” (Zastrow, 2010, p. 258). Illicit drug use, manufacture, and sale are also crimes that result in many incarcerations.

For the last ten years or so, the overall crime rate has been on the decline; however, drug arrests have climbed over the same period. Additionally, while our population of incarcerated violent offenders has doubled since 1980, the number of prison inmates convicted of drug crimes has increased 600% (Gray, 2012). Taking one state as an example, between 1980 and 2008, the number of prisoners in New York incarcerated for nonviolent drug offenses went from 1,500 to 20,000. Over approximately the same time span, the chance of a drug arrest leading to prison time more than doubled (13% vs. 28%) while arrests were increasing by about one thousand percent (Drucker, 2013). It is worth noting that states can change their patterns of incarceration given the right motivation, though--New York jail populations decreased by around 40% in 2019-2021 thanks to bail reform and releases driven in part by the COVID-19 pandemic (Vera Institute of Justice, 2021). There are solutions if we are willing to find them.

Not only are those individuals in prison costing the state money to house, clothe, and feed, they also cannot contribute to the economy by paying taxes through work, and if they have families, that increases the chance those families will need public assistance to survive. When those prisoners get out, of course, their chances of getting gainful employment are notably lower due to felonies on their records, further hampering economic development. These factors must be considered in the economic impact of drugs as well.

 

Four Principles of Drugs

Ksir et al. (2006) mention four specific principles of psychoactive drugs to keep in mind.

  • Drugs are neither good nor bad. Drugs are merely substances; their use may have positive or negative effects, may hurt or harm people, but that says nothing about the drug itself. For example, Vicodin (generic name: hydrocodone)  is a very effective prescription painkiller that provides relief for many people. However, it is also highly addictive, and Vicodin dependence has been known to precede users progressing to heroin use (Heady & Haverstick, 2014), something that has been obvious in America's opioid epidemic. Vicodin on its own is the same chemical compound regardless of how it’s being used. The drug itself is neither good nor bad.
  • Every drug has multiple effects. We have not gotten good enough at crafting drugs to be able to design them to have one specific effect. Drugs have an impact all over the body, including multiple areas of the brain, so it is to be expected that they would engender multiple effects. There is a reason you hear a laundry list of side effects during every pharmaceutical commercial!
  • Both the size and quality of a drug’s effect depend on the amount the individual has taken. At times, a drug simply has a more profound effect as the dosage increases. However, with some drugs, different doses seem to bring about different families of results—a phenomenon known as biphasic effects (Ketcham & Asbury, 2000). For example, one or two drinks may leave someone feeling friendlier and more outgoing, while several more drinks may lead to irritability and anger.
  • The effect of any psychoactive drug depends on the individual’s history and expectations. We have the ability to adjust to the effects of a drug over time—that is known as building tolerance. Drugs also have pharmacological effects and nonspecific effects. Have you ever known someone who thought he/she was drinking alcohol and started to act drunk, even though there was no alcohol in the drinks he/she was being given? This illustrates how powerful the brain can be in shaping the impact of a specific drug. If one’s brain is expecting to feel a certain way, there is an increased chance one will feel that way upon taking the substance, regardless of whether or not the substance was intended to have that effect.

 

Substance Use Disorders

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) is the reference guide for all diagnosis of mental disorders in the United States. It came out in 2013 and will be fully implemented in mental health treatment programs by late 2015. The book (which is covered in far greater depth in Chapter 14) marked a major change in the way disorders related to substance use were recognized and diagnosed. Previously, one could be diagnosed with substance abuse or substance dependence, but the DSM-5 takes a different approach.

Under this edition of the book, all disorders related to substance use fall under the general diagnosis of substance use disorder, whether the use would previously have qualified as abuse or dependence. Under the guidelines of the DSM-5, there are simply specifiers for the degree to which one has a disorder: mild, moderate, and severe (American Psychiatric Association [APA], 2013). In order to receive a diagnosis at the mild level, a client must meet 2-3 out of 11 criteria; for mild, 4-5; and for severe, 6 or more. (See the box below for the full listing of criteria.) There are four criteria that deal with loss of control, three which address social impairment, two involving risky use, and two revolving around pharmacological states (specifically, tolerance and withdrawal; APA, 2013).

Each substance receives a separate diagnosis; that is, one can be diagnosed with alcohol use disorder, mild and amphetamine use disorder, moderate. The drugs are considered individually rather than as a group (APA, 2013). 

Box 13.3: DSM-5 Criteria for Diagnosing Substance Use Disorders

1. The substance is often taken in larger amounts or over a longer period of time than intended.

2. There is a persistent desire or unsuccessful efforts to cut down or control use of the substance.

3. A great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects.

4. Craving, or a strong desire to use the substance.

5. Recurrent use of the substance resulting in failure to fulfill major role obligations at work, school or home.

6. Continued use of the substance despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of opioids.

7. Important social, occupational or recreational activities are given up or reduced because of the use of the substance.

8.  Recurrent use of the substance in situations in which it is physically hazardous.

9. Continued use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance.

10. *Tolerance, as defined by either of the following:
(a) A need for markedly increased amounts of the substance to achieve intoxication or desired effect.
(b) Markedly diminished effect with continued use of the same amount of the substance.

11. *Withdrawal, as manifested by either of the following:
(a) The characteristic withdrawal syndrome for the substance.
(b) The same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms.

*This criterion is not considered to be met for those individuals taking the substance solely under appropriate medical supervision.

Severity: Mild: 2-3 symptoms. Moderate: 4-5 symptoms. Severe: 6 or more symptoms. 

(Source: APA, 2013)

 

These changes were met with some skepticism and resistance by many addiction treatment professionals, partly because people had become accustomed to those previous categories, but also for other reasons. For instance, the degree of the disorder is determined simply by counting criteria, which makes it seem like every individual criterion represents the same degree of concern. As Morrison (2014) noted, however, “Not all criteria are created equal. Some imply far more disability and distress than others,” particularly tolerance and dependence (p. 402). Regardless, this is the current diagnostic scheme and will likely remain so until the next edition of the DSM is released.

Informally, addiction is often considered to be present when an individual has experienced significant negative consequences from using a substance, but continues to use it (Kuhn, Swartzwelder, & Wilson, 2008). One may continue to use a drug—despite that substance causing problems in one’s life—because withdrawal is painful and/or unpleasant, one has become used to relying on the drug to help with difficult emotions, one is self-medicating some degree of pain, or many other reasons.

 

Why Do People Use Drugs?

If we talk about drugs as a whole, the fact is that most people use them. Caffeine, aspirin, and alcohol are all drugs, though we often do not think of them in that sense. Of course, some drug use is instrumental, and some is recreational. However, let us think specifically about recreational drug use. Why do people feel compelled to seek out altered states of consciousness? Here are some prominent theories that aim to answer that question.

Anomie

This sociological theory posits that although we are all told success (as defined by mainstream society—economic and physical comfort) is achievable for everyone, and we are told the means for reaching success (education and hard work), in reality, most of us will not reach the goal by following the prescribed path. Those individuals who struggle may attempt to find other ways to reach the goal outside of society’s norms—for instance, criminal activity. Another option if success cannot be reached is to choose to no longer follow society’s instructions, and to do whatever helps one to feel happy now. For some, this theory argues, that means using drugs, which are mostly disallowed by societal rules, but still reliable in their short-term ability to make people forget negative circumstances.

Social control

According to social control theory, we would all use drugs if we felt we could do whatever we wanted. It is only social norms, rules, and institutions that stop us from doing so. Therefore, drug use is not that hard to understand. Those who are most likely to engage in drug use are those who are least connected to the typical institutions, structures, beliefs, and moral teachings of the society in which we live. People who have a lot to lose will be less likely to risk deviating from expected behavior; people who already do not have a lot of social advantages will be more likely to do what they want and to disregard society’s expectations (Good, 2012; Liska, 1992).

This would explain why people who are already oppressed or denied certain access to resources or opportunities in society may turn to drug use. It also could explain why people who choose not to use drugs make that choice—the perceived costs of deviance are too high. They already “have it good,” so why risk it? However, there are a lot of people who appear to have their lives put together on the outside, who seem to be connected to a lot of social institutions and to have what a lot of people want, yet still use illegal substances.

Differential association

The basic idea of differential association is that one tends to copy what is being done by those in one’s immediate environment: family, peers, neighborhood, general social circles. If it is the norm for people in our family to drink heavily, and we also see many people in our community doing so, we are likely to think that is what most people do. Therefore, we will be more likely to do it ourselves, because we believe it to be expected (Good, 2012; Hollin, 2012).

However, some have argued that this can also go in the other direction—a person could feel like she/he wants to use drugs, and therefore seeks out associations with people who do so, thereby creating a social group which accepts what the person wanted to do in the first place. This may help explain how some people who grow up in healthy, non-using families in relatively low-use areas still end up becoming drug users themselves.

Labeling

In another way of looking at the issue, almost all of us are drug users, at least on occasion. However, most of us never progress to or maintain a level of use that causes us functioning problems for very long. According to this theory, people are more likely to exhibit the problematic behaviors of addiction once they get labeled as people who have a “problem” or an “addiction.” Since that does not happen to most of us, we do not become addicts.

Zastrow (2010), however, points out that labeling theory falls short when it comes to explaining “closet alcoholics” (p. 251) or other people who successfully hide the extent of their use even though it has caused a lot of problems, like author Augusten Burroughs in his memoir Dry, for example (2003).

Addictive personality

There is a belief among pop psychologists, and some researchers who have been looking for evidence of it, that addiction is somehow connected to particular personality traits—something “seen in compulsive drug users but not in others” (Ksir et al., 2006). One problem with this theory is it is impossible to know how much of someone’s personality has been impacted by the individual’s drug use. If we had a personality profile of every person before drug use started, and were able to compare those with the personalities of people at the same age who did not go on to have problems with drugs, we might be able to come up with something useful. Though there appear to be some correlations in studies of that sort (for instance, independence, impulsivity, and nonconformity have been linked to later risk of developing alcoholism), there is no simple cause-and-effect relationship, and many people with those traits do not develop addictions. As of yet, there is no agreed-upon personality profile that leads to addiction (Ksir et al., 2006; Griffiths, 2016).

Genetic susceptibility

Animals can be bred to prefer alcohol over other beverages, and we have significant evidence that alcoholism runs in family units. Even when children of alcoholics are separated from their parents at birth and raised in other families, they are more likely to exhibit the signs of alcoholism later in life than kids whose parents are not alcoholic (Good, 2012; Henningfield, 2008; Ketcham & Asbury, 2000; Galanter & Kleber, 2008). In fact, in studies of identical twins—always the go-to study when it comes to determining genetic influence—similar patterns were found for alcoholism and addictions to cocaine, opiates, and some other drugs (Henningfield, 2008; Galanter & Kleber, 2008). The evidence of genetic links remains strongest for alcoholism, but more research continues to be done regarding the relationship of our genes to other drug abuse.

Box 13.4: Getting Drugs into the Body

methods of administration

Categories of Drugs

Drugs can be grouped into categories based upon the sorts of effects they have on the human body. Different sources may choose to break things down slightly differently, but we will present the following groups: depressants, stimulants, opioids, hallucinogens, inhalants, and steroids.  Marijuana and nicotine will also be discussed separately, as their effects represent a combination of different categories of effects and they are sometimes considered to be uniquely classified.

 

Depressants

Depressants are drugs that slow down the activity of the central nervous system (your brain and spinal cord). They are also been called “downers” due to this basic effect. Depressants make up a large portion of our drug use, largely because of the number one depressant we consume: alcohol. Other drugs in this category include barbiturates, benzodiazepines, GHB, and ketamine.

Alcohol

We have been using and abusing alcohol for millennia in human history, likely even before we were recording history, by consuming rotten fruit and grain. Alcohol is essentially the waste of the yeast microorganism. Yeast consume sugar and they excrete alcohol; once they start, they will continue until they die. Therefore, alcohol can be produced by adding yeast to something with natural sugar—malt or fruit, for example—and sealing it into an oxygen-free environment, where it will carry out the fermentation process. The percentage of alcohol that normally will be created if fermentation is allowed to continue until it ends on its own is about 12-16% (Ksir et al., 2006; Levinthal, 2014). See Box 13.5 for the average alcohol content of different kinds of alcoholic drinks.

Box 13.5: Alcohol content of various beverages

 

 

 

 

 

 

 

 

 

           

 

Beer

Malt liquor

Table wine

Fortified wine

Cordial, liqueur, aperitif

Brandy

Spirits (gin, vodka, whiskey, etc.)

5% ABV

7% ABV

12% ABV

17% ABV

24% ABV

40% ABV

40 % ABV

(ABV = alcohol by volume)

An approximately equivalent amount of pure alcohol (0.5 fl. oz.) can be found in 12 oz. of beer; 8-9 oz. of malt liquor; 5 oz. of table wine; 3-4 oz. of fortified wine; 2-3 oz. of cordial, liqueur, or aperitif; and 1.5 oz. of brandy or spirits. Each of these can be considered “a drink” when you are trying to calculate how many drinks you’ve had in an evening.
(Source: National Institute on Alcohol Abuse and Alcoholism, n.d.)

In fact, alcohol is so ensconced in American culture, it may be the only drug whose use is expected of people; a person who does not use cocaine rarely has to explain that decision, but when someone notes they do not drink, others often expect an explanation. Still, most Americans tend to drink lightly to moderately. In fact, about 60% of the alcohol used in the United States is consumed by the 10% of people who are the heaviest drinkers; on the other hand, about 30-35% of Americans do not drink alcohol at all (Levinthal, 2014; Saad, 2012).

One of the environments in which alcohol use is particularly prominent is college. It is not unusual to start drinking before age 21, as you probably know—in fact, the average age at which kids start if they do not wait until 21 is just 14—but many people reach a peak of alcohol use in college (Levinthal, 2014). Binge drinking occurs in over 40% of students during a given two-week period, and 25% of students reported having academic problems they believed to be connected to their drinking. Additionally, 20 percent of college students say they have had unplanned and/or unprotected sex while under the influence (Levinthal, 2014).

Box 13.6: Impact of Blood Alcohol Content

BAC

Note that when someone passes out, that person is not simply “sleeping it off;” the body continues to absorb alcohol in the digestive system while one is unconscious and alcohol poisoning and death can still occur. Additionally, a passed-out person can vomit and have no way to clear their airway, which could lead to choking. If someone falls asleep when drinking, either get the person to a hospital or continually keep an eye on their status and check on them. Breathing could stop at any time.(Sources: Centers for Disease Control, 2015b; Zastrow, 2010; Kuhn et al., 2008)

Binge drinking is a high-risk behavior that quickly raises one’s blood-alcohol content (BAC). The BAC an individual has can give an idea of how much that person has been drinking recently. Any number of 0.08 (that’s 8 parts per 10,000) or higher is above the legal limit in the United States and can result in an arrest for driving under the influence. In 2011, almost a third of all traffic deaths were alcohol-related (Levinthal, 2014). At a BAC of 0.10, one is seven times more likely to have an accident than if there were no alcohol in one’s system; at 0.08, the risk is still three times greater than with no alcohol. About one in five alcohol-related accidents occurs with a driver whose BAC is between 0.01 and 0.05 (Royce & Scratchley, 1996; Ksir et al., 2006). Contrary to popular belief, the biggest problem with driving under the influence comes not from speeding or swerving; it is the failure to notice something (like a pedestrian or a car pulling out) and react accordingly. Reflecting an understanding of alcohol’s impairing effects, most countries in the world that have a legal limit for BAC while driving have a lower limit than the United States, with some as low as 0.00 (International Center for Alcohol Policies, 2015).

What determines one’s blood-alcohol content? According to multiple sources (Royce & Scratchley, 1996; Ketcham & Asbury, 2000; Kuhn et al., 2008), these are several of the factors:

  • Strength of the drink: The more alcohol in a drink, the higher one’s BAC rises—but you probably could have guessed that.
  • Number of drinks: The more drinks one has, the higher BAC climbs.
  • Time: The more quickly someone consumes alcohol, the higher BAC will rise; two similarly sized men who drink the same five drinks will have different BACs if one downs the drinks in 1 ½ hours and the other one spreads the drinks out over three hours. The passage of time allows one’s body to process and eliminate the alcohol.
  • Sex: A male drinker that weighs 180 pounds will have a lower BAC than a female drinker who weighs 180 pounds and drinks the same amount of liquor. This is due to the sexes’ different body-fat percentages as well as different levels of alcohol dehydrogenase, an alcohol-processing enzyme.
  • Age: Older people generally have higher body fat percentages and therefore will have higher BACs than people of the same sex and weight who are younger.
  • Food in one’s stomach: An empty stomach causes BAC to rise faster. People who drink on a full stomach will absorb the alcohol more slowly because the body is processing food as well as alcohol.
  • Weight: The more one weighs, the lower the BAC will be if all other factors are equal, because the body that weighs more will have more body water in which to distribute the alcohol.
  • Birth control: A person who is on birth control pills eliminates alcohol more slowly than one who is not, resulting in a longer time at peak BAC and a longer wait to return to 0.00.
  • Emotional state: Anxiety, stress, anger, and fatigue are all emotions that slow the absorption of alcohol in the body, unless one is chronically anxious, stressed, or angry—then that person’s BAC actually rises faster.
  • Carbonated drinks: The bubbles speed up absorption of the alcohol, causing BAC to rise faster. So having a rum-and-Coke gets the alcohol into one’s system faster than having whiskey and water. Interestingly, however, a rum-and-Diet-Coke will cause the alcohol to get absorbed slightly faster than even regular Coke, since the regular Coke has sugar to occupy the digestive system as well.
  • Condition of one’s stomach and bowel linings: If the stomach is irritated by alcohol and quickly moves it to the intestine, it will be absorbed earlier, heightening one’s BAC more quickly.
Mixed drink
Mixing your alcohol with soda may actually increase your blood-alcohol content more quickly than if you drank the liquor straight!
"Mixed drink" by MoneyBlogNewz is licensed under CC BY 2.0

 

Beyond the risks of drinking while intoxicated or sustaining alcohol poisoning, alcohol has other significant physical risks. In fact, alcohol kills more than five times as many people as all illegal drugs combined (Royce & Scratchley, 1996). For one thing, alcohol is synergistic with many other drugs, including barbiturates, benzodiazepines, and painkillers. This means that instead of the effects of the drugs adding up when one takes them together, they multiply each other. It is very dangerous to take these substances together, as the risk of overdose is much higher than it would be for either drug on its own. That is one reason a lot of prescriptions indicate that they should not be taken with alcohol.

Some of the other health concerns associated with alcohol are:

  • Withdrawal: In serious alcoholics, withdrawal is very dangerous and can even be life-threatening. If someone who normally drinks frequently and/or heavily develops hallucinations, shakes, tremors, or has seizures, emergency medical assistance should be sought immediately. An alcoholic should not go through withdrawal without medical supervision.
  • Blackouts and memory loss: Once thought to be something that occurred only with more experienced alcoholics, recent studies have shown up to 40% of college students have experienced alcoholic blackouts (Kuhn et al., 2008). Blackouts are more than just “passing out”—they refer to an extended period of time for which the person has no memory of anything that occurred, even though they were walking around and interacting with people much as they normally would. Long-term alcohol exposure appears to lead to brain shrinkage for some drinkers; even low doses of alcohol inhibit the brain’s ability to form new memories (Kuhn et al., 2008).
  • Other brain functions: Over two-thirds of people who submit to treatment for alcohol use disorders suffer from problems with abstract thinking, problem solving, attentiveness, the ability to concentrate and focus, and/or their ability to interpret the emotions of others. Some of this can come back if one stops drinking, but some of the deficits appear to be permanent in long-term heavy drinkers, even if use completely stops (Kuhn et al., 2008).
  • Liver damage: The first stage of chronic alcohol use’s impact on the liver is fatty liver, a reversible condition that nonetheless can be a factor in some deaths (Royce & Scratchley, 1998). Fatty liver can proceed to alcoholic hepatitis, a more serious but also somewhat reversible condition, but the next stage is cirrhosis, and then there is no going back. Cirrhosis is a buildup of scar tissue in the liver that inhibits the organ’s ability to filter out dangerous substances in the blood; produce substances that assist in blood clotting and fighting infection; and potentially leads to gout (Royce & Scratchley, 1998). Cirrhosis and liver disease were the 12th-likeliest cause of death in the United States in 2013; somewhat alarmingly, the rate of death from cirrhosis has been steadily increasing since 2006 (Centers for Disease Control, 2015c), and it became the 11th-leading cause of death by 2017 (Kochanek, Murphy, Xu, & Arias, 2019).
  • Pregnancy: Consumption of alcohol during pregnancy causes a higher risk of intellectual disabilities due to fetal alcohol syndrome or fetal alcohol effects—it is the single biggest preventable cause of such conditions. What’s more, consumption during only the early stages of pregnancy—when a woman may not even yet know she is pregnant—seem to have as much of an impact on overall brain development as consuming alcohol during the entire pregnancy (Maier & West, 2001).
  • Heart problems: High blood pressure, stroke risk, and arrhythmia are all more common in moderate-to-excessive drinkers (Ketcham & Asbury, 2000).
  • Mental health problems: Suicide risk for alcoholics is at least 15 times higher than non-alcoholics; even about a quarter of alcoholics who have had treatment commit suicide. Depression is a common “consequence of alcohol’s widespread disruption of brain chemistry” (Ketcham & Asbury, 2000, p. 81). The COVID-19 pandemic contributed both to increased alcohol use and increased mental health problems; these are often linked (Pollard, Tucker, & Green, 2020).
  • Sex: Alcohol is linked with decreased ability to perform sexually as well as increasing the chance of being involved in a date rape (as either the perpetrator or victim) and lower chance of using contraception correctly (Carroll, 2010).
  • Cancer: Though it shocks many people to hear, it appears that between three and four percent of all cancer deaths in the United States are related to alcohol use—over 19,000 deaths annually (National Cancer Institute, 2013). Increasing alcohol use by 10 grams per day leads to a 10% increase in breast cancer risk in women, and the World Health Organization has placed alcohol on its list of known carcinogens (International Agency for Research on Cancer, 2009).

We have spent a lot of time discussing alcohol, and yet could spend much more, given its status as one of the most destructive and most frequent drugs we use. One final point we will note is its impact on the family. Alcohol use is more strongly linked with an increased risk of domestic violence—both partner abuse and child abuse—and rape than any other drug. Even when there is not violence, alcohol has a profound impact on everyone in the family of the alcoholic.

Sharon Wegscheider-Cruse, a family therapist and founding chairperson of the National Association for Adult Children of Alcoholics, recognized several commonalities in the families with whom she worked if alcoholism was present. Over time, she developed a sense of a few specific roles into which people in alcoholic families seemed to fall. Each one of these roles serves a specific function for the person who fills it, and each one represents that person’s part in what has come to be known as the family disease of alcoholism. That is not to say that the alcoholic’s behavior is anyone else’s fault or responsibility—far from it. However, recovering from the impact of alcoholism on one’s family may require recognizing the role one came to play as an adjustment to an unhealthy home dynamic.

It should be noted that although Wegscheider-Cruse noted these roles in working with alcoholic families, it is easy to apply them to families with other sorts of addictions present, or even to families with some other significant dysfunction. The roles are:

The chief enabler: Often the spouse of the alcoholic (but also possibly a parent), the chief enabler helps the alcoholic to avoid the consequences of drinking. The chief enabler “often acts out of a sincere, if misguided, sense of love and loyalty…[or] may also act out of shame, to protect her own and the family’s self-respect” (Wegscheider-Cruse, 1981, p. 90). While each individual choice seems to be made to help the alcoholic (e.g., calling the alcoholic in sick to work when she/he has a hangover, staying up late to type up a project the alcoholic needs for the next day while she/he is passed out), in reality, the chief enabler’s efforts stop the alcoholic from learning that her/his behavior is destructive and problematic. We tend to learn from our mistakes due to the consequences of those mistakes. When we don’t experience consequences, we may feel no reason to change our behavior (Wegscheider-Cruse, 1981).

The family hero: Often the oldest child in a family, the family hero picks up the slack of the alcoholic inside the home and is a major success outside of it—doing well in school, active in the community, or perhaps a star athlete—perhaps all of these things (Wegscheider-Cruse, 1981). The hero seems to have it together and brings positive attention to the family, since they have produced such an outstanding child. They serve the purpose of helping the family to have some much-needed pride, but they also tend to be very self-critical and even perfectionistic. They throw themselves wholeheartedly into endeavors, for that is what has helped them to feel self-worth when their family has fallen short (Wegscheider-Cruse, 1981).

The scapegoat: Wegscheider often found that the second child in the family was the scapegoat—sort of an anti-hero in the family. The scapegoat spends less time at home and more with peers, and as a result of getting progressively less attention from their family, the scapegoat begins to act out—using substances, getting disciplined at school, getting into legal trouble (Wegscheider-Cruse, 1981). Painful feelings are covered by angry outbursts. The family sees the scapegoat as a possible cause of the alcoholic’s drinking and the scapegoat becomes a lightning rod for criticism, again deflecting the community’s attention away from the foundational issue—the alcoholic’s drinking (Wegscheider-Cruse, 1981).

young kid smoking
The scapegoat in an alcoholic family may draw attention to herself through troublemaking and rebellious behavior.
"young kid smoking" by michaeljoshua1 is licensed under CC BY-SA 2.0

 

The lost child: Sometimes the third child in the family, if there is one, the lost child is a loner and tries to stay out of others’ way. Because the child demands so little attention, very little attention is given (Wegscheider-Cruse, 1981). The family sees the lost child as a relief—not needing excessive attention like the scapegoat nor the family hero. This child still needs affection, support, and encouragement just as much as the others, but does not get it—in fact, the lost child gets almost nothing. This causes major struggles in social relationships, since the normal interactions that help children develop into adults have never really occurred (Wegscheider-Cruse, 1981).

The mascot: Often the youngest, the mascot has been the object of the family’s attempts to keep the problem a secret. The child can still see the dysfunction all around, but doesn’t have the frame of reference to understand it completely. Vague assurances like “It’ll be okay, don’t worry” and sometimes outright lies are told to the mascot in an effort to protect them, but it is futile. The mascot can sense something is wrong, even though others say there is nothing of concern. They compensate by trying to bring everyone’s mood up, by being a goofball, showing off. This gives the mascot the positive attention he/she craves. The mascot serves a helpful role for the family emotionally, giving them something happy to focus upon briefly instead of the family’s problems, but it is only a temporary escape.

Obviously, not every role will appear in every family, and sometimes people may even shift from one role to another—Wegscheider-Cruse (1980) said she had seen some people who went from being hero to scapegoat or vice versa. If you go into this field and work with families with addiction issues, or individuals from such families, you will likely recognize some of these roles being played out.

Barbiturates

Not very widely used any longer, barbiturates once enjoyed a wide range of medical applications. Today, they remain in use primarily as antiseizure medications and anesthetics (Avramut, 2013). Two major reasons for the nearly full replacement of barbiturates with other medications is the dangerous synergistic nature of barbiturates with alcohol, and their relatively small safety margin—that is, the difference between the effective dose and the lethal dose. Their alcohol-like effects also made them popular drugs of abuse—both Elvis Presley and Marilyn Monroe were barbiturate users (Avramut, 2013).

Benzodiazepines

The group of drugs mostly responsible for pushing barbiturates off the market is benzodiazepines (benzos for short). They have become the predominant class of drugs prescribed for anxiety reduction, insomnia relief, and related conditions, and they have a significantly greater safety margin than barbiturates. However, they are still dangerously interactive with alcohol, and combining the two in one’s system can lead to fatal overdose (Brick, Wallen, & Lorman, 2008). Benzodiazepines are one of the most commonly prescribed groups of drugs today; some that you may know well are Xanax, Valium, Ativan, and Klonopin.

Although these drugs are safer than their barbiturate predecessors, some (like Valium) are still prone to abuse. Someone intoxicated on benzodiazepines will likely look much like someone who is fairly drunk: slurred speech, poor coordination, confusion, poor focus, and mood changes (Van Hoey, 2013a). Like alcohol, benzodiazepine dependence can cause problems with brain function that may not be recoverable even if use ceases, and withdrawal can lead to fatal convulsions. Medical monitoring is highly recommended (Van Hoey, 2013a).

Rohypnol is also a benzodiazepine, though it was never legally prescribed in the United States. It is still used in many countries as a highly effective hypnotic drug. Part of the reason for its strict control here and in some other nations is its nature as an effective date rape drug—given the nickname “Roofies” when used for that specific purpose. It works well for these crimes because it induces both sleep and anterograde amnesia—an inability to form new memories while under the influence. Therefore, people are able to slip it into drinks in order to use it to rape unconscious or heavily sedated victims who would then have no memory of the event and potentially no idea whom to report for the crime (Gerald, 2013).

Ivo drops the rohypnol into @jilyjil01 's drink #VSCOcam
Though never legal in the U.S., Rohypnol continues to be fairly easy to obtain from certain sources and is still being used to incapacitate unsuspecting potential rape victims, often when combined with alcohol.
"Ivo drops the rohypnol into @jilyjil01 's drink #VSCOcam" by Gribiche is licensed under CC BY-SA 2.0

Rohypnol is also a drug that has been used in combination with alcohol in many suicide attempts. Nirvana frontman Kurt Cobain attempted suicide with Rohypnol and champagne a few weeks before his final suicide attempt in 1994 (Gerald, 2013).

GHB

GHB (gamma-hydroxybutyric acid) is a naturally occurring sedative substance in the brain. Synthesized in laboratories or by drug dealers, GHB was once sold over the counter as a muscle-building supplement and hypnotic drug. However, like Rohypnol, it proved to be dangerously effective as a date-rape drug—easy to conceal in a drink, and inducing mild amnesia while increasing the victim’s sex drive. The drug is now a controlled substance, only approved for medical uses including the treatment of “narcolepsy, insomnia, [and] clinical depression” as well as an anesthetic (Buratovich, 2013, p. 276).

GHB is a popular club drug due to the ease with which it can be made and the relatively low cost, along with the sedative, euphoric, and libidinous effects. It is also rather addictive, synergistic with alcohol, and long-term use can result in the same severe depression it is sometimes used to treat (Buratovich, 2013). There can also be severe withdrawal symptoms if one attempts to quit, much like withdrawal from long-term heavy alcohol use (Kuhn et al., 2008).

Ketamine

Categorized as both a hallucinogen and an anesthetic, ketamine is sometimes used as a general medical anesthetic, but its use prompted hallucinations in some human patients, so it is now mostly used in veterinary applications. However, its painkilling and perception-bending effects have proven alluring to some people, leading to its emergence as a drug of abuse in the mid-1990s (Kohlmetz, 2013a). A trip on ketamine (also called “K,” “Special K,” or “cat Valium”) has often been called “falling into a K-hole,” described as an out-of-body or cosmic, spiritual experience. Ketamine also has been used as a date rape drug due to its amnesia-producing effects (Kuhn et al., 2008). In the short term, use is dangerous because users may feel no pain and hurt themselves unknowingly.  Overdose is possible with a large dose; panic attacks, severe anger and violence, and paranoia can result from prolonged use (Kohlmetz, 2013a).

 

Stimulants

Stimulants are drugs that “produce a speeding-up of signals through the central nervous system,”  resulting in elevated heart rate, blood pressure, motor activity, and often greater alertness, energy, and positive mood (Goode, 2012, p. 241). The most popularly used drug in this category is caffeine, though many others are also employed for their mood-heightening, energy-boosting, ergogenic effects. Due to these effects, stimulants are sometimes casually known as “uppers.”

Caffeine

Most Americans use caffeine in some form—soft drinks, tea, coffee, energy drinks, you name it. Caffeine increases alertness, elevates mood, and reduces fatigue.  As many coffee or energy drink users will admit, it can be quite addictive and has noticeable withdrawal symptoms including headaches, fatigue, sleep disturbance, and irritability.

the art of the barista [33/366]
We never seem to think of the barista at the local coffee shop as a drug dealer, but caffeine is a popular stimulant drug that many people use frequently in some form.
"the art of the barista [33/366]" by worldoflard is licensed under CC BY-NC 2.0

 

Caffeine has analgesic properties and is used as an ingredient in some headache relief medications to boost their painkilling power. It is also a diuretic, so it has the power to dehydrate the user to a degree. While it is possible to fatally overdose on caffeine, it would likely only be done with caffeine pills, which are sold over the counter as energy boosters or to ward off sleep. Still, amounts of 250mg per day or more (roughly the equivalent of a small coffee at Starbucks) can cause one to be dependent upon caffeine, and 300mg or more may cause pregnancy complications (Van Hoey, 2013b)

Notably, it has become more popular in recent years to combine certain energy drinks with alcohol, like Red Bull and vodka. This is a dangerous combination, as the stimulant effects of the caffeine can cause one not to be able to detect the rise in one’s own blood-alcohol content, which can lead people to feel as if they are not impaired when they are. This can cause greater risk of driving while intoxicated, or of drinking too much alcohol and risking severe physical consequences.

Cocaine and crack

Cocaine is a white powdery substance obtained by processing the leaves of the coca plant. Championed by Sigmund Freud as a panacea, the drug was initially used as an anesthetic for certain optical, oral, and nasal surgeries, and it remains acceptable for certain anesthetic uses today, though it is no longer in common use. It was quickly realized that the drug had powerful addictive effects and its supporters (Freud included) backed off of many of their enthusiastic claims (Gerald, 2013; Thornton, 2006).

Cocaine is commonly used via insufflation (“snorting”) but can also be made into an injectable form. Use results in a sense of euphoria and intense energy, but tolerance to those effects can develop with regular continued use. Use of a higher-than-usual dose can result in irritability, paranoia, and agitation; physical effects of long-term use may include heart attacks, strokes, seizures, and chest pains. Withdrawal can cause a “crash” that induces depression, intense fatigue, and strong cravings (McCoy & Rais, 2013). Long-term use of cocaine can lead to paranoid psychosis, uncontrollable cravings, and auditory hallucinations (McCoy & Rais, 2013).

Crack Cocaine - Addiction
Crack is made from cocaine, baking soda, and water, and dried into a “rock” form which can be heated in order to inhale the vapors and get high.
"Crack Cocaine - Addiction" by Find Rehab Centers is licensed under CC BY 2.0

Crack is made in a simple way: cocaine powder is boiled with baking soda and dried into a rock form which can be smoked. Crack rocks are heated until they begin to vaporize, and the vapor is inhaled in order to obtain a high. This simple process leads to a drug that gets to the brain faster, resulting in a high as fast as 15-20 seconds, no more than just a minute or two (compared to 10-15 minutes from snorting cocaine), but also greatly increasing the risk of dependence or overdose (Kuhn et al., 2008; Gerald, 2013).

Crack is often seen as the cheaper “skid row” version of the drug while cocaine is associated with success and wealth, despite the fact that the active chemical causing one to get high is the same in both drugs. Due to crack’s association with poorer minority users while cocaine was a high-class drug in the 1980s, laws were passed to punish crack possession at a 100-to-1 ratio compared to cocaine possession (Gest, 2006). In other words, in the eyes of the law, one gram of crack was equivalent to 100 grams of cocaine when it came time to hand out punishments for possession. Selling roughly a pound of cocaine (500 grams) would result in a five-year prison sentence; so would selling five grams of crack—about enough to fill two sugar packets (CNN, 2009).

This persisted from the 1980s until 2010, when the Fair Sentencing Act altered the ratio to 18:1, still a strangely unbalanced law considering that a gram of crack actually contains less than a gram of cocaine (Frieden, 2010; Gerald, 2013). The laws do not appear to be evenly enforced, either; in 2009, 79% of people sentenced for crack offenses were black, even though more than 67% of crack users are white or Hispanic (NAACP, n.d.; Kurtzleben, 2010).

Amphetamines

Amphetamines increase energy, alertfulness, and can have a major impact on one’s ability to focus and concentrate. They were originally introduced in the 1930s and widely used by soldiers in wartime to stay awake and vigilant for long periods without sleep, despite evidence that other drugs did so more reliably and easily (Doweiko, 2012). For a time, amphetamines were prescribed as weight-loss pills due to their appetite suppression effects, but this is no longer an approved use, as exercise and diet modification have the same impact without as many negative side effects. Two of the few approved prescription uses today are narcolepsy and ADHD (Doweiko, 2012). It may seem odd that a stimulant would assist in the treatment of a disorder known for hyperactivity, but Ritalin and Adderall (two common ADHD stimulant medications) appear to have the effect of helping children diagnosed with ADHD to concentrate and focus rather than increasing their energy.

While cocaine users are often ready for another dose in about 40 minutes, many amphetamines last up to 2-4 hours; still, it is not unusual for dependent users to binge for multiple days and then go through the crash of amphetamine withdrawal (Kuhn et al., 2008). High doses can cause fever, heart failure, and seizures; long-term heavy use of amphetamines can lead to paranoia, violence, psychosis, confusion, incoherence, and a specific kind of hallucination known as formication (Kohlmetz, 2013b).

Of particular concern in recent years has been the specific drug in this group known as methamphetamine (also crank, ice, speed, crystal, or just meth). Methamphetamine has taken a particular hold of many rural communities in America where unemployment has been high, as graphically depicted in books like Methland (Reding, 2009) and Children of Methamphetamine-Involved Families (Haight, Ostler, Black, & Kingery, 2009). Popular methods of use include smoking, injection, and snorting, although it can also be eaten. As with other drugs, the quickest effect can be felt by smoking or injecting the drug (nearly instant effects), followed by snorting (five minutes) and then eating (20 minutes) (Weisheit & White, 2009).

Some of the most striking drug prevention media on the web can be found by doing a search for “Faces of Meth.” Not only will the original site with that name come up, but a variety of sites that show a very stark view of the effects of methamphetamine on people through series of mug shots that show their deterioration over time. The change in just a few short years is quite shocking.

Harnett Crystal Meth
Methamphetamine in pure, clear form is known as “crystal meth.”
"Harnett Crystal Meth" by NCDPS Communications is licensed under CC BY-SA 2.0

Methamphetamine is produced in clandestine labs, often situated in rural areas to make it easier to keep them hidden, as they often produce noxious fumes that can be easily noticed even well after production ends. Properties that have housed meth labs must be destroyed because of the noxious chemicals within walls, carpeting, appliances, everything—they are “no longer fit for human habitation” (Willis, 2013b, p. 399). Unlike some drugs like marijuana, which often requires expensive equipment to grow in large enough quantities to make a profit, methamphetamine can be easily made at home with $100 worth of ingredients able to be turned into saleable product worth ten times as much (Owen, 2007). Carefully constructed labs with expensive equipment like those shown in Breaking Bad exist as well.

Meth’s use is also highest in rural areas, with 71% of all methamphetamine arrests and drug treatment admissions in one state coming from rural counties despite their far lower populations (Weisheit & White, 2009). Part of this is because a key ingredient in meth recipes is anhydrous ammonia, which is a fertilizer often stored on farms in supercooled form, since it vaporizes at air temperature. While other ingredients for making meth can be bought at hardware stores or grocery stores, anhydrous ammonia cannot, leaving only two options: steal it or get it on the black market at up to 200-400 times the regular market price for farmers (Owen, 2007). Many opt to steal it.

What makes methamphetamine so addictive? Unlike a lot of other drugs, the high can last for a long time—10-12 hours, almost unheard of for any drug. The prolonged rush brings with it “euphoria, decreased fatigue and appetite, and increased energy, alertness, and libido” (Haight et al., 2009) Eventually, upon crashing, the user can fall into a days-long period of sleep before they come back to baseline. After an extended binge, users “tweak,” getting restless, anxious, exhausted, and cranky. Use of methamphetamine will not take away these symptoms, unlike the withdrawal syndrome for most drugs. This is when family members, particularly children, are at the greatest risk (Haight et al., 2009).

Methamphetamine causes impairment of an area of the brain called the anterior cingulated cortex—but you just need to know it’s an area that influences thinking and helps the individual to make behavior choices. Neuroscientific studies have shown that methamphetamine actually inhibits the user’s ability to make healthy choices (Willis, 2013b). Use also carries with it a higher risk of contracting HIV and other sexually transmitted infections, due to shared needles and risky sexual behavior. Another significant physical effect is meth mouth, a result of poor oral hygiene, increased tendency to grind or clench one’s teeth, increased sugar intake, and decreased saliva production. Severe dental decay that would normally take decades can happen within months in methamphetamine users (Willis, 2013b).

Chronically, meth use can also lead to psychotic symptoms, depression, suicide, repetitive behavior (disassembling electronics, picking at one’s skin until it bleeds), formication, and potential heart and eye damage (Weisheit & White, 2009). From a family standpoint, the effects of meth are among the saddest. Not only does it pose significant risks to a developing fetus if the mother uses or is in an environment where meth is made, but the issues continue after birth. Kids can test positive for meth simply by living in methamphetamine-producing homes—more than one-third did in one study (Haight et al., 2009). When these children are removed from their homes, they not only suffer the typical effects of being taken away from one’s parents and placed in foster care. These children also have to leave all their possessions behind—favorite stuffed animals, toys, books, and clothes—because they are all contaminated from the methamphetamine production on the property. The children get to take nothing with them that reminds them of home, only adding to their tremendous sense of loss.

Ecstasy

MDMA (methylenedioxymethamphetamine) is the chemical name for the drug known as ecstasy. In the past, attempts were made to use it medically as an appetite suppressant and therapeutically in individual and couples therapy. However, its hallucinogenic properties led to its discontinuation and illegalization (Montvilo, 2013). Derived from methamphetamine, ecstasy has become a popular club drug, as it increases energy and endurance, allowing partygoers to dance all night without resting. Other short-term effects include heightened perception intensity, so that any touch, for example, may be perceived as immensely pleasurable. Negative short-term effects include clouded thinking, overheating, muscle spasms, and irregular heartbeat (Montvilo, 2013). You may have heard that ecstasy decreases one’s sense of thirst, which can lead to dehydration; users who are savvy about this effect may drink a lot of water to counteract it, but since they cannot tell when they have had enough, they may throw off their sodium balance in their blood to a dangerous point, a condition known as hyponatremia. This can lead to seizures, brain swelling, and even death in rare cases (Kuhn et al., 2008).

VPD seized 107k ecstasy pills. What will get them in trouble? Possession or Olympic brand infringement
Ecstasy (MDMA) pills are often decorated in cute or colorful ways that regular users may recognize.
"VPD seized 107k ecstasy pills. What will get them in trouble? Possession or Olympic brand infringement" by Chris Breikss is licensed under CC BY 2.0

 

Opioids

Opiates are technically drugs that are naturally occurring components of the opium poppy’s resin, while opioids refer to both opiates and the semisynthetic or wholly synthetic drugs that have similar effects in the human body. The term narcotics has been used at times to refer to opioids, but has become more of a legal term than a chemical one, and sometimes people mistakenly include additional illegal drugs in a general group and refer to them all as narcotics (Faupel et al., 2010). Since opioids is the more all-encompassing term, that is what we will use here (National Alliance of Advocates for Buprenorphine Treatment, n.d.).

Opioids are analgesic (painkilling) drugs that can produce a euphoric high in greater doses, followed by a general sense of calm well-being and drowsiness. Because they take over the job of natural compounds in the body that normally are responsible for pain reduction (endorphins), opioid use can actually lead the body to stop producing those chemicals, creating a dire need for the body to have opioids present in order to avoid being in great pain (McCoy, 2013). This is part of what makes them very powerfully addictive drugs, a risk that exists even when an opioid is being used for legitimate medical purposes.

Opium Poppy Heads
Opium poppies, when sliced, exude sap which can be collected and refined into opioid drugs.
"Opium Poppy Heads" by Alastair Rae is licensed under CC BY-SA 2.0

Opium

Opium has been used for thousands of years, with early medical writings of Assyrians, Greeks, and Romans praising its capacity for pain relief and facilitation of sleep (Gerald, 2013). The smoking of opium dates back to at least 1000 BC; as with many substances, medicinal use morphed into recreational use for some people. It is obtained rather simply, by slicing into the pods on top of the plant ten days after it blooms and scraping off the residue that forms. It can then be made into small balls and smoked or processed into many other substances with painkilling properties (Gerald, 2013; Willis, 2013c). Opium’s presence in many patent medicines of America in the 1800s meant it was being used by average American housewives all over the country before it was recognized as a potentially addictive chemical (Kuhn et al., 2008).

Opium became outlawed in America not because of its addictive nature but because it was being used by Chinese railroad workers, who were perceived as taking good American jobs away from Americans. (Does that sound familiar?) Since the government could not very well outlaw Chinese people, they instead outlawed a common habit of the Chinese inhabitants of the area—smoking opium. Never mind that many American women at the time had taken to drinking laudanum—a liquid concoction of opium, alcohol, and spices (Levinthal, 2014). Foreshadowing the cocaine/crack legal dichotomy many decades later, the legislature chose to treat one form of the drug much more harshly than the other for reasons that appeared to be largely motivated by racism.

At any rate, opium use did not persist far into the 20th century because we had by then isolated other opioids that were far more potent—drugs which posed a much bigger legal problem and social threat. 

Box 13.7: Morphine and Opium as Cure-alls

In America in 1908, morphine and opium were being prescribed by doctors for all of the following:

  • Alcoholism
  • Boils
  • Typhoid fever
  • Bronchitis
  • Cancer
  • Hemorrhoids
  • Hysteria
  • Pneumonia
  • Sprains
  • Ulcers
  • Measles
  • Mania
  • Whooping cough
  • Delirium
  • Convulsions
  • Cough
  • Gallstones
  • Gout
  • Diabetes
  • Gonorrhea
  • Diarrhea
  • Sciatica
  • Depression
  • Colic
  • Epilepsy
  • Mumps
  • Dysentery
  • Earache
    (Source: Hodgson, 2001)

 

Morphine

Morphine is part of the opium compound—3 to 17% of its content—and is responsible for the painkilling and addictive qualities of the drug. As such, when it was chemically separated from the other ingredients of opium in the early 1800s, people suddenly had a much more potent drug on their hands (Hodgson, 2001). However, morphine—an extremely powerful and useful painkiller and cough suppressant—was underutilized initially because there wasn’t an easy delivery system. No one had developed the syringe yet. When that was perfected in the 1850s, the morphine boom was on its way. While opium was addictive, the belief was that morphine would not be, since it bypassed the digestive system and went straight into the bloodstream (Hodgson, 2001).

Heroin syringe
The invention of the hypodermic syringe made it possible for humans to use and abuse far more concentrated and addictive opioids like morphine.
"drugs" by dkalo is licensed under CC BY-SA 2.0

 

Ten times stronger than opium, morphine came to be used for a wide variety of ailments. This led to addiction fairly rapidly for many people, and opium became a controlled substance in 1914 thanks to the Harrison Act. Still used today for painkilling purposes in hospital settings, morphine brings (like its opioid brethren, but to a stronger degree) pain relief, cough suppression, and constipation (Bennett, 2013). Heavy doses produce brief euphoria followed by hours of a peaceful, relaxed state, and possible respiratory and circulatory depression, along with the potential for overdose deaths. Withdrawal from morphine is extremely painful and uncomfortable—sweating, diarrhea, strong cravings, alternating hot flashes and chills, muscle tics, and severe nausea—and can last up to two weeks to some degree in certain users (Bennett, 2013).

Codeine

Codeine, another naturally occurring substance in the opium poppy, is not as potent as morphine—about 12 times as much codeine is needed to get the effect of morphine (Faupel et al., 2010). It was originally used as a treatment for morphine addiction, until it was discovered to be potentially addictive as well (Schwartz, 2013). Codeine is sometimes used in cough medications for its cough-relieving effects. Prescription syrups containing codeine have become a popular drug of abuse in some areas of the country, particularly Texas, the origination point for a concoction known as  “drank,” “purple drank,” “lean,” or “sizzurp”—codeine-based cough syrup mixed with soda and hard candies (Schwartz, 2013; Painter, 2014).

Heroin

Few people realize that heroin—one of the most notoriously abused drugs of our modern times—started out as a prescription drug. It was developed by the Bayer company (the same one you know for its aspirin) and given the brand name Heroin due to its heroic capacity for healing (Faupel, et al., 2010; Musto, 2002). It was initially believed to be a non-addictive morphine alternative that could help wean morphine users off their addictions—before it was found to be three times more potent than morphine and even more powerfully addictive (Faupel, et al., 2010; Ciulla-Bohling, 2013). This led to the eventual banning of heroin for medical use in America by 1970, though it is still legally prescribed in England and some other nations. It has had a bit of a rollercoaster history in the United States in regard to its popularity, but seems to be surging again as the use of prescription painkillers causes more opioid addiction, particularly among young people and in the Northeast (Faupel et al., 2010; Levinthal, 2014).

Box 13.8: Police and Public Intervention in Opioid Overdoses

Medical professionals and some in the criminal justice field have been trained to identify the three major signs of an opiate overdose—called the opioid triad—and to administer naloxone (brand name Narcan) to potentially counteract the effects of the opioid in the user’s system. The three symptoms of the opioid triad are:

  • Depressed respiration
  • Coma
  • Pinpoint pupils

More and more police departments are being trained in the recognition of opioid overdose and have been authorized to carry naloxone injectors with them on duty in order to potentially save lives that might be lost if the users had to wait for an ambulance to arrive. As of the date of this book’s publication, more than half the states have at least one department using naloxone, including over 200 in New York alone, and one department—Quincy Police Department, Massachusetts—that has saved 360 people from opioid overdose, making it the most impactful police naloxone program in the country. New Jersey police have saved nearly 1,000 people from opioid overdoses in less than 18 months. (Sources: World Health Organization, 2014; North Carolina Harm Reduction Coalition, 2015)

Though traditionally heroin has been injected, development of purer forms has made it possible for it to be smoked or snorted, and many younger users are opting for these methods (Friedman & Alicea, 2001; Ciulla-Bohling, 2013). This serves as protection against the blood-borne disease issues and potential vessel damage associated with IV injection. Heroin, once taken into the body, is converted into morphine to unleash its painkilling effects; heroin’s chemical structure, however, allows it to have a faster entry into the brain. Users have an orgasmic pleasure reaction upon injection of the drug and then may drift in and out of a peaceful, contented sleep state. Breathing slows, and too high a dose can stop respiration altogether (Ciulla-Bohling, 2013; Kuhn et al., 2008).

The dangers associated with continued heroin use are both physical and behavioral. Physically, heroin suppresses immune system functions, appears to inhibit complex decision-making, and causes brain changes that can lead to permanently altered breathing and low blood-oxygen levels (Kuhn et al., 2008). The withdrawal from heroin is so intense, and the buildup of tolerance so rapid in some users, that it can take as little as a week to become dependent and need a much higher dose than one did before. After a while, the user takes heroin not to get high, but to avoid the tremendously unpleasant withdrawal (Ksir et al., 2006). The fact that heroin can be “cut” with other chemicals to decrease its purity and increase the dealer’s profit margin also carries a risk, since some of the added chemicals may be toxic or destructive to blood vessels—people can even have allergic reactions to an additive and die with the needle still in their arm (Levinthal, 2014).

Heroin is notorious for its ability to prompt people to commit crimes in order to obtain money to fund their habit—particularly prostitution and property crimes. The need to use to avoid being “dope sick” drives people to behaviors they may not ever have considered before starting to use heroin.

Prescription painkillers

Recent years have seen a significant increase in the prescription rate of opioid medications: in 1991, there were 76 million prescriptions for these drugs given out in the United States, and in 2013 there were 207 million—almost two for every three Americans. Accidental overdoses on these drugs have also increased over 300% since 1999 (Volkow, 2014). Some of the more popular drugs that are prescribed legally but pose addiction and overdose concerns are oxycodone (brand name OxyContin), hydrocodone (Vicodin), meperidine (Demerol), propoxyphene (Darvon), dihydromorphone (Dilaudid), and Fentanyl. That last example, Fentanyl, is estimated to be 50-100 times more potent than morphine—33 times as potent as heroin—and copycat versions are often available on the street (Faupel et al., 2010; Gerald, 2013). Fentanyl is the major overdose-causing opioid in many states; in Vermont, for example, 91% of all opioid overdose deaths in the first four months of 2021 were wholly or partially caused by Fentanyl (Vermont Department of Health, 2021).

There is a disturbing trend emerging over the last several years: people are getting legitimate prescriptions for painkillers, building a tolerance, increasing their dose, turning to illegal supplies when legal ones dry up or are not enough, and eventually, turning to heroin as a cheaper, more easily accessible alternative (Volkow, 2014). The number of people who say they used heroin within the last year increased by an astounding 75 percent between 2005 and 2012 alone; in 2012, there were nearly 3,000 fatal heroin overdoses after most of the years of the 2000s saw an annual total of 2,000 or fewer ODs (Volkow, 2014). Heroin use has continued to become more common at least through the year 2017 (National Institute on Drug Abuse, 2021). The increasing number of prescriptions for these potentially dangerous drugs is leading to a significant rise in heroin use and overdose, which is impacting social workers in multiple areas of practice: addiction treatment, family therapy, child protective services, and more.

Methadone clinics have been used in the past to help opioid addicts to kick their habit by trading it for the use of a less dangerous prescription opioid, but methadone can still be abused and diverted to the street for sale. The emergence of buprenorphine, a drug used to treat opioid dependence, has been exciting. An improvement over methadone, it controls cravings and prevents the symptoms of withdrawal without being nearly as capable as methadone of producing a high (Ciulla-Bohling, 2013; Substance Abuse and Mental Health Services Administration, n.d.). Compared to methadone, buprenorphine is also less prone to producing addiction or overdose; it blocks the effects of opioids, so if one were to use an opioid while on buprenorphine, there would not be a high (Substance Abuse and Mental Health Services Administration, n.d.). This holds a lot of promise for new treatment efforts for opioid addiction, and more drug rehabilitation centers have begun including buprenorphine in their treatment regimens.

 

Hallucinogens

Contrary to what the name may imply, hallucinogens do not necessarily cause the user to hallucinate; they do, however, alter users’ perceptions. They may perceive something that is not there (hallucinations), simply misperceive the things that are there (illusions), or believe things that are not true (delusions). Many hallucinogens are quite potent but not very toxic—that is, it does not take much of the substance to have a hallucinogenic effect, but it would take much more of the same substance to do serious harm to the body.

LSD (“acid”)

LSD (lysergic acid diethylamide) is the most well-known hallucinogen today (unless we count marijuana—more on that later). It was first created from the grain fungus ergot in 1943 by pharmaceutical chemist Albert Hofmann, who had originally synthesized it years earlier but put it aside as he struggled to find a useful purpose for it. When he went back to work with it again, he accidentally ingested or absorbed some of it and felt odd. When Hofmann intentionally took more, he had a very intense “trip” and realized the drug was quite potent (Littell, 1996; Shroder, 2014).

LSD was studied as a possible treatment for psychosis, a truth serum, and a general psychotherapeutic drug, but nothing much came of those efforts, though some researchers continue to look for therapeutic uses for LSD today (Shroder, 2014). Harvard professors Timothy Leary and Richard Alpert became highly associated with the drug for giving it to undergraduates to study its effects, then taking it themselves. Leary would go on to advocate for the creation of a new church, the League of Spiritual Discovery, with LSD as a sacrament; this was an effort to get the use of LSD protected as an act of religious freedom, but it instead was part of what prompted the federal government to pass the Controlled Substances Act.

LSD causes a powerful hallucinogenic reaction, often inducing a magnification of one’s emotional state; in other words, if one is anxious, the experience can be quite nerve-racking and even frightening, but if one is relaxed, the “trip” can be exceedingly pleasant and spiritually awakening. One of the more striking effects of LSD is synesthesia, which can result in users reporting that they are able to “see music” or “hear purple.”

LSD’s effects typically begin within an hour and last up to 8 hours, perhaps more (Aanstoos, 2013). There are not significant negative physical effects for most users; in fact, scientists have not identified a lethal dose of the drug (Doweiko, 2012), but psychological effects can vary. Under the influence, one’s judgment is often impaired, and one may be interacting with nonexistent people/situations; safety concerns can result (Aanstoos, 2013). There is also the potential for a “flashback,” in which the individual relives the intense hallucinogenic experience, long after use has ceased. Their likelihood is debatable; some studies have put prevalence of flashbacks at just 3% of former users, and others have said up to 77% (Pechnick & Undergleider, 2004, as cited in Doweiko, 2012; McGlothlin & Arnold, 1971, as cited in Faupel et al., 2010). While tolerance to LSD can build rapidly, spacing out doses keeps one’s tolerance low—the effective dose is tiny as it is—and there appears to be no major risk of dependence (Aanstoos, 2013; Kuhn et al., 2008).

Psilocybin and psilocin

Less potent than LSD are psilocybin and psilocin, the hallucinogenic substances in so-called “magic” mushrooms or shrooms. Psilocybin is converted into psilocin in the body, leading to the "trip," so it appears psilocin is the chemical with the true hallucinogenic effect. They have likely been used for at least 2,000 years (Kuhn et al., 2008). While high on shrooms, the user will sense time distortions, be quite suggestible, and have somewhat unpredictable mood, from elation to depression (Faupel et al., 2010. A trip lasts 2-5 hours and is less intense than an LSD experience (Levinthal, 2014). One should be extremely cautious in deciding to use mushrooms for a hallucinogenic experience, since many mushrooms are toxic to the human body as well. Some poisonous mushrooms look strikingly similar to their hallucinogenic cousins. An inexperienced user may go looking for a head trip but instead end up with a trip to the ER.

psilocybin
A variety of mushroom containing the hallucinogenic compound psilocybin.
"psilocybin" by D.C.Atty is licensed under CC BY 2.0

Mescaline

Mescaline is the hallucinogenic component of the peyote cactus (though it can also be chemically created in laboratories). To prepare the spineless, dome-shaped cactus for use, the crown of the above-ground portion is sliced into disks. These are dried and can be eaten to absorb the mescaline, which produces what many have described as a spiritual sort of hallucination. In fact, this drug has been a part of Native American religious sacraments for about 100 years, and may have been used recreationally up to 5,700 years ago (Gerald, 2013). Its effect is not as intense as LSD, but it can also result in synesthesia. Intense nausea, vomiting, and dizziness can also occur after ingestion of the dried cactus (Kuhn et al., 2008; Levinthal, 2014).

PCP

Known for some time as “angel dust,” PCP (phencyclidine) is a hallucinogenic drug with anesthetic and potential dissociative effects. Usually sold in powder form, PCP can be ingested, snorted, or rolled into cigarettes or marijuana joints and smoked (Faupel et al., 2010). PCP is no longer used as an anesthetic in humans due to the intense hallucinations and distortion of reality it can fuel, along with a possibility of psychotic thinking and behavior that can persist for weeks after use (Gerald, 2013). Long-term use “may lead to memory gaps, disorientation, visual disturbances, and difficulty with speech” as well as “anxiety, nervousness, and antisocial behavior” (Wiegand, Thai, & Benowitz, 2008, p. 468). Abuse of PCP can also lead to kidney failure (Wiegand et al., 2008).

Salvia

Outlawed in some states, legal in others, salvia is a naturally-occurring plant: salvia divinorum (diviner’s sage). It can produce vivid, intense hallucinogenic experiences that are usually rather short in duration (30 seconds to 30 minutes, depending on dose and user familiarity) and has been used in religious ceremonies in Mexico and South America for centuries (Doweiko, 2012). Effects of use include perceptual disturbances, body distortion, detachment, brief catatonic states, intense laughter, mood swings, dissociation, and dizziness. Not all effects happen with each use (Meyers, 2013a). There is little, if any, risk of addiction, but there are frequent reports, especially by inexperienced users, of “bad trips” on salvia. It can bring about intense anxiety, panic, and paranoia; the effects are rather unpredictable overall, causing most users not to repeat use after the first attempt (Levinthal, 2014).

DXM

Dextromethorphan (DXM) is a hallucinogenic compound found in cold and cough remedies like Robitussin and Coricidin (“triple C”). When Robitussin is abused for DXM intoxication, the effect is commonly called “Robo-tripping.” Technically an opioid derivative, DXM is known to produce its “trippy” effects in heavy doses (a full bottle of cough syrup is often consumed by a user). Pleasurable effects include euphoria, hallucinations, and intensified imagination (Gerald, 2013), but users also report vomiting, fever, dizziness, poor motor control, and itching. The other active ingredients in a given medication are worth noting, since their interactions with DXM or their use in large doses may be toxic to the brain, liver, or circulatory system (Meyers, 2013a)

DMT

Dimethyltriptamine (DMT) is a drug that has direct impact on serotonin in the brain, causing intense, short-lived hallucinations and a sense of emotional well-being. There does not appear to be as profound a chance of addiction, as many users repeat use only occasionally or not at all, though they experience relatively few negative side effects during their hallucinogenic experiences. It is a Schedule I drug in the United States, with no accepted medical uses (Winstock, Kaar, & Borschmann, 2013).

Bath salts

A group of designer drugs with both stimulant and hallucinogenic effects, synthetic cathinones are often known as "bath salts." They have no chemical relationship to the actual bath salts sold for your relaxation bathing purposes (Prosser & Nelson, 2012). Reports of bath salt effects in the media have been fantastical at times, reporting zombie-like behaviors including cannibalistic acts (Memmott, 2012).

 

Inhalants

Chemicals like nitrous oxide, spray paint, rubber cement, paint thinner, gasoline, and many others can be abused as inhalants. The use of inhalants is often called “huffing.” Users have several potential methods, like spraying or soaking the substance into a rag and holding it over one’s mouth, or sniffing fumes directly from a container. Drug use of this sort is particularly difficult to stop since it is nearly impossible to rid a home of everything that can be used as an inhalant, and even in that case, new inhalants could be easily purchased from a store without issue.

Inhalants reduce the amount of oxygen that is getting to the brain, causing a lightheaded, dizzy feeling that is pleasurable to some, while making others uncomfortable and nauseated. Minor hallucinatory effects can also occur, along with odd behaviors due to poor judgment. The high comes on quickly and dissipates in about an hour (Levinthal, 2014). The biggest concern with inhalant use is called sudden sniffing death syndrome, an instantly fatal reaction which occurs with particular inhalants more than others (Freon, butane, propane). Nerve damage and cognitive impairment can also occur from repeated use. Repeated use of inhalants is more typically found among children for poorer families, as it’s an inexpensive way to get high (Levinthal, 2014; Kuhn et al., 2008).

 

Marijuana

Marijuana (a drug produced from the cannabis plant, also known as pot, weed, and many other slang names) has been left in its own category since it has multiple effects that do not lend it easily to a single category; however, if your authors were pressed, we would agree with those who consider marijuana a mild hallucinogen, as it does have perception-altering effects. It may not make users hallucinate, but users report that it changes the way food tastes, the way music sounds, how vivid colors seem—all perceptions that get altered. Marijuana can be ingested, but is most typically smoked or inhaled through the use of a pipe, a water pipe, a joint, or a vaporizer.

Marijuana is a plant that has several psychoactive chemicals within it that are worthy of our attention, but we will discuss one here that many of you likely know: delta-9-tetrahydrocannabinol, better known as THC. This compound draws our attention more than any other because it seems to be the most psychoactive of all the cannabinoids by far. It is concentrated in the sticky resin of the plant, which serves to protect the flower and attract pollen to the plant. Cultivators of cannabis know how to process their plants properly in order to get the most potent product, although for various reasons, that may not always be what is desired. Typical street-grade marijuana has THC levels of 2-5%; it has been seen as high as 20%, but that is rare (Kuhn et al., 2008). (Although the percentage of natural THC in a full plant is perhaps one percent, the full plant is not typically used when it comes to abusing marijuana.)

THC is notable because it has many effects on the body and brain—some positive, some less so. There are specific cannabinoid receptors in the brain that THC can activate, giving the chemical a way to directly interact with the brain’s nerve cells much in the way that neurotransmitters normally do when our nerves communicate with each other (Lee, 2012). THC is also notable because it (and its metabolites) are lipid-soluble—that is, it dissolves in fat, and can thereby be stored in the body for a longer period of time. A single heavy dose of marijuana can be detectable for up to three weeks in drug screens, though the levels will taper off as time passes.

When one smokes pot, generally, it has an effect within 20-30 minutes, increasing one’s sense of well-being and relaxation. Many users actually do not feel any sort of noticeable effect the first time (or first few times) they smoke, however. Those that do report an effect seem to have increased sociability, laughter, mild hallucinations, and reduced anxiety (Doweiko, 2012). Less experienced users are more prone than others to increased anxiety and panic reactions when smoking marijuana, though 50-60% of pot users have experienced at least one instance of use leading to increased anxiety (Doweiko, 2012).

Similarly, some people with depression report than marijuana increases their depressive feelings, while others say their depression improves. The impact seems unpredictable in advance (Doweiko, 2012). On rare occasions, users experience psychotic symptoms, but these tend to clear up quickly one use stops. Experienced users also report that while high, they often feel like they are on the verge of an “aha” moment, a big insight—but this rarely coalesces or carries over into a sober state. Whatever effects one notices generally vanish within an hour (Doweiko, 2012).

Marijuana’s other effects on the body include:

  • Decreased coordination
  • Bloodshot eyes
  • Short-term memory impairment, particularly in adolescents
  • Reproductive effects (lower sperm count, disrupted menstrual cycle)
  • Slower cognitive functioning for up to 48 hours after getting high
  • Impaired problem-solving
  • Suppression of REM sleep
  • Coughing and wheezing
  • Potential increased risk of cervical, testicular, and prostate cancer (Doweiko, 2012; Galanter & Kleber, 2008)

You may hear people say, “Marijuana isn’t really addictive—it’s just psychologically addictive.” Well, that is a misleading statement in a few ways. First of all, people can and do get addicted to cannabis—not all of them, not even most of them, but some do. Seventeen percent of admissions to drug treatment centers in 2008 were for marijuana addiction (National Institute on Drug Abuse, 2011). That is the same thing we could say about many potential drugs of abuse. Most people who on occasion smoke pot will probably not experience any significant negative consequences, but some will.

Secondly, the idea that psychological dependence isn’t real dependence is a misconception. Physical dependence may be easier to treat than psychological, since psychological effects like cravings and desire can long outlast physical withdrawal from a substance. The fact is, there isn’t a clearly drawn line between physical and psychological dependence since the brain is part of the body, and anything impacting the brain physically can have a psychological impact. Do not be drawn in by the argument that psychological addiction is somehow less serious.

Another important question about marijuana is whether it leads to a condition called Amotivational syndrome. This is believed by some researchers to be a condition experienced by a number of heavy and/or long-term marijuana users. The idea is that THC collecting in the brain causes a slowdown of brain activity and a decrease in the ability to delay gratification. People with the syndrome, in theory, will just do what seems enjoyable now, without planning for the future. This would mean less likelihood of going to school, getting a job, and so on.

Some researchers have found evidence for the existence of such a syndrome, while others have suggested the lack of motivation could well have been present before the cannabis use. At this point, still more research needs to be done to determine whether amotivational syndrome is caused by pot use (Doweiko, 2012); others say there is simply no convincing evidence the syndrome exists at all (Faupel et al., 2010).

You may also have heard is that pot is a gateway drug. This is another idea that often gets misrepresented. The gateway drug hypothesis (Kandel, 1975) simply states that there is a most common order in which most Americans who use drugs progress. People who use generally start with beer and wine, move on to cigarettes and hard liquor, followed by marijuana, and then other illegal drugs. Therefore, according to this theory, marijuana is the last link in the chain before someone uses really dangerous drugs.

People sometimes believe that this means marijuana somehow makes users driven to use other substances. However, marijuana smokers are simply more likely to use other illegal drugs than people who have never used marijuana are. (Most people don’t decide to try cocaine before marijuana, for example.) More recent research seems to back up the idea that while the gateway progression remains valid in most cases in countries where marijuana use is common, it is not a matter of some internal change, but of access and social factors at play (Degenhardt et al., 2010). Furthermore, if we are going to talk about marijuana being a gateway drug, we should acknowledge that tobacco and alcohol are in the same boat—they usually come before marijuana, in fact, but that may be because those drugs are legal! It is interesting that people often talk about pot as a gateway drug, but alcohol and tobacco rarely get vilified in the same way.

Medical Marijuana Dispensary
About half of the states in the U.S. now have legalized access to medical marijuana—prescriptions can be obtained from one’s doctor and taken to a licensed marijuana dispensary to obtain the drug, just as one would at a pharmacy.
"Medical Marijuana Shop" by Laurie Avocado is licensed under CC BY 2.0

 

Pot is also unique because of our emerging understanding of it as a potential medication for many ailments. More states than ever now allow for some medical prescriptions for marijuana—some have strict rules about which conditions are valid for medical marijuana, and some (like California) are far less picky about it. As of July 2021, over 35 states and the District of Columbia had legalized medical marijuana (National Organization for the Reform of Marijuana Laws, n.d.) and a growing number were legalizing recreational marijuana as well. THC is already available nationwide in one form: a synthetic chemical copy of THC is in the approved prescription pill Marinol. However, most states also allow marijuana to be doctor-recommended (if not strictly prescribed) in non-pill form, to be smoked, eaten, or taken in however people would prefer.

Among the maladies that medical marijuana has been used to treat are glaucoma, spinal cord injuries, multiple sclerosis, arthritis, other degenerative conditions, and pain and nausea from chemotherapy; there are significant research justifications for these conditions, whether the pot merely relieves the patient’s pain or counteracts the condition itself (Lee, 2012; Pfeifer, 2013; Campbell, 2012). There are further indications that marijuana may be useful for other medical applications as well. Some politicians (generally Democrats, but some Republicans as well) have also favored decriminalizing or legalizing marijuana nationally.

There has been increased interest in CBD, another cannabinoid, as well. This component of marijuana is currently sold over the counter in the United States, not yet a controlled substance. While many users of CBD swear by its ability to have a positive impact on everything from PTSD to chronic pain, more study needs to be done to verify its positive effects. Its relative lack of regulation at this time can cause a fair amount of variation in the potency and purity of the CBD products on the market.

One factor that needs to be considered with pot is driving under the influence. Marijuana does notably impair driving ability while one is high, and perhaps even after one stops feeling the effects of use (Anderson, Rizzo, Block, Pearlson, & O’Leary, 2010). There isn’t an agreed-upon “safe” level for THC in the blood. THC can also remain in one’s system for 2-3 weeks without impairing the user’s driving that entire time, so it is unclear how to objectively detect who is truly impaired. This is an issue states will be wrestling with as the laws on marijuana continue to evolve.

 

Tobacco and nicotine use

Much like the cannabinoids we discussed with marijuana, tobacco naturally contains many chemicals with the power to impact the brain. The main substance of concern, of course, is nicotine, which is what drives the addictive nature of smoking and other tobacco use. Nicotine is a stimulant and also has sedative effects. You may have heard people say they need to smoke to get a buzz, and that they need to smoke to relax. In either case, the same chemical is at work.

It was reported by the Centers for Disease Control (2015d) that in 2013, 17.8% of Americans were smokers—a bit over 20% of men and just over 15% of women. By 2019, this had fallen to just 14% of all Americans. The CDC notes that tobacco use causes over 6,000,000 deaths per year worldwide, a number that will increase to 8,000,000 by 2030. It is estimated that one out of every five deaths in America is related to smoking—either directly or via secondhand smoke (Centers for Disease Control, 2015d; Goode, 2008; Centers for Disease Control, 2020).

It is probably not news to you that smoking is dangerous for you in multiple ways—smokers on average live 10 years less than nonsmokers do, and 70% of current smokers say they wish they were not smokers (Centers for Disease Control, 2015d). Here are some other quick facts to note about smoking:

  • Smoking is the number one preventable cause of death in the United States and worldwide (Levinthal, 2014)
  • Tobacco kills more people in the United States each year—440,000—than the total number of deaths from all other drugs, including alcohol (Goode, 2008)
  • Each day, 3,200 kids under 18 use their first cigarette, and 2,100 become daily smokers (Centers for Disease Control, 2015d)
  • The smoking industry continues to increase the nicotine level in its cigarettes; medium/mild non-mentholated cigarettes saw an average nicotine boost of more than 100% between 1998 and 2005 (Levinthal, 2014).
  • Nicotine users take their drug an average of 18.5 times per day in the United States, making its users the most frequent for any drug. This tells us something about how strong the addictive nature of the drug is (Goode, 2008).
death cigarettes
Smoking is responsible for more far more deaths each year than all illegal drugs combined—so why is it legal? It may seem hard to imagine cigarettes being outlawed, but would you ever dream of legalizing any other drug if you knew it would kill over 400,000 Americans per year—like tobacco does?
"death cigarettes" by mabi2000 is licensed under CC BY-SA 2.0

 

Though smoking tends to make smokers feel a boost in energy or a relaxed mood when they have smoked, the feeling fades quickly, requiring another cigarette. The few positives just do not last, other than the appetite suppressant effect. It is not unusual for someone to gain a few pounds upon quitting smoking, in part because nicotine reduces food cravings, but also because the act of putting a cigarette in one’s mouth may be replaced by increased snacking instead (Goode, 2008). The negative effects of smoking, of course, are numerous: many kinds of cancer (particularly lung cancer, but 30% of all cancers are smoking-related; Levinthal, 2014), emphysema, heart attacks, stroke, heart disease, COPD, bronchitis, and so on.

Quitting smoking is extremely difficult for most people. The majority who do quit return within six months, and only 3-5% succeed the first time. Half of all smokers will quit before they die, but only after an average of eight attempts each (Levinthal, 2014; Kuhn et al., 2008). Regardless, there are many options out there for people who do want to quit: patches, nicotine gum, lozenges, spray, even medications. Doctors can help them find a plan that will work for them if they are thinking about quitting. There is a lot of good news—if one does quit, one can regain a lot of your physical health that has been compromised, including a decreased risk of heart attack after just 24 hours smoke-free, stroke risk being back down to that of a nonsmoker in 5-10 years, and a 30% improvement in lung function in just 2-12 weeks (Levinthal, 2012).

It is true that there are also other tobacco use methods, like chewing tobacco, pouches, and snuff. These represent a small percentage of overall use, but still carry a significant risk of addiction and various forms of cancer. Vaping has also become far more popular (more on that shortly). American attitudes about smoking and other tobacco use, thankfully, are becoming more negative. It is not unusual these days to find that people are more positive about marijuana than cigarettes. Perhaps public education campaigns and the never-ending toll of disease and death we see in our loved ones who smoke truly have made an impact. 

Box 13.9: Smoking and vaping frequency by youth and adults

Smoking and vaping

(Source: American Lung Association, 2021)

Vaping presents a growing public health concern. While our smoking rates have been falling for decades, vaping has now taken hold in the market, particularly with young people (who use at eight times the rate of adults). Vaping products still contain nicotine and are still addictive, even if they do not contain the tar and carbon monoxide of cigarette smoke. Long-term effects of vaping are likely to be studied more intensely in the coming years. As you can see from the chart above, more than one in four high schoolers admits to vaping within the last month, but despite their popularity, about two thirds of young JUUL users are unaware that JUUL products always contain nicotine (Centers for Disease Control and Prevention, 2021). Vaping products contain heavy metals and other known carcinogens and emerging studies indicate negative impacts on lung functioning among regular users (Centers for Disease Control and Prevention, 2021).

 

Steroids

Anabolic-androgenic steroids are the ones we are concerned about as drugs of abuse; they have been part of sporting culture since the 1950s. At that time, testosterone was synthesized in a laboratory setting for the first time, birthing an industry (Petrocelli, Oberweis, & Petrocelli, 2008). Initial studies by scientists claimed steroids would not help athletic performance, but we have come to see otherwise.

Many prominent athletes have been found to be using performance-enhancing substances of various types throughout the last few decades, but we have seen an explosion in such cases in recent years—Barry Bonds, Mark McGwire, Lance Armstrong, Rafael Palmeiro, Ryan Braun, Alex Rodriguez (twice), and many more. Do most people use steroids to have a chance to be great athletes?

There are many recreational steroid users who are not competing in anything. Their primary motivation seems to be frustration—over the fact that they were unable to make the muscle gains they were told they could get through exercise and diet alone. Some say they came to realize that the only way to get “ripped” like the people in bodybuilding magazines was to use illegal substances. Some even say they will tell children what the secret is if they get asked (Petrocelli, Oberweis, & Petrocelli, 2008).

Those who are most apt to use steroids are not the big-time competitive athletes or the adult male bodybuilding fanatics—they are teenage boys trying to get an edge over their peers. Steroids are fairly easy to obtain through websites or contacts in the sports world (Kohlmetz, 2013c). The fact that so much underage use occurs is certainly the biggest cause for concern, and yet, high school athletes are very infrequently tested for performance enhancers.

Physical and psychological consequences of steroids include acne, decreased testosterone production, excessive body hair, changes in voice, breast development in males and breast shrinkage in females, mood swings, and anxiety. Teens also risk accelerated puberty and stunted skeletal growth (Kohlmetz, 2013c).

 

Levels of Care in Addiction Treatment

When someone does decide (or gets coerced) to go to drug treatment, there are several different options available. A full assessment is generally done to evaluate what the best placement option would be for the client, along with determining what insurance coverage exists, so the client has the opportunity to take potential financial concerns into consideration.

The following are the general levels of care typically available. There are actually more specific divisions than this (as designated by the American Society of Addiction Medicine), but we will stick to introducing the basics for now. Keep in mind that the goal is to find the lowest-intensity level of treatment that will serve a client’s needs—we do not want to put a client in a highly structured 24-hour inpatient unit if she/he can be reasonably and safely managed on an outpatient unit. This is known as placing the client in the least restrictive environment (LRE). These environments could all apply to mental health treatment as well, except detoxification.

Detoxification

In this level of treatment, a client needs to be carefully observed as he/she goes through withdrawal from the substance(s). Medical monitoring is there to assist with any emergencies that may occur and to help the client to be in as little pain and discomfort as possible. Possible interventions in detoxification include providing benzodiazepines to someone going through alcohol withdrawal, in order to help the client experience a reduction in tremors, hallucinations, and cravings (Lejoyeux, Solomon, & Adès, 1998). The benzodiazepines are tapered off as withdrawal progresses.

Inpatient/residential program

At this level of care, the individual stays at the treatment center 24 hours a day until treatment has concluded or the client decides not to continue. Days are programmed with group and individual counseling, possibly family counseling, reflection opportunities, free time, meals, and so on. The idea is to give the individual a chance to get out of the environment where use was happening on perhaps a daily basis, and be surrounded by a supportive, pro-sobriety system of peers and professionals. Though it was once common for programs like this to last for months, with the current practices of managed care, many inpatient drug treatment programs are now 28 or 30 days.

Partial hospitalization program (PHP)

            The most time-consuming of the outpatient programs, a PHP is often a five-day-a-week program, several hours each day. Time is structured in groups and individual counseling meetings. This is an appropriate environment for someone who needs a lot of assistance but does not have a significant enough problem to warrant inpatient treatment. This is often the most restrictive level of care someone would enter for a first-time treatment, though there are exceptions.

Intensive outpatient program (IOP)

An intensive outpatient program requires less time than a PHP, typically a few hours on a few days per week. Time may be spent only in groups, or there may be opportunities for individual session in some programs. This is a frequent placement for first-time treatment seekers. If a client in this program is being drug-tested and comes up positive for a substance more than once, many programs will refer the client to a PHP or a residential/inpatient program, since the use has continued at the lower level of care.

            Follow-up care from any level should be provided. Ideally, a client will step down from a higher level to the one right below it, all the way through IOP, then to a continuing care or individual outpatient environment. It would be a mistake to take someone in a residential program, congratulate them for completion of the program, and discharge them with no aftercare plan for continued counseling. There will be many adjustments to be made once they return home, and assistance may well be needed; support certainly will be. Of course, clients have the right to choose not to follow through on an aftercare recommendation as well, and some do, saying they are tired of counseling and need to get back to regular life, but gradual steps toward full independence generally result in better outcomes.

 

Abstinence Vs. Harm Reduction

The Alcoholics Anonymous (AA) approach to addiction is that there is one solution: abstinence. This is echoed by other 12-step groups (Narcotics Anonymous, Cocaine Anonymous, etc.). As far as AA philosophy is concerned, when one is an addict, one is always an addict—alcoholism and addiction never go into full remission. The only way to be safe is to completely abstain from substances. Returning to use is a failure, even if one has not yet suffered consequences; the implication is that it will only be a matter of time before one does.

On the other hand, the strategy of harm reduction posits that it is acceptable to get a client to a point where use is reduced, rather than completely stopped, as long as the client is experiencing fewer negative consequences. Put it this way: if you went into treatment for an emotional problem like depression or anxiety, and that problem got 75% better, would that be considered a success? Probably—you would have a lot fewer negative events associated with your mood, right? There would perhaps be occasional problems, but nothing you could not handle with some effort.

Harm reduction is a way to start where the client is. If an individual is not willing to consider abstinence, but the counselor pushes for it, the client may leave treatment, never to return. We have to be willing to accept that there are degrees of success; we do not want our clients to be dichotomous (black and white) in their thinking, so neither should we. As a profession, social work appreciates the contributions of the 12-step model but also supports the philosophy of harm reduction (Watson, 2015).

 

Conclusion

The problem of drug use is a serious one for the individual who uses (micro), the user’s family (mezzo), and the community and society at large (macro). The causes of the drug problem are found on all three levels as well. The solution is neither simply found nor easy to implement. It is clear that some of our efforts have borne fruit—as with the reduction in tobacco use—and others still have a long way to go. Social workers will be a part of addressing the drug problem at all three levels, and our contributions can go a long way toward improving the lives of users, their families, and the larger society.

 

References

Aanstoos, C. M. (2013). LSD. In Addictions and substance abuse (Vol. 1, pp. 335-336). Salem Health.

American Civil Liberties Union (n.d.). Injustice 101: Higher Education Act denies financial aid to students with drug convictions. Retrieved from https://www.aclu.org/injustice-101-higher-education-act-denies-financial-aid-students-drug-convictions.

American Lung Association (2021). Overall tobacco trends. Retrieved from https://www.lung.org/research/trends-in-lung-disease/tobacco-trends-brief/overall-tobacco-trends

American Psychiatric Association (2013). The diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association.

Anderson, B. M., Rizzo, M., Block, R. I., Pearlson, G. D., & O’Leary, D. S. (2010). Sex differences in the effects of marijuana on simulated driving performance. Journal of Psychoactive Drugs 42(1), pp. 19-30.

Anslinger, H. J. & Cooper, C. R. (1937). Marijuana: Assassin of youth. In J. Inciardi & K. McElrath (Eds.), The American drug scene: An anthology (6th ed.). Oxford University Press.

Avramut, M. (2013). Barbiturates. In Addictions and substance abuse (Vol. 1, pp. 64-65). Salem Health.

Bennett, A. C. (2013). Morphine. In Addictions and substance abuse (Vol. 2, pp. 407-409). Salem Health.

Brick, J., Wallen, M. C., & Lorman, W. J. (2008). Interaction of alcohol with medications and other drugs. In J. Brick (Ed.), Handbook of the medical consequences of alcohol and drug use, pp. 527-563. The Haworth Press.

Buratovich, M. A. (2013). GHB. In Addictions and substance abuse (Vol. 1, pp. 276-278). Salem Health.

Burroughs, A. (2003). Dry. Picador.

Campbell, G. (2012). Pot Inc.: Inside medical marijuana, America’s most outlaw industry. Sterling.

Carroll, J. L. (2013). Sexuality now: Embracing diversity (4th ed.). Cengage.

Centers for Disease Control (2015a). HIV in the United States: At a glance. Retrieved from http://www.cdc.gov/hiv/statistics/basics/ataglance.html.

Centers for Disease Control (2015b). Effects of blood alcohol concentration (BAC). Retrieved from http://www.cdc.gov/motorvehiclesafety/impaired_driving/bac.html.

Centers for Disease Control (2015c). 2013 mortality multiple cause micro-data files. Retrieved from http://www.cdc.gov/nchs/data/nvsr/nvsr64/nvsr64_02.pdf.

Centers for Disease Control (2015d). Smoking & tobacco use: Fast facts. Retrieved from http://www.cdc.gov/tobacco/data_statistics/fact_sheets/fast_facts/index.htm#use.

Centers for Disease Control and Prevention (2020). Current cigarette smoking among adults in the United States. Retrieved from https://www.cdc.gov/tobacco/data_statistics/fact_sheets/adult_data/cig_smoking/index.htm.

Centers for Disease Control and Prevention (2021). Quick facts on the risks of e-cigarettes for kids, teens, and young adults. Retrieved from https://www.cdc.gov/tobacco/basic_information/e-cigarettes/Quick-Facts-on-the-Risks-of-E-cigarettes-for-Kids-Teens-and-Young-Adults.html

Ciulla-Bohling, R. (2013). Heroin. In Addictions and substance abuse (Vol. 1, pp. 298-300). Salem Health.

CNN (2009). Study: More whites, fewer blacks going to prison for drugs. Retrieved from http://www.cnn.com/2009/CRIME/04/15/blacks.whites.prisons.drugs/.

Davenport-Hines, R. (2002). The pursuit of oblivion: A global history of narcotics. W. W. Norton & Company.

Degenhardt, L., Dierker, L., Chiu, W. T., Medina-Mora, M. E., Neumark, Y., Sampson, N., Alonso, J., . . . Kessler, R. C. (2010). Evaluating the drug use “gateway” theory using cross-national data: Consistency and associations of the order of initiation of drug use among participants in the WHO World Mental Health Surveys. Drug and Alcohol Dependence 108(1-2), pp. 84-97.

Doweiko, H. E. (2012). Concepts of chemical dependency (8th ed.). Brooks/Cole.

Drucker, E. (2013). A plague of prisons: The epidemiology of mass incarceration in America. The New Press.

Faupel, C. E., Horowitz, A. M., & Weaver, G. S. (2010). The sociology of American drug use (2nd ed.). Oxford University Press.

Frieden, T. (2010, July 28). House passes bill to reduce disparity in cocaine penalties. CNN. Retrieved from http://www.cnn.com/2010/POLITICS/07/28/house.drug.penalties/index.html?_s=PM:POLITICS.

Friedman, J. & Alicea, M. (2001). Surviving heroin: Interviews with women in methadone clinics. University Press of Florida.

Galanter, M. & Kleber, H. D. (2008). The American Psychiatric Publishing textbook of substance abuse treatment (4th ed.). American Psychiatric Publishing.

Gerald, M. C. (2013). The drug book. Sterling.

Gest, T. (2006). Cocaine sentencing policy: Crack versus powder. In E. C. Berne (Ed.), Cocaine. Thomson Gale.

Goode, E. (2012). Drugs in American society (8th ed.). McGraw-Hill.

Gray, J. P. (2012). Why our drug laws have failed and what we can do about it (2nd ed.). Temple University Press.

Griffiths, M. D. (2016). The myth of the addictive personality. Psychology Today. Retrieved from https://www.psychologytoday.com/us/blog/in-excess/201605/the-myth-the-addictive-personality

Haight, W., Ostler, T., Black, J., & Kingery, L. (2009). Children of methamphetamine-involved families: The case of rural Illinois. Oxford University Press.

Heady, T. N. & Haverstick, D. (2014). Heroin: A worsening problem and a challenge for testing. MLO: Medical Laboratory Observer 46(7), pp. 22-23.

Henningfield, J. E. (2008). Addiction in America: Society, psychology, and heredity. Mason Crest Publishers.

Hodgson, B. (2001). In the arms of Morpheus: The tragic history of laudanum, morphine, and patent medicines. Firefly Books.

Hollin, C. (2012). Differential association. In E. McLaughlin & J. Muncie (Eds.), The SAGE dictionary of criminology. SAGE.

Inciardi, J. & McElrath, K. (2011). The American drug scene: An anthology (6th ed.). Oxford University Press.

International Agency for Research on Cancer (2009). IARC strengthens its findings on several carcinogenic personal habits and household chemicals [Press release]. Retrieved from http://www.iarc.fr/en/media-centre/pr/2009/pdfs/pr196_E.pdf.

International Center for Alcohol Policies (2015). Blood alcohol concentration (BAC) limits worldwide. Retrieved from http://www.icap.org/table/BACLimitsWorldwide.

Kandel, D. (1975). Stages of adolescent development in drug use. Science, 190(4217), pp. 912-914.

Ketcham, K. & Asbury, W. F. (2000). Beyond the influence: Understanding and defeating alcoholism. Bantam.

Kochanek, K. D., Murphy, S. L., Xu, J., Arias, E. (2019). Deaths: Final data for 2017. National Vital Statistics Report, 68(9), pp. 1-77.

Kohlmetz, E. (2013a). Ketamine. In Addictions and substance abuse (Vol. 1, pp. 335-336). Salem Health.

Kohlmetz, E. (2013b). Amphetamine abuse. In Addictions and substance abuse (Vol. 1, pp. 335-336). Salem Health.

Kohlmetz, E. (2013c). Steroid abuse. In Addictions and substance abuse (Vol. 2, pp. 585-587). Salem Health.

Ksir, C., Hart, C. L., & Ray, O. (2006). Drugs, society, and human behavior (11th ed.). McGraw-Hill.

Kuhn, C., Swartzwelder, S., & Wilson, W. (2008). Buzzed: The straight facts about the most used and abused drugs from alcohol to ecstasy. Norton.

Kurtzleben, D. (2010, August 3). Data show racial disparity in crack sentencing. U.S. News and World Report. Retrieved from http://www.usnews.com/news/articles/2010/08/03/data-show-racial-disparity-in-crack-sentencing.

Kyvig, D. E. & Jeffers, H. F. (2000). Repealing national Prohibition. Kent State University Press.

Lee, M. A. (2012). Smoke signals: A social history of marijuana—medical, recreational, and scientific. Scribner.

Lejoyeux, M., Solomon, J., and Adès, J. (1998). Benzodiazepine treatment for alcohol-dependent patients. Alcohol and Alcoholism, 33(6), pp. 563-575.

Levinthal, C. F. (2014). Drugs, behavior, and modern society (8th ed.). Pearson.

Liska, A. E. (Ed.) (1992). Social threat and social control. New York University Press.

Littell, M. A. (1996). LSD. Enslow.

Lobosco, K. (2015). Recreational pot: $53 million in tax revenue to Colorado. CNN Money. Retrieved from http://money.cnn.com/2015/02/12/news/economy/colorado-marijuana-tax-revenue/.

Maier, S. E. & West, J. R. (2001). Patterns and alcohol-related birth defects. Alcohol Research and Health 25(3), pp. 168-174.

McCoy, K. (2013). Opioid abuse. In Addictions and substance abuse (Vol. 2, pp. 433-434). Salem Health.

McCoy, K. & Raise, T. B. (2013). Cocaine use disorder. In Addictions and substance abuse (Vol. 1, pp. 138-139). Salem Health.

Memmott, M. (2012). Bath salts suspected in Miami face-eating attack. NPR. Retrieved from https://www.npr.org/sections/thetwo-way/2012/05/30/153989768/bath-salts-drug-suspected-in-miami-face-eating-attack.

Meyers, M. R. (2013a). Salvia divinorum. In Addictions and substance abuse (Vol. 2, pp. 533-535). Salem Health.

Meyers, M. R. (2013b). Dextromethorphan. In Addictions and substance abuse (Vol. 1, pp. 193-194). Salem Health.

Miller, R. J. (2015). Drugged: The science and culture behind psychotropic drugs. Oxford University Press.

Montvilo, R. K. (2013). MDMA. In Addictions and substance abuse (Vol. 2, pp. 368-370). Salem Health.

Morrison, J. (2014). DSM-5 made easy: The clinician’s guide to diagnosis. Guilford.

Musto, D. F. (Ed.) (2002). One hundred years of heroin. Auburn House.

National Alliance of Advocates for Buprenorphine Treatment (n.d.). Opiates/opioids. Retrieved from https://www.naabt.org/education/opiates_opioids.cfm.

National Association for the Advancement of Colored People (NAACP) (n.d.). Criminal justice fact sheet. Retrieved from http://www.naacp.org/pages/criminal-justice-fact-sheet.

National Cancer Institute (2013). Alcohol and cancer risk. Retrieved from http://www.cancer.gov/about-cancer/causes-prevention/risk/alcohol/alcohol-fact-sheet#q2.

National Institute on Alcohol Abuse and Alcoholism (n.d.) What’s a “standard” drink? Retrieved from http://rethinkingdrinking.niaaa.nih.gov/whatcountsdrink/whatsastandarddrink.asp.

National Institute on Drug Abuse (2008). Drug abuse costs the United States economy hundreds of billions of dollars a year in increased health care costs, crime, and lost productivity. Retrieved from http://www.drugabuse.gov/publications/addiction-science-molecules-to-managed-care/introduction/drug-abuse-costs-united-states-economy-hundreds-billions-dollars-in-increased-health.  

National Institute on Drug Abuse (2011). Drug facts: Treatment statistics. Retrieved from http://www.drugabuse.gov/publications/drugfacts/treatment-statistics.

National Institute on Drug Abuse (2021). Heroin research report: What is the scope of heroin use in the United States? Retrieved from https://www.drugabuse.gov/publications/research-reports/heroin/scope-heroin-use-in-united-states.

National Organization for the Reform of Marijuana Laws (NORML) (n.d.) State info. Retrieved from http://norml.org/states.

North Carolina Harm Reduction Coalition (2015). Law enforcement departments carrying naloxone. Retrieved from http://www.nchrc.org/law-enforcement/us-law-enforcement-who-carry-naloxone/.

Owen, F. (2007). No speed limit: The highs and lows of meth. St. Martin’s Press.

Painter, K. (2014, January 23). Sizzurp: What you need to know about cough syrup high. USA Today. Retrieved from http://www.usatoday.com/story/news/nation/2014/01/23/sizzurp-cough-syrup-drug/4793865/.

Pfeifer, D. J. (2013). Medical marijuana should be legal. In M. Haerens & L. M. Zott (Eds.), Medical marijuana, pp. 21-27. Greenhaven.

Pollard, M. S., Tucker, J. S., & Green, H. D. (2020). Changes in adult alcohol use and consequences during the COVID-19 pandemic in the US. JAMA Network. Retrieved

             from https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2770975%C2%A0

Prosser, J. M., & Nelson, A. S. (2012). The toxicology of bath salts: A review of synthetic cathinones. Journal of Medical Toxicology, (8)1, pp. 33-42.

Royce, J. E. & Scratchley, D. (1996). Alcoholism and other drug problems. Free Press.

Saad, L. (2012). Majority in U.S. drink alcohol, averaging four drinks per week. Gallup. Retrieved from http://www.gallup.com/poll/156770/majority-drink-alcohol-averaging-four-drinks-week.aspx.

Schwartz, J. J. (2013). Codeine. In Addictions and substance abuse (Vol. 1, pp. 139-140). Salem Health.

Shroder, T. (2014). Acid test: LSD, ecstasy, and the power to heal. Penguin.

Substance Abuse and Mental Health Services Administration (n.d.). About buprenorphine therapy. Retrieved from http://buprenorphine.samhsa.gov/about.html.

Substance Abuse and Mental Health Services Administration (2014). Drug Abuse Warning Network, 2011: National estimates of drug-relation emergency room visits. Retrieved from http://www.samhsa.gov/data/sites/default/files/DAWN2k11ED/DAWN2k11ED/DAWN2k11ED.htm.

Thornton, E. M. (2006). Sigmund Freud and his experiences with cocaine. In E. C. Berne (Ed.), Cocaine. Thomson Gale.

U. S. Census Bureau (2015). U. S. and world population clock. Retrieved from http://www.census.gov/popclock/.

U. S. Department of Health and Human Services (2013). Drug Abuse Warning Network, 2011: National estimates of drug-related emergency department visits. Retrieved from http://www.samhsa.gov/data/sites/default/files/DAWN2k11ED/DAWN2k11ED/DAWN2k11ED.pdf.

U. S. Drug Enforcement Agency (n.d.). Drug scheduling. Retrieved from http://www.dea.gov/druginfo/ds.shtml.

Van Hoey, N. M. (2013a). Benzodiazepine abuse. In Addictions and substance abuse (Vol. 1, pp. 76-77). Salem Health.

Van Hoey, N. M. (2013b). Caffeine: short- and long-term effects on the body. In Addictions and substance abuse (Vol. 1, pp. 106-108). Salem Health.

Vander Van, T. (2011). Getting wasted: Why college students drink too much and party so hard. New York University Press.

Vera Institute of Justice (2021). Empire State of incarceration. Retrieved from https://www.vera.org/empire-state-of-incarceration-2021

Vermont Department of Health (2021). Monthly opioid morbidity and mortality report. Retrieved from https://www.healthvermont.gov/sites/default/files/documents/pdf/ADAPMonthlyOpioidRelatedFatalities.pdf.

Volkow, N. D. (2014). America’s addiction to opioids: Heroin and prescription drug abuse. National Institute on Drug Abuse. Retrieved from http://www.drugabuse.gov/about-nida/legislative-activities/testimony-to-congress/2014/americas-addiction-to-opioids-heroin-prescription-drug-abuse.

Watson, C. (2015). When “just say no” is not enough: Teaching harm reduction. The New Social Worker. Retrieved from http://www.socialworker.com/extras/social-work-month-2015/when-just-say-no-is-not-enough-teaching-harm-reduction/.

Wegscheider-Cruse, S. (1980). Another chance: Hope and health for the alcoholic family. Science and Behavior Books.

Weisheit, R. & White, W. L. (2009). Methamphetamine: Its history, pharmacology, and treatment. Hazelden.

Wiegand, T., Thai, D., & Benowitz, N. (2008). Medical consequences of the use of hallucinogens: LSD, mescaline, PCP, and MDMA (“ecstasy”). In J. Brick (Ed.), Handbook of the medical consequences of alcohol and drug abuse, pp. 461-490. The Haworth Press.

Willis, S. M. (2013a). Meth labs. In Addictions and substance abuse (Vol. 2, pp. 397-399). Salem Health.

Willis, S. M. (2013b). Methamphetamine. In Addictions and substance abuse (Vol. 2, pp. 395-397). Salem Health.

Willis, S. M. (2013c). Opium. In Addictions and substance abuse (Vol. 2, pp. 434-436). Salem Health.

Winstock, A. R., Kaar, S., & Borschmann, R. (2013). Dimethyltriptamine (DMT): Prevalence, user characteristics, and abuse liability in a large global sample. Journal of Psychopharmacology, 0(0), pp. 1-6.

World Health Organization (2014). Information sheet on opioid overdose. Retrieved from http://www.who.int/substance_abuse/information-sheet/en/.

Zastrow, C. (2010). Introduction to social work and social welfare (10th ed.). Brooks/Cole Cengage Learning.

 

Chapter 14: Mental Health and Treatment

Like many of the topics in this text, mental health is a subject in which you will need to be well-versed in order to be a professional social worker. Social work clients are usually dealing with some sort of adversity in their lives, and those circumstances can take their toll on mental health. Struggling with mental illness can also cause a ripple effect of other problems in one’s life—work or school performance issues, relationship problems, substance use, medical problems, and more. Even if you do not plan to be a clinical social worker or otherwise employed in the mental health field, it is imperative that you feel comfortable working with clients with mental health challenges. You will need to be able to recognize the signs and symptoms of many disorders so that you can help clients to get connected to the resources that can best assist them. Clients who are struggling with their mental health may not be able to work toward goals in any social work program until those needs are addressed.

When you have finished reading this chapter, you should be able to:

1. Define mental health and mental disorders;

2. Explain in brief the history of mental health treatment in the United States;

3. Discuss some of the potential causes of mental illness;

4. Identify the role of managed care and EAPs in mental health treatment;

5. Describe the purpose of mental health medications;

6. List several categories of mental disorders in the DSM-5 and recall an example of a disorder in each category;

7. Discriminate between suicide myths and facts;

8. Identify several important skills and techniques for mental health counselors;

9. List several modalities of mental health treatment;

10. Differentiate between the varying levels of care in mental health treatment;

11. Recognize the special needs of particular populations in mental health treatment;

12. Explain various roles of social workers in the mental health field;

13. Report the importance of self-care for social workers in mental health and other fields.

Counseling
"Counseling" by Alan Cleaver is licensed under CC BY 2.0

What Is Mental Health?

We have come a long way in the terms we use for various psychiatric conditions, though we continue to modify our terminology seemingly at every step. However, it is not unusual for people still to use words like “crazy,” “unbalanced,” “nuts,” “out of it,” “psychotic,” “insane,” or “sick” to describe those who are dealing with mental disorders. These words reflect a lot of things: misunderstanding, fear, disgust, pity, and more. Many people do not have a firm understanding of mental health and it is just easier to think in these unflattering terms.

You may hear the terms mental illness and mental disorder used interchangeably, and there isn’t necessarily anything wrong with that approach. The Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition), commonly called the DSM-5, uses the term mental disorder, and that is what we will use in this text. Some people feel that the term mental illness has too negative of a ring to it and may stigmatize people who have been diagnosed with mental disorders. Others are dismayed by the word “disorder” and what it implies about their state of functioning. The DSM-5’s definition of mental disorder is as follows: “A syndrome characterized by clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning” (American Psychiatric Association [APA], 2013, p. 20).

National Alliance on Mental Illness (NAMI) is the nation’s preeminent advocacy and awareness organization for people with mental disorders (and you may notice they have “mental illness” right in their name). Their definition of mental illness is “a condition that impacts a person’s thinking, feeling, or mood [and] may affect his or her ability to relate to others and function on a daily basis” (NAMI, n.d., para. 1). Both definitions reflect the same basic idea: a mental disorder (or illness) causes problems in day-to-day functioning, sometimes in multiple areas, and is characterized by unhealthy thinking, emotions, and/or behaviors.

How common are mental disorders?

            As with many important topics, it seems that statistics on the prevalence of mental disorders vary. We are going to stick with two very trustworthy sources. The Substance Abuse and Mental Health Services Administration (SAMHSA) reports that 20.6% of adults qualified for a mental disorder diagnosis in 2019; about one in four of those disorders (5.2%) would be classified as severe (2020). NAMI (n.d.a) has similar data. Among adolescents (age 13-18), 46.3% qualify for a mental disorder diagnosis at some point during their teen years, and 21.4% of adolescents would meet the criteria for a severe disorder; in fact, the average age at which a mental disorder begins for someone is age 14 (Bellenir, 2012).

             The numbers from these two respected sources really are not that far apart, and that is significant. One out of four or five adults has some form of mental disorder each year, which certainly means you will come across many people with many different disorders during your social work career, and you need to be prepared to do a good job recognizing the signs of those disorders and helping to get them the resources they need to overcome their conditions.

What causes mental disorders?

There is no simple answer to this question. Here are some of the possibilities:

  • Biological: neurotransmitter levels, brain injury, genetics, brain tumors
  • Psychological: stress levels, poor coping skills, perfectionism
  • Social: socialization, family relationships, abuse, neglect, trauma, economic hardship, loss of a loved one
  • Chemical: medications, drugs of abuse, environmental toxins, poor nutrition
stress
Stress can come from many different sources and manifest itself in several ways, including being a factor in many mental disorders.
"stress" by giuseppesavo is licensed under CC BY-NC-ND 2.0

 

The list could easily go on for a full page of your textbook. Mental disorders are not typically caused by a single event or factor, either—often there is an interplay of multiple factors involved. Just as negative life events can lead to mental disorders, those same disorders can then bring about more problematic events, and the cycle can continue endlessly.

What can be done to help people with mental disorders?

This one is much easier to answer: in most cases, quite a lot can be done. This chapter will delve into some of the different options available to people with mental disorders—both medications and various kinds of therapy/counseling. Although there are many different disorders out there, there are also a lot of clinicians with expertise in a broad range of areas and plenty of research to show how to handle particular issues. Though mental disorders can be difficult, upsetting, even scary in some situations, there is plenty of reason to have hope for recovery and improvements in functioning.

 

History of Mental Health Treatment

At least as early as the 1200s, people with unpredictable and/or unusual behaviors had been subject at times to institutionalization in Europe. As with many other elements of social welfare, a belief in this practice was carried over when Europeans colonized North America (Cox, Tice, & Long, 2016). Without a firm understanding of the nature of mental disorders, at the time people were sometimes believed to be possessed or otherwise cursed in some way, and institutionalization was seen as a practice that was necessary, at times for their safety, and at times for the safety of the community. Sometimes when people were believed to be possessed by demons, they were tortured in efforts to free them from their demonic captors (Zastrow, 2010).

Of course, there were no treatment facilities available when colonists first came to what would become America—the Native Americans certainly had no such institutions, and the colonists were busy simply trying to establish their own sense of civilization in their new land. Therefore, despite the fact that institutionalization was supported in theory, in practice there was no way to carry it out. People with mental disorders were, therefore, left to the care of their families or to survive on their own.

In the early days of America’s independence, true mental health treatment was nonexistent. People in need of care in the 1700s and much of the 1800s were often confined to asylums that were unsanitary and overcrowded, placed in “almshouses with criminals and degenerates,” and sometimes simply imprisoned (Farley, Smith, & Boyle, 2009, p. 153). An early activist and crusader, Dorothea Dix, noticed during her time teaching classes to inmates at the East Cambridge jailhouse that criminals and those with mental disorders were being housed together, as though having a disorder were a crime to be punished. She was appalled (Wilson, 1975).

Dorothea Dix
Dorothea Dix (1802-1887) was perhaps the single most important figure in American history to bring attention to the plight of people with mental disorders being treated terribly; her efforts to reform the system, at a time when women still did not have the right to vote, were remarkable in their scope and impact.
"Dorothea Dix" by exit78 is marked with CC PDM 1.0

Dix traveled the country and worked to alert the public to the horrifying conditions that people dealing with mental disorders were enduring in these prisons and almshouses, acting as an advocate for more humane treatment. She started by attempting to alert her state government into action, penning the following account for the Massachusetts legislature:

I tell what I have seen—painful and shocking as the details often are…I proceed, Gentlemen, briefly to call your attention to the present state of Insane Persons confined within this Commonwealth, in cages, closets, cellars, stalls, pens! Chained, naked, beaten with rods, and lashed into obedience!

...I have been asked if I have investigated the causes of insanity? I have not; but I have been told that this most calamitous overthrow of reason often is the result of a life of sin; it is sometimes, but rarely, added, they must take the consequences; they deserve no better care! Shall man be more unjust than God, who causes his sun and refreshing rains and life-giving influence to fall alike on the good and the evil? Is not the total wreck of reason, a state of distraction, and the loss of all that makes life cherished a retribution, sufficiently heavy, without adding to consequences so appalling every indignity that can bring still lower the wretched sufferer? (Wilson, 1975, p. 122-123)

Dix felt it was not cruelty, but ignorance that caused people to treat those with mental disorders this way, and her passionate recounting of her discoveries to the Massachusetts legislature led to the passing of a bill in 1843 that charged the state with the proper and compassionate care of these individuals (Wilson, 1975). She went on in later years to lobby the federal government to give states land that could be devoted to the construction of facilities to properly care for those in need of mental health care. Though Congress passed a bill approving such a plan in 1954, President Franklin Pierce vetoed it, feeling it was unconstitutional for the government to take such a role in the provision of care; Dix was crestfallen (Morales, Sheafor, & Scott, 2007; Wilson, 1975). However, the attention she brought to the cause was a major impetus for improvements made over the next several decades in the mental health care system; in 1855, the Government Hospital for the Insane (later known as St. Elizabeth's Hospital) was founded by an act of Congress, and by 1860, 28 of the 33 states in the union at that time had constructed at least one psychiatric hospital (Torrey, 2014).

In the early 1900s, Sigmund Freud’s work brought to mainstream awareness the idea that mental disorders were truly illnesses and people suffering from them needed understanding and proper care in order to have a chance to recover. He pushed a very medical perspective of mental disorders, said that early childhood trauma had caused a lot of these individuals’ emotional and behavioral problems, and encouraged psychiatric diagnosis and treatment of individuals (Greenberg, 2013). This led to a far more humanitarian approach, though some of Freud’s specific ideas were misguided (Zastrow, 2010; Greenberg, 2013). (See Chapter 8 for more on Freud’s specific theories about sexuality and development.)

At the same time Freud’s work was gaining steam, social work was truly getting invested in the plight of those with mental disorders. Social work was offered as a service in both Manhattan State Hospital and Boston Psychopathic Hospital by 1910, and Surgeon General Rupert Blue asked the American Red Cross to get social workers involved in the federal hospital system in 1919; “by January 1920, social service departments had been organized in forty-two hospitals” (Farley, Smith, & Boyle, 2009, p. 154).

Despite the increased presence of social work in mental health care, conditions still left a lot to be desired. In 1943, conscientious objectors to the war (often religious young men) were put to work in other ways, some in state mental hospitals. They reported scenes much like Dix had seen in correctional facilities:

Here were two hundred and fifty men—all of them completely naked—standing about the walls of the most dismal room I have ever seen. There was no furniture of any kind. Patients squatted on the damp floor or perched on the window seats. Some of them huddled together in corners like wild animals. Others wandered about the room picking up bits of filth and playing with it. (Torrey, 2014, pp. 22-23).

In 1945, following World War II, there was increased recognition of the impact of mental disorders on America’s troops. Surgeon General Thomas Parran asked Dr. Robert H. Felix, chief of the Mental Hygiene Division of the Public Health Service, to put together a plan for a nationwide mental health care program. Felix had authored just such a proposal for his master’s thesis in grad school and was primed for the task (Torrey, 2014). The National Neuropsychiatric Institute Act was proposed, which became the force behind the foundation of the National Institute of Mental Health in 1949 (NIMH) (Torrey, 2014; Cox, Tice, & Long, 2016).

            Felix’s proposal that the government take a more active role in treating those with mental disorders was fairly revolutionary; he envisioned thousands of centers from coast to coast, at least one in each Congressional district. Though times were good, expansion was not quite as widespread as Felix and his colleagues would have liked (Torrey, 2014). They found a compassionate and powerful ally when John F. Kennedy took the White House in 1961, as Kennedy’s sister Rosemary had undergone a lobotomy and become incapacitated, though this was not information freely shared with the public at the time. Rosemary had been diagnosed with what was then called mental retardation (now “intellectual disability;” APA, 2013), and that was first on Kennedy’s agenda as President, but shortly thereafter he turned his attention to mental health treatment as well (Torrey, 2014).

By 1961, a committee appointed by the President had decided to push for the elimination of state mental hospitals, the deinstitutionalization of those with mental disorders, and the establishment of a network of community mental health centers (CMHCs), a plan approved by Congress in 1963 (Torrey, 2014; Frank & Glied, 2006). The plan provided federal funds to communities to build such centers and to get them up and running for a few years, with the expectation that each center would become economically self-sufficient thereafter. However, the American involvement in the Vietnam War (1965-1975) severely curtailed the funding Congress had planned to provide, while Congress simultaneously tasked the CMHCs with handling new groups of clients: substance abusers, children, and older adults (Frank & Glied, 2006). With these dual concerns, CMHCs had to keep costs down; this meant higher client-to-staff ratios and a pattern of treating people with less severe problems who were easier to help at a lower cost. This, of course, left those with more severe disorders again to public hospitals (Frank & Glied, 2006).

Deinstitutionalization, while well-intended, ended up having some notable negative effects. The desire to give people with less severe mental disorders a chance to be maintained in their communities on an outpatient basis wasn’t a bad one. However, the closing of many of the hospitals and the inability of CMHCs to pick up all the slack meant that many people with severe conditions did not actually have anywhere to go that could provide the level of help they required. This is often seen as a major factor in the rise of homelessness among those with mental disorders, as well as the high proportion of the prison population (estimated at up to 20%) that have psychiatric problems (Frank & Glied, 2006; Torrey, 2014). To complicate the problem further, prisoners with mental disorders are less likely to access follow-up care, more likely to end up back in prison than other prisoners, and on average, return to the correctional system faster (Barrenger & Draine, 2013). By the 1990s, leaders in mental health came to the conclusion that while CMHCs were an important piece of the solution, well-regulated and well-staffed state mental hospitals were also an integral part of a system that could fully address the needs of citizens with mental disorders (Farley, Smith, & Boyle, 2009).

Homeless woman with dogs
Though noble in goal, the deinstitutionalization movement ended up resulting in a lot of people with mental disorders having nowhere to go but to the streets—their problems were too severe to be handled by community mental health centers, but many state hospitals were closing. Being homeless, of course, can also contribute to mental illness.
"Homeless woman with dogs" by Franco Folini is licensed under CC BY-SA 2.0

 

Most recently, laws have been passed on a national scale to reflect the increased recognition of the importance of treating mental disorders with the same degree of attention and coverage that physical illnesses and injuries receive. The Mental Health Parity Act of 1996 and its sister law, The Mental Health Parity and Addiction Equity Act of 2008, require insurance companies to approach the treatment of mental health and addictions in the same manner as medical or surgical treatment—companies may not put stricter lifetime limits, higher co-pays, or higher deductibles on someone’s plan for mental health or addiction treatment than the same person has for most medical/surgical treatments (United States Department of Labor, n.d.). Finally, under President Barack Obama, the Affordable Care Act of 2010 helped to expand Medicaid (now the nation’s number one source of funding for mental health care) and paved the way for more coordination between professionals involved in medical and psychiatric treatment of people with mental disorders (Kuramoto, 2014).

 

Employee Assistance Programs (EAPs)

Many employers have come to recognize that it is to their advantage to handle mental health much like they address physical health, and that giving employees access to mental health treatment and resources not only is the right thing to do, but actually makes for good business. Mental health concerns can be a drain on employee productivity and cause increased absences from work. To that end, more employers have instituted employee assistance programs (EAPs) to link workers with services that can assist them.

EAPs are free for employees to access, and there is an understanding that what’s shared with the EAP is kept confidential from one’s employer. Naturally, if an employee had concerns that their personal struggles would be shared with a supervisor, the individual would be quite unlikely to access EAP services. In some cases, EAPs provide counseling directly, while in others they refer employees to specific agencies, and may cover the cost of a predetermined number of sessions.

EAPs are now required benefits for employees in any federal government workplace (U.S. Office of Personnel Management, n.d.), as well as many state and municipal offices. Among the most common issues addressed by EAPs are:

  • Mental health concerns
  • Substance abuse/dependence
  • Family relationship problems
  • Job stress

Apart from these services, EAPs working with particular employers may also offer services for aging issues and elder care, debt and financial assistance, legal advice, nutritional counseling, smoking cessation, child care, and much more (Employee Assistance Group, 2015).

 

The Multidisciplinary Mental Health Team

You may be surprised to learn that clinical social workers are the number one provider of mental health services in the United States—clients seeking assistance with mental disorders have a 60-70% chance of seeing a licensed clinical social worker (Masiriri, 2008; NASW, n.d.). However, clinical social workers are often just one piece in a multidisciplinary team of individuals working together for the coordination of the client’s care. In certain settings like psychiatric hospitals, residential treatment centers, and outpatient mental health clinics, these teams provide a convenient way for clients to get their needed services in one place, with a group of professionals who are all on the same page.

Some of the people with whom you may work on a multidisciplinary team .

  • Psychiatrist: A psychiatrist is a medical doctor with a specialty in mental health. Psychiatrists can assess and diagnose clients as well as prescribe them psychotropic medication and assess any medical conditions that may be contributing to the issue.
A History Of Psychotropics
Psychiatrists rarely provide therapy anymore, but typically engage in full assessments with clients initially in order to come up with a service plan that may include medication and a referral for mental health counseling. Psychiatrists also work as important parts of multidisciplinary teams in treatment facilities.
"A History Of Psychotropics" by schoschie is licensed under CC BY 2.0
  • Psychologist: Clinical psychologists on a team may conduct therapy, psychological testing, and/or assess and diagnose clients. They generally have doctorate degrees in their field, but cannot prescribe medication.
  • Counselor: A counselor typically has a master’s degree in counseling or a closely related field and may have a credential like LCPC (licensed clinical professional counselor), LMHC (licensed mental health counselor), or LPC (licensed professional counselor). Counselors may engage in assessment, diagnosis, and provision of therapy services.
  • Marriage and family therapist: This specialized area of counseling and therapy involves the professional being specially trained in family and relationship dynamics and helping people to resolve emotional and behavioral concerns impacting those relationships.
  • Art or music therapist: More and more treatment facilities are employing specialized therapists who can assist in the healing process through the use of art, music, dance, and other means of creative expression and relaxation. These individuals often have master’s degrees in their area of specialty and are sometimes called expressive therapists (Neukrug, 2014).
  • Psychiatric nurse: A psychiatric nurse has a nursing degree and license and typically additional schooling to a master’s or doctorate level. Those without an advanced degree can still perform basic tasks like nursing diagnosis and care (Neukrug, 2014). Psychiatric nurses can perform much as counselors, therapists, or clinical social workers do, but also have additional specific training in the medical field. If they are also licensed nurse practitioners or advanced practice registered nurses (APRNs), they can prescribe medication as well (American Psychiatric Nurses Association, n.d.; American Association of Nurse Practitioners, n.d.; Neukrug, 2014).

 

DSM-5 Categories and Diagnoses

As noted earlier, the Diagnostic and Statistical Manual of Mental Disorders is the guidebook of the mental health profession—the most relied-upon source for diagnosis of mental disorders. The fifth edition of the book, DSM-5, came out in 2013 (Coleman, 2014). As with each edition of the text, it was not without controversy. Some of the changes made between the previous edition (DSM-IV-TR) and the DSM-5 were met with skepticism or even disbelief or disapproval in some circles (Wakefield, 2013).

The DSM-5, for better or for worse, is here to stay and will be the guidelines under which mental health diagnosis operates for some years to come. Here are several of the major categories of disorders that compose the DSM-5—those which you will be most likely to encounter in your social work career—and an example of a diagnosis or two in each category.

You will notice that the word “disorder” appears in nearly every category. That word is an important one—think about what it means. Something is not operating as it is supposed to; things are not in working order. It is not unusual for students reading about these disorders and diagnostic criteria to become worried that they may have some of these conditions. They can see some of their behaviors reflected in the lists of symptoms for the varied disorders and start to feel like they might have an undiagnosed disorder. Obviously, if you honestly think you may have one of these conditions, then it may be best to talk to a mental health professional about your concerns. However, before you do, consider the following.

One can have symptoms of a disorder without actually having the disorder. First of all, each diagnosis has a minimum number of criteria that must be met, and sometimes a time frame in which they must have occurred, in order to meet the threshold for having that diagnosis. Secondly, even if one has the requisite number of symptoms to meet a diagnosis, in order for something to be a disorder, it must cause distress or disability in one’s life—that criterion is typically phrased as follows: “the disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning” (APA, 2013, p. 21). In other words, if you have the symptoms of a disorder, but they aren’t causing you problems and you don’t feel bothered by them, then you can rest easy—it is not a disorder.

Neurodevelopmental disorders

These are disorders that become evident in childhood, often before a child begins schooling. They are often co-occurring disorders; it is not unusual for someone diagnosed with one neurodevelopmental disorder also to be diagnosed with another, as with learning disorders and autism spectrum disorders (APA, 2013). Here are two examples of neurodevelopmental disorders with which you may be familiar.

            Autism spectrum disorders—Multiple diagnoses from the DSM-IV-TR were combined to make one diagnosis with multiple levels of severity in the DSM-5. Autism is characterized by “persistent deficits in social communication and social interaction across multiple contexts,” and repetitive behavior patterns or interests (APA, 2013, p. 50). A high-functioning, low-intensity version of autism spectrum disorder was formerly diagnosed as Asperger syndrome (often called Asperger[’s] disorder), but this is a controversial term today. Among the hallmarks of autism spectrum disorder are difficulty relating to other people in social/emotional contexts; struggles interpreting others’ emotions or nonverbal communication; a strong affinity for predictability and routine; great depth of intense interest in particular topics or objects; lack of eye contact; and either overly intense or nearly absent response to sensory stimuli (APA, 2013). 

Box 14.1: Autism Spectrum and Advocacy

One in 68 children is now diagnosed with an autism spectrum disorder (Gnulati, 2014). The above signs may indicate you have a neurodivergent child. While parenting an autistic child can present challenges, some parent support and autism advocacy organizations exist. Some autistic people dislike the work of organizations like Autism Speaks (which has few autistic people on its Board of Directors), preferring the advocacy of organizations led by autistic people (like the Autistic Self Advocacy Network). While autism remains diagnosed as a mental health condition via the DSM-5, autistic people are increasingly asking to be recognized as simply another diverse group in society, whose brains may function a bit differently than most--hence the term neurodiverse.

 

Attention-Deficit/Hyperactivity Disorder (ADHD)—Though you may often hear the term ADD (attention deficit disorder), that is an out-of-date name for this diagnosis. ADHD has multiple subtypes (primarily inattentive, primarily hyperactive/impulsive, and combined), so it is not unusual for someone to have the diagnosis and not really seem to be hyperactive. That person would still be given a diagnosis of ADHD (probably the primarily inattentive type).

People with ADHD are prone to inattention and/or hyperactivity—not necessarily both. Common symptoms include failure to follow through on instruction or work tasks, poor organization, ease of distractibility, difficulty being still or sitting for extended periods of time, difficulty waiting for one’s turn (in conversation and otherwise), intense restlessness, and others (APA, 2013).

ADHD has been a source of some controversy since its original inclusion in DSM-III in 1980 (Lange, Reichl, Lange, Tucha, & Tucha, 2010). The American Psychiatric Association (2013) notes that 5% of children and 2.5% of adults are believed to have ADHD, numbers that some people find to be evidence of overdiagnosis; American children are 20 times more likely to be given a diagnosis of ADHD than kids in Great Britain, and Canadian prevalence is half the American level (Kristjánsson, 2009). Though it can cause serious problems with academic, social, and workplace functioning, many diagnosed individuals will find that some people in their lives do not “believe in” ADHD, saying things like, “It’s just an excuse for being lazy. Put your energy into buckling down and working harder” (Hallowell & Ratey, 2011, p. 327). That can put an undue amount of guilt and shame on a child who may legitimately have the disorder, causing additional psychological and emotional stress.

Schizophrenia spectrum and other psychotic disorders

            Schizophrenia—the disorder which we will discuss in this category—is one of the most misused mental health terms in our culture. You may have already been told this in a psychology course, but many people still believe that schizophrenia has something to do with having multiple personalities. That is a myth; schizophrenia and other psychotic disorders are notable for the presence of two of the following: “delusions, hallucinations, disorganized thinking (speech), grossly disorganized or abnormal motor behavior, and negative symptoms” like lack of energy or communication with others (APA, 2013, p. 87 & p. 99).

Schizophrenia is one of the most severe mental disorders one can have, though antipsychotic medications are available which can help people successfully manage their symptoms, a far cry from the days when we used treatments like inducing an insulin coma or performing a frontal lobotomy (Frith & Johnstone, 2003). It is also quite rare; only about 0.3 to 0.7% of individuals will experience it, though diagnosis varies widely across cultures (APA, 2013). There also appears to be a significant hereditary component; though most people diagnosed with schizophrenia do not have a family history, people who do are more likely to suffer from the disorder (APA, 2013; Frith & Johnstone, 2013; McMillin, 1991). Symptoms must endure for at least six months for a schizophrenia diagnosis, and it is a disorder that typically does not become apparent until at least one’s late teens, sometimes as late as one’s thirties. Men typically experience their first schizophrenic episode (sometimes called a schizophrenic “break”) in their early-to-mid-twenties, while women average about five years later for symptom onset (APA, 2013; Frith & Johnstone, 2003).

Bipolar and related disorders

Formerly listed as mood disorders, bipolar (and related) disorders were placed into their own category in the DSM-5. In the past, the terms manic depression or manic-depressive disorder were used, although they really are related to a specific variety of bipolar which we will discuss briefly.

Bipolar I disorder: Bipolar I is probably what most people think of when they hear the term “bipolar.” It involves the occurrence of at least one manic episode over the course of someone’s life; it does not require the presence of a depressive disorder, though for most individuals with bipolar I, those episodes do occur as well (APA, 2013). Typically, over the span of a lifetime, one will experience many different manic, depressive, and possibly hypomanic episodesA manic episode is probably the easiest symptom of bipolar I to recognize. See the box below for firsthand accounts of experiences with mania.

As with schizophrenia, there is strong evidence of a genetic link for bipolar disorders, and a first episode often does not occur until the adult years, with some cases not beginning until one is 70 or older (APA, 2013). 

Box 14.2: 
People with Bipolar Diagnoses Discuss How It Feels to Have a Manic Episode

“My thoughts ran with lightning-like rapidity from one subject to another. All of the problems of the universe came crowding into my mind, demanding instant discussion and solution—mental telepathy, hypnotism, wireless, telegraphy, Christian science…” (p. 10)

“I made notes of everything that happened, day and night. I made symbolic scrapbooks whose meanings only I could decipher…it was all vitally important.” (p. 11)

“The world was filled with pleasure and promise; I felt great. Not just great, I felt really great. I felt I could do anything, that no task was too difficult…Not only did everything make sense, but it all began to fit into a marvelous kind of cosmic relatedness.” (p. 9-10)

(Sources: Jamison, 1996, Goodwin & Jamison, 1990, Karepelin, 1913, as cited in Mondimire, 2014)

Manic episodes are often characterized not only by these intense positive feelings and thoughts, but by impulsive behavior with high risk of negative consequences, like expensive impulse purchases or indiscriminate sex (APA, 2013). People in a manic state often feel like there is nothing wrong with them—they feel better than they ever have in their lives. It’s those around them whom they perceive as having a problem. Approximately 0.6% of the American population qualifies for a diagnosis of bipolar I in a given year (APA, 2013).

Anxiety disorders

            Anxiety disorders are characterized by tremendous fear and/or anxiety out of proportion to any present cause for such emotions. These disorders are more likely to be diagnosed in women (two-thirds of cases) than men (one-third; APA, 2013).

Nervous?
Anxiety disorders are among the most common conditions in the DSM-5, particularly among women.
"Nervous?" by Freddie Peña is licensed under CC BY-NC 2.0

Panic disorder: This specific condition is noted for the repeated occurrence of panic attacks (APA, 2013). These unpleasant events are occasionally followed by strong concern or anxiety about a potential recurrence and possibly unhealthy behavior changes made in an effort to avoid the onset of a future attack (e.g., avoiding going to work anytime a particular supervisor is present because a conversation with that supervisor preceded the most recent panic attack). About 2-3% of people in America and many European nations suffer from panic disorder each year, and typically, the disorder begins to occur in one’s early twenties (APA, 2013).

Obsessive-compulsive and related disorders

As you might have guessed, obsessions and compulsions are the key features of the disorders in this category, introduced as a standalone category for the first time in the DSM-5. This is a good example of where the word “disorder” makes a difference. Many of you reading this likely have unusual and pointless habits or odd rules you like to follow (like not allowing different kinds of food to touch on your plate, or trying to avoid stepping on cracks in the sidewalk). However, that doesn’t mean you have a disorder unless your rules or habits cause significant distress or problems in functioning.

Obsessive-compulsive disorder (OCD): Typically, someone with OCD has both compulsions and obsessions, but they do not both need to be present in order to receive the diagnosis (APA, 2013). The repetitive thoughts usually lead to anxiety or distress that the person can alleviate by engaging in a particular action—for example, someone obsesses about food sanitation and foodborne illness, and therefore is extremely meticulous about cleaning the refrigerator and all knives and cutting boards on a daily basis. If the person cannot engage in the action he/she is compelled to complete, then the anxiety brought on by the compulsion can become unbearable. In order to receive this diagnosis, one’s obsessions/compulsions must take up more than an hour on a typical day (APA, 2013). Women are more likely to have OCD as adults, while among children, boys are more likely than girls to have the disorder. Overall, 1.2% of Americans experience OCD in a given year (APA, 2013).

Trauma and stressor-related disorders

For all disorders in this category, the affected individual must have experienced a traumatic or stressful event which has caused subsequent psychological, behavioral, and/or emotional difficulties. Their behavior may clearly indicate a fearful or anxious tendency after the event, or it may be manifested more as irritability, detachment, or anhedonia (APA, 2013).

Posttraumatic stress disorder (PTSD): The most well-known of the disorders in this category, PTSD typically involves having recurrent, intrusive, and involuntary memories, dreams, and/or flashbacks to the traumatic event, especially when one experiences stimuli connected to the event (APA, 2013). As a result, one tries to avoid those stimuli. There are also marked changes in thinking and feeling (intense negative beliefs, detachment from others, anhedonia) as well as observable behaviors (hypervigilance, irritability, inability to concentrate, altered sleeping patterns); nearly 9% of all Americans experience PTSD by age 75 and approximately 3.5% experience a problem with the disorder each year (APA, 2015).

While it is normal to feel “on edge” for a time after a traumatic event, most people return to baseline pre-trauma functioning within a few months. People who develop PTSD are “having a unique reaction to an abnormal event” (Banks, 2003). Two populations particularly noted for their experiences with PTSD are a) survivors of sexual assault and abuse, and b) military personnel and veterans. Both sexual trauma and the trauma of serving in an environment where one’s life is at risk (and where one may see friends badly injured or killed) qualify as significantly traumatic and stressful events that can bring on PTSD. Ninety percent of patients in Veterans Affairs/Veterans Health Administration (VA) hospitals have experienced at least one traumatic event on a level that could bring about PTSD; over half of VA patients have endured at least four (Lawhorne-Scott & Philpott, 2013). PTSD is commonly linked with substance abuse, and  both sexual trauma survivors and military veterans with PTSD may also report a sensation of numbing to pain when they reexperience memories of their trauma; at times, this can lead to self-harmful behavior—something we will discuss in greater depth later in the chapter (Davies & Frawley, 1994).

The Intensity of PTSD
Posttraumatic stress disorder can cause people to feel like they are re-experiencing a traumatic event from the past, like soldiers having vivid recollections of being in war zones.
"The Intensity of PTSD" by Truthout.org is licensed under CC BY-NC-ND 2.0

Staff at VA hospitals and sexual trauma treatment centers are often particularly attuned to the symptoms of PTSD and can react accordingly. The VA’s services available for PTSD have increased quite a bit over the last two decades in particular, though the specific amount of resources dedicated to treatment of PTSD, and therefore responsiveness to patients, varies widely from location to location (Lawhorne-Scott & Philpott, 2013). First responders (police, firefighters, emergency medical personnel) are also particularly at risk for PTSD (APA, 2013). This is an area where social workers and other mental health professionals can make important contributions in the coming years as more military women and men return from service with this condition. It’s crucial that professionals in the social work field have a good understanding of PTSD and its symptoms.

Dissociative disorders

            Dissociative disorders have at times been conceived as extreme defense mechanisms of the mind in response to traumatic events. These conditions are “characterized by an involuntary escape from reality” notable for “a disconnection between thoughts, identity, consciousness, and memory” (National Alliance on Mental Illness [NAMI], n.d., para. 1). A small-scale study identified the prevalence of DID, discussed next, at 1.5% per year in American adults (APA, 2013).

Dissociative identity disorder (DID): This is the disorder many people mean when they mistakenly use the term “schizophrenia.” DID has also been called “multiple personality disorder” in the past. DID involves the presence of at least two “distinct personality states” which may have different voices, memories, names, behaviors, gender, and affects (APA, 2013, p. 292). These alternate personalities (often called alters) can sometimes have quite surprising differences, like writing with different hands, needing prescription eyewear or not, or even allergies; the average number of alters is 10, but there can be up to 100 in some cases (NAMI, n.d. c). The alters typically develop due to “repeated exposures to severe trauma in early childhood,” like ongoing sexual assault, child abuse, or witnessing domestic violence on a daily basis (Brown, 2003, p. 138).

DID is a very serious mental disorder which may require antipsychotic medication, and social workers should take care not to attempt to treat anything outside their scope of expertise. If one does not have significant training and experience with DID, it is probably best to connect the client with resources that can help them deal with this condition more effectively.

Feeding and eating disorders

Unusual patterns or significant disruptions of food intake or food-related behaviors are known as feeding and eating disorders. The most commonly known disorders in this category are anorexia nervosa, bulimia nervosa, binge-eating disorder, and pica.

Bulimia nervosa: Although it surprises some people to hear, bulimia nervosa is far more common than anorexia nervosa. Bulimia is a combination of recurrent eating binges and behaviors intended to avoid gaining weight (e.g., using laxatives or diuretics, heavy exercise, or self-induced vomiting), typically peaking in adolescence or young adulthood. The behaviors must continue at least weekly for three months or more in order to meet diagnostic criteria; about 1-1.5% of females could receive the diagnosis in a twelve-month period, while the number of males with anorexia is believed to closer to 0.1% (APA, 2013).

While anorexia is usually far easier to recognize, people with bulimia nervosa blend in more easily. They are typically of average weight or even overweight, and they go to great lengths to cover up their bingeing and compensatory behaviors (APA, 2013; MacDonald, 2003).

Sexual dysfunctions

Sexual dysfunctions are marked by a disturbance in one’s sexual response or capacity for sexual pleasure. They may be primary dysfunctions—meaning they have always existed—or secondary dysfunctions, those that have occurred after a period of healthy, typical sexual functioning (Carroll, 2013). In order to be a dysfunction, the problem must not go away on its own—typically, a six-month duration is required for a diagnosis (APA, 2013; Carroll, 2013).

Genito-pelvic pain/penetration disorder: This condition is characterized by difficulties with vaginal penetration, pain in the vulva/vagina/pelvis during attempts at intercourse, tightening of the pelvis muscles during attempted penetration, or fear/anxiety about these conditions occurring. For example, the inability to allow vaginal penetration during attempted intercourse due to the tightening of pelvic muscles is known as vaginismus. (APA, 2013). This particular disorder has been associated with inadequate sex education and with religious teachings equating sexuality with sin, though findings are somewhat conflicting (APA, 2013). Although it’s not known how common these conditions are, reports indicate around 15% of women in North America report experiencing pain during vaginal penetration or attempted penetration; most of those cases are likely not vaginismus-related (Carroll, 2013; APA, 2013).

Gender dysphoria

Formerly known as gender identity disorder, gender dysphoria is discussed in more detail in Chapter 9. In the DSM-5, it is in its own unique category. The condition is more commonly found in those assigned male at birth (0.005 to 0.014%) than those assigned female at birth (0.002 to 0.003%; APA, 2013).

Disruptive, impulse-control, and conduct disorders

Disorders in this category show disregard for the rights, safety, and respect of others and have the hallmark of a lack of control of one’s emotions and behavior. These conditions are typically discovered in childhood/adolescence, with the exception of one (antisocial personality disorder) that often is not diagnosed until adulthood (APA, 2013).

Pyromania: Like many impulse-control disorders, pyromania is marked by arousal and tension before the act and relief, pleasure, or gratification after its completion; in this case, “the act” is setting fires. The fire-setting is not motivated by money (e.g., not done to fraudulently collect on an insurance policy); as an expression of anger, revenge, or a political statement; “in response to a delusion or hallucination” or other condition impairing one’s judgment; or to cover up one’s criminal activity (APA, 2013, p. 476). With pyromania, the attraction and fascination is with the fire itself. The overall prevalence of pyromania is unknown, but it is rare; even among a group of people in the criminal justice system with a history of setting fires, only 3.3% of the population could be given the diagnosis (APA, 2013).

Substance-related and addictive disorders

For a full look at substance-related disorders, see Chapter 13. However, there are other addiction-related issues; well, there is one, anyway, which we will discuss shortly. There was also discussion over the potential inclusion of sex addiction (Samenow, 2012; Kor, Foegl, Reid, & Potenza, 2013), internet addiction disorder, internet gaming disorder (Bowen & Firestone, 2011), and some other conditions; in the end, the APA decided not to add any of those potential disorders to the DSM-5, opting to wait for more research to be done.

Gambling disorder: Previously known as pathological gambling, this disorder was renamed and placed alongside other addictive disorders instead of being coded as an impulse-control disorder. This reflected increased understanding of the nature of brain chemistry’s role in compulsive gambling, which largely parallels that of other addictions (APA, 2013). Like the substance-related disorders, gambling disorder is characterized by a buildup of tolerance (having to gamble more money to get a “rush”), withdrawal (discomfort and mood disturbances when unable to gamble), multiple failures to cut back or quit, preoccupation, lies to cover up the extent of one’s gambling, continuing to gamble despite interpersonal/occupational/academic problems caused by gambling, and economic difficulties. It is believed that 0.2 to 0.3% of the population have gambling disorder each year, with a 0.4 to 1.0% chance of having it in one’s lifetime; the disorder is three times as common among men as women (APA, 2013).

Gambling addicts
For some people, the allure of gambling is just as strong as the allure of drugs to others. Modern understanding of the brain and neurotransmission has helped researchers to identify parallels in the addictive processes for substances and behaviors like gambling, sex, and shopping.
"Gambling addicts" by Nelson Wu is licensed under CC BY-NC-ND 2.0

 

Neurocognitive disorders

            These disorders are discussed in more depth in Chapter 16.

Personality disorders

In previous editions of the DSM, one could not be diagnosed with a personality disorder until adulthood. Now, there is an allowance in rare cases to diagnose these conditions in adolescence. Personality disorders are among the most difficult disorders to treat in therapy—they are “enduring pattern[s] of inner experience and behavior that [deviate] markedly from the expectations of the individual’s culture, [are] pervasive and inflexible,” and are first noticed in the teenage years (APA, 2013, p. 645). If those traits are rigid, pervasive, and cause problematic consequences for the individual, they may constitute a personality disorder.

People with these disorders see the world in a maladaptive way, and tend to be very resistant to any idea that reality is different from their perception. This can cause a wide range of associated mental disorders due to multiple series of interactions that leave the individual feeling dissatisfied with oneself, the world, or both.

Antisocial personality disorder (APD): Often referred to as sociopathy in the past, antisocial personality disorder is a misunderstood term on its surface. You have probably heard someone use the word “antisocial” to describe a friend who doesn’t feel like going out and socializing. However, the proper term for that is “asocial;” antisocial is quite a different description. Antisocial personality disorder represents a pattern of behavior that disregards the rights and safety of others (APA, 2013). People with antisocial personality disorder are often described as having no conscience; it’s hard to say whether that is accurate, but it is safe to say that people with this disorder often do not feel any genuine remorse over the things they do to harm others. The major motivating factor in their decisions and behavior is whether they will be helping themselves; the consequences on others are not a consideration unless they will also cause consequences for the person with APD. People with APD are often irresponsible, impulsive, irritable, and/or deceitful (APA, 2013).

While it is true that many famous violent criminals have been diagnosed with APD—serial killers John Wayne Gacy, Jeffrey Dahmer, and Ted Bundy among them—people with APD are not necessarily violent. Those who commit white-collar and corporate crimes that bilk people out of their life savings and destroy companies for their own financial gain may very well fit an APD diagnosis as well (Dobbert, 2007). It does, after all, take a profound sense of entitlement and a lack of concern for how one’s behaviors impact others to carry out crimes of such magnitude.

Paraphilic disorders

Paraphilias are “pattern[s] of sexual behavior characterized by sexual arousal to individuals, objects, or situations that [depart] from mainstream normative or typical behavior” (Herdt & Polen-Petit, 2014, p. 505); to be diagnosed as a disorder under DSM-5 guidelines, these conditions also must cause problems in functioning and/or potential harm to others (APA, 2013). Paraphilia is not a synonym for fetish—fetishes are a specific type of paraphilia, and may be well within the bounds of healthy, consensual sexual behavior (Carroll, 2013; Herdt & Polen-Petit, 2014). Though many different paraphilias may rise to the level of a disorder, those that are specifically named in the DSM-5 are among the most common that have the potential to cause harm to others and/or functioning problems for the person with the paraphilic disorder (APA, 2013).

Exhibitionistic disorder: The caricatured stereotype of the exhibitionist is a middle-aged or elderly man wearing a trenchcoat, walking down the street and “flashing” unsuspecting individuals to get a shocked reaction. Like many stereotypes, it fails to accurately reflect reality. People with exhibitionistic disorder do become aroused by the act or idea of showing their genitalia to people who are not expecting it, and generally have engaged in this behavior with an actual nonconsenting person at some point; however, the diagnosis can also result when someone has not yet acted on the impulse but feels distraught about having such urges and fantasies (APA, 2013). Where the stereotype falls short is when it comes to age. This is typically a disorder that first comes to the individual’s awareness in adolescence, though it may not be diagnosed until adulthood. Like many sexual behaviors, exhibitionistic behavior tends to wane with age (Carroll, 2013; APA, 2013). It is estimated to exist in no more than 2-4% of males at some point during their lifetime, and a substantially lower number of women (APA, 2013).

Depressive disorders

Depressive disorders all involve sadness, emptiness, and/or irritability, together with altered thinking and sensation, and have a major impact on the person’s ability to function and interact (APA, 2013). Depressive disorders go beyond “feeling blue”—the condition most commonly involves many individual bouts with severe symptoms, each episode lasting two weeks or more, over a period of months or years (APA, 2014).

Major depressive disorder: One of the most widely known mental illnesses, major depressive disorder (also called major depression, or simply depression) is diagnosable in approximately one out of every 14 adults and adolescents each year, with higher rates among those aged 18 to 29, and females having 1½ to three times higher rates from adolescence onward (APA, 2013). Some individuals with the disorder have nearly constant battles with depressive episodes, while others may go months or years between them. Nearly half of people begin to recover from an episode within three months of its initiation, with 80% starting to improve within a year. Like some of the other disorders we have discussed, there is a strong genetic link to depression, with a 40% heritability rate.

Other than the family history, age, and gender differences we have already noted, risk factors for depression include:

  • Early childhood trauma;
  • Sexual abuse history;
  • Alcoholism;
  • Use of some sedatives and painkillers;
  • Extended period of unemployment;
  • Urban environment;
  • Major life stressors (e.g., divorce, death of a loved one, loss of a job);
  • Chronic pain;
  • Inactivity;
  • Being widowed, divorced, or separated; and
  • Tobacco use (Cheong, Herkov, & Goodman, 2006, as cited in Judd, 2008; APA, 2013; Lyons & Martin, 2014; Centers for Disease Control [CDC], 2013).

    Box 14.3: Self-rating scale for depression

If you are worried you or someone you know may be suffering from depression, this questionnaire may help you to recognize whether additional assessment from a professional should be sought.

Have you experienced either of the following symptoms almost every day for two weeks or more?

1) Feeling sad, blue, or down?

2) Lack of interest or pleasure in things you usually do, even those you normally enjoy?

If yes to either 1 or 2, continue. If not, you are unlikely to have depression.

Have you experienced any of the following symptoms almost every day for two weeks or more?

1) Poor or excessive appetite?

2) Insomnia?

3) Increased sleep, or inability to sleep?

4) Low energy or fatigue?

5) Less activity or verbal communication with others? Slowness or restlessness?

6) Increased tendency to be alone, away from others?

7) Loss of interest in sex and other pleasurable activities?

8) Lack of excitement or pleasure when receiving good news?

9) Feeling inadequate, self-critical, or just generally bad about yourself?

10) Less efficiency or productivity?

11) Lowered capacity to cope with routine responsibilities?

12) Poor concentration or difficulty making decisions?

If you answered yes to one or both of the first two questions, and then four or more questions in the second section, you probably have a depressive disorder and should consult a mental health professional for further evaluation.

(Adapted from Klein & Wender, 2005)

Depression
Though depression is diagnosed more often in women, men may struggle with it more silently due to societal pressures to be stoic and resilient in the face of stress and loss.
"Depression" by Billy Wilson Photography is licensed under CC BY-NC 2.0

Suicide

We chose to discuss depression last among the DSM-5 conditions because it is known for its connection to a risk of suicide. In fact, the final diagnostic criterion for major depressive disorder is “Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide” (APA, 2013, p. 161). Depression is the most high-risk mental disorder for suicide, but suicide is a possible behavior for a range of psychiatric conditions. Still, most people with mental illness are not suicidal and will not attempt suicide; only about two percent of people who receive treatment for depression at some point will commit suicide (Barnes, 2010).

Remember, as a mandated reporter, if someone reports feeling suicidal, you need to assess the situation and possibly make a report in order to keep that individual safe. If you have information that someone is intending to harm themself, you must act on that information. Not only could you face professional consequences for failing to do so, but far more importantly, your client may be quite serious. You need to find out if the client has a specific plan to commit suicide and the means to carry out that plan. If both are present, that is a huge concern and you need to act. Even if there is just a specific plan but no means, you still have a lot of work to do in assessing your client’s mental and emotional state to determine the best course of action.

People are often surprised to learn that men commit suicide more often than women in America (79% of all completed suicides)—in part because they tend to choose more lethal means for their attempts (CDC, 2012). Men's most common method of suicide is by firearm, whereas women's most popular is listed as poisoning, which is often done with medication (CDC, 2012; American Foundation for Suicide Prevention [AFSP], 2013). The presence of a firearm in a home is an additional risk factor for suicide; it would be wise to assess client access to firearms when dealing with severe depression (Judd, 2008). The only country in the world where more women commit suicide than men is China. Females do attempt suicide more often than men worldwide, however, and no suicide attempt should be taken lightly (Barnes, 2010; AFSP, 2013; CDC, 2012).

Another surprising factor to many is that the group most likely to commit suicide is middle-age and older adults—those 45 and older. Adults age 45 to 64 and those 85 and up have relatively equal rates of suicide—nearly double that of those aged 15 to 24 (AFSP, 2013). Suicide rates for men are highest among those age 75 and up and continue to increase as they age, while women are at highest risk from age 45-54 (CDC, 2012; Judd, 2008). What’s more, the death rate in adolescent suicide attempts is just two percent; among men over 45 years old, attempts result in death 25 to 50 percent of the time (Stone, 1999). People often think of suicide as something that happens to young people, but as social workers we need to be aware that people of any age are capable of committing suicide.

Many myths persist about suicide. It is important to know the facts.

Myth #1: Suicide increases during the winter holidays: Actually, suicide is at its lowest rate in December. Among the student population, suicide rates are at their highest during spring semester (Barnes, 2010).

Myth #2: Suicides happen fast; they’re rash decisions. Typically, suicides are not sudden; they rarely occur without warning. Most people who are thinking about suicide tell someone before following through on an attempt. The decision to commit suicide usually comes to someone after a series of contributing events and emotions (Barnes, 2010).

Myth #3: Talking about suicide will give someone the idea to do it. In reality, talking to someone about whom you are concerned shows that person that you are invested in their health and safety, and that act alone is sufficient to reduce the risk of a suicide attempt (Barnes, 2010).

Myth #4: People who claim they are suicidal are just looking for attention. It may be true that some people who talk about suicide are simply looking for people to be concerned about them. However, since most people who commit suicide talk to someone about it first, it is important to take someone seriously when they talk about suicide. The price to be paid if you fail to take someone seriously enough is far too high (Barnes, 2010). In reality, most people who are considering suicide have come to feel their pain is inescapable, interminable, and/or intolerable (Chiles & Strosahl, 2005). Talking to someone about it may help change their mind.

Schools and communities are becoming more aware of the risk of suicide contagion—that is, the chance of additional suicides following an initial suicide, often by a celebrity or teen peer. There is a danger in “glorification or memorialization” of a suicide victim, since kids who have been depressed and/or thinking no one cares about them may see the outpouring of love and sorrow over the loss of a peer and think suicide is an “attractive solution to their problems” (Barnes, 2010, p. 26; Judd, 2008).

myspace suicide note...
Depression is often accompanied by suicidal thoughts, though the overwhelming majority of people who experience depression do not commit suicide. Still, any suicidal message should be taken seriously, especially by social workers, who are mandated reporters.
"myspace suicide note..." by Zadi Diaz is licensed under CC BY-NC-SA 2.0

Be aware of someone exhibiting some of the warning signs of suicide:

  • Suddenly showing atypical interest (for them) in firearms or pills;
  • Feeling trapped;
  • Withdrawal from friends, family, and others;
  • Tying up loose ends;
  • Giving away cherished possessions;
  • Expressing that life is pointless or meaningless;
  • A sudden and unexplained change to positive mood after being depressed or withdrawn for some time;
  • Unexpected declines in academic or work performance;
  • Previous suicide attempts (Judd, 2008).

    Box 14.4: The SAD PERSONS Scale

The SAD PERSONS scale is used to assess suicide risk. Each letter stands for one of the criteria used to make a determination of risk level.

Sex: Men are more likely than women.

Age: Adults over 45 and under 18 are higher-risk for suicide attempts.

Depression: This disorder increases risk, and should also be noted if it seems to go into sudden remission after a period of severe symptoms.

Previous attempts: The number one correlation with suicide attempts is previous attempts.

Ethanol: Alcohol consumption increases suicide risk (as does use of drugs).

Rational thinking loss: The presence of thought disorders is a risk factor.

Social supports lacking: Isolation and lack of meaningful relationships are concerns.

Organized plan: The risk is quite high if the client has a specific plan for suicide.

No spouse: Single people are at higher risk.

Sickness: Serious physical illnesses, particularly terminal ones, are risk factors as well.

(Source: Farley, Smith, & Boyle, 2009)

At any time, if you are worried about the chance of a client hurting themself, and are unsure what to do, talk to colleagues, and especially your supervisor. This is too important a determination to make yourself if you are uncertain. It is better to act preventatively than take a wait-and-see approach. Suicidality is one of the few reasons (along with being a threat to others) that someone can be hospitalized against their will, provided a qualified mental health professional will attest to the client’s need for such treatment for safety purposes.

 

Self-harm

Cutting, burning, scratching, punching, pinching, puncturing, or picking at wounds to prevent healing: there are many methods of self-harm, despite “cutting” being the often-used euphemism. Seventy-eight percent of people who engage in this behavior use more than one method (Adler & Adler, 2011). Self-harm (or self-injury) is a complex behavior that can accompany a number of mental disorders or stressors: depression, borderline personality disorder, eating disorders, bipolar disorders, PTSD, negative body image, sexual abuse or trauma, and more. It commonly begins between the ages of 14 and 16 and is seen more often in girls/women, people of any age and gender may engage in this behavior (McVey-Noble, Khemlani-Patel, & Neziroglu, 2006; Plante, 2007). It can be very difficult for some people to understand why someone would engage in self-harmful behavior, especially because many people who do so do not appear outwardly to have mental disorders, and may even be safety-conscious and/or risk-averse in other areas of their life—wearing seat belts, abstaining from tobacco use, etc.

Many people who engage in self-injury say that they do so to relieve negative emotions like frustration, jealousy, loneliness, sorrow, or anger. The physical pain, in a sense, distracts them from their emotional pain, or the neurotransmitter rush that may accompany self-injury helps to counteract the negative emotions (McVey-Noble et al., 2006; Walsh, 2012; Plante, 2007). Others report that they feel numb to the world around them, or think they’ve forgotten what it’s like to feel anything—and self-injury reminds them that they can indeed feel, and that they are alive.

Still others have intense negative feelings about themselves and hurt themselves because they feel they deserve it; these individuals (and those mentioned in the previous paragraph) may very well injure themselves in places that will not be seen by others due to being covered up by clothing. Some may be intentionally causing injuries in conspicuous, visible places that they know will get the attention of loved ones or authority figures who will then start some wheels in motion that will get the self-injurer the attention necessary to address whatever is going on (McVey-Noble et al., 2006; Plante, 2007; Walsh, 2012). Self-injury is often seen in adolescents and young adults who are exceedingly perfectionistic (academically, regarding body image, etc.) and/or dealing with family dysfunction or divorce (McVey-Noble et al., 2006; Walsh, 2012; Plante, 2007). It is also more commonly seen among middle- and upper-class Caucasians than other groups (Adler & Adler, 2011).

When self-injurious behavior is noticed, it is important to address it as quickly as possible. The longer one waits, the more difficult it can be to get treatment, because self-injury can become addictive, may be the only coping mechanism the individual uses for negative emotions, and may be bringing them a lot of attention (though not a healthy sort; Plante, 2007). Ignoring the behavior, or hoping it goes away, may inadvertently send a message that it is nothing to take seriously, or that one is not concerned about the person who is self-injuring. Without intervention, the behavior can escalate as the self-injurer builds up a tolerance of sorts and begins to cut or otherwise hurt oneself more severely (McVey-Noble et al., 2006; Adler & Adler, 2011). Extreme cases may escalate to behavior like bone-breaking (Adler & Adler, 2010; Walsh, 2012; Plante, 2007). Communities of self-injurers online also exist and may serve as either recovery supports or encouragers of each other’s self-harmful behavior (Adler & Adler, 2011), so it may be best to make sure the online community and self-injuring peers are not the only ones talking to a self-injurer about these behaviors. Identifying with the self-injury community—if they are individuals still active in the practice—may cement the behavior as part of one’s identity (Adler & Adler, 2011).

An important and common question is whether there is a link between self-harm and suicidal behavior. There is definitely enough of a connection to cause concern. Most people who self-injure do not wish to die, and self-injury should not automatically be taken as evidence of suicidality; however, research has placed the percentage of self-injuring individuals who also display some suicidal behavior at 50 to 90%, and 28-41% of those who self-injure have suicidal thoughts while self-injuring (McVey-Noble et al., 2006). People who engage in self-injury, regardless, are almost certainly suffering from some degree of pain and turmoil, whether they want to die or not. It is not a behavior that social workers or loved ones should fail to address or see as mere attention-seeking. Successful treatment methods exist and can be pursued (Walsh, 2012).

 

Counseling and treatment

As noted, clinical social workers are the number one providers of mental health services in America, and that means that they do a lot of counseling. There are many different approaches to counseling/therapy, and each counselor tends to have a unique style. You may have been to counseling yourself (many social workers have as well—it’s not a bad idea to do so), and you may have had the experience of “clicking” with a particular counselor while failing to do so with another. That is to be expected. Should you become a clinical social worker, it is unlikely you will “click” with every client yourself.

People who come in for mental health care may be understandably nervous, apprehensive, or anxious about the process. There are a lot of ideas floating around about what counseling is, how counselors and therapists behave, and what one can expect when one enters a counselor’s office. Some believe counselors will push for them to see a psychiatrist and get on medication. Others have heard that they will constantly talk about feelings and try to uncover hidden traumas or repressed memories of the past. People may even think that a counselor will give them the expert advice necessary to fix their problems.

The truth is that clinical social workers (as well as other counselors) try not to engage in those behaviors. A visit to a psychiatrist may be discussed if medication could potentially be of some assistance, but clinical social workers and other people in counseling roles can and do work with clients who do not wish to take any psychotropic medications (antidepressants, mood stabilizers, antipsychotics, anxiolytics, etc.). Some counselors may be very interested in the past events that led to functioning problems today, but it may depend on the situation, as well as the counselor’s specific theoretical mindset. Finally, clinical social workers and other counselors generally do not give advice. (Clients have usually gotten plenty of that already.) It is the counselor’s job to help the client figure out what he/she wants to do and how to execute it—not to solve the problem on the client’s behalf. For further counseling strategies, tips, and basic techniques, see the box below.

 Many medications available for mental disorders—antidepressants, mood stabilizers, antipsychotics, and more—do not cure any disorders on their own. Prescriptions like these are not meant to be standalone treatment. More likely, they will relieve symptoms and stabilize a client in order to provide an opportunity to get the most out of therapy. Most psychiatrists will routinely recommend seeking counseling along with a lot of the prescriptions they offer. Some may even make prescription refills contingent upon participation in counseling, so that someone is able to monitor the treatment for potential side effects more often, and to help the client more fully address the disorder and its impact.

Box 14.5: Counseling Suggestions

  • Speak briefly: The client should be doing most of the talking. Sometimes beginning counselors think they need to be directing the session in a really structured way, and there are situations that do call for that. In general, though, a counselor is doing a good job when the client is talking a lot more than the professional. Counselors should strive to use just a few words, a couple of sentences at most. Sometimes, just one carefully chosen word can prompt a client to continue speaking and to come closer to key insights.
  • Use silence: Counselors can make the mistake of thinking that silence is a problem. It can be, if the client is waiting for the counselor to respond to something and nothing is being said. However, silence can be productive. Sometimes a client may pause to gather thoughts, respond to intense emotions, or make new connections and insights about something that has just been said in session. Jumping in and filling the silence may short-circuit the necessary process the client is trying to complete. If a client needs the counselor to speak, it should be apparent through eye contact and body language.
  • Plan for termination from the first meeting: The whole point of social work (and counseling) is to make oneself obsolete. We do not want clients to need us forever—we are aiming to empower them on a road to self-sufficiency. With that in mind, a treatment plan should always be in place between counselor and client, with clearly stated goals that can help keep them on track in their work. One question one of your authors was fond of asking his clients in the first session was, “So, how will we know when you do not need to come to counseling anymore?” It was a good way of establishing from the start that this relationship had a purpose and was not intended to be permanent—that the client could succeed and would no longer need counseling at some point.
  • Don’t try to solve problems too early: If a counselor offers a solution to the main presenting problem, the client may feel a bit put off that the counselor thinks the problem is that simple to fix. It may make the client feel unintelligent, or at least that they are perceived that way. Clients have generally tried a lot of different methods of fixing their own problem before they come in to see someone; it is important to talk about all those past efforts and brainstorm ideas for future improvement together.
  • Don’t ask too many questions: The counseling relationship isn’t a friendship, but it’s not a puzzle or an inquisition either. We do not want clients to feel we are interrogating them. As much as possible, a counseling session should feel like a conversation. Statements can be just as provocative and continue the client’s sharing and processing of feelings and events. Particular questions—like ones that start with “why” or are closed-ended questionsshould be used at a minimum. Certain “why” questions can give the impression that a client’s motives or intelligence are being questioned (“Why did you do that?”), while closed-ended questions do not encourage much of a response from the client. Open-ended questions should be the majority of questions asked.
  • Pay attention to nonverbal communication: Remember that your client’s nonverbal communication can tell you a lot, especially if it is incongruent with their verbal communication. Pointing out their nonverbals may be educational for them, as they may not even realize how they look. It may also be an indicator to them that you are very “tuned in” to what is happening with them in session. It is similarly crucial to be attuned to our own nonverbal communication and what it communicates to the client—we do not want to show emotion that is inappropriate for the topic being discussed, or send our own incongruent messages.
  • Make assessments, not judgments: Remember, it is not the counselor’s job to say something is right/wrong, good/bad, normal/abnormal. Those words generally give the impression of judgment. The counselor should be focusing on psychological assessments rather than moral judgments of behavior, especially since clients may already be feeling judgmental toward themselves.
  • Do not try to guess what the client is thinking, feeling, or doing: Beginning counselors (and some experienced ones) may also make the mistake of thinking that if they can guess what the client is thinking or about to say, it looks impressive. However, it is important to allow the client to say what they want to say. It may be very important for them to make a particular statement themselves; they may be acknowledging something openly for the first time. They may need to hear themselves say something to know they can admit to it. Furthermore, if the counselor guesses wrong, it can give the client misgivings about the counselor’s competence or attentiveness.
  • Be culturally competent: This is always important. Remember that different cultures may approach counseling in different ways. Some people will be very reluctant to share personal information and may need more time to become comfortable doing so. People from different cultures may also have different meanings for some of their nonverbal behavior. Social workers must continually strive to be more culturally competent. These differences should be understood and respected, along with the counselor having a recognition of their own culture and its influence on the helping relationship and the counselor’s behavior and communication style.
  • Use shared vocabulary: Talk the way the client talks. This does not mean to dumb down your language, or to use colloquialisms or slang terms the client uses that you do not normally use (teenagers can see right through an adult trying to act “cool”), but avoid using professional terms, jargon, or acronyms. Speak in a way that is easy for the client to understand. Sometimes this means adjusting your terminology from client to client. You would probably speak differently to a 45-year-old professional than you would to a 13-year-old gang member, even though your basic goal—building rapport in order to work on treatment goals—is the same.
  • Show empathy, not sympathy: The counselor should be trying to put themself in the client’s position, to see what it would be like to be dealing with the client’s situations from their own unique perspective. Sympathy, the act of feeling pity or feeling sorry for a client, should be avoided.
  • Start where the client is: Finally, the client has to dictate the direction of treatment to a large degree. If the client does not want to work on a particular issue, even if the counselor recognizes it as the major problem that is occurring, then no work can be done. Counselors cannot (and should not try to) force clients to do work they do not wish to do. Pushing against a client’s resistance will often either firm up that resistance or push the client right out of counseling. If the client has a problem he/she wishes to address first, that is where the counselor should start.]

(Sources: Meier & Davis, 2011; Hutchinson, 2007; Okun, 1997; McHenry & McHenry, 2007)

Types of counseling

Counselors can work with clients in a variety of settings, each with its own advantages.

Individual therapy: One-on-one sessions with clients give them the opportunity to be open and honest about topics that may be more difficult to discuss in a group. The chance to build a solid rapport with the counselor is perhaps stronger in this modality of treatment as well. Sessions for individual therapy typically run 45 to 50 minutes, in accordance with expectations of managed care. Outpatient individual therapy is often done on a weekly or biweekly basis.

Group therapy: Some problems and types of treatment are better suited for group therapy, which may occur weekly or multiple times per week depending on the level of care (See Chapter 13 for a review of levels of care in treatment). Substance use disorders are a good example of a problem that seems to get better treatment results in group settings. In a one-on-one session, a savvy client may be able to fool a counselor; however, that same client using the same technique may get called out for being dishonest by other members of the group, who can speak a bit more directly than would be proper for the counselor. Additionally, group therapy is productive and valued for other client benefits, like universality and the helper therapy principle (Day, 2007).

Group Therapy - ta bai....
Group therapy provides opportunities for healing and feeling connected to others with similar difficulties, so clients can know their struggle is shared by others who are also invested in their recovery.
"Group Therapy - ta bai...." by Xin Li 88 is licensed under CC BY-NC-ND 2.0

Family therapy: Sometimes a clinical social worker or other counseling professional will work with a family as a unit. Having the various family members in session can be very illustrative, as interactions between the clients can be observed that otherwise would just have been reported in perhaps a biased way. The counselor can learn from the interactions of the family what processes may be dysfunctional and in need of change, as well as seeing some of the family’s collective strengths that may not have been observable in working with them individually.

Play therapy: A specialized method for working with younger children, play therapy is a process that helps children to communicate and open up with a therapist about things they might otherwise struggle to put into words. Skilled practitioners of play therapy are able to learn a lot from a child’s methods of play or creative expression that could not necessarily be gleaned from basic talk therapy (McHenry & McHenry, 2007).

There are also many specific schools of thought and families of techniques when it comes to therapy, like cognitive-behavioral, Gestalt, solution-focused, existential, rational-emotive, and more. If you decide to become a clinical social worker, you will have the opportunity to learn a lot more about these various approaches and pick what works best for you.

 

Working with Diverse Populations

Women

Without women as clients, we would need a lot fewer social workers, and yet many of our approaches are rather androcentric. We have not done as good a job of devoting research to problems that specifically impact women, like postpartum depression and premenstrual dysphoric disorder, or of understanding how specific disorders (like major depression or substance use disorders) manifest differently for women. (To give you an example, a quick search of the EBSCO research database in 2021 revealed 8,730 articles with a mention of postpartum depression, but a whopping 15,041 when the search is for erectile dysfunction!)

We are starting to see more attention paid to these imbalances in treatment knowledge. When women are experiencing infertility issues, for example, we now know that there is increased risk of depression every time menstruation occurs, as it may feel to the woman like another “failure” (Seibring, 2003). This can help us to address a woman’s needs from both a medical and psychological/emotional standpoint.

Critics have also recognized problems in taking treatment approaches that were designed by men from their own perspective of what would be helpful and using those same approaches to help women; for example, feminist practitioners and theorists have been critical of the traditional 12-step approach of Alcoholics Anonymous as it relates to women. The first step involves admitting powerlessness. Women who have stated in groups that they already felt powerless, and that may be part of what led them to abuse alcohol, have been at times “shamed, threatened with abandonment, and called resistant” to the 12 Steps (Matheson & McCollum, 2008, p. 1028). It has been suggested that submitting further to an admission of powerlessness may actually increase women’s insecurity and sense of oppression, putting further roadblocks in their way as they try to recover from a difficult condition. Those who already feel disempowered in their general lives are not likely to find it helpful to start off a program that insists on an admission of powerlessness (Matheson & McCollum, 2008). Powerlessness got them into their addiction in the first place, feminists might say—they need to feel empowered and transformed instead of powerless.

From a macro perspective, we have to recognize that there may be a reason women seem to have higher rates of depression and other mood disorders, and it may not necessarily be physical or neurochemical in nature. “The mental health of women and their low social status are intricately intertwined…Any serious attempt to improve women’s mental health condition must deal with the ways in which their mental health is affected negatively by social customs and cultural considerations” (Wetzel, 1995, p. 177).  When women are treated as if they are lesser than men—as they are in virtually every society still today, to some degree—it should be no wonder that they suffer from great degrees of various mental illnesses and may find themselves relegated to lower-paying jobs and a greater likelihood of ending up in poverty. The patriarchal system tells them they cannot succeed, puts limits on their abilities to improve their lives, and then calls the natural emotional and psychological results of systematic oppression a “mood disorder” or “mental illness.”

Men are less likely to feel they live in nonsupportive, controlling environments and therefore are more likely to feel comfortable being assertive. Women in counseling may have to be assisted in learning assertive behavior to help them have better chances of achieving what they would like for themselves and their families (Wetzel, 1995).

Wetzel (1995) has several macro-level suggestions that she feels could make a bigger impact on the overall mental health of women than simply continuing to treat individual women’s problems as they present in social work and counseling offices. They include:

  • “Raising consciousness regarding gender roles and the importance and worth of every female;” (p. 181)
  • “Addressing the fundamental right of every woman to live without fear and domination, whether in the home or society, and to be educated and treated with respect;” (p. 183)
  • “Sharing home maintenance and child care with men on an equal basis; restructuring the family and society from a human rights perspective;” (p. 184)
  • “Teaching fundamental rights regarding health needs, both emotional and physical, including the individual and mutual need for nurturance, freedom from exhaustion, and participation in decision making, within and outside the home;” (p. 185)
  • “Teaching women that both personal development and action, as well as collective social development and action, are essential if their lives are to change for the better;” (p. 186)
  • “Engaging in participative social action research, culminating in new policies and laws, as well as participative psychosocial programs for social change” (p. 187).

Addressing women’s individual mental health concerns, while still important, may be like treating the symptom of a wider problem. In order to make a more significant change in the overall mental health of women in the United States and abroad, efforts toward greater equality may be more productive. This is an issue that can be approached from micro, mezzo, and macro angles.

LGBTQ+ Clients

            Though there is greater acceptance than ever in America for LGBTQ+ people, substantial prejudice still exists and is at times even socially sanctioned. Having to deal with oppression, disenfranchisement, and discrimination from society at large is difficult, but at times, LGBTQ+ clients have also been dealing with similar behaviors from family and friends. Needless to say, this treatment from strangers and loved ones alike can bring about significant mental health concerns. LGBTQ+ people are impacted by depression at a higher rate than the general population, and counselors who behave in heterosexist or heterocentric ways can become barriers to LGBTQ+ people seeking treatment (Bellenir, 2012).

Barrett & Logan (2002) offer the following tips for working with LGBTQ+ clients in counseling.

  • Be aware of your own internalized prejudice: Being raised in a heterocentric society, it is natural for most counselors to exhibit some heterocentrism, often without recognizing it.
  • Be prepared to assist clients with coming out: Be supportive and appropriately aware of the potential pitfalls and difficulties that may occur with the process; respect their desire to come out at their own pace.
  • Be aware of the effects of prejudice: Recognize that clients have been dealing with negative treatment by society and may be living in a world different from the one you inhabit, if you are heterosexual; they may not have experienced society as a supportive and helpful place, and therefore may anticipate different reactions from others than you would.
  • Actively address and combat societal oppression: Think macro! If you want your LGBTQ+ clients to have better mental health functioning, one way to help is to work on changing the environment to reduce those stressors of negative societal reactions and treatment toward your clients.
  • Be comfortable and able to talk about sex and sexuality: Do not allow your client to feel like they need to approach the topic of sex indirectly. Be as willing to discuss their sex life and related concerns as you would with a heterosexual client.
  • Recognize that domestic violence does occur in same-sex relationships: Make sure to have a list of LGBTQ-friendly resources at the ready for such situations, and react in the same supportive way you would to any other individual dealing with domestic violence.
  • Understand substance use and its prevalence in the gay community: Be ready to suggest gay-friendly AA and other non-12-step support groups. Learn about where they are if you do not already know.
  • Use the terms clients use: If clients use terms like boyfriend/girlfriend, husband/husband, wife/wife, partner/partner, or anything else in their relationships, follow their lead. Don’t feel the need to guess—if you are unclear what to say, just ask what the client(s) would prefer.
  • Avoid overfocusing on sexual orientation or gender identity: Like heterosexual, cisgender clients, LGBTQ+ clients have problems that they do not perceive as related to their sexual orientation or gender identity. Do not feel the need to connect every issue back to those elements of identity.

Self-care

We’d like to add one final thought before closing out this chapter, which seems the most appropriate chapter in which to address the topic. It is important to recognize that as a social worker, you will on a daily basis deal with people who are in difficult periods of their life. Frequently, you will encounter clients who are sad, angry, depressed, anxious, frustrated, and hopeless. It will be your job to help them to push through difficult emotions and trying circumstances toward the goals established in the helping relationship. It can be a very rewarding job! However, as has been said by many more talented social workers before us, this is a job that demands your mental health while simultaneously threatening your mental health.

It is a difficult job to often encounter people expressing strong negative emotions. When you are continually taking on sadness and anger and frustration and helping clients have a safe place to unload those feelings, there are days you will leave work absolutely drained, not wanting to do much more than go home and get into bed. Every job probably has days like that, frankly. In social work, it is imperative that you learn how to take care of yourself. Check out the final box below to see some specific ideas on how best to ensure you stay mentally healthy while helping clients shoot for the same goal. If you have not done a good job of taking care of yourself, it will be very difficult to be present at work and able to be fully attentive to the client’s needs. This is true of any job in social work—your health impacts the clients’ health.

Box 14.6: Self-care tips

It is essential for a social worker to do a good job of maintaining a healthy personal life in order to be able to be most effective in helping people with their lives’ struggles. Here are some specific suggestions of how to accomplish this very important goal.

  • Exercise regularly in some way that you enjoy. Physical health impacts your mental health.
  • Enjoy an active social life to the extent that you prefer. There’s no need to see friends every weekend, but having contacts with people with whom you can let loose—whatever that means to you—is important to let go of some of the stresses of the day or week.
  • Set a firm boundary for yourself for when work ends. Do not constantly be in an “at work” mindset. Do not continually bring work home with you. Make your home your sanctuary, and leave work at work as much as possible.
  • Use supervision and consultation to your advantage. When you really need to talk with someone about a case, do it! Seek someone out for that very purpose, whether it is your supervisor on site or a trusted colleague at your agency or elsewhere. But do not spend much of your evenings or weekends at home on this endeavor. Know when to let it go and concentrate on something else.
  • Do not give out your personal phone number or email address to clients. They do not need to be able to contact you at all hours. Your agency likely has a crisis or emergency line and someone who is on call for it. Your clients do not need to be able to reach you directly. If you let clients have your phone number or email, you may as well always be at work.
  • See a counselor yourself. You do not need to do so constantly, but many social workers see a counseling professional from time to time. It not only helps you to process your emotions and stress and let go of negativity, but it also gives you a renewed appreciation for what clients are going through every time they step into a counselor’s or social worker’s office.
  • Make sure you are eating a healthy and balanced diet. Again, physical health impacts your mental health. Don’t skip breakfast and lunch when you have a busy day. If you do not take care of yourself, you cannot attend to others as well.
  • Learn how to recognize your own stress signals and respond to them. Do not expect others to do it for you—they are already dealing with their own stressors!
  • Know how to say “no.” Social workers are often the kind of people who love to pitch in and volunteer. People will often ask you to do so, knowing you work in the field. If something sounds like it will be fun and you’ll enjoy yourself, go for it! If it sounds like a lot of work and you are already overloaded, do not be afraid to say “no.” The momentary twinge of guilt you feel will be easier to deal with tan the additional task on your stuffed agenda.
  • Know how to relax. Spend some time in solitude—running, biking, reading, napping. Get a massage. Bake. Do whatever it is that puts you at peace, and do it regularly.

 

References

Adler, P. A. & Adler, P. (2011). The tender cut: Inside the hidden world of self-injury. New York University Press.

American Association of Nurse Practitioners (n.d.). What’s an NP? Retrieved from http://www.aanp.org/all-about-nps/what-is-an-np.

American Foundation for Suicide Prevention (2013). Facts and figures. Retrieved from https://www.afsp.org/understanding-suicide/facts-and-figures.

American Psychiatric Association (2013). The diagnostic and statistical manual of mental disorders (5th ed.). American Psychiatric Association.

American Psychiatric Nurses Association (n.d.). About psychiatric-mental health nurses. Retrieved from http://www.apna.org/i4a/pages/index.cfm?pageid=3292.

Banks, A. E. (2003). Posttraumatic stress disorder. In L. Slater, J, H. Daniel, & A. E. Banks (Eds.), The complete guide to mental health for women, pp. 214-220. Beacon Press.

Barnes, D. H. (2010). The truth about suicide. Facts on File.

Barrenger, S. L. & Draine, J. (2013). “You don’t get no help:” The role of community context in effectiveness of evidence-based treatments for people with mental illness leaving prison for high-risk environments. American Journal of Psychiatric Rehabilitation, 16(2), pp. 154-178.

Barret, B. & Logan, C. (2002). Counseling gay men and lesbians: A practice primer. Brooks/Cole.

Bellenir, K. (Ed.) (2012). Mental health disorders sourcebook (5th ed.). Omnigraphics.

Bowen, M. W. & Firestone, M. H. (2011). Pathological use of electronic media: Case studies and commentary. Psychiatric Quarterly, 82(3), pp. 229-238.

Brown, L. S. (2003). Women and trauma. In L. Slater, J, H. Daniel, & A. E. Banks (Eds.), The complete guide to mental health for women, pp. 134-143. Beacon Press.

Carroll, J. L. (2013). Sexuality now: Embracing diversity (4th ed.). Cengage.

Centers for Disease Control (2012). Suicide facts at a glance. Retrieved from http://www.cdc.gov/violenceprevention/pdf/suicide-datasheet-a.pdf.

Centers for Disease Control (2013). Depression. Retrieved from http://www.cdc.gov/mentalhealth/basics/mental-illness/depression.htm.

Chiles, J. A. & Strosahl, K. D. (2005). Clinical manual for assessment and treatment of suicidal patients. American Psychiatric Publishing.

Coleman, M. (2014). DSM-5 frequently asked questions by clinical social workers. Practice Perspectives (Winter 2014). Retrieved from http://www.socialworkers.org/assets/secured/documents/practice/clinical/dsm5faq.pdf.

Cox, L E., Tice, C. J., & Long, D. D. (2016). Introduction to social work: An advocacy-based profession. SAGE.

Day, S. X. (2007). Groups in practice. Houghton Mifflin.

Dobbert, D. L. (2007). Understanding personality disorders: An introduction. Praeger.

Employee Assistance Group (2015). Solutions for common issues: Some common issues. Retrieved from http://www.theeap.com/solutions-for-common-issues/.

Farley, O. W., Smith, L. L., & Boyle, S. W. (2009). Introduction to social work (11th ed.). Pearson.

Frank, R. G., & Glied, S. A. (2006). Better but not well: Mental health policy in the United States since 1950. Johns Hopkins University Press.

Frith, C. & Johnstone, E. (2003). Schizophrenia: A very brief introduction. Oxford University Press.

Gnulati, E. (2014, April 11). 1 in 68 children now has a diagnosis of autism spectrum disorder—why? The Atlantic. Retrieved from http://www.theatlantic.com/health/archive/2014/04/1-in-68-children-now-has-a-diagnosis-of-autism-spectrum-disorder-why/360482/.

Greenberg, G. (2013). The book of woe: The DSM and the unmaking of psychiatry. Blue Rider Press.

Hallowell, E. M. & Ratey, J. J. (2011). Driven to distraction: Recognizing and coping with attention deficit disorder from childhood through adulthood. Anchor Books.

Hutchinson, D. (2007). The essential counselor: Process, skills, and techniques. Houghton Mifflin.

Judd, S. J. (2008). Depression sourcebook. Omnigraphics.

Klein, D. F. & Wender, P. H. (2005). Understanding depression: A complete guide to its diagnosis and treatment. Oxford University Press.

Kor, A., Fogel, Y. A., Reid, R. C., & Potenza, M. N. (2013). Should hypersexual disorder be classified as an addiction? Sexual Addiction & Compulsivity, 20(1/2), pp. 27-47.

Kristjánsson, K. (2009). Medicalised pupils: The case of ADD/ADHD. Oxford Review of Education 35(1), pp. 111-127.

Kuramoto, F. (2014). The Affordable Care Act and integrated care. Journal of Social Work in Disability & Rehabilitation, 13(1-2), pp. 44-86.

Lange, K. W., Reichl, S., Lange, K. M, Tucha, L. & Tucha, O. (2010). The history of attention deficit hyperactivity disorder. Attention Deficit and Hyperactivity Disorders 2(4), pp. 241-255.   

Lawhorne-Scott, C. & Philpott, D. (2013). Military mental health care: A guide for service members, veterans, families, and community. Rowman & Littlefield.

Lyons, C. A. & Martin, B. (2014). Abnormal psychology: Clinical and scientific perspectives (5th ed.). BVT Publishing.

MacDonald, J. (2003). Eating disorders and disconnections. In L. Slater, J, H. Daniel, & A. E. Banks (Eds.), The complete guide to mental health for women, pp. 228-237. Beacon Press.

Masiriri, T. (2008). The effects of managed care on social work mental health practice. SPNA Review, 4(1), pp. 83-98.

Matheson, J. L., & McCollum, E. E. (2008). Using metaphors to explore the experiences of powerlessness among women in 12-step recovery. Substance Use & Misuse, 43(8/9), pp. 1027-1044.

McHenry, B & McHenry, J. (2007). What therapists say and why they say it: Effective therapeutic responses and techniques. Pearson.

McMillin, D. (1991). The treatment of schizophrenia: A holistic approach. A.R.E. Press.

McVey-Noble, M. E., Khemlain-Patel, S., & Nezirogu, F. (2006). When your child is cutting:  A parent’s guide to helping children overcome self-injury. New Harbinger.

Mondimire,F. M. (2014). Bipolar disorder: A guide for patients and families (3rd ed.). Johns Hopkins University Press.

Morales, A. T., Sheafor, B. W., & Scott, M. E. (2007). Social work: A profession of Many Faces (11th ed.). Pearson.

National Alliance on Mental Illness (n.d. a). Mental health conditions. Retrieved from https://www.nami.org/Learn-More/Mental-Health-Conditions.

National Alliance on Mental Illness (n.d. b). Dissociative disorders. Retrieved from https://www.nami.org/Learn-More/Mental-Health-Conditions/Dissociative-Disorders.

National Alliance on Mental Illness (n.d. c). Dissociative identity disorder. Retrieved from http://www2.nami.org/Content/NavigationMenu/Inform_Yourself/About_Mental_Illness/By_Illness/Dissociative_Identity_Disorder.htm.

National Association of Social Workers (NASW) (n.d.). Mental health. Retrieved from https://www.socialworkers.org/pressroom/features/issue/mental.asp.

Neukrug, E. (2014). A brief orientation to counseling: Professional identity, history, and standards. Brooks/Cole Cengage Learning.

Okun, B. F. (1997). Effective helping: Interviewing and counseling techniques (5th ed.). Brooks/Cole.

Plante, L. G. (2007). Bleeding to ease the pain: Cutting, self-injury, and the adolescent search for self.  Praeger.

Samenow, C. P. (2012). SASH policy statement: The future of problematic sexual behaviors/sexual addiction. Sexual Addiction & Compulsivity, 19(4), pp. 221-224.

SAMHSA (2020). Key substance use and mental health indicators in the United States. Retrieved from https://www.samhsa.gov/data/sites/default/files/reports/rpt29393/2019NSDUHFFRPDFWHTML/2019NSDUHFFR1PDFW090120.pdf

Seibring, A. (2003). Infertility. In L. Slater, J. H. Daniel, & A. E. Banks (Eds.), The complete guide to mental health for women, pp. 10-17. Beacon Press.

Stone, G. (1999). Suicide and attempted suicide. Carroll & Graf.

Torrey, E. F. (2014). American psychosis: How the federal government destroyed the mental illness treatment system. Oxford University Press.

U. S. Office of Personnel Management (2015). Work-life: Employee assistance programs. Retrieved from http://www.opm.gov/policy-data-oversight/worklife/employee-assistance-programs/#url=Overview.

Wakefield, J. C. (2013). DSM-5: An overview of changes and controversies. Clinical Social Work Journal, 41, pp. 139-154.

Walsh, B. W. (2012). Treating self-injury: A practical guide (2nd ed.). Guilford.

Wetzel, J. W. (1995). Global feminist zeitgeist practice. In N. Van Den Bergh (Ed.), Feminist practice in the 21st century. NASW Press.

Wilson, D. C. (1975). Stranger and traveler: The story of Dorothea Dix, American reformer. Little, Brown, and Company.

World Health Organization (n.d.). Gender and women’s mental health. Retrieved from http://www.who.int/mental_health/prevention/genderwomen/en/.

Zastrow, C. (2010). Introduction to social work and social welfare (10th ed.). Brooks/Cole, Cengage Learning.

Chapter 15: Crime and Correctional Services

Society’s view of criminals as deserving of punishment leaves little room for effective treatment and rehabilitation.  However, like any population, social work has a responsibility to serving those members of society who have been processed through the criminal justice system.  Youth and adults, drug possession to murder, anyone who has had a run in with the law can utilize social work services in order to address any environmental or situational factors that may have led to the offense.  By the end of this chapter, students will:

  1. Understand crime and the criminal justice system in the United States;
  2. Identify different levels and types of crime;
  3. Explain various judgment options for crimes and the impact they have on “criminals”;
  4. Understand the function of social work in relation to the criminal justice system;
  5. Identify ways in which social work practice meets the needs of the social justice system;
  6. Describe the social justice concerns prevalent in crime and criminal justice.

FBI Crime Clock statistics that say a violent crime occurs every 26.2 seconds and a property crime occurs every 3.7 seconds.

 

 

 

 

 

 

 

 

 

Crime and Punishment

            Crime and punishment have been a part of societies for over 4,000 years, well before one of the most known list of laws in history, the Code of Hammurabi (Hammurabi, 1780 B.C./1915).  Rulers like Hammurabi have been concerned with order and protecting citizens, though certain citizens more than others, and created rules for living in their society.  These rules declared certain behaviors to be outside the norm of functioning in that society and anyone deviating from those social mores could be punished.  Punishments can in the form of:

  • monetary compensation to the farmer whose slave was killed,
  • the loss of an appendage or other body part for striking your father or taking someone else’s body part
  • a test to determine if the gods find favor in you when you have been accused of not accepting an alternative form of payment for a drink, or even capital punishment in its many varied forms for stealing (Hammurabi, 1780 B.C./1915)

However, as societies have advanced and countries developed, the laws and their punishments have changed to be more culturally appropriate and what many believe is more humanistic.  In the U.S., the federal and state statutes are written primarily to protect the inherent rights of all people as set forth in the Constitution and the Bill of Rights.  These are the guiding forces that outline what is acceptable behavior in our society.  Federal laws are created to govern all 50 states, but states have the power to determine the laws appropriate for those residing in the state as a way of dealing with issues more pertinent to them.  Even local municipalities can enact regulations, codes, and ordinances to provide their residents with an environment that meets their needs for safety and an enjoyable life.

            Yet, we often forget about those who commit the crimes and get punished.  Society might view “criminals” as a problem, deserving of punishment and poor treatment.  However, social work needs to approach crime from a different perspective.  As you will see in this chapter, one of the main functions of the criminal justice system is the rehabilitation of these criminals with the intent of teaching them how to adjust their behavior and fit in better with the majority of society.  The training they receive, the values they embrace, and the focus they put on their client systems give social workers the right tools to be a part of this process.  This is not to take away from the impact breaking the law has on any victims of crimes, as they are often seen as much more deserving of help and compassion.  Of course, they deserve help and social workers often work with victims of crimes, especially traumatic ones in which the victim was harmed, threatened, or felt in danger.  They help these clients work through the negative emotions and process the bad feelings associated with such experiences.  However, social work does not view them as the only ones deserving of help.  Many of the offenders that end up interacting with the criminal justice system in the U.S. are often dealing with their own problems that have nothing to do with the crimes they committed.  Whether these problems were brought on by themselves, they are the result of being victims to someone else’s crime, or they have been marginalized by society, those who commit crimes still deserve help.  A person’s life is not over when they break the law.  Social workers need to be there ready to assist these clients in order to help them work through the change process so they can make the most out of their life moving forward.

Picture of upper and lower prison cells at Alcatraz.
The rehabilitative aspect of the criminal justice system is thought of as a secondary function, with society more concerned on punishing criminals.  What do social work values say about incarcerating someone and forgetting about them?

 

 

 

Crime in America

            Not following socially accepted ways of behaving or interacting with others can have a wide range of consequences, depending on the severity of the situation.  For instance, people who belch in a nice restaurant may get nasty looks from other patrons or be asked to leave the establishment without any really big fine or a trip to jail.  They may experience shame or embarrassment, whereas someone who robs a convenience store at gunpoint will be arrested and most likely spend time in prison for this action.  The distinction needs to be made between criminal acts and just socially awkward or unusual behavior.  Lawson and Heaton (2010) discussed an idea set forth by Emile Durkheim about socially abnormal behavior falling on a continuum of socially divergent behavior with difference at one end, deviance in the middle, and crime at the opposite end.  It suggested that the degree to which people’s actions do not agree with social norms and the impact they have on others determine where on the continuum the behavior should fall.  It is the difference between piercing one’s bottom lip, getting pierced for sexual pleasure, and stabbing someone.  All of these actions are different from what may be the norm in society, but the degree to which they are seen as different is what determines how they are defined.

            Difference can be seen as things done that do not really have an impact on others.  Diversity in interests, beliefs, and activities just adds to the salad bowl concept of the United States.  How boring would life be if everyone in the U.S. ate the same foods, watched the same TV shows, drove the same car, or listened to the same music?  Many people cannot stand to have that level of routine in their own life, let alone share it with the rest of the country.  America has become a society that emphasizes individualism and, for many, there is a need to define themselves.  However, when those differences are seen by society as going beyond defining oneself, it can raise a lot of eyebrows.  When behavior is judged by the majority of society to be unacceptable, it is no longer difference; it is deviance.  Deviant behavior is not only outside of social mores, it is frowned upon by others, and people who participate in these types of behaviors are judged as being immoral, disgusting, or unclean.  There is a problem with this definition.  Deviance is a relative term, dependent on time, person, place, and situation (Lab et al., 2008).  Killing someone in self-defense is not the same as premeditated murder.  Walking around the house in one's underwear is a lot different than walking around the mall in one's underwear, unless of course you are a two-year-old.  The definition of deviance shifts interculturally and within the same culture over time.  The bathing suits worn by both men and women in the U.S. today would have been seen as too revealing and sexual compared to the Victorian era of the 1800s.  In reality, deviant behavior is socially constructed and situational.

          

Box 15.1 – Types of Crimes

The following categories describe the general type of behavior our society views as crimes along with more specific examples.  Can you think of other crimes that could fit in these categories?  Which of these do you think shouldn’t be illegal?

  • Crimes against persons
    • Murder
    • Sexual assault
    • Extortion
    • Kidnapping
  • Crimes against public morality
    • Incest
    • Prostitution
    • Indecent exposure
  • Crimes against justice and public administration
    • Resisting arrest
    • Perjury
    • Bribery
    • Contempt
  • Victimless crimes
    • Illegal sex acts between consenting adults
    • Drug abuse
    • Gambling
  • Crimes against property or habitation
    • Arson
    • Burglary
    • Larceny
  • Crimes against public order
    • Vagrancy
    • Disorderly conduct
    • Public intoxication
  • White-collar crimes
    • Tax fraud
    • Insider trading
    • Embezzlement
    • Insurance fraud
  • Crimes committed by government authorities
    • Police brutality
    • Taking bribes
    • Torture
    • Civil rights violations

(Adapted from Anderson & Newman, 1998, p. 5-6)

            So how do we make the jump from this idea of deviance to crime?  Crimes are also deviant in the sense that they violate our ideas of socially accepted behavior.  However, these behaviors have been determined to be a threat to our social order and, therefore, should carry with them a punishment based on perceived severity of the behavior.  Some criminology theorists would argue that no act can be inherently criminal because crime is a social construct of the state (Lilly, Cullen, & Ball, 2007).  Crimes are defined only by written laws and are very dependent on what has been deemed by those in power as needing punishment.  Some behaviors have consistently been viewed as worthy of punishment - for instance murder - while others are newer, such as computer hacking crimes.  Still others are debatable in terms of necessitating legal consequences, much like recreational marijuana use.  Whether they have persisted through history or are more recently established criminal offenses, Schmalleger (2008) stated that all crimes are further broken down into the following categories:

  1. Felony – Serious crime usually resulting in a prison sentence of a year or longer.  Those who commit felonies also lose certain privileges afforded to other citizens, such as owning a gun or running for political office.  Typical felonies include murder, rape, burglary, and arson.
  2. Misdemeanor – Less serious crime than a felony, having a prison sentence of a year or less, although some individuals who commit misdemeanors can get suspended sentences resulting in fines and supervised probation.  Petty theft, breaking and entering, and disturbing the peace are examples of misdemeanors.
  3. Infraction – Even less serious than a misdemeanor, those committing these offenses receive a ticket and a fine, but are not arrested.  This category of crime refers to acts such as minor traffic violations, jaywalking, and littering (pp. 80-81)

While certain crimes are always ascribed to one of these three categories, the relative severity of the crime can determine exactly how it is defined and what kind of punishment it carries, like with different degrees of murder or DUI violations.

 

Statistics

           Crime statistics in the United States will give us a picture of what kinds of issues we are currently facing.  Social workers practicing in criminal justice settings should be utilizing these statistics to better meet the needs of society at large, those who are victimized, and those who do the victimization.  This data will present what crime looks like now and it helps people understand changes from the past and trends for the future.  It can also be used to guide prevention efforts and inform policy.

Most of the crime statistics for the U.S. come from two major sources: the FBI’s Uniform Crime Reports (UCR) and the National Crime Victimization Survey (NCVS) from the Bureau of Justice Statistics.  While there are other sources that can add to crime statistics or analysis, these two are the ones most widely used by our criminal justice system today.  The two programs are designed to complement each other.  The UCR collects information about certain violent and property crimes reported to law enforcement, the NCVS collects data from households and individual victims of crimes, even if they were not reported to the police (Bureau of Justice Statistics, 2014d).  These can give us a clearer picture of how much crime is happening and how well it is being addressed.  These two sources will be used to break down some basic statistics for crime today in the United States.  It is important to note that violent crimes include murder and nonnegligent manslaughter, rape and sexual assault, robbery, and aggravated assault due to the involvement of actual force or the perceived threat of it (Federal Bureau of Investigation, 2014b).  Burglary, larceny-theft, motor vehicle theft, and arson are all considered property crimes because they involve the taking of another’s property or money without physical force or threat.  One last type of crime others have set apart is public-order crimes, though these are not represented in the statistics listed below.   These crimes are described as offenses against society and social order, often considered victimless crimes, and include prostitution, traffic violations, loitering, and disorderly conduct (Lab et al., 2008).  Here are some of the highlights from the UCR and the NCVS.

UCR 2019 Statistics

  • There was an estimated 1,203,808 violent crimes in the U.S., a rate of 366.7 crimes for every 100,000 people.  This is an increase of 0.4% from 2018 but a decrease of 3.8% from 2010.
  • The majority of these crimes – 68.2% – was aggravated assaults.  Robbery – 22.3%, rape – 8.2%, and murder – 1.4% followed.
  • Reported property crimes were down 4.1% from 2018 and 24% percent from 2010, at 6,925,677 offenses.  This meant there were 2,109.9 reported crimes for every 100,000 people.
  • Larceny-theft made up the majority of these crimes at 73.4%, followed by burglary at 16.1%, motor vehicle theft at 10.4%.  Total loss of property to the victims of these crimes was estimated at $15.8 billion.
  • This resulted in a total of 11,302,102 arrests, with – 1,559,284 – for property crimes and less than a third of that – 480,360 – for violent crimes. (Federal Bureau of Investigation, 2020a, 2020b)

NCVS 2013 Statistics

  • Simple assault accounted for 65% of all violent victimizations, with the other 35% consisting of aggravated assault, robbery, and rape/sexual assault, from most to least often occurring.
  • Only 41% of violent victimizations were reported to police according to the 2019 survey.
  • Urban areas saw a 20% decline in violent victimization from 2018 to 2019.
  • The rate of property crimes in 2019 was at its lowest level since 1993 when it was at 101.4 victimizations per 1,000 households. (Bureau of Justice Statistics, 2020)
Photo of a person handcuffed and being led somewhere by an officer.
Arrest records only tell part of the story when it comes to crime rates because not all crimes are reported to the police.  In order to get a clearer picture of crime in the U.S., the UCR and NCVS create a well-rounded understanding of all offenses.

 

 

Utilizing these statistics, we can see a few trends in crime in the United States.  Clearly, crime seems to be improving, with both violent and property crime dropping since 2018 and a lot since 1993.  The data also demonstrates how much more prevalent property crimes are compared to violent crimes.  While this means fewer people are feeling threatened or being harmed than there are who are having their personal property stolen or destroyed, do not negate the emotional impact losing property can have on a person.  However, the biggest point the data shows is the huge disparity between what is reported and what actually happens in the United States in terms of both violent and property crimes.  Though it is beyond the scope of this chapter to delve too deep into why there is such a discrepancy, it should be noted that this gap exists and means there is an overwhelming number of people who do not get their needs met by the criminal justice system.  The idea here is not to blame the system or absolve it from any responsibility.  It is more to point out how  social workers, have to constantly strive to meet the needs of all clients in both proactive and reactive ways, and it is important to understand the criminal justice system as it is before we can work to improve it.

 

The Criminal Justice System

It would be great if laws were all that was needed to guarantee everyone’s rights were not violated.  The U.S. Constitution, and in turn the American government, was created to address the fact that people’s basic human rights were being neglected.  We understand that laws will be broken, but we trust that our government will make safeguarding our rights a priority.  This is what the U.S. justice system is supposed to do; it works to process crimes and those who commit them in order to protect all citizens now and in the future.  Like our government’s three branches, the three parts of our criminal justice system – law enforcement, judicial courts, and corrections – have a certain responsibility to prevent each other from having too much power in dealing with crimes and offenders.  This can become a problem, though, when the parts seem to have different goals and are working against each other.  In fact, this led Bumgarner (2004) to refer to our criminal justice system as a non-system.

 

Box 15.2 Purposes for Enforcing Crimes

There are many different views about what our criminal justice system’s purpose or function is in society, or why they do what they do.  Anderson and Newman (1998) discussed the following reasons for the system in the U.S.:

  1. Control and prevent crime
  2. Detect, arrest, convict, & incarcerate offenders
  3. Punish criminals
  4. Deter criminals
  5. Protect the community
  6. Correct/Rehabilitate criminals
  7. Create an ordered society
  8. Ethically secure justice

These purposes can often be counterproductive and as each part of the criminal justice system embodies different purposes, disagreement, confusion, and conflicting actions can result.

Still, this is not to say the system is completely dysfunctional.  In actuality, criminal justice in the United States is not just one system with three components.  It is comprised of many individual state, county, city, and smaller municipalities’ criminal justice systems (Eskridge, 2004).  Trying to coordinate the efforts between all of these parts is truly impossible and the governmental system was never designed to function that way.  State and local governments have the right to govern and protect in the way that makes sense to them.  As discussed, crime is relevant to location and it is important to give people the freedom to decide what is important in their lives.  So while the legislation may be different and systems may be incongruent or clashing at times, they are still similarly structured.  True criminal justice then comes down to the ability of each part to do its job.

 

Law Enforcement

            While some might say the first branch of the justice system is the legislative body that creates laws, let us focus on what happens after the laws are created and people are then identified as breaking social norms to a criminal level.  When someone commits what is deemed to be a criminal act, law enforcement is their point of entrance into the justice process.  The Bureau of Justice Statistics (2013) defines law enforcement as, “The generic name for the activities of the agencies responsible for maintaining public order and enforcing the law, particularly the activities or prevention, detection, and investigation of crime and the apprehension of criminals,” (para. 13).  These agencies employ the local police officers, county sheriffs, state trooper, and federal agents charged with the responsibility of protecting the citizens they serve.  These law enforcement personnel take an oath to serve and protect and are sworn in as representatives of the government for which they work.  Once a crime is investigated and an arrest is made, law enforcement officers process paperwork and prepare the accused to move into the next part of the system and onto the next stage of the criminal justice process.

 

Judicial Courts

            The modern court system in the U.S. represents a structured and diplomatic way of dealing with crimes and those who commit them.  When a person has been charged with a crime by law enforcement, they then go to court to have their case heard by a judge and possibly a jury.  Others involved in this part of the justice system include bailiffs, court reporters, clerks, prosecutors and defense attorneys, and victim advocates.  State and federal governments give power to the courts to make decisions on cases based on what the laws dictate, using a democratic fact-finding process to determine the validity of the claim (Messick, 2004).  This is also known as due process, when the person accused of breaking an established governmental law is given the right to a fair trial in a government-appointed court.  The judicial process ends with the acquittal or conviction and sentencing of a suspect.

Picture of a prison from outside the barbed wire prison wall.
Typically, when we think of corrections many of us automatically think of prisons.  However, there are many different types of sanctions someone who has committed a crime can be given, and they don’t all include incarceration. "Prison" by x1klima is licensed under CC BY-ND 2.0.

 

 

 

Corrections

            The last piece of the criminal justice system, and the last step for someone being processed for a crime, is with corrections agencies.  Most of the time we think of state penitentiaries, local jailhouses, or even juvenile detention centers as the places where criminals serve their time, but the truth is that not all those convicted of crimes are going to prison.  The correctional system is more properly viewed as a continuum from probation to incarceration, with a number of possible intermediate sanctions in between (Tonry, 2004).  Intermediate sanctions include half-way houses, boot camps, work-release programs, and home confinement (Lab et al., 2008).  The sentencing handed down by the judge is dependent on the type and severity of the crime, state and federal guidelines, and legal precedents in similar cases.  However, parole officers, prison guards, wardens, and other employees, including social workers, help correctional institutions carry out these sanctions or – more appropriately – penalties.  As discussed later in the chapter, there has been much debate about the intended versus actual function of corrections in dealing with convicted individuals.

 

Other Pieces of the Puzzle

            While the components of the criminal justice systems here can be defined and understood in general terms, there are specific ways with which certain populations and offenses are handled.  There are even changes being made in how programs are run and who provides certain services.  Since social work and the criminal justice system work collaboratively in helping address crime and a person’s process through the system, those working in that arena are going to gain a lot of first-hand knowledge on the reality of the system, its ins and outs, and how to navigate it best.  Because the system is so complex, it would be too much for us to discuss here.  Instead, let us address a few aspects of the justice system that are important to be aware of in working with clients within it.

 

Drug Court

            The high number of incarcerated offenders and the correlation between drug use and crime provided the impetus for changing how nonviolent, drug-related offenses were handled in the courts (Kassebaum & Okamoto, 2004).  In realizing that addicts were moved by something more powerful than the threat of a prison sentence, the drug court first appeared in Miami in 1989 to help break the cycle of addiction and offending (Fisher, 2014).  Instead of locking people up for a drug-related charge, letting them out when they have served their time, and then locking them up again when they violate parole for failing a drug test, drug courts approach the matter from a treatment perspective.  Treat the addiction, the underlying cause of the criminal acts, and there is less of a chance the individual will reoffend and more of a chance of long-term rehabilitation.  Although the process may differ from court to court across the country, drug courts really have the same foundation and aim.  The National Drug Court Institute (2004) outlined drug courts and their goals:

Drug courts represent an innovative judicial experiment in which offenders are held accountable for their actions but afforded the tools they need to break the patterns of drug abuse that so damage their lives and the communities in which they live. Typical drug court goals are to reduce drug use and associated criminal behavior by engaging and retaining drug-involved offenders in programmatic and treatment services; to concentrate drug-case expertise into a single courtroom; to address other defendant needs through clinical assessment and effective case management; and to remove nonviolent drug offenders from traditional courtrooms and jails, freeing these institutions to focus on more serious crimes and criminals. (p.4).

In working with drug offenders, the courts embody a humanistic and value- driven view of all individuals.  They look to provide for the overall well-being of the individual, thereby addressing both the current state of addiction as well as any causes that might be in a person’s life.  The offenders are still responsible for the criminal behavior that brought them to the court and are given a sentence.  The key is that the sentence will include an opportunity for actual rehabilitation by requiring offenders to get treatment for their addictions, instead of handing down a sentence that is clearly more punitive in nature.  While mandatory treatment is what allows drug courts to make the greatest impact on those it serves, the intrusive role of the court as an overseer of the treatment and its progress can be seen as a controversial aspect of drug courts (Tiger, 2011).  Typically, social workers understand that mandatory counseling, or treatment that is coerced, is not going to be as effective.  It also seems to restrict an individual’s self-determination.  However, offenders can choose not to partake in treatment and face other sanctions, so there is an element of choice in the whole matter.  Despite any objections, drug courts have been shown to be successful in helping drug court program graduates to avoid reoffending.

 

Juvenile Justice

            In 2011, the total number of juveniles arrested in the United States was almost 1.5 million, with property crime representing the highest number of arrests at 23%, simple assaults coming in at 13%, drug abuse violations at 10%, disorderly conduct at 9.5%, and all violent crimes at 4.5% (Puzzanchera & Sickmund, 2013).  Although this data is similar to that of adult offenders, with violent crimes being much lower on the list than property or other crimes in terms of number of arrests, juvenile justice can be a significant concern for society as a whole.  This is because that society has a greater responsibility to youth than it does to adults.  Do you recall the notion of parens patriae from Chapter 11?  It states that the government has a responsibility to care for and protect minors when parents cannot or fail to do so.  This was the foundation for the first juvenile courts, developed in Cook County, Illinois, that were set up to serve individuals under the age of 18 (Mears, 2004).  Before juvenile courts started working with youth offenders as a means of rehabilitation to have a more positive life as an adult, juveniles who broke the law were treated no differently than adults, including receiving harsh punishments.  Today, all states have a juvenile justice process as part of their greater criminal justice system, though they often function much different than the adult justice process.

Hands handcuffed
The juvenile justice system is much more focused on rehabilitation and trying to prevent youth offenders from becoming adult offenders.  Are youth worthier than adults of getting a second chance?  What kind of services can social workers provide in juvenile corrections facilities? "handcuffed" by catbleu4555 is marked with CC0 1.0.

Juvenile justice systems have the same three main parts – law enforcement, judicial courts, and corrections – and the entry into the process is through law enforcement just like with adult justice.  However, the court and correctional components of the process are different.  Juvenile courts are actually civil courts, as opposed to criminal courts, and the sentences handed out are not necessarily based on written sentencing guidelines.  Instead, the court tries the case and the judge gives a sentence on a case-by-case basis, taking into account the type and severity of the crime and the concerns and possible needs of the minor.  Some of the sanctions can include probation, confinement with the intent of rehabilitation, community service, or drug treatment.  One additional piece that is not as integral a component in the adult justice side is that of community organizations.  Since juvenile justice is more focused on rehabilitation and serving those who are seen by the court, wrap around services are instrumental in helping youth more effectively deal with their current life situations.  Social workers generally take on a bigger role with juvenile justice than they do in adult justice.  Also, unlike the general criminal justice system, the four parts of the juvenile justice system can be seen as working more in conjunction with one another (Martin, 2005).

 

Box 15.3 Juveniles Tried as Adults

Read this article about an incredibly young boy tried as an adult in Florida for the murder of his younger brother.  The prosecution wanted to give the boy life in prison for his crime.  What do you think?  Would it have been justified to imprison him forever or was there a chance for rehabilitation?

Today’s juvenile justice systems can vary greatly from state to state, with some wanting to impose stricter sanctions and more punitive sentencing on youth by trying them as adults, such as with the case of 12-year-old Christian Fernandez from Florida (see Box 15.3).  However, in order to properly address the needs of society when it comes to juvenile justice, Martin (2005) outlined four foundational considerations systems should take in providing juvenile justice:

  1. Juvenile justice extends to all youths – The discussion so far in terms of juvenile justice has focused on young offenders.  The other side to this coin is that systems for those under 18 also need to protect young victims of crimes perpetrated by adults and other juveniles.  Child welfare is as much a responsibility of protecting society’s youth as dealing with juvenile offenders is.  Sometimes the two are combined, where an offender has been or is being victimized by someone in their life.  This necessitates greater intervention on the part of the system to help address the overall well-being of the youth.
  2. Juveniles must be subject to adult control – Almost all minors do not have the maturity, life skills, or resources to take care of themselves properly.  As a result, they are required by law to have an adult authority be in charge of and protect them until they are adults and should be able to take on that responsibility themselves.  If parents or guardians do not provide this, it becomes the job of the state to care for the youth.
  3. The juvenile justice system alleviates stigma – Entering the adult justice system can have very stigmatizing affects, resulting in negative judgment by others and a personal embodiment of shame.  Juvenile justice should work to minimize this stigma as much as possible.  Stressing the importance of treatment and rehabilitation, as well as taking a case-by-case approach works more on a strengths-based perspective than a deficiency outlook.  This demonstrates to youth offenders they still have worth as a member of society.
  4. Serious juvenile offenders can be waived into the adult system – Youth offenders who commit severe enough violent crimes can, and quite possibly should, be better served being tried as an adult.  In these instances, states need to determine when it may be a losing battle to rehabilitate an individual and necessary to hold a youth more accountable for their actions.  While the ability of some youth offenders to understand the consequences of their behavior and be empathic is less developed, some juveniles are mature enough to know when their behavior has serious negative implications, such as murder, rape, or aggravated assault. (p. 9)

These concepts follow the original drive behind the creation of juvenile justice courts.  They help ensure protection of everyone’s rights, including those of the juvenile offender, and refocus the function of the justice system.  Instead of giving up on those who enter the system, focusing first on punishment and then possibly rehabilitation (as the system does for adults), the juvenile system focused more on rehabilitation in an effort to give the youth a better future.

 

Private For-Profit Prisons

            It is not uncommon for our government to opt for privatization in the implementation of policies, including that of prisons.  Food services, psychological testing, social services, maintenance, and training have been some of the ways public facilities have had their needs met by private organizations (Schmalleger, 2008).  The beginning of privatization of entire prison facilities began in the early 1980s as a perceived way to cut state and federal costs for the growing inmate population.  Federal and state governments needed to find an alternative to building and staffing new public facilities as the number of inmates increased.    The idea is that these private companies can provide correctional services more efficiently than the government can, including inmate treatment and rehabilitation programming.  States would also not have to endure long-term funding costs or overhead for daily operation of the facilities because they could pay a flat fee.  Today, of the 1,574,700 inmates incarcerated, only eight percent of them are housed in private prisons – which includes seven percent of state inmates and 14 percent of federal inmates (Bureau of Justice Statistics, 2014b).

Corrections Corporation of America (CCA), the largest for-profit corrections company and the first company to provide private corrections services, currently operates over 60 facilities with an inmate population of over 70,000, which is more than half of all privately housed inmates in the United States (Corrections Corporation of America, 2015).  In 2013, they made over $300 billion in profits (Friedman, 2014) for providing the same quality and efficient correctional services as the government at a lower cost.  This statement identifies two of the biggest concerns about for-profit prison systems.  One concern looks at quality of the correctional services being provided.  If companies like CCA are making such huge profits, how can they be providing services that respect and care for the rights of the inmates?  It is unlikely they are incorporating rehabilitation services to help inmates improve their life once they leave the facility.  Actually, there is no definitive evidence that proves private prisons can operate with lower costs than public prisons, with studies supporting both sides (Congressional Research Service, 2014).  Even if private prison expenses are equal to those of the government, it would be interesting to know how the companies can make such big profits.  One might guess that costs are cut in terms of quality of care for the inmates, including food and rehabilitation services, qualified and appropriate staff, or safety and facilities management.  Without being able to know for sure, maybe a better question to ask is, “Should we incarcerate people in private, for-profit prisons even if they do save money?” (Friedman, 2014, p. 568).

This is the other concern: should corrections be a for-profit business at all?  Aside from the fact that they do receive some sort of public oversight in how they run their facilities, private companies like CCA are focused on profits.  When it comes down to it, they are businesses, plain and simple.  Between trying to make money for their investors and making sure they follow governmental guidelines so they do not get sanctioned, the inmates they serve may be a much lower priority than what they should be.  Aman and Greenhouse (2014) pointed out that additional public-imposed safeguards need to be in place for privatization because of potential risk of harm to inmates.  Making a profit on tragic situations or less-than-ideal life experiences of human beings conflicts directly with social work values.  Even if the greater society does not hold the same concerns, for-profit prisons have not proven their superior efficiency in dealing with America’s corrections problem.

 

Experience of the Offender

            As we have discussed, criminal justice is a system that addresses certain deviant behaviors.  The sanctions imposed by the system on those who violate the written criminal code support the victims of these crimes as well as society in general.  Victims of crime need to be offered additional services in order to process what happened and move forward, but they are not the only ones who need that extra help.  It is easy for us to forget about the rights and obligations society has toward those of its members who have offended, especially if they were involved in a violent crime that harmed another person.  Some people say they should lose their rights or they do not deserve to be helped, but this does nothing to solve the problem.  Societal views and theories of criminal justice are formulated based on each individual’s perspective and their experiences in life, including education (Lilly, Cullen, & Ball, 2007).  If I grew up in a wealthy neighborhood, was provided with all my basic needs as well as life luxuries, and had a satisfying home life, I would see crime as deviant and criminals as immoral people choosing wrong over right.  But say I grew up in a low-income neighborhood, where basic needs like food and safety were not being met, and was physically abused by my parents.  I may see burglary as a way to feed me and my family, drug possession as an unfortunate result of living in an environment that reinforced drug use as normal, and murder as a way to proactively protect herself from being physically abused or assaulted.  Deviant behavior and criminal activity must be placed in the appropriate context in order to deal with the action effectively and the person respectfully.

Social work believes in the worth of all humans, even those who commit crimes.  This is not to excuse or ignore the physical and mental anguish they have inflicted on others.  However, this behavior should not automatically discount a person’s worth.  In many cases it is the result of an underlying issue, including their own victimization.  The stigma, though, of being labeled a criminal and undeserving can have far-reaching implications in how the criminal justice system processes individuals, how their needs are met, and what happens to them when they reenter society. 

           

Prison chain-gang working on a road, with a horse and bugging nearby.
In the past, rehabilitation efforts included chain gangs and inmates working in hard labor.  While some states are returning to this approach with some inmate populations, rehabilitation efforts today focus more on education and treatment of underlying contributors to the offending behavior.  "Chaingang workers - 1907" by over 26 MILLION views Thanks is licensed under CC BY-NC-SA 2.0.

 

Rehabilitation vs. Punishment

            There is no general consensus on what the primary goal of the criminal justice system is when it comes to sentencing those who violate our criminal statutes.  Though the U.S. has progressed in terms of using less cruel punishments and a number of states have done away with the death penalty, our interest in protecting the rights of those imprisoned for committing a crime – or crimes – seems to end at physical harm, though many would argue even that is okay and well-deserved.  Spierenburg (2014) talked about our society’s “modern return toward punitiveness” (p. 120) as more people empathize with victims of crimes, call for harsher punishments of criminals as justice, and view prisons as a place of retribution instead of rehabilitation.  This need to dole out harsh punishment, even for nonviolent crimes, is reflected in the numbers of inmates currently incarcerated in the United States.  Currently, the U.S. has the highest number of people incarcerated compared to the rest of the world, with about 1.6 million inmates being housed in state and federal prisons – a slight increase from 2012 but a huge increase from the less than 400,000 inmates in 1980 (Schmalleger, 2008).

 

Box 15.4 True Rehabilitation

Read this article about a different approach in Norway.  Is this something the U.S. should try in order to refocus efforts on rehabilitation?”  Would it even work here?  What are your thoughts on the article?

            Comparing this prison population to the total number of people under correctional supervision, we can see a different overall picture of our correctional situation.  Our inmate population is only about 23 percent of the 6.9 million people in all corrections programs, including incarceration in prisons and jails, probation, and parole (Bureau of Justice Statistics, 2014a).  The same report that provided this data demonstrated that while the number of adults sentenced to prison and on parole has gone up, the number on probation or in local jails has gone down. Prisons are state and federal institutions that house offenders who were involved in more serious crimes and were sentenced to incarceration for more than a year.  Jails are considered local facilities that hold offenders involved in less serious crimes who have sentences of a year or less of incarceration.  People who end up in prison are typically there because of a mandatory sentence for the crime they committed, most likely a felony charge.  Judges have more latitude when it comes to sentencing for misdemeanors, so the drop in jail incarcerations and probation may indicate a slight change in attitude toward the purpose of the criminal justice system.  Instead of wanting to overcrowd correctional facilities and risk recidivism of prisoners who are just warehoused until their sentence is up, judges utilize more options to rehabilitate offenders.

 

Community-Based Corrections

            When judges provide alternative sanctions to incarceration, they are utilizing community-based corrections, or correctional options that take place outside of prison walls in the community.  To provide leniency for some offenders who would benefit from additional services or whose offenses were not as serious, and as an opportunity to help those being released from prison, intermediate sanctions offer intervention efforts to reduce the risk of continued criminal behavior.  Alarid, Cromwell, and del Carmen (2008) stated community corrections complements the overall goals of incarceration because it not only punishes offenders and protects the public, it also provides the following goals to prevent future criminal behavior:

  1. Rehabilitation – While the authors described rehabilitation as correcting inadequacies of the offender, efforts for rehabilitation should be seen more as a way of teaching individuals how to function positively in our society.  Those who end up being processed by the criminal justice system have been suspected of behavior that deviates from the social mores of our culture.  As a result, they have struggled to conform to accepted behavior and need to change.  Rehabilitation can help offenders learn strategies to manage their emotions and actions, incorporate new ways of approaching a situation, and receive the psychosocial assistance they need to improve their well-being.
  2. Community Reintegration – Depending on their sentence length, prisoners can have a hard time adjusting to life in society once they are released.  Focusing on community reintegration allows prisoners to adapt to their new living situation with minimal supervision and maximum support.  Offenders should be provided with opportunities to take on normal daily responsibilities and roles, such as working, parenting, going to school, and enjoying life.  The support given connects the offender to various resources and agencies that can help them meet these objectives.
  3. Restorative Justice – It is important for offenders to own their actions and atone for the injustice they may have caused another individual and society at large.  Whether it is actually paying for the damage or loss they caused the victims, meeting with them face-to-face to apologize, or doing community service and warning others about the dangers of following the same path, these actions help instill personal responsibility.  They also facilitate the forgiveness process between the victim and offender, as well as self-forgiveness for the offender themself.  Restorative justice takes advantage of experiential learning opportunities to enhance positive personal and social growth.
Folding chairs in a circle with short bookshelves behind them.
Community-based corrections can provide a much better opportunity for rehabilitation by offering group sessions in residential facilities or allowing offenders to live within the community, where they have better access to treatment options.

 

 

Alarid, Cromwell, and del Carmen (2008) also mention that shame an effective strategy of community-based corrections.  However, from a social work perspective, shaming a person into change or remorse is not an effective strategy.  The result is not a genuine, enduring change and can cause more emotional harm for both the victim and the offender.  We want individuals to feel remorse for what they have done but we also want them to be able to move forward with their lives for a positive future, not be stuck in a past of which they are ashamed.

 

Probation/Supervision

To meet these goals, a number of options for community-based corrections are employed by various state and local criminal justice systems, as outlined in Box 15.7.  The idea is to choose a strategy that will be most helpful to the offender’s life situation and that fits with the crime that was committed.  Probation is the most basic of all the strategies.  With probation, the accused does not have to serve any jail time.  Instead, their behavior is monitored as a way to make sure they are avoiding getting into further trouble.  If they do end up in front of the judge again, their punishment will be harsher and their sentence will be more demanding.  Probation is usually accompanied by additional conditions such as fines and community service.  The supervision aspect of probation is a mainstay of intermediate sanctions and a necessary part of the punitive aspect of the criminal justice process.

Intensive supervision is an option as an initial sanction or as one provided after an offender is out of prison on parole.  This is a more structured type of monitoring that includes regular meetings, surprise inspections, and possible drug testing as a means of making sure the individual is following the terms of their sentencing or release (Abadinsky, 2000), and may include electronic monitoring for parolees.  This can also include additional conditions to meet the other goals of community corrections.  MacKenzie and Brame (2004) discussed the impact of intensive supervision on offenders, suggesting the more intense the supervision, the more likely offenders are to engage in prosocial activities like employment and treatment or counseling, and the less likely they are to reoffend.  Supervision does not allow offenders the opportunities to engage in behaviors that may have been triggers for their criminal acts.  Even if they are initially coerced into these positive activities, offenders will likely benefit in the long run once they realize the positive impact on their lives.

 

Diversion Programming

Another type of program that offenders may be required to participate in as part of their sentencing is diversion.  Diversion programming is prescribed before the actual sentencing in what is called the pre-trial.  If an offender has a drug issue, mental health concern, or problem with domestic violence, the judge may require that individual to go through a treatment program, see a counselor, or take part in group therapy.  The diversion options – like drug courts that were discussed previously in the chapter – provide an opportunity to address an underlying problem that is directly related to their criminal behavior.  It also prevents offenders from being processed fully through the criminal justice system, which could be more harmful than helpful for some, especially juveniles (Office of Juvenile Justice and Delinquency Prevention, 1999).  Programs can be educational, therapeutic and introspective, or experiential, but the objective is to build the skills and give the offenders tools they need to address the behaviors that brought them into the justice system.  For juveniles who commit status offenses, those behaviors that are only illegal because they are underage, such as smoking, drinking, and running away, diversion programming can be a good option.  Once they complete the requirements of the program successfully, offenders will have their charges dismissed and they are free to go.  Failure to follow the program results in the offender’s case being moved to trial for sentencing which will include more restrictive sanctions such as incarceration.

 

Residential Intermediate Sanctions

            For offenders who need daily supervision and more intense services, and parolees who are not quite ready for life in society, there are residential program options to help provide daily supervision, structure, socialization, and a buffer between them and society.  Though the structure and focus of residential corrections interventions vary between states and even within the same state, there are four main commonalities: residents live in the facility, they must be employed to help cover the cost of their stay in the facility, they are allowed to leave any time for verified employment, and they have to get permission to leave the facility for other reasons (Alarid, Cromwell, and del Carmen, 2008).  Box 15.5 shows some common types of residential corrections facilities.

 

Box 15.5 Common Residential Corrections Facility Types in the United States.

Intermediate sanctions for offenders can include residential corrections other than prisons and may be more appropriate, depending on the crime committed and the individual’s criminal justice past, and can provide better opportunities for rehabilitation.  Here is a list of the various types of Residential community corrections facilities and a short description of each:

  • Halfway house – Residential facility where offenders live and sleep, but is much less restrictive than prison.  Residents are allowed to leave during the day for work or school.  These houses are “halfway” between being incarcerated and being home and are designed to increase good behavior in residents.
  • Correctional boot camps – These boot camps are much like military boot camps and are designed to modify behavior for first-time, offenders who meet certain requirements.  The programs last between 90-180 days typically.
  • Restitution centers – Similar to a halfway house, restitution center residents work to compensate their victim for the crime or to work off community service.  Residents are allowed to go places other than work, such as houses of worship, the store, or treatment, but must return to the center each day.
  • Therapeutic communities – These facilities focus on the long-term treatment of drug addiction or mental health concerns.  Residents stay in the facility but take part in various treatment services.
  • Work and study release – Offenders live in a prison-like facility and are only allowed to leave for verified work or school and must return by a certain time.  Unlike halfway houses, inmates cannot leave the facility for anything else and must have verification of their whereabouts.
  • Women offenders living with children – These are halfway houses for women offenders who have children so that they can still care for their child while completing their sentences.

Adapted from Asmussen (n.d.).

 

Recidivism

            One of the contributing factors in the push for harsher punishments is the recidivism rate we have in the United States.  Recidivism rates look at the number of previously incarcerated offenders who reenter the criminal justices system over a given period of time.  As Abadinsky (2000) pointed out, there are many different ways to calculate recidivism of those who have offended, with no one standard definition.  Some rates just look at criminal convictions, while others may include all arrests despite guilt.  The length of time can be controversial too, as there are rates that look at one year after release, three years after release, and even five years after release.  The longer the time frame and the broader the scope of what counts as criminal activity, the higher the rates will be.  In the most recent study presented by the Bureau of Justice Statistics (2014c), two-thirds of offenders were arrested within in three years of release and three-fourths within in five years, leading to conviction and imprisonment rates of 49.7 percent and 55.1 percent respectively.  The study also indicated property offenders had the highest five-year recidivism rates - 82.1 percent – than drug offenders – 76.9 percent, and violent offenders – 71.3.  Clearly too many individuals are reoffending, and it has not been improving.  Petersilia (2011) discussed a 2002 Bureau of Justice Statistics study provided similar percentages for those released from prison in 1994.

The question, though, is why things are not improving?  There are many theories as to why recidivism rates are not improving.  Those in favor of harsher punishments may say we are not doing enough to deter individuals from committing crimes and that our prison system is too lenient and comfortable for prisoners.  Those who call for better rehabilitation efforts could say currently not do a better job of teaching inmates how to be better criminals than they do of rehabilitating offenders.  Data from small-scale studies evaluating individual programs have indicated some programs could be helping, as Dorne (2008) noted restorative justice programs have shown promising results in reducing the recidivism rate, even for violent offenders.  However, Abadinsky (2000) mentions that the success of programs cannot be determined by recidivism rates alone because of all the other factors that influence it.  One thing is for sure, though, there is still a lot of room for improvement.

 

The Social Worker

One of the biggest troubles with our criminal justice system is that there is no valid way for there to be absolute justice in our society.  Eskridge (2004) said absolute justice was not possible because we cannot identify, apprehend, punish, nor identify the intent of all law violators.  As a result, he contended that mistakes will be made resulting, at times, in the punishment of the innocent, escape of the guilty, more severe punishments than necessary, and less severe punishments than necessary.  These are just a few of the flaws inherent in our criminal justice system.  Of course, from a social work perspective, these flaws can be seen as grave injustices from both the victim’s point of view as well as the offender’s, because they directly relate to each individual’s well-being.  Social work in the criminal justice system is difficult for this very reason.  The client systems with which we work are not always open to our help.  Many aspects, both informal and formal, conflict with social work values, and society does not always value the work we do either. Still, social workers cannot be content with these errors in the system and must work to fix them and provide assistance to those slighted along the way.  Social workers must continue to employ the strengths perspective and realize the positive contributions and necessary role criminal justice plays in our society.  As practitioners, we can continue to work with an imperfect system and its pieces while at the same time helping to improve it.  We need to be able to provide those being processed through the system with the help they need at all levels, and collaboration is the key.  Social workers must remain involved with all aspects of our criminal justice systems.

 

Helping Offenders & the Accused

As you may have picked up throughout the chapter, there are many programs and intervention strategies that generalist social workers can facilitate when it comes to working in the criminal justices system.  Our unique perspective and value in the worth of all humans drive us to work with these “deviant criminals” that many others in society think cannot or do not deserve to be helped.  Social workers involved with practice in this arena provide services to inmates, parolees, and offenders who were not incarcerated to help them deal with the immediate criminal justice issue as well the other concerns in their life that may have contributed to their criminal behavior.  Paula Wright (see Chapter 4) she was a social worker practicing in a correctional facility as a caseworker for the inmates, focused on their rehabilitation.  She provided counseling and drug treatment to her clients individually and in groups, helped organize and runs various rehabilitation programming aimed at teaching personal and professional skills for socialization back into society, and facilitated the transition from prison to release back into the community or a halfway house.  Aside from direct work with those on her caseload, Paula also worked to improve the conditions of the facility she was in as well as the criminal justice system overall, advocating for changes that would hold offenders responsible for their actions while still recognizing their humanity and value to society.

            Practitioners can also address needs from outside correctional facilities as well as part of community corrections.  Social workers are employed in a number of private and public agencies that provide much-needed services to the accused and offenders from their entry into the criminal justice system, to serving their sentence, to reintegration into society.

             First and foremost, social work provides mental health counseling at all stages of the criminal justice process.  Social workers are advocates for the accused, especially if they are juveniles, during their interactions with the courts.  Professionals speak on their behalf, testify to their state of mind or life situation, and make sure their rights are not being violated.  As offenders move into serving their sentence, social workers help them meet the terms ordered by the judge.  If offenders are mandated to get help with underlying psychological or social-emotional issues, such as abuse or a cognitive disability, they are either referred to community mental health agencies or are assigned a social worker to their case in a residential correctional center.

             Social work practitioners also function as parole and probation officers and residential center supervisors, not only helping clients follow the terms of their sentencing and holding them accountable for their behavior, but also mentoring them and providing them with opportunities to engage in prosocial behaviors.  For those who have served their time in prison and are able to return to society, either completely or through an intermediate sanction such as a halfway house or work release program, social workers provide services to help them reintegrate into society at large.  Whether working with criminal justice programs or through agencies like Goodwill Industries that provide job and life skills training, social workers are helping clients get prepared to meet the demands of society and contribute in a positive way.  While each role is different in function, structure, and to whom one is accountable, social work’s generalist skills provide the foundation to effectively serves all those who are processed through the system

Sad woman with her had in her hand, crying.
Social workers involved in work with the criminal justice system can also provide services for those who have survived a crime.  Practitioners can help these individuals process their experience and find closure.

 

 

 

Victim Services

            Aside from the work social workers do with offenders and the accused, it is necessary to discuss the work done with those who have been victimized.  One component that could arguably be seen as a part of the criminal justice system is that of victim services.  During the criminal justice process, there are opportunities for social workers to help victims in many different ways.  Masters et al. (2013) described victims’ services as opportunities inside and outside of the justice system to provide for basic needs like shelter and safety, healthcare related to the incident, legal assistance, advocacy, and emotional support to reduce suffering and promote recovery.  These services can be provided during any stage of the victim’s interaction with the criminal justice system.  Whether a domestic violence worker meets a survivor at the hospital to facilitate a discussion with a police officer, a practitioner speaks on behalf of the victim during a court proceeding, or a clinician provides mental health counseling to an individual after the offender has been sentenced, victims’ services can be integral in every stage.

            As generalists, social workers can play a number of different roles when working with victims of crimes.  However, three concepts stand out as essential for the victim advocate in being able to meet the needs of the clients.  The first is connecting with the client.  Those who have been targeted by an offender can feel unsafe and may not be able to trust others.  By being genuine and empathic, and respecting the client’s boundaries and rights, the worker can build an effective helping relationship.  The second component is being able to advocate for the client.  Social workers must be able to work collaboratively with other agencies and government organizations.  By building relationships with entities such as the police, the courts, health care organizations, and other community agencies, we are able to become more involved in the process and have a greater influence on the outcome (Morgan & Coombes, 2013).  The final piece is empowering our clients.  When individuals experience criminal acts, whether they are violent crimes or property crimes, they can lose their sense of individual power and feel like they have no control.  Regaining a sense that control is important for them to positively move on from the experience.  Whether they confront the offender in court with a personal statement, learn strategies to cope with their fear, anger, and anxiety, or participate in a demonstration for survivors’ rights, clients benefit from social worker assistance to improve their self-efficacy.

 

Additional Efforts

            Beyond the roles already discussed, social workers have other major interactions with the criminal justice system.

Policy Practice & Macro Work

            Throughout the chapter, we have noted the discrepancies between criminal justice policy and values and those of social work.  While the two fields might be working toward similar outcomes, such as lower crime rates, less recidivism, and improved services for victims, there are clear conflicts when it comes to the methods to achieve those outcomes and the justification for them.  The policies of our criminal justice system need to be evaluated and adjusted to ensure they are providing for the fair treatment and rehabilitation of offenders.  Our policy recommendations should emphasize the dignity and worth of those who enter the criminal justice system.  Systems theory and evaluating the biopsychosocial aspects of our clients helps us understand the various areas in their lives that might be causing their criminal actions.  Policy work can incorporate this understanding to create programs and alternative sanctions to better address these needs of our criminal justice clients, providing for less punitive and more rehabilitative strategies.

In addition to the policy work, it should be evident that research needs to be done and best practices need to be identified.  Recidivism rates are quite high, even if they are lowered through certain programs.  Social workers have the skills and abilities to evaluate practice and programming, and make adjustments necessary to ensure positive outcomes.  Social workers can collaborate with governmental agencies, such as the Office of Juvenile Justice and Prevention, to find and use data to drive practice.  This way, effective programs can be adopted by various state and local governments to better address crime and provide for a safer community for all.

Prevention

            When it comes to addressing problems in our society, whether they are health, social, or environmental, we can be very reactive in implementing programs and policies to alleviate these concerns.  When it comes to crime and recidivism rates, we erroneously believe scare tactics and threats of harsh punishments are the answer.  Even neighborhood watch programs are a warning to would-be offenders that suspicious activity could earn a visit from the police.  This does nothing to teach our community members why they should not engage in these activities.  Reactionary techniques are not working as effectively as we think they should.  A different take, and a better approach, is to be proactive.  The Bureau of Justice Assistance (n.d.) discussed the need to target risk factors at the individual, group, and community levels and implement programs focused on reducing those.  While one strategy may be to make changes in the community infrastructure, another is to use educational programs to build individual capacity to resist behaviors that could get someone in trouble with the law.

            In schools, effective prevention programs take the form of supplemental curricula for violence, bullying, and drug prevention.  In the community, media campaigns can utilize billboards, television spots, and periodical ads to inform community members of their role in preventing crime.  Town hall meetings discuss, inform, and motivate the community to address crime and improve the community.  Social workers usually take on a leadership role in implementing and facilitating these efforts, collaborating with other community institutions and organizations.  These collaborations often result in the formation of a coalition designed to specifically address the needs of the individual community.

Man at a protest during the COVID-19 pandemic, wearing a mask, and holding a sign that says, "George Floyd's Life Mattered."
One of the issues that minorities have to contend with is being profiled as a suspect because of their skin color, how they dress, and where they might live.  The murder of George Floyd by a police officer in May 2020 has been held up more recently as another example in the long history of our country when someone received discriminatory treatment because of their skin color.  Profiling is said to be a useful tool in helping the police enforce the law.  Is it ever appropriate to stereotype in the name of protecting others?

 

 

Minority Issues

            Few topics demonstrate the effects of institutional racism like criminal justice does.  According to the Bureau of Justice Statistics (2014b), African-Americans represented the largest proportion of male inmates in 2013 at 37 percent, while the U.S. Census Bureau (n.d.) shows they only represent about 13 percent of the general population.  Reiman and Leighton (2010) discussed how the NCVS and UCR demonstrate that individuals who are black are being arrested at a higher rate than they are being identified as a perpetrator of a crime against someone else.  One of the reasons this happens is that African-Americans are more likely to be targeted by the police.  It is referred to as profiling when officers make initial judgments about a suspect based on outward appearance or behavior.  Social workers might disagree with the effectiveness and the ethicality of it, but it is seen by those in law enforcement as a legitimate tool to help catch criminals.  Take this exert from Bumgarner (2004) for example:

Profiles rooted in a negative and inaccurate stereotype are unfair, unethical, immoral, and counterproductive (particularly due to the inaccuracy element).  A stereotype that all urban African Americans are into drugs and crime is not only extremely negative and unfair to law-abiding African Americans, but it is wildly inaccurate, thereby resulting in false investigations and accusations of innocent people at the expense of more reasoned efforts against the genuinely guilty.

            On the other hand, a stereotype that all Hispanic teenage males in particular Los Angeles neighborhoods who wear certain colored bandanas and have their pants hang low, exposing their boxer shorts, are gang members is one that is rooted in some truth.  Although it would not be completely accurate (that it is true for all such persons), it may be largely accurate despite the negative connotation of being linked to gang membership.  Law-abiding Hispanic teens wearing such clothing in the aforementioned way may find the negative stereotype offensive, but it largely works for law enforcement – thereby giving them a shortcut in making initial judgments of such people.  When police officers in Los Angeles pay special attention to such people while ignoring others, all because of the relatively accurate stereotype, they have engaged in profiling. (p. 37)

Although the author was using this to explain why law enforcement officers practice profiling, it serves to demonstrate the accepted attitude of law enforcement in general about singling out suspects based on information that is not entirely accurate.  The profiling does not stop at being suspicious of individuals it carries on to arresting, trying, and sentencing individuals based on stereotypes.  An officer might wholeheartedly believe that a stereotype is not negative or inaccurate at all, when it is absolutely is.  Yet experience and socialization have taught this officer otherwise and they will defend the decision to pull over a car with two African-American males who were driving five miles over the speed limit.

Racial minorities are not the only groups that are being targeted by the criminal justice system.  Individuals who have lower income or are experiencing poverty are also disproportionately represented in America’s prisons, targeted by laws and law enforcement and disadvantaged during criminal proceedings (Reiman & Leighton, 2010).  Both of these groups separately – though there is also a disproportionate number of African-Americans in low-income or poverty-stricken families – are identified by the majority of society as being acculturated to commit crimes.  We assign characteristics to them based on how they present physically instead of looking at the systemic problems of racism and discrimination.  Social workers need to train other community members and criminal justice personnel on diversity.  They can also advocate for clients’ rights through the criminal justice process and work with policymakers to fight racial profiling and other unjust practices in criminal justice as well as unjust societal policies and beliefs that perpetuate institutional racism.

 

Prostitution & Sex Trafficking

            Social work understanding of systems theory and how it applies to criminal behavior enhances the way we look at crimes and those who commit them.  One type of crime in particular that we need to use this with, and help others understand its nature as well, is prostitution.  Prostitution is often identified as a victimless crime because it causes no harm to people or damage to property (Lab et al., 2008; Schmalleger, 2008).  That is unless one considers the prostitute a victim.  Sure, many people would say that it is the person’s choice to engage in this activity, but this is not entirely true.  Moses (2006) discussed results of a few studies stating many women who become prostitutes use the money to support drug habits or avoid being homeless, have high rates of victimization while on the job, are survivors of child abuse, and are forced into it at as minors.  This last characteristic can be better understood as sex trafficking. While not all prostitutes are currently involved in sex trafficking, they may have been initially as minors (Elrod, 2015).

There is legislation to protect victims of human trafficking.  The Trafficking Victims Protection Act (TVPA) was reauthorized in 2013 at the federal level to demonstrate its commitment to fight human trafficking, but limits criminalization of sex trafficking only when minors are involved (Elrod, 2015).  It negates the fact that many of these women are still not in control of their own lives that choosing to walk away from their trafficker can cause more harm than good.  Social work advocacy and survivor services play a huge part in continuing to improve policy to protect those forced into sex trafficking and prostitution as well as prevent it.  On the individualized level, we need to be brokers and connect them with services that can help them change their lives and counsel them to process their experiences.  However, it is imperative that we work with the criminal justice system to provide survivor services when appropriate, instead of treating them like hardened criminals.

 

Conclusion

The criminal justice system and social work are not always working toward the same goals, as demonstrated in policies, practices, and views on crime and criminals.  However, social work should be recognized as an integral part in reducing crime and recidivism through rehabilitation services we provide.  Client systems within the criminal justice context need our help in surviving and thriving as they go through the process from arrest to reintegration in society.  So it is vital that we understand how the system works, the major issues and concerns, and where we fit into the picture.  Working with clients who have broken the law is the epitome of recognizing the dignity and work of the individual, and we need to stay focused on the rights of our clients while working to build their capacity for a positive future.  Because many offenders will continue to be stigmatized, even after they pay their debt to society, we must continually battle for societal change to be more understanding and accepting of this population, while at the same time working to break down barriers that can contribute to criminal activity in the first place.

 

References

Abadinsky, H. (2000).  Probation and parole (7th ed.). Prentice Hall.

Alarid, L. F., Cromwell, P., & del Carmen, R. V. (2008).  Community-based corrections (7th ed.). Thomson Wadsworth.

Aman Jr., A. C., & Greenhouse, C. J. (2014). Prison privatization and inmate labor in the global economy: Reframing the debate over private prisons. Fordham Urban Law Journal, 42(2), 355-409.

Anderson, P. R., & Newman, D. J. (1998). Introduction to criminal justice (6th ed.). McGraw-Hill.

Asmussen, K. (n.d.) Chapter 8: Residential community supervision programs [PowerPoint slides]. Retrieved from www.peru.edu/professionalstudies/directory/asmussen/powerpointCJUS308chapter8.ppt.

Bumgarner, J. B. (2004). Profiling and criminal justice in America. ABC-CLIO, Inc.

Bureau of Justice Assistance. (n.d.). What is crime prevention? Retrieved from https://www.bja.gov/evaluation/program-crime-prevention/index.htm.

Bureau of Justice Statistics. (2010). Felony defendants in large urban counties, 2006 [Publication NCJ 228944]. Retrieved from http://www.bjs.gov/content/pub/pdf/fdluc06.pdf.

Bureau of Justice Statistics. (2013). Terms and definitions: Law enforcement.  Retrieved from http://www.bjs.gov/index.cfm?ty=tdtp&tid=7.

Bureau of Justice Statistics. (2014a). Correctional populations in the United States, 2013 [Publication NCJ 248479]. Retrieved from http://www.bjs.gov/content/pub/pdf/cpus13.pdf.

Bureau of Justice Statistics. (2014b). Prisoners in 2013 [Publication NCJ 247282]. Retrieved from http://www.bjs.gov/content/pub/pdf/p13.pdf.

Bureau of Justice Statistics. (2014c). Recidivism of prisoners released in 30 states in 2005: Patterns from 2005 to 2010 [Publication NCJ 244205]. Retrieved from http://www.bjs.gov/content/pub/pdf/rprts05p0510.pdf.

Bureau of Justice Statistics. (2014d). The nation’s two crime measures [Publication NCJ 246832]. Retrieved from http://www.bjs.gov/content/pub/pdf/ntcm_2014.pdf.

Bureau of Justice Statistics. (2020). Criminal victimization, 2019 [Publication NCJ 255113]. Retrieved from https://bjs.ojp.gov/content/pub/pdf/cv19_sum.pdf.

Corrections Corporation of America. (2015). CCA at a glance. Retrieved from http://www.cca.com/.

Congressional Research Service. (2014). The federal prison population buildup: Overview, policy changes, issues, and options [Publication R42937]. Retrieved from https://www.fas.org/sgp/crs/misc/R42937.pdf.

Dorne, C. K. (2008). Restorative justice in the United States. Pearson Education, Inc.

Elrod, J. (2015). Filling the gap: refining sex trafficking legislation to address the problem of pimping. Vanderbilt Law Review, 68(3), 961-996.

Eskridge, C. W. (2004). Justice and the American justice network. In C. W. Eskridge (Ed.), Criminal justice: Concepts and issues (4th ed.) (pp. 8-14). Oxford University Press.

Federal Bureau of Investigation. (2014a). 2013 Crime Clock Statistics. Retrieved from http://www.fbi.gov/about-us/cjis/ucr/crime-in-the-u.s/2013/crime-in-the-u.s.-2013/offenses-known-to-law-enforcement/browse-by/national-data.

Federal Bureau of Investigation. (2014b). Crime in the United States. Retrieved from http://www.fbi.gov/about-us/cjis/ucr/crime-in-the-u.s/2013/crime-in-the-u.s.-2013/cius-home.

Federal Bureau of Investigation. (September 2020a). Crime in the United States, 2019. Retrieved August 5, 2021, from https://ucr.fbi.gov/crime-in-the-u.s/2019/crime-in-the-u.s.-2019/topic-pages/violent-crime.

Federal Bureau of Investigation. (September 2020b). Crime in the United States, 2019. Retrieved August 5, 2021, from https://ucr.fbi.gov/crime-in-the-u.s/2019/crime-in-the-u.s.-2019/topic-pages/property-crime.

Feeley, M. M. (2014). The unconvincing case against private prisons. Indiana Law Journal, 89(4), 1401-1436.

Fisher, C. (2014). Treating the disease or punishing the criminal?: Effectively using drug court sanctions to treat substance use disorder and decrease criminal conduct. Minnesota Law Review, 99(2/3), 747-781.

Friedmann, A. (2014). Apples-to-fish: Public and private prison cost comparisons. Fordham Urban Law Journal, 42(2), 503-568.

Kassebaum, G., & Okamoto, D. K. (2004). The drug court as a sentencing model.  In C. W. Eskridge (Ed.), Criminal justice: Concepts and issues (4th ed.) (pp. 197-206). Oxford University Press.

Lab, S. P., Williams, M. R., Holcomb, J. E., Burek, M. W., King, W. R., & Buerger, M. E. (2008). Criminal justice: The essentials. Oxford University Press.

Lawson, T., & Heaton, T. (2010). Crime & deviance (2nd ed.). Palgrave Macmillan.

Lillym J. R., Cullen, F. T., & Ball, R. A. (2007). Criminological theory: Context and consequences (4th ed.). Sage Publications, Inc.

MacKenzie, D. L., & Brame, R. (2004).  Community supervision, prosocial activities, and recidivism. In C. W. Eskridge (Ed.), Criminal justice: Concepts and issues (4th ed.) (pp. 315-325). Oxford University Press.

Martin, G. (2005). Juvenile justice: Process and systems. Sage Publications, Inc.

Masters, R. E., Way, L. B., Gerstenfeld, P. B., Muscat, B. T., Hooper, M., Dussich, J. P. J.,…Skrapec, C. A. (2013). CJ: Realities and Challenges (2nd ed.). McGraw-Hill.

Mears, D. P. (2004). Sentencing guidelines and the transformation of juvenile justice in the 21st century. In C. W. Eskridge (Ed.), Criminal justice: Concepts and issues (4th ed.) (pp. 413-420). Oxford University Press.

Messick, R. E. (2004). The origins and development of courts. In C. W. Eskridge (Ed.), Criminal justice: Concepts and issues (4th ed.) (pp. 189-196). Oxford University Press.

Morgan, M., & Coombes, L. (2013). Empowerment and Advocacy for Domestic Violence Victims. Social & Personality Psychology Compass, 7(8), 526-536. doi:10.1111/spc3.12049

Moses, M. C. (2006). Understanding and applying research on prostitution. National Institute of Justice Journal, 255, 22-25.

National Drug Court Institute. (2004). DWI/Drug courts: Defining a national strategy. Retrieved from http://www.ndci.org/sites/default/files/nadcp/Mono1.DWI%20v2.pdf.

National Institute of Justice. (2015). Number and types of drug courts [Table]. Retrieved from http://www.nij.gov/topics/courts/drug-courts/pages/welcome.aspx.

Office of Juvenile Justice and Delinquency Prevention. (1999). Diversion programs: An overview. In Juvenile Justice Bulletin [Publication NCJ 171155]. Retrieved from https://www.ncjrs.gov/html/ojjdp/9909-3/div.html.

Petersilia, J. (2011). Community corrections: Probation, Parole, and Prisoner Reentry. In J. Q. Wilson & J. Petersilia (Eds.), Crime and public policy (pp. 499-531). Oxford University Press.

Reiman, J., & Leighton, P. (2010). The rich get richer and the poor get jail: Ideology, class, and criminal justice. Allyn & Bacon.

Schmalleger, F. (2008). Criminal justice: A brief introduction (7th ed.). Pearson Education, Inc.

Spierenburg, P. (2014). Violence & punishment. Polity Press.

Tiger, R. (2011). Drug Courts and the Logic of Coerced Treatment. Sociological Forum, 26(1), 169-182. doi:10.1111/j.1573-7861.2010.01229.x

Tonry, M. (2004). Intermediate sanctions in sentencing guidelines. In C. W. Eskridge (Ed.), Criminal justice: Concepts and issues (4th ed.) (pp. 289-295). Oxford University Press.

U.S. Census Bureau. (n.d.). Race: 2009-2013 American Community Survey 5-year estimates [Table]. Retrieved from http://factfinder.census.gov/faces/tableservices/jsf/pages/productview.xhtml?pid=ACS_13_5YR_B02001&prodType=table.

U.S. Census Bureau. (2010). Age groups and sex: 2010 [Table]. Retrieved from http://factfinder.census.gov/faces/tableservices/jsf/pages/productview.xhtml?pid=DEC_10_SF1_QTP1&prodType=table

ushistory.org. (2008). 4c. Hammurabi’s code: An eye for an eye. Retrieved from http://www.ushistory.org/civ/4c.asp.

Chapter 16: Aging and Older Clients

There is a famous saying that the only two certainties in life are death and taxes. While it is unavoidable, death is being delayed more and more today, adding to the growth in our older population. Societal beliefs about this group dismiss the living experiences they have and perpetuate misunderstanding and fear of the aging process. The field of social work needs to be prepared for the growing opportunity to improve the lives of a large part of society, and it begins with understanding the population. After reading this chapter, you will be able to:

1. Describe key characteristics of the aging population in the United States;

2. Identify the possible physical/mental health and aging issues for older adults;

3. Recognize the interaction and impact of the various domains in an older person’s life;

4. Describe current services focusing on the older population;

5. Understand the role social workers play in helping the older generations.

An older Sikh couple sitting on a bench with buildings in the background.
"sikh couple" by petercastleton is licensed under CC BY 2.0

Aging, Not Elderly

In the 1980s there was a commercial for a product called Life Alert, which was a device on a necklace that would summon medical help when activated. The ad depicted an older woman slipping and then not being able to get off the ground. She would activate her Life Alert and say, “Help, I’ve fallen and I can’t get up,” and a young operator would tell her that someone was on the way as he dispatched the paramedics. Today, society is still riddled with many similar stereotypes about older adults that highlight a decline in physical and mental health. Those labeled as “elderly” are notorious for driving and moving slowly, not paying attention, their frailty, forgetfulness, senility, and being grumpy, or so it is believed. Yet, with advancements in medicine and nutrition, as well as information literacy about living a healthy life, both mentally and physically, humans are living longer and longer. The oldest recorded living human in recent history reached 122 years of age. Maybe even more fascinating is an article in Reuters by Kelland (2011) that discussed an English doctor specializing in longevity who predicted that the first person to live to 150 years old is alive today somewhere in the world. While this statement might not be fact, there is no denying that more and more people are living longer. In 2014, the average age of longevity for developed countries was 70-80 worldwide – which was about 30 years longer than it was at the Beginning of the 20th century (Jin, Xumming, & Stambler, 2015). Despite what many stereotypes out there indicate, older Americans can easily continue to be active members of society. Older adults in the United States include many very physically and mentally healthy people with lots of energy, meaningful life goals, and excellent driving skills, a much different depiction than the one we get with the descriptor of “elderly.” Our aging population is more often active than in the past, and their numbers are growing. Therefore, the demand for social services and active living options for older Americans is likely to continue to grow. Aging Americans have some unique needs that generalist social workers are primed to be able to help them meet.

 

Who Are the Aging?

By establishing a federally mandated system of financial support for old age, the Social Security Act (1935) essentially prescribed a societal responsibility to care for older Americans, among others, and prevent those who could not work from having to live in poverty. It was this first piece of legislation that was able to provide a legal definition of the older adult population of the U.S. as anyone 65 or older. Today, depending on when one was born, the age to collect full Social Security benefits is between 65 and 67. However, other organizations and groups set their own mark for someone who is “old.” For instance, the US Department of Housing and Urban Development places the minimum age for a “senior” at 55 years old, and the American Association for Retired Persons (AARP) says a person is an older adult when they have reached age 50 (Souare & Lloyd, 2008). However, the Association for Gerontology in Higher Education, a branch of the Gerontological Society of America and a professional association for those who study old age and the aging process, does not reference a specific number for “old age,” though one of its branches, the Association for Gerontology in Higher Education (n.d.), defines gerontology as “the study of the aging processes and individuals as they grow from middle age through later life.” (What is Gerontology? Geriatrics?, para. 2). What exactly is “middle age”? They never really say.

Although there is little congruence when defining who exactly old adults are or what old age looks like, it is much easier to use terms like aging or older adults in regard to this population. While we are all in a constant state of aging, from the time we are born until our lives end, the aging population can be considered those who seem to be closer to the end of their life than to the beginning. More specifically, we will focus on those who are 65 years of age or older, following the protocol of the U.S. Census Bureau (2014), with the understanding that this is a flexible description and some of the issues that are attributed to the aging population can sometimes apply to individuals who are younger than 65. Part of the reason for this is that while the human body follows a general guideline for aging, not all humans’ bodies age in the same way or at the same rate. Some people take really good care of their bodies, eating healthy and exercising, which can help a person live longer. Others neglect their health by smoking, drinking, and eating foods high in fat and cholesterol, which can prematurely age the body. This is some of the variance in health-related issues for the aging population, but it can also affect some of the other issues, including mental health concerns, both of which will be addressed a little later on in this chapter.

A street crossing sign with an outline of an older couple using a cane.
The older population in the United States is going to continue to grow.  But it's important to remember that stereotypes of inactive, slow, and senile do not describe the typical older American.

It was estimated that in 2013 there were approximately 44.7 million People in the United States who were aged 65 years and older – with roughly six million people who were 85 years and older, or the oldest old (U.S. Census Bureau, 2014). Further breakdown of this statistic shows that about 56 percent of older adults are women and 44 percent are men, with the percentage of women increasing as age increases. If our older adults were a separate country, its population would rank them between Spain and Argentina (Instituto Natcional de Estadística, 2014; Instituto Natcional de Estadística y Censos, 2013). However, by 2050, the size of our older population is expected to double, reaching 83.7 million—in part because the size of the oldest old group will triple during this time (Ortman, Velkoof, & Hogan, 2014). Not only is there going to be a greater number of older adults, but there will also be a smaller percentage of the population that belongs to the younger age categories.

 

Growth of the Older Adult Population

There are a number of factors contributing to the growth of the aging Population in the United States. Most obvious is the advancement in medical knowledge, treatment, and technology. As doctors are learning more and more about medical conditions of all ages, and how to prevent and treat them, we are able to further prolong life expectancy. Reichel, Arenson, and Scherger (2009) identified “further advances in chronic disease management, diffusion of ‘best practices,’ increased attention to maintaining physical, cognitive, and psychological function, and availability of improved treatments for the most common causes of death and disability” (p. 1) as being major contributors to people living longer, more active lives. However, this rise in life expectancy can be seen throughout history as knowledge, techniques, and technology in the medical profession improved.

With new medical knowledge is being disseminated among the public, there is a greater expectation of older adults to be more proactive when it comes to their health. Even insurance companies realize the usefulness and cost-effectiveness of prevention by providing incentives for people to get yearly physicals and take better care of their bodies. People are eating better, exercising more, taking better care of their mental health, and making healthier lifestyle choices. As noted in Chapter 13, the rate of smoking is considerably lower than in the past—in fact, less than 25 percent of people aged 25 to 44 smoke—and the previous increase in obesity (another driver of mortality rates) is leveling off (Ortman and Velkoff, 2014). Not only do these changes have a positive effect on life expectancy, they also provide for more vitality in aging adults, allowing them to continue to be more active even in their much later years.

Aside from health-related progress, one of the reasons for the increase in percentage of the overall population that is made up by older Americans has to do with fertility rate—the rate at which women are getting pregnant and having children. In the United States it is at the lowest point since the 1980s, which is lower than what is needed to maintain our population (The World Bank, 2014). Kurjak, Rukavina, and Stanojevic (2012) indicated this was due more to birthing choices of women instead of health related issues. Women are delaying or choosing not to have kids more and more, which also leads to having fewer total children over one’s lifetime. Combine this overall shrinking population with the fact that the number of older adults in the U.S. is growing at such a rapid pace, and we get a greater ratio of older adults to other age groups.

Today’s low fertility combined with the high fertility rate of the mid-1940s through the mid-1960s creates the largest factor to the growing aging population. Children born between 1946 and 1964 are considered the baby boomer generation because of the major increase in births after World War II, the result of soldiers returning from war after being away from their wives for a long period of time. While this is not an unusual phenomenon after soldiers return from war – a rise in the fertility rate happened for a short period of time after World War I – the fertility rate after World War II did not return to pre-war levels for 18 years (Colby & Ortman, 2014). Consequently, this birthing explosion has greatly impacted the age structure of the United States. As of 2011, the firstborn of this generation started becoming members of the older adult group when they turned 65. Although baby boomers are currently between the ages of 50 and 69, they will all have entered older adulthood by 2030, perhaps marking a peak in the proportion of older adults in the total population.

Older adults arms crossed with hospital bracelets on, including one that says, "Fall risk."
While it is not required that we experience physical, mental, and emotional problems as we age, the probability that we will encounter problems increases.  Some of this we can avoid with healthy lifestyle choices, but some of it has to do with societal perception and stereotypes.  "Mom's Guillain-Barré" by caddymob is licensed under CC BY-NC-ND 2.0.

Problems Faced by the Aging

As an individual, take a moment to think about what you do to keep yourself as youthful as possible. While not everyone will come up with an answer, a good majority of people will come up with at least one thing they do to combat aging, both physically and mentally. Whether it is working out to stay fit and strong, doing mental aerobics with puzzles to get your wits sharp, or using facial creams and/or plastic surgery to prevent or get rid of wrinkles and other visible signs of aging, many people are trying to stay young for as long as they can. While the impetus for these measures might be to prolong life as long as possible, some strategies Americans use are really more to prolong youth.

As a society, we put so much emphasis on staying young, especially physically. One article reported a study presented at the annual conference for the American Public Health Association that indicated we spent more money on medication targeting what used to be thought of as natural effects of aging, such as “mental alertness, sexual dysfunction, menopause, aging skin and hair loss,” (para. 2) than we do on prescriptions designed to counteract chronic illnesses (Drevitch, 2012). Add this to the amount of money spent on over-the-counter anti-aging creams, makeup designed to cover wrinkles, and hair dye for women and men, and we have a better understanding of how society tries to prevent or avoid the aging process.

Box 16.2 - Are you ageist?

Decide if you agree or disagree with each of these statements.

1. In general, elderly people are alike.

2. The majority of elderly persons are senile or demented.

3. Elderly people have no more worries once they retire and start enjoying life.

4. The elderly do not desire, and do not participate in, sexual activity.

5. Most elderly people are set in their own ways and are unable to change.

6. The elderly are unproductive and uncreative; they cannot work as effectively as younger people.

7. The elderly are slow to learn, less intelligent and more forgetful.

8. Elderly people are crabby and hard to get along with.

9. The majority of elderly persons are socially isolated and lonely.

10. Elderly people become more religious as they age.

If you agreed with any of the statements above, you may have fallen victim to ageist socialization. While you may know of someone that fits each of these stereotypes, they should not be generalized to the older aged population. Adapted from Oregon Department of Human Services (2012, p. 1).

 

Ageism

Baby boomers are redefining how we look at age. Old age is no longer seen as a time of fragility and senility, but rather a time of wisdom, being active, and purposeful living (Wilson, 2014). In fact, a study conducted by Pew Research found that a majority of American adults feel their life will be as satisfying or better ten years from now, including a two-thirds majority of those who are considered old-aged (Pew Research, 2013). Yet, ageism, or discriminating against older Americans because of their age, is still very prevalent in our society. We may be comfortable with our own aging, but we generally do not want to acknowledge it unless we must. Then when we do acknowledge it, it is always with the belief that we will be different—that when we grow old, we will not end up or behave like those who came before us. We will make sure we take care of ourselves, unlike those who we see as the “elderly” now. We may not be internalizing the negative beliefs about getting older as much as we used to, but that does not mean as a group we are completely sold on the usefulness of the aging population.

Ageism can be easily seen in hiring practices, as Americans closer to retiring were displaced from their jobs due to The Great Recession and, as a result, try to find new employment. Stereotypes that we have about the “elderly” are translated into the workplace: older workers are considered less flexible in mindset, work style, and techniques, as well as being less efficient and reliable workers due to physical ability and health (Chou, 2012). These beliefs by employers can result in unfair hiring and firing practices, extended periods of unemployment, and forced retirement (both by the company and by an inability to secure a new job). Although these beliefs might be based on a safety concern, generalizing behaviors and abilities of a minority percentage of the older population to everyone in this group can cause us to view the older generation as a liability. Take driver’s license requirements for instance. Despite the lower number of crashes and car insurance claims for those 65 years old and over as compared to those under 65—especially the youngest drivers—more than half of all states have specific license renewal requirements for older drivers that may include shorter renewal periods, vision tests, and road exams (IIHS & HLDI, 2015). Essentially, these regulations create an environment in which the aging population is seen as dangerous behind the wheel, when the facts tell a much different story.

Policies and practice are just some ways we write off the older population and how American society demonstrates its bias toward youth. However, it is not always in overt ways that we treat the aging group differently. Another way in which we perpetuate “elderly” stereotypes can be seen in consumerism and advertising. Products and services related to enjoying life, being active, and any kind of technology are typically marketed to the younger audiences, while the products and services that are about taking care of one’s health, dealing with chronic illnesses, and preparing to live out one’s final years are usually targeting older adults. The fun, the liveliness, and the energy of youth are set aside for quiet, calming, and peaceful tones in commercials for the aging.

What society fails to realize is that these practices perpetuate Stereotypes and are based on atypical experiences and an outdated understanding of old age. The days of seeing older adults as physically weak and cognitively inept need to fall by the wayside. While some of the aging population may present this way, it is more the exception than it is the rule. Still, we are a long way from eliminating prejudice and discrimination of the aging. The truth of the matter is that older adults are not valued. A study done by Yilmaz, Kisa, and Zeynelo˘glu (2012) indicated that while college students do not blatantly discriminate against older people, they do not place importance on spending time with or learning from this group. It is not only college students that feel this way. Many people in society behave as if aging adults are outlasting their usefulness to society.

doctor sharing information on a laptop with an older adult patient .
Diminished health is typically equated with growing old and is a very real concern for many Americans.  One of the contributing factors is ageist perceptions of healthcare providers.  While it is not necessary that our health declines as we grow older in years, there are many different health concerns we need to be aware of.

Physical Health Concerns

Indeed one of the biggest concerns older people have to deal with is healthcare. It is true that as we get older, our bodies age as well. The prevailing thought is that they age so much we are left without strength and without the ability to move quickly. A study done by Santoni et al. (2015) found that most people are still healthy into their late 80s. It is true that the different systems in the human body age in different ways and that they will not be able to function at their peak, but by no means are the aging doomed to using a walker, wheelchair, or oxygen tank for the rest of their lives. Though we may not be able to be as active in our 80s as we were in our 20s, we can and should still be fairly active. What has been seen as normal aging of the body can actually be delayed by taking care of our bodies with proper nutrition, physical activity, and making healthy choices such as not smoking and dealing effectively with stress, anger, and sadness. Unfortunately, older Americans are not necessarily living more healthily than in the past, despite the fact they are living longer (Sourae & Lloyd, 2008). As a result, there are some specific issues concerning physical health with which the older population may be dealing. As you read through, keep in mind this is not a prognosis for later adult life, but rather stronger possibilities for this group if measures are not taken to correct or prevent these concerns.

 

Healthcare Providers

Medical professionals are not immune to displaying ageism and, in fact, may be guiltier than the general public, manifesting it in various ways, including a lot fewer doctors choosing geriatrics as a specialty (Meisner, 2012). It is not uncommon for doctors, nurses, or even nursing Assistants to devalue older patients as people needing medical assistance. Often medical professionals harbor beliefs that physical ailments and complaints that older patients experience are just a fact of the natural aging process, which can further result in misdiagnoses, providing fewer and less effective treatment options, and ignoring the needs of patients in treatment (Nolan, 2011).

Unfortunately, medical personnel’s adherence to ageist stereotypes tends to negate patient experiences and symptoms, giving way to diagnoses that fit better with the doctor’s interpretation of what the patient is going through, regardless of the patient’s input. Younger patients presenting with similar symptoms are viewed in a different light because their bodies are supposed to be strong and not worn down yet. They are generally seen as more active and more likely to survive the illness and any treatments for it, while the oldest patients are given much graver odds for survival. As a result, doctors and nurses may be all too willing to accept death in old age as an inevitability instead of continuing to fight the disease or condition from which the patient may be suffering. These prejudiced attitudes can also be seen in the kind of environment that facilities catering to older patients, especially long-term care facilities, provide. While poor conditions in nursing homes or other long-term care facilities can rub off on patients and employees, highlighting a lack of focus on care for the aging, they also embody the attitudes of the medical field and society in general, giving life to the notion that working with the “elderly” is low status (Kydd, Touhy, Newman, Fagerberg, & Engstrom, 2014). Without adequate medical and financial resources, the substandard care they provide greatly impacts patients’ abilities to have an enjoyable end to their life. Hirose et al. (2014) even found that some health issues residents of nursing homes experience can be connected to the poor daily care they receive at the facility. Too often older patients are seen as bodies that need to be maintained with as minimal an effort as possible instead of as the human beings who deserve the best and most professional care available, being treated with dignity and respect. This is not necessarily representative of all nursing homes and, in fact, many provide great quality healthcare from highly qualified service providers. However, this should be the standard by which all nursing homes operate.

 

Chronic Diseases

While aging adults should not be stereotyped as being weaker and less healthy because of their age, unhealthy habits for living, including lack of exercise; diets high in fat, salt, cholesterol and sugar; smoking; and overdrinking can contribute to various conditions that appear or become exacerbated in later life. Sadly, these cases are too frequent in the older population to be ignored when discussing healthcare concerns of the aging group. Chronic diseases are those illnesses that are not contagious, usually develop over a longer period of time—often as the result of one’s lifestyle—are long lasting, and are not “cured” but rather managed. Some chronic diseases are more common among the aging population and warrant further discussion. Souare and Lloyd (2008) outline six different general conditions that are more common among the older population: arthritis, cardiovascular health, colorectal cancer, diabetes, obesity, and oral health. In addition to these, dementia and Alzheimer’s should be added to the list because of their physical nature as opposed to psychological and social-emotional characteristics of other mental health concerns. As you will see, it is not uncommon for older adults to have comorbid conditions, or more than one illness occurring at the same time. Some diseases are particularly prone to comorbidity.

Arthritis – Arthritis is one of the leading causes of disability (Dominick, Ahern, Gold, & Heller, 2004). The Centers for Disease Control and Prevention (2014) describes arthritis as “including more than 100 different rheumatic diseases and conditions . . . more common among adults aged 65 years and older . . . [and] more common among women (26%0 than men (19%),” (para. 1-3). Those who suffer from arthritis regularly experience pain in their joints and the surrounding tissue. This affects their ability to engage in many daily activities, including getting adequate sleep. Arthritis is highly correlated with obesity and inactivity, and can be prevented, delayed, and even managed by eating well and staying active.

Cardiovascular health – Heart disease is the number one cause of death for men and women of all ages in the United States. Part of this concern for aging Americans is that as we age, so do our bodies naturally age. In terms of our whole cardiovascular system, there are structural changes, including loss of elasticity in arteries, thickening of arterial walls and areas of the heart, and a slowing of cardiovascular functioning (Lakatta, 2002). These changes can be lessened or intensified depending on lifestyle choices we have made and continue to make. A decrease in the likelihood of stroke, heart failure, high blood pressure, and coronary artery disease is specifically related to not smoking, moderate wine consumption, not taking aspirin, being active and exercising, and proper nutritional and diet choices (Burke et al., 2001).

Colorectal cancer – While cancer in general can affect people of all ages, colorectal cancer (also called colon cancer) most often affects people who are 50 years of age or older and is the second leading cause of cancer-related death in the U.S. (Centers for Disease Control and Prevention, 2015). As with other chronic issues, the risk of developing colon cancer, although increasing with age, can be decreased by having a diet with adequate fruit and vegetable intake, proper weight management, and abstinence from tobacco use (Souare & Lloyd, 2008). One study even discussed how slowing down the aging process at the cellular level can delay or deter the development of colon cancer (Piano, & Titorenko, 2015). However, any aging person, No matter how healthy their lifestyle is, can be at risk for developing colon cancer. Everyone should get regular screening exams, such as a colonoscopy, once they turn 50 as a preventative measure against colorectal cancer.

Diabetes – In 2012, about 26 percent of all adults 65 years of age and older had diabetes, mostly type II which is known as adult-onset (American Diabetes Association, 2014), and it is projected that the number of cases will more than double to about 26.7 million people by 2050 (Caspersen, Thomas, Boseman, Beckles, & Albright, 2012). Diabetes has been linked to many other health conditions, including obesity, kidney disease, and cardiovascular concerns, including high blood pressure, heart attacks, and strokes. While Type II diabetes is largely preventable, especially because of its relation to obesity, even when diagnosed the disease can still be managed well to prevent complications and other health issues (Comino et al., 2015). However, it remains a serious health concern for older Americans.

Obesity – One aspect of human senescence is the slowing down of our metabolism. As we age, our ability to break down and utilize food for energy and other bodily processes diminishes. If dietary habits do not change as we age, our body mass will increase more and more. However, metabolism is not the only factor related to obesity in the older population. Arterburn, Crane, and Sullivan (2004) discussed the impact that behavioral factors, such as sedentary lifestyle and unhealthy diet choices, have on obesity in older adults. On the other end of the cause and effect spectrum, being obese can lead to other chronic health issues, like those mentioned above, in people of all ages, with the likelihood increasing as we age (Haslam, 2008).

Oral health – In comparison to some of the other chronic diseases mentioned thus far, oral health may seem like a much less serious of an issue. However, poor oral health can have a great impact on older adults’ lives. In 2000, almost one-fourth of all 65-74–year-olds had some kind of severe dental disease or condition, although this varied based on subgroup, including gender and socioeconomic status (U.S. Department of Health and Human Services, 2000). In 2000, the Surgeon General talked about how older Americans were retaining their teeth more often and, as a result, continued to face oral diseases and disorders, including tooth decay, gum disease, and oral and pharyngeal cancers – which are primarily diagnosed in older Americans(U.S. Department of Health and Human Services, 2000). With the impact poor oral health can have on one’s appearance, ability to verbally interact, and ability to consume and enjoy food, not to mention the pain and discomfort experienced, quality of life for those suffering from oral health concerns can drop.

Box 16.3 – Term Usage

The most recent changes to the DSM included a change from using the term dementia to a more inclusive one that could cover the gamut of neurocognitive disorders (NCDs). We use the term here because of familiarity for the audience. The term Alzheimer’s, on the other hand, is still being used and is still a diagnosis under this new term: NCD due to Alzheimer’s disease. What we call it may change, but the concept is still the same. While all cases of NCD deal with a change or impairment of previous cognitive functioning, some of them fit the description of what we understand to be dementia. However, there are other instances of NCD that might not fit under the concept of dementia because it covers a broader range of situations.

Dementia & Alzheimer’s – Developing dementia is often synonymous with growing old. The idea that people get more senile as they age is a widely held misbelief. In fact, only about ten percent of adults 65 and older will have dementia, though the odds of a diagnosis increase by almost a quarter by the time one reaches 85 (Collins, Rovner, & Marenberg, 2009). The Alzheimer’s Association (n.d.) describes dementia as an umbrella term for conditions that involve a decrease or loss in memory, learning, and cognitive functioning skills that impact a person’s ability to perform activities of daily living (ADLs). Alzheimer’s is probably the most well-known form of dementia, accounting for 60 to 80 percent of all dementia cases, about 4.5 million adults in the United States (Collins, Rovner, & Marenberg, 2009). Because these conditions have such a debilitating effect when it comes to self-care, dementia carries a large price tag, financially and psychologically. The psychological effects of dementia actually have a much greater impact on the family members who are faced with watching a loved one go through an often severe decline in cognitive functioning.

An older adult sitting down with his head in his hand with a confused/worried look on his face.
Aside from the impact Alzheimer's disease and related NCDs have on the individual, family, and friends are also deeply impacted by these disorders.  It can be hard to watch someone you love deal with a change in cognitive functioning.

Health-Related Quality of Life

As previously mentioned in this chapter, even though people are living longer, that does not mean they are living healthier. In the same sense, longer life does not mean a person will enjoy life as much as before, let alone be happier. When looking at physical concerns the aging population deals with, we cannot only consider the impact of physical ability and longevity, but must also take into account how injury, illness, and disease impact their health-related quality of life (HRQoL). Healthy People 2030 (2010) - a national researched-based health campaign - considers the physical, mental and emotional, and social functioning of those dealing with chronic illness in order to assess for HRQoL. Self-reported happiness, a good overall physical condition despite one’s illness, the ability to be involved in social realms, and being satisfied in all these areas demonstrate a high HRQoL. On the other hand, reporting feelings of loneliness and sadness, being unhappy with one’s physical condition, and lack of involvement with peers or the community environment indicates a poorer HRQoL for an individual. With the limitations an aging person can experience due to chronic health issues and conditions, the physical, mental/emotional, and social domains can be adversely affected. If one cannot move around as quickly or independently as one used to before their illness, they might find it much harder to enjoy the same activities they once did. Mobility issues also keep older people from getting out and getting involved with their peers or their community as much. Becoming physically fatigued sooner than one used to or having to deal with pain from being active can shorten the amount of time people engage in satisfying behaviors. Just the mere perception of not being healthy enough can prevent a person from getting out and being active or participating in enjoyable activities. All these things can not only cause  a person to be bored, but can bring about feelings of loneliness, sadness, and lack of purpose in life.

Box 16.4 – Eating as We Age

What we eat and how much we eat can have a huge impact on our physical and mental health. Getting the right amount and the right kind of nutrients is important to help us stay energetic and positive, even as older adults. An article by Segal and Kemp (2015) discussed how certain physical effects of aging can impact our diet, under “Healthy eating as you age: Coping with changing dietary needs”: http://bit.ly/1v7vRRz.

Greater or improved emotional well-being and HRQoL in older adults dealing with chronic health concerns has been linked to a number of environmental factors, including marriage/family involvement, living with others, good financial circumstances, and effective treatment illness treatment (Rathnayake & Siop, 2015). There are also a number of psychological factors that can have an impact on HRQoL. Older adults do not always have control over their environment, but they can directly impact their own emotional state. Many things can boost their well-being: knowledge and understanding of their illness, being religious or spiritual, connecting with a purpose in life, and proper self-care, which includes coping with stress and laughing (Gupta, Uday, Tiwari, Singh, & Singh, 2014; Rathnayake & Siop, 2015; Szymona-Pae˛kowska, 2014). In order to most effectively achieve and maintain a high HRQoL, older adults need to have both environmental and psychological protective factors in place. Being able to manage one’s emotions and keep a positive mood is wonderful, but environmental factors can help us meet belonging and affection needs.

In the same sense, just being around others may not be enough. Understanding how to find joy and meaning in the interactions and Connections we have with other people can improve our functioning in that environment. In the instances when we have no control over certain environmental factors, social-emotional management skills can help deal with those concerns.

Worker pushing a person in a wheelchair looking out over the vista.
Quality of life can be greatly impacted by our physical health.  Social workers practicing with older adults can help alleviate some of the emotional strain physical health issues can cause.

Mental Health Concerns

Ageism is not something reserved for the young in our society. It is not uncommon for people to hold onto some of these beliefs about their own inevitable decline as they age, fearing that they are going to come to a point in their lives when they are just waiting for death. Middle-aged Americans – those who are closer to retiring – are more worried about what their later years are going to bring than those who more recently retired or entered old age (Neikrug, 2003). However, this lack of worrying about the golden years of life does not mean that a large number of older adults are not dealing with mental health concerns. Older adults deal with age-related issues such as emotional isolation, depression, anxiety about death, loss of independence, and the end of close personal relationships, including a marriage, due to death (Sivis, McCrae, & Demir, 2005). Even though mental health concerns are not a necessary part of the aging process, older Americans are often affected by them in later life.

The largest mental health concern for the older population in America is depression. Depression is not a specific issue for the aging population, however. A National Institute of Mental Health (2012) found that only five and a half percent of adults 50 and over had at least one major depressive episode over the previous year compared to almost nine percent for those aged 18 to 25 and about seven and a half percent for those aged 26 to 49, though these numbers did not include aging adults in long-term care facilities such as nursing homes or hospitals.

However, part of the problem with older adult depression is that it too often goes undiagnosed and untreated as a separate health concern and is seen as a natural part of the aging process (Tomkowiak, 2009). As a mood disorder, it is not about the physical changes in an aging body as much as the environmental factors. In fact, some of the symptoms of depression often resemble what are stereotypically thought of as normal effects of getting old, such as sleep difficulties, loss of energy, weight change, and memory and processing difficulties (Erber, 2013). These signs may even be linked to other physical health issues with which an older person is dealing. Oftentimes these things can be associated with health concerns, especially chronic illnesses, but the symptoms can stand alone as depression and have nothing to do with the actual illness.

A decline in health can cause one to have to give up enjoyable activities, leading to an increased risk of depression. Tomkowiak (2009) even mentions a study of inpatient older adults with major depression disorder in which two-thirds of them had one or more medical issues aside from the depression. As we saw with chronic diseases, comorbidity may be present when a person has depression as well. It is hard to have to change the way one functions in life after so many years of doing it the same way. The feelings of sadness, hopelessness, and loneliness associated with depression can be brought on and worsened by changes in one’s physical ability and physical health, social life, and living arrangements.

 

Death and Loss

The only consistent thing that all people will experience in life is death. No one is immortal and the older population naturally has a greater chance of dying. The aging process brings with it a greater possibility of our life ending, whether from a chronic illness, a sudden incapacitating disease, or our bodies just ceasing to function despite being healthy. In the same sense, the chances of losing someone we are close to who is also aging increases as well. With the loss of a significant other, friends, loved ones, and people one knew, even receiving one’s own terminal diagnosis, death and dying is something all aging people will have to deal with eventually and grieve. The grieving process itself can take a tremendous toll on our mental health, at times also affecting our physical health. Deepening depression, a greater possibility of death, physical ailment, increase in levels of stress, loneliness, decrease in memory functioning, and greater risk of dying by suicide are identified as possible negative results of bereavement in later adulthood (Shah & Meeks, 2012).

Shah and Meeks (2012) identified a number of studies that indicated older adults, for the most part, were able to work through the grieving process and initial depressive symptoms and adjust to life after the loss of a loved one. Still, as people age and experience more loss of social relationships, their sadness reaction becomes stronger and can be more overwhelming than those in the younger populations (Seider, Shiota, Whalen, & Levenson, 2011). Whether dealing with losses leads to adjustment in functioning or to greater depression, it is still an important mental health concern for the aging population.

Box 16.5 – Kubler-Ross’s Stages of Grief

In her 1969 book, “On Death and Dying,” Dr. Elisabeth Kubler-Ross outlined five stages people go through in coming to terms with their own death. These five stages were later expanded to grief in dealing with any kind of loss. A person may or may not go through every stage nor in the order they are presented here. The person may also revisit stages that have already been experienced. These five stages of the grieving process are outlined below:

Denial – The initial reaction to hearing of the loss in one’s life, whether it is a loved one passing, the end of a relationship, or one’s own imminent death. Denial can allow us to face the news when we are ready, giving us time to ready our defenses.

Anger – When a person acknowledges the loss is real, they may become angry and lash out at others, including the person who they are losing. When a person is going through this stage, they may seem on edge or as if they have a quick temper, getting upset at anyone or anything that may be in their environment.

Bargaining – This stage involves the person dealing with loss bartering with God, doctors, or other entities in order to postpone the loss. Usually there is a promise to improve their quality of life or behavior in exchange for this extra time.

Depression – As the loss becomes more of a reality and harder to stave off, the recognition that life will never be the same can bring feelings of sadness and longing for the past. The usual result is a depressive state that impacts one’s motivation in life.

Acceptance – After time of dealing with the many emotions brought on by loss, the final stage of grieving is the acceptance of reality. While a person may come to terms with the loss, they still may need time to adjust, particularly if they are losing a prominent person form their life. Adapted from Kübler-Ross, 1969. 

Dr. Bonifas (n.d.) stated older adults can have a much more difficult time with the grieving process for a number of reasons. A few of these are listed below:

1. Experiencing several losses within a short period of time.

2. Not being aware they are grieving instead of just feeling sad.

3. Not having the support network they once had to help them through the process.

4. Chronic or terminal illnesses can interrupt the grieving process.

5. Increased chance of getting physically ill or their illness worsening after a loss. (slides 34-36)

 

Financial Issues

Depending on health status, retirement income, and housing situation, older age can be an expensive part of life. Retirement concerns and healthcare costs can change the life aging Americans were once used to and disrupt financial security. Living arrangements, diet options, ability to stay active, leisure activity options, even the medical treatment they received are greatly affected when the finances are not there. All this can greatly impact quality of life and increase the likelihood of an older adult developing or worsening physical and mental health problems.

There are a number of retirement income planning options available to Americans as they pass through their working years. Pensions, individual retirement accounts (IRAs), 401(k) accounts, and Social Security are the major options people have during their lifetime. Some of these options provide greater financial security and freedom in old age. However, pensions from private companies are becoming obsolete now as fewer people stay with the same company for their entire career. IRAs and 401(k) plans themselves are not always a realistic option either for those receiving a lower wage or those who need every penny they earn to pay the bills. Too often older people are left to rely on Social Security as their retirement income, even though it was not designed to be the sole financial stream for retired people (Erber, 2013). Some aging Americans will return to work as a means to supplement what they already receive in retirement benefits, which can add relief. However, these jobs are usually at a diminished capacity and a lower income than what they are used to.

Healthcare costs also take a toll on older adults’ finances. Ninety-five percent of total healthcare costs for older Americans – which can be three to five times higher for those 65 or older – goes to dealing with chronic diseases (Centers for Disease Control and Prevention, 2013). Health Insurance does not always cover the total cost, especially for anyone entering a long-term care facility (Wilson, 2014). Many older adults have to pay out-of-pocket for at least a portion of their care, which greatly reduces their financial standing. For those aging adults already dealing with financial insecurity, these costs can exacerbate the problem, adding to the growing number of adults 65 years of age and older who are experiencing poverty.

Picture of a billboard public service announcement showing a older adults bruised arm with the caption, "Elder abuse.  Time it was brought into the open."
Elder abuse is one of the issues adults can face as they age.  Although we may think of elder abuse in terms of the physical maltreatment they could endure, older adults suffer from emotional, verbal, and financial abuse as well.  "elder abuse" by speedwaystar is licensed under CC BY-NC-ND 2.0.

Crime Victimization and Elder Abuse

Due to prevalent stereotypes of older people being weaker and slower, some may believe that older adults are susceptible to being victimized by criminals. This is contradictory to data from 2003-2013 that showed those aged 65 years and older were much less likely to be victims of violent crimes or property crimes, with theft being the most common crime experienced by the older population at 51.8 incidents for every 1000 households headed by the older aged (Bureau of Justice Statistics, 2014). However, the same study that provided this data also outlined factors correlated with higher victimization rates, including being male, living in an urban setting, being separated from one’s spouse, living alone without children, renting a residence, and being multi-racial. Some of these may be related; for instance, an older person living in an urban setting is much more likely to rent a place to live instead of owning it. Also, if a person is separated from their spouse as an older adult, they most likely are not going to be living with children.

What can be a bigger problem is how the older adults deal with their experience. Only 56 percent of older victims reported violent crimes that happened to them, and an even smaller number—11 percent—received any kind of victim-related services from appropriate agencies. The number of reported property crimes was even lower, at 38 percent, despite the 13-to-one ratio of property crimes to violent crimes among older Americans (Bureau of Justice Statistics, 2014).

One other aspect of crime against the older population that needs to be addressed is what is called elder abuse. Though we have been using older and aging to describe the oldest populations of adults, elder abuse is a widely-used term to describe the verbal, physical, emotional, and financial abuse and neglect of older adults. This abuse can come from a few different places, but most often involves family members, friends, or caregivers, is perpetrated against those older adults who are vulnerable—physically, mentally, socially/emotionally—and has legal consequences in all 50 states (Administration on Aging, n.d.b). However, there are instances of self- neglect by older adults that can also constitute elder abuse, but are concerning because they are more indicative of underlying emotional or mental health concerns.


Housing and Residence

Many older Americans do not need the social assistance and health assistance provided by nursing homes and other long-term care facilities until they are in their much later years (Santoni, 2015). In fact, while there is a belief that many aging adults enter nursing homes, only about five percent of the population actually needs to utilize the services of a long- term care facility.  Many aging adults still live in private residences they own or rent, such as houses, condos, or non-age-specific apartments. These options are dependent on both level of financial stability and physical health needs.

More recently it has been recognized that most older adults prefer to live in their own residences. They can manage their environment to be as active in their lives as possible, maintain their independence, and retain the control over their lives; this is referred to as aging in place (Iecovich, 2014). If done right, through adjustments in the home environment as needs arise and with support from family members and friends, many older adults can age in place for a long time. Staying where one chooses and with which one is familiar can positively contribute to the overall quality of life experienced by an aging person. However, without proper support, both socially and financially, staying in their own homes is not something all older adults can afford, resulting in having to move in with a family member or seeking a different housing option, which may require more reliance on others and less autonomy.

 

Addressing the Needs of Older Adults

It should be clear at this point that the later years of life can be ones filled with enjoyment, satisfaction, and lots of active living, in spite of the “elderly” individual stereotype that conjures up the thought of frailty, senility, dependence, and hopelessness. These stereotypes are starting to give way to thoughts of being stress-free and actually starting to live life. For many older adults, for many of their later years, life will be very enjoyable. Yet, there are millions of older Americans that are dealing with many different health-related, financial, environmental, and social issues that are reducing their ability to successfully take part in the rest of their lives. These issues are compounded by the institutional and societal prejudice and discrimination perpetrated by younger generations, healthcare professionals, even loved ones who do not understand or want to take care of the needs the oldest generations have.

The aging population can be considered a minority, as this group is often disenfranchised by those in power and unfairly treated by societal mores and beliefs, as well as governmental policies and practices. Like any other minority group, the problems faced by older individuals are even more challenging for members of other minorities (nonwhites, LGBTQ older adults, etc.). The marginalization they face in multiple arenas can needlessly increase their likelihood of depression, chronic illness, and dependence on others.

 

Current Policies, Programs, and Services

Despite the possible needs of older Americans demonstrated in the previous sections, there are already a number of services provided specifically for this population. As much as the population is growing now and deficits in programming and policies are becoming more apparent, recognition of struggles faced by older Americans was the impetus for creating the Older American Act of 1965. According to the Administration on Aging (n.d.a):

Congress passed the Older Americans Act (OAA) in 1965 in response to concern by policymakers about a lack of community social services for older persons. The original legislation established authority for grants to States for community planning and social service research and development projects, and personnel training in the field of aging. The law also established the Administration on Aging (AoA) to administer the newly created grant programs and to serve as the Federal focal point on matters concerning older persons. (para. 1)

Basically, the AoA, in line with the provisions of the OAA, provides services and programs focused on alleviating societal woes of older Americans that are regulated and overseen by state governmental bodies. These services and programs are offered through various social service and healthcare agencies, both public and private non-for profit. While the AoA does the most to meet need, with programming and information dissemination, there are other governmental programs and policies that can be utilized by the older population as well.

Older adult getting out of bed and looking at the sunlight coming through the window.
There are many services for older adults to help them continue with their lives with as little disruption as possible.  If people choose to age in place, they can still be provided with health-related assistance in their home.

Housing and Transportation

Nursing homes can provide wonderful 24-hour care for the most physically vulnerable individuals, while assisted-living facilities are available for those folks who do not need constant care, or only need support for a few daily tasks. Retirement communities, on the other hand, direct services more toward the social aspect of life instead of focusing on healthcare. There are options across the whole spectrum that can provide the necessary support at the most cost-effective price. Ideally, this provides choices and care for older adults that fit their needs instead of forcing them to reside in an environment that is too restrictive. 

Even when it comes to aging in place, there are options for older adults to still receive specialized care from professionals without having to leave the comfort, security, and privacy of their own home. While there are many different items and adjustments that can be added to homes to help an older adult with needs function well in their own home, there are also a variety of services that can meet needs of older adults who might require support from others. Social service and healthcare agencies can send workers out to visit aging adults on a regular basis to help with personal care, house chores, financial management, dietary planning and preparation, and even healthcare needs. Other services can provide pick-up and delivery options to help with grocery shopping, laundry, medical supplies, and prepared food services such as Meals on Wheels. If the older adult needs— or wants—to leave, many towns have transportation programs, aside from transportation, for those who cannot drive themselves. Dial-a-ride programs and the like are able to pick up and drop of aging people at various destinations so they can run errands or go to social events instead of being confined to their home.

All of these amenities can allow those with fewer restrictive needs to continue to enjoy familiar surroundings. If older adults require more and regular assistance from medical professionals, it is usually assumed they will need to move into a nursing home or assisted-living facility. However, those who have chronic or terminal illnesses can still reside in their private residence thanks to hospice programs. Hospice is person-centered, compassionate care for those with debilitating illnesses that utilizes a team approach and can be provided in a home, hospital, or long-term care facility (National Hospice and Palliative Care Organization, n.d.). The team consists of doctors, nurses, home health aides, social workers, and other trained helpers that can provide for all the needs of the adult in order to make their situation as comfortable and dignified as possible. Hospice programs are often funded through grants, but it is also possible for the services received to be covered under Medicaid, Medicare, and private insurance programs.

 

Senior Centers

While the other programs and services discussed in this section primarily narrow in on medical or environmental help, senior centers directly impact the social facet of an older person’s life. Again although we have been using aging and older adults instead of words like “senior” throughout this chapter, locations described as senior centers are still a recognizable feature in many communities. Senior centers are places that organize many different functions aimed at keeping the aging population engaged and active in life through interaction with their peers and enjoyable experiences, such as weekly game nights, arts and crafts activities, barbecues, movie nights, and special outings to places like sporting events, live plays, and even casinos. These activities can also be provided through retirement communities, but they are mainly for residents of the community and not open to the general public. While funding for events at both retirement communities and senior centers may need to be supplemented through participation fees, especially off-site excursions, most of the funding for senior centers comes from grants and tax dollars, as opposed to the resident fees charged by retirement communities.

Box 16.6 – Senior Centers

One of the oddest events that ever happened to our grandmother was the time she went on an outing to a casino organized through her local senior center. Our grandmother had been outings like this before, without any incident, aside from the times she would win big at the casino – my grandmother was a very lucky woman. This time in particular, however, she was enjoying playing the slots, passing the time, and not realizing how late it was getting. Well, by the time she reached her preset gambling limit, she tried to find her group and realized the bus had left without her. She was stranded at the casino all by herself. She ended up calling our uncle who drove the hour and a half to get her (while she was waiting, she won $1000!).

Even after that incident, my grandmother was as involved as possible in her senior center’s outings. They went to sports games, took shopping trips to the mall, saw theater productions, picnicked and grilled, and attended holiday parties. At times, I felt like my grandmother was more active in her 70s than I was in my 20s. Like my grandmother, many seniors are regularly involved in happenings through their senior centers. It gives them an opportunity to interact with peers, try new activities, see new sights, and generally enjoy life as they age.

 

Social Security, Medicaid, and Medicare

Currently there is much debate over if our Social Security Retirement benefits will last. The simplest explanation for how the system works is that those who are working are paying into the “account” and those who are retired are withdrawing from that “account.” The concern is that the money being put in might not be able to sustain the amount being taken out, resulting in a bankrupt Social Security system that will not benefit those who have been paying into it their entire working life. As the retired population grows, the demand for Social Security benefits will only increase, putting even more strain on the system. One of the ways this is being addressed is through an increase in the age people can start collecting their full benefits, from 65 to 67 for those born after 1959.

If you recall from Chapter 12, Medicare and Medicaid are both Supplemental amendments to the Social Security Act that provided monies to help with healthcare needs. While Medicaid is not specific for older Americans—rather, it is provided for the healthcare of those in financial need—it can still be used by those older adults who are without financial stability or health insurance. Medicare, on the other hand, is only for those who are 65 years of age or older. Of course, not all healthcare costs are covered; some must be supplemented through out-of-pocket payments, which can be hard for those older adults who have not planned for and/or do not have the means to cover certain medical costs.

Worker walking with an older adult through a courtyard.
There are a number of different roles social workers play in the practice they do with aging adults.  With the growth of the older American population, social work positions with this group will increase as well.

Social Work’s Role

Social workers are in a unique position when it comes to serving older Americans, understanding the biopsychosocial aspects of the aging process and challenges older adults may deal with as they continue their life into older age. As the aging population grows, more and more professionals will be required to effectively work with this population and help provide for their quality of life, in all levels of practice. The first key to practicing with this group is understanding the various problems they can encounter as aging adults and the barriers they have to enjoying their later years. Social workers need to distinguish facts from myth, confronting stereotypes they have learned in order to find the positive aspects of aging and characteristics of older adults. More importantly, however, is being able to understand the individual, with their strengths and areas of need. While we can use our knowledge of common issues as a guide, we must work to understand their particular situation in terms of work, housing, physical and mental health, finances, social interaction, and family setting. Aging is a unique process for each individual and must be approached that way by those who want to help the aging population.

Social work is one of the few professional fields that has a specialty focus for working with older adults. Gerontological social workers understand the emotional, psychological, and social features of aging and use this to enhance clients’ quality of life (McCallion & Ferretti, 2010). These practitioners are found in many different agencies, settings, and programs that work directly with older adults, such as hospitals, nursing homes, senior centers, and social service agency programs catering to the aging population. However, the positions workers hold in these settings can look very similar in terms of how they help older adults deal with the problems with which they are faced. Our discussion is going to focus on three main functions social workers play in working with aging adults.

Box 16.7 – Skills for Working with Older Adults

Barbara Worthington (2008) discussed why social work with the aging population was a good career option and how to know if it was right for you. Part of the article discussed generalist social work skills needed for this population and how they applied in working with older adults. The article can be found at: http://bit.ly/1NM0BwS. Look for the “Skill Sets” section at the very end of the article, bottom of the page.

Case Management

Case management with older adults still requires workers to take on Different roles to help older clients. The three biggest roles one should hone in on with case management are that of advocate, broker, and teacher. Unfortunately, the voices of older clients in need are too often ignored or neglected, mostly due to ageism and diminishing stereotypes. There are times when healthcare professionals, caretakers, even loved ones negate what the older person says they want, need, or experience because these Social Work & Social Welfare: Modern Practice in a Diverse World people incorrectly assume the older individual is not cognitively all there or they feel they know what is best for that older person. We need to listen to our clients, understand their needs, and work zealously to help them meet those needs. In a similar fashion, when we have clients who have cognitive disabilities or cannot adequately vocalize their concerns as the result of a chronic illness or disability, we need to become experts on their situation, incorporating their illness into our comprehension of what will help them, and work with others to make sure they are receiving compassionate, quality care without prejudice.

Sometimes it may not even be about fighting for our clients, but more connecting our clients with services that would be helpful based on identified needs in their lives. While this chapter has identified services available to the older population, our clients may not be aware of or know how to access certain services or programs. As brokers, it is our job to be familiar with the array of services available in our communities and how those services can meet the diverse needs of our clients. Providing the number for dial-a-ride, connecting clients with social programming at the local senior center, or helping them identify hospice services as an option for treating their chronic conditions are just some ways we connect older clients with appropriate services.

Of course, some of our clients might be having a hard time adjusting to a new life situation due to illness, retirement, or loss of a loved one. As case managers, we might be called upon to help our clients understand just how different their lives are going to be and provide them with strategies to adjust. Whether it is identifying and teaching new ways to perform a routine task, educating them about their condition and the treatment for it, or teaching them how to perform tasks that were previously performed by their spouse, gerontological social workers will help clients build skills appropriate for their new way of functioning. This role, along with the other case management services, can also be utilized when working with the client’s family and/or caregiver. Because of the important role others take on in providing for family members, we can work with them to serve the older client as well as meet their needs as a caregiver or loved one by connecting them with services that can lower the burden they may bear and teaching them strategies and ways of interacting with the older client.

 

Mental Health Services

Although counselor can be a role that is performed under case management, it should not be confused with the mental health functions performed by a clinical social worker. In terms of helping older adults dealing with mental health concerns, such as depression, anxiety, sadness, loneliness, grief, or adjustment issues, social work practitioners can provide both one-on-one clinical services and support or process group services. It is important to keep in mind that mental health issues in older clients are not necessarily due to age but could have been present for a number of years or recently presented independent of age. Clinicians use appropriate interventions to help clients work through any issues with which they may be dealing, whether the issues are new or have been around awhile. No matter what strategies are used to help older clients deal with mental health concerns, it is important to engage the clients in a discussion of the issues. This can help them feel heard and validated, and more prepared to process and move forward. Therefore, it is essential to connect with older clients in a way that demonstrates respect, genuine interest in what they have to say, and an understanding of the wealth of experience and wisdom they can bring to the therapeutic relationship.

 

Policy Advocacy

A significant part of social work with any minority population is identifying and challenging the various institutional and societal barriers that help perpetuate marginalization of said group. For older adults, policy work can focus on creating or adjusting policies or programming that helps meet the needs of the aging population. If programs are not going to effectively meet the needs of citizens, like Social Security going bankrupt, improvements need to be made. Helping eliminate ageism from policies, such as those related to driver’s services, is not only good for older adults, but can stop younger Americans from being trained to think of the older population as “elderly.” Even working to end the media’s negative representation of older folks in commercials, TV shows, and movies can break down the prejudicial stereotypes that lend to negative attitudes about this group.

 

The Challenge for Gerontological Social Work

Probably the biggest challenge for social work with the older population is a lack of interested and qualified candidates. In 1987, the National Institute of Aging predicted that there would be demand for over 60,000 social workers trained in gerontological social work by the year 2020 to meet the demands of the aging population (as cited in Ferguson, 2012). As we get closer and closer to that date, even though numbers may have changed, there is still a shortage of knowledgeable practitioners to work with the aging population, with fears that it will become smaller as experienced workers retire (Simons, Bonifas, & Gammonley, 2011).

The unfortunate reality is many social workers and social work students are ageist themselves, often without realizing it. They hold negative attitudes about the aging population based on misinformed stereotypes, and misunderstand the nature of working with the aging population (Carl, Simons, & Larkin, 2005). Therefore, the field of social work itself should be addressing this issue by increasing educational opportunities for social work students to gain knowledge about and experience interacting with older adults. These allow students to become familiar with the population. Such a strategy would break down prejudiced beliefs and help students gain a better understanding of the true nature of aging and the problems faced by these older adults (Gutheil, Heyman, & Chernesky, 2009). As the demand for gerontological workers increases, those who fill the positions may not have the knowledge or attitude to work effectively with this population if social work programs do not provide adequate training.

Conclusion

Growing old is a natural process in life. However, it is not necessary that as we grow old we have to lose our ability to be active and enjoy our life. In fact, older adulthood can be one of the happiest and most active times of our lives if we take preventative measures to keep ourselves healthy. Many of the physical and mental health issues older adults face can be avoided or delayed by living a healthy lifestyle and finding the appropriate help when dealing with stressful life events. The aging population is only going to get bigger, so it is important for social workers to be prepared to help this population in addressing some of the largest health, social-emotional, and environmental needs of this group. From providing case management services to individual counseling to policy work, social workers have the necessary tools to provide effective services to aging adults. The most important thing, though, is for social workers themselves to become educated with the correct information about the aging process and the aging population in order to avoid the trap of ageism that allows us to dismiss the needs of this group. The demand for more and more social workers to provide services to older Americans is coming; in many ways, it is already here. Being able to make a difference in one of the largest populations can be a rewarding venture, and a great use of generalist social work skills.

Chapter 16 References

Administration on Aging. (n.d.a). Older Americans Act. Retrieved from http://www.aoa.gov/AoA_Programs/OAA/index.aspx.

Administration on Aging. (n.d.b). What is elder abuse? Retrieved from http://www.aoa.gov/AoA_programs/elder_rights/EA_prevention/whatisEA.aspx.

Alzheimer’s Association. (n.d.). What is dementia? Retrieved from http://www.alz.org/what-is-dementia.asp.

American Diabetes Association. (2014). Statistics about diabetes. Retrieved from http://www.diabetes.org/diabetes-basics/statistics/?loc=db-slabnav.

Arterburn, D. E., Crane, P. K., & Sullivan, S. D. (2004). The coming epidemic of obesity in elderly Americans. Journal of the American Geriatrics Society, 52(11), 1907-1912. doi:10.1111/j.1532-5415.2004.52517.x

Association for Gerontology in Higher Education. (n.d.). Gerontology/geriatrics definitions [Webpage]. Retrieved from http://www.aghe.org/resources/gerontology-geriatrics-descriptions.

Bureau of Justice Statistics. (2014). Crimes against the elderly, 2003-2013 (Publication NCJ 248339). Washington, D.C.: U.S. Justice Department. Retrieved from http://www.bjs.gov/content/pub/pdf/cae0313.pdf.

Burke, G. L., Arnold, A. M., Bild, D. E., Cushman, M., Fried, L. P., Newman, A., & ... Robbins, J. (2001). Factors associated with healthy aging: The cardiovascular health study. Journal of The American Geriatrics Society, 49(3), 254-262. doi:10.1046/j.1532-5415.2001.4930254.x

Caspersen, C. J., Thomas, G. D., Boseman, L. A., Beckles, G. A., & Albright, A. L. (2012). Aging, diabetes, and the public health system in the United States. American Journal of Public Health, 102(8), 1482-1497. doi:10.2105/AJPH.2011.300616

Centers for Disease Control and Prevention. (2013). The state of aging and health in America 2013. Atlanta, GA: Centers for Disease Control and Prevention, U.S. Department of Health and Human Services. Retrieved from http://www.cdc.gov/aging/pdf/state-aging-health-in-america-2013.pdf.

Centers for Disease Control and Prevention. (2014). Arthritis: The nation’s most common cause of disability. Retrieved from http://www.cdc.gov/chronicdisease/resources/publications/aag/arthritis.htm.

Centers for Disease Control and Prevention. (2015). Basic information about colorectal cancer. Retrieved from http://www.cdc.gov/cancer/colorectal/basic_info/index.htm.

Colby, S. L., & Ortman, J. M. (2014). The baby boom cohort in the United States: 2012 to 2060. Retrieved from http://www.census.gov/prod/2014pubs/p25-1141.pdf.

Collins, L. G., Rovner, B. N., & Marenberg, M. M. (2009). Evaluation and management of dementia.  In Arenson, C., Busby-Whitehead, J., Brummel-Smith, K., O’Brien, J. G., Palmer, M. H., & Reichel, W. (Eds.), Reichel’s Care of the Elderly (pp. 176-189). Cambridge University Press.

Comino, E. J., Harris, M. F., Fakhrul Islam, M., Tran, D. T., Jalaludin, B., Jorm, L., & ... Haas, M. (2015). Impact of diabetes on hospital admission and length of stay among a general population aged 45 year or more: A record linkage study. BMC Health Services Research, 15(1), 277-297. doi:10.1186/s12913-014-0666-2

Chou, R. J. (2012). Discrimination against older workers: Current knowledge, future research directions and implications for social work. Indian Journal of Gerontology, 26(1), 25-49.

Curl, A. L., Simons, K., & Larkin, H. (2005). Factors affecting willingness of social work students to accept jobs in aging. Journal of Social Work Education, 41(3), 393-406.

 Daily Mail. (2011). Dawn of a new age: The first person to reach 150 is already alive…and soon we’ll live to be a thousand, claims scientist. DailyMail.com. Retrieved from http://www.dailymail.co.uk/sciencetech/article-2011425/The-person-reach-150-alive--soon-live-THOUSAND-claims-scientist.html.

Dominick, K. L., Ahern, F. M., Gold, C. H., & Heller, D. A. (2004). Health-related quality of life among older adults with arthritis. Health & Quality Of Life Outcomes, 25-8.

Drevitch, G. (2012). We now spend more to fight aging than to fight disease: Startling data highlights the controversial surge of anti-aging prescriptions.  Next Avenue, (online). Retrieved from http://www.nextavenue.org/blog/we-now-spend-more-fight-aging-fight-disease.

Erber, J. T. (2013). Aging and Older Adulthood (3rd ed.).  Wiley-Blackwell.

Gupta, A., Uday, M., Tiwari, S. C., Singh, S. K., & Singh, V. K. (2014). Dimensions and determinants of quality of life among senior citizens of Lucknow, India. International Journal of Medicine & Public Health, 4(4), 477-481. doi:10.4103/2230-8598.144122

Gutheil, I. A., Heyman, J. C., & Chernesky, R. H. (2009). Graduate social work students' interest in working with older adults. Social Work Education, 28(1), 54-64. doi:10.1080/02615470802028116

 Haslam, D. (2008). Understanding obesity in the older person: Prevalence and risk factors. British Journal of Community Nursing, 13(3), 115-16.

Healthy People 2020. (2010). Health-related quality of life and well-being. Retrieved from http://www.healthypeople.gov/sites/default/files/HRQoLWBFullReport.pdf.

Hirose, T., Hasegawa, J., Izawa, S., Enoki, H., Suzuki, Y., & Kuzuya, M. (2014). Accumulation of geriatric conditions is associated with poor nutritional status in dependent older people living in the community and in nursing homes. Geriatrics & Gerontology International, 14(1), 198-205. doi:10.1111/ggi.12079

Iecovich, E. (2014). Aging in place: From theory to practice. Anthropological Notebooks, 20(1), 21-33.

IIHS & HLDI. (2015). Older drivers. Retrieved from http://www.iihs.org/iihs/topics/t/older-drivers/qanda.

Instituto Nacional de Estadística. (2014). Cifras de población [Table]. Retrieved from http://www.ine.es/inebaseDYN/cp30321/cp_inicio.htm.

Instituto Nacional de Estadística y Censos. (2013). Estimaciones y proyecciones de población 2010-2040: Total del país.  Retrieved from http://www.indec.mecon.ar/nuevaweb/cuadros/2/proyeccionesyestimaciones_nac_2010_2040.pd.

Jin, K., Simpkins, J. W., Xunming, J., Leis, M., & Stambler, I. (2015). The critical need to promote research of aging and aging-related diseases to improve health and longevity of the elderly population. Aging & Disease, 6(1), 1-5. doi:10.14336/AD.2014.1210

Kydd, A., Touhy, T., Newman, D., Fagerberg, I., & Engstrom, G. (2014). Attitudes towards caring for older people in Scotland, Sweden and the United States. Nursing Older People, 26(2), 33-40.

Kurjak, A., Rukavina, A. S., & Stanojevic, M. (2012). Aging society and declining fertility: How to respond?. Donald School Journal Of Ultrasound In Obstetrics & Gynecology, 6(3), 333-341. doi:10.5005/jp-journals-10009-1257.

Lakatta, E. G. (2002). Cardiovascular ageing in health sets the stage for cardiovascular disease. Heart, Lung & Circulation, 11(2), 76-91. doi:10.1046/j.1444-2892.2002.00126.x

McCallion, P., & Ferretti, L. A. (2010). Social work & aging: The challenges for evidence-based practice. Generations, 34(1), 66-71.

Meisner, B. A. (2012). Physicians’ attitudes toward aging, the aged, and the provision of geriatric care: A systematic narrative review. Critical Public Health, 22(1), 61-72. doi:10.1080/09581596.2010.539592

National Hospice and Palliative Care Organization. (n.d.). Hospice Care. Retrieved from http://www.nhpco.org/about/hospice-care.

National Institute of Mental Health. (2012). Major depression among adults.  Retrieved from http://www.nimh.nih.gov/health/statistics/prevalence/major-depression-among-adults.shtml.

Neikrug, S. (2003). Worrying about a frightening old age. Aging & Mental Health, 7(5), 326.

Nolan, L. C. (2011). Dimensions of aging and belonging for the older person and the effects of ageism. BYU Journal of Public Law, 25(2), 317-339.

Ortman, J. M., Velkoff, V. A., & Hogan, H. (2014). An aging nation: The older population in the United States. Retrieved from http://www.census.gov/prod/2014pubs/p25-1140.pdf.

Pew Research. (2013). Living to 120 and beyond: Americans’ views on aging, medical advances, and radical life extension. In H. W. Wilson (Ed.), Aging in America (pp. 146-152). Grey House Publishing, Inc.

Piano, A., & Titorenko, V. I. (2015). The intricate interplay between mechanisms underlying aging and cancer. Aging & Disease, 6(1), 56-75. doi:10.14336/AD.2014.0209

Rathnayake, S., & Siop, S. (2015). Quality of life and its determinants among older people living in the rural community in Sri Lanka. Indian Journal of Gerontology, 29(2), 131-153.

Reichel, W., Arenson, C., & Scherger, J. E. (2009). Essential principles in the care of the elderly. In Arenson, C., Busby-Whitehead, J., Brummel-Smith, K., O’Brien, J. G., Palmer, M. H., & Reichel, W. (Eds.), Reichel’s Care of the Elderly (pp. 1-13). New York, NY: Cambridge University Press.

Santoni, G., Angleman, S., Welmer, A., Mangialasche, F., Marengoni, A., & Fratiglioni, L. (2015). Age-related variation in health status after age 60. PLoS ONE, 10(3), 1-10. doi:10.1371/journal.pone.0120077

Seider, B. H., Shiota, M. N., Whalen, P., & Levenson, R. W. (2011). Greater sadness reactivity in late life. Social Cognitive & Affective Neuroscience, 6(2), 186-194. doi:10.1093/scan/nsq069

Shah, S. N., & Meeks, S. (2012). Late-life bereavement and complicated grief: A proposed comprehensive framework. Aging & Mental Health, 16(1), 39-56. doi:10.1080/13607863.2011.605054

Simons, K., Bonifas, R., & Gammonley, D. (2011). Commitment of licensed social workers to aging practice. Health & Social Work, 36(3), 183-195.

Sivis, R., McCrae, C. S., & Demir, A. (2005). Availability of mental health services for older adults: A cross-cultural comparison of the United States and Turkey. Aging & Mental Health, 9(3), 223-234. doi:10.1080/13607860500113896

Souare, G. E., & Lloyd, L. S., (2008). Encyclopedia of aging and public health. Loue, S., & Sajatovic, M. (Eds.). Springer.

Szymona-Paękowska, K., Kraczkowski, J. J., Janowski, K., Steuden, S., Adamczuk, J., Robak, J. M., & ... Bakalczuk, G. (2014). Selected determinants of quality of life in women with urinary incontinence. Menopausal Review / Przeglad Menopauzalny, 13(2), 84-88. doi:10.5114/pm.2014.42708

The World Bank. (2014). Fertility rate, total (births per woman) [table]. Retrieved from http://data.worldbank.org/indicator/SP.DYN.TFRT.IN?page=6.

Tomkowiak, J. M. (2008). Clinical Geropsychiatry. In Arenson, C., Busby-Whitehead, J., Brummel-Smith, K., O’Brien, J. G., Palmer, M. H., & Reichel, W. (Eds.), Reichel’s Care of the Elderly (pp. 1-13). Cambridge University Press.

U.S. Census Bureau. (2014). Annual estimates of the resident population for selected age groups by sex for the United States, states, counties, and Puerto Rico Commonwealth and municipios [Table]. Retrieved from http://factfinder.census.gov/faces/tableservices/jsf/pages/productview.xhtml?src=CF.

U.S. Census Bureau. (2014). Income and poverty in the United States: 2013 (Current Population Reports P60-249). U.S. Government Printing Office. Retrieved from http://www.census.gov/content/dam/Census/library/publications/2014/demo/p60-249.pdf.

U.S. Department of Health and Human Services. (2000). Oral health in America: A report of the Surgeon General (NIH Publication No. 00-4713). U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health. Retrieved from http://profiles.nlm.nih.gov/ps/retrieve/ResourceMetadata/NNBBJT/.

Wilson, H. W. (Ed.). (2014). Aging in America. Grey House Publishing, Inc.

Yılmaz, D., Kisa, S., & Zeyneloğlu, S. (2012). University students' views and practices of ageism. Ageing International, 37(2), 143-154. doi:10.1007/s12126-010-9097-5.