Handbook of Social Work Practice with Vulnerable and Resilient Populations [third edition] 9780231537018

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Handbook of Social Work Practice WitH Vulnerable and r e S i l i e n t P o P u l at i o n S

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Handbook of Social Work Practice WitH Vulnerable and r e S i l i e n t P o P u l at i o n S tHird edition

Edited by

alex Gitterman

columbia uniVerSity PreSS New York

Columbia University Press Publishers Since 1893 New York Chichester, West Sussex cup.columbia.edu Copyright © 2014 Columbia University Press All rights reserved Library of Congress Cataloging-in-Publication Data Handbook of social work practice with vulnerable and resilient populations / edited by Alex Gitterman. pages cm Includes bibliographical references and index. ISBN 978-0-231-16362-0 (cloth : alk. paper) — ISBN 978-0-231-53701-8 (ebook) 1. Social service—United States. 2. Social work with people with social disabilities—United States. I. Gitterman, Alex, 1938– HV91.H265 2014 361.3'2—dc23 2013037027

Columbia University Press books are printed on permanent and durable acid-free paper. This book is printed on paper with recycled content. Printed in the United States of America c 10 9 8 7 6 5 4 3 2 1 Cover design: Rebecca Lown References to websites (URLs) were accurate at the time of writing. Neither the author nor Columbia University Press is responsible for URLs that may have expired or changed since the manuscript was prepared.

In memory of my dear friends and colleagues Professors Sherman Barr, George Brager, Richard Cloward, Carel B. Germain, Mary Funnye´ Goldson, Charles Grosser, Melvin Herman, William Schwartz, and Hyman Weiner. All were dedicated educators with profound social vision. And In memory of Lisa S. Steinberg, the daughter of close friends and colleagues, an effervescent young woman, whose genuine warmth, kindness, and zest for life lives on in our hearts.

v❖ contentS

Preface Acknowledgments

ix xiii

cHaPter 1

Social Work Practice with Vulnerable and Resilient Populations

1

Alex GittermAn And lAmbrine A. SideriAdiS

Part i l if e con dition S cHaPter 2

Acquired Immune Deficiency Syndrome (AIDS)

33

GeorGe S. Getzel, Yvonne o. PAtterSon, And StePhen W. Willroth

cHaPter 3

Alcoholism and Other Drug Addictions

54

deborAh m. CourtneY And meredith hAnSon

cHaPter 4

Autism Spectrum

73

CriStinA moGro-WilSon And KAY dAvidSon

cHaPter 5

Borderline Personality

95

ninA rovinelli heller And Ann mArie GArrAn

cHaPter 6

Depression

117

mAnnY J. González And liSA G. ColAroSSi

cHaPter 7

Eating Problems

141

F. diAne bArth

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contentS

cH a Pt e r 8

Schizophrenia

cHaPter 1 8

160

ellen P. luKenS And JordAn e. devYlder

Immigrants and Refugees

cH a Pt e r 9

cHaPter 1 9

Serious Physical Illness and End-of-Life Care

Intimate Partner Abuse

179

392

Jonel thAller, Jill thereSA meSSinG, And bonnie e. CArlSon

mArY SormAnti And GrACe ChriSt

Pa rt i i l i f e c i rcu m Sta n c e S a nd e V e nt S

cHaPter 2 0

Older Persons in Need of Long-Term Care

cH a P t e r 1 0

Adolescent Pregnancy

366

diAnne drAChmAn

415

tobY bermAn-roSSi

205

And timothY b. KellY

KAthleen roundS And ChAritY C. Sneed

cHaPter 2 1 cH a Pt e r 1 1

Bullying

227

Returning Servicewomen and Veterans

441

KAthrYn bAShAm

FAYe miShnA And meliSSA vAn Wert

cHaPter 2 2 cH a Pt e r 1 2

Child Abuse and Neglect

248

Suicide and Suicidal Behavior

462

ninA rovinelli heller

lYnn videKA, GeethA GoPAlAn,

cHaPter 2 3

And beSA h. bAutA

Survivors and Victims of Terrorism cH a Pt e r 1 3

Children in Foster Care

484

S. meGAn berthold

269

And AdeYinKA m. AKinSulure-Smith

AStrAeA AuGSberGer And

cHaPter 2 4

brendA G. m c GoWAn

Survivors of Torture cH a Pt e r 1 4

Crime Victims

289 cHaPter 2 5

JACqueline CorCorAn

Young Men of Color cH a Pt e r 1 5

Death in the Family

509

S. meGAn berthold

535

bruCe J. ArmStronG, AlWYn t. CohAll,

301

And renee mAYer CohAll

nAnCY boYd Webb And lindA oPenShAW

cHaPter 2 6 cH a Pt e r 1 6

Gay and Lesbian Persons

318

cH a Pt e r 1 7 JenniFer m c Clendon And ShAnnon r. lAne

561

edith A. leWiS, izumi SAKAmoto, And lorrAine Gutiérrez

CArol t. tullY And ellen Smith

Homeless People

Women of Color

345

List of Contributors

581

Index

585

v❖ Preface

The Handbook of Social Work Practice with Vulnerable Populations was first published in 1991. The first edition focused on the debilitating life circumstances, events, and conditions faced by large sectors of the client population served by social workers. The associated life stressors are either chronic or persistent, or they are acute and unexpected. An individual’s impaired internal resources and/or external supports exacerbate these stressors. When these factors are present, social workers help people at risk of physical, cognitive, emotional, and social deterioration. Historically, the profession of social work has been assigned the task of providing social services to populations with problems that impede their ability to become fully functioning and respected members of society, including homelessness, family and community violence, or mental illness. The societal response to the needs of these populations has become increasingly punitive and rejecting. While providing general knowledge and skills, most social work practice texts did not sufficiently examine the specialized knowledge base and the different assessment and intervention skills required to effectively help people with diverse life conditions, circumstances, and events. To this end, the Handbook met a significant need. The book was adopted by advanced clinical and generalist programs. Moreover, the text received very positive reviews. A common chapter outline integrated the chapters. After the book’s publication, I had a significant concern. The Handbook had not described how people survive and cope with such debilitating problems as hunger, homelessness, AIDS, family and community violence, and traumatic losses or vulnerabilities such as the consequences of mental illness, developmental difficulties, imprisonment, or job loss. By limiting ix

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Preface

ourselves to a pathology explanatory model, we emphasized vulnerability and risk factors, the deficits and negative aspects of individual, family, and community life. Consequently, other dimensions of the human experience such as resourcefulness, courage, coping, and recovery received insufficient attention. In the second edition, published in 2001, the focus was expanded to include resiliency and protective factors, the positive poles of the human experience, in order to examine such questions as: Why do some people break down under certain life conditions and circumstances while others remain relatively unscathed? What accounts for the marked individual variations in people’s responses to stress and adversity? What accounts for the surprisingly large number of people who somehow, at times miraculously, manage their adversities? How do people adapt, cope, overcome, and meet the challenges of physical and mental conditions, severe losses and traumas, chronic discrimination, and oppression? Why do some people thrive and not simply survive in the face of life’s inhumanities and tragedies? Since many of our theoretical approaches focus on individual pathology, people’s strengths and capacities are unrecognized. This unbalanced perspective may further marginalize and oppress our clients. Developing knowledge and curiosity about the positive as well as the negative poles of people’s lives, social workers are more likely to formulate balanced assessments and responsive interventions. People’s life stories, for example, represent their search to find meaning and coherence in their own lives. By inviting and attentively listening to people’s life stories rather than fitting their behaviors into diagnostic schema and labels, we are more likely to discover how people have managed to survive in stressful or traumatic circumstances. And their strengths provide the foundation and motivation for further mastery. Children dealing with parental alcoholism or divorce, for example, find ways to disengage and to develop psychological distance from daily

conflicts and hassles. The social worker must assess the potential functional and dysfunctional dimensions of the emotional distancing. Adaptive distancing requires the ability to disengage internally while pursuing and sustaining external connections. The combination of internal distancing and external reaching out represent significant protective factors and processes. In contrast, a flight into social as well as emotional isolation symbolizes risk factors and processes. For another example, in helping a disheveled, odorous, homeless woman, the social worker must understand the coping function that smelling and unattractiveness have in coping with sexual vulnerability and potential violence as well as the dysfunctional aspects of alienating potential support networks. To reflect this reconceptualization, the book’s title was changed to The Handbook of Social Work Practice with Vulnerable and Resilient Populations. In the last eleven years, new demographic patterns, research findings, and theoretical developments have evolved. The third edition takes these changes into account, as well as new economic and political realities, legislative developments (immigration laws and policies, health care reform), social policies, and changes in the role of government, and explores their implications for the various populations and respective social services. New chapters have been added on cutting-edge scholarship in emerging life conditions, circumstances, and events. These include autism spectrum, bullying, men of color, returning servicewomen and veterans, survivors and victims of terrorism, and survivors of torture. The third edition is organized similarly to the prior editions. What does the social worker need to know and be able to do to provide resourceful programmatic and clinical services to the identified populations? The Handbook explores these questions, according to two distinctive sets of issues. Part I, “Life Conditions,” examines social work practice with vulnerable and resilient populations who essentially have to cope with chronic life conditions, which have a dynamic genetic, biochemical,

Preface

and physiological bases. Chapters on AIDS, alcoholism and other drug addictions, autism, borderline personality, depression, eating problems, schizophrenia, and serious physical illness all explore the theoretical, empirical, demographic, programmatic, and clinical issues with which social workers need to be familiar to provide relevant and empowering services. Part II, “Life Circumstances and Events,” examines social work practice with populations that often confront desperate life circumstances such as homelessness and very stressful life events such as the death of a family member. Why do some people collapse under relatively minor life strains while others remain relatively unscathed by traumatic experiences such as extreme poverty, racism, homophobia, family violence, sexual and other forms of abuse, or loss of a loved one? Why do some people emotionally survive catastrophe while others become bitter, jaded, and less of a person than they were previously? How do some people forge ahead when life seems unbearable— when trust and hope might have been taken away? Yet others are so emotionally vulnerable that seemingly minor losses and rebuffs can be devastating. Chapters on adolescent pregnancy, bullying, child abuse and neglect, children in foster care, crime victims, death of a family member, gay and lesbian persons, homeless people, immigrants, intimate partner abuse, older persons in need of long-term care, returning servicewomen and veterans, suicide and suicidal behavior, survivors and victims of terrorism, survivors of torture, young men of color, and women of color similarly explore the theoretical, empirical, demographic, programmatic, and clinical issues. Chapters in both Parts I and II are alphabetically arranged, which makes it easy to use and does not privilege one content area over another. A common chapter outline integrates the chapters, as each contributor begins with a

theoretical, empirical, and political examination of the subject. This discussion is followed by a demographic exploration of the specific population and its subpopulations. For example, in a discussion of homeless people, the problems and needs of those who are mentally ill are differentiated from those who became homeless because of job loss and eviction. Each chapter examines the respective population’s and subpopulation’s vulnerabilities and risk factors as well as resilience and protective factors. Each chapter also describes programs and social work contributions and discusses how the social worker assesses clients’ (individual, family, group, community) life stresses, their internal resources and limitations, apparent obstacles and available environmental supports, and how the social worker intervenes depending upon her or his understanding of the condition, circumstance, and event. Distinctive practice principles and skills are highlighted. Finally, each chapter concludes with the presentation of an illustration. While, historically, the profession of social work has assumed the task of providing social services to disadvantaged and vulnerable populations, this task has become significantly more difficult to fulfill. The stubborn truth is that problems have been increasing, while resources to mitigate them decrease. Those with less get less! The societal response to the needs of these populations has become increasingly punitive and rejecting. Given these bitter realities, resilience and heroism are required not only from the client population but from the social work community as well. And this has actually been the case among many social workers in their efforts to provide meaningful services. Through descriptions of responsive social programs and social work’s contributions to them, as well as presentation and discussion of practice illustrations, this book attempts to capture the profession’s resilience and creativity.

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I wish to express my deep appreciation to the contributors for their willingness to prepare a chapter for the Handbook. They accepted and carried out a difficult and comprehensive assignment. I appreciate their conscientiousness in following a demanding outline, their openness to editorial suggestions, their willingness to rewrite drafts, and their good spirit about my constant e-mailing and calling to “inquire” about their progress. I hope you will be as pleased as I am with their significant accomplishments and contributions to the profession’s literature. I also would like to thank Jennifer Perillo, senior executive editor, and Stephen Wesley, editorial assistant, at Columbia University Press for their interest in and commitment to this project. I thank my faculty, administrative, and staff colleagues at the University of Connecticut School of Social Work for their stimulation and support. Finally, I am most grateful to my wife, Naomi, daughter, Sharon, son, Daniel, daughter-in-law, Amy, and grandchildren, Max and Claire, for their ongoing support and love. A.G.

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cHaPter 1 Social Work Practice with Vulnerable and resilient Populations alex Gitterman and lambrine a. SideriadiS

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hrough our teaching and practice experiences, we have become distressed by the increasing degradation and distress faced by large sectors of the client population served by social workers. Students and professionals confront daily the crushing impact of such problems as mental illness, substance abuse, disability and death, teenage pregnancy, and child neglect and physical and sexual abuse. Clients suffer from the debilitating effects of such life circumstances as homelessness, violence, family disintegration, and unemployment. The miseries and human suffering encountered by social workers in the new millennium are different in degree and kind from those encountered in the 1960s, 1970s, 1980s, and 1990s. The dismantling of the welfare state, the consequences of welfare “reform,” and foreclosures are examples of newly devastating social phenomena. Social workers in practice today deal with profoundly vulnerable populations, overwhelmed by oppressive lives, and circumstances and events they are powerless to control. The problems are often intractable because they are chronic and persistent, or acute and unexpected. When community and family supports are weak or unavailable and when internal resources are impaired, these populations are very vulnerable to physical, cognitive, emotional, and social deterioration. Yet, in spite of numerous risk factors and vulnerabilities, a surprisingly large number of children, for example, mature into normal, happy adults. Why do

some people remain relatively unscathed and somehow, at times, miraculously manage their adversities? Why do some thrive and not simply survive in the face of life’s inhumanities and tragedies? To more fully understand the human experience, this book examines vulnerability and risk factors as well as resilience and protective factors. defining and explaining life conditions, circumstances, and events After a brief introduction about the respective population, contributors analyze the definitions of the life condition, circumstance, or event. What are the different political and theoretical definitions and explanations of the condition, circumstance, or event? What are the effects of the definitions and explanations on the larger community, service providers, and service users? With certain “personality conditions” such as chronic depression, schizophrenia, and borderline personality, and with certain addictions such as alcoholism, growing evidence suggests potent predisposing genetic, biochemical factors. Researchers’ studies have, for example, analyzed the life careers of identical twins separated at birth and have used other tracking designs to find significant genetic linkages to alcoholism (Cloninger, 1983, 1987; Doweiko, 2006; Palmer et al., 2012), bi-polar disorder (Gallitano, Tillman, Dinu, & Geller, 2012), depression (Pirooznia, Seifuddin, Judy, Mahon, Potash, & Zandi 2012), and schizophrenia (Gejman, Sanders, & Duan, 2010). 1

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These conditions have in common certain genetic and neurochemical predispositions. With alcoholism, for example, serotonin and dopamine, major neurotransmitters used by the central nervous system, have been associated with depression. Research suggests that chronic alcohol use decreases the number of dopamine receptors in the brain and reduces serotonin turnover. Decreased levels of dopamine and serotonin have been linked to depression and increased risk of violent behaviors, such as suicide, among chronic alcohol users (Doweiko, 2006). The brain also manufactures natural substances that have painkilling properties. Kosten and George (2002) suggest that narcotic analgesics mimic the action of these natural substances resulting in a sensation of drug induced euphoria when the user is not experiencing pain. Thus, neurochemical imbalances appear to be associated with various life conditions. With AIDS, our vulnerability to parasitic relations with microorganisms from within and without is ominous. AIDS continues to be one of the leading causes of death among all Americans aged 25 to 44. The biological reality of AIDS demonstrates how defenseless our immune systems can be to parasitic and toxic environments. With other life conditions such as anorexia and bulimia, the genetic linkages have not yet been discovered. Thus far, personality and family dynamic explanations are most frequently offered to explain these conditions. We should not, however, be surprised if in the near future genetic and biochemical predisposing conditions are discovered. With obesity, however, there is clear evidence of genetic influence (Garaulet, Ordovas, & Madrid, 2010; Spruijt-Metz, 2011). Chronic physical illnesses and disabilities and learning and developmental disabilities reflect problematic physiological and neurological functions. Developmental disability often has genetic determinants (Butler & Meany, 2005). Similarly, possible genetic bases for the condition of Alzheimer’s disease (Kuller & Lopez, 2011) and cancer have also been identified (Hall,

2012). Even though many of the presented life conditions have genetic determinants, they may not be inherited. Certain toxic environmental agents can damage and disrupt normal genetic processes. A mother abusing alcohol, for example, may give birth to an infant with fetal alcohol syndrome, which is often characterized by developmental disability, facial deformity, etc. Radiation can cause infertility and birth defects (Cwikel, Gidron, & Quastel, 2010; Sabin et al., 2012). Whatever the cause, physiological and cognitive impairments severely curtail human activities. People with these life conditions often suffer for protracted and indefinite time periods. Their neurological and physiological disabilities create limitations and burdens of varying severity. Genetics, biochemistry, neurological loading, and predisposition to a condition do not imply, however, that a person will necessarily acquire the condition or, if the person does acquire it, be debilitated by the condition. The resources and the limitations in the person’s environment, i.e., family, relatives, friends, workmates, neighbors, community, organizations, and spiritual life, all transact with individual constitutional resources and limits. On one end of the continuum, high genetic and organic loading may push certain people toward alcoholism, depression, borderline personality, or schizophrenia regardless of how protective and supportive the environment (although a supportive environment can certainly cushion its consequences). Similarly, a youngster born developmentally disabled or severely physically disabled has to function within the constraints of these neurophysiological impairments. Although supportive environments can provide essential instrumental and expressive resources, they cannot eliminate the disability itself. On the other end of the continuum, severely impoverished and invalidating environments may push certain people toward alcoholism or depression no matter how well they are constitutionally endowed. A youngster repeatedly exposed to malnourishment and physical and emotional

S o c i a l W o r k P r a c t i c e W i t H V u l n e r a b l e a n d r e S i l i e n t P o P u l at i o n S

abuse may succumb to these harsh environmental assaults with alcoholism or depression despite limited, or even no, genetic predisposition. Studies of psychiatric epidemiology have demonstrated that the lower the social class, the higher the rates of mental illness and the greater the severity of the mental illness (Mauksch, Reitz, Tucker, Hurd, Russo, & Katon, 2007; Sheperis & Sheperis, 2012). Family, community, and society dysfunctions provide the most frequent theoretical explanations for the distressing life circumstances and events presented in this book. Unplanned pregnancies, for example, are associated with poverty, repeated academic failures, and pervasive lack of opportunities with consequent hopelessness and despair. Community and family norms reinforce or mitigate the personal impact of poverty. In intimate partner violence, the female as victim of her male partner is the principal problem. A pattern of control over the female maintained by physical, emotional, and sexual abuse is associated with violence and battering. On a more general level, sexism and sex-role socialization surely contribute to, if not induce, intimate partner violence. Boys observing their fathers abuse their mothers are more likely than otherwise to be violent toward their own wives (McClennan, 2010). Clearly, intimate partner violence is learned behavior that has to be unlearned. No citizen, regardless of class or social status, is safe from crime. Women, children, and the elderly, especially those living in poor communities, are at highest risk of victimization by crime. They simply are easier prey! Perpetrators tend to be caught in a cycle of family poverty, illiteracy, drugs, racism, child abuse, and family violence. When they are incarcerated, they usually return to their community further damaged, hardened, and embittered. They often become socialized to a lifetime of crime and intermittent incarceration. In poor communities, both the victim and the perpetrator are trapped in the mire of despair. Similarly, the elimination of low-income housing, underemployment and unemployment, sharply

curtailed and disappearing benefit programs, lack of health insurance, foreclosures, and deinstitutionalization have all conspired to create homelessness and an unconscionably large number of adults and children deprived of the basic human need for shelter. The life event of being born black in the United States creates a trajectory with profound impact on education, employment, housing, health, and family life. For example, black Americans suffer higher death rates from most major causes. They receive less and poorer health care and die four to five years earlier than white Americans (National Vital Statistics, 2010). Moreover, major changes have taken place in the composition of black American families over the last several decades. In the 1950s, 78 percent of black families were composed of couples, compared with only 35 percent in 2010. During the same period, the presence of couples in white families witnessed a smaller decline, from 88 percent to 75 percent (U.S. Census Bureau, 2012). When people find themselves in distressing life circumstances and dealing with stressful or traumatic life events, some become helpless, hopeless victims. They live on the margin struggling for day-to-day survival. Others somehow miraculously and astonishingly manage deeply adverse situations as survivors, not as victims. Various theories attempt to explain what differentiates a victim from a survivor. Unfortunately, most of our theories have focused on the deficits and negative aspects of individual and family life. Since many of our theoretical approaches are based on people who do not rebound well from life’s miseries, we know much less about those who do and how they do it. Rutter (1971) eloquently captures this pattern: There is a most regrettable tendency to focus gloomily on the ills of mankind and on all that can and does go wrong. It is quite exceptional for anyone to study the development of those important individuals who overcome adversity, who survive stress and rise above disadvantage. (p. 7)

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By developing knowledge about the positive as well as the negative poles of people’s lives, social workers are more likely to formulate balanced assessments and responsive interventions. For example, children dealing with parental alcoholism or divorce must find ways to disengage and to develop psychological distance from daily conflicts and hassles. Adaptive distancing requires the ability to disengage internally while pursuing and sustaining external connections (Berlin & Davis, 1989). Many theoretical explanations pathologize the black family. By evaluating and judging from the outside, however, we miss the resourceful survival adaptations, such as: “They 1) may be comprised of several households; 2) have a multiple parenting and inter familial consensual adoptions; 3) are child-centered; 4) have a close network of relationships between families not necessarily related by blood; and 5) have flexible and interchangeable role definitions and performance” (Fine & Schwebel, 1991, p. 34). These features provide the kinds of conditions that nurture the development of “protective” factors that also promote resilience. That many poor families of color survive extreme poverty, racism, and oppression is a tribute to their resilience in overcoming overwhelming odds. While various theories attempt to explain what differentiates a victim from a survivor, no single theory is apparently capable of providing a comprehensive explanation. We do know, however, that people’s social functioning and adaptations reflect the interplay and degree of congruence and compatibility between body, mind, and environment. Sometimes people’s exchanges with their environments are mutually fulfilling. The congruence and compatibility between people and their environments provide the context for realization of potential. Other times, these exchanges can lead to isolation and alienation. A poor fit limits realization of potential. How people perceive their constitutional and environmental resources and limitations, their personal attributions and social constructions, also has a profound impact.

Thus, two people with similar constitutional and environmental attributes may perceive subjectively their personal and environmental resources quite differently and consequently function at differing levels. And, finally, there is the simple element of chance—good fortune and misfortune. Although our efforts to be scientific may cause us to shy away from the idea of chance, it may well enhance our understanding and feeling for the human experience. demographic Patterns Each contributing author in this text presents available demographic data about the particular life condition, circumstance or event. Webster’s dictionary defines vulnerability as “capable of being wounded; open to attack or damage.” Research into physical or emotional “wounding” consistently identifies two associated risk factors for physical and emotional deterioration: prolonged stress and cumulative stress. And among many factors, chronic poverty is the major force responsible for both prolonged and cumulative stress. According to the United States Census Bureau October (2011), the poverty rate in the United States increased from 12.2 percent in 2000 to 15.3 percent in 2010, representing the highest level since 1993. Accordingly, 46.2 million people lived in poverty in 2010 (income below their respective poverty thresholds). Although the child poverty rate has fluctuated over the past ten years, the percentage of poor children under the age of 18 years has risen from 16.9 percent in 2001 to 21.6 percent in 2010. Currently, one out of five of the nation’s children is living in poverty with 1.1 million children added to the poverty population since 2009. Poverty creates chronic disadvantages and problems for children. Poor children have higher rates of infant mortality, have higher rates of physical and mental health problems, complete fewer years of education, and are more likely to be underemployed or unemployed as adults (Wagmiller, Lennon, Kuang, Alberti, & Aber, 2006).

S o c i a l W o r k P r a c t i c e W i t H V u l n e r a b l e a n d r e S i l i e n t P o P u l at i o n S

A strong correlation between poverty and family structure is evident. Since 2000 we have witnessed dramatic changes in family structure and living arrangements that impact access to economic resources and social support systems. In 2010 for the first time since data began to be collected and analyzed in 1940, two-parent families represented less than half of all households (48 percent), down from 52 percent in 2000 and 55 percent in 1990. Conversely, the number of female and male householders with no spouses both increased since 2000. Singlemother households rose by 11 percent in 2010, with 8.3 million families maintained by a single female, while single father households increased by 27 percent, representing 2.8 million households. In the last decade the number of nonfamily households, defined as “a householder living alone or with nonrelatives only” increased twice as fast (16 percent) as family households (8 percent). In 2010, 17.2 million women lived alone, compared to 14.6 million in 1996, while 13.9 million men lived alone, compared to 10.3 million in 1996. The number of children living in single-parent homes has also steadily risen. Twenty-six percent of children lived with only one parent in 2010, as compared with only 12 percent in 1970. Of the approximately 75 million children under the age of 18 years in the United States, 69 percent lived with both parents in 2010, compared with 85 percent in 1970. Black and Hispanic children are less likely to be raised in a two-parent household than white children. In 2010, 75 percent of white children lived with two married parents, while only 35 percent of black children and 61 percent of Hispanic children resided with their married parents (Federal Interagency Forum on Child and Family Statistics, 2011). Children living in single-mother families are more likely to live in poverty than children in two-parent families. In 2009 the poverty rate for related children living in female head of household families was four times greater (44 percent) than the poverty rate for children

Median Family Incomes Among Families with Children Under Age 18, by Family Type

ta b l e 1 . 1

Family Type

Married couple Female household Male household

1980

1990

2000

2010

$24,306 8,464 —

41,260 13,092 25,211

63,126 21,915 32,483

77,749 24,487 36,290

Source: United States Census Bureau 2011

living in married couple households (11 percent). In 2010 the median income of married couple households is more than triple that of female households and more than double of male households. Table 1.1 presents the actual median family income among families with children under age 18 by family type (U.S. Census Bureau, September, 2011). The dramatic increase in single-family, female households forebodes a worsening economic trend for our nation’s children. Black children have a significantly lesser chance of being raised in a two-parent household than do white children. In 2010 only 35 percent of black children lived with two parents as compared with 75 percent of white children. As table 1.2 indicates single mothers raise almost half of black children under age 18 (U.S. Census Bureau, 2012). The U.S. Census Bureau reported in 2010 that Hispanic persons of any race comprised 16 percent of the total population of 308.7 million Family Structure and Living Arrangements: Percentage of Children Under Age 18, by Race and Hispanic Origin, Selected Years 1990–2010*

ta b l e 1 . 2

Family Type

1990

1995

2000

2005

2010

Two parents White Black Hispanic

81 38 67

78 33 63

77 38 65

76 35 65

75 35 61

Mother Only White Black Hispanic

15 51 27

16 52 28

16 49 25

16 50 25

16 49 26

*Table adapted and presented in summary form. Persons of Hispanic origin may be of any race.

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Resident 2010 Population of the United States: By Race and Hispanic Origin (Numbers in Millions)

ta b l e 1 . 3

Race

Population

Percentage

223.6 231.0

72.0 75.0

38.9 42.0

13.0 14.0

50.5 17.3 5.2

16.0 5.6 1.7

1.2

0.4

White alone White alone or in combination with one or more races Black alone Black alone or in combination with one or more races Hispanic Asian American Indian or Alaskan Native alone or in combination with one or more races Native Hawaiian or Other Pacific Islander alone or in combination with one or more races Source: United States Census Bureau 2011

people (table 1.3). While comprising only 16 percent of the country’s population, Hispanic persons of any race represent 25.3 percent of the nation’s poor. In 1995 the median household income of Hispanic residents fell 5.1 percent while it rose for all other ethnic and racial groups. Goldberg (1997) noted, “For the first time, the poverty rate among Hispanic residents of the U.S. has surpassed that of blacks.” Language and education appear to account for the growing ethnic and racial disparity. In 2008, Hispanics were nearly four times more likely to drop out of high school (18.3 percent) than whites (4.8 percent), while the dropout rate for black persons was more than twice that of white persons (9.9 percent). High school completion rates also vary between race and ethnic groups. In 2008, 94.2 percent of white persons completed high school as compared to 75.5 percent of Hispanic persons and 86.9 percent of black persons (National Center for Education Statistics, 2010). Hispanic persons continue to be the fastest growing ethnic group in the United States. The Hispanic population grew by 43 percent between 2000 and 2010,

representing four times the growth rate of the total population (U.S. Census Bureau, May, 2011). By the year 2050, the Hispanic population is expected to increase to 30.2 percent of the total projected population. These data suggest that in the decades to come the Hispanic population will account for an increasing proportion of the poor in this country because they are insufficiently prepared to compete in a highly technical society. Societal context After a discussion of the definitions and demographics of the distressing life condition, circumstance, or event, the authors examine how social structures and institutions cushion or “cause” the problems in question. When social structures and institutions provide essential resources and supports, they are critical buffers, helping people cope with life transitions, environments, and interpersonal stressors (Gitterman & Germain, 2008). By providing emotional, instrumental, informational, and appraisal supports, society structures influence the worldviews and self-concepts of people and fortify them against physiological, psychological, and social harm (Cohen, Underwood, & Gottlieb, 2000; Gottlieb, 1988a, 1988b). In contrast, when these resources and supports are unavailable or insufficient, people are apt to feel helpless and lack self-confidence and skill in interpersonal and environmental coping. In the United States, the rich continue to become richer; the poor become poorer. In essence, the gap between the poor and the wealthy, the unskilled and the skilled has been widening for decades.1 In terms of annual income, the disparity between the top 1 percent of Americans and the rest of the population is vast. In 2012, the average annual income of the top 1 percent of the population is $717,000 compared to the average annual income of $51,000 for 99 percent of Americans. In terms of accumulated wealth and other assets, inequality is even more pronounced. The net value of the top 1 percent is about $8.4 million, or 70 times the

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worth of the lower classes (Dunn, 2012). Warren Buffett put the matter correctly when he said, “There’s been class warfare going on for the last 20 years and my class has won” (Stiglitz, 2012). For example, the six heirs to the Walton Empire are worth $90 billion, which is equivalent to the entire wealth of the bottom 30 percent of Americans. The United States is facing its worst economic crisis in 70 years, resulting in hardships for all Americans and particularly for black and Hispanic workers. In 2009, the Economic Policy Institute estimated that 8 million jobs (5.9 percent of all jobs) had been lost and 16 million people were unemployed. However, the crisis in the U.S. economy has not affected all groups equally. In 2010, the nationwide black unemployment rate stood at 15.9 percent, twice that of white Americans, and in several of the country’s large metropolitan areas, the black unemployment rate was significantly higher (Austin, 2011). Moreover, a large and growing number of young black males are hopelessly locked into a life of unemployment. The dramatic economic changes intensified by our country’s long history of racism and discrimination have left the black family extremely vulnerable. In addition, the Great Recession has resulted in severe job losses in construction, manufacturing, and retail that disproportionately affect young black men and women. In 2010, 32.5 percent of young black males aged 16 to 24 were unemployed, more than twice the rate for the white males of that age group (15.2 percent). Similarly, the unemployment rate of young Hispanic males was 24.2 percent (Edwards & Hertel-Fernandez, 2010). Whereas the previously slave-exploited agricultural economy required relatively unskilled labor, our increasingly automated and service economy requires skilled labor. Wilhelm and Powell (1964) suggest that our economy no longer needs the unskilled black male: He is not so much unwanted as unnecessary; not so much abused as ignored.

The dominant whites no longer need to exploit him. If he disappears tomorrow he would hardly be missed. As automation proceeds it is easier and easier to disregard him . . . thus, he moves to the automated urbanity of “nobidiness.” (p. 4)

Lack of employment opportunities institutionalizes poverty and its varied consequences. Not only have workers lost jobs, but their real wages have also declined and the income disparity among races and ethnicities continues. The United States Bureau of Labor Statistics (2010) reports that the median weekly earnings for white men and women exceed earnings of blacks and Hispanics in every age range. As indicated in table 1.4, weekly earnings for black men working full time were $668 or 75 percent of the median earnings for white men ($891). Similarly, black women earned 87.9 percent ($616) of the earnings of white women ($701). However, Hispanic men and women both earned less than blacks and whites, $600 and $525, respectively, and older Hispanic men (ages 55 and over) make only 58 percent ($624) of the weekly earnings of white men ($1,020). Median Usual Weekly Earnings of Full-Time Workers by Age, Race, Ethnicity, and Sex (Second Quarter 2012 Averages, Not Seasonally Adjusted)

ta b l e 1 . 4

Age, race, and ethnicity

Median weekly earnings Men Women

White 16 years and over 16 to 24 years 25 to 54 years 55 years and over

$891 471 925 1,020

$701 421 731 758

Black or African American 16 years and over 16 to 24 years 25 to 54 years 55 years and over

668 392 693 792

616 369 652 727

Hispanic or Latino ethnicity 16 years and over 16 to 24 years 25 to 54 years 55 years and over

600 422 633 624

525 381 564 602

Source: U.S. Bureau of Labor Statistics 2012

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Broad changes in the economy have further victimized the poor. Globalization and the economic recession have negatively impacted the demand for low-skilled workers. Over the last two decades blue-collar and lower-income workers’ wages have eroded as manufacturing plants close and jobs are outsourced to other countries. The loss of blue-collar and lowerincome jobs has created severe economic hardships. In 2009 white-collar unemployment was 6.8 percent, while the rate of bluecollar unemployment was 50 percent higher than the national average (Economic Policy Institute, 2009). At the same time, service industries have grown rapidly and created millions of new jobs, requiring new and advanced technical skills not possessed by many in the manufacturing industry. Blue-collar and lower-income workers are less marketable and have difficulty competing in an informationand technologically driven economy (Sum & Khatiwada, 2010). Education plays a key role in increasing the likelihood of employment and higher wages. At nearly every level of education, blacks and Hispanics are less likely to be employed than whites. Median weekly earnings also vary across race and ethnicity. In 2010, the median weekly earnings of white, black, and Hispanic men, 25 years or older, without a high school diploma, were generally equally distributed, with wages for whites ($488) slightly higher than those of blacks ($466) and Hispanics ($443). In contrast, black men, 25 years or older, with a bachelor’s degree or higher made 75 percent ($1,010) of the weekly wages of white men ($1,354) with equal educational levels, while Hispanic men made 79 percent of the earnings of white men ($1,065). Black and Hispanic women with a college degree or higher fared significantly worse. Black women earned 66 percent of weekly earnings ($889) compared to white males with equivalent education, and Hispanic women earned (63 percent) of the earnings of their white male counterparts (U.S. Bureau of Labor Statistics, 2010).

The environment of poor people is particularly harsh. Because of their economic position, they are unable to command needed goods and services. Good education, preventive health care, jobs, housing, safe communities, neighborhood amenities, and geographic and social mobility are unavailable or extremely limited for the poor. They are not able to compete for societal resources and their leverage on social institutions is extremely limited. A devastating cycle of physical, psychological, and social consequences follows. And with the government reducing its role in providing a safety net, the plight of poor, particularly poor children, can only worsen. In 1996, President Clinton signed into law the welfare “reform” act—the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA). This federal law imposed work requirements and a sixty-month lifetime time limit, promising to “end welfare as we know it.” The new law’s manifest purpose was to end public assistance recipients’ dependence on the government and create economic independence and self-reliance by limiting benefits to a maximum of five years and by providing job training and employment opportunities.2 Some believe that the new legislation’s latent and real purpose was to punish poor women for having children “they shouldn’t have had”—through stigma, economic deprivation, work requirements, and lack of provision of child care. The campaign to gain the public’s approval and to pressure the president to sign PRWORA into law conveniently ignored the fact that in 1995 approximately two-thirds of the recipients receiving Aid to Families with Dependent Children (AFDC) were children and only one-third were adults (U.S. House of Representatives, 1996). In 1996 TANF (Temporary Assistance for Needy Families) replaced AFDC, ushering in a dramatic 50 percent drop in the number of participating families from 3.9 million families in 1997 to 1.95 million families in 2011. Congress enacted changes to TANF in the

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Deficit Reduction Act of 2005 (DRA) that further increased the work requirements of recipients. The three states with the largest number of TANF recipients live in California, (30 percent), in New York, 8 percent, and in Ohio, 5 percent (Loprest, 2012). On the surface, TANF appears to have achieved its goal of reducing long-term welfare dependency, lowering by 50 percent the number of individuals and families receiving welfare. Since its inception, nearly two-thirds of recipients have obtained employment after exiting welfare (Gyamfi, Brooks-Gunn, & Jackson, 2005). Yet these data are misleading. More than 50 percent of those who exit welfare continue to remain poor (Danzinger, 2001). Onehalf to one-third of TANF leavers experience a decrease in income and quality of life. The majority of women (78 percent) who secure employment enter into four low-wage occupations: (1) service, (2) clerical administrative support, (3) sales, and (4) as laborers, operators, and fabricators that offer fewer opportunities to advance (Peterson, Song, & Jones-DeWeever, 2002). Working mothers encounter a lower income as they move into “dead-end” occupations and struggle to make ends meet to support themselves and their children (Danzinger, Heflin, & Corcoran, 2002; Dunlap, Golub, & Johnson, 2003). Many recipients lose other benefits such as Medicaid, food stamps, and child care subsidies that further erode their well-being. Morgan, Acker, and Weight (2010) surveyed 900 mostly single, white women who were ineligible or exited from welfare rolls in 1998 and found that over half (55 percent) took jobs at or below the poverty level and half of these women continued to earn wages below the poverty level two years later. Although TANF represents the only federal means-tested cash safety net for poor families with children, it is estimated that 20 percent to 25 percent of eligible single mothers remain disconnected; that is, they receive no public assistance and have little or no connection to the labor market (Loprest, 2011). In fact,

the number of eligible families who apply for assistance has steadily decreased, with only 36 percent of families participating in 2007 compared to 79 percent family participation in 1996. Confusion about eligibility and difficulty with enrollment are two contributing factors that impact participation in TANF. In the years since TANF was enacted, the demographic characteristics of adult recipients have remained relatively the same. A comparison of characteristics of adult recipients between 1997 and 2009 suggests that the majority of recipients are single (70 percent), female (86 percent), between the ages of 20 and 39 years of age (76 percent), unemployed (47 percent), with 12 or more years of education (58 percent). Fifty-one percent of recipients had one child and 47 percent had two or more children receiving TANF assistance. The percentage of white adults remained the same (35 percent) and slightly outnumbered other racial and ethnic groups, while the percentage of blacks dropped from 37 percent to 34 percent from 1997 to 2009, and the number of Hispanics grew from 20 percent to 24 percent. Yet in over 50 percent of the TANF cases, adults living in households with children are not receiving assistance because they are ineligible or they are not the child’s parent (Loprest, 2012). Although the majority of adult public assistance recipients are white, the United States Department of Health and Human Services (2012) suggests in 2009 blacks families accounted for 33.3 percent of TANF recipients, compared to 31.2 percent for white families, and the rate of Hispanic families enrolled in TANF increased from 25 percent in 2000 to 28.8 percent in 2009. Indeed, 33.5 percent of recipient children were of Hispanic origin, compared with 31.1 percent for black children and 26.1 percent for white children. Finding suitable child care is a problem for most families and significantly more so for larger single-parent poor minority families. Poor children are less likely to enter kindergarten with prior early childhood program

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experience than children living in families above the poverty line. In 2007, 41 percent of children whose family income was below the poverty line were enrolled in an early childhood program, as compared with 65 percent of children living in families whose income was above the poverty line. Hispanic children were the least likely (39 percent) to attend an early childhood program, compared with 65 percent of black children and 58 percent of white children (Federal Interagency Forum on Child and Family Statistics, 2011). For Hispanic mothers, the cultural expectation is that the woman’s primary role is to stay home and raise her children. Day care centers are often deeply distrusted. In a New York State survey, 75 percent of Hispanic mothers feared that their children would be mistreated in day care compared with 45 percent of non-Hispanic mothers (Swarns, 1998). Poor and low-income neighborhoods are another barrier that hinders employment due to lack of access to public transportation and mobility (Smiley, 2001). Minority families are more likely than white families to live in innercity, high-crime, and job-scarce communities. While 71 percent percent of black families and 63 percent of Hispanic families receiving public assistance lived in large urban inner cities, only 31 percent of white welfare families did so. As DeParle (1998) poignantly states, “Race is intertwined with place” (p. A12). Race is also intertwined with job discrimination. Vulnerabilities and risk factors Anthony (1987) analogizes vulnerability and risk to three dolls made of glass, plastic, and steel. Each doll is exposed to a common risk, the blow of a hammer. The glass doll completely shatters, the plastic doll carries a permanent dent, and the steel doll gives out a fine metallic sound. If the environment buffers the hammer’s blow by “interposing some type of ‘umbrella’ between the external attack and the recipient,” the outcome for the three dolls will be different (Anthony, 1987, p. 10). Each contributor identifies the major vulnerabilities and risk factors for

people finding themselves with the life’s condition, circumstance, and event presented in this book. As stated earlier, chronic poverty is the major force responsible for both prolonged and cumulative stress; consequently, it is the most potent risk indicator for many of the distressing life circumstances and events. Poor people are simply most likely to become unhealthy, single parents, homeless, crime victims, abused and violated, imprisoned, pregnant in adolescence, jobless, etc. And among the poor, people of color are at highest risk. Two examples follow. Generally, people who live in societies with large income and wealth disparities are less healthy than those who live in societies characterized by a small disparity in income and wealth. In a society like the United States where differences in income and wealth are extremely large, “your chances of escaping chronic illness and reaching a ripe old age are significantly worse than if you live in place where differences are not as large (Sweden, for example)” (Larder, 1998). The association between family income and health is clearly evident in the health of the country’s children. Family income directly affects the health of children. Studies indicate that children from low-socioeconomic families have poorer health outcomes (Evans, 2003; Poulton et al., 2002). In 2003, the health status of 16 percent of children under 17 was less than optimal (neither very good nor excellent). Depending on the state, children living in poor families in the United States (below 100 percent of the federal poverty level) were over six times as likely to be in less than optimal health (Commission to Build a Healthier America, 2008). A significant factor accounting for this disparity is that poorer children simply receive poorer medical care. A significant number of poor children are not covered by health insurance. In 2009, 10 percent or 7.5 million of our nation’s children were without health insurance (Federal Interagency Forum on Child and Family Statistics, 2011). Most of these children live

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below the poverty line. Without health insurance, poor children receive less preventive, as well as restorative medical care. For example, fewer than half of uninsured children, 45 percent, visit their doctors on a regular basis, as compared to 95 percent of publicly and privately insured children who receive regular medical care by their doctors. In addition, 44 percent of parents of uninsured children report that they have had to delay medical procedures for their children (U.S. Department of Health and Human Services, 2011). White persons are expected to live more than four years longer than black persons. The life expectancy for a white person is 78.8 years, while a black person is expected to live to the age of 74.4 years (National Vital Statistics Report, 2012). The differentials in white and black mortality rates begin at the outset of life and persist throughout the life span. In 2009, the black infant mortality rate was 13.4 infant deaths per 1,000 live births, compared with 5.6 infant deaths per 1,000 live births for white infants. Black infants die at a rate almost two and a half times higher than white infants (Federal Interagency Forum on Child and Family Statistics, 2011). Child mortality rates also illustrate the inequity among race and ethnicity. As table 1.5 demonstrates, in 2009, there were 25 deaths per 100,000 white children ages 1 to 4 years as compared with 42.2 deaths per 100,000 black children of the same age (nearly than twice as many). Among children 5 to 14 years of age, there were 12.4 deaths per 100,000 white children as compared with 20.5 deaths per 100,000 black children. As table 1.5 shows, the Asian and Pacific Islander mortality rate is the lowest for all age children (National Vital Statistics Report, 2012). Black children and adults also suffer higher death rates than whites from most major health-related causes; the gap between black persons and white persons continues to widen in the incidence of asthma, diabetes, tuberculosis, several forms of cancer, and major infectious diseases. Several examples illustrate this

Child Mortality Rates by Age, Race, and Hispanic Origin, Selected Years

ta b l e 1 . 5

1980–2009 (Deaths per 100,000 Resident Population) Age

1980

1985

1991

1994

2009

1–4 White Black Hispanic Asian**

57.9 97.6 — 43.2

46.6 80.7 48.2 40.1

41.7 79.7 47.0 30.4

36.5 77.2 39.1 25.3

25.0 42.5 24.7 16.1

5–14 White Black Hispanic Asian**

29.1 39.0 — 22.5

24.9 35.5 19.6 20.8

22.0 34.2 21.5 15.1

20.3 34.8 20.1 16.2

12.4 20.5 12.9 10.5

*Persons of Hispanic origin may be of any race. Each race category includes Hispanics of that race. **and Pacific Islander

racial health disparity. The asthma death rate between 2007 and 2009 was higher for blacks than whites for every age group, except persons aged 75 years and over. In fact, the asthma rate for black children under 14 years of age, was almost eight times greater than for white children of that age. In another example, the rate of diagnosed diabetes for blacks (12.6 percent) aged 20 years or older, was nearly twice that of whites (7.1 percent), while the risk of developing diabetes was 77 percent higher for blacks when compared to whites. In relation to tuberculosis, in 2010 the rate of tuberculosis disease was disproportionately higher in blacks than whites. Black persons were seven times more likely to contract the disease than whites. Similarly, for coronary heart disease, prevalence data indicate a national overall decline from 2006 to 2010. However, heart disease rates for black men and women rose by 1.6 percent over that time (Centers for Disease Control and Prevention [CDC], 2011). Finally, for every 100,000 live births in 2003, the white maternal mortality rate was 8.7, as compared with a rate of 30.5 for black mothers (Hoyert, 2007). Cancer incidence and death rates in the United States continue the decline first noted in 1990. However, the overall cancer incidence

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and death rates for black men and women were greater than all other racial and ethnic groups, with the death rate of black men 15 percent higher than that of white men. In 2009 blacks had a higher proportion of cancer incidence per year (489.5 for blacks, 471.7 for whites per 100,000 men and women) and more deaths from cancer (216.4 for blacks, 177.6 for whites per 100,000) (National Cancer Institute, 2012). The Center to Reduce Cancer Health Disparities (2008) suggests that black women are more likely than white women to die from breast cancer even though the incidence of breast cancer in white women is nearly twice as great. Comparable disparities apply to other types of cancers. For black men, the incidence of prostate cancer (255.5 per 100,000), the most common type of cancer for men, far surpasses the incidence for white men (161.4 per 100,000), and the death rate for blacks (62.3 per 100,000) resulting from prostate cancer is more than double that of white men (25.6 per 100,000). Similarly, incidence and death rates for lung cancer and colorectal cancers, the second and third most common cancers in men, are greater in blacks than in whites; of 100,000 men and women, the death rates for lung cancer for black persons (62) and colorectal cancer (27) exceeds that of whites for lung cancer (55), and colorectal cancer (19). Cancer health disparities may be attributed to numerous factors, including low socioeconomic status, lack of health care coverage, lower levels of education, obesity, insufficient physical activity, and an unhealthy diet, The Centers for Disease Control and Prevention (2012) estimate that 1.1 million people in the United States are living with HIV, and approximately 50,000 new cases are diagnosed yearly. The introduction of antiretroviral therapy in the mid-1990s significantly extended the lives of people living with HIV and dramatically decreased the number of AIDS deaths. Yet, nearly 18,000 people with AIDS die each year in the United States. In 2009 the greatest incidence of new HIV infections (61 percent) occurred

among men who have sex with men (MSM) of all races and ethnicities. MSM represent only 2 percent of the country’s population but disproportionately account for 61 percent of all new HIV infections and more than half of all people living with HIV. Heterosexuals accounted for 27 percent of newly diagnosed cases, with black heterosexual women most heavily affected. Injection drug users constitute 9 percent of new HIV infections and 27 percent of people currently living with HIV. Among injection drug users, blacks have a higher incidence of new HIV infections. Indeed, black Americans, only 14 percent of the nation’s population, comprise nearly half (44 percent) of new infections and people living with HIV (44 percent). More alarming is a 48 percent increase of HIV among young black men who have sex with men. The second largest group, Hispanics, account for 20 percent of new infections and 19 percent of people living with HIV. The racial and ethnic health inequity that results in higher incidence of HIV in blacks and Hispanics is attributed to multiple complex socioeconomic and environmental factors. Poverty may impact access to appropriate health care for HIV testing and medications that can manage infection and prevent transmission. Lack of appropriate health care increases the rate of undiagnosed or untreated HIV and may result in increased risk of acquiring or transmitting HIV. Similarly, the prevalence of HIV in communities can increase risk of transmission. Finally, stigma related to HIV and the perceived discrimination may discourage people from obtaining medical services to test, prevent, or treat HIV infections (CDC, 2012). Poverty breeds violence. Neighborhoods that have a large number of reported child abuse cases tend to be impoverished, with substandard housing and a low level of neighborhood interaction. Child abuse and neglect have been associated with lower socioeconomic status, unemployment, lack of education, childbearing at an early age, alcohol and drug abuse, and

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spousal violence (Aron, et al., 2010; Slack, Holl, McDaniel, Yoo, & Bolger, 2012). Violence is endemic and epidemic in our society. The country’s poor youth are the primary victims of violent crimes. According to Truman, (2011), youth between the ages of 12 and 17 had the highest rates of violent crime victimization (50.5 per 1,000) in 2010. This age group was nearly three times as likely as those ages 25 to 34 (18.8), four times as likely as those ages 35 to 49 (12.6), and over twenty times as likely as those ages 65 or older (2.4) to experience violent crimes. Youth in households with annual incomes of less than $15,000 were much more vulnerable to violent crimes than youth in higher-income households. Per thousand, 170.4 persons in the poorest households were victims of crimes of violence as compared with 119.3 persons in households with annual incomes of more than $75,000. Although the homicide rate has been continually declining for several years, the number of homicides committed annually is much higher in the United States in comparison to other industrial democratic societies. In 2009, for every 100,000 people living in the United States, 4.4 persons were murdered. In contrast to other nations, the U.S. homicide rate was over twice that of Canada (1.8) and nearly four times higher than industrialized countries in Europe, such as France (1.1), Germany (0.9), and Great Britain (1.2) (United Nations, 2011). While the mass media and public perception frequently equate violence with minorities living in the urban inner cities of the Northeast, Southern states experience a higher homicide rate. In fact, the South has almost double the murder rate of the Northeast. This regional difference has been traced back to the nineteenth century. For example, from 1880 to 1886, the murder rate in South Carolina (then a primarily agricultural state) was four times higher than that of Massachusetts (then the most urban, industrial state). In 1996, the murder rate in South Carolina was 9 per 100,000 people as compared with 2.6 per 100,000 people in Massachusetts.

Currently, “the former slaveholding states of the old Confederacy all rank in the top 20 states for murder, led by Louisiana with a rate of 17.5 murders per 100,000 people in 1996” (Butterfield, 1998a, p. 1). The American tradition of violence has its roots in the Southern code of honor. It evolved from a rich and proud culture that prospered in the antebellum rural South. Southern upperclass gentlemen were compelled to defend their personal and familial honor, risking injury and life itself for the sake of reputation and manliness. Gradually, the African American slave society adapted the Southern code of honor. Since African American slaves and their descendants could not trust or turn to the law and its white institutions, disputes were personally and often physically settled. This traditional code of honor has been transformed into modern inner-city street culture: “Don’t step on my reputation. My name is all I got, so I got to keep it.” As guns and semiautomatics have become available to younger and more neglected and desperate children, “the rituals of insult and vengeance” represent a lethal anachronism (Butterfield, 1996). And true to the Southern tradition of defending honor and proving manliness, most murders are not committed in pursuit of a crime, but rather as an outcome of personal differences, such as lovers’ quarrels or bar or neighborhood brawls (Butterfield, 1998a). The cumulative impact of the exposure to violence is devastating. Exposure to violence has been “associated with feelings of depression and anxiety, higher levels of antisocial and aggressive activities, lower school attainment, and increasing risk taking” (Marans, Berkman, & Cohen, 1996, p. 106). An increasing number of inner-city children, for example, suffer from low self-esteem and a posttraumatic stress syndrome similar to that seen in Vietnam veterans (Lee, 1989). These children have been exposed to violent attacks on and murders of their parents, friends, relatives, and neighbors. They are further traumatized by domestic violence and

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Mortality Rates Among 15- to 19-YearOld Males, by Gender, Race,*

ta b l e 1 . 6

Cause of Death, Selected Years 1985–2009 (Deaths per 100,000 Resident Population, Ages 15–19) Cause of Death

All causes White Black

1985

1990

1995

2000

2005

2009

105.1 105.7 96.3 86.1 82.2 65.9 125.5 199.9 200.1 130.1 122.9 100.3

Motor Vehicle White 47.6 Black 21.9 Firearms White 17.0 Black 46.5

46.9 28.6

38.6 28.6

36.7 22.5

31.5 21.4

20.4 13.3

20.4 20.0 12.3 119.8 118.9 61.5

10.6 59.4

10.3 52.4

*Persons of Hispanic origin may be of any race. Each race category includes Hispanics of that race.

child abuse. These experiences have long-lasting physical, psychological, and social effects. In 2010 serious violent victimization rates for blacks (20.8 per 1,000) age 12 and over, and Hispanics (15.6 per 1,000) were higher than for whites (13.6 per 1,000). For example, black youth are 17 times more likely than whites to be victims of death by homicide. In 2009, among 15- to 19-year-olds, the homicide rate for white males of this age group was 2.9 deaths per 100,000, while the homicide rate for blacks was 50.5 deaths per 100,000 resident populations. Similarly, death by firearms was five times greater among black males (52.4 per 100,000) than white males (10.3 per 100,000). Conversely, as seen in table 1.6, more whites males (20.4 per 100,000) die from injuries sustained in motor vehicle accidents than black males (13.3 per 100,000) (Federal Interagency Forum on Child and Family Statistics, 2011). resiliencies and Protective factors A surprisingly large number of people mature into normal, happy adults in spite of various vulnerabilities and risk factors. Why do some people collapse under certain life conditions and circumstances while others remain relatively unscathed? What accounts for the

remarkable individual variations in people’s responses to adversity and trauma? How do people adapt, cope, and meet the challenges of physical and mental impairments, severe losses, chronic discrimination, and oppression? Why do some people thrive and not simply survive in the face of life’s inhumanities and tragedies? What accounts for their resilience? Webster’s defines resilience as “the tendency to rebound or recoil, to return to prior state, to spring back.” Protective factors are biological, psychological, and/or environmental processes that contribute to preventing a stressor, or that lessen its impact or ameliorate it more quickly. The process of “rebounding” and “returning to prior state” does not suggest that one is incapable of being wounded or injured. Rather, in the face of adversity a person can bend, lose some of his or her power and capability, yet recover and return to prior level of adaptation. Although, as mentioned earlier, most investigations to date have focused on the negative rather than the positive aspects of people’s responses to life’s miseries, some research into children living in highly stressed, traumainducing environments has helped to inform us about the protective factors that children use to negotiate high-risk situations. The protective factors are related temperament, family patterns, external supports, and environmental resources (Basic Behavioral Science Task Force, 1996). Temperament includes such factors as: (1) activity level, (2) coping skills, (3) self-esteem, and (4) attributions. Children with easy temperaments and lower activity levels are more likely to be accepted and nurtured by parents and others. In comparison, unfriendly and overactive children often encounter much greater rejection, anger, and abuse. Adequate coping skills empower children to physically remove or emotionally distance themselves, thereby reducing their exposure to family discord. Children’s concepts and feelings about themselves and their social environments play an important role in their ability to deal

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with life’s challenges. Self-esteem is a dynamic, complex concept as “individuals have not one but several views of themselves encompassing many domains of life, such as scholastic ability, physical appearance and romantic appeal, job competence, and adequacy as provider” (Basic Behavioral Science Task Force, 1996, p. 726). Finally, children’s attribution of responsibility for exposure to trauma-inducing environments also plays an important role. Generally, a self-condemning attribution style has a strong negative impact. People’s subjective realities, i.e., their perceptions of their inner and external resources, their attributions, and social constructions, are essential to professional understanding. Family patterns represent a second protective factor. In family illness studies, one good parent–child relationship served as a protective factor in cushioning dysfunctional family processes, as well as in increasing the child’s self-esteem. The relationship also reduced psychiatric risk. The presence of a caring adult, such as a grandparent, led to similar outcomes. Third, external support from a neighbor, parents of peers, a teacher, clergy, or a social worker is a significant cushioning and protective factor. The importance of social support has been widely documented. Supportive social networks are important sources of positive selfconcept and also help shape one’s worldview (Miller & Turnbull, 1986). Last, the broader environment and the opportunity structure create the conditions for all other factors. When social structures and institutions act as buffers, they enhance people’s abilities to cope with life’s transitions and stressors; when environmental resources are unavailable, or insufficient, people are more apt to feel hopeless and are less able to cope. Many vulnerability or protective processes often concern key turning points in people’s lives rather than long-standing attributes. The direction of a trajectory for the future is often determined by what happens at a critical point. The decision to remain in school, for example,

represents a critical turning point, often leading to more positive trajectories than dropping out of school. In contrast, the birth of an unwanted child to a well-functioning teenager, who is then rejected by family, creates a negative trajectory (Rutter, 1987). Planning in making choices looms as a critical factor in turning-point decisions. Exercising foresight and taking active steps to cope with environmental challenges are critical factors. In a follow-up study of girls reared in institutional care, Rutter (1987) found that if they did not marry for a negative reason, such as to escape from an intolerable situation or because of unwanted pregnancy, and exercised planning in their choice of a partner, they were less likely to marry a man who was a criminal or had a mental disorder. The importance of planning as a protective factor also emerges in areas of school and work (Rutter, 1987). And then there is always the simple element of chance or God’s will: good fortune and misfortune. Although our efforts to be scientific may cause us to shy away from the idea of chance or spiritual beliefs, they may well enhance our understanding of and feeling for the human experience. For example, survivors of the Holocaust know that they survived because they happened to be at the right place, at the right time. For another example, people involved with Alcoholics Anonymous commit to and align themselves with a spiritual force larger than themselves. Two factors in addition to planning in making choices and chance or God’s will are worth noting. One factor is humor. Laughter is essential to life. Laughter “deflects, unmasks, and frees us from unreal, pretentious, and imprisoning beliefs or perceptions” (Siporin, 1984, p. 460). To be able to laugh in the face of adversity and suffering releases tension, provides hope, and takes sadness and “makes it sing.” Eli Wiesel poignantly noted (as quoted in Baures, 1994): The truth comes into this world with two faces. One is sad with suffering, and the other laughs;

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but it is the same face, laughing or weeping. When people are already in despair, maybe the laughing face is better for them; and when they feel too good and are sure of being safe, maybe the weeping face is better for them to see. (p. 31)

And finally, through the processes of helping and giving to others, people help and heal themselves. Frankl (1963), a survivor of the Holocaust, eloquently describes that one finds meaning in life—finds meaning in suffering— not through the pursuit of self-gratification, but primarily through the processes of helping and giving to others. Essentially, when people lend their strength to others, they strengthen themselves. Programs and Social Work contributions Each contributor examines programs and social work contributions in dealing with the population’s life stressors. Managed care has transformed health and mental health services in the United States. Managed care has had a profound impact on almost all social work programs. Spurred by rising health costs and mental health costs, managed care evolved to contain costs and as an alternative to fee-forservice. This change in philosophy, organization, and delivery of health and mental health services has had a profound impact on the quality of services people receive as well as funding of social service agencies and departments. Managed care’s main objective is cost containment. This is accomplished either by placing limits on patient services (e.g., number of days in the hospital, visits to medical and mental health practitioners, total dollar expenditures per year and per lifetime) and/or by increasing copayments and deductibles. Managed care’s dual emphases on minimizing costs and maximizing profit impose corporate values and ideology on health and social welfare agencies. These values and ideology differ radically from social welfare’s commitment to human rights and the provision of safety nets and buffers to our capitalist economic system (Schamess,

1998, p. 24). In health care, for example, social work departments have been decentralized, supervisory positions eliminated, and social work practitioners integrated into service teams. Consequently, social work directors are yielding some of their administrative responsibilities and searching for ways to survive. The diminished administrative structure limits staff opportunities for promotion and leaves them isolated and vulnerable in ongoing turf battles with nurses and other professionals. Furthermore, staff isolation and vulnerability inhibit their ability to advocate for quality patient care. Mental health services were also transformed “from a purely professional undertaking to a business providing professional services” (Lens, 2002, p. 27, citing Abraham & Weiler, 1994, p. 395). The change from professionals to business administrators making crucial therapeutic decisions reshaped professional practice and limited the focus and scope of services to clients (Acker, 2010; Bennett, Naylor, Perri, Shirilla, & Kilbane, 2008; Kerson, 2009). Brief, goaldirected therapy approaches (solution-focused and cognitive behavioral) that focus on acute symptom relief have been defined as the preferred modes of treatment (Cohen, 2003). The emphasis on short-term symptom reduction too often neglects the underlying life stressors that often create the symptoms, or, at the very least, exacerbate them. Since each author examines the specific programs, services, and modalities and, where relevant, the impact of managed care, our discussion is limited to selected ideas about primary prevention programs. What do we do with our knowledge about populations vulnerable and resilient to various pernicious life conditions, circumstances, and events? Primary prevention, a public health concept, aims to anticipate and forestall some undesirable event or condition that might otherwise occur and spread (Gitterman, 1988; Leighton, 2000). Primary prevention has two distinct strategies: (1) specific protection, an explicit intervention for disease prevention in which a population at

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risk is identified and something is done with the population to strengthen its resistance and resilience; and (2) health promotion, an intervention for improving the quality of life and raising the general health/mental health level of a population. Social workers also have inherited from their past a third prevention strategy, environmental change, i.e., doing something about the social conditions that play host to and foster the problems. In times like the present, this tradition, if not ignored, is certainly neglected. Funding, and consequently, professional interests are both primarily engaged in the “specific protection” aspect of prevention. This direction can be a problem. By emphasizing specific protection, our efforts may be promising much more than they can deliver. Childhood poverty, for example, is deeply embedded in our social structure. The decline in actual earnings, decrease in public entitlements, and increase in single parenting and numerous social problems all conspire to enlarge the dimensions of childhood poverty. These children’s problems are becoming more desperate, intractable, and dangerous. In this context, the premise of specific protection prevention, i.e., intervening before a problem has “struck,” must be reexamined. If we identify poverty and racism as the major problems, prevention of social ills becomes elusive, if not illusionary. Intimate partner and child abuse prevention programs, for another example, are being implemented within the context of a violent society. Our society promotes and tolerates violence and few prevention programs deal with the cultural propensity toward violence. Programs that teach selected adolescents to avoid pregnancy by saying “no” or advise parents who may potentially abuse their child to manage their angry feelings, however useful and pertinent, cannot deal with the multidimensional pathways to social problems. In fact, most new immigrant groups have shown high rates of “social pathology,” but as they achieved economic security, the social pathology rates

declined. These social pathologies are analogous to a high fever: in such an analogy, specific protection interventions may momentarily reduce the fever, as, for example, an aspirin does, but they may disguise the problem. Social pathologies are outcomes of complex ecological chains that include attributes of the individual’s genetic, biopsychosocial makeup; the structures of the family, social networks, community, school, workplace, religious organizations, and health system; recreational resources; general culture and subculture; social class; and the overall polity (Gitterman & Germain, 2008). Another problem with specific protection strategies is the difficulty in identifying subpopulations at risk. Certain life problems, for example, have been associated with pathogenic family processes. The problem is what to do about these findings. A boy observing his father batter his mother does not, of course, inevitably become a wife batterer himself. Based on his experiences, he may become determined and successful at not battering his wife. Similarly, a boy growing up in a nonbattering family may, owing to unemployment or addictions, become a batterer. What do we do about aggregate data: do we attribute to the individual the characteristics of the group, thus stigmatizing and defining them to be “at risk”? To draw a parallel, a colleague was asked to study alcohol abuse in a police department. He found that Irish policemen were particularly at risk of alcoholism. It is obvious from a logical (if not political) point of view that action, if any, can only be taken in relation to health promotion for the total police population. When we identify a subpopulation at “risk” as candidates for specific protection interventions, rather than using a universal health promotion approach, we are in danger of adding to the burdens of that population. Moreover, by seeking and accepting restrictively defined prevention funding, we are in effect promising to reduce or eliminate problems such as child abuse, drug addiction, and teenage pregnancy. And when these modestly funded specific

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protection programs are unable to mitigate what are probably the consequences of structurally ingrained poverty, we diminish our profession’s credibility. The second strategy, “health promotion,” is a viable alternative. It attempts to improve the quality of life and foster optimal health in the total population. It focuses on “wellness” and maintaining health rather than treating “sickness” and restoring health. Services based on a developmental approach scheme emphasize access to health education, recreation, and socialization activities, and cultural programs. In effect, the health promotion approach offers multiple pathways to well-being. Examples include genetic counseling, marital counseling, pregnancy planning, pre- and postnatal care, obstetrical care, well baby clinics, preschool programs and enrichment programs, and parental involvement in school programs and sex education. These programs attempt to engage social competence, cognitive and emotional coping, and achievement. Maximizing early positive experiences and minimizing negative experiences are more likely to have long-lasting effects. Thus, in social planning for universal services, programs need to be designed to strengthen major social institutions: the family, the school, the world of work, and the community. When these institutions are strengthened, general health is promoted. Our programs also ought to reflect more involvement with the third strategy, “environmental change.” We need to revitalize the community organization tradition in our practice. Community organization is essential for instrumental accomplishments (e.g., voter registration) as well as for the experience of challenging imbalance in power relations (Carnochan & Austin, 2011; Rusch, 2010). Participation and action can absorb hopelessness, despair, and apathy. Experiencing and developing the belief that one can take initiative to achieve some control over one’s environment is a powerful strategy for promoting physical and mental health.

assessment and interventions Most social workers provide direct services to individuals, families, and groups. We attempt to help clients adapt and cope with the tasks and struggles in day-to-day living. In their transactions with their environments, disturbances and disruptions often occur. People experience stress when they perceive an imbalance between external demands placed on them and their self-defined capability to meet the demands through the use of their own internal and environmental resources. Transactional disturbances create life stressors in three interrelated areas: life transitions and traumatic events, environmental pressures, and dysfunctional interpersonal processes (Gitterman & Germain, 2008). Whether a person has to adapt to depression or schizophrenia or diabetes, to homelessness or foster care status, transitions in life impose new demands and require new responses and can be, therefore, often deeply distressing. All such transitions require some changes, some flexibility, and some creativity in dealing with the environment, processing information and problem solving, and relating to others. Gradual life changes usually provide the opportunity for planning and preparation, and consequently the attendant stress is more manageable than when the change is sudden and unexpected. For some clients, change represents major threats to environmental survival and to self-image. For others, change represents an opportunity for environmental enhancement and self-preservation. But for most people, all change has its difficulties. The immediacy and enormity of a traumatic life event creates a personal crisis. Traumatic life events—such as the death of a child, the violence of rape, the diagnosis of AIDS, the birth of a genetically defective child, or the aftermath of a natural disaster—represent losses of the severest kind. Such events are experienced as disastrous and overwhelming and therefore tend to immobilize us. The state of crisis is time limited in nature, during which ordinary adaptive patterns are

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not adequate, so that novel solutions or coping skills are required. We cannot long remain in the state of extreme discomfort implied by crises. The painful anxiety and/or grief elicit protective measures sooner or later. While social and physical environments can support the tasks of daily living, the environment itself can also be a source of severe stress. A society ridden with prejudice against people of color, women, homosexuals, handicapped, and old people provides unequal opportunities for its citizens. Many clients are dealt a “stacked deck.” If they are impaired physically, cognitively, and emotionally, this “deal” can be insurmountable. Organizations (schools, hospitals, etc.) established to provide essential services might in fact block access and impose harsh and restrictive policies and procedures. Social networks, i.e., relatives, friends, workmates, and neighbors, may be scarce and unavailable, so that clients are, in effect, socially isolated. Physical and spatial arrangements, e.g., density, crowding, safety, and privacy, may be unsuitable and generate a great deal of distress. In dealing with life transitions or unresponsive environments, families and groups may experience intensified stress because of problematic interpersonal relationship and communication patterns. Inconsistent mutual expectations, exploitative relationships, and

blocks in communication are examples of problems in interpersonal communication to individual members and to the family or the group itself. Similar problems may also emerge between workers and their clients. Workers may add to the client’s burden by defining his or her behavior as resistant or unmotivated rather than as a transactional difficulty between them (Gitterman, 1983, 1989; Gitterman & Nadelman, 1999). Helping people with their life stressors provides the social worker with a clear and distinctive professional function: to improve the transactions between people and their environments and to facilitate a better match (i.e., a better level of fit) between their needs and environmental resources.3 The professional function is represented in figure 1.1. assessment and interventions How people experience their daily life stressors and how effectively they manage the associated life tasks will largely depend on the perceived level of fit between their personal and environmental resources. Workers begin by assessing the client’s appraisal of his or her life stressors, i.e., the meaning the client attributes to the situation. For example, a mother becomes depressed when she learns that her adolescent daughter is pregnant. The mother interprets her daughter’s

Difficult Life Transitions and Traumatic Events

Client and Worker

Dysfunctional Family/Group/ Community Processes fiGure 1.1

Professional Function and Life Stressors

Environmental Pressures

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pregnancy as a reflection of her failure in raising her daughter. For the social worker to be helpful, the cognitive meaning of the pregnancy must be understood. The mother’s appraisal of the event results in a judgment that the issue is a stressor rather than an irrelevant or a benign event (Lazarus, 1999). The mother’s continued appraisal will determine whether the stressor represents a harm or loss, or a threat of harm or loss, or a challenge. Distinguishing between harm/loss and threat is a matter of time perspective. Harm/loss refers to current damage and suffering, such as losses of all kinds, while threat refers to an anticipated future loss or harm, such as the announced changes in public assistance or an unwanted retirement. In such instances, efforts to cope are directed to overcoming, reducing, or tolerating the stressor. In the case of threat, efforts to cope are directed to maintaining the current state of affairs, preventing the anticipated harm/loss, or easing its effects. Individuals may oscillate between harm and threat as they appraise the harm already suffered and the threat(s) that may lie ahead, as in the birth of a child with a serious, non-treatable genetic disorder. An appraisal of a stressor is accompanied by a sense of being in jeopardy, with the aroused feelings often interfering with problem solving. This process affects selfesteem, a sense of competence, relatedness, and self-direction. After assessing clients’ primary appraisals of their situations, the worker has to assess the accuracy of their perceptions and thinking. Under intense stress people may err in their evaluation of personal and environmental resources. For example, a substance-abusing client may believe that his or her peer network is a major resource in dealing with life issues when in fact it fuels his or her dysfunctional patterns. Clients may overestimate their resources for dealing with life stressors and thereby fail to cope successfully, or underestimate their resources and believe that the situation is hopeless. In assessment (as well as in

intervention), client(s) and social worker need to determine whether appraisals of stressor and resources are accurate and, if they are not, work on developing greater accuracy. The worker also assesses how the client has coped with the life situation. Coping measures include emotional, cognitive, and behavioral actions to change aspects of the stressful life situation such as oneself, the environment, exchanges between them, or all three. Coping is a process through time; stressors may be of short duration, as in job loss followed soon by another job, or they may be of long duration, as when mourning, raising a child with autism, or living as a solo mother in poverty. An ecological concept, coping expresses a particular person(s)–environment relationship, since both personal and environmental resources are required (Gitterman & Germain, 2008). In assessing personal coping resources, the worker evaluates the client’s motivation; problem-solving and relationship skills; outlook on life; self-confidence; ability to search for and use information from the environment; capacity to restrain rash or impulsive decisions and actions, and to regulate negative emotions aroused by the stressor; and ability to seek environmental resources and to use them effectively. Flexibility is also a personal coping resource. A personal resource such as optimism is also important. In assessing environmental resources, the worker evaluates the availability and responsiveness of the client’s formal service networks such as public and private agencies and institutions of many kinds. Potential resources also include the client’s informal networks of relatives, friends, neighbors, workmates, coreligionists, and so on, who may or may not provide emotional support, material resources, information, feedback, and advice. Just the perception of the availability of informal networks can make it easier to cope with a life stressor (Wethington & Kessler, 1986). Since some formal and informal support systems may be unresponsive, even hostile and destructive, and act as significant stressors rather than buffers, client and social

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worker must evaluate their responsiveness, just as personal resources are evaluated. The worker also assesses relevant dimensions of the client’s physical environment such as provisions for safety, privacy, crowding, accessibility of space, and so on (Gitterman & Germain, 2008). Professional judgments about the meanings clients attribute to the identified life stressors, the accuracy of their perceptions, and the level of fit between personal and environmental resources must be based on reasoned inferences and reasonable premises. To achieve such judgments, workers must have salient data. All inferences have to be based on and supported by data. Without data, the social worker is unable to determine an appropriate purpose and focus of help. Sources of data include the client’s verbal accounts, the worker’s observations of nonverbal communication, verbal and nonverbal presentations by others (obtained only with the client’s informed consent), and written reports (obtained only with the client’s permission, except for the agency’s own earlier records). Mutually agreed upon definitions of the most pressing life stressors and agreed upon goals and methods of working on them determine the direction and the content of the data to be sought. Workers can readily become overwhelmed by a mass of data and, therefore, must organize the data as they are being collected. Once organized, the data need to be analyzed and synthesized to develop reasoned inferences. Workers have to develop inferences based on the following: (1) identification and definition of the clients’ life stressors; (2) the meanings these stressors have for the clients; (3) clients’ strengths and limitations to deal with and work on their life stressors; (4) social and physical environments’ supports and obstacles in maintaining and resolving the clients’ stressors; and (5) the level of fit between the clients’ (individual, family or group) and the environments’ resources and deficits (Gitterman & Germain, 2008). Developing inferred propositions requires two disciplined forms of

reasoning—inductive and deductive. Inductive reasoning is the intellectual process of moving from the data to the generalizations. As professionals, we have to conscientiously distinguish data from inferences and be ever tentative about the validity of our generalizations. Deductive reasoning is the intellectual process of applying the generalizations, i.e., practice knowledge and research findings, to the specific case situation. Disciplined use of informing knowledge is an important aid to determining practice focus and direction. As professionals, we have to be careful that our needs for certainty, constancy, and stability do not compromise our curiosity and ability to individualize clients. Through disciplined forms of reasoning as well as spontaneous intuition, workers assess the level of fit between the client and the environment and their respective demands, resources, and limitations. When an imbalance exists between a perceived demand and a perceived capability to meet the demand through the use of available internal and external resources, people experience stress. How much stress a frail elderly person will experience upon discharge from a hospital, after surviving a stroke and being confined to a wheelchair, will depend on the person’s degree of physiological impairment and damage, amount of physical strength and resiliency, and inner resources (i.e., motivation, outlook on life, coping skills, meaning of illness, etc.). Also extremely important are the family and extended network caregivers, and their ability and willingness to provide emotional and instrumental supports. Moreover, access to such resources as medical staff, homemaking, nursing, physical rehabilitation, speech therapy, financial entitlements, medical insurance, and the financial ability to purchase services will have a significant impact on the final prognosis. Finally, the flexibility of the physical environment, e.g., building entrance door and corridors, furniture, etc., also will affect recovery. Figure 1.2 shows the combined impact of a client’s internal resources and limitations and environmental resources and limitations.

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Environmental Resources Low Low

–

–

High –

+ (B)

(A)

Personal Resources High

fiGure 1.2

+

– (C)

+

+ (D)

Person:Environment Fit*

Low indicates limited resources; high indicates significant resources.

*

Although the figure may be a bit too pat and an oversimplified view of reality, it does offer a representation of the fit between person and environmental resources. In situations of low inner and low environmental resources (A), the client is at most serious risk. The poor person:environment fit suggests potential deterioration and disintegration. These situations require immediate attention and priority and an active and directive worker with sufficient time to become a critical resource for possibly an extended period. Situations of high inner and environmental resources (D) suggest a good person:environment fit and an optimistic prognosis. In these situations, the worker’s activities may be limited to uncomplicated referrals, suggestions, and support. In situations of low inner resources and high environmental resources (B) and high inner resources and low environmental resources (C), less definitive statements can be made. When inner resources are low, the worker usually is required to be active, lending technical problem-solving competence and energy. Finding and connecting the client to available network and community resources to compensate for biopsychosocial deficits are essential professional activities. When environmental resources are low, the worker usually assists the client in asserting his or her needs, seeking alternative resources, or constructing new ones.

Figure 1.2 provides a diagrammatic overview of the fit between client and environmental resources and deficits and general guidelines for different practice directions. To be useful, an assessment needs to be more refined than an overview. One can never, however, collect all of the available data and can never have all of the available knowledge. All professionals must act in the context of varying degrees of ambiguity. Every worker faces an array of cues, messages, and themes, which are at times perplexing and at other times overwhelming. At every moment, the worker has to decide which of these to respond to and which to table or defer. There is little time to think and strategize about the “correct” intervention. Yet, within the context of uncertainty, the worker must act with a certain degree of sureness. What is being suggested here is a way to think about clients and their situations, a way to organize and analyze data and a way to systematize practice. All people have strengths and resilience, although for some, their strengths and resiliencies have been dampened by life circumstances. Social workers therefore must identify, mobilize, and build on people’s inner and external strengths. While internal limitations and external obstacles must be noted, change occurs through the encouragement of people’s positive assets. When social workers are preoccupied with vulnerability, psychopathology, and diagnostic labels, individuals and collectivities are perceived as merely broken objects to be “fixed” (i.e., treated) by powerful experts. This practice form obscures clients’ and practitioners’ humanness. Too often social work education and socialization to the professional stiffens and formalizes social workers’ practice. Students learn to be threatened by ambiguity rather than challenged by it. Students are taught to search for prescriptions, to become cautious and avoid taking risks. And through these and other processes, students are taught to distance and detach themselves from their clients. Wanting to confront and heal from life’s troubles and pains, clients too often come into contact with

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professionals who themselves are hiding and avoiding. Jourard (1971) insightfully analogizes human communication to a poker game. Players do not disclose their hands. Like in a poker game, we wear masks or poker faces and hide our inner feelings and thoughts. Professionals with poker faces and masks inhibit rather than facilitate the healing of their clients. The splitting of our personal and professional selves encourages the other person also to hide within a stereotypical role, e.g., patient or student. An artificial and false communication takes place in which neither party says what he or she really feels or means. The client-worker roles must be carried out in a mutual, reciprocal, and respectful manner and shift from those of subordinate recipient and superordinate expert to those encouraging collaboration (Gitterman & Germain, 2008). By reducing social distance and power differences, the worker helps to encourage clients’ competencies and strengths. When, and only when, social workers deal with the existing power differentials in their relationships with clients can these relationships empower clients rather than reinforce and fuel continued powerlessness (Bransford, 2011; Wagaman, 2011). Professional interventions are directed to person(s), environments (physical and/or social), and their exchanges in order to reduce or eliminate the life stressors. Supporting and strengthening people’s adaptive capacities and problem-solving abilities to deal with life stressors requires the creative use of various professional methods and associated skills, such as enabling and guiding. Enabling is used to mobilize or strengthen clients’ motivation to deal with difficult life stressors and the associated stress they arouse. The enabling method also helps clients to manage their negative feelings and stress that otherwise could lower self-esteem and interfere with effective coping. Enabling skills include: identifying strengths, conveying hope, offering realistic reassurance, and legitimizing and universalizing thoughts, reactions, and feelings.

These skills help clients to mobilize and sustain their motivation and personal strengths. For example, exploring and clarifying skills provides focus and direction to the work. The social worker draws on skills such as partializing concerns, reaching for underlying meaning, clarifying ambivalence, identifying discrepant messages, offering interpretations, providing feedback, and inviting self-reflection. Guiding is used to help clients learn the steps in the problem-solving aspects of coping. Successful coping calls for the ability to: (1) identify and evaluate life stresses, (2) deal with attendant emotions, and (3) delineate and choose among alternative responses in problem resolution (Folkman, Lazarus, Dunkel-Schetter, DeLongis, & Gruen, 2000). Social workers have the potential to become critical teachers of coping skills. The guiding method is particularly appropriate for helping clients to cope with stressful life conditions and circumstances. For this reason, the guiding method and associated skills will be discussed more fully. To help clients improve coping skills, social workers must attend to the different ways in which people process and learn information. Some learn primarily by doing; others learn primarily by summarizing, visualizing, and organizing perceptions into patterns and images. Still others learn primarily by abstracting and conceptualizing (Bruner, 1966). Effective use of the guidance method depends on providing opportunities for activity and doing; visual means, modeling, and role-play; and discussion and exchange of ideas. Guiding skills include the following: providing needed information regarding the stressor and coping tasks, clarifying misinformation, offering advice, providing feedback, specifying action tasks, and preparing and planning for task completion. In helping a client to prepare for major surgery, for example, the social worker explores the client’s beliefs and perceptions about the procedure and corrects mistaken understanding, provides relevant information about the overall features of the impending surgery, restructures

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some of the unhelpful thought processes, and focuses on more effective management of feelings. The worker might also role-play how to ask the surgeon relevant questions and how to listen for responses. If the client is too passive in the role-play, the worker might consider teaching assertiveness skills. An assertive behavior sequence calls for four steps that can help the client complain effectively and feel more empowered and less helpless: (1) describe behavior, (2) express associated feeling, (3) request specified change, and (4) identify positive consequence (Lange & Jakobowski, 1976). Based on the discussion and role-play, the worker might decide to offer specific advice to encourage the client to try a new behavior (e.g., “If you feel the nurse is too rough with you, tell him firmly that he is hurting you and that he should immediately let go of your arm”). Advice also can be offered to discourage a client’s selfdefeating behavior (e.g., “If you continue to pull out your IV, the nurses will have to bind your arms”). Depending on the severity of the problem and the client’s level of functioning, the worker determines how direct the advice should be. This can range from “suggesting” to “urging” to “warning” to “insisting.” The more directive advice is usually most helpful to anxious and impaired clients. In offering advice, the worker has to be familiar with the client and the situation, being careful not to impose his or her own values and coping style. The advice has to be responsive to what a client is actually requesting, rather than reflect a worker’s own need to demonstrate helpfulness. At times, the worker might offer an “informed” interpretation. In offering an interpretation, the worker shares meanings and inferences she or he attributes to the client’s feelings, behaviors, and situations. By patterning available data, the social worker provides a potentially new frame of reference for a client to consider, e.g., “I sense a lot of your concern about your surgery, about the risks, recovery period, etc., is being expressed in disappointment and annoyance with your family. This is understandable.”

Timing is essential to how interpretations are received. To venture an interpretation, the worker has to have sufficient data and sense the client’s trust. Premature insights distance clients from workers. The worker’s interpretation may be incorrect, but even if correct, the client may not be ready to integrate it. It has been suggested that an interpretation should not be made unless it is virtually irrefutable. People are usually unaware of how they are perceived by others—their strengths and their limitations. By sharing one’s own reactions to a client, the worker provides invaluable feedback, rarely available from friends and family. When it is offered out of an objective caring and concern rather than frustration and anger, it is more likely to be received and believed. A worker can decide to share a feeling at a particular moment—e.g., “Right now, I am feeling overwhelmed. When I try to say something, you cut me off. I feel you are running right by me, pushing me away.” The worker uses his or her reactions to examine the client’s experiences and transactional patterns. To be most helpful, the worker’s reaction is presented in concrete, behavioral terms and expressed calmly and empathically. Inviting clients’ reactions should follow directive interventions (e.g., “What’s your reaction to what I have suggested?”). At times, a client will respond directly with whether the advice or interpretation is helpful or unhelpful. Other times, the response will be more indirect, e.g., “I guess you’re right” or “Yes, but. . . .” The worker invites hesitation, lack of clarity, and negative reactions. Even if the advice or interpretation is perceived as unhelpful, the client’s feedback stimulates further work. Without client feedback, the worker may sound “smart” or, in fact, be insightful, but the work may not be deepened. illustration and discussion Each contributor follows the “assessment and interventions” section with a specific presentation of practice (individual, family, group, community, organization, and program

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development) to illustrate and typify the stressors and situations confronted by the client population. Contributors were asked to explore the practice issues related to social class, ethnicity and race, gender, sexual orientation, religious affiliation, disability, and developmental phase. The focus of the illustration is on the worker’s professional behaviors and skills, i.e., what the worker actually does to help. Contributors were invited to pay special attention to this section and to try to capture the art and science of social work helping. This section was emphasized because of a conviction about the primacy of professional skills and competence. As our profession has been pushed into a preoccupation with accountability, one of the consequences has been a preoccupation with practice outcomes, and a tendency to evaluate professional competence and skills primarily on the basis of outcomes specified in advance or beforehand. The client’s progress or lack of progress is attributed to the worker’s skills or lack of skills. This is absurd, if not dangerous, because it leads logically to working only with motivated clients and clients without serious environmental problems. Moreover, evaluating professional competence solely on the basis of outcomes also ignores and negates the reality of what happens in the helping process, i.e., a worker trying to be helpful, and a client deciding whether and how to use help from this particular person at this particular time.4 The worker’s behaviors may be skillful and the client may not progress (or possibly even regress); the worker’s behaviors may be unskillful and the client may progress. We can properly hold professionals accountable for professional skills and informed use of relevant knowledge. It has been said that clients benefit because, in spite of, and without our help. Lawyers who lose their cases may be justly praised for their fine work in a lost cause, and doctors often do well but still their patients sometimes die. In all cases, the question or issue is whether they did well or did the right thing in the circumstances and considering the state of the art

and available options. And, similarly in social work, the behavior of helping has to be evaluated on its own terms and distinguished from the behavior of using help. How can the general public and specific client populations have confidence in a profession that is unclear and uncertain about its methodology? How will professional social workers be able to demonstrate their competence without committing educational and professional careers to the acquisition of established and newly emerging skills? As professionals, we are and become what we do! Being competent is our most reliable means to survival. Although society does not fully appreciate what our profession does and what social workers accomplish day in and day out, this book tries to capture and convey our profession’s vision and our practitioners’ professional competence, spirit, and, in many situations, heroism. conclusion This introductory chapter attempts to introduce the reader to the content of this book. In part I, “Life Conditions,” each contributor deals with issues related to etiology. A complex ecological chain emerges linking genetic, family, and environmental forces. Alcoholism, chronic heart disease, diabetes, learning disability, manic depression, developmental disability, and schizophrenia all appear to have in common genetic predispositions. Inherited levels of cholesterol, other blood fats, and structural defects, for example, set the conditions for heart disease. A family tradition of cooking in fats and grease increases the risk. So does living in a society in which fast-food chains with high-fat hamburgers and potatoes fried in lard are desired staples, smoking by youth is pervasive, and ice cream is a favorite dessert. All of these factors conspire to act on the genetically vulnerable individual. A similar chain exists for many of the life conditions described in this book: i.e., a genetic predisposition; a society and culture that either provide

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insufficient supports and environmental controls or encourage unhealthy behaviors; and dysfunctional family and individual behaviors. For the problematic life condition to develop, all the factors in the ecological chain are usually present to some degree. However, extreme family and environmental factors such as excessive family and work stress can also precipitate serious difficulty even though there is little constitutional basis for it. In part II, each contributor examines the pervasive impact of poverty on most distressing life circumstances and undesired events. Poor children, for example, learn early in life that they have limited control over their lives, that things happen and are done to them. Poor children are at greater risk than others of suffering various acute illnesses and specific health problems. At every age, poor children are at a relatively higher risk of death. They are more likely to be exposed to violence, malnutrition, poor education, family disruption, and institutionalization or incarceration of parents; in turn, they are more likely to respond with antisocial behavior, addiction, and depression (Fite, Stoppelbein & Greening, 2009; Jackson & Nuttall, 2001; Weiss & St. John Seed, 2002). Public health child development researchers using statistical models have catalogued a score of risk factors: poverty; overcrowding; neighborhood and school violence; and parental absence, unemployment, or instability. The higher the score of risk factors, “the more astronomically the odds rise” of the child ending up delinquent, addicted, or chronically mentally ill (Butler, 1997, p. 24). Drugs and drug subcultures, for another example, ravage economically disadvantaged communities and their schools. As poor innercity communities become poorer and as people become more alienated, escape into alcohol and drugs becomes a seductive option. People addicted to drugs relate primarily to drugs and drug-seeking behavior. Chronic users not only cause significant injury to themselves, but they also harm their family members as well as their communities.

While crime appears to be steadily declining, arrests for drug-law violations are climbing. For example, violent crime arrests declined 5.3 percent in 2010 when compared with 2009 arrests (Federal Bureau of Investigation, 2012). However, the FBI’s Uniform Crime Reporting Federal Bureau of Investigation (2012) reported that the highest number of arrests were drugrelated (estimated at 1,638,846 arrests) or for driving under the influence (estimated at 1,412,223). In contrast, only 1.5 million people were arrested for drug-law violations in 1996. Many crimes are committed out of the need to obtain money to purchase drugs and/or under the actual influence of drugs. Drug trafficking and violence go together.5 In virtually every chapter, the author(s) poignantly describe the all-encompassing consequences of poverty. When there is prejudice and discrimination, when family and social network ties are weak, and when individuals have the added burdens of physical, intellectual, or emotional impairments, the impact of poverty is particularly devastating. Poor people with AIDS, homeless people, unemployed black adolescents, and isolated elderly—all are at severe risk of not being able to survive in the environment. Yet some remain relatively unscathed by traumatic experiences such as extreme poverty, racism, homophobia, family violence, sexual and other forms of abuse, or loss of a loved one. They do not become bitter or jaded. They somehow forge ahead when life seems unbearable—when hope and trust have been taken from them. Social workers struggle to help people in greatest need and highest risk. Many do so with great personal commitment and zeal, and professional creativity and competence. These social workers struggle daily to provide relevant services with extremely limited resources. They refuse to abandon social agencies; they refuse to desert these most vulnerable populations and instead they continue to develop programs, provide individualized services, and offer hope. This book is a tribute to these professionals, and we hope it does them justice.

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noteS

1. Martin Luther King once made the mordant observation that our society has socialism for the rich and rugged individualism for the poor. 2. PRWORA requires involvement in some workrelated activities as defined by each state within twenty-four months of receiving assistance. 3. In mediating the exchanges between people and their environments, social workers daily encounter unresponsive environments. Thus, an additional professional function is to influence social and physical environmental forces to be responsive to people’s needs. 4. The author wishes to acknowledge the contribution of William Schwartz to his ideas about the nature of professional skills. 5. Substance abuse also has a profound impact on mental illness, increasing the rates of violence by up to five times. Moreover, the violence is most often directed at family members (Butterfield 1998b).

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cHaPter 2 acquired immune deficiency Syndrome (aidS) G e o r G e S . G e t z e l , y V o n n e o . Pat t e r S o n , and StePHen W. WillrotH

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cquired immune deficiency syndrome (AIDS) has been with us for more than 30 years, after being first recognized by the federal Centers for Disease Control and Prevention (CDC) and later labeled as the greatest public health threat in the United States. In the last three decades we have undergone a period of profound adjustment to the hard reality of AIDS. The early response to the pandemic was too often the abject neglect and abuse of the historic causalities—gay men, intravenous drug users, men and women of color, and recipients of blood products. Extremist solutions of tattooing the buttocks, calls for quarantine, unauthorized disclosure of medical information, and coerced human immunodeficiency virus (HIV) testing was debated by both experts and ideological opportunists. Charlatanism and premature announcement of AIDS cures had devastating effects on desperately ill people and their families. People living with AIDS (PLWAs) faced egregious conduct from health and social providers, and PLWAs’ human rights were routinely breached. Poor treatment included the callous discussion of an HIV or AIDS diagnosis and breaches of confidentiality even when guaranteed by law. Nearly three decades later, the course of the pandemic has assumed a too ready familiarity that is incurring yet more apathy toward the plight of PLWAs and their families (Nichols, 1987; Sontag, 1978). Health care and social

service providers, in some cases, have grown overly euphoric about breakthroughs that have increased the longevity and quality of life of many PLWAs, at least for an uncertain period of time. For the public, it may appear as if AIDS is no longer a threat to them or others. Although we do not have the level of fear, hostility, and indifference that was characteristic of the responses by many health and social service providers in the early 1980s (Caputo, 1985; Greenly, 1986; Leukefeld & Fimbres, 1987; Lopez & Getzel, 1984), the issues currently arising present just as profound challenges for service development and effective interventive strategies as in the beginning of the pandemic. An urgent requirement remains for professionals to keep up-to-date on the changing biopsychological consequences associated with HIV/AIDS, diverse populations infected and affected, the nature of the disease sequelae, and treatment options, access, and compliance. HIV prevention remains a serious issue for health and social service providers now as in the past. Rates of HIV transmission have leveled off in some populations’ cohorts, while growing precipitously in others: this has added to the complexity of service strategies. defining and explaining aidS Since much of systems thinking, such as the concept of homeostasis, as well as ecological concepts, originates from biology (Buckley, 1967; 33

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Cannon, 1939), a biopsychosocial system framework is particularly applicable to the variables associated with AIDS in social work practice. Renee Dubos (1959) wrote that modern persons tend to deny their organismic nature and their place in biological evolution, largely because of widespread elimination of many lifethreatening diseases that, in the past centuries, killed infants, children, and large portions of the population of towns and cities. Clean water systems separated from sewage outlets, fresh food, housing regulations, and mass inoculation for childhood diseases are largely responsible for human longevity and the revolution in life expectations. A likely early death has been superseded by concerns about chronic disease in old age in modern industrial and postindustrial societies. The emergence of AIDS has made us aware that human beings are indeed organisms of exquisite complexity who are subject to parasitic and symbiotic relations with microorganisms from within and without (Bateson & Goldsby, 1989). Microorganisms can disable, disfigure, and kill a larger organism when their numbers reach a sufficient level, if the organism’s resistance to their increase does not stop them. In the highly sophisticated and technologically advanced countries, human beings can falsely believe that they are beyond the grasp of a variety of microorganisms, such as tubercle bacilli and streptococci, as well as a multiplicity of viruses capable of bringing on life-threatening diseases and horrific symptoms. The biological reality, however disconcerting it may be, is that the tissues of the human organism are awash with a variety of bacteria, protozoa, invertebrates, and viruses that are contained because of the multilevel defenses of the immune system. Unless the balance of microorganisms radically shifts in the host, it is perfectly possible for an individual to live his or her life oblivious of their existence. Biologists are beginning to explore the possible benefits of microorganisms, as well as their harm when resistance to

them falters. An investigation of public health measures through the centuries points to social activities such as sanitation and changed behaviors such as hand washing by doctors and midwives that have altered the environments of people and the balance of life-threatening microorganisms (Dubos, 1965). Pestilences like war have caused great social changes, not only by dramatically decreasing population size, but also by challenging cultural expectations (Rosenberg, 1989; Sontag, 1978). Camus (1948) noted that plague and war surprise us because each assumes a size exceeding expectations and forces us to confront mass deaths, which are met with initial denial and slowness to react. The Life Model developed by Gitterman and Germain (2008) uses an ecological system perspective that can be applied to the complexities of AIDS as a biological entity interacting with different psychological, social, and cultural dimensions. AIDS touches and influences the whole fabric of society and its cultural assumptions. Clearly, AIDS points to the Darwinian struggle for survival as human beings begin to engage in a life-and-death struggle to fit into a natural world that is also inhabited by the virus associated with AIDS. Human beings’ failure on the biological, psychological, social, and cultural levels to understand and to adapt to their new place in the natural world is a matter of individual and collective life and death. Bateson and Goldsby (1989) noted that HIV has created a new niche for itself in the natural world, supported not only by the individual human organism but also by the behaviors that transmit HIV to other organisms. Thus, the extent to which the individual human organism has favorable internal and external environments determines the individual’s health and life chances, and specifically whether he or she will become infected with HIV and go on to develop AIDS. While epidemics start by growing exponentially, changes in the infected organism or in the organism’s environment

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slow down the rate of infection. AIDS reveals how vulnerable human beings are in their biological relations with microorganisms, and for that matter with their fellow human organisms in maintaining bodily integrity and well-being. AIDS is a worldwide natural event. Modern transportation links populations all over the world, and in time, material, ideas, and microorganisms are diffused throughout different nations and cultures with significant, and sometime catastrophic, consequences. The resources needed to maintain the health of men, women, and children may not be available, and individuals, families, and whole communities may break down under the crisis of the worldwide AIDS pandemic. The AIDS pandemic taxes the available resources and may call for a redistribution of material resources and expertise in the interest of the whole of the human community—to halt the spread of disease and to care for those infected and affected. AIDS also points out that the human species is highly interdependent: humans inhabit a finite planet and must discover ways to ensure their mutual security and well-being. Social work practice with PLWAs demands a constant review of the emerging knowledge about the nature of the disease, its treatment, and the social and cultural impact on persons infected and ill, as well as on all those who interact with them over time. Medical discoveries related to HIV will have far-reaching effects on medical treatments, strongly affecting the longevity and quality of life, not to mention the hopes and expectations, of persons with life-threatening conditions. The ever-changing character of the AIDS epidemic requires constant updating of knowledge and systematic reflection on the interaction of biological, psychological, social, economic, political, and cultural factors. The biopsychosocial systems framework that has evolved in social work practice in health care is a heuristic for handing the complexity of the data emerging on AIDS and HIV infection; conversely, this tragic epidemic

may be an example par excellence of the usefulness of this framework. demographic Patterns With each year, the basic understanding of the magnitude and the international scope of the HIV/AIDS pandemic grows. There were an estimated 34 million cumulative HIV cases worldwide at the end of 2010 (Kaiser Family Foundation, 2012). Two major strains of retrovirus, HIV I and HIV II, have been located throughout the inhabited world. Sub-Saharan Africa, with approximately 23 million cumulative cases of HIV infection, has the highest concentration of any global geographic area, followed by more than 4 million in Southeast Asia, 1.5 million in Latin America, 1.3 million in North America, 840,000 in Western and Central Europe, and 200,000 in the Caribbean. Since the beginning of the pandemic, the estimated cumulative number of HIV/AIDS cases worldwide is estimated at 60 million, with more than 25 million, or 42 percent dead (Decock, 2008). As of 2010, 1.2 million people are estimated to be living with HIV infection in the United States (CDC, 2010). According to the Centers for Disease Control and Prevention, from 1981 to the end of 2008, there were more than 1,106,391 cumulative cases (CDC, 2010). Of the cumulative diagnosed cases, 47 percent have been identified as men who have sex with men (MSM); 17 percent as intravenous drug users (IDUs); 7 percent as both male homosexuals or bisexuals and IDUs; and 17 percent as adults who were infected through heterosexual contact. The remaining 2 percent are the result of hemophilia, blood transfusion, and risk factors not reported or not identified. Of the total cumulative cases of AIDS, approximately 20 percent have been women, of whom 40 percent had histories as IDUs, 57 percent were infected through heterosexual contact, and the remaining 4 percent were infected through blood, blood products, or undetermined sources. Children under the age of 13 made up a little

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less than 1 percent of the cumulative cases of AIDS, 92 percent having been infected before or during birth and the remaining 8 percent having been infected through blood, blood products, or undetermined sources. Of the total cumulative cases of women with AIDS at the end of 2008, more than 76 percent were black and Hispanic, from inner-city areas, and over 80 percent of all children were black and Hispanic, from inner-city areas where the sources of infection were IDUs. Whole families have become sick and died in poor neighborhoods throughout the United States. Of the more than 1,106,391 cumulatively diagnosed AIDS cases at the end of 2008, more than 42 percent were dead by the end of December 2008. From the period between 1981 and 2008, the rate of newly diagnosed AIDS cases has declined significantly since 1992, and the mortality rate of PLWAs has dropped dramatically since 1995. The decline in mortality is associated with the availability of more effective drug treatments (combination antiretroviral therapies including protease inhibitors). Perinatally acquired AIDS shows a marked decline, principally reflecting successful strategies to promote prenatal HIV testing and drugs administered during pregnancy after diagnosis (CDC, 2010). Societal context AIDS evokes powerful psychosocial responses in persons at the point of diagnosis (and often earlier), and in all those intimates and service providers with whom they interact. Such responses reflect current and changing societal values and assume greater magnitude as more individuals, families, and communities have direct experiences with PLWAs. The meaning of AIDS on a societal and cultural level is constantly delineated and reinterpreted in the mass media, particularly as the number of persons who become ill grows larger. The economic costs of providing expensive, if not scarce, health and social services at the state and local levels of government to

PLWAs are gaining more attention and political concern. Those who do not have AIDS and who perceive themselves as being in no danger of becoming HIV-infected may challenge the use of resources for PLWAs because of their high economic and social costs. In short, compassionate concern may decrease because of self-interest and a protectionist outlook in the general population. Powerlessness and stigma are inextricable aspects of AIDS on a societal level. Ironically, because of their prior stigmatized and isolated conditions, gay and bisexual men as well as intravenous drug users and their sexual partners and newborns have had the heaviest concentrations of HIV infection. The societal prejudice against homosexual persons now has a powerful biological analogue in the form of AIDS, which reinforces the existing enmity toward them and severely limits their civil rights and opportunities to live full and productive lives. The homophobia experienced by gay people is frequently internalized, adding to the pain that vulnerable persons feel, even before they develop HIV-related symptoms or a formal AIDS diagnosis. The largest populations of intravenous drug users are the inner-city poor, black, and Hispanic adults whose health, security, and life chances are greatly diminished even before they are HIV-infected. Poor-quality medical services, lack of access to care, and community distrust and suspicion effectively may deprive inner-city people of required preventive, acute, and long-term health care. Prejudice toward addicts on the part of providers and the public accompany racial, ethnic, and class hostilities. An abiding and very serious question asked by inner-city community leaders and concerned advocates for AIDS services is whether innercity populations are being written off as expendables because they cannot be served easily and because they come with so many enmeshed problems, such as homelessness and poverty. Most HIV-infected women are from poor, innercity, minority backgrounds, and they frequently

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have infected infants and children. The directing of resources of all kinds to this population, as to gay and bisexual men, was initially indifferent and typically slow in response. On a societal level, AIDS challenged the historically new concept of what constitutes a fair share of life by devastating young adults with an exotic array of chronic, life-threatening diseases and with early deaths. AIDS links a death-dealing disease to sexual activities, with far-reaching effects on sexual attitudes and behaviors. Sexual freedom and expression are now fraught with danger, microscopic mysteries, and morality. Vulnerabilities and risk factors The epidemiological evidence gives overwhelming support to the proposition that AIDS cannot be transmitted through casual contact, such as touching, kissing, and using the same toilet; it can be transmitted only through the exchange of blood, semen, vaginal fluid, and mother’s milk. Studies of persons sharing the same households indicate that transmission occurs only between those individuals engaged in sexual activities and IV drug use and to infants born of infected mothers (Kull, 2010). Social workers dealing with AIDS should have a rudimentary understanding of the biology of HIV infection and be able to translate it clearly to clients to assist them in AIDS prevention activities and interpreting AIDSrelated symptoms and infections. Social workers are increasingly called to speak to a wide range of individuals and groups about AIDS and the transmission of HIV. Therefore, all AIDS education for social workers begins with understanding of HIV biology and goes on to considerations of the person, dyadic relations, the family, the community, and the larger social systems. In simple, unadorned language with apt analogies designed for specific audiences, social workers must discuss the nature of HIV transmission and prevention. Social workers should be prepared to react to simple ignorance

as well as to highly intellectualized arguments that reveal a person’s denial of the actual modes of AIDS transmission and the real threats to their lives. AIDS, and underlying disease of the immune system, must be understood as a metadisease process, a generator of otherwise rare opportunistic infections such as Pneumocystis jirovecii pneumonia (PCP), cytomegaloviral infections, toxoplasmosis, and rare cancers such as Kaposi’s sarcoma and Hodgkin’s lymphomas. According to a 1992 revision of the case definition, an AIDS definition also includes adult and children with less than a 200 CD T-lymphocyte count, cervical cancer, recurrent bacterial pneumonia, and pulmonary tuberculosis. AIDS is a disease associated with the imminent or actual catastrophic collapse of bodily immunity and with the presence of HIV infection. As mentioned, HIV is transmitted only through the intimate exchange of bodily fluids, specifically semen, vaginal fluid, blood, and mother’s milk. The activities identified with a high risk of the transmission of HIV are anal, oral, and vaginal sex; the use of infected blood or blood products; the sharing of infected drug paraphernalia; and breast-feeding. HIV is also transmitted from mother to fetus in the uterus or during birth (Kull, 2010). Not all persons who have contact with HIV become infected, nor do all persons infected develop HIV symptoms (such as night sweats, swollen glands, weight loss, and rashes) or fullblown AIDS with the appearance of an opportunistic infection or through blood test finding. Because of the dangers of spreading infection to others and exacerbating existing infections, it is vital for all persons with or without current HIV infection to be aware of the modes of transmission; to practice safer sex through the use of rubber latex condoms during anal, oral, and vaginal sex; and to avoid the sharing of intravenous drug paraphernalia. In the course of their direct practice with individuals, families, and groups, social workers have frequent opportunities to assist clients

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to examine the activities that place them at risk of infection. Social workers must develop comfort in discussing sexual practices and drug use so that they can help clients make behavioral changes to avoid infection. Neither the induction of fear nor calls for abstinence are sufficient to encourage new, lifesaving behaviors. Social workers have created exciting approaches to teaching safer sex behaviors by positive techniques such as eroticizing the use of condoms with both gay and nongay men and women (Getzel & Mahony, 1988; Shernoff, 1988). Scientific knowledge about HIV and the cellular processes of infection has grown dramatically since the 1990s as research proceeds in the United States and throughout the world. Because of its specific attraction to T4 helper lymphocytes (blood cells), HIV infects them, replicates, and thus overwhelms the individual’s overall immune capacity. The growth of opportunistic infections and cancers may proceed rapidly or over a long period of time. There is strong evidence that HIV has a long latency period before replicating. Scientists are investigating the conditions or cofactors associated with the development of specific symptoms and opportunistic infections related to the flaring up of HIV infection. HIV infection can be readily detected by the use of antibody tests and emerging new strategies. These tests have been useful in the mass screening of blood in hospitals and blood banks. The use of antibody testing for individuals presents serious practical, clinical, and other ethical questions. The tests check for the presence of HIV antibodies, which the body produces six weeks to three months or longer after infection has occurred. There is clearly a possibility of a false-negative test finding; it is therefore recommended that persons abstain from high-risk activities and be tested again in within six months (Kull, 2010). The test is a diagnostic tool, and negative test findings are not a signal that a person is immune from infection. There is a strong danger of magical thinking that turns the test into

a stimulus for unsafe activities. Consequently, there is a profound need for pretest counseling about what the test is and is not, as well as for an exploration of the meaning of both a negative and a positive test finding. Skilled posttest counseling by a social worker or other qualified health professional is vital to reinforce safer sex guidelines and to handle the often strong emotional responses of those hearing a positive test finding. A person with a positive test finding may become depressed or even suicidal. Other reactions may be a fear of informing intimates and rage at those who are perceived as the source of the infection. In certain jurisdictions, important practical and ethical issues arise about the counselor’s legal requirement to report positive test findings to government officials, to the tested person’s intimates, and to other agencies (Bayer, 1989; Dickens, 1988). The client should know the reporting requirements in advance. Anonymous testing sites, where available, provide the opportunity to assist in teaching AIDS prevention activities and helping the client get necessary health care. To the extent possible, test findings should be kept confidential. Some states protect test findings legally, a most difficult task in many health care agencies. The revealing of a positive test finding or an AIDS diagnosis may cause the loss of job and benefits, breaches of civil liberties, and incidents of violence. Medical treatment for persons with HIV infection and AIDS has changed radically since the beginning of the epidemic in 1981. Changes in the treatment of HIV infection and opportunistic diseases are occurring rapidly because of the introduction of new treatment procedures and drugs. Such developments have significantly affected the quality of life of people with HIV and AIDS. Multiple drug therapies have radically changed the clinical condition of many who have been symptomatic and facing foreshortened lives. Some long-term survivors assumed from the premature death of their friends and family from HIV-related

acquired immune deficiency Syndrome (aidS)

conditions that they only had months or at best a few years to live. Consequently, they left jobs and were forced to use most of their financial resources. A so-called Lazarus effect has been noted among these populations who have felt they have come back from the dead. It is not unusual for these survivors to have seemingly paradoxical reactions of depression, agitation, and disorientation to unexpected quality-of-life enhancement and increased longevity. A major emphasis of social workers in recent years has been to help those who have benefited significantly from “state-of-the-art” treatments to accept that they have a future and begin to plan for reentry into the hurly-burly world of work, contact with family and friends, and reintegration into community activities. Social workers and other professionals committed to working with PLWAs also have been disoriented by these medical breakthroughs that eliminate quick death from opportunistic infection shortly after AIDS diagnosis. HIVrelated illnesses and disabilities have shifted from an overwhelming chronic syndrome with successively worsening acute life-threatening episodes to a chronic condition with indeterminate symptom display characterized by less frequent acute life-threatening episodes. Important advances also have been made in the treatment of opportunistic infections and cancers historically associated with an AIDS diagnosis. Medical treatments tend to be administered more often by health professionals in the client’s home than in acute care hospitals. Social workers in health care must now work with the family as a whole in adjusting to intrusion of medical treatment in the home that may involve their participation in supporting medical treatment. Not all persons have benefited from these revolutionary medical advances; some have initially rallied only to become acutely ill again, while others have not benefited at all. Such patients and those frustrated health care professionals caring for them may feel a profound failure.

resiliencies and Protective factors While HIV/AIDS opens people to biopsychosocial vulnerabilities from forces from within and without, core resiliency and reserves of strength of people affected by HIV/AIDS represent a stunning resource for the practitioner. The early indigenous PLWA movement demanded that researchers and clinicians not use terms such as sufferer, afflicted, and patient, connotative of an inherent moral weakness of the person. PLWAs were also to be represented at all public forums, educational presentations, and panels and boards reviewing AIDS service projects. The dignity and humanity of PLWAs were recognized as crucial to expanding human rights and enhancing public understanding (Poindexter, 2010; Kamya, 2010). AIDS service organizations such as GMHC and the San Francisco AIDS Foundation developed legal and public policy arms to support PLWAs and their families in challenging violations of their civil rights at the workplace and in public accommodation. Thus, built into the social construction of an individual’s career as a PLWA was the expectation or at least the possibility of standing resolutely against prejudices and other forms of societal violence. In short, participants in the AIDS movement endeavored to disabuse themselves and the public of the image of the PLWA as a pitiable victim with a tainted moral status. With the support of organizations and community-based self-defense structures, the strengths and resiliency of PLWAs had a sociopolitical context for recognition and support. PLWAs and their loved ones saw the practical virtues of challenging threats from enemies of their interests. From a position of self-defense and identity politics, the PLWA came to represent someone who not only needed assistance from time to time but also had contributions to make toward the well-being of the rest of the population who were in denial of their vulnerability to HIV infection and the AIDS pandemic. Interestingly, many PLWAs assumed roles as expert HIV educators and AIDS service providers after their diagnosis.

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The AIDS movement provided important semantic distinctions and behavioral stances that contributed to the possibility of a wholesome identity arising out of an AIDS diagnosis or later an HIV-positive test finding. For example, a self-help organization of HIV-positive men and women in New York City was named “Body-Positive.” Paradoxically, AIDS and HIV for many affected people became an affirmative, transformative experience. Upon discovering that they are infected with HIV or have an AIDS diagnosis, some people make fundamental changes in their lives, such as the recovery from substance abuse and the assumption of a more healthful diet or lifestyle. They may even see HIV/AIDS as a gift or an opening to spiritual regeneration. In support groups and other contexts, PLWAs typically demonstrate coping styles or survival strategies that prove very useful in more effectively managing the shifting states of vulnerability associated with the biopsychosocial twists and turns of symptoms and illness. The dangerous stances for people affected by HIV/AIDS are related to two extremes: either becoming morbidly preoccupied with HIV/ AIDS or assuming an outlook of total denial of HIV/AIDS that includes continuation of poor health habits and unsafe sex. However, there are alternative strategies that have survival benefits that are continuous with social types familiar to us all from life and literature; for example, “The Hero” who valiantly fights foe, AIDS, and although he or she may be vanquished in the end, lives bravely in others’ memories. In addition to a heroic survival strategy, a PLWA may use beneficence, or helping others, as a positive mode of coping while being helped him- or herself. Other PLWAs become instrumentalrational by reading medical journals or seeking out experts in devising self-care approaches for themselves and others. For others, the use of artistic-spiritual expression may be their mode of transcending or understanding the boundary and the existential problems associated with illness, death, and meaning.

The survival strategies represent socially validated constructions that are personally driven efforts to avoid the extremes of morbidity and blanket denial of life-threatening conditions. Social workers should be respectful of these survival strategies as wholly human efforts to deal with existential concerns. As human actions, they reflect social connection with others, a historical period and intentionality (to move beyond the here-and-now to images of a future). These are the mechanisms to resiliency that represent strengths existing alongside vulnerabilities. Strengths can only exist in a context of support and recognition that is imparted significantly in social workers’ attitudes and actions toward people with HIV/AIDS. Despite social workers’ myopic preoccupation with disease and dysfunction, the essential truth is that we work with people through their evident strengths or those reserves of strength that are hidden for the moment. Just as PLWAs use maladaptive stances and positive survival strategies, social workers benefit from honest appraisals of their own stances to HIV/AIDS that support or deter PLWAs’ healthful efforts. For example, some social workers have been shocked and confused by PLWAs who were literally dying of complications of AIDS, now having remarkable recoveries because of revolutionary new medicines. We are reaching a period when learning to live with AIDS is far more prevalent than learning to die from complications. Programs and Social Work contributions The nearly 30 years of activities by social workers with and on behalf of PLWAs have been characterized by heroic humanitarianism in meeting the acute, crisis-related problem of persons infected or affected by HIV (Lopez & Getzel, 1987; Palacios-Jimenez & Shernoff, 1986; Ryan, 1987, Sonsel, Paradise, & Stroup, 1988; Wheeler, 2007). The humanitarian strategy created an array of AIDS-specific programs either de novo in the case of voluntary communitybased AIDS organizations, or through political

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agitation for special entitlement for PLWAs— income maintenance programs, housing, mental health care, drug reimbursement, and AIDS-designated medical units and long-term facilities. In addition, some governmental units have provided PLWAs with varying degrees of legal protections and assistance. Heroic humanitarianism has created an appreciable, but often shoddy, service network for PLWAs. For example, in New York City it is not unusual for formerly impoverished, homeless PLWAs to say, “After I got AIDS, they treated me like a human being.” This form of exceptionalism on behalf of PLWAs, while life enhancing in many instances, creates resentment among other needy people with non-AIDS-related conditions that are no less threatening and serious. Of particular concern now that medical breakthroughs are improving the health of many PLWAs is that these critical survival benefits will be removed. Since the early 1980s many social work programmatic efforts have been undertaken in response to the AIDS epidemic in the United States. Social workers have participated in the development of community-based programs for PLWAs and their loved ones under gay auspices, first in the establishment of the Gay Men’s Health Crisis in New York City in 1982 (Lopez & Getzel, 1984), followed by the Los Angeles AIDS Project and the Shanti Project in San Francisco. These innovative programs operate through the large-scale use of nonprofessionals and professionals as volunteers providing an array of personal services to help PLWAs and their loved ones to handle the multiple crises associated with diagnosis and the subsequent biopsychosocial crises precipitated by illness, hospitalizations, financial difficulties, legal and employment problems, familial conflicts, and entitlement concerns. Hundreds of community-based programs for PLWAs initially started by the gay and lesbian community now serve thousands of gay and nongay persons throughout North America and parts of Europe.

Social workers and other professionals have been particularly influential in the development of and leadership in volunteer crisis intervention teams, whose members are available to provide emotional support and advocacy activities to PLWAs and their loved ones at critical periods of stress in the psychosocial sequence of the disease (Lopez & Getzel, 1987). Volunteer crisis workers undergo careful recruitment and require ongoing supervision and training. Another widespread innovative program uses volunteers as “buddies” who do light household chores for disabled PLWAs as well as provide social contact to break down social isolation. Community-based programs offer support groups for PLWAs, which are generally run by social workers and other professional volunteers. Membership in these groups may be open-ended and as needed, or closed-ended and long-term (Gambe & Getzel, 1989). Support groups for family members and care partners are also quite common. Innovative couples’ groups for both gay and nongay couples are sometimes used, as well as groups that focus on bereavement adjustment, which are generally time limited. Educational and more didactic-oriented group programs are increasingly used to teach safer sex by cognitive behavioral techniques. Support groups for persons who are HIV-positive, but who are otherwise asymptomatic, that focus on more healthful living and on social support are becoming more widespread as testing for the virus is related to experimental treatments to ward off symptoms and an AIDS diagnosis. Social workers and other health care professionals may conduct such groups in community health programs or at HIV testing sites. The special problems of women who are HIVinfected, of children who have siblings with AIDS, and of survivors of multiple losses due to AIDS may be addressed through special focus groups that universalize their difficult situations with peer support.

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Family counseling with persons from a variety of backgrounds, conducted by social workers, has proved promising (Walker, 1987). Increasingly, social workers in private practice and agency work are seeing the direct and indirect influence of AIDS and HIV infection in their caseloads. For example, agencies serving the visually disabled are being asked to work with PLWAs blinded by different opportunistic infections and cancers. Long-term care facilities and home care programs are being pressed into service for multiply disabled PLWAs, including individuals with AIDS dementia. Hospice programs tailored to the particular needs of PLWAs have been established. A primary setting for social work intervention remains the acute care hospitals during health crises of PLWAs. Whether dispersed or in a designated area, PLWAs and their families require focused crisis intervention and even short-term groups. Increasingly, case management work by social workers is an area of importance because of the growth of outpatient care provisions. Sensitive work with PLWAs is necessary as they become more disabled and disoriented. Homelessness and poverty among inner-city hospital AIDS patients require intensive case management and the elimination of routine bureaucratic red tape. Social workers frequently become strong advocates for entitlements and prompt responses from large public agencies, especially when their clients are in crisis and are under stresses of life-threatening conditions. A high degree of interprofessional cooperation is not unusual in hospital programs designed for AIDS patients. Support networks for social workers have also developed in different parts of the country to allow exchanges of information as well as to provide professional recognition and emotional support. Social workers also have given expert testimony to local, state, and federal panels on AIDS and HIV infection. The advent of so-called welfare reform, privatization, and managed care further highlight

societal failures to effectively deal with a grave public health emergency. Placing money and cost containment before the needs of people has serious consequences for PLWAs. The absence of a national health care program in the United States places all citizens at risk during pandemic and other health care emergencies, because there is no comprehensive system for the dissemination of public health education. Hopefully, the passage of the Affordable Health Care Act will make a significant difference in AIDS patients’ lives. Scientists also lack accurate baseline epidemiological data on all Americans so that the progression of the pandemic can be adequately monitored. Citizens may be wary of how for-profit insurance companies and other corporate entities will use sensitive medical information to deny them services or infringe on their privacy. The social work profession through its national association and other organizations have continued to respond slowly to the pandemic. Conflicts of interest also exist when professionals collude with managed care and insurance programs for short-run financial rewards. The federal government continues to resist funding needle exchange programs that effectively reduce HIV infection among users of intravenous drugs. Despite these considerable limitations, there is a need to generate programs that address the niche requirement of women, adolescents, older people, AIDS orphans, long-term survivors, prisoners, immigrants, the newly infected, and the cumulatively traumatized through serial bereavement. Social workers clearly have and can continue to assume leadership in these areas of emerging need. assessment and interventions Social work practice with PLWAs must be particularly sensitive to the diversity of the people infected and affected in each case. Individuals, families, communities, and regions reflect different patterns and variations that significantly influence diagnoses, assessments, and interventions. The following case illustrations point

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to the complexity of understanding needed to work with persons with AIDS and HIV infection.

Peter is currently hospitalized in a room filled with cards and flowers. This is his third hospitalization in four months. He is a white 34-year-old gay man and the first college-educated member of his workingclass suburban family. Peter has known that he is HIV-positive for ten years. Four years ago, his T cell count dropped below 200, and the volume of HIV infection grew in his body. Peter was among the first patients to take combination antiviral drugs. The drugs reduced viral activity and his blood work improved as did his sense of well-being. Recently, viral activity has increased because of his diminished response to combination drug treatment. He has been hospitalized three times in the last two months for hepatitis and bacterial pneumonia. Peter has lost 30 pounds. His friends and his former lover have been available to help him at the hospital and at home. He has grown depressed and agitated and has told his sister that they should plan his suicide. mArthA is a Hispanic female, aged 40, and is a recovering narcotic addict with a history of drug abuse from the age of 14 to 35. She had one child when she was 20 years old; when that child was 6 months of age, the department of child welfare removed the child from her. After her second child was shot to death in a gunfight, Martha joined Narcotics Anonymous and has been drug-free for five years. She joined an AIDS support group shortly after being diagnosed six months ago. Martha, a leader in the group, says the group helps.

is a white 35-year-old bisexual man who is married and has no children. His wife does not know about his AIDS diagnosis; he is frightened that she is HIV-infected. Warren has been able to continue working but spends all his available time reading medical journals; he tells his social worker at the clinic that he will “beat” AIDS. Warren has been asymptomatic since discovering Kaposi’s sarcoma lesions on his chest a year and a half ago.

WArren

JAne is a 25-year-old middle-class woman who was exposed to HIV through a six-month relationship with a man with a prison record who did tell her he had AIDS. She was diagnosed as HIV-positive after losing a great deal of weight and having recurring fevers. Her current boyfriend, Roberto, accepted the news of Jane’s HIV diagnosis and he subsequently tested HIV-negative. A month later, he proposed marriage. They have expressed interest in adopting a child in a year or two.

is a 16-year-old hemophiliac who became HIV-positive from infected blood products used for their clotting substance. Allan’s older brother, also a hemophiliac, died several years ago from AIDS. Allan is currently unaware that his father, a hemophiliac, is HIV-positive, while his mother is not. Recently, his parents have been fighting and have discussed a trial separation.

AllAn

Each person with HIV infection has a unique history, specific life experiences, social supports, and other resources. In considering how to serve this population, social workers should pay particular attention to the following assessment criteria and intervention foci. Christ, Weiner, and Moynihan (1986) indicated that at diagnosis, an individual generally goes through profound and far-reaching emotional responses to the psychosocial consequences of the illness. In turn, all persons intimately related to the diagnosed person may experience similar strong emotional reactions. The social worker must understand the intensity of the coping efforts that underlie the strong and sometimes confusing reactions of individuals and their families. Panicky reactions build if a person develops night sweats, swollen glands, weight loss, and other HIV-related symptoms before the presence of an AIDS diagnosis. Paradoxically, once the PLWA develops an opportunistic infection and finally receives a formal AIDS diagnosis, he or she may be emotionally relieved for a time. A PLWA often feels, “At least I can now stop worrying that I’m going to get AIDS.”

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Pre- or post-diagnosis preoccupation with becoming ill results in social isolation. Affected individuals may see themselves as possessed by the disease—controlled at every turn by thoughts about illness—and subtly and not so subtly reminded by others that they have a potentially progressive and fatal condition. Therefore, PLWAs often see themselves as toxic, stigmatized outcasts worthy of others’ reactions. Susan Sontag (1977) wrote, “Any illness that is treated as a mystery and acutely enough to be feared will be felt to be morally, if not literally contagious” (pp. 5–6). The association of AIDS with homosexuality and substance abuse has contributed to the public’s fear and the legitimation of prejudice and aversion. Unfortunately, many PLWAs also assume these powerful negative images themselves, which are too frequently reinforced by the acute withdrawal of kin, friends, and others who become fearful of becoming ill or tainted by their contact with AIDS. Family members’ and friends’ vulnerabilities are heightened if they share PLWAs’ lifestyle, age, interests, and personal habits. Aversive and rejecting behaviors by providers of health and human services are particularly potent in feeding depression, diminishing self-esteem, and engendering rage in already stressed and burdened PLWAs. Mounting social isolation contributes to PLWAs’ feeling withdrawn, depressed, emotionally worthless, physically fatigued, and sexually void. PLWAs may experience shame at being exposed as gay or as drug users or as sexually linked with these populations. Tragically, some PLWAs may associate AIDS with a personal attribute and not with past activities. Defensively, these PLWAs may bargain to go straight or to swear off the use of drugs, if they might be cured. This kind of magical thinking and self-condemnation becomes a dead-end approach by PLWAs to overcome the crises of diagnosis, illness, and disabilities.

Social workers must carefully assess the positive coping elements in PLWAs’ emotional expression during crisis periods. During crises, PLWAs’ characteristic methods of coping with feeling states problem solving falter. An emotional roller-coaster ride of anger, guilt, rage, sadness, and fear represents PLWAs’ early efforts to cope with each bit of medical information, new symptoms, and functional losses. Social workers are most helpful when they assist PLWAs to understand their reactions at a specific time. For example, sadness and depression reflect, in part, authentic grieving over actual bodily and functional losses. As PLWAs are able to give themselves time and space to grieve, they can approach other aspects of personal mortality. The prospect of dying from AIDS often opens up memories of the deaths of family members and friends. PLWAs may feel guilty about the burdens that they believe their illness is placing on loved ones for their care. Consequently, PLWAs may be reticent to ask for help from others. PLWAs’ anger and rage are reflections of the injustices of falling ill and being rejected by others. Anger can be positive, if it can be channeled into being more assertive with physicians and other providers of health and societal services. Becoming a thoughtful and responsive consumer of help results from social workers’ legitimating PLWAs’ sometimes diffuse anger and sense of impotence when approaching the staffs of hospitals and social agencies. Far too often, PLWAs feel powerlessness as they face making new and greater demands for care. If PLWAs can gain a sense of control over their care, they are apt to experience enhanced responses and practical assistance from the medical establishment, social agencies, employers, and others. Finally, in the face of ultimate questions of life and death, PLWAs show remarkable capacities for hope. Even though PLWAs occasionally intimate as well as actually speak about suicide, expressions of hope are ubiquitous. In many situations, denial of being ill or of

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having a foreshortened existence is a necessary and useful coping strategy. Hope is supported when PLWAs live as fully as they can. Just as PLWAs should be allowed to deny aspects of their illness, they should be free to express concerns about dying and death, which often come up in the discussion of wills, funeral arrangements, and living wills that control quality of life while dying. Social workers and other professionals serving people with HIV infection and AIDS—and, for that matter, responding to a variety of other problems and contributions—should draw a broad operational definition of family, so that it includes all relatives, life companions, and friends who demonstrate a long-term commitment to caring for the person in need. Social workers should identify a PLWA’s functional family as the network that provides some measure of emotional support, guidance, material resources, and help with practical, everyday routines and chores. Members of the family network play an important role in determining how PLWAs receive needed health care, social services, legal assistance, and other services, particularly during crisis periods and at points of incapacitation. The family network undergoes changing patterns of closeness and social support to a PLWA as he or she experiences the crises associated with HIV and AIDS. A PLWA may be overwhelmed at the prospect of revealing a diagnosis to unsuspecting relatives for fear of emotional rejection and abandonment. The pressure on the PLWA is heightened if family members also discover the “secret” of homosexuality or drug use. While such fears cannot be dismissed, it is also not uncommon for relatives and friends to move closer after such revelations, paradoxically surprising the wary PLWA. The decision to inform a family of an AIDS or HIV-positive diagnosis must always be the PLWA’s; the social worker can be most helpful in assisting the PLWA to find the appropriate time and way to share the diagnosis with particular family members and friends. Family

dynamics as well as cultural and ethnic styles may be factors in how and with whom information is first shared. Clearly, there are political consequences in and outside the family network when an AIDS diagnosis is revealed. Very often, the social worker’s balanced, nonjudgmental, and accepting attitude toward a PLWA, during good times and bad, serves as an antidote to recurrent feelings of isolation, diminished self-esteem, and suspicion. One of the most powerful and effective tools for helping a PLWA to break down isolation and regain a sense of normality and trust is the PLWA support group, which universalizes experiences and provides true understanding and a safe environment (Getzel & Osteen, 2011). AIDS may prompt family members to try to resolve long-standing concerns related to sexuality, drug use, and other significant historical issues in the kinship network. A PLWA and a family member may share guilt and recriminations, holding themselves or others responsible for the irreversible tragedies each person perceives. Gay couples may experience a breakdown in their relationship and in their capacity for trust and intimacy. Family members may be ashamed to share their feelings with friends who are perceived as too judgmental about the subject of AIDS. Fear of HIV contagion is especially upsetting to members of the family network who fear casual contact or who are justifiably concerned about sexual, intravenous needle, or fetal transmission. Therefore, in the course of their work with family members, social workers must assess the risks of transmission and the wisdom of HIV antibody testing in the immediate and long-term interests of the members of the kinship network. Social workers have an important role in the direct teaching of families about AIDS transmission and prevention and about safer sex practices. If spouses and life companions of PLWAs are HIV-positive or believe themselves to be infected, they may fear developing symptoms

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or opportunistic infections. Powerful feelings of anxiety, helplessness, and even anger toward PLWAs may make it difficult for spouses and life companions to acknowledge self-concerns, especially if they are providing significant caregiving. They may have recurrent fatalistic fantasies and fears of becoming ill alongside the PLWA. Even if a spouse or life companion is HIV-negative, he or she may experience survivor’s guilt and feelings of personal unworthiness. If a child is infected; the emotional burdens for the mother and others in the family are catastrophic. Social workers should be aware of the ethical questions entailed in sharing information about HIV infection and AIDS. Legal requirements for reporting test results to a person’s sexual partners exist in certain jurisdictions, as well as rules for strict confidentiality about sharing test findings and diagnoses. Families of intravenous drug users may have several members who are infected and ill at different times or all at once; over time the family network may collapse functionally and physically from within. Such families require humane and continuous survival services and ongoing grief and bereavement counseling. Child welfare services become very important (Anderson, 1986). Before care can be provided and formal diagnoses made, poverty, racism, and cultural barriers must be overcome by community-based service providers and inner-city hospitals’ staff who often discover HIV-infected men, women, and children who have long been ill and are severely debilitated. Intravenous drug users’ survival strategies frequently entail subterfuge, criminality, and suspicion, which continue in their relationship with AIDS service providers, who in turn become antagonistic adversaries. Relapse prevention strategies have assumed central importance in the psychosocial treatment of HIV-positive addicts. The burdens of family caregivers deepen with successive health crises. PLWAs’ concerns about becoming increasingly dependent on others may be expressed in strong emotional

reactions to family members. Stresses from the indignities of illness and from historic conflicts within the family network are bound to overwhelm even the most even-tempered PLWAs from time to time. Support groups for family caregivers provide valuable opportunities to discuss practical concerns and emotional issues with others who are having similar experiences. When conflicts erupt in the family network, social workers should assume a mediating function. The well-being of the PLWAs must always be of paramount concern. When PLWAs face life-threatening health crises, family members may wish to discuss such contingencies as living wills, powers of attorney, funeral arrangements, and estate planning. If these arrangements are made carefully in advance, they help families avoid excessive conflict during periods of stress. Discussions of these practical concerns of living and dying allow anticipatory grief expressions and some partial acceptance of the prospective losses. Many persons now appear to be living longer with AIDS. An immediate death from opportunistic infections may be less likely because of more sophisticated medical treatments and the effectiveness of antiviral medications. As PLWAs live longer with AIDS, they make plans against a backdrop of incertitude. Life cycle events like baptisms, weddings, bar mitzvahs, and holiday rituals assume greater importance because they break down social isolation and allow opportunities to participate in activities that represent continuity and contributions to others. PLWAs often desire ways to identify their legacies to loved ones as they review the meaning of their lives during or after lifethreatening episodes. Family members and PLWAs exhibit considerable variations in their capacity to discuss illness directly, regardless of how ominous circumstances become. Caregivers may need help to accept respite from the increasing anxiety and pressures that occur during the course of the disease. Often, a PLWA is relieved of guilt if the burdens of caregiving are lightened for

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a primary-caregiving family member. Family members continue to struggle with AIDS after PLWAs die. The need for remembrance, validation, and continued expressions of grief is natural and predictable. Loved ones may benefit from bereavement groups geared to the special needs of “survivors” of AIDS. There are no simple formulas for adjusting to the loss of so many people cut off in the prime of their lives by devastating illnesses. Family members who care for PLWAs may find volunteer work in AIDS service organization a meaningful way to memorialize relatives and friends, and to participate anew in life’s sorrows and joys. illuStrAtion And diSCuSSion

It is in specific cases that the human face of AIDS is revealed. Understanding human responses to AIDS is important, not only in indicating how the mechanics of diagnosis and intervention may be accomplished, but also in sensitizing clinicians to the pathos of PLWAs, who often must face, in addition to the indignities of disease, societal stigma and isolation. In preparation for AIDS work, practitioners may benefit from an examination of the emerging literature of firsthand encounters with AIDS (Monette, 1988; Peabody, 1986; Whitmore, 1988) or accounts by practitioners (Greenly, 1986; Snow, 1987). The following case description focuses on Marcos Vega, a 24-year-old Latino man who sought out help from a community-based AIDS clinic after finding Anita, his 20-year-old wife, was HIV-positive after a routine prenatal examination revealed abnormal blood findings. Marcos was 21 years old when he met Anita, who was completing her senior year in high school. Marcos had a history of substance abuse since the age of 13, culminating with heroin addiction. Marcos did not know his father, who left the family when Marcos was 4 years old; he persistently dreamed of uniting with his father, but he feared that he might have died. His mother had tried repeatedly

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to get Marcos into rehab and felt increasingly helpless in her ability to take care of him. Marcos was tossed from one family member to another. After multiple rejections, he began receiving welfare benefits and continued to fail in all drug programs he was required to attend. The road to sobriety was long with many arrests, homelessness, loneliness, depression, and suicidal gestures. Persuaded by a friend of his mother, Marcos began to attend Narcotics Anonymous (NA) regularly; he felt strong for the first time in his life. His confidence grew with each month of sustained sobriety. Marcos was well liked by others in “the rooms” of NA. He soon met Anita after being introduced by a friend from NA. They both remember it was love at first sight. Despite her father’s reasonable concerns about Marcos’s ability to earn a living and take care of his beloved oldest daughter, they were married. Anita successfully completed high school and continued to work at a local grocery, contributing money to her family as well as pooling income with Marcos, who worked as a peer educator in his drug treatment program. Marcos was widely seen by his peers as a role model of successful recovery accomplished by hard work. A few months into their marriage, Anita was pregnant. Although surprised, they felt confident that all would be fine. Unfortunately, even with all of his determination, the Vegas were going to face even more daunting challenges arising from HIV and AIDS. Anita’s first prenatal visit showed an abnormal count for white blood cells, the cells that help to fight infection. The Vegas were referred to a hospital social worker who, after a brief interview, noted factors in their history placing them at high risk for HIV infection. The worker told the Vegas that given Marcos’s historic drug use, she strongly recommended that they each be tested for HIV. Anita looked confused and asked if anything bad could happen to their baby. The social worker noted if Anita were HIV-negative, the baby could not be HIV-positive. If she were HIV-positive, there were drugs that help the fetus avoid infection. Anita looked confused and disoriented.

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Phase 1. In the first phase with a family affected by HIV, social workers engage and assess the condition of the persons at risk of an HIV/AIDS diagnosis. The beginning phase of the intervention also is characterized by approach avoidance responses prompted by the at-risk person’s unconscious sense of dependency and the loss of control that is associated with simply reaching for help. HIV/AIDS itself is emblematic of uncertainty and the prospect of the loss of bodily control. Therefore, the social worker working with people affected by HIV/AIDS must strive to give them a sense of control by allowing them to define their needs at their own pace and on their own terms. The interventive approach is, therefore, nonconfrontational and typically permits a PLWA to ritually tell and retell his or her survival story beginning with diagnosis and attendant concerns. The social worker points out commonalties of the experience and acknowledges explicit and implicit painful affects, including shame, guilt, loneliness, rage, and sadness. Marcos grew extremely agitated, blaming himself for never having a complete blood workup. Avoiding his wife’s eyes, he told the social worker that he was confident that there was absolutely no risk to the baby. As if he were pleading his case to the social worker, he reiterated that the only possible route of infection was his multiple sexual partners from the period he was out in the streets and using. Marcos remembers using drugs intravenously one time with a buddy of his from high school, all the other times he did his usual snorting. Marcos felt assured that this was the first time for his friend. Marcos hadn’t seen this friend in at least seven years; no one had. After a long painful interview with their social worker, the Vegas decided to be tested for HIV. In Anita’s words, “not for themselves but for the baby.” Anita and Marcos met with their doctor and the social worker when they discovered they both tested HIV-positive. They were shocked and never had an idea of the possibility.

The next few weeks were filled with heartache and pain. In silence and secrecy, both Anita and Marcos found their attention primarily focused on the pregnancy and HIV. Anita tearfully told the worker that she had no one to talk to about her concerns. Marcos spent a great deal of time working and going to the NA meetings. Anita was particularly fearful of her father’s reaction and thought that it would hurt him too much. Marcos kept it quiet among his friends, only telling his Narcotics Anonymous sponsor, afraid of former addicts’ reactions. The Vegas each privately told the social worker that they were concerned about the well-being of the other and did not know where to turn. The social worker asked them how helpful it would be if they came together for a few sessions to speak about the pregnancy as a couple. During a single session they began to ask each other out loud: Would we soon get ill and die? Do we need to be taking medications? What about our unborn child? The Vegas realized that they had each other for support, but they also needed other forms of help. The social worker suggested that they make active use of counseling with her and join relevant support groups that the agency offered. Phase 2. Assisting and supporting persons with HIV/AIDS, the social worker continues to identify and to explore complex psychosocial problems with clients. The social worker must avoid the temptation to preempt self-determination out of anxiety arising from perceptions that the persons with HIV/AIDS are automatically weak and vulnerable. The worker identifies the strengths and resiliency. Anita said to the social worker that she was afraid to be in an HIV support group. She was also concerned about her father finding out that she was HIV-positive. Anita was feeling like she was in the eye of a hurricane with everything imaginable turning in every direction around her, saying, “Everything was blur.” Anita decided she would see the social worker weekly and when any crisis occurred. She noted that she could no longer keep herself bottled up inside.

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The first in a series of crises occurred when Anita was four months pregnant. The Vegas met with a physician and a social worker, specialists in HIV treatment. This made it possible for the Vegas to get an updated physical with blood results and give a psychosocial history that would hopefully assist them in receiving state-of-the-art treatment and much-needed assistance with illness and complex treatment protocols. Anita was told that in addition to having the HIV antibodies, she had been exposed to hepatitis; with these both, the risk of liver failure was highly possible. This stress on her body could impact the welfare of her unborn child as well. Her CD4 count, also referred to as the T cell count (number of white blood cells), was beginning to decline, probably due to, among other things, the high stress level in her life. When she was diagnosed, Anita’s count was around 400, but since then consistent drops had occurred. Medications were immediately started, antiretroviral combination therapy for Anita. Her doctor told her of the importance of starting them now and how the treatment might allow the child not to contract the HIV virus. Phase 3. A person affected by HIV/AIDS often receives quick relief by hearing similar situations and responses from peers in a support group led by a social worker. Although many group members may be locked into their own emotional world, a support group offers nonthreatening acceptance from peers and recognition of shared experiences. They can also discuss the quality-of-life issues for themselves and loved ones.

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was concerned that Marcos was at a higher risk of relapse into addiction with the many stresses now evident in his life. In their interviews, the worker frequently checked in on Marcos’s use of an already strong peer support system. Despite his acute depressive episodes, Marcos went to several NA meetings weekly, and several supportive friends in recovery cared about his welfare. The social worker strongly reinforced keeping this level of connection with the meetings and speaking daily with his NA sponsor. Marcos also started attending a support group for newly diagnosed people who also used the same HIV/AIDS clinic. Accustomed to being in groups, Marcos shared a flood of concerns about Anita’s diminishing health and whether the baby would be healthy. Two male members pointed out to Marcos that he seemed to speak more about his wife than himself. Marcos seemed not hear their comments. Phase 4. Its not unusual for a person affected by HIV/AIDS to challenge the authenticity of the helping relationship and the meaning of HIV/AIDS for him- or herself. This is yet another step in the client’s efforts to maintain autonomy in the face of uncontrollable bodily changes. Unexpressed rage at family members, friends, and others with better life prospects (including the social worker) may be expressed metaphorically or in strong emotional responses. People affected by HIV/AIDS are quick to pick up cues of the social worker’s and others’ survival guilt, death fears, and sadness.

Marcos’s health was more robust than his wife’s constantly weakening condition. His CD4 count remained at a stable 700. Although he also had signs of exposure to hepatitis A, likely arising from sharing intravenous drugs, his liver seemed to be holding up fine. Marcos and his doctor made the decision not to start medications at this time.

Marcos’s attendance at the support group became erratic; on two recent occasions, he called the worker to say that “something came up at work,” but he surely would be there next week. When the worker told the group about Marcos’s messages, members made no audible comments. The worker called Marcos before the next group session about the time and place of the meeting. Marcos told the worker not to worry, that he would attend. He came to the session as agreed and was unusually silent. Other groups members acted as if he were not present.

Marcos grew increasingly more taciturn and depressed in his contacts with the social worker, who

During a lull in the group discussion, Marcos announced, with muted affect, that he would be leaving

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the group. Marcos told the group that he really needed to maintain his sobriety and coming to the group interfered with a more important NA meeting. The group members grew restive and seemed unable to express their obvious shock and anger. The social worker noted that Marcos might also be angry at her for calling him to come to today’s group meeting. Marcos vigorously denied he was angry at the worker or the group. The social worker stated that it was always a group member’s right to leave a group, but that in this case, she felt that Marcos was flying away from the group and, perhaps, not examining some of his HIVrelated concerns. A few group members wished him well, while two members said they regretted Marcos’s decision to leave so quickly. The following week, Marcos returned and told the group that he would stay. He expressed growing anxiety about Anita’s health and whether the baby would survive to term. The group members commiserated with him and noted how upsetting these new developments were for him and for them. One member asked him if he ever thought that he might become sick and be unable to care for his family. Marcos sadly acknowledged he worries about that each night before he goes to sleep and looks at Anita . . . Phase 5. The social worker supports persons affected in the family system by recognizing the possibility of foreshortened lives and yet the need to live fully in the present. With the succession of symptoms, affected people begin to acknowledge directly the cumulative declines in functioning due to the disease process. Intimations of death are expressed metaphorically or as a contingency to be planned for and thus controlled. Events in the past assume saliency as future planning is fraught with uncertainties. A social worker should assist affected individuals and members of the family system to recognize the actual functional consequences of HIV/AIDS without encouraging either a morbid preoccupation with or denial of the implications of specific health concerns. Of critical significance is the social worker’s powerful emotional identification with a declining PLWA, which may propel the social worker to assume either

premature fatalistic or magical solutions to the more tragic elements of the disease process. Through an ongoing life-review process, a PLWA and others seek modes of mastery through active use of the past to make sense of the present and an uncertain future. Relationships with family members and longtime friends are examined in light of the realities of shifting life chances. Anita presented many psychosocial issues; she was falling into a deep depression, which was distracting her from following proper care associated with her drug intake. Now six months pregnant, she felt alone. Marcos could not give her the attention that she felt she needed. Anita continued to keep her HIV status from everyone, but her father grew increasingly concerned and suspicious; he could sense that something was wrong. Anita denied any problems: “I have been working too hard, that’s all, Father.” During an interview, Anita insisted that a support group could not help her, but she would attend if Marcos insisted. Two weeks later, Anita expressed her questions and concerns in the women’s AIDS support group. A major topic in the group was the consequences of telling family and friends about their diagnosis. Some of the group members used the group as a source of guidance and support to inform their parents and friends. Anita felt group pressure to do the same. Anita wanted the support of her family but wondered if it was possible. She told group members how upset she was when her father kept the mortal illness of her mother a secret until a few weeks before her death. Weeping, she said that she could not have carried out her household responsibilities caring for her siblings if she had known her mother was dying. The social worker told Anita and the group that she felt some of the weight of Anita’s continuing grief over the death of her mother. Anita nodded yes. The group began discussing how Anita might tell her father about being HIV-positive. At the next session, Anita told the group that she was going to talk to her father, but something inside stopped her. Later, unexpectedly, after asking her about a recent visit to the doctor, Anita’s father was

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dissatisfied with her response and felt she was holding something back. Anita told the group she was no longer able to hold it in. Her father asked once again and she told him the whole story. Anita began crying in the group. Marisol and Linda reached forward and held Anita’s hands. Anita said sometimes you need a good cry, but expressed concern to the group about how her father would accept Marcos after the baby was born. Phase 6. During episodic crises, the social worker monitors and supports HIV/AIDS-affected people. As PLWAs grow more seriously ill, they naturally become more dependent on others for care and emotional validation. The social worker assists affected people to become more observant of their changing health status, and to acknowledge the need to accept help from others. Anita’s health was rapidly deteriorating. Now, seven months into her pregnancy, she was complaining that she did not have much energy in the morning and did not feel like going into work some days. When support group members suggested the possibility of her staying home, Anita’s bristled, saying that it was impossible because they needed the money. Even though she now had the strong support from her father and other family members, Anita started distancing herself from Marcos and her family. She said that Marcos was too worried about her and he had plenty to do just to remain sober. At one point in the group, the discussion turned quickly to the virtues of stopping work and going on disability benefits. Anita was concerned with falling into greater depression and isolation if she stopped working. Going to so many medical appointments and managing her medications has become a second career. She said she envied the two members who decided to stop work and accept disability insurance. After the eighth month of pregnancy, Anita was becoming weaker with each passing day. She also noticed a persistent cough and was fearful of its moving into her chest. Her next doctor’s appointment confirmed her exposure to tuberculosis and

the need to stay isolated in the hospital for its initial treatment. Visitors were required to wear a mask in the room with Anita. While in the hospital, Marcos and Anita spent hours talking about their hopes and dreams. Anita told the social worker she dreamed that the baby would live and she would die. Marcos discussed his fear about Anita “making it” and the chance of her missing most if not all of the child’s life. The worker said even though it was difficult to discuss, his concern about planning for the child was important to him and Anita. Phase 7. As a person with HIV/AIDS grows more seriously ill, the worker supports efforts made toward greater intimacy and more active grief work. As a person with HIV/AIDS experiences a more precipitous decline, especially in mental status and mobility, more sustainable discussion starts among the ill person and loved ones. As her medical condition worsened, Anita’s became depressed, speaking only to Marcos and refusing to see the social worker. Marcos told the social worker that he asked a doctor if Anita and the baby would survive. The doctor indicated that the fetus seemed to be healthy, even though Anita was weaker. The birth would be very stressful, but hopefully she would make it. Marcos later told his support group members and sponsor that he was frightened to ask the doctor, but he had to make plans for the baby even if Anita could not. Later, Marcos and the social worker talked about a plan to speak to Anita’s father about her oldest sister helping Marcos care for the baby after its birth. He said it would be hard speaking to his father-in-law, but they both shared a love for Anita and her baby. Later, Marcos spoke during a group session, to the applause of other members, about his successful conversation with Anita’s father. Phase 8. The social worker assumes a more direct role in caring for and advocating on behalf of persons affected by HIV/AIDS. An ill PLWA may not

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be able to discuss concerns. Caregivers become vital for their assistance at obvious points of intervention. The social worker supports and advocates for appropriate and dignified care during the often upsetting last days of life. Anita gave birth to a baby boy. She seemed to be flushed with energy after the birth, returning home a week later. Unfortunately, her health declined rapidly and she was hospitalized for bacterial pneumonia. Anita survived the respiratory distress, but she was unable to eat and required tube feeding. Marcos slept evenings and weekends in her hospital room or outside in the hall. The social worker encouraged Marcos to follow his routine of NA attendance and going to his support group. The group assisted him in a decision to follow Anita’s advance directives to withdraw all extraordinary means to keep her alive, if there were no hope of recovery. Her wish was to have maximum pain relief. Anita’s weight dropped to 60 pounds and she was transferred to a subacute facility for PLWAs, where she died three weeks later. Marcos continued attending the support group and had periodic contact with

referenceS

Altman, D. (1986). AIDS in the mind of America. New York: Anchor Book. Anderson, G. B. (1986). Children and AIDS: The challenge for child welfare. Washington, DC: Welfare League of America. Bateson, M. C., & Goldsby, R. (1989). Thinking AIDS. The social response to the biological threat. Reading, MA: Addison-Wesley. Bayer, R. (1989). Private acts., social consequences: AIDS and the politics of public health. New York: Free Press. Buckley, W. (1987). Sociology of modern systems theory. Englewood Cliffs, NJ: Prentice-Hall. Cahill, K. M. (1984). Preface: The evolution of an epidemic. In K.M. Cahill (Ed.), The AIDS epidemic (pp. 2–6). New York: St. Martin’s. Camus, A. (1948). The plague. New York: Knopf. Cannon, W. B. (1939). The wisdom of the body. New York: Norton. Caputo, L. (1985). Dual diagnosis: AIDS and addiction. Social Work, 30, 65–73. Christ, G., Weiner, L., & Moynihan, R. (1986). Psychosocial issues in AIDS. Psychiatric Annals, 16, 173–79.

the social worker prompted by bouts of grief and anxiety about how he could care for his son, who turned out to be HIV-negative. He started to speak about making arrangements for the child’s care if Marcos became sick and died.

conclusion It is not hyperbole to say that the measure of our society and the profession of social work will be made in how we respond to the AIDS pandemic in this country and throughout the world. Every aspect of our knowledge and our values will be challenged by the multilevel complexity of the efforts at prevention, treatment, and social reconstruction called for by HIV infection and AIDS. Camus (1948) concluded in The Plague that in times of pestilence, there will hopefully be more to admire in humankind than to despise. In social solidarity, social workers, with other professionals and an educated citizenry, can and must act humanely and intelligently in the days and years ahead, as together we face the complexity and challenges of the pandemic.

Decock, K. M. (2008). The global epidemiology of AIDS. In P. Volberding, M. A. Sande, J. A. Lange, W. C. Greene, & J. E. Gallant (Eds.), Global HIV/AIDS medicine, (pp. 1–12). Philadelphia: Elsevier. Dickens, B. M. (198). Legal rights and duties in the AIDS epidemic. Science, 239, 591–96. Dubos, R. (1959). Mirage of health: Utopias, progress and biological change. New York: Harper & Row. ——. (1965). Man adapting. New Haven: Yale University Press. Gambe, R., & Getzel, G. S. (1989). Group work with gay men with AIDS. Social Casework, 70, 172–79. Getzel, G. S., & Mahony, K. (1988). Education for life during the AIDS pandemic. Social Casework, 69, 393–96. Getzel, G. S., & Osteen, P. (2011). Group work services to people living with HIV/AIDS during a changing pandemic. In G. L. Greif & P. H. Epliross (Eds.), Group work with populations at risk (pp. 49–65). New York: Oxford University Press. Gitterman, A., & Germain, C. B. (2008). The life model of social work practice: Advances in knowledge and practice. New York: Columbia University Press.

acquired immune deficiency Syndrome (aidS)

Greenly, M. (1986). Chronicle. New York: Irvington. Kaiser Family Foundation (2012, July). The global HIV/ AIDS epidemic. http://www.kff.org/hivaids/upload /3030–17.pdf Kamya, H. (2010). Underlying principles of helping in the HIV field. In C. C. Poindexter (Ed.), Handbook of HIV and social work: Principles, practices, and populations (pp. 31–40). Hoboken, NJ: Wiley. Kramer, L. (1989). Reports from the holocaust: The making of an AIDS activist. New York: St. Martin’s. Kull, R. M. (2010). HIV history, illness, transmission, and treatment. In C. C. Poindexter (Ed.), Handbook of HIV and social work: Principles, practices, and populations (pp. 3–30). Hoboken, NJ: Wiley. Luekefeld, C. G., & Fimbres, M. (1987). Responding to AIDS. Washington, DC: National Association of Social Workers. Lopez, D. J., & Getzel, G.S. (1984). Helping gay patients in crisis. Social Casework, 65, 387–94. ——. (1987). Strategies for volunteers caring for persons with AIDS. Social Casework, 68, 47–53. Monette, P. (1988). Borrowed time: An AIDS memoir. San Diego, CA: Harcourt Brace Jovanovich. Nichols, E. K. (1987). Mobilizing against AIDS: The unfinished story of a virus. Cambridge: Harvard University Press. Palacios-Jimenez, L., & Shernoff, M. (1986). Eroticizing safer sex. New York: Gay Men’s Health Crisis. Peabody, B. (1986). The screaming room: A mother’s journal of her son’s struggle with AIDS. San Francisco: Old Oak. Poindexter, C. C. (2010). Preface. In C. C. Poindexter (Ed.), Handbook of HIV and social work: Principles, practices, and populations (pp. xiii–xvi). Hoboken, NJ: Wiley. Risse, Guenter B. (1988). Epidemics and history: Ecological perspectives and social responses. In Eliza-

beth Fee & Daniel M. Fox, (Eds.), AIDS: The burdens of history, (pp. 33–66). Berkeley: University of California Press. Rosenberg, C. E. (1989). What is the epidemic? AIDS in historical perspective. Daedalus, 118, 1–17. Ryan, C. C. (1987). Statement of challenge. In C. G. Leukfeld & M. Fimbres (Eds.), Responding to AIDS (pp. 1–6). Washington, DC: National Association of Social Workers. Shernoff, M. (1988). Integrating safer-sex counseling into social work practice. Social Casework, 69, 334–39. Shilts, Randy. 1987. And the band played on: Politics, people and the AIDS epidemic. New York: St. Martin’s. Snow, J. (1987). Mortal fear: Meditations on death and AIDS. Cambridge, MA: Cowley. Sonsel, G. E., Paradise, F., & Stroup, S. (1988). Cash management practice in an AIDS service organization. Social Casework, 69, 388–92. Sontag, S. (1977). Illness as metaphor. New York: Random House. Sontag, S. 1978. AIDS and its metaphors. New York: Farrar, Straus & Giroux. United States Department of Health and Human Services, Centers for Disease Control and Prevention. (2010, June). HIV surveillance report, 2008, 20. Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention. http://www.cdc.gov/hiv/topics/surveillance/resources /reports/ Walker, G. (1988). AIDS and family therapy, part II. Family Therapy Today, 2, 1–6. Wheeler, D. P. (2007). HIV and AIDS today: Where is social work going? Health and Social Work, 32(2), 155–57. Whitmore, G. (1988). Someone was here. New York: New American Library.

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ddiction is a major public health and social problem with far-reaching physical, psychological, social, and financial consequences. Physical health consequences include cardiovascular disease, seizures, memory loss, cancer, HIV/AIDS, hepatitis or other liver disease, and lung disease. While many of these problems occur after prolonged periods of use, others may emerge after just one episode of use (Substance Abuse and Mental Health Services Administration [SAMHSA], 2011). For example, more than half of all emergency room visits for multiple bone fractures are linked to substance abuse (Vaillant, 1995). Addiction can also lead to reactions like shame, guilt, and anger. It is not uncommon for these experiences to progress into more serious psychological problems like depression, anxiety, paranoia, psychosis, and thought disorders (SAMHSA, 2011). Alcoholics are estimated to be three times more likely to be depressed and probably comprise up to 30 percent of all suicides (Vaillant, 1995). Socially, substance misuse and addiction are associated with many consequences. Driving under the influence is related to over half of vehicle-related deaths. Violence and crime also are highly correlated with addiction, leading to increased incidents of sexual violence, domestic violence, and childhood sexual abuse. The economic costs of addiction are estimated to exceed a half trillion dollars annually in the United States due to health care expenditures, lost productivity, and crime. A 2009 Center on Addiction and Substance Abuse report found that in 2005 state and local government spending was at least $467.7 billion. The more 54

astonishing statistic is that for every dollar spent on addiction, 95.6 cents went to cleaning up the resulting devastation such as hospital visits, car crashes, and crime. Only 1.9 cents were spent on prevention and treatment, 0.4 cents on research, 1.4 cents on taxation or regulation, and 0.7 cents on outlawing drugs (National Center on Addiction and Substance Abuse, 2009). Despite the complexities of addiction, clinical research is making promising advances in our knowledge base. According to Nora Volkow, the director of the National Institute on Drug Abuse, “Groundbreaking discoveries about the brain have revolutionized our understanding of addiction, enabling us to respond effectively to the problem. .  .  . [A]ddiction is a disease that affects both brain and behavior. We have identified many of the biological and environmental factors and are beginning to search for the genetic variations that contribute to the development and progression of the disease” (National Institute on Drug Abuse, 2007, p. 1) These advances provide hope for the helping professions and the general public. Given the prevalence of addiction, and the multiple negative consequences, it is imperative for social workers to take a more active role in providing services, including comprehensive assessment, individualized treatment, prevention, education, and advocacy for clients, families, and communities affected by addiction. defining and explaining addictions Defining alcoholism and other drug addiction is important because how we define a condition greatly influences how services are delivered

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and the particular areas where assistance is focused (Gitterman & Germain, 2008). In order to clearly define addiction, a brief historical perspective is necessary. In seventeenth century America, spirits such as rum and gin were considered nutritious, a good supplement to poor water supplies, and effective treatments for medical problems. The high regard for alcohol made it pricey and affordable by the upper social classes only (Rorabaugh, 1979). In the eighteenth century the discourse began to change, and frequent drunkenness began to be linked to laziness and lack of production, resulting in a new view of drunkenness as a moral, spiritual, and social problem. Further into the nineteenth century, as prices of alcohol dropped and there was greater consumption among people from the lower social classes, reactions to addiction became even more rooted in religious beliefs that “drunks” had weak wills or moral deficits (Rorabaugh, 1979). Eventually, criminal sanctions were utilized as punishments for inappropriate behavior associated with alcohol and drug use. The Harrison Act of 1914 officially made drug use illegal, marking a significant shift to viewing addicts as criminals rather than as people in need of medical assistance. It can be argued that the moral-legal perspective shift to substance use being a sin and crime was a major influence in changing the face of the addict from the wealthy, upper classes, to poorer, ethnic minority, working classes, furthering the oppression of those groups (Severns, 2004). Not until 1952 did the American Medical Association define alcoholism as a disease, and it was in 1967 that professionals officially recognized addiction as a complex disease that the medical field had a responsibility to treat. At this time, the discourse on addiction and its treatment began to shift from a focus on alcohol to include all drugs. Therefore, the term alcoholism began to be replaced with chemical dependency or addiction (Severns, 2004). Colloquial terms like social drinker, problem drinker, and alcoholic are often used to differentiate drinkers. Social drinkers can be described

as those whose patterns of drinking are low risk, whereas problem drinkers experience periods of heavy drinking that result in negative consequences such as physical illness, and car accidents. Problem drinking is most readily represented in college-age adolescents, with 72 percent of people having a period of heavy drinking in their lives lasting between three and four years and peaking between the ages of 18 and 24 (National Institute on Alcohol Abuse and Alcoholism [NIAAA], 2006). The distinguishing feature differentiating problem drinkers from alcoholics is that alcoholics cannot consistently control their drinking pattern or cut back on consumption despite facing numerous negative consequences of their drinking, whereas problem drinkers can make changes in their behavior. Vaillant’s (1995) findings from the longest formal study of alcohol use, beginning in 1940 and spanning over forty years, provide evidence for these distinctions. His major findings included that the amount of alcohol consumed and frequency of intoxication are not reliable predictors of alcoholism. The number one predictor that distinguished alcoholic men from problem drinkers was the inability to control alcohol use. There are several different conceptual frameworks from which addiction is viewed. The prevailing theoretical models for understanding addiction include moral models, disease/ medical models, psychological models, sociocultural models and biopsychosocial models. It is important to develop an understanding of these different models because one’s theoretical understanding greatly influences assessment and treatment of the client. Moral models of addiction were apparent in the historical review of addiction. While some clinicians still operate from this framework, it is not a prominent framework that guides professional practice today. The impact of moral models is more apparent in legal approaches to addiction and in the imbalance in the allocation of funds for treatment initiatives versus the punishment and control responses to substance abuse.

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Moral models assert that addiction is a personal choice, which typically results from a flawed, weak personal character and lack of spirituality. This judgment-based approach does not foster optimism with regard to treatment. While proponents of these models argue that personal responsibility empowers people to make better choices to overcome addiction and fosters spiritual growth, a number of concerns arise when moral models are employed. First and foremost, people receiving mental health and substance abuse services already face a significant amount of stigma in society, and the judgment base of these models further perpetuates any existing stigma. Increased stigma may result in lower rates of treatment seeking, along with increased shame and guilt, which could in fact increase a person’s substance use. The disease/medical models of addiction are the most prominent frameworks utilized by professionals. While moral models may view an individual as a degenerate, disease/medical models take the onus off of the individual and place it onto the physiological root of the addiction. These models posit that addiction is a chronic and progressive condition that has a physiological root, such as an endocrine dysfunction, genetic predisposition, or biological changes resulting from substance use. The signature symptom of the “disease” is loss of control (Jellinek, 1952; Vaillant, 1995). In other words, there is a physiological reason why addicts react differently to substances than do nonaddicts, the primary difference being the inability to control consistently the amount of substance consumption or when consumption will stop. The fact that these models frame addiction as a disease can significantly reduce the stigma, shame, and guilt often attached to addictive behavior. Some critics view these models as too dismissive of personal responsibility for deviant behavior. Despite this criticism, research shows that substances do have a chemical impact on the brain, targeting a bundle of neurons called the mesolimbic dopaminergic pathway. This is the brain’s reward pathway that regulates how

a person feels pleasure. In other words, when a drug hits this part of the brain, dopamine receptors are overstimulated, releasing dopamine and resulting in pleasure. Over time more of the chemical is needed to produce this effect, resulting in tolerance and dependence. This chemical reaction supports the disease model of addiction. The fact that some people can use a drug recreationally and not develop an addiction, while others cannot, further supports the disease aspect of the model. Family studies also reveal the high genetic component of addiction: 36 percent of people with a substance disorder also have a family member with addiction issues, as opposed to 15 percent of those without a substance disorder (Merikangas et al., 1998). While addictive behavior can frequently lead to chaos both internally and externally, the disease/medical models provide very tangible frameworks from which to understand addiction. The clear clinical language and diagnoses that come along with a medical formulation provide a number of advantages. More specifically, they can result in common clinical language for treatment discussions, clear treatment goals, a definitive diagnosis that provides higher chances of insurance funding, and greater funding for addiction research. With regard to treatment, disease/medical models assert that addiction is a primary disease that can be treated but cannot be cured. Since addiction is viewed as irreversible, abstinence is typically regarded as the only viable treatment goal. Treatment can involve any supportive system that will help foster and maintain abstinence, such as twelve-step programs like Alcoholics or Narcotics Anonymous, direct counseling, psychoeducation, and pharmacotherapy, such as methadone maintenance. A number of different frameworks exist under the larger umbrella of psychological models, including psychodynamic, relational, personality traits, and learning/conditioning perspectives. The overarching assumption that exists across these frameworks is that psychosocial

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factors lead to distress, which substances help to relieve. Thus, addiction is secondary to the psychological distress, which must be addressed before the addiction will alleviate. Utilizing psychological models minimizes guilt, shame, and stigma typically associated with addiction, and addresses complex, underlying psychological factors that aid in long-lasting growth and insight, and improves the chances of recovery. The psychological models help us to understand addictive behavior as part of a more complex psychosocial syndrome. The psychodynamic framework employs classic Freudian concepts, along with notions from ego psychology, object-relations theory, self-psychology, and relational theories. Addiction is understood in terms of the personal pathology of the individual caused by unconscious conflicts. The vulnerabilities that arise from these conflicts, including ego deficits, poor object relations, and sense of self, make it difficult for addicts to soothe themselves and cope with feelings, resulting in the need for substances to cope with pain (Murphy & Khantzian, 1995). Hypothetically, substance use represents an attempt by addicts to eliminate pain associated with psychic impairment and to achieve adaptive functioning through “selfmedication” (Khantzian, 1985). A more contemporary psychodynamic understanding of addiction stems from the literature on relational theory. Research suggests that beyond having relationships with others, people may also have a relationship with an object or experience. Thus, addiction develops when a relationship with a substance develops and the individual believes that the substance is essential in his or her life. The importance of this relationship persists despite continuing negative consequences (Byington, 2009). In this model, the addiction is associated with, but not caused by, the substance itself. It is theorized that the addicted person is searching for connection, but as the relationship to the substance increases, it is likely that relationships with other people are harmed, leading

to a cycle of use and reliance on the substance (Byington, 2009). Personality trait theory emphasizes the personality structure of the individual. Research suggests that personality traits such as being moody, irritable, anxious, impulsive, and aggressive are highly correlated with substance use problems. Additional research provides further evidence for a connection between antisocial personality traits, personality changes, and alcoholism (Jang, Vernon, & Livesley, 2000). While different personality factors seem to increase a person’s risk of developing a substance abuse disorder, researchers have not found a set of personality traits or a personality structure that predicts conclusively whether or not one will develop an addictive disorder. That is, there is no personality type that causes a person to become addicted, nor is there a set of personality traits present only in people who are addicted (Berglund et al., 2011). To paraphrase William Miller’s (1995) comments about problem drinkers, research suggests, “[addicts] tend to be as variable in personality as are [nonaddicts]” (p. 90). Learning/conditioning frameworks assert that addiction behavior is learned and maintained through the process of reinforcement. For example, if an individual experiences a significant reduction of social anxiety symptoms after drinking alcohol, this will likely reinforce the drinking behavior and lead to an increased use, particularly in times of anxiety. This example captures the theoretical components of behavioral reinforcement that are at the foundation of many conditioning theories. Social learning theory (Bandura, 1986), which emphasizes the significant role-modeling plays in addictive behavior, argues that the social cues that people take in from their environment, behavior of parents, and behavior of peers influence their substance use behavior. Evidence supporting these models suggests that factors learned in the environment have stronger influences on substance use behavior than factors related to genetics or personality.

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Rewards, such as feeling good after using a substance, typically result in increased frequency, intensity, and duration of drug use. Since the development of addiction is a learned process, the model posits that it is important to help clients build new behaviors so more adaptive coping skills can replace addictive behaviors (Marlatt & Donovan, 2005). This cognitive behavioral framework is at the core of relapse prevention and is seminal to much addiction treatment research. Sociocultural models assert that environmental systems including family, peer groups, and cultural and ethnic factors play significant roles in substance abuse and addiction (Hanson & Sealy, 2013). Longitudinal research, for example, has revealed that individuals who matured in birth cohorts with more restrictive social norms related to drinking were significantly less likely to drink alcohol than were individuals who matured in cohorts with more permissive norms (Keyes et al., 2012). Therefore, the surrounding sociocultural domains in an individual’s life must be taken into account when considering alcohol and other drug use and appropriate treatment options. Some strengths of this approach include an ability to identify at-risk populations, and a focus on prevention efforts for these groups. Along the same lines, education about culture, norms, and systems is also valued. A potential disadvantage of these models is that cultural stereotypes that could lead to biased assessment and unresponsive treatment could be fostered. Like the traditional social work definition of biopsychosocial, these models posit that factors from the biological, psychological, and sociological realms of an individual’s life must be considered together in order to gain a comprehensive understanding of an individual’s addiction (Kissin & Hanson, 1982; Marlatt, 2005). The biopsychosocial model incorporates assumptions from each of the other frameworks. Its value is that it places clients in the context of their ecological systems, fostering comprehensive approaches to individualized

treatment. This perspective suggests that the interaction of factors from each domain of an individual’s life can increase or lower the risk for developing a substance use problem. demographic Patterns Addiction exists across all cultures, classes, genders, and age groups, but has a differential impact within those groups. In 2010, SAMHSA found that approximately 22.6 million Americans (12 or older), or approximately 8.9 percent of the population, had used an illicit drug within the past month (SAMHSA, 2011). The prevalence of current illicit drug use has been on a steady rise, evidenced by 13 million Americans’ endorsing current drug use in 1996 and 19.5 million Americans endorsing the same in 2002 (SAMHSA, 1997, 2003). A similar increase in numbers specific to alcohol use is evident. In 2002, SAMHSA found that of the 120 million adults who drank alcohol, 27.5 million were binge drinkers and 8 million were heavy drinkers. While the overall number of drinkers increased from 100 million in 1996, the number of heavy drinkers decreased by approximately 3 million (SAMHSA, 1997, 2003). However, more recent numbers reveal that in 2010 more than half of Americans aged 12 or older, or 131.3 million Americans, reported being current drinkers of alcohol, with 58.6 million people reporting binge drinking and 16.9 million people reporting heavy drinking (SAMHSA, 2011). Men continue to have higher rates of drug abuse than women, with rates of 11.2 percent and 6.8 percent respectively. However, women experience more adverse consequences and may experience those consequences more quickly than do men. Women are less likely than men to receive treatment due to child care responsibilities, lack of financial resources, and higher rates of comorbid mental health problems (Greenfield, Trucco, & McHugh, 2007). The oppressive nature of the socially constructed addiction paradigm coincides with the racial and ethnic trends that exist. Specifically,

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African Americans have the highest percentage of current drug abuse (10.7 percent), followed by white Americans (9.1 percent), Hispanic Americans (8.1 percent) and Asian Americans (3.5 percent). However, whites are the most common ethnic group to engage in current alcohol use (56.7 percent) (SAMHSA, 2011). Significant trends associated with age also exist in the literature. In 2010, the highest rate of current illicit drug use was among 18- to 20-year-olds (23.1 percent), with the next highest rate among 21- to 25-year-olds (20.5 percent). While the rates for late adolescence are the highest, rates for older adults are the lowest, at only 1.1 percent (SAMHSA, 2011). Alcohol consumption decreases with age for a number of possible reasons: heavy drinkers may have earlier mortality, they may be strongly encouraged to stop because of health complications as they grow older, or they may have fewer social opportunities to drink as they age (SAMSHA, 2011). It is important to note, however, that in recent years older adults have not curbed their drinking habits as significantly as in the past. Among those aged 50 to 59, the rate of pastmonth illicit drug use increased from 2.7 percent in 2002 to 5.8 percent in 2010 (SAMHSA, 2011). These trends may be partially due to the aging of the “baby boomers,” whose lifetime rate of illicit drug use has been higher than that of earlier cohorts. Societal context The United States has been described as a “society steeped in drugs” (Richter, 2005). Nearly half of all Americans take prescription pills regularly, with the age of initiation into “pill-popping” getting younger and younger. Favorable attitudes toward drug use, increased opportunities, and social pressures to take drugs are among the factors that create a culture tolerant of excessive drug use, significantly influencing individuals’ substance use behaviors. A better understanding of the epidemiology of drug use can help uncover the social and cultural factors related to initiation and progression

of addiction. Research reveals that societal and cultural factors, such as family members’ drug use, may influence child development through both direct and indirect pathways. For example, direct pathways can include genetic transmission of vulnerability to drug use disorders and environmental exposure to drugs in the home. Indirect pathways can include early traumas such as child abuse, or other stressful life events. The majority of both direct and indirect factors are reinforced by behaviors of family members, peers, neighbors, authority figures, public figures, etc. Further, peer-group influences, along with social and institutional processes, also play a major role in substance use behavior (Compton, Thomas, Conway, & Colliver, 2005). Sociocultural beliefs largely shape behavior regarding substance use, and play a central role in forming the expectations about potential harm (and benefits) that may result from use (Abbott & Chase, 2008). Acculturation is one such issue that clinicians must be aware of that is related to substance use and abuse. Research reveals that, in general, as members of ethnic minority groups become more acculturated, their drinking patterns and related problems become more like those of the dominant culture (Hanson & Sealy, 2013). For example, research shows that illegal drug use in the previous month and increased alcohol use were reported by 7.2 percent of acculturated Hispanics compared to less than 1 percent of non-acculturated Hispanics (recent immigrants) and 6.4 percent of whites, indicating that indigenous cultural values can be protective in nature, whereas acculturation may generate greater stress and higher rates of substance use (Abbott & Chase, 2008). Higher rates of drinking among less acculturated individuals may also emerge due to “acculturative stress” related to language differences, loss of homeland, and racial discrimination (Hanson & Sealy, 2013). A culture of trauma in families is also important to consider, as research shows a significant generational history of trauma in families where addiction is present. Specifically, in an

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Australian study, the majority of participants had experienced painful and traumatic childhoods in their families of origin, which contributed to their subsequent addictive behavior and current negative familial relationships (Schafer, 2011). The role of family relationships is important with regard to modeling of behavior as well because drug use is a learned behavior. Parental behavior and peer influences have a strong relationship to substance use due to the learning that occurs when having continual and reciprocal interaction among people in an environment that culturally approves of the behavior. Research suggests that peer drug use, parental drug attitudes, sibling drug use, and adult drug use all have relatively strong effects on adolescent drug use (Bahr, Hoffmann, & Yang, 2005). Despite the fact that substance use is learned in social contexts across all social strata, problems associated with use and risks for becoming addicted are not equally distributed among all social groups. Drug abuse appears to pose a greater threat to individuals from more disadvantaged and vulnerable social groups (Chilcoat & Johanson, 1998). This could be due to the significant environmental demands and stressors that are placed on vulnerable social groups, leading to increased use of substances to cope with these stressors, along with decreased access to legitimate opportunities. As substance use continues, individuals can become enmeshed in the drug culture, where status and identity begin to be related to the drug use, leading to further alienation from positive sources of support (Bourgois, 1995). Vulnerabilities and risk factors Risk factors are those factors that help us understand the origins and pathways of addiction. While these factors can give us a better understanding of addiction pathways, it is also imperative to understand that risk factors are unique to each individual, and many who have particular risk factors will not develop an addictive disorder. Risk factors seem to be additive, meaning that the more factors individuals

are exposed to, the more likely they are to abuse drugs (SAMHSA, 2011). The most commonly discussed biological risk factor for addiction is genetic predisposition, meaning that if one has a relative with an addiction history, he or she is more likely to develop an addiction. Studies reveal that children of addicts are eight times more likely to develop an addiction (Merikangas et al., 1998). Moreover, studies based on the differences between identical and non-identical twins suggest that 50–60 percent of addiction may be due to genetic factors (Enoch & Goldman, 2002). Another biological factor is the innate temperament that infants are born with. Research has revealed that infants that show tendencies to withdraw and have low frustration tolerance as an infant have a higher likelihood of developing socially problematic behavior later in life, also leading to higher rates of substance abuse (SAMHSA, 2003). People with psychological risk factors as evident in mental disorders like depression, attentiondeficit/hyperactivity disorder, and schizophrenia have a higher risk of addiction (SAMHSA, 2003). Trauma exposure also is a significant risk factor, as studies indicate that nearly 60 percent of adolescents with post-traumatic stress disorder (PTSD) subsequently develop substance abuse problems, likely in an attempt to numb themselves from the intense painful emotions that can result from trauma exposure (Giaconia et al., 2000). Likewise, loneliness and poor sense of self are psychological factors associated with increased risk. Aggressive behavior, which boys consistently exhibit more of in the classroom, can lead to rejection by peers, conflict within the family, punishment in school, and academic failure, which may be related to the research showing that aggressive behavior early in life is a risk factor for substance abuse later in life (National Institute on Drug Abuse, 2009). Mezzo- and macro-level social factors cluster on this domain. For instance, the family plays a significant role in potential pathways for addiction. If a child is not receiving appropriate

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parental supervision, lives in a chaotic environment, is witnessing substance abuse at home, is in a home or neighborhood where drugs are readily available, and attends a school with an unspoken tolerance for drug abuse, he or she is at higher risk for developing a substance abuse problem (Bahr et al., 2005). While every family, regardless of socioeconomic group, educational level, geographic region, and racial and ethnic group, is potentially vulnerable to the devastating consequences of addiction, the effects are often disproportionally distributed. resiliencies and Protective factors As with risk factors, understanding the protective factors that help people cope with and overcome the potentially devastating effects of addiction is important and can influence successful prevention and treatment efforts. Like risk factors, protective factors can be separated into different categories, most notably biological, psychological, family, and social factors. Many Japanese, Korean, Chinese, and Thai individuals are born with a genetic factor, known as an alcohol-flush reaction that may protect some of them from developing alcohol addiction. This reaction causes uncomfortable physiological reactions to alcohol such as dizziness, nausea, and facial swelling, which may inhibit desire to consume large amounts of alcohol (Crabb, Edenberg, Thomasson, & Li, 1995). Other innate characteristics that have been shown to be protective factors are higher intelligence and an easygoing temperament (Crabb et al., 1995). Since these genetic traits are socially desirable, they likely could lead to positive experiences with others and fewer stressors that may be triggers to substance use. Research shows that psychological factors such as self-esteem, one’s sense of worth, and perceived self-efficacy, the perception that one can affect one’s environment, are significant psychological factors that impact resilience. A sense of purpose and meaning, along with a feeling of hopefulness, also can serve as protective factors (Mann, Lehert, & Morgan, 2004).

All of these factors may help individuals stand up to peer pressure, develop healthier coping skills, and gain a sense of deserving a healthy life. The quality of family relationships, adequate parental supervision and practices, consistent and appropriate disciplinary measures, financial stability, parental education, and the integration of families into positive community, school, and extracurricular activities can all serve as protective factors against addiction (Claes et al., 2005). These family characteristics may serve as moderators and help reduce the negative effects associated with some risk factors, thereby increasing individuals’ resilience. Availability of resources and services for individuals and families in the community is considered a protective factor (Slee, 2006). For example, if a child has access to positive social programming such as the YMCA and school support, substance use is less likely. Along the same lines, community supports such as active churches, recreational centers, and other positive groups help decrease the likelihood of substance abuse. Programs and Social Work contributions The passing of the Mental Health Parity and Addiction Equity Act in 2008 was promising because as of 2010, group health plans that provide any mental health and addiction treatment have been mandated to provide the same coverage for mental health and addiction treatment as they do for all other medical care (National Center on Addiction and Substance Abuse, 2009). However, the service needs of individuals impacted by addiction remain largely unmet. In 2009, 23.5 million persons aged 12 or older needed treatment for an illicit drug or alcohol abuse problem (9.3 percent of persons aged 12 or older). Of these, only 2.6 million, 11.2 percent of those who needed treatment, received it at a substance abuse specialty facility (SAMHSA, 2011). Treatment is typically diversified across various organizations targeting different aspects of care.

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Although they are not part of the formal service delivery system, Alcoholics Anonymous (AA) and other twelve-step self-help groups have reached the largest number of persons with addiction-related problems. Such twelvestep groups, along with non-twelve-step selfhelp groups like Rational Recovery (RR) and Women for Sobriety (WFS) are fellowships that provide unconditional support and acceptance, while promoting structured programs of recovery for alcohol- and drug-involved individuals (McCrady & Delaney, 1995). Given the significant impact substance abuse has on families; several twelve-step groups have adapted to serve children, other family members, and associates of drug abusers (e.g., Al-Anon, Nar Anon, Adult Children of Alcoholics groups). Self-help groups are integral adjuncts to most professional treatment. A 2006 meta-analysis of eight studies that investigated the efficacy of both AA and nonAA twelve-step programs concluded that the effectiveness of AA is not supported by evidence (Ferri, Amato, & Davoli, 2009). However, SAMSHA (2011) found that persons who are receiving formal treatment report that increased involvement with AA, particularly attending meetings more frequently, significantly increases abstinence rates. SAMSHA (2011) have found further that people who attended AA first, rather than formal treatment first, had longer sustained attendance at AA and higher rates of abstinence. Other treatment options exist for those who may be seeking a more secular oriented or professional approach to treatment. Harm reduction therapy is one such alternative. Marlatt and Donovan (2005) explain that because of its tolerance of treatment goals besides abstinence, harm reduction therapy expands the availability of substance abuse services to people who have not benefited from traditional abstinence models. Other research suggests that harm reduction models and abstinence models can be integrated, by allowing for goals besides abstinence initially, and

then incorporating abstinence as individuals become more committed to recovery (Futterman, Lorente, & Silverman, 2005). Methadone maintenance is an example of the harm reduction model in action. While there is some controversy over methadone maintenance as a form of treatment, research supports its effectiveness, reporting a high retention rate of two-thirds of clients, significant reductions in high-risk and criminal behavior, and continued improvement, as evidenced by reduction in rates of overdoses, HIV-related illnesses, and criminal behavior after two years of treatment (Razzaghi et al., 2006). Other harm reduction initiatives like needle and syringe exchange programs have developed throughout the United States. On average, 425,000 U.S. residents aged 12 or older each year use a needle to inject heroin, cocaine, methamphetamine, or other stimulants (SAMHSA, 2011). The majority of these individuals (71.0 percent) do not clean their needle before using it, while approximately one-half (51.0 percent) reuse a needle, 17.7 percent report that someone else used their needle after them, and 13.0 percent say they used a needle they suspected someone else had used before them. The outcome studies on needle exchange programs show a reduction in the spread of HIV when used as a component of comprehensive HIV prevention, decreased numbers of contaminated needles in circulation, and lower rates of infectious disease. The educational components of these programs provide an opportunity to reach out to persons who are often difficult to engage in treatment (Vlahov & Junge, 1998). Research indicates that exchange programs do not increase the incidence of illicit drug use, needle stick injuries, or drug-related arrests (Friedman, Perlis, & Des Jarlais, 2001). Social workers are an integral part of the addiction treatment workforce, with 87 percent reporting that they have worked with people experiencing addiction-related problems (Center for Health Workforce Studies & National Association of Social Workers, 2006).

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Some clinicians may be dually credentialed as both licensed social workers and certified addiction counselors; however, most do not seek an additional addiction counseling license (Harwood, 2002). Agency setting and mandate establish the parameters for social work assistance. Thus, the functions of social workers employed in nonspecialized settings may differ greatly from the responsibilities of social workers in specialized addiction agencies. For instance, in settings such as primary care clinics, employee assistance programs, and school-based health clinics, social workers will likely be identifying substance abuse patterns in assessment, then providing appropriate information and referral sources. Once appropriate assessments are conducted, linking clients with the proper level of care in specialized addiction services is necessary. The specialized addictions treatment system includes several levels of care: prevention and education programs, detoxification services, early intervention and outpatient clinics, day programs and partial hospitalization centers, residential and inpatient rehabilitation services, therapeutic communities (TCs), and dual diagnosis programs for persons with coexisting substance use and mental disorders. Social workers in these settings occupy positions such as case managers who coordinate care; clinicians who deliver treatment; and administrators who supervise staff, evaluate program effectiveness, design and develop new programs, and manage daily program operations. When making decisions regarding appropriate placement and later developing effective treatment plans, the American Society of Addiction Medicine suggests that professionals should assess the following: acute intoxication and withdrawal potential, biomedical condition, emotional and behavioral status, relapse/continued use probability, client preference (motivation and acceptance/resistance potential), and environmental supports and resources (American Society of Addiction Medicine [ASAM], 1996).

Prevention and education programs are on the rise in the United States. In 2002, nearly 2 million people were served by Substance Abuse Prevention and Treatment Block Grant (SAPTBG) funds, which were distributed to over 10,500 community-based organizations in 60 eligible states, territories, and tribes. This is an example of how today the role of the private sector in treatment has lessened, and community-based programs are taking on more of the responsibility for treatment (Black, 2009). Educational and preventive initiatives include policy-level responses, like alcohol taxes and raising the minimum legal drinking age, and community/educational interventions. Among the most effective education and prevention programs are group-based approaches targeting peer dynamics among adolescents. Detoxification can occur in inpatient or outpatient settings; it consists of a set of medical interventions aimed at safely managing acute intoxication and withdrawal symptoms among patients. A detoxification program is not designed to resolve long-standing psychological, social, and behavioral problems associated with substance abuse and is not considered substance abuse treatment. Therefore, it is important for social workers to provide education about the importance of substance abuse treatment, use motivational interviewing skills to increase motivation for treatment, and coordinate services for post-detoxification. Residential/inpatient services and therapeutic communities (TCs) may be an appropriate level of care after detoxification as they are designed to serve clients who need safe and stable living environments in order to develop recovery skills (ASAM, 1996). Generally, inpatient rehabilitation services last from three to four weeks, but TCs provide social therapy that can extend much longer. Social workers in these settings work in partnership with counselors who are recovering alcoholics or drug addicts to promote a recovery-oriented mutual aid system. They help prepare clients to return to their natural environments by helping

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them to anticipate threats to sobriety and locate resources that will support drug-free lifestyles (Hanson, 1997). Often, clients are treated for multiple disorders, including other addictions, eating and sexual disorders, and mental health disorders such as PTSD and depression (Black, 2009). With regard to dual disorders, integrated treatment combined with case management services, delivered in a supportive milieu environment, produces the best therapeutic outcomes (Drake, Mueser, Clark, & Wallach, 1996). A level of care that is a step down from inpatient services includes partial hospitalizations or day programs, which are appropriate when clients lack the social supports necessary to facilitate abstinence. Generally, these programs are group and milieu oriented, providing from nine hours to more than twenty hours of structured programming per week (ASAM, 1996). Social workers at these settings provide psychoeducation about substance abuse, individual and group therapy focusing on coping skills to help maintain abstinence, and alternative social supports that will reinforce drug-free lifestyles, such as positive social events. The least restrictive level of care includes outpatient and early intervention, which are most appropriately utilized when minimal risk of withdrawal exists, clients are able to establish and maintain abstinence, and a supportive recovery environment is available (ASAM, 1996). A major treatment benefit of outpatient services is that clients are able to face behavioral patterns in the social contexts in which they arose and in which they are living. Social workers are often the clinicians providing such services, and they have to be mindful of using brief interventions that are reimbursable by insurance companies. Coordination of care after outpatient services is also necessary, likely involving clients in self-help groups. assessment and interventions A comprehensive and accurate assessment must precede any intervention. The traditional social work biopsychosocial assessment puts clients

in the greater context of all of the systems that impact their lives. There are a number of ways clinicians can gather such information, including but not limited to clinical interviews with clients, clinical interviews with significant others, and behavioral observations (SAMHSA, 2005). During the assessment process, clinicians should also be aware of neurobiological responses to different substances, the potential long-lasting impact on neurotransmitters and the brain, and the effect of various substances on the nervous system. Physiological and psychometric instruments can be particularly helpful in assessing for the presence and severity of substance abuse problems. A number of brief substance abuse screening instruments can be administered in under ten minutes to determine if further more comprehensive evaluation is necessary (e.g., the CAGE, Ewing, 1984; the TWEAK, Russell, Martier, Sokol, & Jacobson, 1991; the Michigan Alcohol Screening Test [MAST], Selzer, 1971). The CAGE involves four yes/no questions, in which two or more yes answers are indicative of a drinking problem and should be followed up with further assessment. The questions include: Have you ever thought you should cut down on your drinking? Have you felt annoyed when people criticize your drinking? Have you ever felt bad or guilty about your drinking? Have you ever had a drink first thing in the morning or when you wake up to steady your nerves or to get over a hangover (eye-opener)? The TWEAK is a five-item scale that was developed as an adaptation of the CAGE, to be utilized with pregnant women. The Alcohol Use Inventory (AUI) (Horn, Wanberg, & Foster, 1987) and the Addiction Severity Index (ASI) (McLellan, Luborsky, O’Brien, & Woody, 1980) are examples of morein-depth evaluations that can be used with adults. The ASI is a semi-structured interview that not only assesses for use of alcohol and drugs, but also for employment/support, medical, legal, family, and social issues, and psychiatric concerns. For adolescents, the Personal

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Experience Screen Questionnaire (PESQ) (Winters, 1991) has been found to have strong reliability and validity. A number of physiological screening methods also are used in treatment facilities, including toxicology reports, which examine drug levels in urine, blood, or hair samples, along with body scans to locate signs of drug use such as track marks (McPherson & Pincus, 2006). An important factor to consider during assessment is the high prevalence of dual diagnoses, i.e., having a substance abuse diagnosis and another Axis I mental health disorder. Statistics show that approximately 20 percent of the seriously mentally ill either abuse or are dependent on substances (SAMHSA, 2003); in one major sample 47 percent of a schizophrenic population had a substance misuse disorder at some time in their lives (Kessler et al., 1994); and 70 percent of institutionalized adults have had both substance use and mental disorders during their lifetimes (Regier et al., 1990). History reveals that the idea of helping those with addictions goes back many generations. In the 1840s, the first temperance group, the Washingtonians, formed in Baltimore, Maryland, after hearing a lecture on the negative effects of alcohol. By 1845 they had over five million members in America, marking the beginning of modern-day addiction recovery (Black, 2009). In the late 1800s and early 1900s some bizarre approaches to treatment were condoned, including laxatives and enemas in the belief that the poisons would be released from the body. The founding of Alcoholics Anonymous (AA) by Dr. Bob Smith and Bill Wilson in 1935 in Ohio set the stage for the future of addiction treatment. Grounded in their own experiences, they recognized the importance of addicts’ helping addicts. Their Big Book outlining the twelve steps was written on a spiritual foundation and 5,000 copies were published in 1939. The millions of copies that exist today evidence the success and evolution of AA. In 1950, Wilson’s wife founded AlAnon, the twelve-step program for families and

friends of alcoholics. The “Minnesota Model,” an abstinence model based on the twelve steps was developed in 1951 and has been a foundation for addiction treatment from the 1970s to the present (Black, 2009). It is apparent that historically substance abuse treatment was not a domain of practice for mental health “professionals.” AA, other twelve-step groups, and specialized treatment programs such as Synanon, which was founded by an alcoholic in recovery, and Daytop, created as a halfway house for addicts leaving prison, emerged and grew quickly, largely because of professionals’ resistance to working with substance abusers. In fact, it wasn’t until the 1970s that federal programs such as the National Institute on Alcohol Abuse and Alcoholism, the National Institute on Drug Abuse, and the agency now known as the Substance Abuse and Mental Health Services Administration (SAMHSA) were developed, legitimizing professional work with addictions. The evolution of evidence-based practices (EBP) over the past few decades has lead to a growing number of federal and statewide initiatives that mandate EBP implementation, along with increasing numbers of social workers treating addiction. While lists of evidence-based treatment approaches have been compiled, a gap still exists in the dissemination of these approaches in clinical settings (Glasner-Edwards & Rawson, 2010). Among the treatment interventions that have a substantial amount of evidentiary support are Motivational Interviewing (Miller & Rollnick, 2013), Cognitive Behavioral Therapy (Kadden et al., 1992), Relapse Prevention Therapy (Marlatt & Donovan, 2005), and Multidimensional Family Therapy (Liddle et al., 2001). These interventions can be implemented on an individual, family, or group level, and the evidence supports that they effectively address the central addictions-related difficulties most substanceabusing clients face (SAMHSA, 2011 GlasnerEdwards & Rawson, 2010). They are aimed at helping individuals lessen ambivalence,

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increase motivation, change addictive lifestyles, develop more effective coping skills, and establish social support networks that will reinforce abstinent behavior. The National Institute on Drug Abuse (2009) posits a number of principles professionals should adhere to in order to deliver comprehensive, client-centered, and effective substance abuse treatment. Among these are: (1) Addiction is complex and impacts brain function and behavior, but is treatable, (2) No single treatment is appropriate for everyone, (3) Treatment must be readily available, (4) Effective treatment attends to multiple needs of the individual and not just the drug use, (5) Adequate time in treatment is critical, (6) Counseling is the most common form of treatment, (7) Medication in combination with counseling is important, (8) Treatment plans should be continually assessed and modified, (9) Co-occurring mental disorders must be assessed for and treated, (10) Detoxification is only the first phase of treatment and should be followed up by other modalities, (11) Involuntary treatment can also be effective, (12) Drug use during treatment should continually be monitored, and (13) Medical and infectious diseases should also be assessed and treated, and high-risk behaviors should be a focus of treatment. illuStrAtion And diSCuSSion

The following case example illustrates the process of differential assessment, developing a mutual agreement, and helping a drug-involved client. The case illustration is not a “recipe” to be followed for effective social work practice, but rather highlights useful practice concepts. Mia is a 16-year-old biracial young woman, of Caucasian and Japanese decent, who was mandated to treatment by her juvenile probation officer after she was arrested for possession of cocaine on school property. According to the referral paperwork, Mia has a history of alcohol, marijuana, and cocaine

use. In reviewing Mia’s history, her probation officer found that Mia had been suspended from high school on a number of occasions for reasons including extended absences, coming to school drunk, and drinking on school property. The school reported holding case conferences with the family and attempting to help Mia through the school-counseling center; however, when the most recent incident of possession of cocaine on school property occurred the administration contacted outside legal authorities. Mia went before a judge and was placed on probation for two years. One of the major mandates of Mia’s probation was ongoing treatment and weekly drug tests. If Mia were compliant with treatment and established abstinence, the charges would be expunged from her record. Upon the first meeting, the social worker assessed quickly that the client was reluctant to engage in treatment, so she focused on relationship building. She thanked the client and her grandmother (and primary guardian), Jackie, for coming to the office, explained that she had reviewed the materials her probation officer had sent over, and asked her to share her impressions of the situation. Mia minimized and rationalized the situation by stating, “All teenagers use drugs. I just got caught.” When asked directly if she thought she had difficulties with drugs, Mia replied, “I like to have a good time,” indicating that she was in the “precontemplation” stage of change with respect to the addictive behavior (i.e., she did not attribute her difficulties with her school, her family, and the legal system to drug use, despite evidence to the contrary) (Miller and Rollnick 2013). The social worker suspected Jackie, who was sitting quietly in the seat next to Mia, might view the situation differently. However, given the history of family tensions and frequent arguing between the two, as reported by the probation officer, the social worker decided to wait to get the grandmother’s perspective at a later time. In order to engage the client and her grandmother in the helping process, the social worker followed an evidence-informed practice approach and discussed

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with them the mandated requirements of service and attempted to negotiate goals, which can be more challenging when working with mandated clients (Gitterman & Germain, 2008; Young, 2002). She told them that she understood that probation required Mia to be sober and in addictions treatment, and that these conditions seemed nonnegotiable from probation’s perspective. She added, “Since we have to be here, I’m wondering what could happen that might make our time together worthwhile.” Jackie quickly responded, “Getting my granddaughter back and stopping drugs from corrupting my family.” The social worker acknowledged her voice and then asked Mia how she felt about her grandmother’s words. Mia just shrugged and looked away. The social worker asked Jackie what steps she thought needed to be taken to attain these goals. She said, “Mia needs to hang out with healthier people; I need to get my son out of the house; and Mia needs to learn that she can have a different life than her dad.” The social worker responded, “I can sense the concern and how much you care about your granddaughter. The fact that you are both here is already a big step. I know that this must be a difficult time, but your connection shows me how committed you are to making progress.” Jackie nodded in agreement and Mia sat quietly, looking less “tough” than she did at the beginning of the session. The social worker sensed that an initial rapport was being established, so she asked Mia if she would mind telling her a little more about the things her grandmother mentioned, particularly about getting her son out of the house and having a different life than her father. Mia went on to explain that her father got into a car accident when she was 3 years old, became paraplegic, and had been abusing drugs, including cocaine and heroin, ever since. The social worker expressed empathy for how difficult that must have been throughout her childhood and asked how she thought it had affected her. Mia exhibited some insight saying, “Well, drugs is what I know. I have been seeing my dad do them my whole life. My house has been raided by the cops more times that I can remember, so I guess it’s

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no surprise that I am here.” While actively listening, the social worker further assessed the client’s safety in the home and discovered that Child Protective Services had been involved in the client’s life her whole childhood due to her father’s addiction and her mother’s severe depression. Mia’s mother moved cross-country when she was very young, so guardianship was given to Jackie, her paternal grandmother. Once it was determined that there was no immediate safety danger in the home, the social worker continued to use motivational interviewing and client-centered interviewing skills, like reflection, open-ended questions, and summarization to further explore and assess Mia’s situation. When the social worker asked how these experiences affected her, Mia revealed that she holds a lot of anger inside, feels depressed often, and uses drugs to help her cope with the bad memories and difficult feelings. The social worker was able to formulate early on that Mia had a significant history of childhood trauma and that in order for effective work to be done a trauma-informed perspective and family systems approach to treatment would be necessary (Miller & Guidry, 2001). The biopsychosocial perspective allowed the social worker to understand the client’s situation comprehensively. While the client had no physical problems, she had a genetic predisposition to addiction. Psychologically, she also had a predisposition to depression. Therefore, the potential dual diagnosis of depression and substance abuse needed to be ruled out. Given the significant early childhood trauma history, a diagnosis of posttraumatic stress disorder also was considered. Socially, the client had a number of “friends” who were also abusing illegal substances and were involved in the juvenile justice system. Although she was obviously bright and well spoken, she was struggling in school due to frequent absences, likely connected to the substance-abusing behavior. This was the client’s first experience in addictions treatment. A situational assessment of her addictive behavior revealed that her substance use had

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escalated over the course of the past year, from frequent marijuana smoking to snorting cocaine almost daily. This had led to frequent arguments with Jackie, which precipitated more drug use. When asked how she would get access to the drugs, Mia reported, “Friends . . . we do each other favors.” Without explicitly stating so, she made reference to also performing sexual favors for peers in return for drugs. Sensing the client’s hesitation and given the potential shame that can often accompany such behavior, the social worker decided to explore this topic later in an individual session. Preparatory to developing an intervention plan with the client, the social worker provided personalized feedback (Miller & Rollnick, 2013). She presented the results of the situational assessments and summarized that Mia, by her own report, consumed much more alcohol and drugs than other people did. She observed also that given her family history she was at risk for developing more serious problems if use continued. She balanced the feedback on risks by pointing out that the client had strengths—her intelligence, insight into her family system, and a loving, supportive grandmother. The social worker concluded by saying, “Your goals are clear and there are some specific things we can do to help you. If you maintain sobriety and strengthen your ability to cope in healthy ways, I will report this to probation so that your legal case will be expunged.” Mia responded positively, saying, “I don’t want to follow my dad’s footsteps.” Jackie added, “She is capable of so many beautiful things.” The social worker provided them with some psychoeducation about genetic predisposition to addiction and about abstinence. She also provided psychoeducation about the impact trauma can have on the brain and emotional regulation, explaining that there are a number of trauma-informed treatment perspectives that they could utilize in treatment to help her learn how to more effectively cope with the feelings that resulted from her difficult early experiences, such as empowerment and seeking safety models (Fallot & Harris, 2002; Najavits, 2002).

The following objectives were established with the client: (1) Mia would increase her awareness of drug use cues and correctly identify situations in which she was at risk to use. (2) She would chart situations in which she felt tempted to use drugs and those in which she felt no temptation, keeping track of her triggers, thoughts, feelings, and actions. (3) She would develop healthy coping skills for handling interpersonal encounters—first general social encounters, then temptations to use drugs, and finally interpersonal conflict. (4) She would process in session her early trauma experiences and gain insight into how these experiences impact her emotions and behaviors. To attain these objectives Mia contracted with the social worker to participate in weekly individual sessions and peer group counseling. Jackie also agreed to participate in regular family sessions with Mia. Mia further agreed to attend local teen AA meetings and decide whether or not they could be helpful to her. Since probation wanted a progress report in six months, a six-month time frame was established for the contract. In individual counseling, Mia worked on feeling identification and expression, cognitive behavioral techniques, skills training to cope with feelings and triggers, and psychoeducational approaches to address recovery and healing to help her take her power back and learn how to set boundaries with drugs and in relationships. She also learned grounding techniques, how to nurture herself and create a more meaningful narrative than one primarily focused on addiction (Fallot & Harris, 2002; Najavits, 2002). In group sessions, Mia learned problemsolving and coping skills and practiced completing “functional analyses” of situations in which she was at risk for using drugs and to practice alternate ways of handling those situations. Techniques included role-playing, modeling, coaching, positive feedback, support, and practicing new skills in “real life” (Carroll, 1998). It appeared that one of the most positive effects of the group for Mia was relearning how to engage with peers in a productive way while sober and not under the influence of drugs. As a

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result of positive group feedback and cohesion, her confidence and perceived self-efficacy improved. After six months Mia had a couple of positive marijuana toxicology screens; however, the majority of her screens were clean, indicating a significant reduction in substance use. Her mood had improved, evidenced by fewer emotional outbursts and brighter affect. Her attendance and school grades improved, and Jackie reported that she saw her interest in old activities, such as cheerleading, resurface. Mia’s treatment continued for an additional year, where progress was steady and abstinence was achieved. Treatment concluded when Mia was admitted to college and moved out of state to attend as a full-time student. A two-year follow-up revealed that Mia remained drug free and occasionally attended AA. This practice illustration highlights important features of social work practice with alcohol- and drug-involved people. Clinical assessments and interventions were individualized to meet the client’s life circumstances. Assistance built on strengths and rooted in the trauma-informed perspective deemphasized the “addict” label (stigma) (SAMHSA, 2012). Once differential, situational assessments were completed, a collaborative treatment contract that established a stepwise hierarchy of assistance was negotiated. The intervention plan focused on developing both general coping skills (e.g., grounding techniques, interpersonal skills, empowerment, conflict resolution skills) and drug-specific coping skills (e.g., drug refusal skills). In order for recovery to progress, both categories of skills had to develop, since the general coping skills provided the context in which drug-specific skills could emerge. As Mia gained insight into her traumatic experiences, family system, and drug behavior, she improved her sense of self-efficacy and competence. Social supports, including her relationship with her grandmother, AA, new positive peer relationships, and school activities, were strengthened. A multidimensional intervention strategy that included all of the

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domains of the client’s life helped her develop the skills needed to meet situational demands and create social networks that would be more supportive of her efforts at adaptive functioning. Consequently, two years after formal services ended Mia’s progress continued, and she was not only coping with life stressors in a healthy way, but enjoying her life and succeeding.

conclusion This chapter has provided an overview of social work practice with people affected by addiction. Addiction is a complex disorder that is influenced by various factors across the biological, psychological, and social domains in one’s life. Thus, it is imperative for social work professionals to adopt the person-in-environment framework when working with individuals struggling with this life condition. Utilizing the person-in-environment and ecological perspectives enables social workers to understand individuals’ stressors, their perception of the role substances play in their lives, and how they may be using substances to cope and adapt to stressful life circumstances. The ecological perspective also allows for thorough and comprehensive assessments of the problems and needs of individuals across domains, leading to supportive and effective evidencebased treatment strategies. While the harmful impact of addiction is far reaching, affecting individuals from all social groups, advancements in the understanding of this problem and treatment approaches are promising (Black, 2009). It is imperative for social workers to continually educate themselves about addiction and its treatment. Current knowledge is essential in order to develop and implement effective assessment and intervention strategies at the individual, family, and social levels, fostering supportive communities that are less affected by drugs and addiction.

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Harwood, H. J. (2002). Survey on behavioral health workplace. Frontlines. Washington, DC: Academy Health. Horn, J. L., Wanberg, H. W., & Foster, F. M. (1987). The alcohol use inventory (AUI). Minneapolis, MN: National Computer Systems. Jang, K. L., Vernon, P. A., & Livesley, W. J. (2000). Personality disorder traits, family environment, and alcohol misuse: A multivariate behavioural genetic analysis. Addiction, 95(6), 873–88. Jellinek, E. (1952). Phases of alcohol addiction. Quarterly Journal of Studies on Alcohol, 13(4), 673–84. Kadden, R. M., Carroll, K., Donovan, D., Cooney, N., Monti, P., Abrams, D., Litt, M., & Hester, R. (Eds.) (1992). Cognitive-behavioral coping skills therapy manual: A clinical research guide for therapists treating individuals with alcohol abuse and dependence. Vol. 4, Project MATCH Monograph Series. Rockville, MD: National Institute on Alcohol Abuse and Alcoholism. Kessler, R., McGonagle, K., Zhao, S., Nelson, C., Hughes, M., Eshleman, S., Wittchen, H., & Kerdler, K. (1994). Lifetime and 12-month prevalence of DSM-III-psychiatric disorders in the United States. Archives of General Psychiatry, 51(1), 8–19. Keyes, K. M., Schulenberg, J. E., O’Malley, P. M., Johnston, L. D., Bachman, J. G., Li, G., & Hasin, D. (2012). Birth cohort effects on adolescent alcohol use: The influence of social norms from 1976 to 2007. Archives of General Psychiatry, On-Line First, E1–E10. Khantzian, E. (1985). The self-medication hypothesis of addictive disorders: Focus on heroin and cocaine dependence. American Journal of Psychiatry, 142(11), 1259–64. Kissin, B., & Hanson, M. (1982). The bio-psycho-social perspective in alcoholism. In J. Solomon (Ed.), Alcoholism and clinical psychiatry (pp. 1–19). New York: Plenum. Liddle, H. A., Dakof, G. A., Parker, K., Diamond, G. S., Barrett, K., & Tejeda, M. (2001). ‘Multidimensional family therapy for adolescent substance abuse: Results of a randomized clinical trial. American Journal of Drug and Alcohol Abuse, 27, 651–87. Mann, K., Lehert, P., & Morgan, M. Y. (2004). The efficacy of acamprosate in the maintenance of abstinence in alcohol-dependent individuals: Results of a metaanalysis. Alcohol Clinical and Experimental Research, 28(1), 51–63. Marlatt, G. A., & Donovan, D. M. (Eds.). (2005). Relapse prevention: Maintenance strategies in the treatment of addictive behaviors (2nd ed.). New York: Guilford. McCrady, B., & Delaney, S. (1995). Self-help groups. In R. K. Hester & W. R. Miller (Eds.), Handbook of alcoholism treatment approaches: Effective alternatives (pp. 160–75). Boston: Allyn & Bacon. McLellan, A. T., Luborsky, L., O’Brien, C. P., & Woody, G. E. (1980). An improved diagnostic instrument

for substance abuse patients, The Addiction Severity Index. Journal of Nervous and Mental Diseases, 168, 26–33. McPherson, R. A., & Pincus, M. R. (2006). Toxicology and therapeutic drug monitoring. In R.A. McPherson & M.R. Pincus (Eds.), Henry’s clinical diagnosis and management by laboratory methods (21st ed). Philadelphia: Saunders Elsevier. Merikangas, K.  R., Mehta, R.  L., Molnar, B.  E., Walters, E. E., Swendsen, J. D., Aguilar-Gaziola, S., . . . Kessler, R. C. (1998). Comorbidity of substance use disorders with mood and anxiety disorders: Results of the international consortium in psychiatric epidemiology. Addictive Behavior, 23, 893–907. Miller, D., & Guidry, L. (2001). Addictions and trauma recovery: Healing the body, mind, and spirit. New York: Norton. Miller, W. R. (1995). Increasing motivation for change. In R. K. Hester & W. R. Miller (Eds.), Handbook of alcoholism treatment approaches: Effective alternatives (2nd ed., pp. 89–104). Boston: Allyn & Bacon. Miller, W. R., & Rollnick, S. (2013). Motivational Interviewing: Helping People Change (3rd ed.). New York: Guilford. Murphy, S., & Khantzian, E. (1995). Addiction as a ‘selfmedication’ disorder: Application of ego psychology to the treatment of substance abuse. In A. M. Washton (Ed.), Psychotherapy and substance abuse (pp. 161–75). New York: Guilford. Najavits, L.  M. (2002). Seeking safety: A treatment manual for PTSD and substance abuse. New York: Guilford. National Center on Addiction and Substance Abuse (CASA). (2009). Shoveling up II: The impact of substance abuse on federal, state and local budgets. http://www.casacolumbia.org/articlefiles/380 -ShovelingUpII.pdf National Institute on Alcohol Abuse and Alcoholism, NIAAA (2006). Young Adult Drinking. NIH Alcohol Alert Publication No. 68. pubs.niaaa.nih.gov/ publications/aa68/aa68.htm. National Institute on Drug Abuse. (2009). Treatment Approaches for Drug Addiction. http://www .drugabuse.gov/sites/default/files/if_treatment _approaches_2009_to_ni da_92209.pdf National Institute on Drug Abuse. (2007). The science of addiction. Retrieved from http://www.drugabuse .gov/sites/default/files/sciofaddiction.pdf Razzaghi, E., Nassirimanesh, B., Afshar, P., Ohiri, K., Claeson, M., & Power, R. (2006). HIV/AIDS harm reduction in Iran. Lancet, 368, 434–35. Regier, D., Farmer, D., Rae, B., Locke, S., Keith, L., Judd, F., & Goodwin, F. (1990). Co-morbidity of mental disorders with alcohol and other drug abuse: Results from the epidemiological catchment area (ECA) study. Journal of the American Medical Association, 264, 2511–18.

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Slee, P. (2006). Families at Risk: The Effects of Chronic and Multiple Disadvantage. Adelaide: Shannon Research Press. Substance Abuse and Mental Health Services Administration (SAMHSA). (1997; 2003; 2005; 2011). National Household Survey on Drug Abuse: Main Findings. Rockville, MD: Substance Abuse and Mental Health Services Administration, Office of Applied Studies. Vaillant, G. (1995). The natural history of alcoholism, revisited. Cambridge: Harvard University Press. Vlahov, D., & Junge, B. (1998). The role of needle exchange programs in HIV prevention. Public Health Reports, 113, 75–80. Winters, K. (1991). Manual for the Personal Experience Screening Questionnaire (PESQ). Los Angeles, CA: Western Psychological Services. Young, D. (2002). Impacts of perceived legal pressure on retention in drug treatment. Criminal Justice and Behavior, 29, 27–55.

cHaPter 4 autism Spectrum criStina moGro-WilSon and kay daVidSon

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utism spectrum condition is a range of complex neurodevelopmental conditions, characterized by social impairments, communication difficulties, and restricted, repetitive, and stereotyped patterns of behavior. Autism spectrum conditions range from the most severe form of autism, often called classical autism, to other conditions along the spectrum that include a milder form known as Asperger’s syndrome, childhood disintegrative disorder, and pervasive developmental disorder not otherwise specified (usually referred to as PDD-NOS). Autism occurs in all ethnic and socioeconomic groups and affects every age group. Family income, education, and lifestyle do not seem to affect the risk of autism. The exact number of individuals with autism is not known. A report released by the U.S. Centers for Disease Control and Prevention (Centers for Disease Control and Prevention [CDC], 2012) estimates that one out of eighty-eight children age 8 will fall on the autism spectrum. Males are four times more likely to be diagnosed with autism than females. These numbers suggest that autism and related conditions are more common than previously thought. It is unclear whether this is due to an increasing rate of the condition or an increased ability to diagnose it. Social workers have been involved with individuals coping with autism in a variety of capacities. These include providing individual and group counseling; leading parent and siblings groups; and working in schools, treatment facilities, foster care, settlements and community centers, and the legal system, in all of which

individuals with autism are to be found. Social workers are involved in work with individuals dealing with autism in interdisciplinary environments and use a family- and person-centered approach. Social workers play an important role, often as part of a large interdisciplinary team, by providing an ecological and systems approach that spans the entire family and social system, identifying strengths and weaknesses, and helping the family and individual build on strengths. Social work skills in helping integrate an individual dealing with autism into the school and community and in providing the necessary supports are very important in meeting the needs of individuals with autism. Given the increasing autism diagnosis rates in children and adults, every social worker, regardless of the practice area, is likely to work with an individual or family member living with autism. Almost every social service system serves individuals living with autism, so it is critical for social workers to have at least a baseline understanding of how to effectively serve this population of children and adults across the life span. defining and explaining autism The word autism has been in use for about 100 years and originates from the word autos meaning “self ” in Greek. In 1911, Eugen Bleuler, a Swiss psychiatrist, first used the term to describe some symptoms of schizophrenia. In the 1940s, Leo Kanner, a doctor from Johns Hopkins University, used it to describe the withdrawn behavior of several children he studied. At about the same time, Hans Asperger 73

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(1944), in Germany, identified a similar condition that is now known as Asperger’s syndrome. In the mid-1940s, studies of autism moved from a focus on a behavior disturbance characterized by a collection of peculiar behaviors, to a theory that autism was not innate but was caused by a poor parenting style (Wing, 1993). Psychoanalysts of the era embraced the notion that autism resulted from behavior of mothers who were cold, distant, and rejecting, (often referred to as “refrigerator mothers”) and that children were thus deprived of the chance to bond properly (Bettelheim, 1967). Autism and schizophrenia remained linked in many researchers’ minds until the 1960s. From the 1960s through the 1970s, research into treatments for autism focused on medications such as LSD, electric shock, and pain-inducing behavior change techniques. During the 1970s the understanding of autism was related to the notion that people with disabilities could be perfected, and focused on isolation, rather than social inclusion of those with the condition (Mackelprang & Salsgiver, 1996). This isolation was fueled by the “medicalization of disability,” where individuals with autism were perceived to be victims of illness. In moving away from the medical model of isolation and illness, DeJong’s independent living paradigm (1979) included independent living and community-based options as the norm for people living with impairments and disabilities. DeJong’s contributions set the stage for inclusivity for all types of disabilities, including autism, rather than exclusion of people with impairments from society. In addition, DeJong’s contributions demonstrate a response to civil rights activists who sought to ensure that the rights and lives of people with disabilities could be maintained within their home-based communities (Wolfensburger, 1974). During the 1980s and 1990s, the role of behavior therapy and the use of highly controlled learning environments emerged as the primary treatments for many forms of autism and related conditions.

The understanding of autism has changed over the last several decades, moving from a medical model to a strengths-based approach, focusing on independence of the individual and family, in concert with recognition of disability as difference rather than deficit. This movement was in line with social work’s professional values, focusing on a strengthsbased perspective, highlighting an individual’s capabilities, capacities, and opportunities and viewing disability as a difference (Early & GlenMaye, 2000). Two of the main tenets of a strengths-based approach for individuals with autism are independence and availability of the least restrictive environment, both components extended from the civil rights and human rights movements of the 1960s. Most social workers are trained in empowerment techniques that focus on client selfdetermination and view the client-consumer as capable of personal or family decision making rather than passivity, and empowerment rather than powerlessness. Autism is a physical condition linked to abnormal biology and chemistry in the brain. The exact causes of these abnormalities remain unknown, but this is a very active area of research. Genetic factors seem to be important. For example, identical twins are much more likely than fraternal twins or siblings to both have autism. Similarly, language abnormalities are more common in relatives of autistic children. Chromosomal abnormalities and other nervous system (neurological) problems are also more common in families with autism. Individuals with characteristics of autism may have co-occurring conditions, including fragile X syndrome (which causes mental retardation), tuberous sclerosis, epileptic seizures, Tourette’s syndrome, learning disabilities, and attention deficit disorder. About 20 to 30 percent of children with autism develop epilepsy by the time they reach adulthood. In the Diagnostic and Statistical Manual of Mental Disorders: DSM-5 (American Psychiatric Association, 2013), a diagnosis of autism

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spectrum disorder requires that an individual must meet the criteria of A, B, C and D. (A) persistent deficits in social communication and social interaction across contexts, not accounted for by general developmental delays and manifest by all 3 of the following: (1) deficits in social-emotional reciprocity; (2) deficits in non-verbal and communicative behaviors used for social interaction; and (3) deficits in developing an maintain relationships. (B) Restricted, repetitive patterns of behavior, interests, or activities as manifested by at least two of the following: (1) Stereotyped or repetitive speech, motor movements, or use of objects; (2) Excessive adherence to routines, ritualized patterns of verbal or nonverbal behavior, or excessive resistance to change; (3) Highly restricted, fixated interests that are abnormal in intensity or focus; (4) Hyper-or hypo-reactivity to sensory input or unusual interest in sensory aspects of environment; (C) Symptoms must be present in early childhood (but may not become fully manifest until social demands exceed limited capacities) (D) Symptoms together limit and impair everyday functioning

The criteria have changed in the  DSM-5, compared to the DSM-IV, becoming more stringent, with the result that some people for whom the autism diagnosis currently brings accommodations in several settings would no longer qualify for them (Lord & Jones, 2012). In order to respond to autism conditions from a strengths-based perspective, we need to understand autism differently from the clinical definition used in DSM-5 (American Psychiatric Association, 2013). Social workers need a definition of autism that will help them to identify both the strengths and needs of individuals with autism. Many autobiographical accounts suggest that people with autism are dissatisfied with the term autistic spectrum disorder (Gerland, 2000; Jackson, 2003; Lawson, 2003). The medical model defining autism as a

“disorder” has given way to an understanding that it is a condition characterized by certain behaviors (some idiosyncratic) that may be seen and evidenced in some environments but not in others. This suggests that people dealing with autism are disabled by factors external to themselves, leading to the recognition of autism as a difference that will have positive and negative aspects, depending on the stimuli present in particular environments. In the wellknown case of Dr. Temple Grandin, features of her autism have led to her career success in the environment of animal care (Grandin, 1996). demographic Patterns According to the Centers for Disease Control and Prevention report released in March 2012 (CDC, 2012), one in eighty-eight children have been diagnosed with autism in the United States. However, this number has been in constant flux and the first known epidemiological study in autism in the United States dates back to 1970, when the prevalence rate was one in 5,000 children (Treffert, 1970). It increased to one in 150 in 2000, and increased even further to the current one in eighty-eight. This marks a 23 percent increase since the last CDC report in 2009 and a 78 percent increase since 2007. Being on the autism spectrum is almost five times more common among boys (one in 54) than girls (one in 252). Reasons for the increase in diagnoses of autism are debated, and some of the increase may be due to how children are identified, diagnosed, and served in their local communities, although exactly how much is due to these factors in unknown. Internationally, the numbers are also increasing; studies in Asia, Europe, and North America have identified individuals with autism to have an average prevalence of about 1 percent. A recent study in South Korea reports a prevalence of 2.6 percent, suggesting that one child in thirty-eight will receive an autism diagnosis (Kim et al., 2011). Ethnicity and socioeconomic status do not influence the prevalence of autism (Dyches, Wilder, Sudweeks, Obiakor, & Algozzine, 2004;

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Palmer, Blanchard, Jean, & Mandell, 2005). Yet it is important to note that children and youth from ethnic minority groups seem underrepresented in mental health settings that focus on the treatment of autism (CDC, 2006). Possibly, professionals screen for autism less often in children from minority groups (Mandell, Listerud, Levy, & Pinto-Martin, 2002). Language and social problems related to immigrant and ethnic status may lead to a decreased detection of autism symptoms. Communication problems that characterize autism could be interpreted as language problems related to minority groups in general. In addition, problems in social interaction, which are characteristic of autism, may be interpreted in children from immigrant ethnic minority groups as problems related to acculturation (Reijneveld, Harland, Brugman, Verhulst, & Verloove-Vanhorick, 2005). These factors could lead to a decreased awareness of symptoms of autism and a decreased diagnosis rate for autism in minority groups. Societal context Societal and social welfare thinking have evolved from a medical model focused on pathology and treatment and moved toward an empowerment- and strengths-based focus. People affected by autism have initiated the neurodiversity movement, based on the belief that difference is common and that normalcy simply does not exist. The term neurodiversity is often credited to Judy Singer, a sociologist diagnosed with Asperger’s syndrome (Ortega, 2009; Singer, 1999). The neurodiversity movement was developed in the 1990s by groups of individuals with autism meeting online. The movement is now associated with the struggle for the civil rights of all those diagnosed with neurological or neurodevelopmental conditions, such as attention-deficit/hyperactivity disorder, bipolar disorder, developmental dyspraxia, dyslexia, epilepsy, and Tourette’s syndrome (Fenton & Krahn, 2007). Neurodiversity continues to be a controversial concept.

Advocacy efforts, including those by social workers, have led to increased initiatives on behalf of individuals with disabilities as well as to their integration in the community. The empowerment movement seeks to involve those with disabilities in all aspects of life, and often cites the motto of the Autism Self Advocacy Network “Nothing about us, without us.” Despite the progress and the growth in disability rights, individuals with autism often face ongoing social problems, such as stigma, discrimination, and loneliness (Bauminger & Kasari, 2000). Individuals coping with autism report negative experiences of other people’s attitudes toward them. Often, there is pressure on individuals with autism to become “normal.” Williams (1998) writes, “These ‘helpful’ people were trying to help me to ‘overcome my ignorance’ yet they never tried to understand the way I saw the world” (p. 80). While many people with autism have exceptional talents, a general societal prejudice about autism conditions suggests that people have a negative view of autism’s differences rather than a positive one. Positive aspects of autism should be explored with a focus on abilities rather than disabilities. Vulnerabilities and risk factors The cause of autism is unknown, and given the complexity of the spectrum of the condition, it is likely there are many causes and contributors. One strong factor may be a genetic contribution (Betancur, 2011). A number of different genes may be involved, making some children more susceptible to autism. Genes may affect the severity of symptoms and brain development or the way the brain cells are communicating with each other (Abrahams & Geschwind, 2008; Lander, 2011; State, 2010). Genetic issues may be inherited or happen spontaneously. In addition to genetic contributions to the cause of autism, there are environmental factors. Current research is exploring the possible impact of environmental factors such as viral infections

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and air pollutants as playing a role in triggering autism (Hu, 2012). One of the greatest controversies about autism is centered on whether a link exists between autism and certain childhood vaccines, particularly the measles-mumps-rubella (MMR) vaccine. Many parents are worried that some vaccines are not safe and may harm their baby or young child. They may ask their doctor or nurse to delay the vaccine, or even refuse it altogether. Some people believe that the small amount of mercury (called thimerosal) that is a common preservative in multidose vaccines causes autism or ADHD. No reliable study has shown a link between autism and the MMR vaccination. The American Academy of Pediatrics and the Institute of Medicine (IOM) agree that no vaccine or component of any vaccine is responsible for the number of children who are currently being diagnosed with autism. They conclude that the benefits of the vaccines outweigh the risks. Co-occurring diagnoses for individuals with autism arise more often in people who have certain genetic or chromosomal conditions. About 10 percent of children with autism are also identified as having Down syndrome, fragile X syndrome, tuberous sclerosis, and other genetic and chromosomal conditions (Cohen et al., 2005; DiGuiseppi et al., 2010; Zecavati & Spence, 2009). The co-occurrence of one or more psychiatric diagnoses, such as social anxiety disorder, attention-deficit/hyperactivity disorder and oppositional defiant disorder, is 10 percent for individuals with autism (Levy et al., 2010; Simonoff et al., 2008). Autism can cause people to experience high levels of stress and distress, particularly when they are in highly stimulating and demanding environments. People with autism show much greater physiological reactivity to environmental stressors compared with their non-autistic peers. Gillott and Standen (2007) also identified elevated levels of anxiety in adults with autism compared with adults with intellectual

impairments. There were frequent occurrences of panic/agoraphobia, separation anxiety, obsessive-compulsive disorder and generalized anxiety disorder. This stress experienced by people with autism has been referred to as “exposure anxiety,” which describes the way people with autism protect themselves from stimuli in the environment (Williams, 2002). Exposure anxiety explains why a person living with autism may be able to communicate verbally and through other effective means in an environment that is quiet and without high levels of distracting stimuli. However, in a busy environment with high noise levels and bright lights, the same person may “shut down” and be unable to speak, sitting in a corner and rocking. Others might simply seek to run away. Many of the services provided to people across health and social care are in environments that are often busy, noisy, stimulating, and demanding. Approximately 70 percent of people with autism will have a “sensory perceptual impairment” (Cascio et al., 2008). Leekam, Nieto, Libby, Wing, and Gould (2007) found that 90 percent of children with autism had sensory abnormalities. Families with one child diagnosed with autism often consider increasing their family size by having more children. However, parents are confronted with the fact that their next child will have an increased chance (2–18 percent) of also being affected (Ozonoff et al., 2011). In addition, children born to older parents are at a higher risk for an autism diagnosis (Durkin et al., 2008). Children of older fathers, in particular, are known to be more at risk for autism (Callaway, 2012). A new study, (Callaway, 2012) found that older fathers transmit more new DNA variations to their children than younger dads, increasing the risk of autism for their children. The risk factors for diagnosis of siblings of children with autism and advanced parental age make the discussion of family planning important for social workers working with families.

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The divorce rate for parents with a child on the spectrum is often cited at 80 percent, but new research shows no significant differences in family structure or divorce when children with autism are compared with those without (Doheny, 2010). Family stress levels can be elevated because of their isolation or separation from other family members and friends who may have a difficult time accepting the child or youth and their behaviors. Often the family members isolate themselves, feeling unable to take the child or youth anywhere due to a fear of tantrums (King, Zwaigenbaum, King, & Baxter, 2006). Social workers can work with families to slowly move toward community integration and assistance in managing behaviors in public. It is important to note that when a child with autism around ages 3 to 5 has tantrums in public, they are easier to control and more culturally normative than when a youth who is 13 or 15 has them. Often police assistance is called to help the parent manage the older youth. In addition to isolation from family events or other social gatherings, issues of child care or respite care are important when working with families. Parents often need a break, and although families with neurotypical children make use of a babysitter or family members to relieve the pressures of parenting, this is not always an option for families with children on the spectrum. Families often mention and speak about high levels of stress due to financial issues, therapeutic concerns, child safety concerns, and adulthood transitions for their children. Having adequate financial resources necessary to support an individual with autism is often a difficult area for families. Individuals affected by autism who had private medical insurance had average medical expenditures that exceeded those not affected by autism by $4,110–$6,200 per year (Shimabukuro, Grosse, & Rice, 2008). Families enrolled in Medicaid had average medical costs of $10,709 per child, which was about six times higher than costs for children without autism (Peacock, Amendah, Ouyang, & Grosse, 2012). In addition to medical

costs, the costs of therapeutic interventions for children with autism can cost up to $40,000 to $60,000 per child per year (Amendah, Grosse, Peacock, & Mandell, 2011). These added financial costs can cause stress in the family unit and contribute to marital discord. Safety issues are a matter of concern to many parents of children and youth living with autism. Many individuals with autism do not experience the same reactions to pain as neurotypical individuals. Some do not have a normal range of sensations and may not feel cold, heat, or pain in a typical manner. They may fail to acknowledge pain in spite of significant pathology being present. They may show an unusual pain response that may include laughter, humming, singing, or removing of clothing. This can mean that if other siblings are hurting the child with autism, the parent might not notice, or if the child with autism is hurt the parent might not be aware. Families may need assistance in making sure their environment is safe for their child coping with autism. Parents will often say that their child will put a hand on a hot stove, and not scream or yell and hold it there until the parent notices. Social service providers such as police, medical responders in hospitals, and emergency medical services should be trained to respond appropriately. Parents often like meeting with local emergency responders to introduce their child or youth and discuss individual concerns. A paramount safety concern for many families is that their child with autism will get lost. Children living with autism may wander off and become separated from the group or family. In these cases the child or youth will state that he or she did not feel lost that and knew exactly where he or she was. This relates to a common characteristic related to individuals with autism called theory of mind, which is the ability to understand other people’s point of view, and to recognize that other people have understandings and beliefs different from your own (Baron-Cohen, 1995). In neurotypical children, theory of mind develops around

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age 5, but for some children dealing with autism it will never develop. An example of theory of mind may be seen as follows. Take an empty juice box and fill it with crayons and close it. Hold up the juice box and ask, what is in here? The answer will be juice. Then open the juice box and take out the crayons, and ask again, what is in here? The answer will be crayons. Then ask, if we go and get your dad from the hallway and ask him what is in here what will he say? A neurotypical individual will respond “juice,” understanding that the father has a different point of view and was unable to see you open the container and show the crayons. An individual lacking theory of mind will respond “crayons,” because it is hard to understand another point of view, or someone else’s thinking. For this reason, when a child is lost and a parent is looking for him or her, the child will respond that he or she knew his or her precise whereabouts and cannot understand why the parent did not know. Individuals living with autism have difficulty reacting and communicating socially. Often this translates into issues in playing with others, or making and maintaining friendships, and has implications for romantic relationships in adulthood (Bauminger & Kasari, 2000; Howlin, 2000; Stewart, Barnard, Pearson, Hasan, & O’Brien, 2006; Strain & Schwartz, 2001). Many interventions have been shown to be useful, such as including formal skill-teaching techniques based in natural environments, such as school and community settings, where the focus is around the framework of actively recruiting and training typical peers to interact with the child who is having social difficulties (Chan et al., 2009; McConnell, 2002). Many children dealing with autism exhibit specific interests that they focus on to the exclusion of other topics (Klin, Danovitch, Merz, & Volkmar, 2007). The literature suggests that playground activities that use these interests as the theme of games can improve the social engagement of the child with autism with his or her neurotypically developing peers (Baker,

Koegel, & Koegel, 1998). Finally, children with invisible disabilities, such as Asperger’s syndrome, experience bullying at rates higher than their typical peers (Heinrichs, 2003). Peer-topeer pairing in school settings for young children with autism, as well as a more formal paid mentor for older youth are also options. The mentor often goes with the youth into social settings that are age appropriate, such as movies, the mall, and bowling, and assists with social interaction. What is often most difficult for families is seeing their child playing alone, with few friends, and not invited to birthday parties or play dates. For many parents, the lack of friendships will be their largest concern for their child’s future, above and beyond educational outcomes. Social workers are uniquely positioned to help with community integration and friendship building, as well as the inclusion of these goals on Individual Educational Plans (IEPs) in school settings. Mothers of children with autism report significantly higher levels of stress than mothers of neurotypically developing children, and this type of stress may lead to negative physical and mental health outcomes for parents (Brobst, Clopton, & Hendrick, 2009; Hoffman, Sweeney, Hodge, Lopez-Wagner, & Looney, 2009; Lee et al., 2009). Children with disabilities are almost four times more likely than those without disabilities to be the victims of physical and/or emotional abuse and neglect. They are almost three times more likely to be the victims of sexual abuse than children without disabilities (Sullivan & Knutson, 2000; U.S. Department of Health and Human Services, 2004). Research on experiences of children with autism is consistent with that of children with other developmental disabilities, indicating that children on the autism spectrum experience abuse at rates higher than the general population (Autism Society, 2006; Mandell et al., 2005). Children with autism are vulnerable to abuse and neglect, as they are generally taught compliance from a very young age, making them easy targets for perpetrators of

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violence (Petersilia, Foote, & Crowell, 2001). Children and adults with autism have difficulty picking up social cues (social referencing) and understanding other individuals’ thoughts and intentions (Wetherby & Prizant, 2000), making them vulnerable to a range of crimes. Triggering conditions for child abuse are persistent crying, a child’s misbehavior, lack of disciplining success, and difficulties with toilet training, which are all common for children with autism. In addition, many children with autism have limited access to critical information pertaining to personal safety and sexual abuse prevention (American Academy of Pediatrics Committee on Child Abuse and Neglect and Committee on Children with Disabilities, 2001). Respite care services can be provided as a support for families caring for individuals with disabilities, particularly children with autism. Families identify respite care as a basic need (ARCH, 1992, 2007). Respite should be seen as an important component of comprehensive family support and made available on an ongoing basis as well as in the event of a crisis or an emergency. A growing body of research has focused on the influence that a child with autism may have on his or her typically developing siblings. A youth with autism may add variable amounts of stress to the family unit and place children who are predisposed to psychosocial difficulties at increased risk of developing internalizing and externalizing disorders (Orsmond & Seltzer, 2009). However, findings within the literature are contradictory. Some studies have reported higher rates of behavioral and emotional issues (Giallo & Gavidia-Payne, 2006; Ross & Cuskelly, 2006) and fewer pro-social behaviors (Hastings, 2003) among typically developing siblings. Other research has reported that siblings of children with autism are well adjusted and benefit from the relationship that they have with their sibling with autism (Hastings, 2007; Kaminsky & Dewey, 2002; Pilowsky et al., 2004; Verté, Roeyers, & Buysse, 2003). Typically developing siblings may display resiliency when

faced with a significant stressor on the family system. It is important that social workers not assume pathology will exist among siblings exposed to adversity in the family system. resiliencies and Protective factors Resilience is a person’s capacity to navigate through life successfully regardless of harsh conditions or misfortune (Alvord & Grados, 2005). Families and individuals with autism face many challenges but continue to thrive and navigate through life with enjoyment and laughter (Harris & Glasberg, 2003). O’Brien (2007) attributes resilience in families affected by autism to flexibility, and to the parent’s ability to accept the disability and learn to live with uncertainty (O’Brien, 2007). Resilience can emerge with support and appropriate intervention (Sivberg, 2002). Appropriate intervention can help to mitigate the common feelings of guilt and vulnerability associated with the autism diagnosis (Stern & Bruschweiler-Stern, 1998). Family members can be encouraged to retain or reestablish a sense of order or control with assistance from community, extended family, and friends. Dale, Jahoda, and Knott (2006) determined that mothers who felt that they were solely responsible for their child with autism suffered from feelings of isolation and depression, while social supports available to the family played a significant role in the mother’s reduction of stress. Social supports that were useful for parents included counseling for parents and their children, as well as early intervention programs for the child with autism (Dale, Jahoda, & Knott, 2006). Psychological characteristics of the parent, such as perceived self-efficacy, ability to positively handle stress, and coping strategies, are attributes that assist in developing a strong sense of accomplishment and well-being (Dunn, Burbine, Bowers, & Tantleff-Dunn, 2001). Heiman (2002) lists the variables contributing to resilience as successful adjustment in terms of self-esteem, social support, problemsolving skills, well-defined faith, coping skills,

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interdependence, and the ability to reframe barriers and obstacles. These characteristics enable parents to function and to maintain their morale and optimism during times of crisis and to cope in a productive way (Heiman, 2002). Sivberg (2002) suggests that maintaining a keen sense of family coherence has a powerful stress-reducing effect on parents of a child with autism. Sivberg (2002) concluded that parents should strive to achieve two specific dimensions of cohesion within their family: (1) comprehension or the constant pursuit of knowledge associated with autism; and (2) the development of manageability of the child’s condition, specifically the ability to manage abnormal behaviors. The siblings of children with autism also need support and guidance. Harris and Glasberg (2003) point out the importance of recognizing the difference between the normal frustrations of childhood and the special impact of having a sibling with autism. They explain that siblings need information on autism and its impacts, assistance in coping with anger and other emotions, and the skills to play or interact with their siblings. Despite the challenges families face, parents often are able to succeed and children and youth with autism are able to flourish. Amy LenhardGoehner, mother of a son with autism states: “The challenges of this world are greater, but the accomplishments—those firsts—are that much sweeter” (Nash, 2002, p. 45). As children age, their strengths and many abilities often become more apparent. For example, individuals with autism tend to understand concrete concepts very well; they often can memorize rote material easily and quickly and recall visual images and memories easily. In addition, many individuals living with autism understand and use concrete rules and sequences; they are often perfectionistic in approach to tasks and can be very precise and detail oriented so they can be depended upon to maintain schedules and to be on time. Individuals with autism are often very honest and have difficulty being devious. They have a strong sense of integrity and tend to be extremely genuine.

Family resiliency is often viewed as a flexible process that indicates the family’s strength at different points during the life cycle of the family, and within different circumstances (Walsh, 2003). A family is resilient when it demonstrates strength, even if it may not demonstrate the same attribute at another point in time (Walsh, 2003). Several key factors that contribute to a family’s becoming resilient are: (1) making meaning of adversity, (2) affirming strength and keeping a positive outlook, and (3) having spirituality and a belief system (Walsh 1998). In addition, for a family to rebound in face of a challenging situation, the family needs to possess certain organizational qualities, such as flexibility, connectedness, communication, and being able to utilize resources (Walsh, 2003). Raising a child with autism involves major stressors, and there are times when their families may not function at an optimal level, but many families of children with autism may be considered resilient families, families who grow out of adversity strengthened, and with a more positive outlook. Often the family or individuals in the family unit change for the better, by having learned important lessons, which might have life-altering consequences for them. Provision of strengths-based services means that social workers should not limit their focus to alleviating the problem. Such a focus often misses opportunities of growth, and fails utilize families’ strengths to build on the positive when providing intervention (Blundo, 2001). A social worker working with a family should capture the whole experience of the family, and not just the negative experiences. Service providers who interface with families of children with autism can communicate to them a conviction that these families can be resilient and build the necessary components of resilience such as flexibility, connectedness, and communication (Lietz, 2006). Assisting parents and families to recognize and nurture these positive strengths is often a necessary and different perspective from the pathological medical focus. A strengths-based

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perspective in social work intervention promotes a focus on capabilities, capacities, and opportunities instead of impairments or disabilities (Early & GlenMaye, 2000). Miley, O’Melia, and DuBois (1995) describe the empowerment intervention as focusing on three areas: client strengths, neighborhood/community resources that exist within one’s own system, and a vision that solutions are possible. Programs and Social Work contributions Most research on autism has focused on assessment and diagnosis, looking for causes and genetic contributions to the condition. Much less attention has been given to the policies and community and social interventions necessary to accommodate the needs of people coping with autism, not only in early childhood, but through the life span. In the United States, the primary federal law concerning autism is the Combating Autism Act, which was signed into law in December 2006. This historic piece of legislation authorized nearly $1 billion over five years for the National Institutes of Health to conduct autism research, surveillance, education, early detection, and intervention. The Combating Autism Reauthorization Act (CARA) of 2011 was signed into law on September 30, 2011, by President Obama; the law authorizes $693 million in continued federal investment over three years for autism research, treatment, and services. The Expanding the Promise of Individuals with Autism Act of 2007 (EPIAA) has a section titled “Support for Individuals with Autism and Their Families,” added to the Public Health Service Act, complementing the work done by the Combating Autism Act. While the Combating Autism Act authorizes new federal autism research, the EPIAA is focused on new federal autism service programs. This includes the creation of a Treatments, Interventions and Services Evaluation Task Force, which will evaluate evidence-based biomedical and behavioral treatments for autism. It also establishes Demonstration Grants, multiyear

grants of $20 million to states for the provision of evidence-based autism treatments, services, and interventions; and Grants for Services for Adults, a one-time, single-year planning grant program of $20 million and a multiyear service provision demonstration grant program for states. The Individuals with Disabilities Education Act of 2004 requires that public school educators provide an education to all disabled students, which includes children with autism, as well as design an individualized educational program for each child with special needs. The most accepted treatment as of late has become “applied behavior analysis,” which requires thirty to forty hours of individual attention and might cost up to $60,000 per year. Currently, there is a shortage across the United States of special education teachers, and those currently employed do not necessarily have the training in autism treatment that provides the most appropriate care (U.S. Department of Education, 2010). While funding has been increasing, the training and certification of licensed, eligible teachers has not kept up with the sharp increase in diagnosis and constitutes a major current problem facing school provision for autism. All children who are receiving and eligible for Social Security Income (SSI) under age 21 and who are receiving Medicaid are entitled under federal law to receive services such as immunizations, health education, dental care, and screenings for physical and mental health, vision, hearing, and lead exposure. They are also eligible for treatment for all diagnosed physical and medical conditions, and many school districts provide health-related services such as occupational therapy (OT) and physical therapy (PT) to children with autism who have low family income. Insurance coverage is a major issue for parents, but generally for higher income families. Individuals with autism usually can find insurance coverage for basic services such as speech and language therapy, OT, PT, and applied behavioral analysis. These

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services are now seen as medically necessary, as autism is beginning to be viewed as a biologically based mental illness by insurance companies. Social workers make valuable contributions to families and individuals dealing with autism. Social workers work in a variety of settings where they will come across a family or individual affected by autism, whether in a hospital, a school, or an individual’s home. The role of the social worker is to provide support to people with autism and their families. This would include linking clients and their families to services and resources such as counseling, respite, and home support. They may also advocate on behalf of those unable to do so for themselves. Social workers assume various roles and have various skills: to advocate, negotiate, mediate, advise, inform, guide, plan, and/ or monitor. The high demands on social workers can only be effectively realized with teamwork. Frequently, social services overlap with therapy that provides applied behavior analysis and coordinate with speech and language therapy from a speech and language pathologist. A holistic approach is encouraged and, in this perspective, social work services are intertwined with educational systems. Social work services for individuals with autism have shifted from a narrow focus on clinical practice to a broader approach using activities and skills directed to increasing independent functioning. assessment and interventions For families, the journey of coping with autism often begins very early, when many parents note that something seems “not quite right” with their child. Sometimes this occurs as early as when the child is one year old, while other parents notice it more around two to three years of age (Lord et al., 2006). Often parents note the child’s lack of responsiveness, inability to maintain eye contact, and, most noticeable at this age, the slow acquisition of speech. Early identification of autism is important because it seems that the earlier intervention can begin,

the better the outcome. Autism can sometimes be detected at 18 months or younger. The American Academy of Pediatrics recommends routine screening for autism at 18- and 24-month pediatric visits. All social workers working with children at this age should have an idea of proper screening tools and any “red flags” for autism. The most common red flags for autism are lack of smiles or other warm, joyful expressions by six months; no back-andforth sharing of sounds, smiles, or other facial expressions by nine months; no babbling by 12 months; no back-and-forth gestures such as pointing, showing, reaching, or waving by 12 months; no single words by 16 months; no twoword spontaneous meaningful phrases, without imitating or repeating, by 24 months; and any loss of any language or social skills. Social workers can conduct this screening and then, if necessary, refer the family for diagnosis. There are many screening tools, with one of the most common being the Modified Checklist for Autism in Toddlers (M-CHAT), which was published in 2001. It contains twentythree yes-or-no items that the parent can complete alone or with assistance from the social worker. It can be administered when the child is between the ages of 16 and 30 months. It has a current rate of sensitivity between 85 and 95 percent. A positive screen indicates a risk for autism but is not equivalent to a diagnosis of autism. The checklist is available free on the Internet. Most screenings are conducted in pediatricians’ offices and the child who is scared of the doctor’s office may be crying, running around, or climbing on things. In addition, siblings may be in attendance too. Given this environment, the parent trying to self-administer the M-CHAT test in the pediatrician’s office may not be able to pay full attention to the measure. It may prove helpful to re-administer the screening in a less stressful and distracting environment. Once a child has a “positive” screen for autism, social workers can refer the family for diagnosis. The person making the diagnosis is

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often a developmental behavioral pediatrician, a clinical psychologist/neuropsychologist, a pediatric neurologist, or a child and adolescent psychiatrist. Diagnosing autism can be difficult since there is no medical test, like a blood test, to diagnose the condition. Doctors look at the child’s behavior and development, since the diagnosis is a DSM-V supported clinical judgment based on observing the child’s behavior. The most common diagnostic tools used are the Childhood Autism Rating Scale (CARS), the Autism Diagnostic Interview schedule (ADI), and the Autism Diagnostic Observation Schedule (ADOS). In addition to a referral for a diagnosis, families should be referred to Early Intervention in their state, as they do not need a diagnosis of autism to receive the services. Bromley, Hare, Davison, and Emerson (2004) explain that parents of children with autism are more likely to experience serious psychological distress than parents of children with other developmental disabilities, because autism is a complex and difficult disability to understand. With other diagnoses, professionals are able to educate parents and caregivers and can often provide a comprehensible prognosis for the future of the child. However, because outcomes for children coping with autism are so diverse, professionals are somewhat averse to providing conclusive or definitive predictions for the child. A lack of consensus among professionals about the best treatment for children with autism can be cause for additional stress and parental confusion (Whitman 2004). Parents are confused as to which treatment will best assist their child, and there are a number of treatment options to consider (Whitman, 2004). Early Intervention programs, support services, and access to adequate health services for families have been identified as vital for parents learning to live with autism (Thomlison, 1997). Stern and Bruschweiler-Stern (1998) explain that the experience of being told that something is wrong with your child is unexpected and emotionally unimaginable. Upon hearing the diagnosis, the parents’ hopes and fantasies

for their child are suddenly shattered (Boushey, 2001). Parents are instead held prisoner in an enduring present (Stern & Bruschweiler-Stern, 1998). There is a grief cycle that is a natural process when a loss is experienced, and parents of the child who receives a diagnosis of autism may go through that cycle, due to the loss of the hopes and dreams that they had for their child. A parent of a child with autism states: “. . . things become blurry after this devastating news. You continue to function, but you don’t know how you do it . . .” (Boushey, 2001, p. 2). As parents move past the cycle of grief, they can become advocates for their children and begin the process of intervention (Boushey, 2001). The National Professional Development Center (NPDC) on autism has identified twenty-four practices that meet the criteria for evidence-based practices (EBP) for children and youth with autism. One of the EBPs for children and youth with autism is discrete trial training, which is a technique of applied behavioral analysis (ABA); see table 4.1 for the list of EBPs. The NPDC is developing online modules for each of the twenty-four identified evidencebased practices available on their website. In addition, there are briefs written on the EBP for autism that include an overview of the practice, step-by-step directions for implementation, an implementation checklist, the evidence base for the practice, and supplemental materials. (Please see the website at http://autismpdc.fpg .unc.edu/content/evidence-based-practices.) Crucial to the implementation of EBP is the use of natural learning environments, with interventions applied as part of daily living, family routines, rituals, and community celebrations and traditions (Dunst, Hamby, Trivette, Raab, & Bruder, 2000). Therefore, interventions need to be implemented where the skills are used, in a predictable and routine fashion, utilizing peer role models while taking into consideration environmental conditions. Person- and family- and environment-centered planning is the key to developing an intervention plan and goals that focus on the needs of

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List of Evidence-Based Practices for Individuals with Autism

ta b l e 4 . 1

• • • • • • • • • • • • • • • • • • • • • • • •

Antecedent-Based Interventions (ABI) Computer-Aided Instruction Differential Reinforcement Discrete Trial Training Extinction Functional Behavior Assessment Functional Communication Training Naturalistic Intervention Parent-Implemented Interventions Peer-Mediated Instruction and Intervention Picture Exchange Communication System (PECS) Pivotal Response Training Prompting Reinforcement Response Interruption/Redirection Self-Management Social Narratives Social Skills Groups Speech Generating Devices/VOCA Structured Work Systems Task Analysis Time Delay Video Modeling Visual Supports

the family and individual. Individuals dealing with autism often need accommodations that will allow them to learn and process the intervention or skills being taught. Individuals with autism commonly have heightened experience of senses, such that noises seem unusually loud or smells are overpowering. Some tools are available to assess sensory differences for young adults with autism, such as the Sensory Behavior Scale (Harrison & Hare, 2004), which can help with screening and individual assessment. Reasonable adjustments can be made, such as purchasing appropriate light bulbs (nonfluorescent) or moving some classroom activities to a room without the air conditioning unit that has a loud humming noise. It is not always easy for adults with autism to recognize the difficulties they encounter in environments and then explain these difficulties to others. For example, Hale (1998, p. 55) reflects on living in a typical university dormitory residence: “Any highly contrasting pattern

is a problem. For instance trying to have a conversation with someone who is wearing a black and white striped shirt is almost impossible. The pattern appears to be jumping around in a mesmerizing fashion and can cause my vision to go fuzzy and remain fuzzy long after the pattern is out of sight.” It would be a reasonable adjustment to request that staff wear clothing without patterns while supporting this student at the university. Social workers can promote desensitization techniques to deal with some sensory issues in the environment, such as trial runs in the environment or limited exposure to the environmental concern to help the individual. For example, one school-aged child dealing with autism would start hand flapping and echolalia because of the loud flush of the toilet in the classroom bathroom. The school social worker used desensitization techniques to help the child process this sound. She audio taped the flushing of the toilet, and would play it in therapy sessions on low volume, and slowly increase the volume over the course of therapy. Finally, she would start with the child standing outside the classroom and flush the toilet, and then slowly over time bring the child closer and closer to the toilet while it was flushing, until finally the child could stand in the bathroom and hear the flushing without reacting to the sound. Other reasonable adjustments can be made to the communication and interaction methods used with individuals with autism. In unfamiliar environments, someone with autism may be unable to process a lot of verbal information. Visual information such as photographs, videos, and diagrams may enable easier access to information for people with autism. Visual scheduling, using cut-out pictures of what will happen throughout the day, will help the individual with autism process the information. In addition, not touching the person without asking is important. As Temple Grandin (1996, p. 104) states, “When touched unexpectedly we usually withdraw, because our nervous system

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does not have time to process the sensation.” Talking about the person’s area of special interest can reduce stress and develop rapport. In providing services to young adults with autism, part of the intervention plan should include developing self-awareness, so that the youth understand their needs and how to meet them. Often, assisting the youth in describing medical concerns and speaking with medical professionals is helpful, in addition to describing how autism affects them and the accommodations they need to teachers, staff, and other educational professionals. Teaching selfadvocacy for youth with autism can assist them in transitioning to adulthood. Children and youth with autism can receive various supports and accommodations, including speech and language therapy, occupational therapy, physical therapy, and the use of assistive devices or technology. One-to-one supports are available, such as having a paraprofessional to assist in a variety of tasks, providing sensory breaks during difficult times, and facilitating social interactions. Social workers can help with interdisciplinary collaboration between service providers and assist in overcoming time, communication, and professional differences. illuStrAtion And diSCuSSion

This illustration, about James, demonstrates the uniqueness of each individual dealing with autism, and the difficulties presented depending on age and diagnosis, in addition to cultural and socioeconomic conditions.1 James was referred for outpatient psychotherapy at the age of 15 years. He was referred to the clinic due to developmental and behavioral concerns. His parents and the school were seeking to know what could be done to help James. James lives at home with his biological mother and father and younger brother. James was diagnosed with Asperger’s syndrome at the age of 7. His diagnosis was attained through the Brigance Inventory of Early Development, ECO Scales to assess communication and

interactive skills and the Childhood Autism Rating Scales (CARS). The family is a middle-class, African American family living in the inner city. James attends public school in the inclusion program. There is extended family involvement and the parents and James identify the maternal grandmother and aunt as support resources. James’s school performance has been inconsistent since he began preschool at age 3. He did not have Early Intervention services, although in retrospect the parents agree that they should have pursued this because of speech delays and idiosyncratic play that were obvious. At the time, they considered him “slow.” There was resistance within the family to pursuing services for James as they felt he was “just immature.” James has an average IQ of 98. He has a secondary diagnosis of Mood Disorder NOS. In the home, James is very difficult for the parents to manage. He is physically and verbally aggressive, continually arguing and fighting with his brother, is abusive to the family cat, and has frequent incidents of threatening family members. Ongoing conflict with his brother has led to parental interventions that resulted in the State Department of Children and Families (DCF) investigating the father’s actions, such as using physical restraint. James demonstrates extreme rigidity regarding routines and expectations and becomes extremely dysregulated when routines are disrupted or when his expectations are not met. In school, James displays behaviors from one extreme to the other. Either he withdraws by pulling his shirt or hoodie over his head and refusing to respond, or he becomes agitated, pacing, threatening, and posturing in a manner that intimidates others, especially peers. James is able to read and write and his language skills are average for his age. There are topics upon which James becomes “stuck” during the school day. He will become fixed on anything related to the Three Stooges and to maps. He remembers his bus route, the directions to their vacation location, exact directions to his grandmother’s home, etc. Strengths in school are

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that James always completes his homework and does it correctly. He is interested in academics, enjoys taking tests, and most days follows the posted classroom rules.

but I don’t know too much about them so I can’t really talk to you about them. JAMES: Yeah, feelings, feelings, feelings!

James was easily engaged in counseling with me (social worker) because of his strong language skills and his cognitive ability. There were many occasions when the topics that were frequently problematic in school and at home, such as the Three Stooges, were utilized as the jumping off point to work on problem solving and to look at James’s behavior through a lens that he could relate to easily. This was possible because I set clear boundaries that were written down and established early in our work. James had a strong ability to comprehend and follow written rules and contracts. Outpatient therapy focused on system-level interventions and individual-level interventions that utilized cognitive behavioral therapy, and cognitive restructuring. In addition, services for James included family therapy and parent consultation as needed. Initially, family therapy was once per month and parent consultation, usually through phone contact, was weekly.

ANNE: I feel interested in what you have to say about the Three Stooges because when you tell me stories about them I learn something.

Areas of focus included problem solving and anger management strategies such as separating from the problem and engaging in a preferred activity or selfsoothing strategies such as taking a shower, getting in bed and wrapping up tight in the blanket, and playing music. The following recorded excerpt is from a typical individual session in which we dealt with James’s relationship with his brother.

JAMES: It’s hitting but it doesn’t hurt them, they are just acting.

ANNE: Hi, James. How are you feeling today? JAMES: Feelings, feelings, feelings. Is that all you want to talk about?

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JAMES: OK, so there’s the Three Stooges and there’s pies and they are supposed to be pies to eat but the Three Stooges start arguing and then they start throwing the pies so no one gets to eat them. They get to eat them because the pies got thrown in their faces!! (smiling, not laughing) ANNE: So when the Three Stooges feel angry because they can’t get along, they become aggressive toward each other? JAMES: Yes, all the time but it’s funny hitting. ANNE: Funny hitting? Can you tell me more about that?

ANNE: OK, I understand. So when the Three Stooges feel angry because they can’t get along and they hit each other it doesn’t hurt? JAMES: That’s correct. ANNE: Is this true of let’s say, you and Billy? When you and Billy feel angry because you are having trouble getting along and you hit each other, does it hurt? JAMES: Of course I hurt him. That’s the point.

ANNE: Let’s talk about something that interests you. JAMES: Hmmm, let’s see. You won’t talk about the Three Stooges, so that’s out.

ANNE: Do you think there is another way to show him that you feel angry and work out the getting along problem without hitting?

ANNE: You may tell me one story about the Three Stooges, or draw one picture about the Three Stooges,

JAMES: You know, maybe sometimes but sometimes, I just have to hit him.

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ANNE: Can we talk about times when you were angry but could have done something different than hit him? JAMES: Sure, but I really don’t think this is a good topic for us to talk about. While James and I continued individual sessions, other supportive services were developed. We made a home emergency plan to use mobile crisis services and/or 911 in an emergency situation, with safety strategies, utilizing extended family members (grandmother and maternal aunt) who have positive relationships with James. The parents were helped to restructure their responses to behavior in the home, from focusing on undesirable behavior to rewarding desirable behaviors. Referral for medication management led to James being placed on an antipsychotic medication and a mood stabilizer. System-level interventions included connecting the client to In-Home Therapy to stabilize the home environment. The school was contacted weekly with parental consent. The school program worked in conjunction with the In-Home Therapy program as well as with me to develop a more effective Individual Behavior Plan for James. James was a good candidate for contracting because of his ability to read and his drive to follow the written word. Contracting was used in school as a major aspect of his Individual Behavior Plan. This diffused the need for the authority figures to confront behaviors and the school staff was able to refer to the written contract that listed both rules and consequences (rewards and discipline). On three occasions because of James’s violent outbursts while at school, there was consultation with Mobile Crisis Services. DCF was consulted about the investigation of the parents that resulted from a report filed by the school. There had been concern about bruising that followed the father’s physical restraint of James after a violent episode in the home.

The parent(s) would update me on the course of the week and let me know if there were any significant issues that I might be able to help James with that week. Most weeks the issues were related to one of two topics: conflict with Billy, his younger brother, or mistreatment of the cat. James is becoming increasingly aware through his experiences that Billy is doing more independently and is developing a social network that James does not have. Prior to the last year, James was unaware that his younger brother had more social outlets and community connections. For James, the struggles that he has with communicating feelings, as well as the awareness that he has gained of the developmental differences between him and his brother, contribute to the ongoing aggression he frequently initiates toward Billy. James struggles with self-expression and labeling feelings and demonstrates his feelings through behavior that creates conflicts in all his relationships, even with the family pet. Increasing James’s ability to effectively communicate required a team approach with the school-based speech pathologist. Visual prompts were paired with feelings, images, and voice intonation appropriate to the feeling being discussed. James was also taught how to tell what someone else is feeling by how they look, how they sound, and how they move. The strengths that this approach utilized were James’s abilities to understand the task and comply with the protocol. He was motivated to learn age-appropriate social behaviors and enjoyed role-playing each lesson. In this process recording, we focus on the three things that indicate how a person is feeling. ANNE: Was it difficult to tell Billy that you were getting angry with him for ignoring you when his friend was visiting? JAMES: I don’t know. ANNE: Can you tell me a story about how things went when you became angry with Billy? JAMES: A story or the truth?

Work with James continued with weekly contact with the parent(s) either through phone or e-mail.

ANNE: The truth please.

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JAMES: Well, it’s like this. Billy has this kid over and they are playing video games (names game and provides details of the game). ANNE: Thanks for explaining the game. What happened while they were playing that game?

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JAMES: No, I was behind the couch. ANNE: Could the boys hear your voice ask to play? JAMES: Nooooo. ANNE: Could the boys see your body language?

JAMES: You know, the same old thing that happens every time. ANNE: I may not know, so if you could tell me about it, that would help me to understand. JAMES: Ok, well, I wanted to play the game and there are only two controllers and they just hogged the game and wouldn’t give me a turn. ANNE: Can you tell me what you said to the boys while they were playing? JAMES: Nothing. ANNE: Did you ask them, “Can I play”? JAMES: Nope. ANNE: How do you think that Billy and his friend knew you wanted to play? JAMES: ’Cause if I’m standing there, what do you think I wanted to do? Of course I want to have a turn! ANNE: Hmmm, now I’ll put our feeling game on my computer. (We play a game on the computer that helps to develop awareness of feeling words and facial expression.) Now I am going to start playing. (I say nothing more for a few minutes.) ANNE: Did you want to play with me? JAMES: Yeah, I could use a turn. ANNE: James, how could I tell that you wanted a turn? I was not looking at you to see your face. Were the boys able to see your face while you were watching them play?

JAMES: If they couldn’t see my face, they can’t see my body. ANNE: Do you remember the three ways that you can try to tell how someone is feeling? JAMES: NO, Yesssss. How their face looks, how their voice sounds, and what they are doing with their body. ANNE: YES, exactly! James continues to be seen in counseling, now meeting with me every other week. His medications have been reduced and he is maintaining control. James is doing well in school, with good academic results, although he strongly resists encouragement to participate in school-based activities and after-school activities. Family relationships are repairing and stress in the home is significantly reduced. The InHome Therapy supports have been gradually decreased and the case is scheduled to be closed due to the progress made. James has several characteristic features of Asperger’s syndrome, notably becoming focused on narrow interests and avoiding social interaction. A significant role for the social worker, as illustrated in this case situation, was to provide support by focusing on the strengths of the client, by redirecting the interventions to meet his interests, and using his ability to read and make a contract. In addition, her assessment of the role of the family and provision of in-home supports proved very useful for James and his family. Safety planning and providing emergency planning was important for James, as it often is with older children. Utilizing family members as supports, beyond the nuclear family, can be

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extremely useful with clients from many cultural groups. The client’s violent and aggressive behavior is usually, as in this case, a result of mismanagement of stimuli, and creating a positive, reinforcing parental response can often have constructive results.

conclusion Autism is a complex life condition with the presentation of symptoms in a wide range of areas such as behavior, communication, and sensory experience. This means that simply knowing a client has been diagnosed with autism does not mean you know about the needs of that particular individual. This makes individualized assessment, planning, and intervention services of paramount importance. Social workers are well prepared through their training to take the lead in planning and advocacy efforts for individuals and families affected by autism. Roles taken by social workers include implementation of screening tools such as the M-CHAT, lending support during the diagnostic phase, and providing therapeutic services for the individual and/or family member. Social workers can also provide case management, lead interdisciplinary group meetings, and provide evidence-based interventions in communication and social skills, daily living skills, anxiety management, and coping strategies. Social workers can also give safety skills trainings for noteS

1. Anne Cuvellier, M.S.W., graciously provided the case example.

referenceS

Abrahams, B. S., & Geschwind, D. H. (2008). Advances in autism genetics: On the threshold of a new neurobiology. Nature Reviews Genetics, 9, 341–55. Alvord, M. K., & Grados, J. J. (2005). Enhancing resilience in children: A proactive approach. American Psychological Association, 10(1), 735–828. Amendah, D., Grosse, S. D., Peacock, G., & Mandell, D. S. (2011). The economic costs of autism: A review. In D. Amaral, D. Geschwind, & G. Dawson (Eds.), Autism spectrum disorders (pp. 1347–60). Oxford: Oxford University Press.

first responders, and training in avoiding sexual abuse and violence, as well as facilitating social support groups for individuals, parents, and siblings. Linking to services in the community for things such as respite care, and serving as effective policy advocates are also areas in which social workers have expertise. When such services are evaluated, social workers can provide evidence of effective interventions. Approximately 75 percent of social workers report working with people with developmental disabilities, which include autism (National Association of Social Workers, 2006). Social workers encounter people with autism in their work in child care, in health and other social services, and in schools, and must be prepared to meet their needs. As more information is uncovered on autism and how it affects the brain, our knowledge of how to best assist individuals and families will develop to better serve this population. Remaining aware of current knowledge is a challenge, but is necessary to provide current information to individuals and families and to intervene appropriately. Even with changes in autism diagnosis, and more knowledge of its prevalence and causative factors, families and individuals with autism will need help through the identification, assessment, and diagnostic processes, as well as in navigating numerous interventions, identification of resources, and advocacy efforts.

American Academy of Pediatrics Committee on Child Abuse and Neglect and Committee on Children With Disabilities. (2001). Assessment of maltreatment of children with disabilities. Pediatrics, 108(2), 508–12. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author. ARCH National Resource Center for Respite and Crisis Care Services. (1992). . http://archrespite.org/images/docs/Factsheets/ fs_9-respiteautism.pdf. ——. (2007). Factsheet Number 14: Respite and Crisis care. http://www.archrespite.org/docs/FRIENDSfactsheet14 -Respite.pdf

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cHaPter 5 borderline Personality nina roVinelli Heller and ann marie Garran

b

orderline personality disorder (BPD) is distinctive among psychiatric diagnoses for its historical gender discrepancy, comorbidities, association with adverse childhood events, high acuity, and theoretical and practice controversies. Social workers who work with clients diagnosed with BPD often find the impulsivity, self destructive tendencies, and rage associated with the condition to be challenging. At the same time, advances in our understanding of complex etiological, developmental, biological, and social dynamics have yielded increasingly effective interventions for this population. In addition to relieving struggles for these clients and their families, these advances may help to attenuate the pejorative attitudes, which have been common among mental health professionals. defining and explaining borderline Personality The lens through which a social worker views mental health conditions determines what data is observed and assessed; one’s views about prevalence, etiology, course, and prognosis; and importantly, what interventions are employed and to what end. This is particularly so for borderline personality disorder, a mental health condition which is well known both for its controversies among mental health professionals and for the stigma attached to the diagnosis. Definitions can be narrow, with a focus only upon descriptive symptoms, or broader, with attention to more dynamic factors such as interpersonal relationships and sociocultural factors. Social workers must examine their own

etiological assumptions about the condition; if one subscribes to the notion that BPD is primarily a genetic/biological condition, interventions aimed at influencing biological symptoms will be warranted. In this case, psychopharmacology will be the mainstay of intervention. If certain adverse childhood events (ACE) are considered central in the development of BPD, intervention aimed at the amelioration of the effects of these on an individual will be critical. Social workers might see their function at the macro level of prevention and early intervention aimed at eradicating the experience of these adverse effects, which may result in a later diagnosis of BPD. Likewise, if BPD is thought to develop primarily from poor attachment relationships with early caregivers, psychotherapy aimed at modifying attachment “templates” would be indicated. If BPD is believed to be the result of learned patterns of emotional reactivity and impulsivity, efforts would be aimed at helping clients develop improved self-regulatory and coping skills. Finally, if the social worker sees BPD as a static, chronic condition, rather than one that is amenable to modification and recovery, both the interventions and the sense of hope that one can bring to the work with clients may be different. A social work perspective will hold that the development of BPD, like many mental health conditions, results from a complex interaction of biological, interpersonal, social, genetic, environmental, and sociocultural influences that converge in a pattern of maladaptive behaviors that reflect an individual’s attempt to adapt to internal and external systems that threaten to overwhelm. 95

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Viewed in this way, these clients are “doing the best they can” and may require help in a number of domains in order to improve their functioning, decrease their maladaptive behaviors, and live satisfying, purposeful lives. Borderline personality disorder is one of several conditions subsumed under the broader classification of personality disorders. Personality disorders, according to the Diagnostic and Statistical Manual (American Psychiatric Association [APA], 2000), are persistent and stable maladaptive patterns of behavior and relating that first emerge in early adulthood. BPD, specifically, is marked by a constellation of symptoms including difficulties related to fears of abandonment, unstable and intense interpersonal relationships, identity disturbance, impulsivity, suicidal behaviors and/or ideation, affective instability, intense and “inappropriate” anger, and occasionally, transient paranoid thinking and/or dissociation. While the DSM-IV-TR is the prevailing nosological classification system used in the United States, the parallel International Classification of Diseases (ICD-11) is used globally. These descriptive diagnostic systems have significant limitations, and the social work literature provides cogent critiques based upon their focus on client deficits, the medical model, and the lack of attention to any sociocultural factors (Kirk & Kutchins, 1992). The proposed classification system for personality disorders in DSM-5 replaces the categorical approach in favor of a more dimensional model. In a review of the research, the DSM-5 Task Force identified several problems with the existing criteria: extensive co-occurrence of personality disorders; extreme heterogeneity among clients within a category; lack of severity dimensions for symptoms; temporal diagnostic instability; poor coverage of personality psychopathology (Personality Disorder, Not Otherwise Specified is the most frequently diagnosed PD in both research and clinical practice); and poor convergent validity (0.27 between structured interviews and personality questionnaires) (http://www.dsm5 .org/ProposedRevision/Pages/proposedrevision .aspx?rid=17#). A hallmark of the earlier DSM

personality disorder classification was the stability of the condition. This has had a significant negative impact on both clinicians’ and clients’ expectations about recovery. In fact, the evidence from prospective studies suggests that the stability of these concepts is less than generally assumed. Therefore, the proposed DSM-5 system focuses, rather, on relative stability. This is an important shift, particularly from a social work perspective, which increasingly sees recovery as a dominant paradigm in the work with people with mental health conditions. In response to the DSM, the Psychodynamic Diagnostic Manual (PDM Task Force, 2006) was developed to deal with some of the former’s limitations and is characterized by a focus upon a broader range of an individual’s functioning. It is designed to be used alongside the DSM classification system. There is an attempt to deepen understandings of complex etiology as well as the individual’s subjective experience of a mental health condition. The result is a more nuanced and multidimensional approach to the diagnostic process, which focuses on three areas: Dimension I—Personality Patterns and Disorders; Dimension 2—Mental Functioning; Dimension III—Manifest Symptoms and Concerns. The approach to personality condition classification by this system is best characterized by the premise that “personality is what one is rather than what one has” (p. 17). This represents a more dynamic understanding of the complexities and idiosyncrasies of personality that assumes that individuals have both conscious and unconscious processes in their attempts to accommodate to challenging life events and patterns. The task force responsible for the writing of this system makes the important distinction between a “disorder” and a response to chronic stress. Hence, it is not possible to diagnose a personality disorder accurately without attention to other possibilities that explain the patient’s behavior, the context of that behavior, and the question of whether it represents longterm functioning rather than a more acute state. (PDM Task Force, 2006, p. 20).

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Unfortunately, the PDM is not widely used in clinical practice. This may reflect, in part, current challenges in agency practice to make rapid diagnostic assessments in order to comply with insurance billing practices and to provide fairly rapid and short-term interventions. These are particularly concerning pressures, especially in the work with people with BPD, given that one area of general consensus among clinicians from various theoretical perspectives is that interventions with this population, to be effective, generally must be longer term. For social workers, the diagnostic approach promoted by the PDM is clearly more in line with social work perspectives, values, and models, and merits further attention. However, it does not address issues related to the influence of external social and cultural factors. While the labeling involved in the use of classification systems has variable and potentially negative effects for people with many psychiatric conditions, this is particularly so for those with BPD. Oftentimes, symptoms are activated and maintained by interpersonal events, perceived or real loss, and abandonment. Furthermore, affective reactions tend to be rapid, labile and intense, with accompanying impulsive and reactive behaviors. This can be trying for people in the individual’s life, for their mental health providers, and importantly, for clients themselves. This often creates a circular feedback loop in which the client’s behavior may induce strong reactions and distancing and rejection from others—all of which simply confirm the client’s worst fears. These fears may involve the cognitions that they are “unlovable” and that they cannot extract what they need from the world and people around them. In turn, this can confirm others’ beliefs that the person with BPD is difficult at best and unable to be helped. Thus begins, according to Aviram, Brodsky, and Stanley (2006), a dialectical self-fulfilling prophecy that leaves both parties feeling stigmatized and ineffective. Shedler and Westen (2004) argue that the mental health field has developed a profile of those with BPD that

is characterized by pejorative terms such as “manipulative . . . treatment resistant . . . and attention seeking” (Stone, Stone, & Hurt, 1987). In counterpoint to the negative consequences of “labeling,” one of the authors (NH) reports that some clients express relief at having an explanation for a set of experiences (mood lability, impulsivity, interpersonal reactivity, and fears of abandonment) that wreak havoc in their personal and occupational lives. For these clients, having a label helps to contain, explain, and offer hope for the possibility of change. It can also have important implications for the working alliance; one client reported that she felt the worker “finally got it.” In addition to the classification systems, different theoretical schools have distinctive understandings of the definitions and etiology of BPD. In the earliest accounts, the term borderline was used in reference to people who were “in between” the psychotic and the neurotic poles on the continuum of personality organization. Early psychoanalysts found that certain clients, when in psychoanalysis, became disoriented and sometimes transiently psychotic, particularly when asked to free associate and engage in analysis of transference responses. What ensued were typically highly polarized transference responses that swung rapidly from premature and rigid idealization of the therapist to as dramatic a denigrating, devaluing position. These clients were deemed unsuitable for psychoanalysis (rather than, perhaps, psychoanalysis being unsuitable for them; hence the beginning of a stigmatizing attitude toward these clients). Adjustments to the psychoanalytic treatment frame were subsequently made and the object relations school of psychoanalytic theory focused upon the deficits in the triad of personality organization, defensive structure, and object relations, the process related to internalizing parental figures. Kernberg (1984), a pioneer in the work with people with borderline personality organization, focused upon the second of these deficits, the defensive structure, with a focus upon

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splitting, idealization, omnipotence, and devaluation. According to this framework, treatment interventions utilized modified psychoanalytic technique to interpret and modify maladaptive defensive strategies, with a focus upon challenging the negative transference phenomenon that appeared to characterize the work. In the field of social work, Goldstein (1995) argued that an ego psychological approach was particularly useful in work with clients with BPD, in that through supportive psychotherapy, ego deficits can be repaired and issues related to separation and individuation can be modified. Importantly, she emphasized the centrality of the therapeutic alliance in all phases of the work. Goldstein can be considered as having built a “bridge” between the psychoanalytic tradition, which rests largely on a deficit model, and social work, which considers the importance of evaluating and using client strengths. Ego psychology in a social work tradition promotes the systematic assessment of deficits simultaneously with the consideration of ego strengths through an assessment of ego functions. Interventions are then developed on the basis of developing strengths and increased coping strategies in those domains in which the client struggles. This provides a theoretical scaffolding for the introduction of cognitive behavioral interventions aimed at shoring up the areas of diminished coping capacities, such as self-regulation of affect and behavior (Northcut & Heller, 1999). More recent psychodynamic explanations for BPD are put forth by Fonagy and Bateman (2008) in a model that incorporates an understanding of constitutional vulnerability and attachment theory. According to this model, early disruptions in attachment relationships with primary caregivers, combined with later trauma, can adversely interact with neurobiological development. This results in hyperresponsiveness to the mentalizing system, which is the human capacity to make sense of our own and others’ behaviors in terms of subjective states. According to this theory, one’s ability to

understand others is predicated on having had the experience of being understood ourselves as infants. Understanding the mentalization model requires an understanding of recent advances in neurobiology. These advances have fostered critical understandings of the complexity of all of the personality conditions. In regard to borderline personality disorder, two areas have merited particular attention: impulsive aggression and affective instability (Siever, Koenigsberg, & Reynolds, 2003). Dysregulation in the neurotransmitter systems, particularly serotonin, are implicated in the problems with aggression often found in people with BPD. This appears to be related to both serotonin release and the sensitivity of the receptors. For people with BPD, dramatic mood shifts are common and cholinergic, noradrenergic, and GABAminergic systems play a role. These may also affect reactivity to environmental stimuli, which in these clients also manifests as irritability and high degrees of risk taking. Further evidence for the involvement of these systems in the etiology of BPD is the fact that medications commonly used to stabilize mood (Depakote, lithium, and carbamezepine) have shown positive effects in these clients, through their impact on the neurotransmitter GABA, which promotes inhibition (Siever, et al., 2003). In fact, some argue that borderline personality disorder is a variant of bipolar disorder, although Gunderson et al. (2006) found only a modest association. Irregularities of both structure and function in the amygdala and the frontal cortex of the brain have all been tentatively implicated in BPD (Fonagy & Bateman, 2006). Genetics also appear to play a role in the development of BPD. While there is not clear evidence that BPD itself produces via family transmission, the traits of impulsivity and affective instability are more frequent in these families (Siever, Koenigsberg, & Reynolds, 2003). More recently, Mondimore and Kelly (2011) report a concordance rate of 35.3 percent among identical twins and 6.7 percent

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among fraternal twins. The gold standard in mental health epidemiological research is twin studies, particularly when the sample includes twins raised apart. In regard to BPD, adverse childhood events such as abuse are implicated in much of the variance in the twin studies. A pioneer in the retrospective study of childhood sexual abuse, Herman (1988) found adult BPD rates as high as 81 percent for clinic samples; community studies noted a higher prevalence of BPD in women (Paris, Zweig-Frank, & Guzder, 1994), while childhood physical abuse was implicated more frequently in males (Herman, 1992). The families of origin of people with BPD were once believed to have had a pernicious influence on their offspring, most usually described as over-involved and overprotective parenting styles (Fonagy & Bateman, 2008). Like the mid-twentieth-century theories of the etiology of schizophrenia that posited that such individuals had “schizophrenogenic” mothers or that those with autism had “refrigerator” mothers, there was little research evidence to support these claims, and these theories have largely been debunked. More recent prospective studies of children suggest that parental emotional uninvolvement may place children at risk for poor socializing skills and suicide (Johnson et al., 2003). While it is tempting to try to make direct causal relationships between “good” or “bad” parenting and the development of BPD in offspring, the influences of the combination of parental styles, child temperament, and known or unknown genetic factors may yield more robust, fair, and useful theories and importantly, interventions. Social baseline theory has been extended by Hughes, Crowell, Uyeji, and Coan (2012) to explain the development of the emotional dysregulation or affective instability common to the condition. This is a model that explains the interdependent relationship between insecure attachment and emotional dysregulation. The theory holds that emotional regulation is a complex biological achievement that requires

a secure attachment figure who initially coregulates emotions. In the absence of such a figure and relationship, it is posited that the individual does not develop the capacity for regulating emotions and this results in anxious or preoccupied attachment styles and a lack of trust that one’s emotional needs will be tended to by others. However, childhood experiences as a standalone variable appear to be relevant. Recent research does suggest a higher incidence of physical and sexual abuse in the histories of people with BPD (Herman, Perry, & van der Kolk, 1989; Paris & Frank, 1992). Most of these studies are retrospective, however, and critics suggest that there may be recall bias in individuals whose cognitions may be distorted, particularly regarding emotional abuse. Zanarini, Frankenburg, Hennen, Reich, and Silk (2006) also found that fully 84 percent of clients with BPD retrospectively reported the experience of neglect and emotional abuse by both parents. The role of sexual and physical abuse in the genesis of borderline personality disorder continues to be a matter of debate and controversy (Vignarajah & Links, 2009; Dahl, 2008; Skodol, 2005). Fonagy and Bateman (2006) conclude that “abuse alone is neither necessary nor sufficient for the development of BPD and that predisposing factors and contextual features of the parent-child relationship are likely to be mediating factors in its actual development” (p. 11). Similarly, Everson, Hunter, Runyon, Edelsohn, & Coulter (1989) report that parental response to abuse (the degree to which they believe, protect, and/or provide validation to the child) mediates the development of the condition. It is now well understood that all those who are subjected to the trauma of sexual and physical abuse do not go on to develop posttraumatic stress disorder (PTSD). Less well understood is the relationship between BPD and PTSD. There have been calls (van der Kolk, Roth, Pelcovitz, Sunday, and Spinazzola 2005) for the establishment of a new diagnosis, Complex PTSD, which

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is believed to be both more accurate and less stigmatizing. In addition to the high incidence of childhood abuse in people later diagnosed with PTSD, comorbidity for the two disorders is high, with 58 percent of individuals with BPD also meeting the criteria for PTSD (Zanarini et al., 2004). This is statistically and clinically significant, given that in the general population PTSD is figured at 10 percent. However, not all people with BPD have trauma histories and many people with trauma histories do not go on to develop PTSD. According to Lewis and Grenyer (2009) it is important to remember that “Just because two disorders are similar in their symptomatic presentations and etiologies does not imply that they are the same phenomenon. . . . The distinction between BPD and PTSD is a matter of degree as measured by the type, severity, and length of traumatic experiences (325). On the other side of the controversy about the relationship between BPD and PTSD lies the model of the nontraumatic path in the development of BPD. Building upon the data that suggest that a sizeable minority of people with BPD do not, in fact, report childhood sexual or physical abuse, Graybar and Boutilier (2002) propose a hypothesis relevant to the development of BPD in these individuals. The model they propose is based upon the diathesis-stress model of vulnerability to mental health conditions and implicates constitutional disposition and environmental nurturing or trauma. This nontraumatic model emphasizes the important contribution of the constitutional disposition (“deficits in information processing, affect regulation, mood and interpersonal relatedness and the vicissitudes of his or her environment, such as being exposed to ‘good’ or ‘bad’ or ‘horrific’ parenting,” p. 154) in addition to a range of sociocultural experiences. Furthermore, they suggest that “extremely negative contributions from either end of the nature-nurture continuum have the potential to over-ride or offset very good genes or very good parenting” (p. 154). This model is compatible with a genetic etiological hypothesis.

Finally, there exists some controversy re the course of the borderline condition. DSM-IV describes personality disorders in general as a cluster of “enduring . . . inflexible . . . and pervasive” patterns of thinking, feeling, relating, and functioning. Furthermore, the diagnosis is typically not given until age 18, when it is believed that the personality is fully formed. Implicit in this definition is the notion that there is a chronic course to the condition. While there had been prior clinical “wisdom” that people with BPD “burned out” by middle adulthood, this phenomenon was not considered a “cure.” In the earliest studies, Stone (1990) and Paris, Nowliss, and Brown (1988) found relatively good functioning fourteen to sixteen years beyond the index point. Zanarini et al. (2006) noted that these studies were hampered by a number of methodological limitations. These authors then conducted a longitudinal study over a ten-year period, with five follow-up points. They found that of the 290 former inpatients, 50 percent achieved recovery from BPD during the previous two years while 93 percent attained a remission of at least two years during the study period. Additionally, a full 86 percent had sustained recovery lasting four years. However, 34 percent “lost” their recovery and 30 percent had recurrence of symptoms. Of those who had a sustained remission (four years) only 15 percent had a recurrence. The authors conclude that recovery is difficult for many clients but once a client attains a sustained remission, it is relatively stable over time. The findings have important implications for practice; the attainment of recovery is possible for many people with BPD, but the recovery course is prolonged and may be punctuated with symptomatic relapse. Overall, the literature regarding BPD is extensive, but often contradictory. Social workers are encouraged to consider the complexity of the condition and the evolving controversies, which have significant implications for practice. In a review of the empirical literature of 2006 and 2007, Dahl (2008) found certain

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trends including support for the dimensional approach to diagnosis of BPD, as proposed in DSM-5; a lack of new research on psychopharmacology (in spite of high usage in clinical practice); and outcome studies for psychotherapy, most of which find considerable support, across theoretical perspectives. The research suggests that the development of the borderline condition is complex, including bidirectional relationships among a range of influences including genetics, psychological traits and attributes, established behavioral patterns, neurobiological processes, prenatal and perinatal exposures, interpersonal interactions, and life events (Siever et al., 2003). Good practice requires a willingness to deal with the complexities that this research reflects, with particular consideration of the pejorative views that mental health providers continue to hold. demographic Patterns The Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions provides the most recent and comprehensive data regarding the prevalence and comorbidities associated with BPD. This broad-scale study of 34,653 adults yielded surprisingly high prevalence rates among the general population. Grant et al. (2008) report a lifetime prevalence rate of 5.9 (with equal rates among men and women). Higher rates were found among younger and separated/divorced/widowed adults and those of lower socio-economic status (SES), lower income, and lower education. Among ethnic groups, Native American men, Latina/os, and Asian women also had elevated rates. In terms of disability, BPD was associated with substantial mental and physical disability, with higher rates for women, suggesting differential impacts on functioning. As with previous research, high comorbidity existed with bipolar disorder and with two other personality disorders, narcissistic and schizotypal. Interestingly, there was no support for comorbidity with other psychiatric conditions previously believed to have strong associations with BPD.

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Historically, the most striking and consistent prevalence data has been the disparity of the diagnosis between men and women. Johnson et al. (2003) reported that early estimates were that from two-thirds to three-quarters of people with BPD were women. Consequently, most of the research and clinical literature focused on women, often not using gender as a variable. Limited comparative research exists on the rates, course of the condition, and presenting or dominant symptoms. Standardized criteria for BPD first appeared in the DSM in 1980, and the DSM-IV-TR (2000) reported a 3:1 female-to-male gender ratio (Sansone & Sansone, 2011). Grant et al. (2008), reporting on the National Epidemiological Survey, found no gender disparity. However, in a review of the literature, Sansone and Sansone (2011) report that men were more likely to demonstrate explosive temperaments, novelty seeking, and harm avoidance and more likely to have comorbid substance abuse and antisocial tendencies than women; eating disorders, mood disorders, anxiety disorders, and posttraumatic stress disorder (PTSD) are more common in women. In a finding that may provide an explanation for why we continue to associate BPD more with women, Goodman et al. (2010) found that men with BPD are less likely to use as much psychotherapy and psychotropic medications over their lifetimes as women, but were more likely to utilize substance abuse services than their female counterparts. Zanarini et al. (2004) reported high utilization of treatment rates among those with BPD, 12 to 17 percent higher than for those with other personality disorders. They also found that these clients tended to use psychotherapy and medication over longer periods of time than others. Furthermore, polypharmacy (the taking of three or more psychotropic medications simultaneously) was not unusual, at rates of 40 percent. As with other diagnoses, it is important to differentiate between prevalence rates and

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biases in diagnosing, which may include setting and regional differences. For example, on inpatient psychiatric units in the 1980s it was rare to have men diagnosed as borderline. This raises the questions of whether the condition has actually increased among men, whether women are more likely to seek or be offered inpatient hospitalization, or whether there exists some gender bias in diagnosing patterns among providers. Those issues aside, both men and women are diagnosed with the condition, although their symptom presentations may vary by gender. Societal context The role of the social context and sociocultural influences has been grossly under-studied and explored. At the most elemental, this has significant implications for our understanding (or lack thereof ) of how culture shapes personality and the development of a clinical condition. Clearly, the association between childhood abuse and BPD is a clear and well-substantiated one, which provides support for our profession’s attention to the social context of these clients and for people as a whole. Johnson et al. (2003), in a study of gender differences, found that men and women with BPD had similar rates for childhood physical abuse, childhood sexual abuse, and childhood witnessing of abuse; clearly being male is no longer a protective factor for the development of the condition. Prevention and early intervention are activities within the social work domain, in many practice settings, particularly in our child protective services. In addition, there is some evidence that an invalidating environment can have negative influences on the development of some of the features associated with the cognitions and mentalizations of people with BPD. Given this, micro and macro interventions that provide for the validation of negative life and interpersonal experiences are important. This may have implications for services provided in schools and communities.

Socioeconomic status is also under-examined in the literature, although Grant et al. (2008) in the report of the National Epidemiological Survey, reported that respondents in the lowest three income brackets ($0–69,999) were more likely to have BPD, as were those who were separated, divorced, or widowed. In both instances it is impossible to conclude whether those findings suggest higher risk and/ or whether they are consequences of the interpersonal and social impairments in functioning common to the condition. Vulnerabilities and risk factors As previously discussed, the primary risk factors for the development of BPD are childhood abuse and/or neglect (Lobbestael, Arntz, & Bernstein, 2010), high novelty seeking and high harm avoidance, childhood and adolescent depression, hypomania, conduct disorder, and alcohol and drug dependence. These represent combinations of factors from the domains of temperament, adverse childhood experiences, and adolescent psychopathology (Joyce et al., 2003). Fossati (2012) identifies attachment disturbance as a risk factor for BPD as well, a view earlier proposed by Fonagy and Bateman (2008). In addition, there have been significant advances in our understanding of the roles of genetics and neurobiology. The most pressing challenge in our understanding of the role of risk factors is to avoid simplistic and reductionist approaches. For example, while high numbers of people with BPD have histories of childhood sexual and physical abuse, many more people with similar histories do not go on to develop BPD as a consequence. While it is tempting to assume a singular and direct relationship between adverse childhood events and BPD, it is the confluence of a range of factors— psychological, genetic, neurobiological, familial, and relational—that are implicated in the development of the condition. A sophisticated understanding of what we do know and some humility about what we don’t yet know about the development of the condition will allow the

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pursuit of both sufficiently rigorous research design models and responsive and comprehensive interventions. resiliencies and Protective factors The literature is nearly nonexistent on the explicit issue of resilience and protective factors for people with borderline personality disorder. Clearly, the elimination of primary risk factors; childhood sexual, physical, and emotional abuse; and emotional neglect—tasks with which the profession is involved on micro and macro levels—is critical. Beyond that, early intervention, although not without its own risks in terms of labeling and stigmatizing children and adolescents in particular, may be important. This is so particularly for those who have developed self-harming behaviors. We also have much to learn from those adults who suffered any of this abuse or neglect and grew up without developing the borderline condition. The question of what accounts for a person’s meaningful and satisfying engagement in the world, in spite of a combination of constitutional vulnerabilities, invalidating environmental experiences, and adverse childhood events (all common to those with BPD), is critical to the concept of resiliency. Resiliency, an individual’s ability to “bounce back” from life’s adversities, is particularly challenging for those individuals with BPD. These clients have often developed schemas and attributions, rooted in their early experiences and reconfirmed in subsequent ones, that the “world is malevolent,” “I can’t count on anyone,” and “I deserve to suffer because I am bad.” These firmly held beliefs appear to be incompatible with the notion of being able to “bounce back.” However, a lifecourse view of development posits that rather than personality being fixed at particular epigenetic stages, fundamental change can occur at any point. This view holds that modifications in one’s view of self, other, and the world are continually shaped and modified by internal and external experiences. For example, a relationship with a “steady,” validating “other,”

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whether a friend, partner, family member, mentor, or mental health professional, can challenge an individual’s earlier negative views about oneself and others. In turn, this view of development as an ongoing process may account in part for the emerging research that shows an unexpectedly positive recovery rate from the borderline condition. If positive changes can occur, these are likely related to the effects of good interventions that increase a client’s capacity and skills needed for affect regulation and impulse control, and with relationships with others that are affirming. The specific role of the working alliance between practitioner and client has indeed been implicated in positive outcomes in therapy. For example, in a systematic review of psychotherapy outcome literature, Barnicot et al. (2012) found that “the therapeutic alliance is an important common factor predicting outcome in patients with BPD, even in highly disorder-specific treatments” (p. 400). It is also no accident that people who have suffered early childhood abuse now refer to themselves as survivors rather than victims. This distinction in language is important; the former connotes a sense of self-efficacy and survival, while the latter implies exactly the opposite. For clients with BPD, this distinction can make the difference in their belief in their ability to “bounce back” or their belief that their personality and ways of relating to the world are “written in stone” and hence immovable. In addition, the literature suggests that a combination of risk factors must likely be present for the condition to develop. Interventions aimed at ameliorating the effects of a difficult temperament or a background of abuse, by correcting an invalidating environment, may be important. Once a client has been diagnosed with BPD, there are many things natural support networks and service providers can provide. As noted earlier, some clients find it relieving to “be labeled”;

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in any event, psychoeducation about the condition, its course, available interventions, etc. can be enormously helpful to clients and their families. The experience of having this condition is overwhelming enough; the reactions that others have to the rage, emotional instability, and interpersonal reactivity that are central features serve to further alienate clients. This in turn can result in a sense of abandonment and a retreat to selfharming behaviors, or to escalating externalizing behaviors that alienate others. When significant others in the client’s life have an understanding of this condition and its manifestation and are also provided with skills for engaging with their loved ones, interpersonal patterns can be improved. Allen (2001) describes a model for integrating understandings from individual and family theories to alter family patterns that may serve as triggers to people with BPD. Regardless of treatment orientation or method, treatment for BPD tends to be longerrather than shorter-term. This means that eight or ten outpatient sessions are unlikely to be sufficient, except when instituted as a “booster shot” later in the course of ongoing treatment. Access to high-quality continuum-of-care services is essential. Because particularly in the early stages of the work, frequent crises are the norm, access to reliable after-hours help is critical. Suicidal ideation and attempts are not unusual; availability of crisis beds and careful monitoring are also important. Most important of all is an orientation of recovery that is realistic and attainable for the client, family, and provider. Zanarini et al. (2010) note that there has been extensive emphasis on symptom reduction and very little attention to psychosocial rehabilitation for people with BPD. The social work “strengths” approach is not evident in much of the broader or social work literature, and that likely reflects prevailing attitudes and beliefs. Recovery work with people with BPD will focus on the maximization of personal and social strengths; the acquisition of behavioral, relational, and

affective management skills; and the cultivation of hope and the capacity for meaningful relationships and work. Programs and Social Work contributions Social workers provide ranges of services to clients with BPD in a variety of settings, and with a number of different modalities; individual, group, and occasionally, family. They may also function as case managers in public and private mental health outpatient clinics, inpatient psychiatric units, day treatment, intensive outpatient settings, residential programs, prisons, group homes, and private practice. Occasionally, the social worker’s identified client will be a child or adolescent but adjunctive work with the parent with BPD will be warranted, such as in child protective services. Social workers working with these clients must have knowledge in the areas of mental health diagnoses and intervention, embedded in a strong social work practice framework; an understanding of the complexities of BPD; advanced skills of engagement; and the values of deep respect, empathy, and hope for clients who they may find challenging. assessment and interventions Clients with borderline personality disorder typically seek services when they find themselves overwhelmed with the affective instability, behavioral impulsivity, and interpersonal stress that are hallmarks of the condition. Alternatively, they may be “urged” to seek help by family, friends, or colleagues who also find themselves overwhelmed by the client’s symptoms. Precipitants to seeking treatment often include a perceived or “real” rejection from a person important to them or an incident of non-suicidal self-harm or suicidal thoughts. In all instances, an evaluation of safety is critical; beyond that, the establishment of the therapeutic alliance is important, regardless of additional interventions. The assessment of personal, interpersonal, and environmental

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resources is important, particularly in terms of the degree of stability of interpersonal relationships. Because people with BPD struggle significantly with maintaining these relationships, a broad assessment of both current and previous highest level of interpersonal supports will help the worker obtain a comprehensive and dynamic understanding of the role these play in the client’s life. In clinical practice, in addition to the psychosocial and mental status assessment, which should be ongoing functions, social workers may also use symptom checklists and other screening instruments. These include the welldeveloped and validated Structured Interview for DSM-IV-TR Personality Disorders (APA, 2000). However, this not used regularly in most clinical outpatient settings; it is more apt to be administered as part of research studies or in clinics associated with researchbased activity. A self-report screening tool, the McLean Screening Instrument for Borderline Personality Disorder (MSI-BPD) has been recently validated (Zanarini et al., 2012) and is found to yield high sensitivity and specificity for the diagnosis. Additionally, Zimmerman et al. (2010) have found that the Mood Disorder Questionnaire (MDQ), typically used to screen for bipolar disorder, may have some utility for screening for BPD. The two conditions share some clinical symptoms, making differential diagnosis difficult. In addition to screening and assessment for BPD, the presence of any comorbid diagnoses and conditions should be screened and assessed. For example, a comprehensive assessment will include evaluation for substance abuse disorders and posttraumatic stress disorder. Women should be evaluated for eating disorders, men for externalizing conditions such as explosive intermittent disorder. In addition, all clients should be asked about any history of sexual, physical, and emotional abuse. The evaluation of self-injury and suicidality deserves particular mention. The association

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between the two is both overlapping and distinct. Self-injury involves deliberate self-harm to oneself, often in the form of superficial cuts, head-banging, or burning, in the absence of suicidal intent. These behaviors, their prevalence, and their phenomenology have been well documented in the literature (Heller, 1990; Selby et al., 2012). These clients typically report their wish to “feel the physical pain, rather than the emotional.” Clients themselves who have self-injured and made suicide attempts are often able to discriminate between the motivations, circumstances, and feeling states that preceded the incidents. Nonetheless, both symptoms should be evaluated; people who have self-injured may become habituated to it; those who attempt suicide are immediately at higher risk for eventual completion of suicide. Paris (2002) found a 10 percent suicide rate for individuals with BPD, one of the highest for any psychiatric condition. There are several well-validated instruments available for suicide screening, including the Columbia Suicide Severity Instrument. Clinicians and researchers have long held that personality conditions in general are diagnosable only from age 18 onward and there has been a prevailing belief that symptoms of some, such as BPD, become less pronounced with advancing age. However, recent literature may suggest otherwise and the presentation of symptoms and appropriate interventions may vary according to the life course. Bradley, Zittel Conklin, and Westen (2005) report that the precursors and eventual symptoms of BPD are evident in adolescence. In fact, one of the behavioral manifestations, self-injury, is reported to be present in fully two-thirds of adolescents with the diagnosis (Zanarini et al. 2006). The combination of affective instability, impulsivity, and interpersonal struggles common in BPD are particularly problematic in adolescence, a time period normally marked by increased risk taking and substance use. Stepp (2012) reports that BPD symptoms in

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adolescence may also interfere with normal developmental processes. Wiongrad, Cohen, and Chen (2008) found that symptoms of BPD in adolescence predicted worse academic, social, and relationship functioning as long as 20 years later. These are findings that support early screening and intervention. However, many practitioners are reluctant to diagnose the condition in adolescents, and Stepp (2012) makes a convincing argument for the importance of early identification. Possibly, the earlier pejorative attitudes toward people with the diagnosis influence the general reluctance to “label” adolescents with BPD. Diagnosing BPD in adolescence is, however, complex. Stepp (2012) notes that BPD may share common pathways (neurological, cognitive, and behavioral) with attention-deficit/hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD). This overlap lends support for a more dynamic rather than categorical approach to understanding symptoms and interventions, as well as a reexamination of worker attitudes toward people with certain diagnoses. For example, in the continuum of “pejorative” attitudes, practitioners may have even less empathy for an adolescent with oppositional defiant disorder than one with BPD. This reinforces the importance of understanding troubling symptoms as complex biological/social/emotional manifestations, particularly when they occur in adolescents who are biologically, socially, and cognitively “works in progress.” On the other hand, Cartright (2008) argues against diagnosis of BPD in childhood and adolescence, noting that one has to balance the effects of early identification against those of stigmatization. Much of the literature and research is in fact, based upon young adults, the life phase in which BPD is most commonly first diagnosed. The developmental implications for young adults with the constellation of symptoms associated with BPD are considerable and Bagge et al. (2004) found that these individuals had poorer social and academic outcomes. Given that the major developmental goals of young adulthood

include the establishment of intimate adult relationships and occupational identities and capacities, the symptoms associated with BPD may complicate these tasks. Mothers diagnosed with BPD have been largely neglected in the literature, and this has important implications for both mothers and infants. Newman and Stevenson (2008) note that psychological tasks of parenting pose particular challenges for the mother with BPD. These challenges may include the tolerance of dependency (both physical and psychological) as well as conflicts regarding nurturing. Muir et al. (1999) developed the Watch, Wait and Wonder (WWW) program for mothers with BPD. An attachment-focused intervention, it involves the in vivo teaching of mothers to focus on the infant’s attempts at communication with them. The intervention is designed to “improve dyadic interaction and promote security of attachment by promoting maternal capacity to observe and reflect on the meaning of the infant’s behavior and emotional communication” (507). In addition, Newman and Stevenson (2008) stress the importance of the worker’s containment of maternal anxiety and distress and the dual goals of improving infant security and maternal capacities. This kind of intervention with parent and child can be considered preventive as well. In regard to later life, Hunt (2007) argues that these age groups have been largely ignored in both the clinical and research literatures and where they do exist, references to patients beyond 50 years old are rare. The presentation of symptoms appears to be different in older adults; impulsivity is less, but relationship and affective disturbance may persist in those who continue to be symptomatic. However, Paris and ZweigFrank (2001) in a twenty-seven-year followup of previously diagnosed people with BPD (mean age of 51) found no significant changes in impulsivity and highly significant decreases in relationship difficulties. Furthermore, only 8 percent still met the criteria for the diagnosis. This is good news for the possibility of late-life recovery from BPD, but critics suggest that the

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diagnostic criteria may not be sensitive to this population. Agronin and Maletta (2000) suggest that the mode of expression of impulsivity and self-harm in older adults with BPD may take different forms from that of their younger counterparts. They suggest that noncompliance with medications, polypharmacy, and disordered thinking may be more likely manifestations of the condition. A few studies have examined BPD in residents of nursing homes and other long-term care settings (Himelick & Walsh, 2002; Rosowsky & Gurian, 1992) and found that BPD-associated behaviors have difficult impacts on these settings. Along with Trappler and Backfield (2001), they acknowledge that loss and fear of abandonment may pose particular challenges for these patients and that the validation by staff of their physical and emotional needs is particularly important. It is suggested that this can minimize the incidence of “splitting” (a form of dichotomous polarization) common to individuals with BPD. Institutional care poses particular challenges for these clients and their caregivers. Ethnicity as a factor in the development of personality disorders in general and in BPD, specifically, is markedly under-examined. Chavira et al. (2003) note the peculiarity of this, given the fact that culture is “intertwined with personality . . . [through] child-rearing practices, theoretical worldviews (e.g., interdependence vs. individualism), interpersonal expectations, and self-concept” (p. 483). Furthermore, culture influence’s one’s perception and expression of problems, as well as behaviors related to seeking and using professional help. In their study, Chavira et al. (2003) found a strong association between ethnicity and BPD via the use of a structured diagnostic interview in a clinical setting. Hispanics had disproportionately higher rates of BPD than Caucasians and African Americans, particularly in terms of intense anger, affective instability, and unstable relationships. They speculate that experiences of acculturation and related effects of identify confusion, feelings of emptiness and alienation, mood instability,

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anger, and difficult interpersonal relationships may account for the higher prevalence in some segments of this population. Another factor may lie with misdiagnosis and diagnostic bias among clinicians unfamiliar with cultural norms about behavior, gender roles, and culture-bound syndromes. In an earlier study, Akhatar, Byrne, and Doghramji (1986) found that African American men had lower rates of BPD pathology. Grant et al. (2008), in a large epidemiological study, found the incidence of BPD highest for Native Americans and lowest for Hispanics. On the other hand, Newhill, Eack, and Conner (2009) found racial differences between African Americans and Caucasians. They report that African Americans experienced greater affective intensity and emotional dysregulation, and more thoughts of interpersonal aggression, but fewer self-harming behaviors than their Caucasian counterparts. Importantly, the authors note that variations in substance abuse and treatment accounted for some of the affective symptom discrepancy, but not for the behavioral symptoms. Clearly, the literature on the relationship between race/ethnicity and BPD is confusing at best; it is hoped that with a greater focus on health disparities and available funding, the research about prevalence, treatment utilization, and successful intervention will fill the current gap. Most studies on ethnicity have not controlled for immigration and acculturation. These are important cultural variables and should be accounted for when teasing out issues of normalcy and abnormality in personality development. Nielsen, Ziegenbein, and Seiberer (2011) found that in Germany in a study of 2,494 psychiatric patients, 15 percent had an immigrant background and met the criteria for BPD. The authors conclude that in this study, immigrants were diagnosed less frequently than their indigenous counterparts, suggesting that immigration was not a risk factor for BPD. As with the racial/ethic variable, further research is indicated. This population may also provide rich opportunities for understanding factors related

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to resiliency and the ability to develop functional personality patterns under sometimes adverse conditions. There are many theoretical approaches for work with people with BPD. Dialectical Behavioral Therapy (DBT) has become the predominant practice approach for work with people with BPD, particularly those who exhibit selfharming behaviors. Developed by Marsha Linehan, who has since revealed her own struggle with the disorder, it is now used in every kind of treatment setting, including recently prisons, and has been adopted by many state departments of mental health. Originally a derivative of cognitive behavioral therapy, DBT is an integrative approach that draws upon behavioral science, dialectical philosophy, and Zen practice (Linehan & Dexter-Mazza, 2008). At the same time, the approach contains elements familiar to psychodynamic, alternative, and cognitive therapies. Linehan (1983) sees emotion dysregulation as the defining element of the BPD condition, and interventions are developed to target this for change. At the same time, the theory holds that the temperament that gives rise to problems with regulation is particularly vulnerable to the effects of what Linehan calls the “invalidating environment.” This is defined by its “tendency to negate, punish, and/or respond erratically and inappropriately to private experiences, independent of the validity of the actual behavior” (p. 373). This invalidating environment may include primary caretakers, but can also include extended family, school, communities, and work environments. This invalidating environment first will indiscriminately reject communication of private experience; second, will punish emotional displays while intermittently reinforcing emotional escalation; and third, may oversimplify the “ease” of problem solving. Central to the theory is the concept of dialectical dilemmas, which manifest as treatment-interfering behaviors. These include the poles of emotion vulnerability/self-invalidation; active passivity/ apparent competence; and unrelenting crisis/

inhibited grieving. The interventions are organized around stages: (1) attaining basic capacities, which focuses on attaining behavioral control; (2) post-traumatic stress reduction; (3) resolving problems in living and increasing respect for self; and (4) attaining the capacity for freedom and sustained contentment. The interventions are delivered through individual therapy, group skills training, and telephone consultation. DBT has a strong and growing evidence base for its effectiveness. Strengths of the model include the simultaneous focus upon validating the clients’ experiences, and developing coping skills and strategies for eventual self-management of the most persistent and painful of the symptoms of the condition. The initial focus on eliminating self-harm behaviors and “therapy-interfering” behaviors are particularly vital. While the evidence is strong for DBT, as with all approaches, examination of treatment failures provides additional information about the suitability of models under varying conditions and for individual people. Increasingly, practitioners are “importing” elements of DBT into other practice approaches in the work with clients with BPD. There is some controversy about this, with Chapman, Turner, and Dixon-Gordon (2011) recommending against the practice. They maintain that fidelity—adherence to the behavioral and dialectical components of DBT—will ensure that interventions are effective, coherent, and consistent. In any event, the practice of integration is not uncommon and the major assumptions in DBT (Linehan, 1983) are consistent with a social work approach with this population. These assumptions are: clients are doing the best they can and want to improve; they need to do better, try harder, and be motivated for change; while they have not created all their problems, it is incumbent on them to solve them; their lives as currently lived are unbearable; they must learn new behaviors and not fail; and therapists treating them need support. These principles provide a useful antidote to prevailing pejorative beliefs held by many

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mental health professionals and provide the framework for the therapeutic experience of a validating environment. Psychodynamic therapy has continued to be used in work with clients with BPD, although innovations in theory and technique make it nearly unrecognizable from the early days of drive theory. Martens (2005) reviews the evidence for four of these psychodynamic approaches: mentalized-based treatment, transference-focused psychotherapy, cognitive-analytic psychotherapy, and psychoanalytic psychotherapy. He found that all psychodynamic approaches appeared to be more effective than treatment as usual, but cautions that there are significant limitations to a number of elements of study design. He concludes that there is some evidence for efficacy but recommends that more random and controlled studies are needed to augment what is currently available and to examine the degree to which each variation might effectively be combined with other types of treatment. Bateman and Fonagy (2001) wrote that there is some increasing evidence of accumulative positive effect beyond the termination of treatment with psychodynamic treatments generally, something that does not hold true for behavioral approaches. In his study of therapeutic predictors and correlates of recovery, Martens (2005) found that more adequate treatment is possible when the correlates of good outcomes exist, such as creativity, intelligence, an ability to experience pleasure and tolerate pain, emotional involvement of family, family stability, age- and gender-related factors, and use of medication. These are examples of human conditions and variables that are difficult to study but may be important in furthering our understanding of what can be “curative” in the work with people with BPD. Time-limited cognitive-analytic therapy of borderline personality disorder targets the shifting self and affective states experienced by the client with BPD. In this structured intervention approach, clients are asked to record these

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shifts in affect and diagram them. This provides the structure for systematic examination and modification of negative interpersonal patterns related to the common mood shifts. Ryle and Golynkina (2000) studied an intervention that consisted of twenty-four sessions plus four follow-up sessions and found that post-follow-up more than half no longer met criteria for BPD. Those with poorer outcomes had pre-study greater severity of symptoms, histories of selfcutting, alcohol abuse, and unemployment. There are many well-developed theoretical treatment approaches for helping people suffering with borderline personality disorder. Outcome literature must be considered in terms of study strengths and limitations. In a systematic review of factors predicting the outcome of psychotherapy for borderline personality disorder, two consistent positive predictors emerged. According to Barnicot et al. (2012) these were pretreatment symptom severity and patient-related therapeutic alliance. This is consistent with the common factors approach (Frank, 1961; Lambert, 1992; Messer & Wampold, 2002; Rosenzweig, 1936). Lambert (1992) maintains that there are four therapeutic factors that account for client improvement; client/extratherapeutic factors; relationship factors; placebo, hope, and expectancy factors; and model/technique factors. According to the common factors model, only 15 percent of client improvement is considered to be related to technique. While there is certainly room for debate on this, the model underscores the importance of the therapeutic alliance. Particularly in work with clients who struggle with significant relational difficulties, establishing and navigating the vicissitudes of the helping relationship is a critical worker skill. illuStrAtion And diSCuSSion

The following case illustrates elements of assessment, interventions, and things social workers must take into account in the service of a client with borderline personality disorder.

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Valerie, a 38-year-old single white woman, sought mental health services at an outpatient clinic housed in a local hospital. Born to working-class parents, she is herself middle-class, is college educated, and has no stated religious affiliation. She relocated to this town, 1,200 miles from her hometown, about eighteen months ago after having earned what she initially called a long-awaited promotion. While she was delighted with the move at first, she complains now that she is struggling with relationships both in and outside of work, leaving her feeling disillusioned, angry, frustrated, and at times, lonely. Recently at work, Valerie was meeting with her staff to review annual performance appraisals, and during this process she had a series of confrontations with one of her colleagues. Her supervisor insisted that she seek counseling. Valerie believed that she did not have an outburst, and reported that she was in control of her emotions during the meeting in question. She claimed, though, that this is not the first time that her behavior had been perceived as problematic by others. Valerie spoke almost longingly about her job, saying that it has always been something of an organizer in her life. She has always prided herself on her strong collegial relationships, particularly with newer staff members. She enjoyed her role as informal mentor so much that eventually she founded and led a training program for new, young staff who joined the company. During the initial evaluation, Valerie recounted her recollection of the run-in with her colleague, but did so rather concretely and without much affect. She believes her behavior has been consistent since her arrival, and she thinks this colleague feels threatened by her at times and is out to get her job, though she could not substantiate this claim with any examples. She was a bit perplexed by this recent “confrontation” because she thought they worked well together. Initially, Valerie was forthcoming with details about her life, her work, and her family history. She revealed that she was the eldest of three female

children. She has been in several heterosexual relationships, each of which lasted between eight months and two years. She said she gets restless and is summarily accused by her partners of “not having balance.” She disagrees and says that they were all threatened by her success and her drive. Valerie had little to say about her family. She is not particularly close to her parents but says she has a love-hate relationship with each of her sisters—they are either in touch on a very regular basis or they have a falling out and are not in touch for several weeks at a time. She has made friends since moving to her new town, but she tires easily of one group of people and moves around from one circle to another. There were some early challenges that the worker faced with Valerie. She refused to hear any feedback in anything but a defensive manner. Her behavior showed a certain level of impulsivity that was initially difficult for the worker and other colleagues to manage: Valerie would often phone to change session dates and times or to seek information about insurance reimbursements or less-pressing matters that could have waited until the next session, and if she did not receive a call back within twenty or thirty minutes, she would phone frequently, leave repeated voice messages, and make undue demands on the worker or staff members at the clinic. This behavior was mirrored in her private life as well, as Valerie described herself as an action-oriented person who wanted to make plans and get things moving; she was not terribly patient. When the worker tried to explore with her whether or not she understood that others might find her behavior intrusive, impulsive, provocative, and at the very least discomforting, Valerie laughed it off or alternatively became somewhat belligerent, sat in angry silence, and said very little. Invariably, she would then become defensive or argumentative. After a few sessions, Valerie talked about the ups and downs of the training program she established at work. She is quite possessive of it and particularly of the trainees involved. She worked hard to engage them but then expressed feeling quite bewildered when they distanced themselves from her. Rather

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than seeing their growing confidence as a developmental milestone and a sign that the program was a success, she grew increasingly agitated. This agitation was manifest by her becoming more strict and controlling of their performance in the company, even if she was not the direct supervisor. When any of the trainees approached her to discuss her apparent frustrations with them, she would avoid contact by ignoring e-mails, not returning phone calls, or missing meetings. She once heard some of the trainees warning some newcomers to the company that they should not “cross” Valerie, as she would turn on them without a moment’s notice and it would be hard to get back into her good graces. At one time or another, everyone struggles with the regulation of emotions or behaviors. For individuals with borderline personality disorder, the problems are far more severe, chronic, and disruptive. Along with dysregulation of emotions and behaviors, people with BPD often have protracted and persistent relationship problems; low self-esteem; feelings of emptiness about the self; abject fear of abandonment—real or imagined; suicidal ideation, gestures, or attempts; and seeming paranoia that others are out to get them or, at best, take advantage of them. Maladaptive thought patterns and exaggerated rules (or alternatively, near-complete absence of boundaries and/or structure) often govern individuals whose lives are punctuated by projection, splitting, and a profound fear of abandonment. Valerie revealed through action and word that she was terrified of feeling the powerful range of emotions that lived inside her. So at times, rather than share even a little of what she was feeling, her default was to shrug her shoulders, say “I don’t know,” or deny that she was feeling anything at all, when it was clear from her body language that she knew something was coming up for her. Valerie seemed to need a good measure of adulation in her relationships, whether professional or personal. At the same time, though, the intensity of these relationships seems to frighten her to the

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point of lashing out, as she did not initially have any way of regulating her negative reactions to the closeness and to the fear she felt as these relationships grew more intense. With the training program, she chose to focus on young people entering the company with little experience but great drive to succeed. She was a welcoming face and a fount of information. Her relationship with the trainees served a great function for her, in that she needed and seemingly craved the adulation they offered. However, problems arose over time when reality set in. When a person with BPD realizes that someone she holds in high esteem is not without fault, the need to attain and maintain perfection can cause great strife. People with BPD struggle with dichotomous thinking, and they struggle with the realization that people make mistakes innocently and not with sabotage in mind. When Valerie’s trainees began to feel more comfortable, they operated more freely and did not check in with her as often. Other trainees distanced themselves after having felt how inconsistent and unpredictable she was from day to day. Valerie secretly felt undervalued, and so she started the mentoring program in hopes of feeling more valued and vital in the company. When the success of the training program did not garner the attention she had hoped it would, she reverted to setting up a dynamic where she projected her feeling undervalued onto the trainees or others colleagues. Valerie internalized the challenges she had with trainees and the critiques others had about the training program and personalized the feedback. As such, rather than hearing that there were problems with the program, she heard “You, Valerie, are a failure and are no good.” As her difficulties at work mounted, Valerie reverted to cutting herself with a small scalpel, behavior she had first engaged in as an undergraduate student. The work of the helping process with Valerie was multifaceted. First of all, she needed to devote time and energy to recognizing and acknowledging her potential triggers. It was important to work with Valerie to help her to find a semblance of balance between the tension that arises in her as a result of her

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tendency toward more emotional thinking and the need for her to react and act in more socially acceptable ways. Valerie also needed to learn that emotions are a critical part of communicating and of being in relationships with others. The tricky piece for her was that she had to learn (and maybe initially be convinced) that emotions were not all good or all bad. Given her propensity for splitting, this was initially difficult for her to accept. Another aspect of the work was to help Valerie regulate her cognitive and affective distortions. The worker felt that over time, Valerie needed to understand her tendency to distort. While she did not agree that she engaged in this behavior, she eventually admitted that she did distort at times and was able to see how others might be thrown by it. Valerie was taught and ultimately used many of the principles and exercises of DBT and came to understand what effect this move to distortion had on those around her. DBT helps a person to find balance between accepting and understanding one’s current behaviors and the need for change. With DBT, a person’s ability to be mindful and in the present is increased while self-harming behaviors decrease. Through DBT, too, the person with BPD learns to regulate emotions, behaviors, and thoughts. One of the keys to maintaining an effective helping relationship with a client with BPD is to find ways to cope with the intensity and fast-changing nature of the relationship. Because impulsivity, projections, and an overall lability of affect predominate, setting limits and boundaries is critical. Key structural elements of the work with Valerie included the organization and structure of the session, as well as starting on time and ending on time. Initially the worker felt seduced by Valerie. She was a gratifying client in that she was articulate, was well-educated, had a good sense of humor, and seemed to show capacity for insight. However, this changed over the course of their work together. One major area of focus was to help Valerie to recognize and understand the roots of her behavior and perhaps most importantly, the impact of

the behavior. She was frequently angry during the course of the work. She declared that she did not have a challenging upbringing and said repeatedly that her behaviors were indeed not the by-products of what some call “dysfunctional parenting.” As the worker and she spoke more, signs of her internalized low self-esteem intensified, and she was able to discuss (with great difficulty) early family dynamics that she found frustrating and often felt at a loss to control. Valerie recounted incidents of feeling not good enough at anything, something her father seemed to reinforce with great frequency with very negative, unsupportive, highly critical comments. She recalls working extra hard to impress both of her parents, only to have her efforts devalued or ignored. Valerie describes her mother as a silent partner in the family, which angered Valerie very much. Her mother partnered with some friends to run a small, successful canning business, but Valerie experienced her mother as detached and uninvolved. Ultimately, Valerie was able to express deep resentment for the fact that she often felt abandoned and on her own where her parents were concerned. This angered her a great deal and the worker helped her to mourn these losses. With insight came the pain and clarity that were hard for her to manage, and she resumed cutting for a time. However, somehow, living in the truth of understanding her past provided her with an escape that was healthier than any maladaptive behaviors she had used. By tracing her triggers and keeping track of them in a journal, she was able to learn to hold her reactions rather than give in to them in unhealthy, unhelpful, and often aggressive ways. She and the worker devoted a great deal of time to identifying triggers that would reignite feelings of inadequacy, frustration, annoyance, or rage. She would bring the journal to her sessions and she and the worker would spend time discussing the difficulties, challenges, and triumphs of the week as reflected in the journal. Special attention was paid at these times to helping her to understand, rather than vilify, the range of underlying emotions that were reflected by her entries in the journal. Valerie and her worker spent considerable

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time helping to identify self-soothing techniques she could use when feeling triggered. Valerie’s list included downloading and listening to music, going for a long run, or taking a bubble bath. Along with these activities, Valerie learned to use breathing exercises, visualizations, and relaxation techniques as ways to focus inward rather than run from strong affect or lash out at others. Thus, Valerie learned to recognize internal signals that cropped up, for instance, when she was feeling rejected or abandoned. Another way she learned to interrupt the aggression that was welling up in her was to realize that she will inevitably experience painful emotions—but she can learn to manage them in more constructive, less destructive ways. The worker felt this to be a critical step in helping Valerie, as she needed to learn not to fear overwhelming affect. By paying more attention to her own reactions, she made great strides in minimizing the potential for flare-ups that had previously resulted in a great deal of conflict with others. The final piece of work Valerie and her worker did was in the area of interpersonal relating. Valerie longed to be in relationship with others, whether at work, in her family, or in her personal life. Over time, by honing her listening and communication skills, she was able to interact with people at work without feeling the need to overpower conversations. She was also able to re-organize the mentoring program and invited colleagues to participate in it. She felt less of a need to single-handedly oversee the program and was able to be more accepting when mentees formed relationships with others in the company aside from her. Valerie also reported that she had joined a newly formed book club in her neighborhood and was beginning to meet people with similar interests. She was hopeful that she would start to build a small network of friends from this group.

referenceS

Akhatar, S., Byrne, J. P., & Doghramji, K. (1986). The demographic profile of borderline personality disorder. Journal of Clinical Psychiatry, 47(4), 196–98.

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conclusion Work with clients with the borderline personality condition requires skill, patience, a commitment to understanding complex dynamic issues and the willingness to continually seek out, evaluate, and integrate emerging knowledge into practice. Theoretical models that are compatible with a recovery paradigm and that thoughtfully and selectively integrate theoretical concepts and techniques hold great promise. Evolving knowledge and research about complex neurobiological processes and how they are activated at various stages of human development, triggered by certain environmental experiences, and ameliorated by others, will provide the profession with important innovations in our work with these clients. Even with advancements in our knowledge base, this work can challenge the most skilled workers. A client’s rapid mood shifts, impulsive acting out, rage, and desperate fears about abandonment can manifest in behaviors that can be difficult for mental health professionals to tolerate. Here, the active cultivation of empathy is key. In these most difficult moments the client is conveying to the worker what it feels like to “be borderline.” When workers can identify their own senses of incompetence, rage, and rejecting impulses toward the client, they have effectively understood the overwhelming experience of the client. In this sense, countertransference, used both to understand the experience of the client and to shape therapeutic response, is invaluable. In the words of one client, “I don’t have to feel or act ‘crazy’ to let you know how desperate I feel—you get what I am saying . . . but you don’t let me overwhelm you . . . I’m not too much for you, after all.”

Allen, D. M. (2001). Integrating individual and family systems psychotherapy to treat borderline personality disorder. Journal of Psychotherapy Integration, 11(3), 313–31.

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Agronin, M., & Maletta, G. (2000). Personality disorders in late life: Understanding and overcoming the gap in research. American Journal of Geriatric Psychiatry, 8(1): 4–18. American Psychiatric Association (APA). (2000). Diagnostic and statistical manual of mental disorders (4th ed., Text Revision). Washington, DC: Author. Aviram, R., Brodky, B., & Stanley, B. (2006). Borderline personality disorder, stigma, and treatment implications. Harvard Review of Psychiatry, September/October, 249–56. Bagge, C., Nickell, A., Stepp, S., Durrett, C., Jackson, K., & Trull, T. J. (2004). Borderline personality disorder features predict negative outcomes 2 years later. Journal of Abnormal Psychology, 113(2), 279–88. Barnicot, K., Katsakou, C., Bhatti, N., Savill, M., Fearns, N., & Priebe, S. (2012). Factors predicting the outcome of psychotherapy for borderline personality disorder: A systematic review. Clinical Psychology Review, 32(5), 400–12. Bateman, A., & Fonagy, P. (2001). Treatment of borderline personality disorder with psychoanalytically oriented partial hospitalization: An 18-month follow-up. American Journal of Psychiatry, 158(1), 36–42. Bradley, R., Zittel Conklin, C., & Westen, D. (2005). The borderline personality diagnosis in adolescents: Gender differences and subtypes. Journal of Child Psychology & Psychiatry, 46(9), 1006–1019. doi:10.1111/j.1469–7610.2004.00401.x. Cartwright, D. (2008). Borderline personality disorder: What do we know? Diagnosis, course, co-morbidity, and aetiology. South African Journal of Psychology, 38(2), 429–66. Chapman, A., Turner, B., & Dixon-Gordon, K. (2011). To integrate or not to integrate dialectical behaviour therapy with other therapy approaches? Clinical Social Work Journal, 39, 170–79. doi:10.1007/s10615– 010–0283–4. Chavira, D.  A., Grilo, C.  M., Shea, M.  T., Yen, S., Gunderson, J. G., Morey, L. C., . . . McGlashan, T.H. (2003). Ethnicity and four personality disorders. Comprehensive Psychiatry, 44(6), 483–91. doi:10.1016/ S0010–440X(03)00104–4. Dahl, A.  A. (2008). Controversies in diagnosis, classification and treatment of borderline personality disorder. Current Opinion in Psychiatry, 21(1), 78–83. doi:10.1097/YCO.0b013e3282f2289f. Everson, M. D., Hunter, W. M., Runyon, D. K., Edelsohn, G. A., & Coulter, M. L. (1989). Maternal support following disclosure of incest. American Journal of Orthopsychiatry, 59(2): 197–207. Fonagy, P., & Bateman, A. (2006). Progress in the treatment of borderline personality disorder. The British Journal of Psychiatry, 188, 1–3. doi:10.1192/bjp.bp.105.012088. ——. (2008). The development of borderline personality disorder—A mentalizing model. Journal of Personality Disorders, 22(1), 4–21.

Fossati, A. (2012). Adult attachment in the clinical management of borderline personality disorder. Journal Of Psychiatric Practice, 18(3), 159-171. Frank, J. D. (1961). Persuasion and healing: A comparative study of psychotherapy. Oxford: Johns Hopkins University Press. Goldstein, E. (1995). Ego psychology and social work practice. New York: Free Press. Goodman, M., Patil, U., Steffel, L., Avedon, J., Sasso, S., Triebwasser, J., & Stanley, B. (2010). Treatment utilization by gender in patients with borderline personality disorder. Journal of Psychiatric Practice, 16(3), 155–63. doi:10.1097/01.pra.0000375711.47337.27. Grant, B.  F., Chou, S.  P., Goldstein, R.  B., Huang, B., Stinson, F.  S., Saha, T.  D., . . . Ruan, W.J. (2008). Prevalence, correlates, disability, and comorbidity of DSM-IV borderline personality disorder: Results from the wave 2 national epidemiologic survey on alcohol and related conditions. Journal of Clinical Psychiatry, 69(4), 533–45. doi:10.4088/JCP.v69n0404. Graybar, S. R., & Boutilier, L. R. (2002). Nontraumatic pathways to borderline personality disorder. Psychotherapy: Theory, Research, Practice, Training, 39(2), 152–62. doi:10.1037/0033–3204.39.2.152. Gunderson, J. G., Weinberg, I., Daversa, M. T., Kueppenbender, K.  D., Zanarini, M.  C., Shea, M., . . . Dyck, I. (2006). Descriptive and longitudinal observations on the relationship of borderline personality disorder and bipolar disorder. American Journal of Psychiatry, 163(7), 1173–78. Heller, N. R. (1990). Object relations and symptom choice in bulimics and self-mutilators. Doctoral dissertation. Smith College School for Social Work. Published by UMI Dissertation Services. Herman, J.  L. (1998). Recovery from psychological trauma. Psychiatry and Clinical Neurosciences, 52: S98–S103. Herman, J., Perry, J., & van der Kolk, B. (1989). Childhood trauma in borderline personality disorder. American Journal of Psychiatry, 146, 490–95. Himelick, A. J., & Walsh, J. (2002). Nursing home residents with borderline personality traits: Clinical social work interventions. Journal of Gerontological Social Work, 37(1), 49–63. doi:10.1300/J083v37n01_04. Hughes, A.  E., Crowell, S.  E., Uyeji, L., & Coan, J.  A. (2012). A developmental neuroscience of borderline pathology: Emotion dysregulation and social baseline theory. Journal of Abnormal Child Psychology, 40(1): 21–33. Hunt, M. (2007). Borderline personality disorder across the life span. Journal of Women & Aging, 19(1), 173–91. Johnson, D. M., Shea, M. T., Yen, S., Battle, C. L., Zlotnick, C., Sanislow, C.  A., & Zanarini, M.  C. (2003). Gender differences in borderline personality disorder: Findings from the collaborative longitudinal personality disorders study. Comprehensive Psychiatry, 44(4), 284–92. doi:10.1016/S0010–440X(03)00090–7.

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Joyce, P. R., McKenzie, J. M., Luty, S. E., Mulder, R. T., Carter, J. D., Sullivan, P. F., . . . Cloninger, C.R. (2003). Temperament, childhood environment and psychopathology as risk factors for avoidant and borderline personality disorders. Australian & New Zealand Journal of Psychiatry, 37(6), 756–64. doi:10.1111/j.1440 –1614.2003.01263.x. Kernberg, O. (1984). Severe personality disorders. New Haven, CT: Yale University Press. Kirk, S. A., & Kutchins, H. (1992). The selling of DSM: The rhetoric of science in psychiatry. New York: Aldine de Gruyter. Lambert, M. J. (1992). Implications of outcome research for psychotherapy integration. In J. C. Cross & M.R. Goldfried (Eds.), Handbook of psychotherapy integration. (pp. 94–129). New York: Basic Books. Lewis, K. L., & Grenyer, B. F. S. (2009). Borderline personality or complex posttraumatic stress disorder? An update on the controversy. Harvard Review of Psychiatry, 17(5), 322–28. doi:10.3109/10673220903271848. Linehan, M. M. (1983). Cognitive-behavioral treatment of borderline personality disorder. New York: Guilford. Linehan, M.  M., & Dexter-Mazza, E. (2008). Dialectical behavior therapy for borderline personality disorder. In D.  H. Barlow (Ed.), Clinical handbook of psychological disorders: A step-by-step treatment manual (4th ed.). (pp. 365–420). New York: Guilford Press. Lobbestael, J., Arntz, A., & Bernstein, D. P. (2010). Disentangling the relationship between different types of childhood maltreatment and personality disorders. Journal of Personality Disorders, 24(3), 285–95. Martens, W.  H.  J. (2005). Effectiveness of psychodynamic treatment in patients with borderline personality disorder. Journal of Contemporary Psychotherapy, 36(4), 167–73. doi:10.1007/s10879–006–9021–1. Messer, S. B., & Wampold, B. E. (2002). Let’s face facts: Common factors are more potent than specific therapy ingredients. Clinical Psychology: Science and Practice, 9(1): 21–25. Mondimore, F. M., & Kelly, P. (2011). Borderline personality disorder: New reasons for hope. Baltimore, MD: Johns Hopkins University Press. Muir, E., Cohen, N., Lojkasek, M., Muir, R., Parker, C. J., Barwick, M., et al. (1999). Watch, wait, and wonder: Testing the effectiveness of a new approach to mother-infant psychotherapy. Infant Mental Health Journal, 20(4), 429–51. Newhill, C. E., Eack, S. M., & Conner, K. O. (2009). Racial differences between African and white Americans in the presentation of borderline personality disorder. Race and Social Problems, 1(2), 87–96. doi:10.1007/s12552–009–9006–2. Newman, L., & Stevenson, C. (2008). Issues in infantparent psychotherapy for mothers with borderline personality disorder. Clinical Child Psychology & Psychiatry, 13(4), 505–14. doi:10.1177/1359104508096766.

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literature review. Personality and Mental Health, 3(3), 217–24. doi:10.1002/pmh.89. Winograd, G., Cohen, P., & Chen, H. (2008). Adolescent borderline symptoms in the community: Prognosis for functioning over 20 years. Journal of Child Psychology and Psychiatry, 49(9), 933–41. Zanarini, M. C., Frankenburg, F. R., Hennen, J., Reich, D.  B., & Silk, K.  R. (2004). Axis II comorbidity of borderline personality disorder: Description of 6-year course and prediction to time-to-remission. Acta Psychiatr Scand., 110(6), 416–20. ——. (2006). Prediction of the 10-year course of borderline personality disorder. American Journal of Psychiatry, 163(5), 827–32. Zanarini, M.  C., Frankenburg, F.  R., Reich, D.  B., & Fitzmaurice, G. (2010). Time to attainment of recovery from borderline personality disorder and stability of recovery: A 10-year prospective follow-up study. American Journal of Psychiatry, 167(6), 663–67. doi:10.1176/appi.ajp.2009.09081130. ——. (2012). Attainment and stability of sustained symptomatic remission and recovery among patients with borderline personality disorder and axis II comparison subjects: A 16-year prospective follow-up study. American Journal of Psychiatry, 169(5), 476–83. Zimmerman, M., Galione, J. N., Ruggero, C. J., Chelminski, I., Young, D., Dalrymple, K., McGlinchey, J.B. (2010). Screening for bipolar disorder and finding borderline personality disorder. Journal of Clinical Psychiatry, 71(9), 1212–17.

cHaPter 6 depression manny J. González and liSa G. colaroSSi

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he term depression has many variations. It connotes an emotional state of varying severity or a psychiatric diagnosis with different categories and subtypes. It has roots in psychological development and cognitive functions, physiological conditions, or social circumstances. Thus, social workers must specify how this term is being used when discussing the condition of a specific client, because the term may substantially affect assessment and intervention planning. With such variety, depression has a wide range of consequences. Some argue that depression can be an adaptive emotional state when it drives a process of reflection and problem clarification (Nesse 2000). Most often, however, depression is associated with a state most people would like to avoid and can even become a life-threatening condition. Approximately 60 percent of people who die from suicide suffered from depression. The percentage increases if there is a co-occurring substance abuse disorder (Harwitz & Ravizza, 2000; Moscicki, 2001). Depression can also disrupt economic productivity, family functioning, health outcomes, and educational functioning (Katon, 2003; Pratt & Brody, 2008; Wells et al., 1989). More than two-thirds of depressed individuals report loss of work productivity due to absenteeism and/or reduced work performance, which is estimated to cost the U.S. economy $44 billion annually (Stewart, Ricci, Chee, Hahn, & Morganstein, 2003). The World Health Organization (WHO) notes that major depression is the leading cause of disability worldwide (WHO, 2002).

The plethora of individual consequences to health, psychological function, and social relationships, which have been widely documented, drive about 4 percent of the total U.S. population to seek mental health services each year (Kessler Berglund, Demler, Jin, Koretz et al., 2003), while over 9 percent of the adult population meet criteria for some type of depression in the last year whether or not they received professional services (CDC, 2010b); Kessler, Chiu, Demler, & Walters, 2005). During the course of adolescence, 14 percent will experience some form of depression (Merikangas et al., 2010). The high prevalence of depression and the potential consequences pose an imperative for social workers to accurately assess depression across its multiple forms and plan effective treatment options for individuals and families. defining and explaining depression Everybody feels sad or depressed sometimes; however, we will use the term depression to connote a mood disorder occurring if specified mental health criteria are met for clusters of symptoms for specified durations and severity. A variety of ways are available for social workers to assess depression, including standardized questionnaires that yield diagnostic scores and specify discrete symptoms; interviews that solicit information about symptoms, severity, duration, and effects of those symptoms on daily functioning; and use of the latest version of the American Psychiatric Association’s (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) (APA, 2000) as a guide to diagnostic categories and criteria for 117

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different kinds of depression and other potential co-occurring disorders. Assessment of depression should always include multiple domains of functioning that take into account cognitive, emotional, social, behavioral, and physiological indicators (Hankin, Fraley, Lahey, & Waldman, 2005; Hyde, Mezulis, & Abramson, 2008). Cognitions are thoughts, which can take the form of beliefs, motives, intentions, values, and memories. Cognitive assessment should include the presence of rumination patterns and content related to worthlessness, futility, pessimism, hopelessness, helplessness, loss, and suicidal ideation (Gotlib & Joormann, 2010). Motivation is likely to be low for most activities, as well as ability to think concretely, decisively, or clearly without confusion or racing thoughts. Emotionally, social workers should assess mood types and shifts in moods over time, which may move from excited and agitated to anxious and sad, or become chronically sad without shifts in mood. The behavioral dimensions may include changes in appetite and sleep patterns, behavioral shifts from restlessness and agitation to slowed speech and movements, and other somatic symptoms. Physiologically, a person should have a complete medical assessment for conditions that may be associated with, causing, or even exacerbated by depression, such as heart disease, diabetes, thyroid, and medication effects as well as effects of non-prescribed drugs and alcohol. The social context, including family, work, friendships, and social activities should be assessed similar to physiology, because depression may be caused by social conditions or it may exacerbate or create new problems in social relationships that were not present prior to the onset of depression. Social supports, violence, work stress, stressful life episodes, and/or developmental crises such as birth, death, divorce, relocation, and job changes can be associated with depression (Johnson Meyer, Winett, & Small, 2000) Assessment of depression in children and adolescents necessitates special consideration

of developmental characteristics associated with age and social context. Assessment should include standardized tools that have been validated with children and adolescents, rather than for adults alone; educational needs and intellectual development; the impact of family system characteristics and parenting practices; and normative developmental patterns vs. deviations from age-appropriate characteristics (Allen-Meares, Colarossi, Oyzerman, & DeRoos, 2003). Once these areas have been described, clarifying which criteria, if any, are met for specific diagnostic categories of depression is important for determining best courses of intervention (i.e., best practices based on empirical evidence to date). When many, but not all, diagnostic criteria are present, clinicians sometimes use the term subclinical to describe the condition. Course of treatment will vary for different types, potential causes, and severity (clinical vs. subclinical levels) of depression. In the DSM-IV-TR, types of depression are described in the mood disorders section. The first part of this section describes characteristics of mood episodes: major depressive episode, manic episode, mixed episode, and hypomanic episode. These episodes are not diagnoses in and of themselves—they serve as overviews of symptom clusters. Next, the criteria for diagnoses of major depressive disorder, dysthymic disorder, and bipolar disorder are listed, which include the presence or absence of a particular type of mood episode(s), the most recent episode, and the course of recurrent episodes. Here is a summary of these classifications, but in practice it is best to refer directly to the DSM-5 (APA, 2013). Major depressive disorder (MDD) requires two or more major depressive episodes of depressed mood and/or loss of interest or pleasure in life activities for at least two weeks and with at least five of the following symptoms that cause clinically significant impairment in social, work, or other important areas of functioning almost every day: (1) Depressed mood most

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of the day; (2) Diminished interest or pleasure in all or most activities; (3) Significant unintentional weight loss or gain; (4) Insomnia or sleeping too much; (5) Agitation or psychomotor retardation noticed by others; (6) Fatigue or loss of energy; (7) Feelings of worthlessness or excessive guilt; (8) Diminished ability to think or concentrate, or indecisiveness; (9) Recurrent thoughts of death (APA, 2013). Major depressive disorder may involve specifying conditions such as: a. Major depression with psychosis or catatonia b. Postpartum depression c. Seasonal affective disorder Sometimes symptoms of major depression are associated with other disorders as their primary causes, which are then separately diagnosed. These are substance-inducted mood disorder, mood disorder due to a general medical condition, and adjustment disorder with depressed mood. Substance-induced mood disorder is very common. DSM-IV-TR defined it as “a prominent and persistent disturbance of mood . . . that is judged to be due to the direct physiological effects of a substance (i.e., a drug of abuse, a medication, or somatic treatment for depression, or toxin exposure)” (APA, 2000, p. 405). The mood can manifest as manic (expansive, grandiose, irritable), depressed, or a mixture of mania and depression. A substance-induced mood disorder may be of shorter duration as it coincides with intoxication or withdrawal, so it is context specific. In a mood disorder due to a general medical condition it is important to establish that the depressive symptoms, which need not meet full criteria for major depression, are a direct physiological result of the medical condition, not just a psychological response to a medical problem. This should involve a consultation with a medical practitioner. Adjustment disorder is a psychological reaction to overwhelming emotional or psychological stress, resulting in depression or other symptoms.

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Some situations in which an adjustment disorder can occur include divorce or other family changes, job loss or change, relocation, or other stressful life event or crisis. Depressive symptoms may be acute for a few months or become chronic if they persist in an ongoing way after the stressor. Determining the existence of depressive symptoms prior to a stressful life event will help determine whether the symptoms are the result of the event or exacerbated by it, which may change the diagnosis to major depression or dysthymia. Dysthymic disorder is a depressed mood most of the day, on most days, for at least two years, and the presence of two or more of the following symptoms that cause impairments in social, cognitive, and/or behavioral areas of functioning: (1) Poor appetite or overeating; (2) Insomnia or sleeping too much; (3) Low energy or fatigue; (4) Low self-esteem; (5) Poor concentration or difficulty making decisions; (6) Feelings of hopelessness (APA, 2000, p. 380). Bipolar disorder is characterized by shifts, or cycling, between depressed episodes (as above) and manic episodes. Manic episodes are: 1. A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary), and 2. During the period of mood disturbance, at least three of the following symptoms have been persistent: a. Increased self-esteem or grandiosity; b. Decreased need for sleep (e.g., feels rested after only 3 hours of sleep); c. More talkative than usual or pressure to keep talking; d. Flight of ideas or subjective experience that thoughts are racing; e. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli); f. Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation; g. Excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments). (APA, 2000, p. 362)

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Bipolar disorder is indicated by two or more bipolar cycles, for which there are three types. Bipolar I disorder is manic or daily cycling episodes of mania and depression. Bipolar II disorder is recurrent depression accompanied by hypomanic episodes, which are a milder mania with symptoms that are not severe enough to cause impairment in functioning, but are observable by others. Cyclothymic disorder is a chronic state of cycling between hypomanic and depressive episodes that does not reach the diagnostic standard for bipolar disorder (APA, 2000, pp. 388–92). As depression encompasses a diverse spectrum, so does the etiology. Causes may include psychological (cognitive and emotional disturbances), sociocultural (environmental context), or biological (genetic and evolutionary, hormonal or other physiological conditions, and/ or neurological) foundations. Many practitioners and researchers believe that major depression and dysthymia are most often caused by a combination of factors, and fall along a continuum of depressive symptoms more than they are distinctly categorical (Hankin et al., 2005). Further, because there are large gender differences in age of onset (about twice as many girls as boys develop depression in adolescence) (Merikangas et al., 2010), causal models have taken into account biopsychosocial factors that explain this difference as well as causes of depression overall. Hyde and her colleagues (2008) provide a clear description of the theoretical and research developments over the last two decades. They lay out an “ABC model” of depression that incorporates: (A) affective vulnerability in biological temperament and emotion regulation patterns, (B) biological vulnerability of genetic predispositions and pubertal hormones and timing (earlier puberty is creates more vulnerability for depression than late), and (C) cognitive vulnerability of negative thoughts and rumination. These individual factors then interact with life stressors such as discrimination and victimization, which may be experienced

more often by girls and by some racial and ethic groups to increase the likelihood of depressive onset during adolescence. Earlier depressive onset may then set a foundation (“kindling”) for recurring depression into adulthood (Monroe & Harkness, 2005). As in unipolar depressions, bipolar disorder is neither all environmental nor physiological, it is a multifactorial combination of genes and environmental factors that conspire to create the disorder (Alloy, Bender, Wagner, Abramson, & Urosevic, 2009). However, because bipolar disorder tends to run in families, there may be greater genetic influences resulting in neurobiological factors that are more responsive to medication (Miklowitz & Johnson, 2009). Nonetheless, psychosocial factors can play a strong role in prevention and response. These include predicting and managing social triggers such as relationships and life events that create strong emotional responses (even if positive), prodromal symptoms before full-blown recurrence, and medication adherence (Johnson, Meyer, Winett, & Small, 2000; Lam, Wong, & Sham, 2001). As a reminder, some diagnostic categories of depression require that a preexisting or coexisting condition be present for assigning the diagnosis: substance-induced mood disorder and adjustment disorder with depression. In these cases, there are primary precipitating factors, but other factors may interact to cause depression. For example, not all people experiencing a difficult adjustment or substance abuse will experience depression. Social workers must also keep in mind that the direct physiologic effects of medical conditions and substances may cause depression and other mood alterations. For example, several of the many medications used to treat hypertension cause depression. When the medication is discontinued, the symptoms remit. Similarly, hypothyroidism produces a syndrome that includes low mood, decreased energy, increased sleep, and many of the other symptoms of depression.

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demographic Patterns Depression is common, with over 21 percent of people experiencing some form of mood disorder in their lifetime (Kessler, Berglund, Demler, Jin, & Walters, 2005). The recent National Comorbidity Survey (NCS), a large-scale epidemiologic survey of mental disorders in the United States, found that in a twelve-month period, 9.5 percent of the U.S. adult population has experienced some form of depression (Kessler, Chiu, et al. 2005). Major depression is most common (6.7 percent per year), followed by bipolar disorder (2.6 percent), and dysthymia (1.5 percent). About half of affected adults will seek treatment. The average age of onset is younger for bipolar disorder, at 25 years old compared to dysthymia and MDD at 31 and 32 years old, respectively (Kessler, Berglund, et al., 2005). Lifetime prevalence of depression for 13- to 18-year-olds is 14 percent (Merikangas et al. 2010), and for younger children (8 to 15 years) it is 3.7 percent (CDC, 2005). About 11 percent of these are MDD and dysthymia, while about 2 percent are bipolar disorders. Bipolar disorder typically begins in late adolescence or early adulthood, but there are some cases earlier in age. Later adolescents (17–18 years) are more likely than early adolescents (13–14 years) to experience any type of mood disorder (Merikangas et al. 2010). The rates of depression among the elderly tend to be lower than for earlier adulthood; however, the suicide risk for depressed older adults is very high, with adults over age 65 making up 12 percent of the population but accounting for 16 percent of all suicides (CDC, 2005). Moreover, depression among the elderly varies by other health indicators and living environment, such that those with home health care and hospitalization have much higher rates than those living independently. Further, this is complicated by the more frequent presence of medical illnesses with symptoms that mimic or resemble that of depression, as well as medication that may

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cause mood changes and associated symptoms (Hybels & Blazer, 2003). Women are 50 percent more likely than men to experience a mood disorder at some point in their lives, and 70 percent more likely to experience major depression in particular (Kessler, Berglund, et al., 2005). Higher depression prevalence for women is found across racial and age groups. Although depression is more often diagnosed in women, more men than women die as a result of suicide by a factor of 4.5:1, mostly through use of firearms (CDC, 2010a). The National Comorbidity Study (NCS) shows that non-Hispanic Caucasians are more likely than both African Americans and Hispanic Americans to experience depression in their lifetime (Kessler, Berglund, et al., 2005). However, the CDC Behavioral Risk Factor Surveillance System Survey (BRFSS; CDC, 2010a) data show that the highest rates of current depression are among non-Hispanic Black Americans (12.8 percent) compared to nonHispanic Caucasians (7.9 percent) and Hispanics (11.4 percent), but that Caucasian men complete more than 78 percent of all suicides. Statistical differences between epidemiological surveys result from different criteria and time periods used in the measurement instruments. While the NCS measures lifetime and twelvemonth prevalence, the BRFSS measures the incidence of depression in the past two weeks. Socioeconomic status (SES) and alcohol and drug use are factors that often confound racial and ethnic differences, such that after statistically controlling for SES and alcohol use, racial and ethnic differences become smaller. Social context Having an income below the poverty level increases the risk of depression, with one out of seven poor Americans experiencing a mood disorder (Pratt & Brody, 2008). Further, the BRFSS (CDC, 2010b) shows an increased incidence of any depression in individuals without health insurance coverage (14.9 percent) versus those who had coverage (7.9 percent).

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Unemployed persons are more likely to be depressed (21.3 percent) than those who are employed or retired (about 6 percent each), and even more likely if unemployment is due to disability (39 percent). Individuals without a high school diploma (6.7 percent) and high school graduates (4 percent) were more likely to report major depression than were individuals who had attended at least some college (2.5 percent). Moreover, income inequality exacerbates other social events. Exposure to social stressors such as disaster, violent neighborhoods, and unexpected social changes in one’s environment predict depression in interaction with the degree of the event exposure, economic resources, and individual coping skills (Ahern & Galea, 2006; Heyman, Brennan, & Colarossi, 2010). Depression also varies by geographic location, indicating economic and cultural factors. The BRFSS (CDC, 2010a) estimated current depression in the United States from 4.8 percent in North Dakota to 14.8 percent in Mississippi, mainly concentrated in the southeastern region of the United States. Internationally, the first study using standardized measures for a crosscountry comparison found that depression is a significant public-health concern across all regions of the world and is strongly linked to social conditions (Bromet, Andrade, Hwang, Sampson, & Alonso, 2011). The results showed that 15 percent of the population from highincome countries were likely to get depression over their lifetime compared to 11 percent for low to middle-income countries. As in the United States, across international countries, women were twice as likely to suffer depression as men. One interpretation of differences in depression by geographic location is that there are cultural differences that are often geographically located. While a full examination of the role of culture in mental health is beyond the scope of this chapter, culture should be considered as a factor in depression to the extent that we understand that cognitive schemas and social roles are highly influenced by culture;

and these cognitive and social role structures are the more proximal influences on depression (Brown, 2002). In sum, social conditions interact with individual biological and psychological factors to influence depression. Social conditions alone may create stressors or risks, but these are filtered through individual coping, role requirements, social networks, and biological vulnerabilities. Vulnerabilities and risk factors Ample evidence shows that mood disorders are biopsychosocial in nature. Biopsychosocial risk factors contribute to cause, precipitate an episode, and/or exacerbate an episode; and biopsychosocial protective factors may reduce severity and duration, or prevent an episode altogether. Risk and protective factors may impact an initial episode, or onset, or only become relevant for recurring episodes. As such, these factors must be uniquely assessed for each individual and used to assist in preventive interventions, as well as to support tertiary treatment. Overall, the total number of risk factors in combination with the presence or absence of protective factors, taking into account the quality of both (as well as quantity) combine to determine the probability of an episode of depression at that time (Rutter, 1985; Smith & Carlson, 1997). Since mood disorders are polygenic, there are shared genetic predispositions among the unipolar and bipolar disorders, and they are often part of a person’s family history (Alloy et al., 2009). The term genetic loading refers to a predisposition but not necessarily a singular causal factor for depression. Genes are believed to interact with other risk and protective factors to influence mood disorders. A family history of depression doubles or triples the risk of major depression (Goldin & Gershon, 1988; Weissman, Kidd, & Prusoff, 1982). Different rates of depression are observed in identical and fraternal twins: identical, or monozygotic, twins have higher rates of depression than fraternal, or dizygotic (Goldin & Gershon, 1988). A family history of depression is an important risk factor,

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but in most cases, a family history contributes a combination of biological and environmental factors. For example, a study of twins and their family contexts showed that genetic factors, defined as the difference between the rates of depression in monozygotic versus dizygotic twins, was one of the largest predictors of MDD onset (Kendler, Neale, Kessler, Heath, & Eaves, 1992). However, other nongenetic family variables were also significant predictors, including parental warmth and childhood parental loss. Genetic factors may influence the risk of onset of unipolar and bipolar depression by creating greater “sensitivity” to stressful life events and negative cognitive styles (Alloy et al., 2009; Kendler et al., 1995). Additionally, there has been much debate about the role of hormones in depression, especially due to the greater likelihood of depression for women than men. The emergence of large gender differences in depression during puberty (ages 13–15 years) implicates hormonal risks. However, decades of research into the role of DHEA, estrogen, and testosterone has not provided strong evidence for the role of hormones without interaction with other psychosocial factors such as negative life events during adolescence, such as early puberty and sexual harassment, sexual victimization, gender discrimination, and negative cognitive styles— all of which tend to be experienced more by teenaged girls than boys (Hyde et al., 2008). Postpartum depression is another risk that implicates the role of hormones. Postpartum depression may occur soon after delivery or up to a year later. Pregnancy and postpartum adjustment involves many physiological processes in additional to hormonal shifts, including changes in brain chemistry, thyroid, and the physiological effects of lack of sleep. Social changes are also prominent related to work, social, and marital relationships. Psychological risks include worries about motherhood, finances, and lack of freedom (Pearlstein, Howard, Salisbury, & Zlotnick, 2009). Postpartum changes may initiate an onset of depression or

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trigger a recurrence, so that a history of depression should be assessed prior to a pregnancy. Biological vulnerability, however, not only refers to a genetic component, but also to other physiological factors. For example, stopping smoking has been found to create vulnerability for depression because nicotine is a mild stimulant, as is caffeine, and when it is withdrawn, depression may emerge (Covey, Glassman, & Stetner, 1997). This has also been found to occur with use of benzodiazapines, typically used for anxiety and panic, and alcohol (Nunes & Levin, 2004). Biological factors, in turn, interact with social factors. Social learning of certain behaviors, coping styles, and relationship dynamics during childhood may lay the foundation for later risks for depression. Social contexts, particularly acute stressful events, may also trigger a first or recurrent episode. Because of the wide range of social experiences that can create risk, many interventions focus on the social environment. For example, poverty in and of itself does not create risk for depression, but poverty may increase more proximal risk factors for depression such as poor medical care, nutrition, exercise, and increased risk of victimization and other stressful life events. Conversely, the wealthy are not immune from depression, as we see that higher-income countries such as the United States have higher rates of depression than some low-income countries (Bromet et al., 2001). Wealth allows for access to a variety of protective factors such as early and highquality mental health care and more resources to manage stressful life events, but does not protect from other risks like substance abuse, genetics, and lack of social support. Changes in family structure such as divorce, separation, and widowhood, as well as increased family mobility with a concomitant loss of the extended-family system can be risk factors, especially when conflict and hostility are present (Carbonell, Reinharz, & Giaconia, 1998; Hooley & Teasdale, 1989). These indicators often represent disrupted attachments and

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deficient social supports. Even without separation, depression is highly correlated with unhappy marriages and marital distress (Kessler, McGonagle, Swartz, Blazer, & Turnbull, 1993), exposure to drug or alcohol abuse in the family, lack of support from intimate family members, and disturbed family functioning (Hooley, 1986; Keitner et al., 1995). Stressful interpersonal relationships may contribute to or exacerbate depression, but depression can also reciprocally influence relationships with family members. A circular process can occur when the depressed person and other family members interact to create and maintain a system that resists change (Keitner & Miller, 1990; Turner, Wheaton, & Lloyd, 1995). A depressed person may engage with others in a way that increases frustration and conflict. Communications of hopelessness, helplessness, and irritability by the depressed person are answered with direct reassurances, but are countered by the depressed person with negative appraisals of self and others (Coyne, Kessler, & Tal, 1987). In time, depressive symptoms arouse guilt and annoyance in others, because reassurance is rebuffed and feelings of annoyance and hostility occur, accompanied by simultaneous rejection and avoidance of the depressed person. In this way, negative vs. positive cognitive styles affect mood as well as relationship dynamics with others (Burns, 1999; Coyne & Downey, 1991; Keitner & Miller, 1990; Turner, Wheaton, & Lloyd, 1995). Similarly, it has been difficult to determine the direction of influence between stressful life events and depression, e.g., which events are independent of the behavior of the individual, as opposed to those that are possibly dependent, i.e., likely to have been caused either directly or indirectly by the individual (Coyne & Downey, 1991). For example, the loss of a job may lead to depression, but depression may also lead to job loss. Predisposing (or distal) events must be differentiated from precipitating (or proximal) ones. Predisposing, or distal, events are ones that occur long in the past, often years

before the onset of depression. Precipitating, or proximal, events are the “triggers” for an actual episode of depression. Stressful events in childhood are often considered predisposing factors for major depression during adulthood (Kendler, Neale et al., 1992). Qualitative aspects of the loss, such as the nature of the loss (whether it was due to illness, marital separation, or death), its timing (the developmental stage when the loss occurred), the nature of the attachment, the adequacy of the care following the loss, and family stability are all critical protective elements that may influence the outcome (Bifulco, Brown, & Harris, 1987; Coyne & Downey, 1991; Rutter, 1985). The link between childhood experiences and vulnerability to adult depression is hypothesized to produce a “kindling” effect or sensitivity, upon which are built other proximal factors such as cognitive style and environmental supports that create risk and resilience for depression (Alloy et al., 2011). Traumatic events are those that involve overwhelming amounts of stress and usually include an element of threat to life. Traumatic occurrences during childhood have been found to be predisposing events for the later onset of depression. Childhood sexual and/or physical abuse, perhaps the most common traumatic events of childhood, is particularly significant (Levitan et al., 1998; Liem et al., 1997; Lizardi et al.,1995). Various adult experiences of trauma can also create risk for onset or recurrence of depression such as intimate partner violence and other forms of victimization; loss of a family member or friend through suicide, homicide, or sudden accident; and witnessing disaster (Brent, Perper, Moritz, et al., 1993; Heyman, Brennen, & Colarossi, 2010). Finally, chronic life stressors are often related to ongoing social circumstances such as immigration, relocation, acculturation, and low socioeconomic status (typically a combination of low educational level, high social stigma, and low income), creating risk for both major depression and dysthymia due to disruption, long adjustment periods, lack of access to resources,

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discrimination, and increased negative daily experiences (Blazer, Kessler, McGonagle, & Swartz, 1994; McLeod & Kessler, 1990; Takeuch et al., 1998; Turner et al., 1995). On a psychological level, more than 40 years after Aaron Beck (Beck, 1967) developed the cognitive theory of depression, cognitive style has remained one of the most empirically supported individual factors in mood disorders. Beck posited, and provided empirical evidence, that automatic negative cognitions about the self, the world, and the future (the cognitive triad) created and maintained depressed mood and negatively influenced relationships with others (Beck, 1991). Cognition involves ways in which we think about, interpret, and cope with day-to-day events as well as stressful life events, and relationships with others. The literature on the treatment of depressive disorders (Areán & Chatav, 2003) would seem to suggest that the cognitive styles of individuals who suffer from mood disorders appear to be related to three significant overarching psychological variables: (1) people’s cognitive appraisals of themselves, their lives, and others; (2) whether people proactively solve problems or avoid them; and (3) degree to which proactive attempts to cope with stress have been successful. Three decades of research has specified the significant roles of negative automatic thoughts, rumination, and biases in attention, interpretation, and memory (Mathews & MacLeod, 2005) in depressed mood, as well as anxiety. Informed by negativistic thinking (see Beck et al., 1979), people with depression tend to expect failure and disappointment within their life space on an ongoing basis, and focus only on past failures as a way to confirm negative beliefs about themselves and others. People with negative thinking (or negative automatic thoughts), rumination, and bias in attention, interpretation, and memory also have poor self-esteem and are passive when confronted with problems in daily living. Even when depressed people are able to demonstrate mastery over a possible ego-taxing situation in the

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social environment (i.e., securing a promotion in a competitive job market), they often downplay the successful experience as an unusual event or an event that occurred despite the odds against it. Negative-pessimistic thinking mars the interpretation and understanding of success, and this type of thinking impedes the objective perception of a person’s ability or level of competence (Gotib & Joormann, 2010). In addition to contributing to the belief of expected failure and disappointment within the environment, negative automatic thoughts make it difficult for depressed people to engage in and enjoy activities that once gave them pleasure (Vinokur, Shul, & Caplan, 1987). This noted difficulty increases a depressed person’s level of social isolation and decreases the opportunity for social support that may be found within the person’s social orbit. Negative automatic thoughts in people diagnosed with depressive disorders also appear to contribute to passive copings skills and impaired problem-solving abilities (Alloy et al., 2012). These liabilities are often the by-products of preexisting social skills deficits or learned helplessness and hopelessness. Learned helplessness is a phenomenon caused by repeated attempts and failures to cope with problems (Seligman, 1975). People who suffer from a mood disorder often avoid proactive steps to solve problems in living because they believe that they are not capable of exerting control over their lives or of finding effective solutions to their needs. Hopelessness is the result of the impaired appraisals that depressed people make about their problems and stressful life events (Alloy et al., 2012). resiliencies and Protective factors Resiliency and protective factors often take the form of individual and environmental characteristics that compensate for or buffer the effects of stress. Compensatory models define resiliency as having protective factors in numbers that outweigh the number of stressors or risks over time, while buffering models focus

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on available resources that decrease the impact of a stressful event. A physiological factor that has been shown to have a protective effect for depression is exercise, which has been found to be as effective as antidepressant medication (Dunn, Trivedi, Kampert, Clark, & Chambliss, 2005; Harris, Cronkite, & Moos, 2006). Dunn and her colleagues found the effects of exercise for alleviating depression to be equal to that of antidepressant medication and longer lasting. Walking fast for about 30 to 60 minutes a day can have a significant influence on mild to moderate depression symptoms. Exercise may be protective by increasing brain chemicals, like norepinephrine, that affect mood as well as helping to prevent other physiological illnesses that create risks for depression such as hypertension requiring medication, diabetes, and hypothyroidism. Social support is one of the most studied protective factors for many health problems, including depression. Social support is fundamentally conceptualized as falling into two types: structural support and functional support (Cohen & Wills, 1985; Kessler, Price, & Wortman, 1985). Structural support is considered to be the number of social connections (or relationships) within one’s family and community. It assesses the existence of a relationship, but does not speak to the depth or quality of those relationships. It is, therefore, purely a measure of network size or the potential for support availability from people with whom one has a relationship. Some evidence exists that large networks can increase an individual’s stress by raising the potential for negative exchanges or the number of members who ask for more support from the individual than they themselves provide (Antonucci, Akiyama, & Lansford, 1998; Ingersoll-Dayton & Antonucci, 1988). Most often, however, measures of structural support have been associated with protection as a protective buffer to stress and as a coping strategy (Cohen & Wills, 1985). A diverse social network can provide opportunities and

resources through social exchange of goods, information, and other kinds of instrumental assistance. Functional support is the type of, or reason for, support perceived by a person to be provided by others (even if it is not actually enacted, but perceived to be present), which includes emotional support related to emotions and instrumental support related to provision to help or assistance with tangible needs like financial support, child care, or accompaniment to a medical appointment (Cohen & Wills, 1985; Kessler, Price, & Wortman, 1985). Both alternate kinds of support (e.g., emotional support vs. instrumental support) and support providers (e.g., parents vs. peers) differentially affect mood disorders (Barrera & GarrisonJones, 1992). Alternative kinds of support (e.g., emotional support vs. instrumental support) and support providers (e.g., parents vs. peers) differentially affect mood disorders (Barrera & GarrisonJones, 1992). Also, research has consistently found that gender differences exist in the amount and kind of support that adolescents receive and from whom (Furman & Buhrmester, 1992; Levitt, Guacci-Franco, & Levitt, 1993). For example, girls receive more support from peers, while boys receive more support from family sources. If these supporters have different impacts on developmental outcomes, then the nature of the support adolescents receive and from whom, how it affects healthy development, and whether gender differences exist in these processes must be assessed. Perhaps most important, research shows that individuals’ perceptions of support are more strongly related to well-being than are reports of actual supportive behaviors performed by others (Cohen & Wills, 1985; Ingersoll-Dayton & Antonucci, 1988; Wethington & Kessler, 1986). This finding suggests that the role of cognitive interpretation of social relationships is more important, or more proximal to, emotional outcomes. We must keep in mind that all social factors filtered through individual

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psychological processes of cognitive interpretation, coping, and emotional regulation and do not stand alone as risk or protective factors for depression. Therefore, research suggests that an individual’s global belief or schema that people will be supportive when needed has a greater impact on perceived emotional well-being that what actual supporters provide to the person. This research shows the interplay between social factors and cognitive coping styles, as all social factors (positive and stressful) must be filtered through cognitive interpretations and behavioral responses. Coping theories have described the interplay between protective cognitive styles and behaviors. Active coping strategies, such a problem solving, distraction, and seeking assistance from others buffer risks for depression (Mathews & MacLeod, 2005). Cognitive styles that protect against depression include optimism, beliefs that others will be there when needed, acceptance of self and others, and internal locus of control (Burns, 1999). Individuals may turn to different coping strategies as they deal with distress (Solomon, Mikulincer, & Avitzur, 1988; Zeidner & Hammer, 1992). Coping pertains to a person’s constantly changing cognitive demands and behavioral efforts used to reduce feelings of threat, challenge, or loss following a stressful life event (Lazarus & Folkman, 1984). Coping may be a function of both the individual’s cognitive appraisal of the situation and environment constraints and opportunities. The two prominent types of coping strategies are problem-focused and emotion-focused. Problem-focused coping is often described as managing the problem, while emotion-focused coping is “directed at regulating emotional responses to the problem” (Lazarus & Folkman, 1984, p. 150). Other researchers emphasize the importance of religion and spirituality as central to the problem-solving phases (Pargament & Hahn, 1986; Pargament et al., 1988). This builds on the hypothesis that intrinsic religious motivation can help to lessen stressful events. Pargament and colleagues (1988) note that

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religious beliefs often promote positive appraisal of negative situations. Allport and Ross (1967) cite the importance of understanding the two different dimensions of religious motivations: extrinsic and intrinsic. Extrinsic refers to how individuals use religion toward a behavioral end, while intrinsic refers to how an individual may internalize beliefs and reframe the interpretation of negative experiences. In sum, risk and protective factors are in dynamic interplay to increase or prevent depression. This explains why not all people living in poverty exhibit depressive symptoms, and conversely, why the wealthy are not immune to depression. Higher-income countries such as the United States have higher rates of depression than some low-income countries (Bromet et al., 2001). Also, for example, it seems counterintuitive that a racial or cultural minority group should have lower rates of depression than the European American majority. Certain stressful life events that are more common to African Americans, such as poverty and racial discrimination, are correlated with depression (Stevenson, Reed, Bodison, & Bishop, 1997). However, these risk factors appear to be balanced by important protective factors, such as religion, intragroup social support, social participation, and cultural values of perseverance (Fellin, 1989). This highlights the complex interplay between risk and protective factors. Programs and Social Work contributions Callahan and Turnbull (2001) have noted that “programmatic social work responses to depression can occur at three levels: at the interpersonal level, at the organizational and policy level, and through social work education” (p. 178). At the interpersonal level, clinical social work practitioners have been trained in an array of helping approaches aimed at ameliorating the symptoms of depression, and many have contributed to the development of therapeutic approaches that have addressed depressive symptoms in selected client populations (Austrian, 2005; Drake, Merrens, &

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Lynde, 2005; Turner 1995, 2000, 2005). Social work clinicians provide the majority of mental health services throughout the United States (Gibelman, 2005), and many are contributing to practice-based research endeavors aimed at ameliorating depression in the lives of vulnerable populations (Weissman, 2006). On a national level, the MacArthur Foundation (2011), for example, has launched the Initiative on Depression and Primary Care. The initiative is based on the recognition that depression is a common but disabling psychiatric disorder that can lead to death. The Foundation aims to equip health care providers to detect and help clients in primary health care settings who may present with a range of emotional and physical symptoms that may be linked to an undiagnosed mood disorder. Because improving the biopsychosocial functioning of depressed clients has not been a top priority within the medical community or federal agencies, the Foundation has developed a Three Component Model (TCM) aimed at enhancing the quality of care and outcomes for clients with depressive disorders who are seen in primary care practices. According to the MacArthur Foundation (2011), “under TCM, the primary care clinician, a care manager, and a mental health care professional cooperate with the patient and with one another in providing evidence-based care to patients with symptoms of depression” (p. 1). The cooperation is informed by prescribed practices, programs and tools aimed at client well-being. Preliminary evaluation findings on the model appear to suggest that there is a significant reduction of depressive symptoms among clients who receive care under TCM as compared to clients who receive “usual care.” The National Depression Screening Day (NDSD) had made a significant impact in the early detection, diagnosis, and treatment of depression in the United States since its inception in 1991 (Callahan & Turnbull, 2001). Developed and introduced by Screening for Mental Health, Inc.—a not-for-profit organization

dedicated to the promotion of mental health by providing the public with education, screening, and intervention resources—NDSD has reached over 85,000 people in 3,000 sites nationwide (Mental Health America, 2012). The NDSD program also maintains a toll-free, year-round phone line for free, anonymous screening locations through the United States. Participants at screening events receive educational materials on depression and other mental illnesses, hear an educational session on depression, complete a written screening test, discuss the results with a mental health professional, and, if required, learn where to go for additional mental health assistance. As an innovative national program, NDSD provides individuals at risk for depression with linkages to mental health care—and, to an extent, primary prevention. Partnerships between state offices of mental health and schools of social work are providing a venue for the preparation of practitioners who will be able to address the mental health needs of vulnerable populations. In New York State, for example, a formal partnership was established between the NYS Association of Deans of Schools of Social Work and the New York State Office of Mental Health (NYSOMH, 2011). A key goal of the partnership is to prepare master’s-level social work students to enter a changing workforce that focuses on empirically validated treatments for individuals diagnosed with a serious mental illness. Through careful classroom and field practicum instruction, graduate-level social work students are introduced to evidence-based approaches that have been proven effective in reducing psychiatric symptoms and increasing emotional wellness in individuals and families who are affected by chronic mental illness, including the full gamut of mood disorders. The treatment approaches include Assertive Community Treatment (ACT), Wellness Self-Management (WSM), Supported Employment, Social Skills Training, Medication Management, Family Psychoeducation and Integrated Dual Disorder Treatment (IDDT) for individuals who are suffering from

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both a mental health and substance abuse disorder (Drake, Merrens, & Lynde, 2005). Students also learn the skills and knowledge that are required for the successful implementation of evidence-based treatments in community-based clinical settings. The partnership is informed by the conceptual tenets of the recovery perspective and cultural competency. This successful initiative exemplifies a programmatic statewide social work response—at an organizational and educational level—that will positively impact individuals who are living with mental illness including major depressive and bipolar disorders. assessment and interventions The primary intervention for mood disorders occurs within the domain of the mental health service delivery system. The nature and type of treatment will vary depending on whether the depressed client is receiving outpatient or inpatient care and if medication is prescribed for the amelioration of depressive systems. Smith (2011) has documented the levels of care (e.g., outpatient clinics, intensive outpatient programs, partial hospitalization, inpatient hospitalization) required for the effective counseling of depressed individuals, and the range of roles that clinical social workers assume within these noted levels of care. The roles may entail providing psychosocial intervention and support to clients and their families, group intervention, coordination of care with other health/mental health professionals, discharge planning, mobilization of social and community resources and collateral contact with key individuals or systems within a client’s social network. Irrespective of practice approaches or service settings, the core goals for helping people suffering with depression—amelioration of life stressors; reduction of symptoms; restoration of hope; a sense of mastery, competency, and self-efficacy; increase in self-esteem and psychosocial functioning; and the examination of maladaptive patterns of interpersonal relationships, communication, and behavior—should serve to

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guide the clinical care of individuals who are diagnosed with a mood disorder (O’Neil, 2000). Findings from treatment outcome studies and medical research (Alloy et al., 2012; Austrian, 2005; Smith, 2011) have provided a body of evidence for a number of effective biological and psychosocial interventions aimed at decreasing the symptoms of depression. The three most effective and documented interventions are underscored: antidepressant medication, interpersonal psychotherapy, and cognitive behavioral therapy. In the treatment of depressive disorders the major groups of medication include: tricyclic/ heterocyclic antidepressants (TCAs), monoamine oxidase inhibitors (MAOIs), selective serotonin reuptake inhibitors (SSRIs), serotonin and norepinephrine reuptake inhibitors (SNRIs), and atypical antidepressants (Alloy et al., 2012; Austrian, 2005; Preston, O’Neal, & Talaga, 2005). Discovered in the late 1950s, tricyclic and heterocyclic antidepressants have been considered the mainstay of the treatment of depression. The most common tricyclic antidepressants are amitriptyline (Elavil), amoxapine (Asendin), clomipramine (Anafranil), desipramine (Norpramine, Petrofrane), doxepin (Tofranil), maprotiline (Ludiomil), nortriptyline (Pamelor, Aventyl), protriptyline (Vivactil), trazodone (Desyrel), and trimipramine (Surmontil) (Preston et al., 2005). Dry mouth, constipation, sedation, sexual difficulties, weight gain, hypotension, and cardiac arrhythmia are the most common side effects of tricyclic antidepressants. Phenelzine (Nardil), tranylcypromine (Parnate), and isocarboxazid (Marplan) are the best known—although cautiously prescribed— MAOIs. MAOIs are mainly prescribed when other antidepressants have failed in effectively reducing symptomatology in individuals who are suffering from a major depression. Preston and colleagues (2005) note that MAOIs can cause a hypertensive reaction in individuals that may potentially lead to cerebral hemorrhage or death. This reaction can be caused

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by eating foods high in tyramine content (e.g., smoked fish, cheese, yogurt, cured/fermented meats, and alcoholic beverages), over-thecounter cold medications (i.e., decongestants and prescribed medications that may contain stimulants) (Bieck and Antonin, 1988; Shulman Walker, MacKenzie & Knowles, 1989). MAOIs may produce the same side effects as those observed with tricyclic antidepressants. In addition, sedation, insomnia, agitation, and confusion may be possible. Fluoxetine (Prozac), citalopram (Celexa), escitalopram (Lexapro), fluvozamine (Luvox), paroxetine (Paxil), and sertraline (Zoloft) represent a newer class of antidepressants known as selective serotonin reuptake inhibitors (SSRIs). These antidepressants are widely prescribed for the treatment of depressive conditions because of their effectiveness, significantly few side effects and safety in overdosage. Because they have fewer side effects, SSRIs are often the treatment of choice for older adults and for individuals with moderate levels of depression (Austrian, 2005). SSRIs have been proven to be as effective as tricyclics, and they are a better alternative for individuals who do not respond well to tricyclic/heterocyclic antidepressants. As with all antidepressant medication, SSRIs may produce side effects. Nausea, gastrointestinal upset, sweating, headache, lessening of sexual desire, delayed or absent ejaculation in men, and anorgasmia in women may be common. Prescribing psychiatrists usually address these side effects by dose reduction of the specific SSRI medication, drug holidays, or the use of other medications as antidotes (e.g., Viagra, buproprion) (Preston et al., 2005). Often used in the treatment of severe depression, SNRIs are dual-action antidepressants that affect both serotonin and norepinephrine neurotransmitters (Wheatley, van Moffaert, Timmerman, & Kremer, 1998). Found mainly in the gastrointestinal tract and the central nervous system, serotonin helps to regulate mood, sleep, appetite, learning, and memory. Norepinephrine is both a hormone—secreted by the

adrenal gland—and a neurotransmitter that gives the body energy during times of stress (Alloy et al., 2012). The three most common prescribed SNRIs are venlafaxine (Effexor), duloxetine (Cymbalta), and mirtazapine (Remeron). The side effects produced by SNRIs are similar to the side effects of SSRIs. Bupropion (Wellbutrin), nefazdone (Serzone), and amoxapine (Asendin) are atypical antidepressants that have been proven effective in reducing symptoms associated with a mood disorder (Austrian, 2005; Preston et al., 2005). Asendin, for example, is often prescribed for insomnia—a symptom often observed in people who suffer from a mood condition. The most common side effects of atypical antidepressants are nausea, headache, anxiety, sedation, and dizziness. Insomnia is a side effect of Wellbutrin and there is an increased risk of seizures for individuals who are maintained on this medication (Austrian, 2005). Seizure activity has been primarily noted in patients who present with an eating disorder. The new sustained release formulation of Wellbutrin (Wellbutrin SR and Wellbutrin XL), however, appears to decrease the risk for seizures (Preston et al., 2005). Pharmacotherapy is considered to be the first-line intervention for the treatment of bipolar depression. Lithium or lithium carbonate is widely accepted as the drug of choice for individuals suffering from acute mania—a distinguishing diagnostic characteristic or symptom of bipolar depression (American Psychiatric Association, 2013). Lithium is effective in 70–80 percent of cases in the treatment of mania (Austrian, 2005). It is often prescribed as a mood stabilizer in conjunction with an antidepressant agent and an anticonvulsant. In some cases a benzodiazepine and/or antipsychotic agent may also be added to the medication regimen. The three anticonvulsant agents with demonstrated efficacy for the treatment of bipolar disorder include carbamazepine (Tegretol), divalproex (Depakote), and lamotrigine (Lamictal) (see Li, Ketter, & Frye, 2002). Clozapine (Clozaril),

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risperidone (Risperdal), olanzaoine (Zyprexa), and quetiapine (Seroquel) are the types of antipsychotic medications that may be used in conjunction with lithium—and/or an anticonvulsant agent—to manage an episode of mania that is accompanied by severely distorted or psychotic thinking (Austrian, 2005). The integrated and multiple use of medication for the management of bipolar depression is clearly informed by the severity and complicated course of the illness. Increased urination, thrush nausea, irritability, weight gain, loss of concentration, and memory loss are the most common side effects of lithium carbonate (Preston et al., 2005). Interpersonal psychotherapy (IPT) is a relatively brief treatment approach (twelve to sixteen sessions) that focuses on both symptom relief and improvement in interpersonal relationships and social role expectations (Robertson & Stuart, 2003). The approach has a primary here-and-now focus while underscoring the genetic, developmental, environmental, and personality factors that might cause depression. The underlying principal of IPT is that regardless of the biological or environmental etiology of the depression, it occurs in an interpersonal context that can significantly influence its course (Mufson, Weissman, Moreau, & Garfinkel, 1999). If a clinician can identify and improve problemsolving strategies in an identified client’s interpersonal relationships, it is likely that the depression will be alleviated. Within IPT, symptom relief is achieved in part through the provision of didactic information that helps clients who suffer from mood conditions to understand their depression. Clients are informed about possible ways to help depressed people, including the use of antidepressant medication as a means of achieving optimal psychosocial functioning. As a treatment model, IPT guides clinicians in isolating and addressing the interpersonal etiology or problem area that is directly influencing the client’s depression. The etiological factors or

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problem areas include grief, role disputes, role transitions, and interpersonal deficits (Weissman, 2006). Austrian (2005) has noted that implementing IPT involves three defined steps: “(1) developing an understanding of what depression is, based on social, biological, and medical data, with a distinction made between normal sadness and clinical depression, identifying symptoms, determining the problem focus, and setting a framework and contract for intervention; (2) focusing on the current interpersonal problem area(s) identified through assessment of early family relationships, previous significant relationships and friendship patterns, and on alleviating symptoms; and (3) termination during which feelings are discussed, progress is evaluated, and, although the individual has usually improved, an outline is made of work that remains to be done without the therapist” (p. 53). The primary mechanism of therapeutic change in IPT is believed to be improved communication. This is achieved through a variety of strategies such as functional communication analysis of interpersonal conflict, role-playing, and clinician modeling of effective communication and needs (Robertson & Stuart, 2003; Weissman, 2006). Functional communication analysis refers to the technique of analysis of discrete examples of conversations between the client and a significant other (e.g., parent, partner, adult child) that are associated with depressed feelings. Similar to a critical incident analysis (Gitterman & Germain, 2008), the interpersonal event is analyzed according to every statement that has transpired between the depressed client and identified significant other. From an intervention perspective, the clinician periodically stops the client and asks such questions as: How did that make you feel? What could you have done differently? How would that have felt for you or the other person? How do you think that made him/her feel? Was that your goal? What else could you have said? Could you have said it in a different way?

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What would have been the impact? (Weissman, Markowitz, & Klerman, 2000). The primary goal of functional communication analysis— as in IPT technique of therapeutic change—is to help the client to start thinking and practicing more adaptive ways of communicating in relationships. Informed by Sullivan’s (1953) theory of interpersonal psychiatry, the analysis of communication patterns and interpersonal processes are linked back to the client’s feeling state as a means to increase awareness of the association between interpersonal events and feelings of depression. Other therapeutic techniques that serve as mechanisms of change within this approach include the use of role-playing conversations, encouraging appropriate expression of affect, clarification of feelings about a situation or person, feedback from the clinician regarding the impact of how one expresses feelings to others within the actual therapeutic session, and learning to see another person’s perspective on a situation so one can learn to negotiate and/or compromise for a solution (Robertson & Stuart, 2003; Weissman, Markowitz, & Klerman, 2000; Weissman, 2006). Elkin and colleagues (1989) were the first to examine the effectiveness of IPT in the treatment of depression. The results of this study indicated that IPT was an empirically supported psychosocial intervention— and other studies have yielded similar results (Weissman, 2006). Cognitive behavioral therapy (CBT) is a brief, twelve- to sixteen-session treatment for depression that may often include monthly maintenance sessions. Although a number of cognitive behavioral treatments exist, the most frequently cited and evaluated cognitive intervention is Aaron Beck’s cognitive therapy for depression (Beck, 1967, Beck, et al., 1979; Beck, 1991). As alluded to earlier in the chapter, Beck’s (1991) cognitive theory of depression posits that individuals’ cognitions are based in large part on their schemata—belief systems that are derived from past experiences. These schemata color the way in which individuals interpret the world

around them. Individuals whose schemata— and the cognitions that are based on these schemata—are maladaptive interpret their world in a negative manner, leading to a psychological disorder such as depression or anxiety. CBT is based on the proposition that depression results from a cognitive deficit, whereby individuals who suffer from mood conditions tend to see themselves and the future in negative and selfdefeating terms (Austrian, 2005). Cognitive therapy attempts to identify clients’ maladaptive or dysfunctional beliefs and attitudes, guide clients in real-life experiences to test the validity of these beliefs, and then correct these erroneous beliefs. Behavioral strategies are also used to enhance the effectiveness of the treatment. From a behavioral perspective, for instance, a depressed client may be asked to monitor weekly activities in an attempt to increase pleasurable activities and challenge dysfunctional beliefs, both of which should have the effect of reducing feelings and symptoms of depression. Cognitive restructuring—a CBT technique aimed at correcting faulty negative beliefs, offering a new way of thinking and alleviating depression—is a major mechanism of change in the treatment model. Sanderson and McGinn (2001) have noted that the three steps used to accomplish cognitive restructuring are: (1) monitoring negative automatic thoughts; (2) analyzing the identified negative automatic thoughts; and (3) generating a rational response to the negative thoughts. Cognitive behavioral therapy usually begins with a didactic presentation to clients of the theoretical background and foundation of cognitive behavioral intervention (Beck et al., 1979). Clients are then taught to monitor their negative automatic thoughts and the negative cognitions that arise when they encounter problems in living. Clients are also taught to examine their thoughts for faulty logic, such as overgeneralization or all-or-none thinking (Beck, 1991). Clients are further taught to test hypotheses about identified negative cognitions and to replace dysfunctional thoughts with adaptive cognitions

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and ways of thinking. Last, clients are guided in the identification of the underlying beliefs that sustain their negative automatic thoughts on a day-to-day basis. The treatment model uses structured homework assignments, psychoeducation, detailed journal recordings of weekly activities and associated feelings, and assertiveness training as a means of improving patterns of communication, social skills, and adaptive thinking patterns. Empirical studies (Alloy et al., 2012) have strongly suggested that changing clients’ schemata and teaching them new behavioral skills may lead directly to clinical improvement in the treatment of depression. These findings support CBT as an effective treatment for individuals who are diagnosed with mood conditions. illuStrAtion And diSCuSSion

Caleb is an 18-year-old young man, of Italian-Cuban descent, who applied for services at a local community mental health clinic by recommendation of his freshman college faculty advisor. His presenting complaint was that he wanted to overcome a history of traumas caused by family problems. The initial intake evaluation confirmed a diagnosis of a major depressive episode as per the prescribed DSM-IV-TR (American Psychiatric Association, 2000) symptom criteria. Caleb was assigned to a male social worker who was trained in interpersonal psychotherapy (IPT), an evidence-based intervention model for helping people suffering from depression. Caleb is the youngest of three male siblings. His family history revealed episodes of domestic violence of his father toward his mother, and episodes of significant corporal punishment toward the older sibling by the father. The family history also uncovered the father’s other problems, such as alcoholism and a diagnosis of schizoaffective disorder. Caleb reported, for example, that on one occasion his father seriously injured one of his own brothers because of jealousy. The family has also confronted economic hardships and relocation to a new neighborhood because of foreclosure on their home.

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Caleb currently lives with his oldest brother, but does visit his mother and other family members quite frequently. Although now divorced, Caleb’s parents maintain a degree of closeness with each other and communicate often via phone. Caleb’s history is impressive. He graduated from a parochial high school with honors and was able to successfully complete a number of advanced college placement courses. He is pursuing an undergraduate degree in urban studies and is contemplating law school or a graduate degree in urban planning. While Caleb appears to excel academically, he reports dissatisfaction in relationships with peers and friends. In the initial sessions, the social worker established an empathic relationship with Caleb. The history of the major depressive episode was obtained. Caleb’s symptoms included chronic fatigue, hypersomnia, poor appetite, weight loss, depressed mood, less than optimal concentration, low self-esteem, and feelings of guilt. Caleb stated that his reported symptoms are exacerbated by witnessing arguments or disagreements between friends or by noisy environments—like a shopping mall. Consistent with the practice principles of interpersonal psychotherapy (Mufson et al. 1999; Weissman 2006), the initial phase of the helping process was used as a time to obtain an interpersonal inventory that reflected a pattern of social withdrawal and isolation at different phases during Caleb’s development. As an assessment tool, the interpersonal inventory should be used to obtain the following information: (1) the nature of the client’s interpersonal relationships, including frequency of contact and activities shared; (2) what the client expects from each relationship, including instances in which those expectations were met; (3) a review of the satisfactory and unsatisfactory aspects of a specific relationship, as well as detailed examples of both aspects; and (4) the ways in which the client would like to change the relationship through changes in him- or herself or changes in the other person (Robertson and Stuart 2003). During the beginning phase, Caleb was able to recognize his history of social impoverishment,

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his unsatisfactory relationship with his parents, and his difficulty in establishing and maintaining relationships with others. Caleb identified the desire to relate better to others as an important goal. Improving Caleb’s interpersonal deficits was a critical component of therapy. In the ongoing phase, the social work clinician used certain material that Caleb brought to sessions— such as family pictures and selected entries from a journal—as a means to explore his relationship to others. The process of exploration revealed that Caleb was not able to establish a satisfactory relationship with his parents. This inability was directly linked to his difficulty in developing and sustaining new satisfactory relationships with others and his depressive symptoms. To improve Caleb’s interpersonal relationships—insession—relational skills were practiced through techniques such as communication analysis, roleplaying, and clarification (Klerman et al. 1984; Weissman, Markowitz, and Klerman 2000). Caleb reported that he was consistently worried about his parents’ relationship. Although the parents were divorced, he was concerned that their ongoing contact with each other may give way to serious conflict and possible violence. During this helping phase, Caleb also explored his concerns about moving into a new apartment in a three-story house that he and his brother found. The owner of the house lives in one of the apartment units and is—according to one of the tenants—an alcoholic. Caleb stated that the description that he received on the owner reminded him greatly of his father. These noted concerns were used to identify negative patterns of communication, particularly when Caleb is faced with authority figures. Caleb was able to articulate the difficulty that he has in communicating his feelings to others including his parents and siblings. This difficulty was associated to the client’s low self-esteem and his noted interpersonal difficulties. As a means of increasing Caleb’s capacity to engage in adaptive communication with others—participation in nonthreatening social support networks was encouraged.

Caleb agreed to participate in an urban studies student club that met twice a month at his college. Because the faculty advisor who referred him to the agency served as the leader of the club, participation in this type of forum did not appear to be an egotaxing endeavor. The club was identified as a forum through which Caleb may establish friendships and connection to others. As work progressed on improving Caleb’s pattern of interpersonal communication and self-esteem (Gitterman & Germain, 2008), he continued to connect his present interpersonal difficulties to his past relationship with his parents. These two domains of functioning were directly linked to the client’s symptoms of depression. At the end of this phase Caleb reported he is still working toward the resolution of interpersonal difficulties. Both he and he clinician acknowledged that movement toward change is gradual and incremental. Caleb was able to state that involvement in the urban studies student club has significantly contributed to favorable changes in his style of communication with others. He reported that he has gained a better understanding of himself and how his symptoms of depression are connected to his social orbit. Caleb further acknowledged participation in the urban studies student club has decreased his sense of social isolation and disconnection from others. He reports feeling more hopeful about the future and less depressed. Given the shortterm nature of interpersonal psychotherapy and the course of depression, the possible reappearance of depressive symptoms and the option to pursue a second course of IPT in the future were discussed with Caleb. ——— According to the central conceptual formulations of interpersonal theories of depression (Alloy et al., 2012), depressed individuals engage in various maladaptive interpersonal strategies in an attempt to improve or regulate mood. The strategies are usually ineffective and lead to impaired psychosocial functioning—and poor transactions between

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the depressed individual and his or her social environment. Consistent with an ecological perspective on person and environment transactions and the principles of interpersonal psychotherapy (as discussed earlier in the chapter), the case of Caleb underscores the importance of an individual’s social context in the maintenance and amelioration of depressive symptomatology. The human organism is constantly adapting in an interchange with differential aspects of the social environment. Both the individual and the social environment react to each other and change within a transactional matrix (Gitterman & Germain, 2008). The person and the environment can be understood only in terms of their relationship, in which each continually influences the other within a particular context. From an interpersonal perspective, Caleb was assessed not only in terms of his presenting symptoms of depression and family trauma, but also within the context of a social and family environment that produced toxic transitions resulting in dysfunctional interpersonal processes, low self-esteem, an impaired sense of mastery and competence, and the presence of a mood condition. His coping strategies at the point of initial evaluation were ineffective, while his need for interpersonal connections with an adaptive social network was great. Gitterman (2009) has noted that throughout the life course people attempt to maintain a harmonious fit with their surrounding environments. This harmonious fit is usually achieved through a sense of selfefficacy—or when the human organism feels positive and hopeful about his or her capacity to survive and thrive within multiple social contexts—and the environment’s responsiveness to human need via provision of life-sustaining resources. Conversely, this noted harmonious fit might be seriously compromised when the individual lacks adaptive coping capacities or when such capacities have been placed at risk by psychosocial stress and toxic environmental conditions. Gitterman and Germain (2008) have conceptualized stress as a psychosocial state spawned by inconsistencies between the human organism’s needs and capacities and environmental

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qualities. As a psychosocial condition, stress is the by-product of complex transactions between person and environment. All individuals will encounter stress or experience life stressors over the life course. Life stressors are bred by complex and precarious life issues that human organisms perceive as greater than their coping capacities and environmental resources (Gitterman & Germain, 2008). Stress or life stressors will arise or become manifested in the following three interrelated areas of living: life transitions and traumatic life events, environmental pressures, and dysfunctional interpersonal processes. While Caleb presented with dysfunctional interpersonal processes, his history appeared to also indicate that he had experienced environmental pressures and traumatic life events, and he was now coping with entrance into young adulthood and college life—both of which are developmental phases that pose opportunity and risk. Given that adaptive connection to others is vital for optimal mental health functioning (Goldstein, 2001; Weissman, 2006), interpersonal therapy (IPT) was the treatment of choice for Caleb. Through the therapeutic mechanisms of change of IPT (Robertson & Stuart, 2003) Caleb was helped to improve his patterns of interpersonal communication, bolster his sense of self-esteem, and connect to reciprocal, adaptive interpersonal encounters that would facilitate psychosocial restoration, self-confidence, and a positive outlook on life. All of these domains are vital in decreasing symptoms of depression and promoting emotional well-being. The overarching goal of the intervention—based on the central tenets of IPT— was to guide Caleb into a more effective means of self-expression. His patterns of interpersonal communication and behavior were closely examined, given that these represent significant areas of functional impairment among individuals who suffer from depressive conditions. In addition, Caleb’s ambivalence, wishing to remain alone while longing for connection to others, was explored within the context of his presenting problem and symptoms of depression.

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conclusion This chapter has summarized the definition, diagnostic criteria, demographic variables, theories, risk and protective factors, assessment, and treatment implications associated with depression. A person and environment perspective was applied to the chapter to ensure that the material presented would allow for holistic appraisal of individuals (including children and adolescents) who are diagnosed with a depressive condition. Because the social environment is vital in both sustaining and negatively impacting mental health outcomes in individuals and families who are affected by a diagnosed mood disorder, the chapter has highlighted specific programmatic social work responses to the treatment of depression. Although depression is a major mental health condition that produces extensive biopsychosocial impairment, effective interventions are currently available at every level of care (e.g. outpatient services, partial hospitalization,

inpatient, day hospital). Antidepressant medication, interpersonal psychotherapy, and cognitive behavioral therapy were discussed as empirically supported therapies with proven positive treatment outcomes. While depressive conditions are quite treatable, in contrast other types of psychiatric conditions such as mood disorders are often misunderstood by both the public and many health care professionals (Smith 2011). This misunderstanding often contributes to a delay in accessing timely and appropriate interventions. A delay in timely and appropriate interventions compromises effective outcomes and may exacerbate the risk factors that were discussed in this chapter, including suicide. As a major provider of public and private mental health services, the social work profession must continue to assume a vital role in the prevention and treatment of depression and in addressing the social conditions that negatively impact the emotional wellbeing of vulnerable populations.

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age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication (NCSR). Archives of General Psychiatry, 62(6), 593–602. Kessler, R. C., Chiu, W. T., Demler, O., & Walters, E. E. (2005). Prevalence, severity, and comorbidity of twelve-month DSM-IV disorders in the National Comorbidity Survey Replication (NCS-R). Archives of General Psychiatry, 62(6), 617–27. Kessler, R.  C., McGonagle, K.  A., Swartz, M., Blazer, D. G., & Nelson, C. B. (1993). Sex and depression in the National Comorbidity Survey: Lifetime prevalence, chronicity, and recurrence. Journal of Affective Disorders, 29, 85–96. Kessler, R.  C., Price, R.  H., & Wortman, C.  B. (1985). Social factors in psychopathology: Stress, social support, and coping processes. Annual Review of Psychology, 36, 531–72. Klerman, G. L., Weissman, M. M., Rounsaville, B. J., & Chevron, M. S. (1984). Interpersonal Psychotherapy of Depression. New York: Basic Books. Lam, D., Wong, G., & Sham, P. (2001). Prodromes, coping strategies and course of illness in bipolar affective disorder: A naturalistic study. Psychological Medicine, 31, 1397–1402. Lazarus, R. S. & Folkman, S. (1984). Stress, coping and appraisal. New York: Springer. Levitan, R. D., Parikh, S. V., Lesage, A. D., Hegadoren, K. M., Adams, M., Kennedy, S. H., & Goering, P.N. (1998). Major depression in individuals with a history of childhood physical or sexual abuse: Relationship to neurovegetative features, mania, and gender. American Journal of Psychiatry, 155, 1746–52. Levitt, M.  J., Guacci-Franco, N., & Levitt, J.  L. (1993). Convoys of social support in childhood and early adolescence: Structure and function. Developmental Psychology, 29(5), 811–18. Li, X., Ketter, T. A., & Frye, M. A. (2002). Synaptic, intracellular, and neuroprotective mechanisms of anticonvulsants: Are they relevant for the treatment and course of bipolar disorders? Journal of Affective Disorders, 69(1–3), 1–14. Liem, J.  H., James, J.  B. O’Toole, J.  G., & Boudewyn, A. C. (1997). Assessing resilience in adults with histories of childhood sexual abuse. American Journal of Orthopsychiatry, 67, 594–606. Lizardi, H., Klein, D.  N., Ouimette, P.  C., Riso, L.  P., Anderson, R. L., & Donaldson, S. K. (1995). Reports of the childhood home environment in early-onset dysthymia and episodic major depression. Journal of Abnormal Psychology, 104, 132–39. MacArthur Foundation (2011). Initiative on depression and primary care. Chicago: Author. Mathews, A., & MacLeod, C. (2005). Cognitive vulnerability to emotional disorder. Annual Review of Clinical Psychology, 1, 167–95. McLeod, J.  D., & Kessler, R.  C. (1990). Socioeconomic status differences in vulnerability to undesirable life events. Journal of Health and Social Behavior, 31,162–72.

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cHaPter 7 eating Problems f. d i a n e b a r t H

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er worried parents brought a 20-year-old woman to a clinic for help. Excruciatingly thin, she had an engaging smile and a friendly personality, and the body of a prepubescent child. She acknowledged that she exercised a great deal, running six to seven miles a day and setting her alarm to wake up in the middle of the night so that she could work out, because, as she said, “I don’t want to gain weight while I’m sleeping.” However, she denied that she restricted her food intake, saying that she wasn’t hungry for breakfast but ate “a huge lunch and dinner every day.” A detailed inquiry revealed that those meals were salads that consisted of lettuce, tomatoes, and baby spinach and nothing else and that her only other calories came from a single power bar consumed daily at 4 PM. She drank large quantities of diet soda and coffee with artificial sweetener. She had no fat anywhere on her body, but she said that she would stop dieting as soon as she “stopped jiggling.” According to her, she had “jiggly thighs and upper arms” that she was determined to turn into solid muscle. She had not had a menstrual cycle since she was 12. Her diagnosis was anorexia nervosa. Because physical as well as psychological factors can contribute to an eating disorder, and because of the potential physical damage to the body from the symptoms, clients presenting with any eating, weight, and diet issues should have a complete examination by a physician as part of the initial workup. The medical exam on this young woman showed signs of possible damage to her heart, liver, and kidneys, as well as osteoporosis, or thinning of her bones. She

denied any physical discomfort, but the doctor also found that she was suffering from edema, or swelling, of her ankles, which was possibly associated with heart disease. Her medical condition was so precarious that she was hospitalized until she could be stabilized. What led her to engage in such a dangerous diet and exercise regimen? Did she hate herself? Was she trying to commit suicide? What else might have been going on? In other words, what makes someone vulnerable to developing an eating disorder? What factors protect other people from these symptoms? And what are the best ways to help them recover? Problematic eating like anorexia nervosa, bulimia nervosa, and binge eating is extremely complex and often the result of a combination of biological, psychological, social, and environmental determinants. At times these behaviors can be transient and need no intervention, such as when a toddler going through an individuation phase refuses all foods except those colored white or orange or when an otherwise healthy teen worries about and tries to control her changing body. When unhealthy, self-destructive behaviors continue for a period of time, they generally require professional assistance. In some cases, individuals do not recognize that they need help and are brought in by concerned family or friends. Even those who reach out to a clinician may not reveal the extent of their eating and related difficulties until they have developed some trust for a counselor, often months or sometimes even years into therapy. Sometimes there is an obvious condition, for example when an anorexic 141

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is starving or a binge eater has become obese, but at other times there may be no physical evidence of an eating disorder. Weight and diet-related struggles can signal the presence of other areas of difficulty, including physical illness, cognitive processing, and a variety of psychological issues, including obsessive-compulsive disorders, body dysmorphic disorder (i.e., obsessive focus on a part of the body that seems flawed to the individual but not to anyone else), anxiety, depression, personality disorders, and some forms of schizophrenia. For example, anorexia is not uncommon in the elderly and can be reflective of depression, loneliness, a lack of physical mobility or ability to care for oneself, and/or physical illness not yet diagnosed. Sometimes, when underlying problems are dealt with, eating issues resolve on their own. At other times, nutritional and behavioral intervention is required along with supportive and/or insight-oriented work. Some individuals recover quickly, while others may struggle with the symptoms and the related psychodynamic issues for a very long time, even when they are working hard to change. A full psycho-social-medical assessment of anyone who presents with eating issues can help alert a clinician to psychodynamic, family, work, and other current and long-term life stressors, as well as physical difficulties such as diabetes, thyroid or celiac disease, infections, and cancer. A clinician’s empathic interest in the details of a client’s symptoms can be key to discovering significant information. For example, a young woman was referred to her college counseling department for difficulty concentrating, inability to get out of bed, and a sense of hopelessness and helplessness. She was diagnosed with depression and referred for medication and group therapy. The counselor also saw her for several individual sessions. As a trusting therapeutic relationship developed, the student revealed that she had always disliked her body and had a long history of food binges. She had gained a great deal of weight during her

freshman year, which she believed contributed to her depression. She also had a history of cutting herself on her arms and legs. She was not trying to kill herself, but the cutting gave her some relief from her painful feelings. She had been too ashamed to tell anyone before, but she believed that the counselor understood and cared about her. “I’m ready to try to work on this,” she said. Eating disorders often go along with other self-harming or potentially self-destructive activities like cutting, excessive tattooing, unsafe sexual encounters, kleptomania (compulsive stealing), and excessive shopping, drug, and alcohol use. Research has found that these behaviors are often related to difficulties in affect (or feeling) regulation and impulse control (Christenson et al., 1994; Connors, 2006, 2011; Fairburn, 1995; Krueger, 1997; Schore, 2003). Numerous authors suggest that rigid dieting, binge eating, purging, and over-exercise are all attempts to regulate the self (e.g., Albers, 2009; Bromberg, 2001; Connors, 2006, 2011; Fairburn, 1995; Schore, 2003). Despite their potential destructiveness, these behaviors are frequently attempts to adapt to otherwise untenable or unmanageable situations, experiences, and feelings. When faced with these behaviors, it is important for a clinician to remember that food is about much more than nutrition, in that it has psychological, familial, social, and cultural meaning. The behaviors, which help cope with pressures and feelings coming from all of these sources, can therefore be very difficult to “give up” until other coping methods are in place. As one client put it, “bingeing and purging saves my life and my sanity.” Change may therefore occur very slowly. While learning other techniques for soothing herself (taking warm baths, listening to music, reading, watching television, calling a friend), another client said, “when I’m really upset, nothing stops the feelings as well as bingeing and throwing up.” A relationship with a professional who listens without making judgment and responds with both understanding and techniques for

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managing feelings can be an opportunity to develop new ways of self-regulation. Neuroscientists hypothesize that talking to another person can change brain chemistry (Schore, 2003; Siegel, 1999). Yet, although naming feelings and talking about them is a crucial tool in the process of healing, many clients also need more direct, concrete interventions. Symptomfocused dynamic psychotherapy (Connors, 2006, 2011) and relationally and psychodynamically oriented behavioral therapy (Wachtel, 1997) are among a growing number of approaches that integrate psychodynamic and behaviorally based techniques. defining and explaining eating disorders The symptoms of eating disorders are complex and varied. They often coexist with other diagnostic categories, including mood and affect disorders, impulse control disorders, body dysmorphic and other somatoform disorders, adjustment disorders, and even psychoses. They are usually multi-determined, dependent on a variety of psychological, biological, social, and environmental factors. In a world that idealizes both thinness and athleticism, it is not surprising that so many people focus not only on changing and controlling their bodies, but also on increasing their self-esteem, through diet and exercise. The three major categories of eating disorder are anorexia nervosa, bulimia nervosa, and binge eating disorder. Anorexia nervosa and bulimia nervosa are defined in the Diagnostic and Statistical Manual of the American Psychiatric Association, 4th edition (DSM-IV; American Psychiatric Association, 1994). While binge eating disorder was not given formal diagnostic status in the DSM-IV, it is recognized by many professionals and has been included in DSM-5. Anorexia nervosa is characterized by a combination of refusal to maintain a healthy body weight that is at or above the lowest possible normal weight for an individual’s age and height; intense fear of gaining weight or becoming fat, even when objectively underweight;

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disturbed body image and a self-evaluation that focuses on body weight, shape, and size; denial of the seriousness/and or extremity of current low body weight,” and in females who have reached menarche, the absence of at least three consecutive menstrual cycles and/or the inability to have a period without the administration of hormones such as estrogen (American Psychiatric Association, 1994, pp. 251–52). Some people with anorexia lose weight by dieting and exercising excessively; others lose weight by self-induced vomiting, or misusing laxatives, diuretics, or enema. Eating, food, and weight control become obsessions. A person with anorexia typically weighs herself or himself repeatedly, carefully portions food, and eats only very small quantities of certain foods. Some who have anorexia recover with treatment after only one episode. Others get well but have relapses. Still others have a more chronic form of anorexia, in which their health deteriorates over many years as they battle the illness. Studies have suggested that anorexia nervosa has the highest death rate of any mental illness (National Association of Anorexia Nervosa and Associated Disorders [ANAD], 2012a). Some, but not all, of these deaths are purposeful suicides. Low body fat can lead to heart, kidney and liver, and bone difficulties. Bulimia nervosa is characterized by recurrent episodes of binge eating, which involves eating, in a discrete period of time (such as within a two-hour period), an amount of food that is comparatively larger than most people would eat during a similar time frame. It is also characterized by a feeling of not being able to control the eating during the episode, that is, not being able to stop eating or take charge of how much or what one is consuming. Bulimia also includes “recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, enemas, or other medications; fasting; or excessive exercise” (American Psychiatric Association, 1994, p. 253). The DSM-IV defines two types of bulimia nervosa: “purging

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type,” in which an individual regularly selfinduces vomiting or uses laxatives, diuretics, or enemas excessively and/or inappropriately, and “nonpurging type,” in which an individual uses other inappropriate compensatory behaviors, such as severe restriction or over-exercise, after a binge. Individuals with bulimia often fall within a normal weight range for their age and height. The behavior is frequently carried out in secret and is accompanied by feelings of shame. As with anorexia, self-evaluation of individuals with bulimia is overly dependent on physical factors such as body shape and weight. Both groups often also “have co-existing psychological illnesses, such as depression, anxiety and/ or substance abuse problems.” (ANAD, 2012c) Bulimia nervosa can cause esophageal and stomach irritation, electrolyte imbalances, and serious and expensive dental damage. Binge eating disorder, which is a new diagnosis in the DSM-5 (American Psychiatric Association, 2012) is characterized by recurrent episodes of binge eating, that is taking in an abnormally large quantity of food in a discrete period of time and a feeling of not having control over eating during the episode. This sense of lack of control is an extremely important part of a binge eating disorder diagnosis. It is not simple “overeating,” but eating that is out of control. Symptoms of binge eating disorder include rapid eating, eating to a point of severe discomfort, eating large amounts of food when not hungry, eating alone or in secret because of shame about the quantities one consumes, and feelings of guilt and disgust about the eating behavior (American Psychiatric Association, 2012). The behaviors can occur any time of the day or night and are often ways of dealing with stress. Unlike bulimia nervosa, there is no compensatory behavior to eliminate the possible weight gain caused by a binge. Binge eating disorder is more common than either anorexia nervosa or bulimia nervosa. About 5 million women and 3 million men in the United States suffer from binge eating disorder.

It is also believed to be equally common in African American, Caucasian American and Hispanic American cultures (ANAD, 2012b). Despite the significant behavioral dissimilarities, the disorders also have a number of psychodynamic aspects in common. Individuals who begin with one disorder may over time switch to another. According to Tozzi et al. (2005) up to 62 percent of individuals with anorexia develop bulimia. Many also become binge eaters. People with binge eating disorder often speak of wishing they could be bulimic or anorexic, but complain that they are unable to vomit or restrict. Former anorexics who successfully gained and maintained a healthy weight have often revealed, years after they stopped restricting, that part of the reason they forced themselves to eat so little was because of their secret wish to binge. The behaviors often begin with a desire to control weight and improve body image. Perfectionism, self-criticism, shame, and mood dysregulation are features of many eating conditions. Obsessive concern with flaws that seem minor or invisible to others is often present in individuals with these disorders. These symptoms may be indicators of body dysmorphic disorder (BDD), in which concern about these so-called flaws can interfere with an individual’s social, school, and work life. Body dysmorphia is a disorder that the DSM-IVTR (American Psychiatric Association, 2000) categorizes as one of a group of somatoform disorders, which are generally characterized by complaints about medical or physical conditions that have no ascertainable physical or psychological cause. BDD has been linked with obsessive-compulsive disorder (Bjornsson, Didie, & Phillips, 2010) and needs to be treated with medications and cognitive behavioral tools. Given the cultural pressure on both men and women to achieve some sort of physical “perfection,” however, obsession with perceived bodily flaws is often a “normal” and transient symptom of adolescence. It can also be a symptom of an eating disorder without signaling

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the presence of BDD. In such cases, the focus on a specific bodily imperfection improves as the other symptoms begin to diminish. Studies have shown that disordered eating is frequently related to both unregulated or unmanageable affects and a concomitant inability to control impulses, and that there are often links to other impulse control disorders such as compulsive shopping, kleptomania, self-mutilation, drug and alcohol abuse, and harmful sexual activities (Christenson et al., 1994; Connors, 2006, 2011; Fairburn, 1995; Schore, 2003). There is some suggestion in the literature that these clients suffer from attachment disorders, which makes sense given the current literature linking attachment disorders with disorders of affect regulation (e.g., Connors, 2006, 2011; Fonagy, 2002; Schore, 2003; Siegel, 1999). Viewing these conditions as adaptive as well as maladaptive leads a clinician to look not only for problems in a client’s life that led to the development of psychological and emotional difficulties in adulthood, but also for the positive experiences that may have contributed to an individual’s resilience throughout his or her life. Feelings of shame and a tendency to self-isolate in order to hide the behaviors can lead to a loss of social support. Recognizing that the behaviors are adaptive can help alleviate some of the shame. demographic Patterns At one time eating disorders appeared to affect mainly upper-middle-class Caucasian women, especially those in their late teens and early twenties. However, while adolescent girls are still more vulnerable than adolescent boys (National Institute of Mental Health, 2012a), there is growing evidence that the symptoms of all three of the major categories can be found in girls and women of a wide range of ethnic, cultural, and socioeconomic backgrounds, and that an increasing number of males are also struggling with these issues (ANAD, 2012a; National Institute of Mental Health, 2012a; Martin & Baugh, 2009; Steiner-Adair, 1986; Striegel-Moore & Smolak, 2000). The range of

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nationalities of individuals suffering from problematic eating behaviors has also expanded. For instance, in the 1980s clinicians working with college students with eating disorders who wanted to spend a semester or a year abroad had difficulty finding colleagues outside of the United States who were familiar with enough with the problems to counsel these clients while they were away. Today, students traveling to ever more countries as part of their college experience are easily referred to clinicians who are knowledgeable about these dynamics. In 2012, for example, alarmed by deaths of several overly thin fashion models, Israel joined Italy and India in banning women under a specified weight from appearing in fashion shows (Reuters, 2012). In cultures where food is relatively plentiful, eating disorders have become almost universal, although adolescents, the elderly, and women are most vulnerable (ANAD 2012b; National Institute of Mental Health, 2012b). Societal context While not everyone in contemporary “first world” cultures suffers from a diagnosable eating disorder, it would not seem to be a great leap to suggest that many contemporary societies are breeding grounds for problematic eating behaviors. Cultural emphasis on thinness, athleticism, and perfection offers a perfect environment for the development of eating problems. International media, the fashion industry, and much advertising present images of thin, even emaciated women (and recently, more and more men) as the model of attractiveness. The medical profession, school and public officials, friends, and family communicate that slenderness is a sign of both physical health and psychological well-being and leads to happiness and success, whereas a heavier body represents poor health, unhappiness, and the potential for failure. Even in cultures in which a larger body size is appreciated, self-esteem and selfvalue may depend on physical appearance. Airbrushed and enhanced pictures in advertising,

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film, and magazines offer unrealistic images of men and women. Some $10.1 billion were spent on cosmetic plastic surgery procedures in the United States in 2010, and the number of people utilizing Botox, liposuction, fat injections, and other forms of cosmetic surgery all over the world has been climbing every year (American Society of Plastic Surgeons, 2011). Eating issues are common in high schools and colleges, with their high levels of competition and peer pressure. For many years research on eating disorders with female college students in the United States has focused mainly on Caucasian women (Mulholland & Mintz, 2001), but current findings show that all ethnic groups struggle with a variety of eating disorders (Martin & Baugh, 2009). Recent data has shown that while young women are still at higher risk than young men for developing anorexia nervosa and bulimia nervosa, young males are increasingly at risk for binge eating (Mayo Clinic, 2012). Distorted body image, dissatisfaction with their bodies, and a desire to be lean, muscular, and “fit” can lead to eating issues in both males and females. Male athletes in sports in which weight is carefully monitored—e.g., lightweight crew, jockeys, and wrestlers—often regularly purge, restrict, and use diuretics prior to competition in order to qualify for a lower weight group. Male body builders, gymnasium users, and ballet dancers are also highly vulnerable to display problematic eating behaviors, although they do not always meet all of the criteria for a diagnosis (Byrne & McClean, 2001; Ravaldi et al., 2003). In the United States, where thinness is overvalued and obesity considered one of the largest health risks to the population, the diet industry brings in $40 billion per year (Reisner 2008), yet 2.8 percent of the adult population of the United States suffers from binge eating disorder (National Institute of Mental Health, 2012b). Not only does dieting not solve the problem, since “most dieters regain about one third of the weight lost during the next year and are

typically back to baseline in three to five years,” (Wing et al., 2006, p. 1564), but the constant focus on weight and the value placed on selfdeprivation may actually promote eating issues, because restricting food intake can actually contribute to binge eating (Albers, 2009; Eating Disorders Review, 2009; Fairburn, 1995; Mayo Clinic, 2012). Parents, educators, and medical professionals, wanting children to be healthy, may actually be promoting eating problems. Vulnerabilities and risk factors It is not uncommon to assume that eating disorders result from childhood trauma or neglect. However, many people with these conditions have no history of significant trauma, and others with serious childhood neglect do not develop eating issues. What makes one person vulnerable to these difficulties and another not? Because of the complexity of eating disorders, there is no simple explanation for why they develop. One universal risk factor, however, appears to be a cultural overvaluing of thinness, in which an individual’s body shape and size come to represent his or her personal value. The presence of family members with difficulties with food and/or some of the other common accompanying issues, such as drug and/or alcohol abuse or addiction; shopping compulsions, sexual issues, gambling, pornography; problems with impulse control (including difficulty managing one’s temper); and/or depression and/or anxiety disorders (Corcoran & Walsh, 2010; Tozzi et al., 2005) can also be a risk factor. Children who grow up in families with these tendencies may learn to use food and other substances to help manage their feelings (Connors, 2006; Fonagy & Target, 1997; Schore, 2003; Siegel, 1999). However, a growing body of research indicates that, like depression and other mood disorders, the predisposition to develop an eating disorder may also be biological, or genetic (DeAngelis, 2002). Other potential vulnerabilities include poor social skills, lack of general coping mechanisms, and low self-esteem (Corcoran & Walsh, 2010).

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Young children and adolescents, who are particularly vulnerable to messages from the media, advertising, and social networks, and who long to “fit in” with peers, are highly susceptible (Steiner-Adair, 1986). College and other times of separation are common triggers (Barth, 1989, 2003; Connors, 2006; McKinley Health Center, 2012; Stortelder & Ploegmakers-Burg, 2010). Individuals who suffer from alexithymia, or an inability to use thoughts or words to process emotions, are also vulnerable (Barth, 1998, 2008; Krueger, 1997; Krystal, 1988; McDougall, 1989; Schore, 2003). McClintock Greenberg (2009) notes that alexithymia involves “difficulties identifying and describing feelings, differentiating between emotional and physical sensations, and exhibiting a concrete and externally oriented cognitive style” (p. 136). Connors (2006) has found that a lack of sense of agency, or a sense that one cannot have an impact on one’s world, is also a contributing factor. Throughout history, food has been part of celebratory and mourning rituals. Individuals at risk for developing issues around eating are often vulnerable because they have learned to use food as a primary method for managing strong feelings. A young woman who had been anorexic explained that she felt strong and safe when she starved herself. A man said that when things got “rough” at work, he calmed himself down by eating a couple of candy bars from a stash he kept in his desk drawer. The problem was that often once he started, he could not stop. Poor or traumatic attachment experiences may cause eating conditions, but rather than focus on specific attachment styles or assumptions about history, when a client reveals an eating disorder it is more helpful to think about the specifics of an individual’s current attachment behavior or “attachment state of mind” (Dozier, Stoval-McClough, & Albus, 2008). Safran and Muran (2000) concur that it is more useful to focus on a client’s characteristic style of attachment as it unfolds in the present than to make definitive historical statements based

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on that attachment style. In their research on suicide in adolescent girls, for example, Gilligan and Machoian (2002) found that girls are simultaneously at their most optimistic and most vulnerable when, in their thirteenth and fourteenth years, they begin searching for relationships. This is the time when many eating disorders begin to develop. It is also, according to the authors, a time during which girls are at the highest risk of suicidal behavior. The authors suggest that these girls often find themselves in a catch-22: Threats of suicide can obviously be maladaptive, for example, when people begin to respond with irritation at repeated threats, and of course when a suicide attempt is successful. But paradoxically, they can also be adaptive, such as when the behaviors act as a wakeup call for attachment figures. The same can be said for problems in the arena of weight and eating. The behaviors are both an attempt to self-regulate and a request for help. When the request is heard and responded to, the behaviors have served an important purpose. As Gerber (2006) writes, it can be difficult to distinguish adaptive behaviors from pathological ones in adolescents. Neuroscience has established that the brain does not finish maturing, particularly in the area of judgment and decision making, until the age of 21 (Stortelder & Ploegmakers-Burg, 2010), yet many cultures, like that of the United States, place tremendous value on independence and put pressure on young people and their parents to separate before this developmental process has been completed. This combination of factors can leave adolescents alone to manage difficult social situations for which they have neither adequate internal resources nor adequate support from adults. At an age when they search for acceptance among peers who are often neither generous nor kind, youngsters can emerge from this time with a sense of inadequacy and inferiority. The more resilient manage to find other ways to build self-esteem and a sense of agency. Paradoxically, an eating disorder can be one of these ways.

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resiliencies and Protective factors Since the early resilience research in the early 1980s, a number of studies have shown “that the achievement of signifiers of psychosocial success, in spite of significant adversity, is an ordinary rather than a remarkable outcome.” (McMurray, Connolly, Preston-Shoot, & Wigley 2008, p. 300) Resilience, or the capacity to “spring back” in the face of “significant challenges to adaptation or development” (Masten & Coatsworth, 1998, p. 208) is believed to be influenced by a number of biological, psychological, and/or environmental processes. “In essence, the phenomenon of resilience is a reflection of the relationship between personal characteristics and factors in the environment that result in one’s (i.e., individual or group) ability to meet the stress and adversity with coping and adaptation” (Ahern, 2006, p. 176). Because symptoms of eating disorders can be obviously harmful and self-destructive, it is understandable that family, friends, and professionals look for the negative aspects of personal and family life. Yet in many instances, these symptoms can actually be part of an adaptive process and, therefore, represent both the vulnerability and the resilience of the individuals struggling with them. Contemporary western culture, social structure, and beliefs provide a fertile breeding ground for the development of eating disorders. Families and educators who do not buy into widely accepted expectations that link physical and emotional health to slender, athletic bodies can help youngsters stand against the pressures coming from outside. Such support can encourage children to develop an independent sense of self and can emphasize a wider set of values by which to judge themselves, something Steiner-Adair (1986) has called teaching a child to be “wise.” Feelings of self-esteem and a sense of competence are frequently linked to resilience (Masten & Coatsworth, 1998). While many individuals with eating disorders have difficulties with low self-esteem, years of clinical work have shown that many of those who are most resilient have a sense of competency

in some area—e.g., sports, social relationships, academic pursuits, and/or work skills. Many times these feelings of competence are not integrated into a whole sense of self, and clinical work involves helping clients overcome a sense that the competent self is a false one and integrate their strengths into a more complex and realistic self-view. It is hypothesized that a positive relationship with one or more adults in childhood (parent, grandparent, aunt or uncle, teacher, minister or rabbi, etc.) can be a protective factor in a child’s development. Often these important others are idealized and negative thoughts about them are split off or unprocessed because they feel disruptive or dangerous. Individuals who have learned to manage such disillusionment without feeling cut off from important caregivers appear to be more resilient and less vulnerable to the development of difficulties with eating, weight, diet, and body image (Basch, 1980). One trait that appears to be predictive of resilience is a capacity to tolerate contradictions. Like Gilligan and Machoian (2002), SteinerAdair (1986) suggests that there is an adaptive component of eating disorders that underscores the resilience of those who suffer from them. Paradoxically, eating disorders are often a sign of difficulty and, at the same time, of an individual’s potential resilience. Biological gifts, such as temperament, a sense of humor, and an ability to step back from a situation and look at it without taking it personally (which is also something that is learned) also promote resilience and protect individuals from developing eating disorders. And perhaps most of all, an ability to remain “wise” in the ways that Steiner-Adair (1986) formulates— that is, to separate oneself from the popular view of what one is supposed to be, to accept and value oneself for who one is, and to value what one has to offer—is most protective. Programs and Social Work contributions A wide variety of programs are available for individuals with eating problems, including

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outpatient psychotherapy and counseling, day programs (often called “partial hospitalization”), and inpatient or residential treatment. No single method has been found to be most effective. In many programs, social workers form part of a team with nutritionists, psychologists and psychiatrists, and nurse practitioners. Individual psychotherapy, family and group counseling, medical attention, and nutrition education are frequently offered in inpatient settings, day hospitals, and clinics, but even when clinicians are working in private practice, it can be useful to work with a psychiatrist and physician and possibly a family therapist, to address the many different facets of these symptoms. In some techniques, such as the Maudsley model (Duke University Health System 2004), in which parents are put in charge of their child’s eating, families are an active, even central part of the therapeutic work. The social work maxim to “start where the client is” is an important part of any therapeutic approach to eating disorders. Social workers are taught that one of the central questions of motivational interviewing, for example, “what does the client want,” has many different possible answers, and that a client’s first response is often not a complete one. What do eating behaviors tell us about what a client wants? Starving, exercising, bingeing, and purging have a variety of meanings, including a belief that a “perfect body” is the key to happiness. They also represent a wish to be in control, to manage her or his needs, to be loved, to manage distressing feelings, and more. The information does not appear at the beginning of any therapeutic encounter but emerges over time. According to Kohut and Goldberg (1984), a clinician’s interest in what is important to a client is the most important aspect of any therapeutic relationship and is a key to therapeutic change. Connors (2006) points out that an approach in which affect regulation, limit setting, symptom relief, and understanding are integrated can be the most effective. Research (National Institute of Mental Health, 2011) has

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shown that combining educational and nutritional guidance, psychotherapy to understand the causes of the behavior, mindfulness techniques, and cognitive behavioral approaches can be most effective. Social workers are particularly well positioned to work with this multifaceted approach. Medication for depression and/or anxiety can be effective in conjunction with these other techniques, although assessment of compliance and physical condition is important. Starving anorexics, for example, cannot physically utilize antidepressants. While inpatient hospitalization is sometimes necessary when a client is in physical danger, there is some controversy about its long-term effectiveness (Wiseman, Sunday, Klapper, Harris, & Halmi, 2001). A team-based model is particularly valuable for this population, who often require a combination of individual, group, and family counseling; medication and medical supervision; and nutritional and educational guidance. A client’s tendency to use splitting as a defense (e.g., seeing one person as “all good” and another as “all bad”) can be disruptive to the work. Frequent contact with one another and discussion of dynamics can help a team manage disruptive behaviors and model a more integrated view of self and others for a client. assessment and interventions What does a clinician need to think about when a client presents for help with an eating disorder? Given that these disorders can run through a number of other diagnostic categories, a full mental status and social and medical history are of paramount importance. Information about eating issues must be understood from within a broader picture of how an individual has functioned throughout her or his life as well as how he or she is functioning at the present time. Some of this material can be elicited in the first few sessions, and may come not directly from a client but from family members, friends, and other professionals. When taking such information, it is important to be aware that clients in

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the throes of a severe eating disorder are often not very accurate self-reporters. Current medical status is a primary concern, because physical issues can both cause and result from these conditions. Therefore, any client presenting for help with eating problems needs to be referred for a full medical workup. It is, of course, helpful if the medical evaluation can be done by a physician or nurse practitioner who is familiar with eating disorders. With more than 400 different types of therapy available, it may seem hard to decide what approach to take with a client. At this point in time, no specific type of therapy is considered best for individuals with eating disorders, although a mix of cognitive behavioral and psychodynamic approaches; individual, group, and family work; nutritional education; and medication where appropriate are probably used most often. Assessment of a client’s needs, the severity of the symptoms, and the client’s psychosocial and biological strengths and vulnerabilities, as well as of the support system available to him or her, helps a clinician decide where to begin the work. Although some clients have experience with therapy and others have none, it is also important to assess the current level of psychological functioning as well as apparent insight. Clients with these difficulties can sometimes be extremely articulate and insightful without being able to use that self-knowledge to help themselves (Barth, 1998, 2003). It is important for a clinician to begin to think about both psychodynamics and practical needs from the beginning. Collaboration with other professionals, including medical, dental, educational, psychiatric, and nutritional, helps to work with the whole person, rather than just focus on the eating symptoms. Starving anorexics are a special case, in that their physical state makes it almost impossible for them to make use of “talk” therapy or insight. In these cases medical and nutritional concerns are a clinician’s primary concern. The severity of a client’s physical condition

can require hospitalization, but Gowers et al. (2010) suggest that outpatient care supported by brief inpatient stays when medically necessary is more effective over the long term than inpatient for anorexic clients. Once the questions of physical and emotional stability have been addressed, and it is determined that a client is stable enough to engage in outpatient work, an ongoing assessment of his or her support system is also crucial. Who provides support for a client? Is it a family member, friends, someone at school or at work? Sometimes clients have difficulty managing activities of daily life such as regular bathing, sleep, and meals but are highly functional at work. A detailed inquiry into the small and apparently insignificant day-to-day routines of an individual’s life provides important information. For example, some articulate, charming, and apparently high functioning individuals reveal, on being asked about their daily activities, that they are isolated and unable to do much other than eat and watch television. Others do well when a boyfriend, spouse, parent, or child is present, but when they are alone, they often engage in unhealthy eating behaviors. Both those who self-isolate and those who have difficulties when they are alone may have problems with separation and with object constancy— for example, they may have difficulties holding onto a positive image of others when they are not present. Clients with eating issues may lose friends because they are hiding their symptoms, ashamed of the amount they eat or afraid to be tempted by foods outside of their usual restricted range. Alternatively, other individuals drink heavily to manage social anxiety and suppress their appetite, although alcohol and drugs can also disinhibit their eating restrictions as well. All of these issues need to be unpacked and discussed over time. Sometimes simply having put them into words to a counselor may be enough to initiate change. Sometimes other interventions, including teaching tools for selfsoothing and long-term psychotherapy with a focus on separation issues, are most helpful.

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While some clinicians do not like to engage a client’s family in the work, feeling that it is better to protect a client from the dynamics that may have created the problems, it is useful for a clinician to think about how and when a family might provide support for a client. Family work is often extremely useful. Engaging with a client’s support system instead of rejecting it can send a number of important messages. An accepting and empathic attitude toward family members can shift problematic interactions, which may lead to a decrease in the behaviors and begin to change some of the underlying dynamics. Sometimes family work is done by one clinician while individual work is done by another, but both professionals must maintain a balanced stance toward all family members, acknowledging both negative and positive aspects of a family’s dynamics. Similarly, one will want to request regular information about other aspects of a client’s life—friends, work, school, religious and other communities in which a client is involved and which offer sustenance and/or create conflict for a client. A clinician needs to think about the possibility that a client has difficulty integrating positive and negative feelings about others and about him- or herself. Numerous authors have described the ways in which a beloved or idealized parent or spouse will, over time, turn out to have feet of clay; but it is equally true, and less regularly recognized, that people who are viewed in a negative or hostile light often turn out to be extremely significant, positive influences (Barth, 2009; Basch, 1980). It is important to remember that clients with eating issues can be very articulate, bright, and insightful (Barth, 1998) and still have difficulty with reality testing and insight. A useful tool for a counselor to use to help clarify a client’s experience and to help a client link together feelings with thoughts and words is a variation of Sullivan’s “detailed inquiry,” (Barth, 1998, 2009), in which a clinician asks a client to talk about seemingly insignificant details of daily life, for example, what time he woke up that

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morning, how he prepared for work or school, what he ate for breakfast. It is not unusual, in such an inquiry, to discover, for example, that a client who has said she has no difficulty sleeping actually does not fall asleep until two or three o’clock in the morning, and regularly has troubles waking up and getting to work on time. Such details gradually lead clinician and client to a more integrated view of a client’s experience. Not only does it clarify that there are multiple behaviors tied to eating issues, but that these behaviors, which are all part of a client’s whole self-experience, also have psychological and emotional meaning. Given that so many clients develop eating disorders in adolescence, it is useful to think about issues related to this stage of development, even with clients who are not chronological adolescents. Since Erikson’s (1968) groundbreaking work on adolescents and identity, adolescence has been recognized as an age of developing an identity separate from the family in which a child grows up. Peer relationships become crucial during this stage of development. However, searching for acceptance among peers who are often neither generous nor kind, youngsters can emerge from this phase with a sense of inadequacy and inferiority. The more resilient manage to find other ways to build self-esteem and a sense of agency (e.g., Steiner-Adair & Sjostrom, 2005). For some, an eating condition can seem to be a solution to many of the problems. Exploring the ways an eating disorder has made it possible for a client to function, in the past and in the present, is often far more productive than looking for historical problems. Focusing on the details of a client’s current experience—positive as well as negative—combined with developing tools for managing the small, almost insignificant-seeming feelings that are part of daily life, can be the most effective way to lead to a genuine understanding of the multiple meanings of the symptoms. Similarly, while clients often appear to be functioning well in the world despite the eating issues, it is useful to assess their object

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constancy, which often offers information about their ability to separate and remain connected at the same time (Lyons-Ruth, 1991). Mahler, Pine, and Bergman (1973) suggest that the development of “emotional object constancy” (as opposed to the cognitive awareness that an object still exists when it is not available to the child) “is a complex and multidetermined process” that includes “trust and confidence . . . the relief of need tension . . . and the cognitive acquisition of the symbolic inner representation” of the “unique love object: the mother.” They add that “numerous other factors are involved,” including innate endowment and maturation (Mahler, Pine, & Bergman, 1973, p. 110). Because failures in the development of object constancy are often associated with borderline personality, it is not uncommon for therapists to look for childhood traumatic antecedents for these problems. Unfortunately, again, this process can lead to parent blaming and a negative view of a client’s childhood that can in turn facilitate splitting and truncate the therapeutic process. Connors (2006, 2011) has found that people with eating issues frequently lack of sense of agency. Recognizing the adaptive qualities of the eating symptoms while also acknowledging the pain that “feeds” the behavior can provide a crucial first step in helping a client begin to feel a sense of agency. An assessment of the need for medication and also of a client’s ability to comply with the treatment (e.g., follow a daily routine, take pills prescribed, and follow any dietary restrictions related to the medications) is important, as some medications, particularly those that help with mood and affect management, have been found to be useful. Often interventions will need to be altered over time, as a client’s needs or abilities change. As individuals become more adept at managing and regulating their feelings, new emotions may appear. These new feelings may be distressing, but together client and social worker can assess whether they represent a regression or the emergence of something new and important, even though

frightening, because of the work that has been done. Sometimes even regressions, such as a disruption of self-regulation related to a counselor’s upcoming vacation or departure from a clinic, can be understood as an opportunity to work with old feelings in a new way. Acceptance and understanding, as well as new tools for self-regulating, lead to a different relationship with both the self and the important others in an individual’s life. Research has shown that simply talking to another person who is interested in the details of one’s life can lead to significant neuropsychological change (Schore, 2003; Siegel, 1999). As a client puts into words difficulties with parents, siblings, and other important loved ones, a counselor listens for the multiple components of these relationships, assessing whether it is most important to acknowledge the pain or to explore other aspects of what a client is talking about. Often acknowledgement of pain and unexpressed sadness, anger, and other feelings is the first task of a clinician, and can go on for some time before anything else can be discussed. But over time a social worker needs to listen for and begin to help a client integrate some of the positive aspects as well. Integration of split-off or dissociated images of others is closely tied to the development of an integrated self-image, which contributes to the ability to manage feelings, regulate the self, and maintain object constancy. Finding words for unarticulated feelings and knowledge about parents is an important step to self-awareness. Unpacking beliefs about what motivated their behavior is an important step in that process (Demos, 1993; Fonagy, 2005). Mirroring the damage done by parents, as experienced by a client, is important. As counseling progresses, the meanings of parental behavior need to be reviewed and reassessed from the perspective of a client’s developing and more complex self-understanding. Basch (1980) suggests that a therapist can aid the work by gradually and empathically offering alternative ways of understanding parental behavior, which might not be available from a child’s

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perspective. When a parent has been abusive or neglectful, social workers often offer such explanations to counter childhood beliefs that the child deserved the parent’s scorn or abuse. Yet given that many abused children also identify with their abusers (see, for example, Barth, 1989; Bloch, 1984; Schafer, 1994), they need to be helped as adults to understand and at times even empathize with some of the emotional underpinnings of certain behaviors even while condemning the behaviors themselves. It is not always easy for social workers to come to such a position. When faced with reports of maltreatment at the hands of parents, social workers naturally feel protective of clients, often identifying with them and becoming critical of and angry with their parents. Eventually, however, a social worker needs to find a way to recognize that behavior that is unacceptable may have at least some understandable underpinnings if one understands something about the parents’ makeup and/or needs. Such understanding on a social worker’s part often leads to a gradual opening up of a client’s ability to think about the multiple meanings of parental behavior and ultimately to understand themselves more fully. This process has a second, crucial function in the helping of clients with eating problems. Recognizing some of the complexity of the antecedents of the behaviors, including both (often) loving and hurtful behavior on the part of parents, can be part of the process of coming to grips with the idea that a client also has multiple parts to her- or himself. Furthermore, it makes it more understandable when a therapist suggests that the eating behaviors are not all bad, but that despite their negative consequences, they may be a sign of resilience and adaptability. For example, they may have served to help a client regulate emotions and thoughts that threatened to disrupt their sense of wholeness as a person. Viewing these symptoms (as well as frequently concomitant behaviors of self-harm, alcohol and drug use, sexual addiction, over-shopping, and so on) as serving an adaptive, albeit still problematic, function

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helps a client recognize that he or she is not “all bad” or “all disordered,” which gradually helps in what Lachmann and Stolorow (1980) describe as “the establishment of a cohesive, stable, and positively colored self representation.” (p. 222). In the process of developing a more integrated, cohesive sense of self and of others, a client both taps into and increases his or her personal resilience. illuStrAtion And diSCuSSion

Elyse, a petite, delicate-looking woman in her midtwenties, came to the social worker for help with her eating problems. She had been anorexic in middle school and had begun bingeing and purging in high school, but had been asymptomatic for several years and thought she was “cured.” She was both embarrassed and worried about the recurrence of the symptoms. A professional performance artist, she was engaging and articulate and quickly gave me a clear synopsis of the history of her symptoms. She had developed anorexia at the age of 12, because she was feeling “fat and sluggish.” At this time she had her first menstrual cycle. Her family took her to her pediatrician, who put her on a regimen to gain some weight. Elyse was not sure that the regimen would have worked without the accompanying threat from her parents that she would not be allowed to attend gymnastics camp that summer if she did not put on ten pounds. At camp that summer, Elyse learned to control her weight by throwing up her meals. Combined with the intense exercise regimen of the camp, this new “diet” helped her lose several pounds and became a daily habit throughout middle and high school. Elyse described her father as emotionally and physically abusive and her mother as neglectful and disorganized. Family meals were seldom served with any regularity. “My dad would have a temper tantrum and Mom would run into the bedroom and lock the door, just as she was starting to prepare dinner.” Elyse and her sister would either finish cooking what they could or, more often, would have a bowl of cereal or peanut butter and jelly sandwich

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for dinner. Elyse’s father was obese and, as time went on, the social worker and Elyse concluded that he had a binge eating disorder. Her mother was tiny and extremely proud of her body. She was a heavy smoker, and Elyse suspected that she used cigarettes to control her weight. Elyse’s older sister was also thin, but Elyse did not believe that she had an eating disorder. The social worker was curious to know how Elyse understood her sister’s escape from what appeared to be a family tendency, which suggested both biological and psychological underpinnings. Elyse was unable to answer this question, in part because she idealized her older sister and was unable and unwilling to consider any potential “flaws” in her personality. Elyse had overcome her symptoms with the help of a beloved dance teacher. After a particularly frustrating dance class, during which Elyse had been unable to perform some of the more difficult steps, Elyse was sitting in the dressing room unable to make herself change out of her exercise clothes. One of the other girls got the teacher, who took Elyse into her office. She told Elyse that she was a talented dancer, but that if she did not eat more healthily and keep some weight on her, she would never professionally get anywhere. She said dancers have to respect and nourish their bodies in order to get the best work from them. And then she wrote down exactly what Elyse needed to eat and when she needed to eat it every day. Elyse followed the diet but at first continued to throw up daily. Within a short time, however, the purging “seemed to go away by itself.” She was deeply disturbed by the return of the symptoms and could not understand what had caused their reappearance. At the social worker’s invitation, she began to describe the events in her life just before she began to binge and purge again. Elyse said she had gained a few extra pounds and decided to diet to take them off. The diet had quickly spun out of control and before she knew it she was eating huge amounts and throwing up. The social worker explained that this was a not uncommon pattern, but then added that although it was distressing, the social worker had found over the years that it was

also a sign that her body and her psyche were working to find a healthy solution to some things that were disturbing her. Not surprisingly, she looked doubtful. The social worker acknowledged that she could see that this did not make sense to her, and that she understood that it was hard to take in, given that the behavior was potentially physically dangerous and certainly problematic in terms of her social and professional activities. The social worker explained that there were two parts to her thinking. First, she believed that her initial urge to diet might have been motivated by something more than a feeling that she was gaining weight, and that their job would be to tease that out. The social worker continued that most eating disorders develop as an attempt to manage painful or confusing feelings, and as a way of adapting to something that we cannot quite figure out how to cope with or even to think about. Furthermore, it was often a sign of both physical and psychological health that she was not able to starve herself anymore. Her body had managed to override her mind’s wish to make it live without enough food by forcing her to binge. The social worker saw that as highly adaptive and, at the same time, highly problematic. Their job was to figure out what she was struggling with, find other ways to help her cope with the difficulties, try to help her undo bad habits, and take a realistic look at her eating, nutritional, and exercise needs. These ideas seemed to help Elyse settle into the work. Although the social worker knew she still had anxiety about her symptoms, on the one hand, and the possibility of gaining weight if she stopped bingeing and purging on the other, they were building a good working alliance that would, over time, help regulate some of the emotions she was currently using bingeing and purging to manage. The relationship was also important in helping her to find and begin to use some specific techniques for changing the behavior. The worker offered both concrete suggestions about how to eat, and also ideas about managing her feelings. For example, with the worker’s encouragement she began eating small snacks of

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foods she considered healthy and manageable, such as yogurt, almonds, and fruit—without bingeing or throwing up. She also began to notice when certain feelings—including both stress and pleasure—triggered a binge cycle. (Many clients call a cycle of bingeing and purging, a “binge,” so social workers must ask them to be specific about what they are referring to.) Several weeks into the work Elyse realized that just before she had decided she was fat and needed to lose weight, her boyfriend, Rich, had proposed to her. “I was thinking about wanting to look good in my wedding dress,” she said. She described her feelings about getting married as “euphoric! It’s what I’ve wanted forever!” Rich was a wonderful man, she said, adding that she did not know how she could have gotten so lucky. Not surprisingly, the fairy tale romance had some difficulties. Some days before Rich joined Elyse in her session he had gotten into an argument with her father. Although her description of the event was a little confusing, the social worker had the sense that some sort of physical threat was exchanged between the two men. When the social worker met with Elyse and Rich, Rich immediately began to inform the social worker that he was concerned that she was not taking Elyse’s symptoms seriously enough. “I want to marry this woman,” he said. “And I want her to be healthy.” The social worker told him that we all had the same goal and asked if he could explain why he thought she was not taking the symptoms seriously. He said that I was telling her that her behavior was adaptive. “This is not adaptive behavior,” he said adamantly. “This is sick behavior.” He added that he wanted me to know that Elyse’s family was toxic to her, and that she had to get away from them. “They’re making her sick.” The social worker had the feeling that Rich’s reactions probably represented some of Elyse’s own feelings. She may have had the thoughts herself, but have been afraid to voice them to the worker, or they may have been part of what Bollas (1989) calls “the unthought known” or what Bromberg (1998) and others think of as unformulated, unarticulated, and/or dissociated material. It was also a

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symptom of alexithymia (Barth, 2003; Krystal, 1988, McClintock Greenberg, 2009; McDougall, 1989), the inability to use language to help process emotions, which is frequently to be found in individuals with eating disorders even when they seem to be able to talk clearly and insightfully about feelings. Elyse had traditionally been the family diplomat, soothing hurt feelings and calming volatility while unable to access her own feelings or manage them with the use of language. Perhaps she was repeating this experience with Rich, and perhaps he was expressing some of her split-off anger, frustration, and resentment with both her family and with the social worker. Because eating disorder symptoms are often part of an individual and a family ecosystem (Gitterman & Germain, 2008), the social worker should attempt to help a client begin to think about her or his feelings within the context of that system. In this case, the social worker tried to work with both Elyse and Rich to help them begin to talk about their feelings and thoughts as part of an interactive experience. Elyse’s symptoms represented part of that system. Her family was also part of it, and whatever they stirred up in Rich was also part of the relational system he brought with him. Yet as a new part of the system, the social worker had to reflect her understanding that Rich’s concern had meaning. She said, “I know that the behavior is extremely troubling and can even be dangerous. I don’t particularly like calling it ‘sick,’ but I do understand that it seems like it is an illness that needs to be managed.” The social worker then went on to explain that she thought the hardest thing about eating disorders in general was that they contained so many opposites. Elyse seemed skeptical, so the worker explained that one has to deal with both the compulsive behavior and the psychological cause— which creates conflict, since it’s hard to get at the one without taking care of the other. The social worker understood that Rich was in a hurry to get Elyse “better,” but that she thought she would heal more completely if we could go a little more slowly. Because Rich also represented some of the issues Elyse struggled with in her family, the social worker asked him to tell me more about how her parents were

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“toxic.” While he shared his observations, Elyse of course felt the need to defend her parents. The social worker suggested that they might think of their reactions as two aspects of a larger picture, or as pieces of a puzzle. “If we start to put them together, we start to get a more complex, but maybe also a more realistic perspective.” Both Rich and Elyse had difficulty with this idea. Rich began to launch into a description of the negative family dynamics. Elyse stopped defending them and said that she thought he was right. She was sick and her family was sick and she needed to get away from them. The social worker’s reactions in that moment could have led the work into a difficult situation. She was feeling that Rich, himself, was toxic to Elyse, and the worker wanted to get her away from him. Instead, the worker reminded herself that Elyse and Rich had brought her into the center of the kinds of interactions that probably fed into the eating symptoms. She was probably feeling what Rich felt with Elyse’s family, although in this case it was directed toward Rich instead of the parents. The task at the moment was to try to help them process the tension between the opposites that neither of them could manage. Elyse was smart, articulate, and competent; yet in that moment, she felt helpless and incompetent. Both qualities were parts of her. Rather than reject her relationship with Rich, and thereby encourage her to split off part of herself, the social worker focused on helping her integrate and manage both these and other contradictory qualities in her person. Rich’s presence helped the social worker become far more aware of an underlying conflict between helplessness and competence that had been a major part of Elyse’s dynamics throughout her life. They worked not only on recognizing her desperate sense of inadequacy and her need to be nurtured, but also on her real capabilities and strengths. For Elyse, as for many clients with eating disorders, this paradox of being both needy and competent is both extremely difficult to integrate and also a trigger for eating symptoms. This and similar contradictions exist in this population no matter what their social class,

ethnicity/race, gender, sexual orientation, religious affiliation, developmental phase, and diagnostic categories. In fact, the difficulty in managing the clash of opposites is a central issue in the world today and perhaps one of the reasons that eating conditions are on the rise. The work with Elyse continued for several years, during which she became much more comfortable with the contradictory, often conflicting and paradoxical aspects of herself that had all been part of the development of her eating disorder. In time she realized that she had been experiencing Rich as though he were a part of her—a part that could stand up to and disagree with her parents and protect her in some ways, but also one that could express anger, frustration, and a desire to be in control. Elyse learned to soothe some of her anxiety and other overwhelming emotions through talking, exercising, sleeping, and a variety of other nonharmful mechanisms. Over time, she began to have a richer and more complex self-image. With this understanding of herself came a more complete sense of her family, her friends, and her boyfriend. She gradually decided that Rich was not helping her get better but was in fact, albeit unconsciously, reinforcing her anxiety and her need for her eating behavior. As she became more comfortable with herself, Elyse also became more able to discuss her feelings with her parents—even when they did not understand or actually disagreed with her response to any given experience. Eventually, she ended the relationship with Rich and became involved with a man who, as she told her therapist, “likes to talk about things—maybe even too much—but he gives me lots of space to know what I’m feeling.”

conclusion Eating disorders are extremely complex and can be surprisingly complicated. They are often symptoms of difficulties in many areas, most having little to do with diet and weight. They have meanings, causes, and repercussions in cultural, psychological, physical, professional (or school), personal, and family areas.

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No single treatment approach has been found to be most effective with these symptoms, but a combination of several different approaches, such as family, individual, and group therapy; supportive, psychodynamic, and cognitive behavioral therapy; medication; education and nutritional guidance, seems to be the most useful. A social worker is often a member of a team working with different aspects of a client’s difficulties and needs. Because individuals with difficulties in these areas often have some trouble integrating different aspects of themselves and others, one important task for a social worker is to assess moments in which there is been a splitting off of emotions, thoughts, and experiences, whether with family, friends, self, or in the clinical work. It is important to help clients begin to articulate these unknown or unspoken

experiences, but psychodynamic understanding and articulating feelings is usually most useful in conjunction with other more directive interventions. Nutritional guidance and education, techniques for self-soothing, and focused symptom management need to be integrated into the work as well. Finally, recognizing that an eating disorder itself is part of a client’s capacity for resilience is an important part of the work. This is not to suggest that eating disorders are healthy, but to remind clients and workers that the symptoms, like everything else in life, are multifaceted, neither all good nor all bad. The overall goal with these clients is to help them develop tools for managing their need for food differently while also developing a perspective in which their selfvalue is no longer exclusively dependent on their weight and physical appearance.

referenceS

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cHaPter 8 Schizophrenia e l l e n P. l u k e n S a n d J o r d a n e . d e V y l d e r

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chizophrenia is a disease of the brain that affects approximately 1 percent of the population worldwide (Manderschied & Sonnenschied, 1992). It is characterized by a combination of symptoms that can alter a person’s sense of reality and change the ability to attend to normal life functions, such as work, school, and relationships. At its worst it can interfere with the ability to take care of and monitor even simple activities of daily living. It is a chronic and multifaceted illness that affects every aspect of an individual’s life; it can distort sense of self and alter how the person experiences the environment. Those who are affected describe a sense of loss of self, disorientation, and emptiness. According to the standard set by the American Psychiatric Association in the Diagnostic and Statistical Manual of Mental Disorders IV (DSM-IV), schizophrenia is typically recognized and diagnosed by a common set of symptoms, usually referred to as the positive and negative symptoms. The positive or psychotic symptoms include hallucinations, delusions, bizarre behavior, disorganized speech, and disorganized or withdrawn behavior. The negative symptoms, which are sometimes referred to as residual or deficit symptoms, include affective flattening, alogia, or loss of volition. These are accompanied by a significant disturbance in cognition and functioning, particularly as regards work, interpersonal relations, or self-care (American Psychiatric Association [APA], 1994; Kirkpatrick, Fenton, Carpenter & Marder, 2006). In spite of this grim description, important developments over the last several decades offer 160

increased opportunity and hope for persons with the illness. These include the availability of new psychotropic medications, strengths-based psychosocial interventions with an emphasis on education and wellness, and an increasingly visible and active recovery movement. defining and explaining Schizophrenia Descriptions of schizophrenia as one form of severe mental illness have been clearly documented since the turn of the twentieth century, although emphasis on particular diagnostic characteristics has varied. The seminal work of Emil Kraepelin and Eugen Bleuler characterized the illness in terms of what are now referred to as the negative symptoms. Kraepelin described loss of cognitive function and mental integrity, accompanied by progressive deterioration, loss of will, and abnormalities in attention and interest, memory and affect (Kraepelin, 1919/1971). Bleuler considered schizophrenia a cognitive disorder, characterized by fundamental and accessory symptoms and expressed through disturbance in experience and behavior. The fundamental symptoms included abnormalities in affect, attention, and volition, as well as decreased sense of identity or ego function; accessory symptoms included delusions, hallucinations (both now considered positive symptoms), and associated loss of orientation, memory, and attention (Bleuler, 1911/1950). Such emphasis on vulnerability and loss of functioning remained central to the understanding of schizophrenia until Kurt Schneider’s work appeared in the 1950s.

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Schneider veered away from a focus on underlying vulnerabilities. Rather he concentrated on what he termed the first-rank symptoms, specifically delusions, hallucinations, bizarre behavior, and thought disorder (Schneider, 1959/1980). Following Schneider’s work, and until the publication of the DSM-IV in 1994 when the negative symptoms again were described as primary, the illness had been diagnosed according to the positive symptoms (APA, 1994). The renewed attention to the negative symptoms has encouraged mental health professionals to look beyond distortions in thinking and belief systems and again to attend to impact on experience and functioning. However, effective treatment for negative symptoms still remains elusive, despite their detrimental effect on social and role functioning and quality of life (Kirkpatrick, Fenton, Carpenter, & Marder, 2006). The diagnostic picture for schizophrenia has changed as policies, attitudes, and explanations regarding mental illness have evolved over the last several centuries. In the United States, changes in policy occurred as the society became increasingly industrialized and urbanized. During the eighteenth and nineteenth centuries, mental disorders were associated with indigence, immorality, and poor habits. Care generally was assigned to the family or local community, and lunacy or insanity was considered a social and economic problem rather than a medical problem. Backup care was typically the local jail or almshouse. During the late 1700s, some medical hospitals began to admit people who were considered insane, and in 1770 the first mental hospital opened in Virginia (Fellin, 1996; Grob, 1994). At the end of the eighteenth century, various reform movements in Europe trumpeted more proactive care, with cure as the hoped-for outcome. In France, Phillipe Pinel developed a moral treatment approach, which involved psychologically oriented care in an asylum, and in England William Tuke established the York Retreat to help asylees develop mechanisms for self-control. In the United States, the work of

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social reformer Dorothea Dix during the 1830s and 1840s led to the development of more than 30 mental hospitals designed to serve the needs of those deemed both mentally ill and impoverished (Fellin, 1996; Grob, 1994). Over the next century some additional 5,000 institutions were built in the United States. Until the end of the nineteenth century, these hospitals typically served people with more acute cases of mental illness, and individuals would typically return to the community after relatively short-term hospitalizations of less than a year (Grob, 1994). But many people did not recover and gradually the mental hospitals became long-term care facilities where individuals with persistent illness resided for most of their adult lives. This approach continued through the end of World War II. The discovery of Thorazine, the first antipsychotic medication that seemed to decrease positive symptoms, as well as the increasing scrutiny of the mental hospitals among social reformers during the 1950s, intensified the push toward discharge to the community (Grob, 1994). After the Community Mental Health Act was passed in 1963, thousands of long-term residents were deinstitutionalized on the assumption that more effective care could be provided outside a hospital setting. But newly developed community programs were not fully equipped or prepared to handle the challenges involved in managing an illness as unpredictable and misunderstood as schizophrenia. After spending a significant number of their adult years in closed environments, many of those discharged found it challenging to manage and fend for themselves (Fellin, 1996). Not surprisingly, families were expected to step in. But they too were unprepared for this responsibility and had limited access to the information, resources, and support services needed to alleviate burden of care (Anderson, Hogarty, and Reiss, 1986; Starr, 1982; Solomon, 2000). Moreover, early theoreticians and clinical researchers, following the work of Bleuler and Kraepelin, and influenced by psychoanalytic theory, argued that impaired

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family dynamics, particularly between mother and child, contributed to the development of schizophrenia (Kasinin, Knight, & Sage, 1934). Hence, the stigma attached to mental illness in general and the widely held belief that families caused the illness further promoted isolation and burden (Lefley, 1996). Attitudes toward the role of the family in schizophrenia have changed dramatically since that time. Currently there is strong evidence that schizophrenia is a biological disease that includes a genetic component and that is affected by a range of environmental factors that can hinder or facilitate functioning and stability (van Os, Kenis, & Rutten, 2010). Work on the psychosocial aspects of schizophrenia focuses on potential protective factors (i.e., coping; availability of formal, community, and family supports; quality of life) as well as risk factors (emotional and financial burden, sadness and loss among all members of the family) (Macgregor, 1994; Marsh et al., 1996; Struening et al., 1995). In recent decades, professionals, persons affected, and families have worked together to identify personal and environmental stressors, enhance resilience, and bridge professional services and informal supports (Dixon & Lehman, 1995; Dixon et al., 2011). Major advocacy groups, particularly the National Alliance on Mental Illness (NAMI), have contributed greatly to public understanding of schizophrenia and offers extensive resources on symptoms, diagnosis, range of treatment options, stigma, education, and support (www.nami.org). Local and national advocacy groups also promote education regarding mental illness. The National Alliance on Mental Illness (NAMI), has synthesized such knowledge for its members while promoting and teaching advocacy skills (Sommer, 1990). Its work has significantly increased national awareness and understanding of all forms of acute and chronic mental illness (Lefley, 1996). In the last decade there has been increasing attention by professionals, advocates, and those facing the illness as to the potential for recovery

from schizophrenia, and how to understand and promote individual potential in the face of this challenging illness (Davidson & Roe, 2007). Recovery-oriented approaches embrace hope, choice, and the opportunity and supports needed to manage one’s own life and to reside in the community (Barber, 2012; Fisher & Chamberlin, 2004; Lieberman et al., 2008). For those with schizophrenia, recovery is individual and multifaceted, encompassing strategies that maximize functional capacity and cognition, satisfaction with quality of life, personal power and agency, ability to live independently, and freedom from or management of psychosis (Hopper, 2007; Lieberman et al., 2008; Whitley & Drake, 2010). demographic Patterns Schizophrenia is an illness that is associated with great individual, social, and financial cost. Although there is variation in prevalence across cultures with a reported range of 0.2 percent to 2 percent, the estimated lifetime prevalence rate worldwide is about 1 percent (APA, 1994). Of note are findings that a person with an identical twin with schizophrenia has 25 to 45 times greater chance of developing schizophrenia than the average person. But this also means that genetics alone does not explain the illness (Brown & Patterson, 2012). For example, there is an overlap in the genetic basis of schizophrenia and bipolar disorder in that those with first-degree relatives with schizophrenia are at an increased risk for bipolar disorder, and vice versa (Lichtenstein et al., 2009). Geneenvironment interactions provide a promising yet underdeveloped direction for expanding our understanding of schizophrenia etiology (van Os, Rutten, & Poulten, 2008). Schizophrenia usually manifests itself in early adulthood, with a median age of onset in the early or mid-twenties for men and late twenties for women (APA, 1994; Gureje & Bamidele, 1998). Initial presentation of symptoms is variable; for some it is abrupt, for others gradual. Often there is some problematic

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or prodromal behavior that appears prior to help seeking (Insel, 2010). It is difficult to identify reliably those who will transition to full psychosis (Yung et al., 2007), although attempts to intervene at this stage have been promising (Dequardo, 1998; McGorry et al., 2009). The course of illness is highly variable, which complicates diagnosis, assessment, and treatment (Möller & von Zerssen, 1995). In reported studies of course of illness over time, it is estimated that about one-third of those who are originally diagnosed recover and return to baseline functioning, one-third suffer mild to moderate impairment in life functioning, and one-third face chronic challenges (Möller & von Zerssen, 1995). The prevalence of schizophrenia is approximately the same across class, ethnicity, and race, although there are certain differences in presentation that are important to consider if we are to fully understand the disease (Kealey, 2005; Minksy, Vega, Miskimsen, Gara, & Escobar, 2003). Within the United States, African Americans and Native Americans are more likely to be hospitalized for schizophrenia than either Mexican Americans or Asian Americans (Manderscheid & Sonnenscheid, 1992; Neighbors et al., 1992), and are more likely than white Americans to be diagnosed with schizophrenia even when controlling for socioeconomic status (Bresnahan et al., 2007). Those with less education are two to three times more likely to be hospitalized for schizophrenia than those with more education (Aro, Salino, & Keskimaki, 1995). A possible explanation is that those of minority ethnicity or lower socioeconomic status are more poorly treated by the formal system; thus they receive less adequate care and are more freely diagnosed with severe mental illness (Neighbors et al., 1992). However, one recent study notably found that clinicians more frequently diagnose African Americans with schizophrenia even when presented with ethnicity-blinded diagnostic assessments (Gara et al., 2012). Immigration likewise appears to be a risk factor for schizophrenia based on data primarily

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from European epidemiological studies. A meta-analysis of eighteen studies demonstrated that both first- and second-generation immigrants experience a substantial increase in risk, especially if the country of origin is primarily black (Cantor-Graae & Selten, 2005). This is most likely due to post-immigration social factors (Bourque, van der Ven, & Malla, 2011) given the lack of evidence for selective migration of people with schizophrenia. Not only are the rates of schizophrenia higher among immigrants, but symptoms also appear to be more severe, particularly persecutory delusions, bizarre behavior, visual hallucinations, negative symptoms, and depression (Veling et al., 2007). Regardless of the causes underlying these ethnic differences, the illness must be understood in relation to the culture in which it appears (Dassori, Miller, & Saldana, 1995). For example, beliefs associated with particular religious values might fall within the belief system for that society rather than be truly reflective of mental illness (Mezzich & Caracci, 2008). Schizophrenia is also associated with other factors that make it particularly frightening to those affected and their families. Five to 10 percent of people with schizophrenia commit suicide and approximately 20 to 40 percent make an attempt at some point in their lives (Palmer, Pankratz, & Bostwick, 2005). Risk for suicide is especially high in the early course of schizophrenia, with suicidal ideation rates of 31–52 percent over the one month preceding initial treatment contact for a first psychotic episode (Melle et al., 2006) and as high as 59 percent over a two-week period during the “prodromal” phase prior to initial onset of a first psychotic episode (Hutton, Bowe, Parker, & Ford, 2011). Of those who complete suicide, about 60 percent have already made a previous attempt, with attempts usually associated with particularly intrusive and disturbing psychotic symptoms (Harkavey-Friedman et al., 1999). People with schizophrenia are also at higher risk for drug and alcohol abuse than those in the general population. An estimated 45 to

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50 percent have at least some history of substance use disorder (Volkow, 2009). Substance use may contribute to onset of schizophrenia, as evidenced for example by the prospective associations between adolescent cannabis use and the later development of the illness (ManriqueGarcia et al., 2012). Most persons with schizophrenia do not enter long-term relationships or partnerships and, without adequate supports, may be challenged in their efforts to maintain employment in competitive jobs (Anthony, Cohen, & Farkas, 1990; Bond, 2004). Schizophrenia usually strikes at a time in the life course when a person would typically seek higher education and/or employment, or partnership and possibly family. Instead he or she becomes dependent on the mental health and social service systems, and possibly the family of origin. This inevitably compounds the levels of burden and stress that exacerbate the illness and hinder recovery (Amering & Schmolke, 2009). Societal context Schizophrenia has a profound effect on daily life. Vigilance by providers and significant others helps the person keep on track and avoid the demoralization and stigma attached to revolving-door hospitalizations or inadequate or stultifying community care. For social workers and professionals this involves attention to the cycles of vulnerability and disenfranchisement that a person faces. The most significant psychosocial needs include housing, financial support, structured activity if work is unrealistic or unavailable, resources and support in the workplace if work is a viable possibility, psychiatric monitoring and medication, medical support, crisis intervention, and hospitalization when necessary (Dixon et al., 2010). If the negative symptoms are prominent, particularly lack of motivation or inability to make and maintain relationships, the challenges become even more complex. The state of vulnerability that underlies a brain disease is worsened by the fact that the

person may seem idiosyncratic in behavior, speech, or appearance. This lends itself to labeling, the negative beliefs or attitudes that contribute to stereotyping, prejudice, ostracism, and tarnished identity. Labels can in turn affect outcome negatively through associated stigma (Phelan, Bromet, & Link, 1998; Rosenfield, 1997). Efforts by professionals and advocates to describe a person with schizophrenia as someone who suffers from an illness, or who has an illness, as opposed to schizophrenic, counters the message that the person is solely defined by illness. Avoiding stigmatizing language makes it easier to identify areas where the person is functioning well, and helps to capitalize on these. Educating professionals, families, and the general public to differentiate between person and illness is not an easy task, particularly given that the illness affects both internal perception and external presentation. Each group has different concerns and perspectives on how they, either individually or collectively, will be affected. Addressing stigma across systems may sensitize the general public to the illness and increase their willingness to support needed interventions, programs, and policies. But for the person with illness, and their family members and advocates, the stakes are significantly higher. If social workers understand the impact of stigma, they can more effectively assist and advocate for individuals and families as they navigate complex medical, social services, and psychiatric systems. Vulnerabilities and risk factors Stress serves as a major risk and complicating factor for any illness, regardless of presenting symptoms (Nicholson & Neufeld, 1992; Nuechterlein et al., 1992). The Stress-Diathesis Model (or Vulnerability Stress Model) places schizophrenia in the context of both biological and environmental (psychosocial) risk factors (Zubin & Spring, 1977; Walker, Mittal, & Tessner, 2008). The model suggests a transactional relationship between psychosocial or

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environmental stressors with genetic or otherwise biological vulnerability that can evolve into early symptoms and eventually chronic psychosis in susceptible individuals. Sensitivity to the stress of daily life is closely related to symptom severity early in the course of illness (DeVylder et al., 2012) and may be instrumental in triggering initial onset (Corcoran et al., 2003), especially in people who have a particularly emotional response to stressful events (Myin-Germeys, van Os, Schwartz, Stone, & Delespaul, 2001). Lack of support or stimulation may also serve as a source of stress, particularly if a person becomes withdrawn and isolated (APA, 1994). At the other extreme, change and transition can be stressful as well; as such there is strong evidence that structure and routine can help to ground and focus persons who suffer from mental disorders (McFarlane et al., 1995). External variables also serve as risk factors, particularly those related to availability of resources across system levels, including society, community, and family. In their work on the fundamental causes of illness, Link and Phelan (1995) consider the potential for differential impact of proximal and distal causes. The distal (external) risk factors include socioeconomic status and access to resources such as power, money, knowledge, and prestige. For someone with schizophrenia the very nature of the illness interferes with such access. The lingering Western model of assigning personal responsibility for control over one’s illness magnifies this by focusing on proximal (immediate) factors. Link and Phelan argue for a shift in locus of responsibility such that both distal and proximal factors are weighed in assessing burden of disease and need for services, and developing and implementing appropriate programs and policies. This approach is congruent with social work in that assessing risk and protective factors across system levels is one of the fundamental tenets of the profession. Research on risk factors in schizophrenia has focused increasingly on the first episode of

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psychosis, as well as the prodromal or “clinical high risk” state that precedes that initial episode. Although research is still in its preliminary stages, emerging evidence suggests that a variety of interventions during the clinical high-risk phase may have value in delaying or even preventing the onset of schizophrenia. These include cognitive behavioral therapy (Addington et al., 2011), antidepressant or antipsychotic medications (Walker et al., 2009), and even supplements of omega-3s from fish oil (Amminger et al., 2010). Similarly, individual and family psychosocial interventions and pharmacological treatments have shown promise in preventing or delaying relapse following an initial psychotic episode (Alvarez-Jimenez et al., 2011). Together the early identification of symptoms and the use of carefully regulated medication may effectively improve the course of schizophrenia (Marshall et al., 2005; Perkins, Hongbin, Boteva, & Lieberman, 2005). resiliencies and Protective factors Resiliency refers to the internal strengths that a person draws on under duress and stress; protective factors represent those resources that facilitate such resiliency and promote selfdetermination (Amering & Schmolke, 2009). For someone suffering from schizophrenia, the ability to recognize and use personal strengths can be impaired by the illness. Those surrounding the person can help to identify and capitalize on these internal strengths by reinforcing external supports, and identifying concrete resources. Social supports and networks refer to the nature and extent of interpersonal relationships that tend to have a protective effect against stress exposure and psychosocial distress (Maulik, Eaton, & Bradshaw, 2010). Satisfaction with one’s social network is prospectively associated with quality of life among people with schizophrenia (Pernice-Duca & Onaga, 2009), whereas insufficient social support is associated with reduced time to relapse/readmission (Bengtsson-Tops & Hansson, 2001).

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Because schizophrenia is frequently characterized by withdrawal and isolation and impaired interpersonal relationships, ongoing support is essential to monitoring the illness. Family members can fulfill this function, as can friends, clergy, family, or peers. But even the most vigilant and caring members of a social support system may not be enough to carry a person through changes in functioning, especially if he or she is unaware of the patterns. Providing adequate support requires a coordinated and sensitive effort on the part of professionals, family, or other community members with attention to timing and planning. If professional services are accessible and sustainable (Dixon et al., 2010), individuals and families will be willing and able to seek care. Social workers can inform those they work with as to the value of using and complying with medication regimens and, as important, that medication alone is not adequate treatment; up to 50 percent of those who are fully adherent to antipsychotic medications still relapse within a year’s time (Lindenmayer, 2000; Kane and Correll, 2010a, 2010b). Education across systems is among the most critical components in providing comprehensive care and promoting resilience. For social workers and other mental-health professionals, this means staying abreast of important developments in the field, ranging from evolving theories regarding course and prognosis and new medications, to psychosocial interventions, models, and resources that are available both nationally and locally. They can then translate and share this knowledge so that care recipients can understand and use the information to advocate for and improve care. Maintaining open and mutually respectful lines of communication allows the social worker to learn from the everyday experiences of those facing illness. Such collaboration enhances the potential for bridging the formal (professional) and informal (family and community) systems of care and helps to dispel any residual tendency to blame the family for this

particular life condition (Pescosolido, Wright, & Sullivan, 1995). As with NAMI, the advocacy groups organized by those with mental illness have also provided valuable venues for individuals to work together, battle stigma, raise self-esteem, and create opportunities for themselves through advocacy, peer-run businesses, and other important services (Bellack, 2006). Programs and Social Work contributions Social workers are responsible for much of the day-to-day care and outreach to those with severe mental illness and their families and have been directly involved in the development of many innovative community-based programs and interventions. A growing number are evidence based; they have been tested under defined and rigorous conditions following a designated research protocol (Dixon et al., 2010; Drake, Bond & Essock, 2009; Shean, 2009). Such programs are widely endorsed by mental health professionals and advocates alike and are important for social workers to recognize and implement when adequate training and supervision are available. They include comprehensive programs such as the Assertive Community Treatment (ACT) Program, Integrated Dual Diagnosis Treatment (IDDT), the Critical Time Intervention (CTI), Fountain House and related community-based recovery centers, and targeted programs such as Illness Management and Recovery (IMR), Supported Employment, and Family Psychoeducation. Promoted through the nationally recognized Schizophrenia Patient Outcome Research Team (PORT) (Lehman et al., 1998; Dixon et al., 2010), these programs also are cited and described in detail by the National Registry of Evidence-Based Programs and Practices (http://nrepp.samhsa .gov) and are well described in the professional literature (Drake, Merrens & Lynde, 2005; Mueser et al., 2003; Phillips et al., 2001; Rubin, Springer, & Trawver, 2010). Focused strategies such as cognitive remediation and shared decision making also are attracting growing attention because of

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improved functioning and related outcomes. Services provided by family, peers, and community advocates are invaluable and offer a unique form of care that draws on the lived experience and perspective of those intimately involved with the challenges of illness. All aim to enhance quality of life by recognizing strengths and facilitating recovery, growth, and potential. Assertive Community Treatment (ACT) teams serve as primary providers and brokers of care, offering continuity of care and caregiving that promotes healing across functional areas and time (Coldwell & Bender, 2007). Developed in the early 1970s by mental health professionals, these multidisciplinary teams are on 24-hour call seven days a week, with participants receiving individualized treatment as often as needed. The teams distribute and monitor medication, offer crisis support, arrange hospitalization, and provide long-term and continuous care. Staff assist with housing, employment, social relations, child care, and other skills of daily living. Repeated assessments of ACT have showed reduced symptomatology and relapse, increased community tenure, enhanced satisfaction with life, and improved functioning, particularly regarding employment, social relationships, and the daily activities of living such as personal hygiene, shopping, travel, or money management (Phillips et al., 2001; Test, 1998). Those with schizophrenia frequently struggle with substance use; estimated rates for comorbid substance abuse or dependence are as high as 47 percent and for comorbid alcohol abuse as high as 33.7 percent (Drake et al., 2002; Regier et al., 1990). The premise for Integrated Dual Diagnosis Treatment (IDDT) is that both conditions must be treated simultaneously to maximize effectiveness. Until recently, services were offered in separate settings, leading to fragmented and often uncoordinated care. In contrast, the IDDT approach stresses integrated and time-unlimited services and universal screening for substance abuse among those with mental illness. It incorporates access to techniques such as motivational interviewing and psychoeducation that address

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co-occurring symptoms and encourage treatment adherence, appropriate medication, and opportunities to participate in self-help groups such as Alcoholics Anonymous and other twelve-step groups (Mueser et al., 2003). The Critical Time Intervention (CTI) model focuses on the crucial nine-month period after discharge from a psychiatric admission when people are most vulnerable and at risk. Originally designed for men facing comorbid mental illness and homelessness, CTI is strengths based and individualized; participants must attain clearly stated objectives regarding personal functioning as they move toward increased independence and self-monitoring. CTI personnel work closely with the individual to adhere to treatment and build a sustainable system of community resources and supports. The model is effective in increasing community tenure and decreasing homelessness and relapse of symptoms (Herman, Conover, Felix, Nakagawa, & Mills, 2007; Herman et al., 2011). Fountain House is a recovery-oriented approach that promotes shared responsibility among staff and members for the day-to-day functioning of programs. The model has been widely replicated and emphasizes the critical nature of relationships, work, and tasks that have meaning. It aims to create a safe environment for persons with a range of mental illnesses to come together, organize themselves, and learn, work, and interact in a supportive community that stresses choice and consensus decision making (Aron, 2008; Dudek & Aquila, 2012). As we have seen, the symptoms of schizophrenia affect people in a wide variety of ways. For many, the illness can interfere with their ability to form and sustain relationships, carry out typical social roles (such as worker or partner), and satisfactorily monitor personal needs (APA, 1994). In some situations, the individuals do not have an opportunity to fully develop these skills; others have had the skills in the past, but they diminish in conjunction with the illness. Challenges in managing the illness and participating in functional roles contributes to

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demoralization, stigmatization, and isolation, which may contribute to relapse and interfere with everyday functioning and entry or reentry into the workplace. Illness Management and Recovery (IMR) helps people identify and pursue personal recovery goals, and supports the development of skills and behaviors that allow individuals to interact with others and function well in the community, which in turns enhances their quality of life. Core elements include psychoeducation, cognitive behavioral approaches that focus on increased awareness and insight, adherence to treatment, strategies for coping with symptoms, developing a relapse prevention plan, and training on social, advocacy, communication and problem-solving skills. Sessions continue weekly for nine months or more. The curriculum covers eleven topics that include facts about mental illness, building social support, using medication effectively, coping with stress, and healthy lifestyles. IMR sessions follow a common structure that includes a brief period of socialization, review of the previous session, follow-up on steps taken toward personal goals, agenda setting, introduction and practice of new content and skills, collaborative planning of homework, and a session summary. Techniques include modeling and role-play, verbal reinforcement and feedback, shaping, and time allotted to practicing skills until they are automatic and can be generalized from one situation to another (Gingerich & Mueser, 2011; Mueser et al., 2006). Family Psychoeducation is strengths based and offers individuals and family members information and skills to cope with and manage the illness (Luckstead, McFarlane, Downing, Dixon, & Adams, 2012; McFarlane et al., 1993; McFarlane et al., 1995). This model aims to educate, support and advocate for all members of the family by building collaborative relationships among providers, family members, and peers. The model incorporates individual joining sessions to assess strengths and challenges, a psychoeducational workshop, and ongoing individual-family or multiple-family-group

meetings over at least a nine-month period. The workshop covers topics related to diagnosis, epidemiology, medication, and crisis intervention and offers guidelines for lowering and managing stress. The multiple-family-group or individual-family sessions focus on strategies to identify, partialize, and solve problems; build coping, advocacy, and communication skills; and integrate and use information gained through the initial workshop. The approach emphasizes the importance of family as a powerful and stabilizing resource, and serves to counter historical tendencies to pathologize and negate the value of family influences (Lukens & Thorning, 2010). Although unemployment is high among those with schizophrenia and related illnesses, a significant number acknowledge that they would prefer to work (Bond, 2004). Supported Employment aims to enable people with mental health challenges to seek and sustain competitive employment (Bond, 2004; Bond, Drake, & Becker, 2008). Trained employment specialists work with providers and potential employers to identify settings where a person can function effectively and where necessary supports are available that enhance and sustain potential (Gates, Mandiberg, & Akabas, 2010). The structure and potentially rewarding nature of the work environment can further serve to focus and ground the individual. The effectiveness of supported employment highlights the potential for recovery-oriented approaches that maximize potential and opportunity (Bond, Drake, & Becker, 2008). Cognitive remediation is a staged model conducted either with individuals or in small groups. It addresses challenges such as poorly regulated affects that can interfere with functioning and recovery (McGurk, Twamley, Sitzer, McHugo, & Mueser, 2007; Hodge et al., 2010; Wykes, Huddy, Cellard, McGurk, & Czobar, 2011). Participants learn to manage external stress through traditional behavioral techniques (i.e., modeling, rehearsal, practice, feedback, and homework) that focus on increased

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awareness and adaptive strategies in everyday settings. The approach has been well received by recipients and can be combined with other approaches to care (Wykes et al., 2011). Other major programs include those developed by families and consumers for themselves. The Family-to Family Education program is a group intervention facilitated by family members trained as volunteers. This curriculumdriven group model covers topics related to symptoms and diagnosis, treatment and resources, personal care, stress, and coping skills, and aims to reduce stigma and promote connection and exchange among participants (Pickett-Schenk, Lippincott, Bennett, & Steigman, 2008). The service is free and has been implemented nationwide (Burland, 1992; Dixon et al., 2011). Peer-led services and businesses also serve as a critical resource (Deegan, 1992; Mancini, Hardiman, & Lawson, 2005). They include programs such as the NAMI sponsored Peer-toPeer, a nine-week course conducted by mentors who are in recovery from mental illness, which addresses topics including trauma and stress, stigma, culture, substance abuse, relapse prevention, mindfulness, spirituality, medication, and advocacy. Such programs allow those with illness and/or their family members to learn together, share experiences, and offer mutual support without professional presence. The exchange helps to decrease stigma and promote healing for caregivers and care recipients alike (Pickett-Schenk et al., 2008; Ridgway, 2008). In this section several important communitybased interventions have been described, all backed by professionals and family advocates (Dixon et al., 2010; Lehman et al., 1998). Many other outstanding programs exist, including intensive case management programs (Solomon, 2000), housing first programs that offer supported housing regardless of mental health or substance abuse status (Tsemberis, Kent, & Respress, 2012), and supported education programs that encourage individuals to pursue educational goals by providing needed supports and resources (Mowbray, 2005; Gutman, 2008).

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As new and emerging programs are developed, they must be carefully evaluated and well described in the literature so they are accessible to professionals in the field. Clearly defined treatment principles are critical; they allow for individual and cultural differences, strengths, resources, and needs, and build on a strong alliance among professionals, the person with the illness, and available social and community supports. Successful and sustained implementation also involves readily available training and supervision for social workers and other mental health professionals (Drake, Merrens, & Lynde, 2005). assessment and interventions Assessment begins immediately but continues throughout the helping process, and requires the collaboration among the individual, the health and mental health professional(s) linked with care, and available supports (Pescosolido, Wright, & Sullivan, 1995). Because schizophrenia tends to be episodic, recognizing how episodes play out is critical if the person is to function adequately in the community. If early warning signs of decompensation can be identified and monitored, relapse may be forestalled through thoughtful and ongoing medical and/ or environmental intervention (McGlashan & Johannessen, 1996). Diagnosis is part of this process, although it represents a more static construct than does assessment. To date, schizophrenia is not an illness that can be diagnosed by laboratory test; rather it is always diagnosed through clinical dialogue and observation and collaborative information. Furthermore, diversity of presentation and outcome has increasingly led researchers to view schizophrenia as a broad syndrome, which may be eventually understood as comprising many different illnesses (Kirkpatrick, Buchanan, Ross, & Carpenter, 2001; Insel, 2010), as initially proposed by Kraepelin a century ago (Kraepelin, 1919/1971). Clearly there is always room for diagnostic error, and diagnosis is only a first step toward understanding the full circumstances of the illness.

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Many factors can interfere with a full assessment, including the lack of external supports and informants and the cognitive deficits and associated denial of illness or lack of insight that is frequently characteristic of schizophrenia (Amador & David, 1998; Silverstein, 1997). Mental health professionals are faced with the ongoing challenge of trying to assist and work with people who because of impaired insight may be denying the existence of any need for assistance. This raises ethical concerns, particularly around issues of self-determination, which has contributed to efforts to promote shared decision making with those affected (Deegan & Drake, 2006; Drake & Deegan, 2009). The shared decision-making approach involves mutual agreement between providers and the person affected as to care planning (Drake & Deegan, 2009; Kane & Correll, 2010b). Social workers can contribute to this approach by sharing knowledge regarding services, resources, and treatment options, including knowledge about medications and their side effects, and by helping those they work with develop strong self-advocacy skills. Treating schizophrenia successfully with medications continues to be challenging, and results vary by individual and over time (Kane & Correll, 2010a). However, medication is usually considered as part of an initial effort to treat the most disturbing and overt psychotic symptoms; by law medication is prescribed by licensed medical personnel, usually a psychiatrist or physician. The fact that the psychotropic (i.e., neuroleptic) medications have side effects that mimic or exacerbate other symptoms, or that interfere with functioning in and of themselves, complicates the process. Distinguishing among effects and side effects requires careful communication between the prescribing physician and the person with illness (Drake & Deegan, 2009). For some, medications effectively control symptoms and increase levels of cognitive functioning. Increased insight and acceptance of illness can follow as well. But improved insight

sometimes can have unexpected drawbacks (Duckworth et al., 1997). Recognizing the profound impact of schizophrenia on the self may contribute to depression, suicidal behavior, fear, mourning, and a sense of loss of “what might have been.” Paradoxically, as a person improves, the disappearance of familiar symptoms may also be experienced as a kind of loss. Such reactions may range from mild to extremely debilitating and must be addressed carefully so the person can reach some level of acceptance, while adjusting to a new level of functioning (Duckworth, Nair, Patel, & Goldfinger, 1997). An important part of ongoing assessment and care is maximizing a person’s social network and supports. Availability and access to concrete resources must be carefully considered as well, including any benefits to which the person is entitled, such as social security income (SSI), social security disability income (SSDI), Medicaid, Medicare, and access to housing. If the person wishes to work or pursue some form of higher education, careful evaluation, planning, and monitoring can help to assure that he or she can function adequately in these arenas (Drake et al., 2005; Mowbray, 2005). The social worker plays a central role in both assessment and intervention for a person with schizophrenia. This involves close attention to a person’s immediate needs and strengths, with particular consideration of personal, interpersonal, and community resources. Identifying a network of support and maintaining a sustained connection over time can serve as a lifeline and engender hope, helping the person weather and manage illness-related challenges and stressors and focus on wellness (Herman et al., 2011; Rubin, Springer, & Trawver, 2010). Navigating a complex and multilayered system of mental health and related services can be daunting for even the healthiest person; for someone contending with psychotic symptoms this can be paralyzing, disorienting, and even terrifying. If the individual can build reflective functioning and planning skills, he or she can more easily manage these challenges and

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related periods of stress and transition. The social worker provides a stabilizing force, serving as advocate, educator, therapist, and sometimes simply as a sounding board. Social work principles and values are both incorporated and reflected in the evidence-based practices for schizophrenia (Herman et al., 2011; Rubin, Springer, & Trawver, 2010). Recurring professional techniques and skills draw on cognitive behavioral therapy, motivational interviewing, psychoeducation, care management and coordination, and shared decision making (Gingerich & Mueser, 2011; Herman et al., 2011; Lukens & Thorning, 2010). illuStrAtion And diSCuSSion

Mohit is 32 and has the diagnosis of schizophrenia, paranoid subtype. He had immigrated to the United States with his family when he was 15. At that time he spoke only Hindi; however, he was a gifted and motivated student and quickly became fluent in English. By the time he graduated from high school he was an honors student, accepted into the state university of his choice. During his first year in college Mohit did well academically and seemed to thrive socially, but during the first semester of his second year he became depressed and withdrawn and his grades fell. By the middle of his sophomore year he became increasingly disoriented and developed a delusion that his parents had abandoned him and returned to India. He insisted in speaking only in his native language. After a roommate reported that Mohit might be suicidal, he was hospitalized for the first time, and after a thorough evaluation, received a diagnosis of schizophrenia, paranoid subtype. Following discharge, he seemed better for a time, but his symptoms returned and he dropped out of college early in his junior year. For the next decade Mohit lived at home with his family. He completed a few courses at the local community college, but did not continue in his education. He received treatment at his local community mental health center, and his social worker suggested that he attend their day treatment program and participate

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in their activities. He attended day treatment sporadically, where he was well liked; the social workers described a quiet man who when he was less symptomatic seemed to take an interest in others, particularly those who appeared most ill. However, he had been unable to work for any sustained period of time, finding the demands of a regular schedule stressful and overwhelming. This frustrated him and seemed to contribute to a sense of apathy and personal failure. Although his parents were patient and more than willing to have him live at home, they worried about his recurring bouts of illness and wished for him to be more settled, focused, and happy. During the times when he was doing better he seemed to enjoy working in the family garden and spending time at a local diner where he was well liked and accepted by the owner and regular patrons. Sometimes he helped out by running errands for the owner. Periodically his symptoms increased and he became belligerent and fearful, often suicidal. Almost always a sign of decompensation would be his refusal to speak English. When Mohit experienced severe symptoms, he was hospitalized again. After this hospitalization, a social worker at the day treatment program mentioned to him that the staff was endorsing a group model referred to as “Illness Management and Recovery” (IMR). The purpose of this new initiative would be to teach people diagnosed with schizophrenia to learn about individualized techniques to manage the illness and promote recovery. The groups would help people define recovery for themselves, and identify and pursue goals that were important to them as individuals. IMR sessions would cover curriculum that had been found to be helpful to people in managing their illness and pursuing their recovery goals, and would meet weekly for nine months or more. Participants would use a workbook, and each session would focus on a topic designed to improve everyday functioning and promote quality of life and recovery. Mohit was initially hesitant to join the group—he was fearful, stating, “I just don’t like groups—they always make me feel worse about myself and kind

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of stupid.” The social worker explained that this was a different kind of group model, very focused and individualized. After some discussion Mohit agreed to give it a try for at least six weeks. During the first few sessions Mohit seemed dispirited and withdrawn, but during a discussion focused on the stress and vulnerability model of schizophrenia, he became more engaged. He acknowledged that he had never thought about his illness from this perspective, about factors and triggers that hindered and helped one’s ability to stay outside the hospital. He seemed to appreciate the opportunity to examine his own patterns and discuss them in the group; he took the homework assignments seriously and reported back on what he learned. He identified that he would like to pursue work as his recovery goal, although he was unsure about what kind of work. Unfortunately, just at this point his mother was hospitalized for medical reasons and for about six weeks Mohit refused to attend the group altogether. However, the social worker stayed in regular contact during this period and Mohit eventually returned. As the year progressed, Mohit admitted that he looked forward to the sessions and enjoyed the homework assignments, which he completed carefully. In one session he mentioned that he was thinking of expanding the family garden. A lively group discussion ensued and another member suggested that maybe Mohit could seek employment in the local nursery—in fact, Mohit knew the owner from time spent at the coffee shop, but it had never occurred to him that the connection could possibly lead to a job. The group leader picked up on this, noting that a nursery would be a place where Mohit could work outdoors and where he might not feel stifled by the demands and routine of a 9 to 5 job. He suggested that Mohit might start with a part-time schedule just to try it out. A group member suggested they role-play a phone call between Mohit and the nursery owner, so he could practice exploring the possibility of employment. The group became invested in supporting Mohit in this effort; after the role-play he decided to approach the owner in person. In fact the nursery owner was open to the idea—he suggested they try a part-time schedule for a month and if they were both happy with

the arrangement, Mohit could work during the afternoon shift. The description provides examples of some of the difficulties involved in this work, particularly in the earlier stages. IMR allows participants to begin to understand and absorb some of the complexities and mysteries of the illness and to identify their own strengths and resources. But learning illness management skills and pursuing personal goals can be challenging for clients, so the work may seem slow at times, with periods of both success and setbacks. Given this, it was not surprising that Mohit needed to take a break when his mother became ill. This may be frustrating for participants and facilitators alike. However, as group members work together to understand that reflection and monitoring are critical to positive outcome and resiliency, group members become increasingly focused and effective. Because schizophrenia is complex and often unpredictable, working with one’s own strengths and challenges may require approaches that are not immediately obvious to the person facing the illness. As the group cohesion increases, participants can help each other to address and overcome day-today challenges in ways that enrich quality of life. At its best this work fosters a true partnership between individual group members and professionals, enhanced by the expanded social support system that helps to define the group. In this setting both professional and practical knowledge can be exchanged and group members have the opportunity to witness and validate the experiences of others. This is exemplified by Mohit’s decision to seek employment that could build on his strengths and interests and by the willingness of other participants to support this effort. This example not only draws on the principles of IMR but follows other guidelines for effective practice that have been identified throughout this chapter. IMR is strengths based and recovery oriented; as such it offers hope and encourages possibility. The social worker and Mohit talk through the pros and cons of group participation before Mohit agrees to

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attend—a form of shared decision making. After some initial struggles early on, Mohit begins to recognize the value of understanding how the illness plays out him in terms of symptoms, triggers, and protective factors. When his mother becomes ill, the social worker stays in good contact, maintaining continuity of interest and care. Later on the flexibility of the IMR model becomes clear; the facilitator allots time for Mohit to role-play an interview with a potential employer. For this particular individual the IMR group offered a structure and source of support that grounded him and allowed him to identify and pursue a realistic goal while simultaneously learning new ways to manage the challenges associated with his illness.

conclusion Clearly schizophrenia can be profoundly debilitating, and intervention is complicated by the fact that a person may be unaware of or unwilling to admit the presence of illness. Because persons with this illness are sensitive to even subtle changes and stressors in the environment, careful monitoring is key to successful intervention supports recovery. Points of transition are particularly stressful, those phases when a person moves from hospital to home or community residence, from home to community residence or apartment, or from a community treatment program to competitive employment. In each of these vulnerable situations, a lack of continuity or coordinated care may create setbacks OR points of crisis (Herman et al., 2007; Lehman, 1994). But thoughtful attention to these transitions also can generate perspective and hope. As exemplified by the described models and the illustration, maximizing such opportunity calls for collaborative and ongoing effort among the professional and lay community, including the person affected and family and friends. Building alliances with and valuing the lived experience and input of families contributes greatly to positive outcome and healing. If an individual is working, this community may be extended to include supervisors and colleagues as well.

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Medications can provide relief for some persons with schizophrenia if the more disturbing and overt symptoms can be more adequately controlled. Prescribing and supervising medication is legally outside the purview of social work. However, maintaining an up-to-date and working knowledge of the antipsychotic medications and their effects and side effects enables the social worker to share and translate this information so that those affected can understand and collaborate in their own care (Drake & Deegan, 2009). Regardless of a person’s response to or acceptance of medication, access to ongoing support remains critical, particularly regarding housing, relationships (Drake, Merrens, & Lynde, 2005; Lukens & Thorning, 2010). Housing is a most fundamental need. Although a significant number of adults with schizophrenia reside with their families, many others have little or no access to family supports. Among the homeless population in the United States, an estimated 10 percent have schizophrenia (Brekke & Slade, 1998). For those who do reside with relatives, alternative living situations might more adequately serve their needs and the needs of their families. Matching individuals with appropriate housing, in a setting where needed supports are in place, provides an ongoing challenge, particularly given limited availability and funding support (Ridgway, 2008). To date people with schizophrenia have had limited opportunity to succeed in competitive employment. However as supported employment becomes more commonplace people will be more able to meet the requirements of regular employment. Social workers can play an important support role for those who seek employment if they become well-versed in the policies and services related to the rights of persons with disabilities in the workplace (Campbell, Bond & Drake, 2011; Gates et al., 2010). Access to satisfactory housing, benefits and employment contribute to quality of life, and all can be elusive for those with schizophrenia.

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Yet new approaches to care offer possibilities for personal growth and prospects for individuals to participate actively in their own recovery. As Mohit’s story suggests, working with a person to build on strengths and to recognize opportunities while weathering the episodic nature of schizophrenia is central to the mandate and

values of social work. Social workers are well positioned not only to offer day-to-day care and advocacy that maximizes individual potential but also to develop and disseminate new programs and influence policies that address the changing needs and multiple strengths of people coping with this complex mental illness.

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Walker, E., Cornblatt, B. A., Addington, J., Cadenhead, K. S., Cannon, T. D., McGlashan, T. H., . . . Heinssen, R. (2009). The relation of antipsychotic and antidepressant medication with baseline symptoms and symptom progression: A naturalistic study of the North American prodrome longitudinal sample. Schizophrenia Research, 115(1), 50–57. Walker, E., Mittal, V., & Tessner, K. (2008). Stress and the hypothalamic pituitary adrenal axis in the developmental course of schizophrenia. Annual Review of Clinical Psychology, 5, 189–216. Whitley, R., & Drake, E. E. (2010). Recovery: A dimensional approach. Psychiatric Services, 61(12), 1248–50. Wykes, T., Huddy, V., Cellard, C., McGurk, S. R., & Czobar, P. (2011). A meta-analysis of cognitive remediation for schizophrenia: Methodology and effect sizes. American Journal of Psychiatry, 168(5), 472–85. Yung, A. R., Yuen, H. P., Berger, G., Francey, S., Hung, T-C., Nelson, B., Phillips, L., & McGorry, P. (2007). Declining transition rate in ultra high risk (prodromal) services: Dilution or reduction of risk? Schizophrenia Bulletin, 33(3), 673–81. Zubin, J., & Spring, B. (1977). Vulnerability: A new view of schizophrenia. Journal of Abnormal Psychology, 86, 103–26.

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egardless of work setting or target service population, twenty-first-century social workers are very likely to encounter people whose lives and well-being are affected by serious physical illness. Although hospitals and hospices are still important sources of care for those with serious physical illness, they are no longer the only locations in which social workers are called upon to apply their knowledge and skills with this vulnerable group. As advances in medicine and technology have slashed mortality rates for many life-threatening—if not once fatal—conditions, countless individuals who would have died much sooner or remained hospitalized for much longer are returning to their families and communities and making efforts to resume the daily roles and responsibilities they held before getting sick. This shift from a health care model focused predominantly on acute life-threatening illness to chronic illness has yielded increasingly complex treatment options and outcomes. More people are now living longer with diseases and conditions whose symptoms and treatments affect the quality of both their lives and those of their loved ones (Levine, Halper, Peist, & David, 2010). As a result, individuals and families across the life course are likely to seek and access psychosocial services to support their illness-related needs in a wide variety of non-medical settings connected with their work, school, and home lives. Because experiences of serious physical illness are characterized by wide variation at both individual and systems levels, social

work assessment and intervention are richly challenging. Contextual factors associated with geography, socioeconomics, and family decision-making styles, for example, shape all aspects of health care including: who seeks and accesses services, what and where service providers are engaged, when (i.e., at what point in the individual or family experience with the health issue of concern), for how long, and perhaps most important, a family’s satisfaction with the care received. Over the past two decades, society’s once-narrow focus on the biological factors of disease has slowly broadened to include the social, psychological, and cultural dimensions of illness. An expanding body of psychosocial research has illuminated key areas of risk and resilience associated with adaptation to a broad range of diseases and shaped the ongoing development of social work interventions that address the increasingly complex set of psychosocial issues associated with them. Given the profession’s enduring promotion of a person-andenvironment approach to service provision, social workers are uniquely trained to assist individuals whose lives are deeply affected by serious illness anywhere on its continuum and across service settings. Skilled social workers have long recognized the interactions between physical and mental health as well as the importance of comprehensive assessment, interdisciplinary communication, and care coordination to successful intervention with those affected by serious physical illness. 179

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With strong leadership from social work, a number of significant health-related sociocultural shifts are well underway within mainstream U.S. society. These include: (1) growing recognition that the most effective health care plans are those built upon the articulated needs and desires of individuals and families, (2) greater acceptance of individuals’ and families’ rights and abilities to advocate for themselves within our profession-based medical care system, (3) increased understanding of the complex intersections among health and mental health within a broad ecological context. These changes reflect the long-standing values and priorities of the social work profession and underscore our central role in the provision of care to the most vulnerable in our society. With our unique knowledge base and expertise we have contributed to the development and implementation of interventions that improve quality of life for countless individuals and families coping with serious physical illness. However, despite these efforts and the now common backdrop of ongoing impressive advances in medicine and technology, care for those with serious physical illness lacks commensurate breadth and depth. Far too few individuals and families receive care that tangibly reflects the sociocultural shifts previously noted. The general public remains largely un- or misinformed about many aspects of serious physical illness, and the health care system overall is fraught with many of the same inequities in access and treatment that have plagued too many for too long. As a result, people suffer needlessly and at ever-increasing socioeconomic costs for everyone. Contemporary social work practice, which addresses the multiple interactions between disease, treatment, and ecological context, are more critical than ever. This chapter provides an overview of the enormous psychosocial impact of serious physical illness for individuals, families, and society and describes intervention models and techniques that aim to mitigate this impact and facilitate healthy adjustment.

defining and explaining Serious Physical illness and end-of-life care For most people today, the related concepts of health, illness, and quality of life are markedly different from those held by those in previous generations. At the beginning of the twentieth century, infectious and parasitic diseases were common and frequently killed individuals at young ages that seem hardly believable today. Since then, remarkable advances in medical knowledge and technology, along with overall improvements in basic environmental conditions (e.g., sanitation, nutrition, housing) have contributed to a steady decline in mortality rates from infectious diseases and a steady increase in longevity; people are living longer—even those who get very sick. Despite the readily apparent and deeply valued positive implications of these outcomes, rapid social and medical advances have also raised different, perhaps unforeseen, challenges. While the eradication of diseases that once killed children and young adults made it possible for these very individuals to lead longer lives, a new and uniquely challenging paradigm emerged. An era dominated by disease-related mortality evolved into one in which acute, even life-threatening, diseases and conditions can be treated or managed with the assistance of modern medicine. A distinctive and complex set of issues and questions associated with all aspects of the human condition emerged from this transformation (e.g., personal, professional, social, emotional, cultural, financial, ethical). Chronic illness, which may occur gradually or suddenly and without warning, is distinguished from acute illness by at least three different dimensions: illness duration, interference with ordinary functioning, and impact on quality of life (U.S. Dept. of Health and Human Services, 2010). The National Center for Health Statistics considers an illness chronic if its duration exceeds three months (National Center for Health Statistics, 2007). Some chronic conditions may have relatively stable courses; others may be progressive

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(Atwood & Gallo, 2009). In all cases chronic illness can significantly impact physical, psychological, and social functioning and overall quality of life for ill individuals and their families (Dobbie & Mellor, 2008). Moreover, treatment itself can result in impairments that interfere with an individual’s identity, development, and lifestyle. Accordingly, the emphasis of treatment is on effective management of the symptoms or residuals of disease (Cameron & Leventhal, 2003). The severity of the burden of a chronic illness varies considerably depending upon multiple contextual variables. The most prevalent chronic diseases with severe impact include arthritis, cancer, dementia, diabetes, epilepsy, heart disease, respiratory illness, stroke, substance abuse, and AIDS (Centers for Disease Control and Prevention & The Merck Company Foundation, 2007). Additionally, while many chronic conditions are of no consequence to one’s life span, some are potentially life shortening or fatal. Although the clinical indications that a disease or condition has progressed to a point at which curative therapy is no longer desired or viewed as an option can vary greatly from patient to patient, there is general agreement that this period (commonly referred to as the “end-of-life”) is marked by: (1) the presence of a chronic disease(s), worsening symptoms, or functional impairments that diminish one’s health; and (2) the requirement of care for a disease or impairment that can lead to death (National Institutes of Health, 2004). For some individuals the end-of-life period unfolds over a span of one or many years; for others its onset is very rapid and its course brief. In all cases, the fundamental aim of care during the end of life (i.e., end of life care) regardless of its duration is to enhance comfort and well-being. Hospice and palliative care are the foremost treatment models for the care of individuals and families facing end-of-life issues. Their conceptual and practical overlap—with one another and with acute care—is described in the remainder of this section.

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Definitions of hospice care and palliative care differ by country and practice setting, obscuring their distinctions and similarities, and in turn adding a layer of ambiguity and concern for those considering their use.This challenge even exists within the medical profession itself. Among medical professionals, confusion about the distinctive yet complementary aims and roles within the palliative care and hospice models contributes to an unnecessary division between the fields and a related misperception that the goals of palliative care and acute care are mutually exclusive (Byock, 2012; Meier & Brawley, 2011; Pattison, 2011). During the past two decades, practitioners and leading scholars in the overarching field of end-of-life care have strived to educate people (both the general public and professionals) about its many components and their beneficial outcomes as well as its valuable fit with acutecare medicine, with its primary aim of curing disease. This body of work has articulated the essential distinction between hospice and palliative care as being largely one of scope, with hospice care generally viewed as a specialized subset of palliative care. According to the National Hospice and Palliative Care Organization (2012), hospice services, which include “pain management, and emotional and spiritual support expressly tailored to the patient’s needs and wishes,” are available to “patients with any terminal illness” and their loved ones, and are most frequently provided in patients’ homes (p. 3). The overarching goals of hospice care are to help people who are dying to live their remaining days in peace, comfort, and dignity, and to support families during the ill person’s life and after her or his death. The World Health Organization (WHO) describes palliative care as an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical,

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psychosocial, and spiritual (WHO, 2012). Given its comprehensive scope of care, palliative care is best provided by a collaborative team of professionals from multiple disciplines (e.g., medicine, nursing, social work, physical therapy, chaplaincy, nutrition) who work together to address the needs of sick individuals and their families (Borasio, 2011). Palliative care addresses all aspects of the illness experience (e.g., physical, psychological, social, spiritual, existential, legal, ethical, cultural) for everyone affected by it. This includes not only individuals who are living with a disease, injury, or condition that has adverse effects on their functioning and well-being but also family members and significant others who provide them with support. Clinical practice guidelines developed by the National Consensus Project for Quality Palliative Care (2009) recognize that even palliative care professionals are affected emotionally by their engagement with those to whom they provide services. Although its philosophical underpinnings, goals, and care delivery approach are similar to those of hospice, palliative care is not limited to individuals who are terminally ill or expected to die soon (i.e., within a specific period of time) or for whom medical treatments are/are no longer considered “curative.” Rather, palliative care services are designed to address the needs and concerns associated with any serious illness and at any point in the illness experience (e.g., at diagnosis, at onset or completion of treatment, at end of life). Palliative care interventions can be integrated with disease-specific treatments, such as dialysis or chemotherapy, to alleviate symptoms and enhance well-being (Byock, 2012; University of Minnesota Center for Bioethics, 2005). demographic Patterns Although estimates of the incidence of serious and chronic illnesses (i.e., their frequency) and prevalence (i.e., the number of those affected at a given time) vary, the relative contribution of severe and chronic illnesses to mortality and

morbidity has increased over the last several decades (Anderson, 2010; Brault, 2008). Prevention of many infectious childhood diseases and improved technology for the care of newborns and infants has allowed survival even for those with serious health problems and disabling conditions. One in six children younger than 18 years of age has a chronic illness (Wise, 2007). Many children, who previously would have died as a consequence of their illnesses, now survive into adulthood. In the United States today more than 145 million people (45 percent of the U.S. population) live with a chronic condition (e.g., diabetes, bronchitis, or arthritis); the most common chronic condition is hypertension (Anderson, 2010). In the United States, the proportion of individuals with multiple chronic conditions increased from 24 percent in 2001 to 28 percent in 2006 (Anderson, 2010). Among this population of individuals with multiple chronic conditions, nearly one-third report being unable to carry on their major activity as a result of these conditions. In the United States overall, the proportion of people living with disabilities (Brault, 2008) or multiple chronic conditions (Anderson, 2010; U.S. Dept. of Health and Human Services, 2010) is increasing. Interestingly, the proportion of individuals reporting activity limitations due to chronic diseases has remained relatively stable, except for children under the age of 18. Even those who do not report significant impairments as a result of their chronic condition may live with the threat of longer-term limitations and impairments, higher health care costs, and days lost from work. As noted recently by two prominent health care analysts/scholars, “What ‘progress’ has given us is an enhanced ability to keep sick people alive at a high cost financially and a no less high cost in terms of pain and suffering at the end of life . . . a kind of perverse and very temporary kind of indefinite longevity. We have new and usually painful—not to mention costly—ways of keeping very sick people alive just a little bit longer” (Callahan & Lawler, 2012, pp. 2–3).

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Individuals with serious, chronic conditions are at greater risk for being underinsured (Schoen, Doty, Collins, & Holmgren, 2005), which means they are more likely to incur high out-of-pocket costs for medical services relative to their family income. For those individuals who are poor, lack education, and are from ethnic/racial groups that experience ongoing and structural disenfranchisement, the risks accompanying serious illness and disability are even higher. For example, despite extensive evidence that thorough prenatal care greatly decreases the risk of mortality and morbidity for infants, it is least likely to be obtained by women who are poor, unmarried, young, not well educated, living in a rural area, or Hispanic (Bengiamin, Capitman, & Ruwe, 2010). Poor children are likely to have more illnesses and more severe illness than their nonpoor counterparts (Allen, Vessey, & Schapiro, 2009). Social context Because the prevalence, complexity, and chronicity of serious medical illness has steadily increased in tandem with major advances in medicine and technology, leaders from the fields of health care, public policy, and related fields have been forced to analyze this paradox. An extensive reevaluation of health care interventions, programs, policies, and systems as well as the values and beliefs that shape them has been underway for the past several decades. This work has yielded greater recognition of the wide-ranging effects of serious illness on individuals, families, communities, and society as a whole. In turn, there is evidence of a fundamental shift away from an almost exclusive focus on the biological nature of health problems toward an expansive exploration of the myriad social, psychological, and cultural contextual variables that intersect with the biological. This more holistic and comprehensive focus includes professional and societal reexamination of definitions of health and illness as well as the emphases and parameters of health care interventions. Because a comprehensive

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understanding of the interface among individual-, family-, and societal-level factors is a hallmark of social work practice, social workers are uniquely committed and trained to help people successfully navigate these distinctive circumstances. In the absence of comprehensive and meaningful health care policies and legislation, noteworthy advances in medical knowledge and treatments have been insufficient to improve the quality of care for all people affected by serious physical illness. In a bitter irony, the health care system of the United States, which is among the wealthiest of the world’s nations, is riddled with significant problems that contribute to the presence of enormous health disparities. Major impediments to health care access, supportive services, education, housing, and employment continue to affect the health and quality of life of millions. Additionally, available services vary tremendously from one disease to another. For example, the presence of an interested specialist or a particular comprehensive clinic can mean a dramatically higher level of services for one condition than for another in the same locale. The gaps in the continuity of services are often reflected in a lack of communication and coordination of services among providers for effective care of these complex diseases and conditions. The dominant culture in American society continues to place a high value on those who go through challenging life experiences such as illness unscathed, are able to bounce back, and then continue life without missing a beat, at least in any visible or observable way (Siegel & Christ, 1990). Even in the case of terminal illness, there is ample evidence of a societal emphasis on “independence,” “fortitude,” and “action.” Also valued is the concept of dying with dignity. But this is not necessarily the experience of most individuals with serious, chronic illness. While life has been prolonged, ongoing impairments coupled with the very real threat of later exacerbations challenge individuals to maintain their relationships and

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a meaningful quality of life in the midst of great uncertainty. Serious physical illnesses constitute transformative experiences in individuals’ lives that can alter not only their view of the world but also the way they view themselves. This latter assault on identity is a fundamental source of suffering for individuals living with serious and chronic illness (Charmaz, 2008). There are few social role models in the dominant culture for living with the day-to-day rigors of managing a chronic deteriorating illness with dignity and meaning. Societal attitudes often shape the kinds of services provided to, or withheld from, individuals affected by illness and disability. For example, with medical advances, increasing numbers of cancer patients were cured. However, the intensive treatments sometimes led to disabling physical and psychological conditions. These conditions could occur months, even years after cancer treatment and patients encountered numerous obstacles to obtaining medical care for these late effects. Having cured a serious and life-threatening disease, physicians wondered what more the patient could expect of them. The patient’s perspective was quite different. Knowing they had a longer survival time, they were more concerned about physical problems caused by the treatments that impeded their quality of life. They wanted the loss of body parts, vision and hearing problems, and cardiac conditions to be rehabilitated. They wanted symptoms such as depression, anxiety, loss of energy, and other psychological symptoms to be treated. As the number of survivors increased, they were able to effectively advocate as a group of patients with knowledgeable professionals for attention to the residual psychosocial as well as physical effects from their disease and treatment (Christ, 1987). Society’s values also shape the solutions provided for quality-of-life problems. For example, society values maximum independence for individuals with disabilities and often proposes to foster this with technological assists. However, someone may prefer a home health aide

who provides socialization rather than technological assistance that enhances independence but requires isolation. Quality of life implies an individually defined situation, and availability of a broad range of service options is required to accommodate the wide array of individual values and choices. Programs of comprehensive medical and social support services are needed to treat chronic illnesses as well as disabilities of all kinds (Au et al., 2011; Boult & Wieland, 2010; Rapp & Goscha, 2004). However, despite the prevalence of chronic conditions, the predominant focus of the U.S. health care system remains the treatment of infectious diseases and acute illnesses rather than the provision of treatment and care systems that can more adequately address these longer-term health problems. Treatment and rehabilitation programs that are community based rather than institution based are integral to making services accessible over a longer period of time. Interventions that enhance communication between multiple specialists enable the sharing of treatment information and expertise essential to effective treatment and continuity in care. In the current social milieu, management of serious medical illnesses and conditions is associated with greater numbers of people becoming more informed and active participants in their own health care. Although many people continue to rely primarily on the information and guidance offered by a primary care physician or specialist overseeing their treatment, many others turn to other sources of information at some point during their illness. Greater numbers of individuals seek second and third opinions about their diagnosis, prognosis, and recommended treatment. Many people now use the Internet as a mechanism for conducting their own research and for sharing illness-related information and experiences within what Conrad and Barker (2010) describe as illness subcultures and illnessbased social movements. Significant demands

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are also placed on family members and other informal caregivers who provide an astonishing level and variety of care for their loved ones. In the United States alone it is estimated that more than 42 million individuals take on this responsibility. According to a report published by the United Hospital Fund and the AARP Public Policy Institute (Reinhard, Levine, & Samis, 2012), almost half of family caregivers in the United States perform medical and nursing tasks including management and administration of intravenous medications, wound care, and operating and monitoring specialized medical equipment. Caregiving of this nature has significant emotional costs. In one study, family caregivers who reported high levels of emotional or physical strain associated with caregiving had nearly two-thirds higher risk of dying in a four-year period than age-matched controls (Byock, 2012). Vulnerabilities and risk factors Both adults and children with chronic illnesses and disabilities are at greater risk of experiencing a broad range of psychological and social problems than individuals who do not have these conditions. Although most research on the psychosocial consequences of chronic illness has occurred within particular disease categories, some consensus has emerged about vulnerabilities and special needs across diseases for both children and adults. Social workers must be aware of factors and characteristics that make some individuals more vulnerable than others so that they can fully appreciate both the quantity and the quality of stress experienced by each individual and structure their interventions to mitigate the impact of vulnerabilities. Identified vulnerabilities and risk factors include (1) demographic factors, (2) functional status and illness and treatment symptoms (3) psychological symptoms, (4) coping style/capacity, (5) social support networks, (6) professional relationships, (7) illness appraisals and attributions, and (8) concurrent and cumulative stresses.

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Managing a serious physical illness can be an expensive process; therefore, individuals with fewer or limited access to resources have greater problems with out-of-pocket costs associated with health care procedures, equipment, and community-based services intended to facilitate healing and adjustment to adaptive challenges. Individuals from poorer areas are more vulnerable to chronic illness and disability and are more severely disabled by their illnesses. There is also substantial evidence that people from “minority” racial/ethnic groups receive poorer health care and exhibit poorer health outcomes than whites (Betancourt, Green, Carrillo, & Ananeh-Firempong, 2003; Bloche, 2012). In fact, Crawley (2005) asserts that “[w]e now have documented evidence of disparities in almost every area of health care” (p. 1). In a large national study that examined family members’ retrospective perceptions of a deceased relative’s end-of-life medical care (Welch, Teno, & Mor, 2005) relatives of African American decedents were: (1) less likely than those of white decedents to rate the care their loved one had received as excellent or very good and (2) were more likely than those of white decedents to report having experienced communication-related problems with their loved one’s physician. Research continues to document the importance of education in maintaining health and length of life (Olshansky et al., 2012). A recent study reported that white American men and women without high school diplomas now live an average of 67.5 and 73.5 years respectively while the most educated white men and women—those with a college degree or more— live 80.4 and 83.0 years respectively, a difference of about a decade for both genders. In fact the life expectancy for those with limited education has declined over the past decade. Some suggest causes include a lack of access to health insurance that is more prevalent among lesseducated individuals, lack of knowledge about appropriate uses of medication and the complex demands of current treatment protocols,

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and the tendency to engage in high-risk behaviors such as smoking, excessive drinking, and eating that lead to obesity. Literacy and especially health literacy is a significant benefit in helping individuals take an active role in their own care (Bailey, McCormack, Rush, & Paasche-Orlow, 2012). Patients are increasingly being given more responsibility for decision making about their treatment and care in the emerging health care system. Without access to information about current treatments for a specific condition and best health practices, an individual’s capacity to manage illness and disability is severely limited (Schulman-Green, et al., 2012). Individuals with less education also have more difficulty negotiating with health professionals and managing the complex demands of current treatments. The role of gender in facilitating adaptation to chronic illness varies by type of illness, but women are better able to adapt to some illnesses than their male counterparts (Siegel & Christ, 1990). Age is also an important demographic factor. Each stage in development brings its own particular adaptive challenges. For example, younger individuals are more vulnerable to emotional distress when confronting chronic illness. Disease is less expected in younger ages and presents an interference with important normative life tasks of the young adult. Older individuals are more vulnerable to difficulty managing physical realities such as comorbid conditions related to aging, and resolving practical problems in functioning. Their experience of comorbidities or multiple illnesses and disabilities can lead to what is called polypharmacy, the use of multiple drugs, some of which may be unnecessary and interact with others in negative ways. Older adults may have more experience in managing illness and stress, but they are more vulnerable to the presence of concurrent illnesses and increased limitations in their functional capacities. Specific aspects of the illness and treatment experience can create vulnerabilities across the continuum of care. More recent research has

documented the importance of providing surveillance and psychosocial interventions during critical transitions in chronic illness or when there are changes in the disease and treatment process (Coleman, Parry, Chalmers, & Sungjoon, 2006; Fann, Ell, & Sharpe, 2012; Pai & Schwartz, 2011). Individuals and families need psychosocial as well as medical surveillance and support after a period of acute treatment to assist them in creating a “new normal” as they learn to live with the impact of the disease process and its treatment on their psychosocial and physical functioning. For example, a proposed intervention for individuals with cancer who have successfully completed acute treatment is the creation of a “medical home” that provides ongoing medical and psychosocial support during the ensuing phases of the illness experience. The greater the functional limitations imposed by illness, the greater the degree to which an individual must confront the struggle of dependence versus independence and rely more on informal caregivers. The greater the uncertainty of the outcome of the illness, the more psychological distress the patient experiences (Fortier, Batista, Wahl, Maurer, & Kain, 2012; Haisfield-Wolfe et al., 2012; Kurita, Garon, Stanton, & Meyerowitz 2012). Individuals with illness or treatmentrelated neurological and sensory impairments experience greater difficulty secondary to diminished coping capacities. Some conditions require intensive and life-threatening treatments such as organ transplantation. Each phase or stage of an illness brings its own challenges and every individual’s experience of these is unique. For example, leaving the many resources of the acute-care hospital can be stressful for many individuals, especially those who live in communities with limited or difficult-to-access resources. Adults with chronic illness are at greater risk for experiencing depression, as well as other psychological symptoms in response to the impact of their disease and treatment. Some illnesses, most notably AIDS, and some cancer diagnoses have higher rates of suicide (Johnson, Garlow, Brawley, & Master, 2012; Marks & Rosielle, 2012).

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And while there is great variability in children’s response to chronic illness, they are about twice as likely to develop some form of psychiatric disturbance relative to their healthy peers (Mitchell, Vahabzadeh, & Magruder, 2011). Individuals with chronic illnesses may be at risk for psychiatric disturbances that need to be identified and treated. Individuals with mental illnesses are also more likely to have chronic medical conditions. Clearly the individual’s mental illness is an added vulnerability and risk factor for compromised adaptation to physical illness. Individuals who do not use active coping strategies such as reaching out for information and support, who have low self-esteem, and who do not perceive themselves as able to master the demands of their illness are more likely to experience depression and other indicators of compromised adaptation (Nezu, Nezu, Felgoise, McClure, & Houts, 2003). Problem solving and teaching problem-solving skills for meeting the challenges of illness have been found to be effective interventions that reduce patients’ distress and facilitate their adaptation to their illness condition. (Nezu et al., 2003; Zabora, 2011) The importance of social support, that is, help from family, friends, and community, in facilitating adaptation to illness is noted in many studies (Taylor, 2007). One’s perception of the quality of this social support appears to protect chronically ill individuals from severe depressive symptoms. However, the particular aspects of that support that are needed for a given illness may vary—for example, emotional support seems more helpful for individuals confronting a life-threatening illness, whereas more instrumental or practical support is required by individuals who are struggling with functional disability (Penninx et al., 1998). For children, the family environment is the more critical support network. More family conflict and less cohesion in family functioning create a greater risk for compromised adaptation to chronic illness (Drotar, 1997). School and community support systems that do not make adequate accommodations for the child with a chronic illness or

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disability to succeed as he or she matures also increase the ill child’s vulnerability to adaptive failure. Social isolation has been identified as a consequence of the vulnerabilities of some children with chronic illness. The following example illustrates how limitations in social support and education as well as a lack of psychosocial interventions at critical transitions in patient care can limit a patient’s ability to function over the course of a chronic illness. Thirteen-year-old Susan was from a small rural community. Neither her parents nor her older siblings had completed high school, and she was the youngest in the family. Prior to her development of osteosarcoma she had been achieving high grades in school, was an ice-skating champion, and had been chosen as a class officer. After her successful knee replacement and chemotherapy, she became fearful of returning to school. Her parents were unaware of the problems of her giving in to this fear and they permitted her to remain at home. The school system had no home tutoring program. As time went on she fell further behind in her work and became isolated from friends as she watched television all day. When evaluated at age 17 years, she had never returned to school. At that time she had decided to get married and just obtained a job at a local supermarket. Her surgery was successful, her disease cured, but her disability was profound. Some studies suggest that the professionals’ relationship to the chronically ill client influences their ability to adapt to rigorous and long-term treatment protocols as well as medical crises (Troug, Christ, Browning, & Meyer, 2006). The relationship of professionals to the chronically ill individual can now extend over many years. In a study of children with diabetes, mothers who reported greater perceptions of racism and family stress were significantly less satisfied with their children’s medical care than those from less stressful environments (Auslander, Thompson, Dreitzer, & Santiago, 1997). Those mothers who perceived racism also had greater difficulty adhering to the required treatment protocol. This

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finding emphasizes the importance of families’ relationships with professional staff in facilitating treatment effectiveness. Families also report distress when professionals fail to acknowledge their unique tragedy during medical crises and the professional is perceived to make insensitive or critical comments about their efforts to cope. Increasingly, studies have focused on how individuals’ way of thinking about their illness affects how they feel about it and how well they adapt to it. Their level of optimism that treatments will be effective, their belief in their ability to master the many physical and psychological challenges of the illness, and their ability to maintain selfesteem while transforming identity in ways that integrate the realities of their medical condition do seem to influence their ability to adapt. Ongoing negative thoughts about the self and the illness are correlated with continuing depressed mood (Schiaffino & Revenson, 1995). Pollin (1994) identified eight fears that she believed individuals with chronic illness confront: (1) loss of control, (2) loss of self-image, (3) loss of independence, (4) stigma, (5) abandonment, (6) expression of anger, (7) isolation, and (8) death. She proposed a brief treatment to help individuals cope with these specific fears. Finally, individuals who struggle with many other stresses in their lives as well as the chronic illness, face additional adaptive challenges. Some families experience a “pileup” of stressors (McCubbin, Thompson, Thompson, & Fromer, 1998) or “cumulative stresses” often secondary to or exacerbated by the chronic illness condition. Others experience concurrent stresses unrelated to the patient’s illness. These might include other illnesses or deaths in the family, severe financial problems, or other major losses. These additional stresses can make it more difficult for individuals to adapt to the psychological and practical demands of the illness. resiliencies and Protective factors Identifying vulnerabilities and risk factors for individuals with chronic illness and disabilities

has been accompanied more recently by a search for characteristics associated with individuals who adapt well to their illness. Becoming more active in identifying strengths, factors that seem to protect individuals from adverse consequences of the stresses of illness, and characteristics of resilience that can foster individuals’ ability to cope with chronic illness has increased significantly over the past decade. This has led to a focus on “coping resources” and other factors that are associated with better adaptive outcomes. This is critical in order to be able to develop interventions that aim at ways to increase resilience and strengths, to prevent coping failures as well as to mitigate the impact of vulnerabilities. Research has shown that those who cope well with stress, whether it be a serious illness, job loss, or a natural disaster, are those who don’t deny the adversity or tragedy of the situation, but who are also able to see it as a challenge, to make positive changes in their life and their relationships, and who can derive some positive meaning out of the situation. This is an empowering process that provides the individual with the critical tools of sense of mastery and self-efficacy, and improved self-esteem. Facilitating this process is an important role for social work. Resilience and protective factors are the converse of vulnerabilities and risk factors. Adults who adapt well to chronic illness use active coping strategies such as engaging in a partnership and dialogue with professionals about their condition. They tend to have more economic and educational resources. They work actively to identify specific problems caused by each stage in the illness process, and they focus on resolution of associated problems. While acknowledging the losses and disappointments in their situation, they view it as a challenge, and they consider ways to develop a positive meaning of this experience, using it as a source of personal growth and learning (Nezu et al., 2003; Zabora, 2011). A perception of strong social support is another characteristic associated with better adaptation. Better-adapted individuals reach

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out for help and assistance from a broad range of individuals outside the family and have families who are highly supportive of their efforts to “keep the illness” in its place rather than permitting it to dominate their total life experiences. Their reaching out often seems to signify a recognition of the reciprocal nature of the recovery process. They feel a sense of self-efficacy, empowerment, and less conflict with their level of dependence. They feel good about what they have accomplished and are able to identify and value their positive attributes. They recognize that life has changed and they seek to integrate that reality into their future plans. This is often described as establishing a new normal. The better-adapted individuals have large support networks that include other patients, family, and friends as well as professionals. They often seek self-help groups for information and normalization as well as emotional release. Social work’s strong tradition of a strengths perspective has clear and relevant application to promoting adaptation to illness. It is described well by Saleebee’s (2006) description of the “CPR” strengths approach as a triangle, showing the interconnectedness of core life elements that he believes must be part of social work assessment and intervention (Cadell, Shermak, & Johnson, 2011). The letter C represents competencies, capabilities, courage, and character. In chronic illness strengths such as character can be valued and supported in assisting individuals to master the rigors of treatment, recovery, and rehabilitation from a broad range of illnesses and disabilities. Building on remaining capacities can be powerful in creating a sense of competence often lost over the course of a lengthy illness. P of CPR signifies promise, purpose, possibility, and positive expectations. While some things may not be changed in chronic conditions, patients benefit from embracing new possibilities and realistic hope for finding new approaches, meaning, opportunities, value, and esteem in their situation. Finally R in CPR stands for resources, resilience, relationships, resourcefulness,

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resolve, and reserves. Relationships are of particular value to those facing chronic, potentially life-limiting illnesses both in their personal and professional networks in combating isolation and fear and providing a sense of value, normalcy, and human connection. These protective factors and characteristics of resilience are reflected in the range of interventions and programs being developed and implemented by social workers in their ongoing work with individuals and families living with serious illness. Information about the outcomes and effectiveness of many of these interventions is systematically collected and examined through the mechanism of scientific research studies. As importantly, their clinical relevance and impact is always closely monitored and evaluated by social work practitioners and administrators as a routine component of service delivery. Programs and Social Work contributions Social workers provide service to individuals and families affected by serious illness in a wider array of practice settings than was true just a decade ago. While many services relevant for this population continue to be located within acute-care medical and longterm nursing-care facilities, a sizable number are now offered outside these traditional health care settings under the auspices of communitybased programs with a broader, more holistic focus on psychosocial issues (Egan & Kadushin, 1999). Across service settings, however, effective social work practice with this population includes a set of fundamental roles and associated tasks/interventions. These include: (1) outreach and assessment, (2) advocacy and provision of individual and family-centered care, and (3) support and collaboration with health care colleagues. The patient and family-centered care initiative has been promoted in health care settings over the last decade since the Institute of Medicine (IOM) issued its landmark report Crossing the Quality Chasm: A New Health System for the 21st Century. The goal was to transform health

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care through accomplishing six aims. One of these six aims that is integral to all others was defined as providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions. (Institution of Medicine, Committee on Quality of Health Care in America, 2001). In 2010 the Joint Commission released new standards and revised existing standards by which hospitals would be evaluated on their ability to incorporate patient-centered care. Patient and family-centered care places an emphasis on collaborating with patients and families of all ages, at all levels of care, and in all health care settings. “Further, it acknowledges that families, however they are defined, are essential to patients’ health and well-being and are allies for quality and safety within the health care system” (Newman & Medeiros, 2013). This approach includes equitable, coordinated, and integrated culturally competent care; timely, candid, and useful information; communication and education; individualized care; physical comfort; emotional support; involvement of family and friends; shared decision making and collaboration with patients and families in the planning delivery and evaluation of care (Newman & Medeiros, 2013). This patient and family-centered care initiative is syntonic with the social work role, values, and practices and as such provides a strong support for social work functioning and social work leadership to assist in changing the institutional environment to be more responsive to patients and families. In hospitals, one intervention used to accomplish this mandate is the patient and family council; these councils offer an institutionally supported structure for the provision, review, and development of programs and initiatives that address the needs of sick individuals and their families. Patient and family councils may include the use of family meetings to facilitate communication and social work advocacy to give voice to patient and family concerns and questions. Social workers can provide leadership

in promoting patient and family-centered care within health care by implementing programs such as family councils that advocate for their voice to be heard on all aspects of the structure and delivery of health services. Social workers in health care settings work both independently and collaboratively as members of interdisciplinary teams to provide efficient and quality services to individuals and families around their practical, psychosocial needs. In the acute-care medical setting with a central focus on curing serious illness, the personal voice and concerns of the patient and family and the psychosocial/cultural perspective about their situation may be minimized or at times altogether missed. The social worker is a champion of the psychosocial perspective within this context, taking every opportunity to: 1.

2.

3. 4. 5.

6.

heighten awareness of psychosocial needs across the continuum of care including transitions in care and changes in illness, or family/community contexts. become active in programs that facilitate the coordination and continuity of care from inpatient to outpatient and community, from diagnosis through treatment and posttreatment rehabilitation, through illness exacerbations, advanced conditions, terminal illnesses, and bereavement. create opportunities for team discussion of the personal and familial responses to serious illness. alert other professional staff to psychosocial risk factors for patient and family adaptive failures. provide continual assessments of individual and family vulnerabilities and strengths in order to ensure needs are met and resources that support their coping are accessible and relevant. develop counseling support programs that validate individuals’ and families’ need for help with problem solving around changes and choices associated with illness and treatment.

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7.

collaborate with colleagues from other disciplines who work directly with psychosocial/cultural dimensions of care (e.g., chaplains, nurses, other mental health professionals, physical therapists, care coordination professionals, child life workers, patient navigators) and can assist in bringing the individual and family voice into every discussion. 8. create and facilitate programs that validate the impact on staff of exposure to human suffering and loss associated with work in the field of serious illness and assist staff in building and enhancing resilience that will allow them to remain effective caregivers. 9. advocate for development of family councils that can provide an ongoing mechanism for individuals and families (i.e., consumers) to voice their concerns, ideas, and suggestions about best practices and ways to improve patient and family care. 10. address misperceptions and knowledge gaps about what social workers do to colleagues from other disciplines—especially those with whom we collaborate as members of health care teams. In addition to these vital roles and tasks, social work practice with individuals and families living with serious illness also incorporates therapeutic techniques and strategies with demonstrated effectiveness in addressing many of their most salient concerns. Following are brief summaries of several of these evidencedbased interventions and their associated benefits for individuals and families coping with serious illness. Problem-solving therapy (PST) has been used effectively with multiple populations, including children, older adults, and Spanish-speaking populations (Areán et al., 2010; Fann, Fann, & Unützer, 2009; Gellis & Bruce, 2010; Seid, Varni, Gidwani, Gelhard, & Slymen, 2011). Problem-solving therapy has been found to be effective for helping individuals cope with serious illnesses. PST has been shown to be

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effective for reducing depressive symptoms among individuals coping with cancer (Fann, Fan, & Unutzer, 2009; Hopko et al., 2011; Nezu et al., 2003), cardiovascular disease (Gellis & Bruce, 2010), Parkinson’s disease (Mackin, Areán, & Elite-Marcandonatou, 2006), and major depression (Areán et al., 2010; Chibanda et al., 2011). Studies with individuals who have cancer (Nezu et al., 2003) and asthma (Seid et al., 2011) also indicate PST can improve their overall quality of life. Caregivers of persons with cancer, traumatic brain injury, and other chronic illnesses also reported reductions in depressive symptoms from interventions utilizing PST (Eccleston, Palermo, Fisher, & Law, 2012; Nezu et al., 2003; Wade et al., 2012). Cognitive behavioral therapy (CBT) delivered in a group modality has been found to reduce symptoms in persons with serious illnesses. Group CBT reduced depressive and anxiety symptoms in children with ADHD (Waxmonsky, et al., 2012) and autism spectrum disorders (Reaven, Blakeley-Smith, Culhane-Shelburne, & Hepburn, 2012), and adults with multiple sclerosis (Forman & Lincoln, 2010; Sinclair & Scroggie, 2005). In addition, there is some evidence that individuals diagnosed with cancer found group CBT to be helpful for reducing fears of their disease progressing (Herschbach et al., 2010). Group CBT has also been reported to improve overall quality of life among persons with bipolar disorder (Costa, Cheniaux, Range, Versiani, & Nardi, 2012). Group CBT was also effective in reducing physical symptoms. The positive impact of group CBT on reductions in heart attacks among those with heart disease (Gulliksson et al., 2011; Saab et al., 2009) and improvements in glycemic levels among individuals with diabetes (Weinger et al., 2011) have been reported. Studies from other countries indicate that mindfulness-based therapy could be a promising intervention for use with individuals diagnosed with serious medical illnesses. Cancer patients in Australia who received MBT reported reductions in anxiety and depressive symptoms

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(Chambers, Foley, Galt, Ferguson, & Clutton, 2012; Sharplin et al., 2010). They also reported improvements in avoidance behavior and use of mindfulness skills (Chambers et al., 2012). Additionally, findings from Canada provided some evidence that MBT improved sexual functioning among women with gynecological cancers (Brotto et al., 2012). Psychoeducation appears to be a promising intervention for persons suffering from serious illnesses. Time to dialysis was shown to improve for patients with kidney disease in a nurse-led psychoeducation intervention (Devins, Mendelssohn, Barre, & Binik, 2003). In addition, cancer patients who had received nurse-led psychoeducation reported reduced psychological distress (Allard, 2007; Park et al., 2012), improved mood (Bakitas et al., 2009), better ability to manage pain (Allard, 2007; Miaskowski et al., 2004), and improved quality of life (Meneses et al., 2007; Park et al., 2012). Nurse-led psychoeducation may also help patients with diabetes adhere to their medications and reduce their depressive and anxiety symptoms (Haynes et al., 2008; Penckofer et al., 2012). Recent studies in the social work literature also indicate psychoeducation interventions may be useful for working with persons suffering from serious illnesses. An online psychoeducation group for adolescents with diabetes indicated that psychoeducation could potentially improve participants’ social relations, decrease isolation, and increase knowledge regarding diabetes (Nicholas et al., 2012). A study by Pomeroy, Kiam, and Green (2000) reported that a psychoeducation group intervention with male inmates was effective in increasing knowledge of AIDS and decreasing depression, anxiety, and trauma symptoms. In addition, there is some evidence that persons with bipolar disorder who participate in a psychoeducation intervention can improve their general impulsivity and reduce the instability of their relationships (Zanarini & Frankenburg, 2008.)

Family psychoeducation therapy has been shown to be beneficial for people affected by the stresses associated with many chronic conditions. A culturally based family psychoeducation intervention was found to decrease stigma, increase coping skills, and improve empowerment skills among Korean American families with children suffering from chronic mental illnesses (Shin, 2004). Barrio and Yamada (2010) also reported that a culturally based family psychoeducation intervention could improve illness knowledge and reduce family burden in Latino families coping with schizophrenia. Another study indicated a family psycheducation group was effective in improving social functioning and family relations in families coping with major depression (Sanford et al., 2006). Support groups have been shown to be effective in improving the psychosocial functioning of persons with serious illnesses. There is evidence that support groups can decrease depressive symptoms and improve social support among HIV youth and their caregivers (Smith Fawzi et al., 2012). In addition, support groups could improve the morale and quality of life of cancer patients (Gottlieb & Wachala, 2007). Furthermore, the literature indicates that support groups can help reduce anxiety in patients with schizophrenia (Larsen-Barr & Owens, 2012) and improve caregivers’ burden (Chien, Thompson, & Norman, 2008). Peer support groups were also found to be effective in reducing depressive symptoms among those with major depressive disorder (Pfeifer et al., 2011). Individual psychotherapy has been shown to reduce depressive symptoms in individuals with major depression (Mohr et al., 2012; Moritz et al., 2012; van der Zanden et al,. 2012). Studies also indicate individual psychotherapy can produce promising outcomes when delivered via face-to-face, phone, or online (Mohr et al., 2012; Moritz et al., 2012; van der Zanden et al., 2012). Among persons with panic disorder, individual psychotherapy has been found to be effective in decreasing panic symptoms and comorbid depressive and anxiety

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symptoms (Silfvernagel et al., 2012). Adults with Tourette’s syndrome found individual psychotherapy to be helpful in decreasing the number of tic episodes they experienced (Wilhelm et al., 2012). Furthermore, there is evidence that individual psychotherapy can reduce anxiety among patients with terminal cancer (Greer et al., 2012). Cancer patients undergoing surgery also reported reductions in their pain anxiety after receiving individual psychotherapy (Snow et al., 2012). Family therapy has been used to improve the lives of individuals and their families suffering from a serious illness. A randomized controlled trial of persons with schizophrenia and their family members indicated that family therapy contributed to fewer clinical relapses and hospitalizations, and improvements in positive and negative symptoms, social role performance, social relations, employment, and family burden (Girón et al., 2010). Individuals with obsessivecompulsive disorder also reported that family therapy was effective in reducing disease severity and functional impairment (Piacentini et al., 2011). Furthermore, in a study of depressed parents and their children, family therapy was found to be beneficial in reducing children’s selfreports of anxiety and depression and likelihood of developing major depressive disorder (Compas et al., 2011). There is also some indication that family therapy can decrease suicidal ideation and depressive symptoms among individuals who are suicidal (Diamond et al., 2012). In addition, among adolescents with anorexia nervosa, family therapy was found to be helpful in improving weight and menstrual patterns over time (Godart et al., 2012; Le Grange et al., 2012). One study indicated family therapy could help parents of children with autism increase their self-efficacy and advocacy skills (Banach et al., 2010). In-home support has been shown to improve the lives of persons with serious medical illnesses. Individuals with diabetes who are receiving in-home support have reported lower glycemic levels and improvement in blood pressure levels (Nguyen & DeJesus, 2011). In

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addition, children with asthma have reported more symptom-free days while receiving inhome support (Krieger et al., 2009). There is also some evidence that in-home support can reduce disease symptoms among persons diagnosed with acute psychiatric illnesses, such as mood disorders and non-affective psychosis (Singh et al., 2010). Furthermore, in-home support may be useful for reducing number of hospital visits and improving quality of life of individuals with dementia (Reilly et al., 2010). Activity camps have been shown to be effective in improving the quality of life of children living with serious illnesses. Most notably, activity camps for children with cancer have demonstrated positive psychosocial outcomes, improvement in depressive affects, and greater quality of life (Békési et al., 2011; Meltzer & Rourke, 2005; Wellisch et al., 2006) Youth living with HIV/AIDS who had participated in HIV/ AIDS-specific activity camps reported less isolation, greater feelings of reprieve, and increased knowledge, attitudes, and skills for coping with their disease (Gillard, Witt, & Watts, 2011). Children with epilepsy who participated in activity camps also reported improved adaptive behaviors and social interactions (Cushner-Weinstein et al., 2007). Furthermore, activity camps were found to be beneficial for improving the quality of life of children living with diabetes and arthritis (Békési et al., 2011). These groups have also been effective for bereaved children (McClatchey & Wimmer, 2012). Evidence indicates the delivery of multifamily group therapy (MFGT) online is both feasible and effective for families coping with serious illnesses (Chiquelho et al., 2011; Rotondi et al., 2010). In families coping with adolescent cancer, MFGT was shown to reduce posttraumatic stress symptoms (Kazak et al., 2004). Families with children suffering from asthma found MFGT to increase their knowledge of asthma and reduce their emergency department visits (La Roche, Koinis-Mitchell, & Gualdron, 2006). Additionally, MFGT has been shown to improve the likelihood

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that mothers with HIV would monitor their own health (Rotheram-Borus et al., 2004). Children of HIV-positive mothers who had participated in MFGT were also found to be less likely to use drugs than children of HIVpositive mothers who had not participated in MFGT (Rotheram-Borus et al., 2004). illuStrAtion And diSCuSSion

Shelly is a 63-year-old woman who has lived with insulin-dependent diabetes for many years. She currently lives alone in one unit of a two-family home, which she has rented for many years. Although she was quite debilitated at the time of her initial diagnosis (at age 19) and required several weeks of inpatient medical care, Shelly’s condition and overall good health have remained mostly stable as a result of regular visits to her doctor and adherence to her medically prescribed treatment plan. Two instances over the course of her illness are noteworthy exceptions: (1) At 24 years of age, during her senior year of college, Shelly required a brief overnight stay in a community hospital for treatment of dehydration resulting from high blood sugar levels, and (2) At age 50, she required emergency room treatment (i.e., stitches) for a head wound incurred during an accidental fall from a treadmill while exercising; lab results at the time indicated high blood sugar levels as the cause. Two years ago, Shelly’s primary care physician, who provides services through an outpatient clinic at the local hospital, expressed concern that Shelly’s routine lab results were suggestive of an increasingly elevated risk for heart and kidney disease. Together they reviewed Shelly’s treatment plan and the physician recommended a slightly altered diet, which she hoped would lower this risk. Despite considerable efforts to follow her doctor’s advice, the course of Shelly’s diabetes became more complicated. New symptoms emerged (i.e., tingling and numbness in her feet) and old symptoms reappeared more frequently or with greater intensity. Simultaneously, per the reports of her adult son William, Shelly became depressed. According to him, it was around this time that Shelly began to withdraw from friends and

family members (even an older sister with whom she was quite close) and spent less and less time engaging in activities she typically enjoyed and found meaningful. Other than going to and from the local housewares store, where she had been an associate floor manager for nearly eight years, she spent much of her time alone. She had even cut back on the time she volunteered at a community center in a neighboring town, where many of its regular participants and staff—both young and old—considered her presence indispensable. Some of the youth who spent time in and around the center and generally kept other adults at arms’ length fondly addressed her by one or another nickname (e.g., “Momma Pearl”) they created especially for her. At her most recent doctor’s appointment, Shelly learned that she had developed significant heart and kidney disease as a complication of her long-term diabetes. Despite her doctor’s assurances that (1) these complications were not Shelly’s “fault” (e.g., they did not arise as a result of something Shelly did or didn’t do with regard to her diabetes management), and (2) the complications, though incurable, could be managed with additional treatments, Shelly was devastated by this news. For almost a week she didn’t talk to anyone about this. During an unexpected visit from William over the weekend, she tearfully disclosed the information to him. William expressed great concern for his mother and repeatedly asserted that he would do whatever he could to support her. The next morning, without his mother’s knowledge, William left an angry voice mail for Shelly’s doctor, accusing him of “malpractice.” William firmly believed that Shelly would not have developed heart or kidney disease if her doctor had been “taking appropriate care of her . . . the kind of medical care he probably gives to people who look more like his mother or grandmother.” After listening to the voice mail, Shelly’s doctor, who was surprised and upset by it, made two phone calls—one to the administrator he reported to in the clinic, and one to Shelly. Shelly’s story highlights many of the individual, social, cultural, and systemic issues commonly faced by those affected by serious illness. Her experience

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also includes myriad opportunities for social work intervention that could enhance and expand upon Shelly’s resources, mitigate areas of vulnerability and stress, and facilitate her quality of life. Using the previously described social work roles, associated tasks, and evidence-based data as a guide, a meaningful and effective intervention plan for Shelly is likely to include the following efforts: Social worker begins a comprehensive psychosocial and functional assessment (i.e., ability to manage activities of daily living, pain, and other physical symptoms that may respond to intervention) and specifically evaluates Shelly for depression and anxiety that might respond to treatments of those symptoms. Through this assessment, the social worker identifies areas of strength and resilience that Shelly had pulled from previously to cope with her disease, and explores why Shelly believes those or related strategies are not working for her now. Consideration is given to how Shelly’s current strengths and resources might be supported and enhanced going forward as well as the possibility that additional previously untapped resources might be available. Most important, the social worker directly asks Shelly about her major concerns, needs, and service requests. The social worker assesses Shelly’s understanding of her illness in general and her most recent medical test results within the context of having so successfully managed her diabetes for so many years. The social worker should pay careful attention for indications that Shelly may be experiencing self-blame, unrealistic helplessness or hopelessness, or misperceptions about her condition, which might interfere with her ability to focus on, plan for, and implement next steps in her health care. If these or other unhelpful cognitive constructs are present, the social worker can gently challenge them and support Shelly in developing newer, accurate thoughts that will facilitate self-efficacy and well-being. The social worker should also determine whether Shelly has experienced any stressful interactions with her health care providers, for which the social worker might intervene on her behalf. For example, the social worker could offer to (1) join Shelly during meetings with her providers,

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and (2) independently speak to providers on Shelly’s behalf to underscore her concerns and needs. The social worker acknowledges her son William’s concerns and suggests a joint meeting with both of them. The social worker explores Shelly’s perceptions of her son’s role in her health care and her level of satisfaction with his involvement. In a family meeting, the social worker assesses William’s understanding of Shelly’s condition and his ability to function as a caregiver (if that is indeed what Shelly wants). Importantly, the social worker validates William’s love and concern for his mother and normalizes the impact of her illness on him. The social worker non-defensively explores William’s concern that his mother may not have received appropriate medical care and offers to make plans to facilitate a family meeting with Shelly’s health care team. The social worker facilitates a family meeting with Shelly, William, and Shelly’s physician in order to clarify goals of medical treatment and care, address Shelly’s and William’s fears and concerns, identify next steps and delineation of responsibilities, and establish a plan for ongoing communication. The social worker engages Shelly in a thoughtful examination of her support network, focusing on possibilities for reengagement with existing sources of support (e.g., Shelly’s sister, staff and others at the community center she volunteers with) and problem solving anticipated challenges or resource deficits that may inhibit Shelly’s willingness or capacity to engage with or access this previously strong support network. After an initial engagement, assessment, and intervention period, the social worker continues to reach out to Shelly to maintain an updated sense of her medical status, her needs and concerns, and her coping and well-being. As needed, the social worker facilitates referrals for reassessment and treatment of pain, anxiety, or depression, as well as community-based resources. Also, the social worker maintains a position as communication liaison, assuring that Shelly’s concerns and questions are always addressed in a timely and sensitive manner.

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conclusion It is hard to imagine a social work caseload in the twenty-first century that will not require both a solid understanding of the psychosocial demands associated with serious physical illness and the skills to deliver interventions that facilitate their successful negotiation. Regardless of practice setting or target population, social workers are very likely to find themselves working with individuals who are affected in one way or another by the presence of a significant, life-altering disease or condition and its treatment. For example, social workers in school settings will find themselves working with children whose academic and social performance is affected by the illness of a parent or grandparent. Similarly, social workers in the child-welfare

system will find themselves working with children who have been forced to enter the system after a parent has died and aunts, uncles, and grandparents who provide kinship care for the children of a brother, sister, son, or daughter who has died as a result of serious illness. This chapter provides a broad overview of contemporary psychosocial issues associated with serious physical illness and interventions aimed at facilitating individual and family adjustment to them. Although new health-related sociocultural shifts are likely to emerge alongside those already underway, for the foreseeable future there is ample, important work for social workers to do with and on behalf of individuals and families affected by serious physical illness at any point on its continuum.

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cHaPter 10 adolescent Pregnancy k at H l e e n r o u n d S a n d c H a r i t y c . S n e e d

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espite a major decline in adolescent pregnancy since the early 1990s, the United States still has the highest rates of teen pregnancy and birth among developed nations. Three out of every ten American teens get pregnant by age 20 years (Kost & Henshaw, 2012). Pregnancy can have a significant impact on the life course of teens and their children because teen pregnancy and parenting interrupt adolescent development as well as teens’ educational and employment opportunities. Because adolescent girls are addressing their own developmental demands, teen mothers may not have the resources to adequately parent and support the development of their children. Teen pregnancy and parenting is also a major public concern given the long-term costs associated with the poor developmental and social outcomes that are typical among teen mothers and their children. The decline in adolescent pregnancy in the United States provides evidence that teen pregnancy is preventable. Intervention science, especially the research on resiliency and risk and protective factors, has informed the design and evaluation of interventions aimed at reducing the rate of adolescent pregnancy. This research has produced a growing body of evidence-based interventions with proven effectiveness. However, more work is needed on interventions to support pregnant and parenting teens to disrupt the pathway to long-term negative outcomes, including intergenerational teen pregnancy. Social workers with knowledge of evidence-based interventions can play key roles at the macro and direct-practice levels to

prevent teen pregnancy and to promote positive outcomes for teens and their children. defining and explaining adolescent Pregnancy Adolescent pregnancy, commonly referred to as teen pregnancy, is pregnancy between the ages of 13 and 19 years. Usually, teen pregnancies are unplanned and occur outside of marriage. The literature on teen pregnancy addresses the important and related issues of preventing teen pregnancy as well as supporting pregnant teens and teen parents to promote positive developmental outcomes for teen mothers and their children and to prevent repeat pregnancies. In the United States, teen pregnancy is generally defined as a problem with moral, developmental, and socioeconomic dimensions. However, some segments of society consider teen pregnancy, particularly among older teens, as a positive and normative event and not as a problem (Beers & Hollo, 2009). Among many religious and cultural groups, teen pregnancy is viewed as a “moral failure” on the part of the teen and her family. The stigma attached to teen pregnancy stems from moral values and beliefs that adolescents should abstain from having sexual intercourse and that sex before marriage is immoral. These moral beliefs have shaped every level of policy, funding, and programming related to pregnancy prevention—federal, state, and local—since 1981 by emphasizing teaching abstinence over birth control (Dailard, 2006). “Abstinence-only” policies were tightened between 1996 and 2009 by policy that 205

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extended the abstinence-only mandate to teach “abstinence-only-until-marriage” (Sexuality Information and Education Council of the United States [SIECUS], 2012). With the new presidential administration in 2009, federal policy changes began to reflect prevention research and the reality of teen sexual behavior. Policymakers have shifted toward promoting research-based programs to delay teen sexual debut while teaching teens to prevent pregnancy through programs that effectively teach both abstinence and contraceptive use. The effect of teen pregnancy on the developmental dimension is supported by ample evidence of the increased risks for poor developmental outcomes faced by parenting teens and their children (Campa & Eckenrode, 2006; Meade, Kershaw, & Ickovics, 2008). Given the demands of parenting and caring for a child, teen parents have limited time to devote to critical tasks such as completing school and job training, learning relationship skills, and moving toward increased independence. Without major support from their families, community, and school programs, parenting teens are likely to experience substantial vulnerabilities and to miss developmental opportunities. Moreover, children of teen parents are vulnerable to poor developmental outcomes, both in the short and long term. For many teen parents, learning how to be a sensitive and responsive parent while dealing with their own developmental challenges proves to be a difficult task. The difficulty of this challenge is reflected in the high rates of child abuse and neglect among teen parents (Wildsmith, Manlove, Jekielek, Anderson Moore, & Mincieli, 2012). What remains unknown is what portion of the developmental vulnerabilities experienced by children of teen parents is caused by the mother’s biological and developmental age and her parenting skills versus what portion is the result of the mother-child socioeconomic context (Beers & Hollo, 2009). Teen pregnancy has a twofold economic dimension that is personal and public. Prior

to a teen pregnancy, a majority of the teens involved were living in poverty. Becoming a teen parent increases the likelihood that these young parents and their children will continue to live in poverty (Whitson Martinez, Ayala, & Kaufman, 2011). Teen parenting reduces the likelihood of completing high school or of attaining higher education, and negatively affects long-term job prospects and earnings. The National Campaign to Prevent Teen and Unplanned Pregnancy ((The National Campaign to Prevent Teen and Unplanned Pregnancy, 2011)) estimates that as compared with children of older parents, children whose teen mothers did not complete a high school education are nine times more likely to grow up in poverty. Second, teen pregnancy represents a cost to the public, not just in dollars to support pregnant and parenting teens, but also the cost to society in long-term dependence of teens and their children. This cost falls to taxpayers and places extra burdens on the already cash-strapped federal, state, and local budgets. Teen childbearing cost taxpayers $10.9 billion in 2008—or $1,647 per child of a teen mother per year—which primarily includes long-term costs of health care, child welfare, incarceration, and lower taxes paid by the children of teen mothers ((The National Campaign to Prevent Teen and Unplanned Pregnancy, 2011). demographic Patterns Almost 40 percent of the nearly 42 million U.S. adolescents live in low-income families, of which more than three-fifths identify as black or Hispanic (Macartney, 2011). Between 2010 and 2025, the number of girls 15 to 19 years old is expected to increase by more than half a million (Centers for Disease Control and Prevention [CDC], 2005), increasing the population at risk for teen pregnancy. The rate of adolescent pregnancies (inclusive of live births, abortions, and miscarriages) has followed a downward trajectory since 1991; in 2008 the rate had decreased 42 percent from the 1990 rate of 116.9 pregnancies per 1,000 adolescent

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women (Guttmacher Institute, 2012). In 2008, the pregnancy rate among adolescents was 67.8 per 1,000 older adolescents (i.e., females 15 to 19 years old), which was about 7 percent of the total female population in this age range and accounted for 733,000 of all pregnancies for the year (Guttmacher Institute, 2012). In addition to the decline in pregnancies among older adolescents, the pregnancy rate for women younger than 15 years fell even more (62 percent) from 17.5 to 6.6 per 1,000 women, reflecting both a decline in sexual activity and an increase in contraceptive use among adolescents (Guttmacher Institute, 2012). In conjunction with lower pregnancy rates, the birthrates among adolescent women have also sharply decreased over the past 20 years. At its height in 1991, the overall birthrate for women 15 to 19 years was 61.8 per 1,000 women; however, in 2010, the birthrate among adolescents dropped by more than one-third to 40.2 births per 1,000 women—the lowest rate in the nearly seventy-year history of consistent data reports (Hamilton & Ventura, 2012a). Before the downturn, birthrates among 18- and 19-year-olds were slightly more than double the rate among 15- to 17-year-olds; however, in 2008, the proportion of teen births shifted toward the oldest group of adolescents (18 to 19 years), which accounted for nearly 70 percent more adolescent births than 15- to 17-year-olds (Kost and Henshaw 2012). This shift in the age of teen mother illustrates that adolescents are delaying sexual activity, which reduces the risk for unplanned pregnancies. Second births, or higher-order births, among teens have also dramatically decreased, declining by more than 50 percent between 1990 and 2009 (Hamilton, Martin, & Ventura, 2012b).). Aside from live births, which account for nearly two-thirds of pregnancies among 15- to 19-year-olds, the abortion rate has also significantly declined, dropping from 40.5 per 1,000 young women in 1990 to 17.8 per 1,000 women in 2008 (Kost & Henshaw, 2012). Despite the 20 percent increase in the adolescent female

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population from 1990 to 2008, the rate of miscarriages has remained less than 15 percent, abortions have decreased by 56 percent, live births decreased by 33.3 percent, and overall adolescent pregnancies decreased by nearly 50 percent (Guttmacher Institute, 2012; Kost & Henshaw, 2012), all of which are evidence of the decline in sexual activity and increase in contraceptive use among teens (Guttmacher Institute, 2012). Most of the literature on adolescent pregnancy and births focuses on females, with only limited data available on teen fatherhood. The available research that has included male adolescents has reported similar trends among male and female teens regarding sexual activity, contraceptive use, and birthrates. According to the Guttmacher Institute (2012), seven in ten adolescents, regardless of sex, have had sexual intercourse by age 19 years. Since 1995, the percentage of adolescents having sex before 15 years of age decreased by 7 percent for both females and males, although the proportion of male teens with sexual experience (21 percent) continues to be slightly larger as compared with female teens (19 percent; Guttmacher Institute, 2012). Among male teens with sexual experience, 85 percent reported using contraceptives (primarily condoms, 80 percent) the first time they had sex and 93 percent reported continued use of contraceptives, which is an 11 percent increase in continued contraceptive use since 1995 (Guttmacher Institute, 2012). Despite improved use of contraceptives, over 200,000 male teens became fathers in 2006—a rate of 18 per 1,000 males (Guttmacher Institute, 2012; U.S. Census Bureau, 2011a). However, similar to the birthrates for adolescent females, the rate of fatherhood for males 15 to 19 years old dramatically decreased by 25 percent from 1990 to 2006, but the rate varies significantly by race (Guttmacher Institute, 2012). As of 2006, black adolescent males experienced the most substantial decline in teen fatherhood (38 percent drop since 1990); nevertheless, black male adolescents are more than twice as likely as their

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white counterparts to become a father before 20 years old (Guttmacher Institut,e 2012). Despite the overall declines in rates of adolescent pregnancies and births, significant disparities remain across racial and ethnic subgroups. During the period from 1990 to 2008, the pregnancy rate among non-Hispanic whites decreased by half, declining from 86.6 to 43.3 per 1,000 women (Kost & Henshaw, 2012). For the same period, non-Hispanic blacks and Hispanics also experienced dramatic drops in pregnancy rates, decreasing by 48 percent and 34 percent, respectively (Kost & Henshaw, 2012); however, these rates are disproportionate to the representation of these racial/ethnic groups in the larger population. For example, in 2008, blacks comprised 16 percent of the U.S. female population 15 to 19 years old (U.S. Census Bureau, 2011b) but accounted for more than 25 percent of all births to adolescents, which is a pregnancy rate of 117 per 1,000 women (Guttmacher Institute, 2012; Hamilton, Martin, & Ventura, 2012b.). Similarly, the pregnancy rate for Latina adolescents is significantly higher than for white adolescents, with Latinas having a rate almost 2.5 times greater (106.6 per 1,000 women) than the rate among whites (Kost & Henshaw, 2012). The racial/ethnic disparities evident in adolescent pregnancy rates are also apparent in birthrates. As compared with non-Hispanic white women, who have the lowest rate of births during adolescence at 26.6 per 1,000 women, Latinas have the highest rate at 70.3 per 1,000 women—a rate more than two and a half times that of their white peers (Kost & Henshaw, 2012). The racial/ethnic disparities have persisted even with declines in birthrates. In 1990, black adolescent females had the highest rate of births (112.9), but they have since experienced the most significant decrease, declining by more than half to a rate of 60.1 births per 1,000 women in 2008 (Kost & Henshaw, 2012). Although this is a considerable drop in births among black adolescents, additional resources are still needed to reduce the higher risk for

unplanned pregnancies and births among minority adolescents. Between 2007 and 2009, birthrates among young adolescents (ages 15 to 17 years) declined in 31 states, and rates among older adolescents (18 and 19 years) dropped in 45 states (Ventura & Hamilton, 2011a). However, states in the lower Midwest and Southeast regions of the United States continue to have the highest prevalence of births among adolescent females (Mathews, Sutton, Hamilton, & Ventura, 2010). In 2008, Mississippi, New Mexico, Texas, Arkansas, and Oklahoma had the highest prevalence of births to adolescents (respective birthrates 65.7, 64.1, 63.4, 61.8 and 61.6 per 1,000 women; Mathews et al. 2010). In contrast, the lowest prevalence of adolescent births were reported in New Hampshire (19.8 per 1,000 women), Massachusetts (20.1), Vermont (21.3), Connecticut (22.9), and New Jersey (24.5), all of which are within the Northeast region of the country (Mathews et al. 2010). The variation in birthrates among states seems to coincide with the variation in Hispanic and black populations; states with higher adolescent birthrates tend to have a higher percentage of racial and ethnic minorities (Mathews et al., 2010). However, racial/ethnic demographics do not consistently predict adolescent birthrates. Arkansas and Oklahoma are among the states with the highest adolescent birthrates, yet blacks and Hispanics collectively account for less than 22 percent of the population in Arkansas and just 16.3 percent in Oklahoma (U.S. Census, 2010). Similarly, in Connecticut and New Jersey, states with the lowest adolescent birthrates, blacks and Hispanics comprise 24 percent and 32 percent (respectively) of the state population (U.S. Census, 2010). A close relationship appears to exist between rates of poverty and rates of births to adolescent mothers. States with the highest adolescent birthrates also have the highest percentages of children living in poverty across all race/ethnicities (Macartney, 2011). For example, in 2011, the percentage of children in poverty in Arkansas (27.2 percent),

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Mississippi (31.0 percent), New Mexico (25.3 percent), Oklahoma (22 percent), and Texas (24.4 percent) exceeded the national average of 20.0 percent, with two of those states having rates roughly 10 percentage points higher (Macartney, 2011). Conversely, the five states with the lowest birthrates among adolescents also had relatively lower proportions of child poverty for all race/ethnicities, ranging from 10 percent of children in poverty in New Hampshire to 13.5 percent in New Jersey (Macartney, 2011). This correlation between teen births and child poverty suggests low socioeconomic status plays a role as a risk factor for adolescent pregnancies and births. According to the Guttmacher Institute (2012), almost half of adolescents reported they had engaged in intercourse by age 17 years, with less than one-sixth reporting they had sex before 15 years old. Within the last fifteen years, the percentage of adolescent females 15 to 19 years old who had never had sex increased from 49 percent in 1995 to 57 percent in 2010, with younger adolescents (15 to 17 years) twice as likely to report not having sexual intercourse experience than older adolescents (CDC, 2012). Since 1995, the age of sexual debut (first sexual intercourse) among adolescents has increased. The delay in sexual debut has increased by 29 percent among Hispanic teens, by 34 percent among black teens, and 15 percent among white teens (CDC, 2012). Contraceptive use among sexually active adolescents has also increased considerably, which is reflected in the 86 percent decline in U.S. pregnancy rates since 1991 (Guttmacher Institute, 2012). The majority of adolescents (82.1 percent) report using at least one contraceptive method (e.g., withdrawal, emergency contraception, condoms, pills, intrauterine device), but the number of adolescents using these methods varies by age (younger versus older), race/ethnicity, and the level of the method’s effectiveness (CDC, 2012). The use of contraceptives among sexually experienced 18- and 19-year-olds has remained relatively consistent

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since 1995 with 83.7 percent reporting contraceptive use. Among sexually experienced 15- to 17-year-olds, contraceptive use has increased from 76.1 percent in 1995 to 80.5 percent in 2010 (CDC, 2012). In addition, contraceptive use among white adolescents increased from 81.9 percent in 1995 to 85.4 percent in 2006–2010 (CDC, 2012). Conversely, contraceptive use has decreased over the past fifteen years among sexually experienced black adolescents, declining from 78.6 percent in 1995 to 74.4 percent in 2006–2010 (CDC, 2012). Moreover, despite the 23 percent increase in the use of highly effective methods of contraception, such as intrauterine devices (IUDs) and hormonal contraceptives (birth control pills) since 1995, black and Hispanic teens are less likely than their white peers to use these effective methods of contraception (CDC, 2012). From 2006 to 2010 White adolescents (65.7%) reported a higher prevalence of using highly effective contraceptive methods than Black adolescents (46.5%) and Hispanic adolescents (53.7% (CDC, 2012), which increases not only the risk of pregnancies but also the risk of sexually transmitted infections (STIs). Societal context The larger societal context critically influences perceptions of teen pregnancy and parenting as well as support for prevention initiatives and support services for pregnant and parenting teens. This larger context includes societal views of adolescent sexuality and pregnancy expressed in various forms of media as well as the political and policy environment. Today’s adolescents mature in a media-rich environment that presents unrealistic messages that fail to address the responsibility and consequences of sexual behavior, and a political and policy environment with polarized views about women’s reproductive rights and the role of government in providing services and programs to support those in need. On average, U.S. adolescents spend 7.5 hours daily interacting with or viewing some form of

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media such as television, music, movies, magazines, the Internet, and smartphones (Rideout, Foehr, & Roberts, 2010). For the most part, popular media does not portray adolescent sexuality in ways that address the risks of unprotected sex, early sexual initiation, or multiple sexual partners. In their study of teens’ exposure to sex via the media, Brown, Keller, and Stern found that 70 percent of top-rated teen television programs included sex, but only 10 percent of the programs mentioned the risks associated with sexual behavior. In addition, these researchers found that 37 percent of popular songs referred to sexual activity, including sexual acts that degraded females. Further, they found the use of contraception was rarely portrayed by the 25 percent of teen movie characters who engaged in sexual intercourse, and that teens had unprecedented access to pornographic sexual images on the Internet (Brown, Keller, & Stern 2009). Other studies have shown that the way teen sex is portrayed in the media affects teen sexual behavior (Chandra et al., 2008). In a review of studies, Rich (2008) found that frequent exposure to sexual content in the media was consistently associated with earlier sexual initiation (sexual debut), multiple sexual partners, and a higher risk of pregnancy and STIs. One research team that studied how exposure to sexual content in the media influenced teen behavior found such exposure increased sexual behavior among teens by heightening their perception of social pressure (i.e., they perceived that teens like them were having sex; Bleakly Hennessy, Fishbein, & Jordan, 2011). The enactment of the Adolescent Family Life Act in 1981 marked the beginning of the federal government’s campaign promoting abstinence education as a means to prevent teen pregnancy (Dailard, 2006). When the federal welfare reform law was enacted in 1996, abstinence-only-until-marriage became the cornerstone of policy and funding for sex education and pregnancy prevention, with the intention of preventing out-of-wedlock pregnancies (Boonstra, 2007). During the eight years of

the George W. Bush administration, funding for abstinence-only-until-marriage programs grew exponentially. In addition to the Adolescent Family Life Program and the Title V block grant program used to fund abstinence-only programs, Congress created the CommunityBased Abstinence Education program that directly funded community-based organizations promoting sexual abstinence, including faith-based organizations (Dailard, 2006). In 2007, the congressionally mandated nineyear evaluation of the federal abstinence-only program conducted by Mathematica Policy Research found that the program had no impact on teen sexual behavior (Boonstra, 2010). Subsequently in 2009, Congress passed and the Obama administration enacted legislation to require comprehensive and evidence-based sex education and pregnancy prevention programs; this legislation replaced the Community-Based Abstinence Education program and significantly reduced funding for the Title V abstinence-onlyuntil-marriage program (Boonstra, 2010). The programmatic changes resulting from this major policy shift are discussed later in this chapter (see Programs and Social Work Contributions section). Although the federal government has moved toward science-based policy, thus increasing the availability of comprehensive programs to prevent pregnancy, many state legislatures have moved toward reducing women’s access to contraception and abortion. For example, Montana and New Jersey eliminated their state family planning programs, New Hampshire cut family planning funding by 57 percent, and Texas cut family planning funds by 66 percent and closed half of its state-supported family planning clinics (Simon, 2012). In addition, legislation has been introduced at the federal and state levels to strip funding of Planned Parenthood by preventing the organization from receiving federal Medicaid and Title X family planning funds. Finally, several state legislators have introduced legislation such as “Personhood Amendments” to further restrict access to abortions

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(Eckholm, 2011) or make abortions more difficult to obtain. For example, the Virginia Ultrasound Bill requires women to undergo a transabdominal ultrasound at least twenty-four hours before having an abortion (Bassett, 2012; Celock, 2012), and specifies that the screen must face the woman while the doctor describes the developmental status of the fetus. Provisions under the 2010 Affordable Care Act increased teens’ access to contraceptive and pregnancy care services. For example, individuals can be covered by their parents’ health insurance up to age 26 (Frerich et al., 2012), and health insurance plans are required to cover contraception (Pear, 2012). However, one unanticipated consequence of this increased access is that the teens’ parents, as the primary policyholders, will receive an explanation of benefits (EOB) statements—and young women might consider this disclosure a lack of confidentiality in care received. For teens and young adults who do not want their parents to know that they are using contraception, the EOB statements describing services rendered to all individuals covered under the policy are likely to discourage their use of parental health insurance to cover contraception (Frerich et al., 2012). Even though federal funding for comprehensive pregnancy prevention programs has increased, other efforts to reduce access to contraceptive services have, and will have, a negative effect on teens’ ability to access services, especially public services. Given that a majority (86 percent) of the reduction in teen pregnancy has been explained by the increase in use of contraceptives (Santelli Lindberg, Finer, and Singh, 2007), decreased access is likely to negatively affect teen pregnancy rates. Vulnerabilities and risk factors Risk factors are “any influences that increase the chances for harm or, more specifically, influences that increase the probability of onset, digression to a more serious state, or maintenance of a problem condition” (Fraser, Kirby, & Smokowski, 2004, 14). Using Bronfenbrenner’s

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(Bronfenbrenner & Morris, 2006) bioecological framework, risk factors can be further specified within the individual, family, school, and neighborhood, and the broader social context. By examining risk factors within context and across systems, social workers can identify multiple points of intervention to prevent teen pregnancy and to support pregnant and parenting teens. Researchers have identified more than 500 factors known to increase or decrease teens’ likelihood of engaging in risky sexual behavior (Kirby, 2007), the most salient of which are discussed in the following section as they occur at the individual, family, and school and community levels. Risk factors at the broader social context level were discussed in the earlier section on societal context. Some of the risk factors for adolescent pregnancy such as substance abuse and age at sexual debut are also risk factors for repeat pregnancies for parenting teens. Adolescents experience asynchrony among physical, emotional, and cognitive development that puts them at risk for engaging in unprotected sexual behavior that can lead to pregnancy. Most females experience menarche and males experience puberty at a time when they are not cognitively able to fully understand the consequences of sexual intercourse and are not emotionally able to negotiate condom use or use of other contraceptive methods. This age and developmental difference can set up a power differential that makes young girls with underdeveloped decision-making skills particularly vulnerable to coercive sexual demands of older boys, leading to early sexual debut and/or unprotected sex (Rounds, 2004). Female adolescents younger than 16 years are more likely to have a much older male partner (more than five years older), which is correlated with early sexual debut. In their study of young teenagers and older sexual partners, Manlove, TerryHumen, and Ikramullah, (2006) found that for females younger than 16 years, having an older male partner at first sexual intercourse was associated with having a teen birth.

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Less disparate developmental asynchrony exists among older adolescents, and thus, adolescents 16 to 19 years old are more likely to use contraceptives. However, older adolescents are at risk for pregnancy simply because they are more likely to engage in sexual intercourse, have a higher frequency of sexual intercourse, and are more likely to have had sex with more than one partner (Kirby, 2007). Another risk factor associated with high risk of becoming pregnant as an adolescent is poor mental health. As compared with adolescents without depression, depressed female adolescents are more likely to have sex at an earlier age (Rink, Tricker, & Harvey, 2007) and are less likely to take initiative in using contraceptives when they have sex (Martin, 2001). The relationship between depression and pregnancy risk might be affected by a number of factors, including an adolescent’s history of substance abuse or sexual and physical abuse. Aggression, which is often a symptom of mental health problems, has also been associated with pregnancy risk. Physically aggressive girls are more likely than nonaggressive girls to become teenage mothers, and aggressive, risk-taking male adolescents are more likely to be become involved in teen pregnancy than nonaggressive males (Xie, Cairns, & Cairns, 2001). Young adults who use substances are more likely to engage in risky sexual behavior such as unprotected sex, anonymous sex, or sex with multiple partners (Grossman & Markowitz, 2005; Sen, 2002). The impaired judgment that accompanies alcohol and drug use decreases the likelihood that an adolescent will engage in protected sex. One research team found that heavy alcohol consumption was positively correlated with reduced use of condoms, and therefore, correlated with increased risk of pregnancy (Grossman & Markowitz, 2005). Victims of sexual abuse and assault have higher rates of teen pregnancy than adolescents without histories of sexual abuse or assault (Saewyc, Magee, & Pettingell, 2004). Researchers have suggested that sexual victimization

might result in victims having a negative selfimage that affects their perception of sexual behaviors; that is, victims may confuse sex with intimacy. Sexual abuse may also alter how victims view their bodies in that victims might perceive their bodies as something to be used by others (Erdmans & Black, 2008). These altered perceptions of sexual behavior and body image might lead to earlier sexual debut, sex with multiple partners, and anonymous sex or sex with partners with whom a person is not familiar (Saewyc, Magee, & Pettingell, 2004). An individual’s values and attitudes about teen sex are drivers of that person’s sexual behavior. In a review of twenty-four studies that examined the relationship of teens’ attitudes about sex and abstinence with the teens’ intentions and actual sexual behavior during the previous year, Buhi and Goodson (2007) found that teens’ positive attitudes toward abstinence were related to delayed sexual debut and lower likelihood of having sexual intercourse. On the other hand, permissive attitudes about sexual behavior were associated with the teens’ intention to have sex, early sexual debut, and having had sexual intercourse during the previous year. Teens’ intention to have sex was the most stable predictor of initiation of sexual intercourse (Buhi & Goodson, 2007). However, family, peers, and neighborhood context heavily influence teens’ values, attitudes, and intention to engage in sexual intercourse. Having a mother, father, or older sibling who was a teen parent is a risk factor for teen pregnancy (Wildsmith, Manlove Jekielek, Anderson Moore, & Mincieli, 2012). Research has shown that daughters of teen mothers were three times more likely to be sexually experienced than peers whose mothers gave birth in adulthood, and daughters of teen mothers were three times more likely to become teen mothers themselves (Meade, Kernshaw, & Ickovics, 2008). Similarly, sons of teen mothers are at higher risk for teen pregnancy involvement. Compared with sons of mothers who delayed parenthood until adult ages, sons of teen mothers are 1.8 times more

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likely to be sexually experienced as adolescents. In addition, sons of adolescent fathers are 1.8 times more likely to father a child during adolescence than peers whose fathers were in the adult age group (Campa & Eckenrode, 2006; Sipsma Biello, Cole-Lewis, & Kershaw, 2010). A subgroup at particular high risk for teen pregnancy is the population of teens in foster care, who are two times more likely to become pregnant by age 19 than teens who are not in foster care (James Montgomery, Leslie, & Zhang, 2009). This increased risk might be the combined effect of a number of factors, including a history of physical or sexual abuse, a tenuous or conflictual relationship with biological or foster parents, a lack of connectedness to school or community, and a teen’s desire to create a family of his or her own. Moreover, teens in foster care might not have adequate access to sex education. The instability of some foster care situations means that these teens often have to transfer to new schools and, therefore, are more likely to have missed sex education content. In addition, foster care parents can deny a teen in their care permission to participate in schoolbased sex education based on the parents’ religious or moral beliefs (Boonstra, 2011). Through peer relationships, the influence of adult neighbors, and neighborhood environments (as a result of structural factors), plays a key role in adolescent development and wellbeing. Throughout adolescence, peers in the school and neighborhood have a major effect on teens’ sexual beliefs, attitudes, and behaviors (Akers, Muhammad, & Corbie-Smith, 2011; Warner Giordano, Manning, & Longmore, 2011). School and neighborhood peers establish social norms that influence the timing of a teen’s sexual debut and the acceptable number of partners (Warner, Giordano, Manning, & Longmore 2011). Teens living in neighborhoods with high rates of early teen sexual activity, teen pregnancy, and intergenerational cycles of teen pregnancy are more likely to consider these histories to be the social norm (Akers, Muhammad, & Corbie-Smith, 2011).

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Within the neighborhood context, structural forces pose factors that increase the risk of teen pregnancy; these structural forces include neighborhood poverty, unemployment, and the lack of recreational opportunities. Studies that examined teen pregnancy risk and controlled for family income, parents’ education, welfare receipt, and family structure have found that teens living in high-poverty neighborhoods were more likely to become pregnant than those living in low-poverty neighborhoods (Browning, Leventhal, & Brooks-Gunn, 2004; Harding, 2003). Harding (2003) found that a high-poverty neighborhood increased the teen pregnancy rate among non–African American adolescents by 11.5 percentage points, and in effect tripled the odds of teen pregnancy compared with a low-poverty neighborhood. Among a matched sample of African American adolescents, a high-poverty neighborhood increased the rate of teen pregnancy by nearly 16 percentage points. Teens in high-poverty neighborhoods might have limited exposure to economically successful role models that emphasize the importance of long-term planning and delayed childbearing (Billy, Brewster, & Grady, 1994). Researchers have also found that the lack of recreational activities in high-poverty neighborhoods increases the risk of pregnancy because teens are more likely to engage in sexual activity when they do not have other activities (Akers, Muhammad, & Corbie-Smith, 2011). In a study of rural African American youth, the participants reported that adolescent sexual behaviors were negatively affected by neighborhood characteristics such as a lack of access to recreational options and diverse leisure-time activities, including options for teens who are dating, limited safe environments for socializing, and lack of adult monitoring of teen social activities (Akers, Muhammad, & Corbie-Smith, 2011). Teens who are pregnant or parenting and their children face an array of risks that are experienced as immediate and long-term

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vulnerabilities. For example, pregnant teens are more likely to receive no prenatal care or receive only late-term prenatal care, increasing the chances of giving birth to a preterm and/ or low birth weight infant (Meade, Kenshaw, & Ickovics, 2008). Poor birth outcomes increase the likelihood that infants will experience long-term developmental delays (Whitson et al., 2011). In the long term, teen parents are more likely to have repeat pregnancies during adolescence, have low levels of educational attainment, experience chronic poverty, and remain a single parent (Beers & Hollo, 2009; Whitson et al., 2011). These parental outcomes increase the vulnerabilities and risks for their children. Children of teen parents grow up with fewer economic and social resources, higher rates of both school failure and problem behavior, and greater likelihood of living in a single-parent home; they face increased risks for problematic parent-child interactions as well as becoming a teen parent themselves (Campa & Eckenrode, 2006). resiliencies and Protective factors Resilience is conceptualized as achieving “a normal or even exceptionally positive developmental outcome in spite of exposure to major risk for development of serious social or health problems” (Fraser, Kirby, & Smokowski, 2004, p. 22). For teens who experience risk factors such as those discussed in the preceding section, resilience is seen as avoiding pregnancy. For pregnant and parenting teens, resilience is seen as continuing and completing their education, working toward financial stability, learning how to parent responsibly, and preventing repeat pregnancies. Protective factors are “internal and external resources that modify risk” (Fraser, Kirby, & Smokowski, 2004, p. 28) and promote resilience. Examples of protective factors that modify a teen’s risk of pregnancy include a social connectedness (i.e., social networks) and parental monitoring. For pregnant and parenting teens, support in the form of tangible and

social supports is an additional protective factor that reduces vulnerability to negative outcomes and promotes resilience. Markham and her colleagues (2010) conducted a systematic review of 268 peerreviewed studies to determine if a protective association existed between “connectedness,” sexual behavior, and reproductive health outcomes. Their study defined connectedness as “the emotional attachment and commitment a child makes to social relationships in the family, peer group, school, community, or culture” (Markham et al., 2010, p. 23). Their review found evidence for a protective association of family connectedness, partner connectedness, and school connectedness with sexual behavior and reproductive outcomes. Successful parental monitoring that continues over time can mitigate adolescent risk behavior, including early sexual initiation (Huang, Murphy, & Hser, 2011). Sieverding, Adler, Witt, & Ellen (2005) found that teens who had experienced successful parental monitoring with more hours of supervised or restricted time were less likely to have norms and intentions favorable to initiating sex. Indeed, teens with histories of more parental monitoring perceived less social expectation to have sex. In a study that compared teens with high and low levels of parental monitoring, Huang, Murphy, and Hser (2011) found that higher levels of parental monitoring delayed teens’ sexual initiation by 1.5 years. In addition, Huang and colleagues found that as compared with teens whose parents were disengaged, teens whose parents (especially fathers) were engaged (i.e., interested in the teens’ activities and knew their child’s friends) reported lower levels of sexual risk behaviors. Parenting that is consistent, involved, and uses effective monitoring has been shown to mediate the intergenerational cycle of teen pregnancy (Meade, Kershaw, & Ickovics, 2008). However, it is important to note that over-monitoring by parents has also been shown to be a risk factor for teens engaging in sex (Markham et al., 2010).

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In addition to effectively monitoring teens, parents can influence teen sexual behavior through effectively communicating their views about delaying sexual initiation (Markham et al., 2010). Studies have consistently found that adolescents who perceive that their parents would disapprove of them engaging in sexual intercourse have higher rates of sexual abstinence and lower rates of sexual intercourse (Buhi & Goodson, 2007). Tangible support (i.e., material items, clothing, money) and social support (i.e., affirmation, encouragement) are both protective factors that promote resilience and reduce vulnerability for pregnant and parenting teens (Beers & Hollo, 2009). For a pregnant teen, support takes many forms, including informal support from family members, male partners, friends, neighbors, and faith communities. Formal support might come from nonprofit and public agencies as well as government programs. Tangible support ranges from child care provided by grandparents to financial aid provided by federal and state programs, including TANF (Temporary Assistance for Needy Families), medical insurance through Medicaid and SCHIP (State Children’s Health Insurance Program), and nutritional support through SNAP (Supplemental Nutritional Assistance Program) and WIC (the Special Supplemental Nutrition Program for Women, Infants, and Children). A variety of comprehensive programs provide multiple services to support pregnant and parenting teens and their children, such as primary and preventive health services, which include reproductive health services, nutrition counseling, case management, parent training in child care, educational and vocational services, mentoring, health education, and mental health and psychosocial support (Beers & Hollo, 2009; Kan et al., 2012). These comprehensive programs are offered in a variety of settings such as community agencies and clinics, schools, social services and health departments, and in clients’ homes. The common aim of these programs is to strengthen teens’ internal resources and help

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pregnant and parenting teens access external resources such as family support and community services to minimize the risks and vulnerabilities that they and their children experience. Programs and Social Work contributions The following brief history of the development and evaluation of programs to prevent teen pregnancy and support pregnant and parenting teens provides a background for understanding the current state of the field. Alarmed by the rising teen pregnancy rate in the 1970s and 1980s, the federal government passed Title VI of the Public Health Service Act (PL 95–626) in 1978 to establish the Office of Adolescent Pregnancy Programs, which administered the first federal program providing services to pregnant and parenting teens. In 1981, Title XX replaced Title VI, and funded the Adolescent Family Life Act. This act funded research, care, and prevention demonstration projects aimed at reducing repeat teen pregnancies and improving the outcomes associated with early childbearing for teens and their children (Office of Population Affairs, 2012). In the 1980s, the federal government also funded abstinence-only-until-marriage programs. The dollar amount of this funding grew considerably from 1996 to 2009. At the same time, there was considerable funding, development, and evaluation of interventions to impact teens’ sexual knowledge, attitudes, and behavior that put them at risk for HIV and STIs. Many of these programs were comprehensive in focus; that is, the programs targeted behaviors that increased risk of HIV, STIs, and pregnancy. After evaluation research demonstrated that abstinence-only-until-marriage programs were ineffective, federal government support for these programs decreased (Boonstra, 2010). Early in the Obama administration, the government established the Office of Adolescent Health (OAH) and reduced funding for abstinence-only-until-marriage programs by two-thirds and increased funding for evidence-based programs (OAH, 2012).

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The creation of OAH and the 2009 passage of the Consolidated Appropriations Act of 2010, which included money for the President’s Teen Pregnancy Prevention Initiative, signaled the federal government’s move toward comprehensive approaches to sex education that are based on current research. In 2010, the OAH established three funding initiatives to prevent teen pregnancy: (1) replication of the thirty-one evidence-based programs identified in a review conducted by Mathematica and Child Trends; (2) research and demonstration programs to develop and test new models and innovative strategies; and (3) a collaboration with the CDC to develop community-wide, multicomponent interventions targeting communities with the highest rates of teen pregnancy (SIECUS, 2012). In addition, the Affordable Care Act of 2010 included the creation of the Personal Responsibility Education Program. This program is administered by the Administration on Families and Youth, and provides funding for (1) state grants to fund evidence-based programs that teach teens about abstinence and contraception to prevent pregnancy, HIV, and STIs; (2) grants to fund innovative programs that are developed for high-risk populations that are disproportionately vulnerable to and affected by teen pregnancy such as youth in the foster care system or homeless youth; (3) grants to American Indian tribes and tribal organizations; and (4) funds for research, technical assistance, and training (SIECUS, 2012). Over the past three decades, significant progress has been made in the evaluation of primary prevention interventions, yielding a clearer understanding of what works under what conditions to prevent teen pregnancy. As a result of being able to demonstrate program efficacy, policy makers and funders now routinely require agencies or programs to use evidence-based interventions, or to include a rigorous evaluation if they are testing new interventions. This evaluation research has focused on primary prevention programs (i.e.,

preventing teen pregnancy in the first place); the research on effectiveness of secondary prevention programs (i.e., supports to lessen the negative outcomes associated with teen pregnancy for parents and child, preventing additional pregnancies during adolescence) remains limited. The following section examines the current knowledge about evidencebased approaches to prevent teen pregnancy and to support pregnant and parenting teens, and describes the contributions of social work to this area of practice. Primary pregnancy prevention programs aim to increase teens’ knowledge about how to prevent pregnancy, influence their attitudes about sexual activity and pregnancy, and teach them specific behaviors such as delaying sexual initiation and consistent use of effective contraceptives once they become sexually active. Many primary prevention interventions also include behavioral targets such as reducing the number of sex partners and the frequency of sexual intercourse. Kirby (2007) conducted a rigorous review of 115 evaluations of primary prevention programs targeting teen pregnancy. Among these, forty-eight programs were considered to be comprehensive in that the programs promoted both abstinence and the use of effective contraceptives once teens became sexually active; two-thirds of these comprehensive programs were found to be effective in changing sexual behavior and preventing pregnancy or STIs (Kirby, 2007). Because no national data exist on the impact of publicly financed family planning services on the rates of teen pregnancy, Kirby’s (2007) review did not include an evaluation of publicly financed family planning clinic services. Public health departments, school-based teen clinics, Planned Parenthood, and communitybased health clinics typically provide these services. Many of these clinics employ social workers to provide teen clients with counseling and health education as well as to follow up with pregnant teens to ensure they have access

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to additional services as needed. Studies have shown clinics that provide one-on-one counseling and specific, clear messages on abstinence and contraception effectively increase the use of contraception and condoms (Kirby, 2007). For example, in 1997, California established the Family PACT (Planning, Access, Care, and Treatment) program. Through the Family PACT program, both public and private clinics offer free, confidential reproductive health services to teens; it is estimated that the program averted 79,000 unintended teen pregnancies in 2007 (Foster et al., 2011). The National Campaign to Prevent Teen and Unplanned Pregnancy produces updates of Emerging Answers 2007. For example, What Works 2011–2012 (Suellentrop, 2011) detailed whether programs were effective in delaying sexual initiation, improving contraceptive use, or reducing teen pregnancy. The update describes each study setting and sample as well as selected effects of the program. The National Campaign maintains a database with detailed information on programs and information on how to access program curriculum (see http:// www.TheNationalCampaign.org). In her recent review of curriculum-based programs, Suellentrop (2011) organized programs into five categories: curriculum-based education, service learning, youth development, parent programs, and community-wide programs. These categories vary in the extent to which they focus exclusively on pregnancy prevention (Suellentrop, 2011). The following is a brief description of each category and an example of an evidence-based program for each category. Curriculum-based education programs focus specifically on increasing sexual knowledge, promoting attitudes and teaching specific behaviors to delay the onset of sexual activity and increase contraceptive use among sexually active teens. Kirby (2007) analyzed components of successful curriculum-based programs and identified seventeen shared characteristics, which were grouped into three categories: (1) curriculum development process (e.g., the

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process is consistent with community values and involves experts); (2) curriculum content (e.g., the curriculum provides clear messages and teaches specific behaviors such as how to respond to peer pressure and how to effectively use condoms); and (3) program implementation process (e.g., the program carefully selects trainers and provides effective training, monitoring, and support). It’s your game: Keep it real intervention is an example of a curriculum-based HIV, STI, and pregnancy prevention program that has proven to be effective in delaying the initiation of sexual activity (defined as oral, anal, and vaginal) for up to twenty-four months. The intervention was tested in a predominantly African American and Hispanic population of an urban school district in Texas. The curriculum consisted of twelve lessons, each lasting forty-five minutes and delivered using a mix of trained facilitators, computer-based instruction, and personal journaling (Tortolero et al., 2010). Service learning programs focus on engaging teens in service to their community and school. Service learning is based on the rationale that— for early adolescents—helping their communities and others not only fosters positive self-concept and pro-social attitudes among the adolescents but also helps them learn problemsolving skills and other life skills (Schine, 1997). Reach for Health–Community Youth Service Learning is an evidence-based in-school service learning program for middle school students in an urban setting. The intervention combines community service with an in-class health curriculum. The community service portion requires students to complete three hours of service per week in a community placement such as a nursing home, health clinic, child-care facility, or senior center. The health curriculum focuses on three primary health risks: drug and alcohol use, violence, and sexual behaviors. Evaluation of Reach for Health showed the program was effective in delaying participants’ sexual initiation and sexual activity for two years (O’Donnell et al., 1999).

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Youth development programs focus on reducing risk factors and increasing protective factors associated with teen pregnancy. These programs are based on the premise that, in addition to receiving sex education to prevent pregnancy, teens need to develop the motivation to engage in healthy sexual behavior. These programs hold that adolescents are more likely to engage in healthy sexual behavior and to sustain positive behavioral change when surrounded with a supportive network of adults and when given help to develop a positive vision of their future (Gavin, Catalano, & Markham, 2010). The Carrera Program of the Children’s Aid Society is the youth development program with the longest history of implementation. This intensive five-day-a-week program was conducted in six sites in New York City, and recruited high-risk teens between 13 and 15 years old; participants were provided services throughout their high school years. The program components included sex education, health care (mental and physical), academic and employment support, sports and arts activities, counseling, and mentoring. The Carrera program also involved parents. Evaluation results showed that, as compared with girls in a control group, the girls who participated in the Carrera program were 18 percent less likely to have sex, 55 percent less likely to become pregnant, and 80 percent more likely to use dual contraceptive methods at last sex. However, the evaluation found no changes in sexual behavior among the boys who participated in the Carrera program (Philliber, Kaye, Herrling, & West, 2002). Parent programs often involve both parents and their teens and focus on improving parentteen communication about sex, substance use, and other issues. These programs are based on research demonstrating that parental monitoring and communication have a positive impact on teen sexual behavior (Coley, Votruba-Drzal, & Schindler 2009; Huang, Murphy, & Hser, 2011; Sieverding et al., 2005). Families Talking Together is an example of an evidence-based parent program. With

the aim of delaying sexual initiation in early adolescence, the program was designed to be delivered by social workers in health clinics (Guilamo-Ramos, Bouris, et al., 2011) and by peer facilitators in community-based settings (Guilamo-Ramos, Jaccard, et al., 2011). Parents met individually with a social worker or community interventionist for a thirty-minute session and were given materials and activities to help them discuss sex with their teens. Compared with the control group, teens in the intervention group showed a statistically significant reduction in the rate of transitioning to sexual activity and frequency of sexual intercourse. Community-wide programs are much broader than programs in the other four categories in that they target the entire community and focus on primary prevention with the aim of increasing awareness about teen pregnancy and community prevention efforts as well as on reducing teen pregnancy rates. These programs often involve multiple initiatives and collaborations among various community groups including schools and other community organizations, which makes evaluating these programs more difficult (Suellentrop, 2011). Finally, a discussion of pregnancy prevention programs would not be complete without covering the evaluation of the effectiveness of programs using the abstinence-only-until-marriage approach. The research on these programs has found that emphasizing abstinence does not delay teen sexual debut and, in fact, might increase the risk of teen pregnancy because the program’s exclusive focus on abstinence and criticism of contraception delays or prevents the use of contraceptives among sexually active teens (Boonstra, 2010). However, interventions with very young teens that focus on delaying sexual debut—but not delaying until marriage—and that do not criticize the use of condoms have shown some effectiveness (Jemmott, Jemmott, & Fong, 2010). Secondary prevention programs for pregnant and parenting teens have been in general use for more than three decades. With the main

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focus of preventing repeat pregnancies, these programs often target other outcomes that focus on the teen mother (and sometimes her male partner), her child, or her family: 1. Programs focus on teen outcomes such as continuing in school and earning a high school diploma or equivalent, developing employment skills for self-sufficiency, and ensuring timely receipt of health and mental health services; 2. Programs focus on child outcomes such as a promoting factors that contribute to a healthy birth and physical, cognitive, and social development; ensuring timely receipt of health and developmental services, and increasing access to services that promote school readiness; and 3. Programs focus on family system outcomes such as parenting skills to promote child development, prevention of child abuse and neglect and family violence, and promotion of family involvement to support the mother-child dyad and father involvement when appropriate. Programs for pregnant and parenting teens operate under the auspices of and are delivered in a range of settings including schools, community clinics, health departments, public social services departments, and community agencies (Beers & Hollo, 2009). Programs include a combination of various components such as home visits, case management, individual counseling, mentoring, psychosocial education and support groups, parenting classes, academic and job-skill support, and clinicbased medical and reproductive services. Although progress has been made in the evaluation of interventions designed to prevent teen pregnancy, similar progress has not been achieved in the development and testing of interventions targeting pregnant and parenting teens. Lachance, Burrus, and Richmond Scott (2012) argued that even though many strategies have been advocated in the field, evaluators do

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not agree on which interventions and strategies are the most effective. These researchers have called for more rigorous evaluation to determine which “strategies and components are effective under which conditions and with which population groups” (Lachance, Burrus, & Richmond Scott, 2012, p. 1830). Meta-analyses of evaluations of programs for pregnant and parenting teens have reported mixed results (Corcoran & Pillai, 2007; Klerman, 2004). Klerman (2004) reviewed evaluations of nineteen secondary prevention programs and found the number of repeat births was close to the number that would have been expected without an intervention; in other words, the interventions were ineffective at preventing repeat pregnancies in the two years after birth of the first child. Corcoran and Pillai (2007) conducted a meta-analysis of sixteen control and comparison group evaluations and found that although there was a 50 percent reduction in the odds of a second pregnancy at about nineteen months after the first birth, the difference between the control and comparison groups disappeared by thirtyone months post first birth. In other words, although the program had an initial effect on preventing repeat pregnancies, the program effects did not persist beyond thirty months. Neither of these reviews found that one intervention approach or setting seemed to be more effective than others. Klerman (2004) concluded that the following components seem to contribute to success in secondary pregnancy prevention programs: (1) developing a close and sustained relationship between pregnant or parenting teens and the social worker or interventionist with whom they are working; (2) providing early and sustained intervention; that is, involving teens during a first pregnancy and maintaining contact and participation for at least two years; (3) staffing the program with personnel professionally trained to provide counseling on contraceptives and domestic violence issues; (4) providing intense one-onone counseling rather than only group-format

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sessions; (5) working closely with teens on their understanding of, attitudes toward, and behavior related to contraception—ideally encouraging the use of long-lasting, noncoital contraception; (6) providing support such as child care so that teens can complete school and job training; and (7) encouraging teens to live with their parents, other adults, or in a maternity group home rather than with a boyfriend. A recent comprehensive cross-site evaluation of the Adolescent Family Life Program studied the outcomes for twelve projects and 1,038 adolescents who either received services or “usual care” (Kan et al., 2012). These demonstration projects all directly provided or referred teens to core services, including pregnancy testing, maternity counseling, adoption counseling, health and mental health care, nutrition counseling, screening and treatment for STIs, family life education, educational and vocational services, and counseling and referral for family planning services. The evaluation found that within twelve months of intake, the teens in the intervention group had lower odds of a repeat pregnancy than teens in the group that received usual care. In addition, the teens in the intervention group were more likely than peers in the control group to use long-acting contraception and have received child care for their baby in the past month (Kan et al., 2012). The evaluation found positive outcomes were associated with the following project characteristics: greater frequency of home visits by social workers, greater frequency of school-based activities, greater frequency of one-on-one case management meetings with teens, and program messages culturally tailored to teens. Social workers fill a wide range of roles in programs to prevent teen pregnancy and in programs to support pregnant and parenting teens. These roles include direct-practice activities such as case management, one-on-one counseling, facilitating support and psychoeducational groups, and providing health education. In addition, these roles include macro practice activities such as program development and evaluation,

community and coalition building, and policy development and advocacy. Whether in direct or macro practice, social workers can make a significant contribution by advocating for the use of programs and interventions that are evidence based as well as urging the rigorous evaluation of untested interventions. Given social workers’ knowledge, training, and commitment to social justice, these professionals play a valuable role in developing strategies to increase and ensure teens’ access to program services and in designing program components that are culturally and linguistically appropriate for the at-risk vulnerable population with whom they are working. assessment and interventions During interviews with adolescent clients, social workers often use standardized instruments to assess adolescent well-being and risktaking behaviors. Assessment instruments such as the Rapid Assessment for Adolescent Preventive Services (RAAPS, 2011), Health Survey for Adolescents (Adolescent Quality Improvement Work Group, 2008), and the Problem-Oriented Screening Instrument for Teenagers (Follansbee & Stuart, 2009), enable practitioners to gather information about an adolescent’s health, social development and relationships, family context, and involvement in risky behaviors (Springer, 2008). These assessments are helpful in forming an overall view of an adolescent’s life conditions and concerns. Social workers also use interview instruments or questions to assess sexual health, which is a significant aspect of adolescent development. To evaluate an adolescent’s risk for an unplanned pregnancy, social workers need to ask questions specific to stages of development and sexual activity in conjunction with questions pertaining to family and peer relationships, emotional health, and other potential sources of risk and resilience (Enfield Youth Support Services, 2010; Monasterio, Combs, Warner, Laren-Fleming, & St. Andrews, 2010). Using standardized instruments, practitioners are able to address concerns about sexual

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development and reproductive health among adolescent clients by learning about the following areas in an adolescent’s life: the teen’s understanding of physiological changes that occur during sexual development; sexual intentions, attractions, activity, and experience, including specific behaviors and contraceptive use; family history of teen pregnancy; relationships with family and friends; family, peer, and neighborhood norms regarding adolescent sexual behavior; substance use; education attainment and aspirations; emotional health; and additional areas of vulnerability. Understanding the risk and protective factors in teens’ lives is crucial to designing individual and programmatic interventions. Moreover, risk and protective factors should guide efforts to identify teens most at risk for adolescent pregnancy. Interventions should focus on malleable risk and protective factors that have the most direct effect on teen sexual behavior. As noted earlier, the overarching goal of preventing teen pregnancy has many constituent goals, including delaying sexual debut, reducing the frequency of sex, reducing the number of sexual partners, and increasing the use of condoms and other effective forms of contraception. Kirby (2007) stressed that the risk and protective factors that can be changed most easily are those directly related to sexual behavior such as knowledge, values, perceptions of peer norms, motivation, and self-efficacy directly related to engaging in safe sexual behavior. illuStrAtion And diSCuSSion

Social workers are involved in both macro and direct practice in pregnancy prevention and in supporting pregnant and parenting teens. As macro practitioners, social workers organize community coalitions and develop, implement, and evaluate programs at the community, state, and national levels. Social work direct practitioners provide individual and group counseling, health education, and case management services to teens in pregnancy and parenting programs as well as in reproductive

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health clinics, teen clinics, and primary care settings. The following case study illustrates how school social workers are particularly well positioned to identify teens at risk for pregnancy and to work with pregnant or parenting teens. Lisa, a 14-year-old eighth grader, has attended the same middle school since sixth grade and has developed relationships with teachers, staff, and administration, who regard her as a good student. After returning to school in the fall following summer break, Lisa has had both academic and behavioral difficulties, including coming to school dressed inappropriately, angry outbursts toward other students, falling asleep in class, and refusing to complete homework assignments. Lisa’s homeroom teacher has also noticed that Lisa has had lower energy levels and mood swings, and has missed several days of school due to illness. As she prepared to begin class, the physical education teacher realized that Lisa was not present in the gymnasium. When she checked the locker room, she found Lisa curled up on the floor and crying; she immediately wrote Lisa a pass to the school social worker’s office. Meeting privately with Lisa, the social worker began the counseling session by encouraging Lisa to discuss why she was so upset; Lisa shared that she was worried that she was pregnant. To deal with Lisa’s concern and evaluate the person-and-environment factors that might have put Lisa at risk for an unplanned pregnancy, the social worker conducted a pregnancy-risk assessment with Lisa. As the social worker asked Lisa questions regarding her physical development, sexual activity, and relationships, Lisa shared that she had sexual intercourse for the first time last year but did not engage in sexual intercourse again until she became involved with her 17-year-old boyfriend over the summer. Lisa informed the social worker that they used condoms only “some of the time” and that she did not use a secondary birth control method because she thought that pills and “the shot” would make her gain weight. She thought that she would not get pregnant because her boyfriend would withdraw before ejaculation; however, after missing her

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last period, she is concerned that she is pregnant and will have to drop out of school. After completing the pregnancy-risk assessment with Lisa, the social worker provided several options for Lisa to obtain a pregnancy test including going to a local women’s clinic or community health center, both of which provide free pregnancy testing to women younger than age 18 without requiring parental consent. The social worker assured Lisa that if she received a positive pregnancy test, the social worker would be available to facilitate a conversation between Lisa and her mother to discuss the pregnancy, the support services available to Lisa, and the steps to keep Lisa in school. The following week, Lisa contacted the social worker to inform her that she visited the local women’s clinic and was about two months pregnant. Lisa had not yet informed her boyfriend or her mother about the pregnancy and wanted the social worker’s help talking with them about her desire to keep the baby. Before calling Lisa’s mother to schedule a home visit or school conference, the social worker contacted community agencies and local programs to identify resources that would be available to Lisa, her baby, and Lisa’s family; the social worker also developed an individual plan for Lisa to continue her education while parenting. Because the social worker represents the middle school in the local teen pregnancy and parenting community consortium, she was intimately familiar with resources and had developed relationships with several agency social workers, enabling her to effectively help Lisa access services and support. During the Child and Family Team meeting at the school, Lisa’s mother expressed anger and disappointment in finding out that her daughter was pregnant. Lisa’s mother had been 16 years old when she gave birth to Lisa and she had hoped that her daughter would not follow in her footsteps. The mother lamented that she had not been involved with Lisa as much as she had wanted to because she had to work long hours “just to make ends meet.” The mother agreed to support Lisa through this

transition, but voiced her concerns about the possibility of losing her job if she missed work time to help Lisa and her uncertainty about how she was going to cover the cost of supporting her pregnant daughter and future grandchild. The social worker reviewed the resources that were available to Lisa through the school system, such as access to at-risk student funds for supportive services as well as the option to attend an alternative school program for pregnant teens or receive tutoring from a homebound teacher later in the pregnancy and during post-pregnancy recovery. Next, the social worker referred Lisa and her family to the Adolescent Parenting Program at the local department of social services. The Adolescent Parenting Program provides pregnant adolescents with services such as transportation to doctor’s visits, prenatal multivitamins, education on child development and parenting, and information on additional public assistance programs funded through the state such as Medicaid and Temporary Assistance for Needy Families (TANF). The social worker also referred Lisa to the public health department’s Baby Love program, which provides prenatal and postpartum care, and helped her enroll in the Women’s Infant Nutrition Program (WIC). Throughout the progression of the pregnancy, the social worker regularly checked in with Lisa through face-to-face meetings as well as telephone calls with Lisa and her mother to ensure that Lisa remained connected to both the school and the community resources, and remained on track to graduate from middle school. The social worker played a key role by providing counseling and coordinating a network of services, including school support services, the Adolescent Parenting Program, and health department services. By using the identified services, Lisa was able to maintain her health during the pregnancy and, therefore, was able to continue in school; the well-being of the baby was supported, and the family unit received valuable assistance. This coordination of supportive services encouraged Lisa’s continued enrollment in school, strengthened her parenting skills, and ensured that

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both she and her baby received timely medical care and preventive health services. Before Lisa moved on to high school, the middle school social worker facilitated a meeting between Lisa and the one of the high school social workers. Both social workers encouraged Lisa to remain active in the Adolescent Parenting Program until she finished high school so that she would continue to receive support for parenting, academic success, life skills, and preventing a repeat pregnancy.

conclusion This chapter has addressed the epidemiology of teen pregnancy and parenting, the risk and protective factors associated with teen pregnancy and parenting, and the policy and evidence-based programs to prevent pregnancy and support pregnant and parenting teens, as well as provided an illustration of how social workers provide services to pregnant and parenting clients. Teen pregnancy and parenting have a significant and substantial impact that creates a ripple effect influencing individuals, families,

referenceS

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communities, and future generations. The risk that teen pregnancy will also disrupt adolescents’ education puts already economically vulnerable teens and their children at long-term socioeconomic disadvantage and at risk for negative developmental outcomes. The societal cost of teen pregnancy and parenting is profound. A society that does not fully educate and prepare its adolescents for a productive adulthood incurs major costs—in terms of both lost productivity and poor outcomes for families and communities. Finally, it is critical to disrupt the intergenerational cycle of teen pregnancy. There are two ways to disrupt this cycle: (1) prevent teens from getting pregnant, and (2) when teens do become parents, surround them with support so that the teens can complete their education, acquire employment skills, effectively parent, and prevent repeat pregnancies. To accomplish this goal requires that national and state policy makers, community leaders, and social workers who care about the lives of teens tackle the problem of teen pregnancy with laser-like focus, determination, perseverance, and commitment.

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Brown, J. D., Keller, S., & Stern, S. (2009). Sex, sexuality, sexting, and sexed: Adolescents and the media. Prevention Researcher, 16(4), 12–16. http://go . g a l e g r o u p. c o m . l i b p r o x y. l i b. u n c . e d u / p s / i .do?id=GALE percent7CA213032887&v=2.1&u=unc _main&it=r&p=AONE&sw=w. Browning, C.  R., Leventhal, T., & Brooks-Gunn, J. (2004). Neighborhood context and racial differences in early adolescent sexual activity. Demography, 41(4), 697–720. doi:10.1353/dem.2004.0029. Buhi, E. R., & Goodson, P. (2007). Predictors of adolescent sexual behavior and intention: A theory-guided systematic review. Journal of Adolescent Health, 40(1), 4–21. doi:10.1016/j.jadohealth.2006.09.027. Campa, M.  I., & Eckenrode, J.  J. (2006). Pathways to intergenerational adolescent childbearing in a high-risk sample. Journal of Marriage and Family, 68, 558–72. doi:10.1111/j.1741–3737.2006.00275.x. Celock, J. (2012). Virginia ultrasound bill passed by legislators with rape exception clause. Huffington Post, March 1. http://www.huffingtonpost.com/2012/03/01 /virginia-ultrasound-bill-rape-exception_n_1314490 .html Centers for Disease Control and Prevention. (2005). Population projections, united states, 2004–2030, by state, age and sex, on CDC WONDER On-line Database [Data file]. http://wonder.cdc.gov/controller/ datarequest/D7;jsessionid=30AB22296520D52B58A 07DBBF5AA2709?stage=results&action=sort&direc tion=BYVARIABLE. ——. (2012). Sexual experience and contraceptive use among female teens—United States, 1995, 2002, and 2006–2010. Morbidity and Mortality Weekly Report, 61(17), 297–301. http://www.cdc.gov/mmwr/preview /mmwrhtml/mm6117a1.htm?s_cid=mm6117a1_w Chandra, A., Martino, S., Collins, R., Elliott, M., Berry, S., Kanouse, D., & Miu, A. (2008). Does watching sex on television predict teen pregnancy? Findings from a national longitudinal survey of youth. Pediatrics, 122, 1047–54. doi:10.1542/peds.2007–3066. Coley, R. L., Votruba-Drzal, E., & Schindler, H. S. (2009). Fathers’ and mothers’ parenting predicting and responding to adolescent sexual risk behaviors, Child Development, 80(3), 808–27. doi:10.1111/j.1467– 8624.2009.01299.x. Corcoran, J., & Pillai, V.  K. (2007). Effectiveness of secondary pregnancy prevention programs: A metaanalysis. Research in Social Work Practice, 17(1), 5–18. doi:10.1177/1049731506291583. Dailard, C. (2006). Legislating against arousal: The growing divide between federal policy and teenage sexual behavior. Guttmacher Policy Review, 9(3), 12–16. http:// www.guttmacher.org/pubs/gpr/09/3/gpr090312 .pdf Eckholm, E. (2011). Push for “personhood” amendment represents new tack in abortion fight. New York Times, October 25. http://www.nytimes.com/2011/10/26/us

/politics/personhood-amendments-would-ban-nearly -all-abortions.html?pagewanted=all Enfield Youth Support Services. (2010). Enfield Teenage Pregnancy Risk Assessment Checklist. http://www .enfield.gov.uk/youth/downloads/file/42/teenage_pregnancy_risk_assessment_checklist_for_age _11–17 Erdmans, M. P., & Black, T. (2008). What they tell you to forget: From child sexual abuse to adolescent motherhood. Qualitative Health Research, 18, 77–89. doi:10.1177/1049732307309004. Follansbee, K., & Stuart, G. (2009). Problem oriented screening instrument for teenagers. In G. Fisher & N. Roget (Eds.), Encyclopedia of substance abuse prevention, treatment, & recovery (pp. 717–718). Thousand Oaks, CA: Sage. doi: 10.4135/9781412964500.n247. Foster, D.  G., Biggs, M.  A., Rostovtseva, D., de Bocanegra, H. T., Darney, P. D., & Brindis, C. D. (2011). Estimating the fertility effect of expansions of publicly funded family planning services in California. Women’s Health Issues, 21, 418–24. doi:10.1016/j. whi.2011.05.008. Fraser, M. W., Kirby, L. D., & Smokowski, P. R. (2004). Risk and resiliency in childhood. In M.  W. Fraser (Ed.), Risk and resilience in childhood: An ecological perspective. (pp. 13–66). Washington, DC: NASW. Frerich, E.  A., Garcia, C., Long, S., Lechner, K., Lust, K., & Eisenberg, M. (2012). Health care reform and young adults’ access to sexual health care: An exploration of potential confidentiality implications of the Affordable Care Act. American Journal of Public Health, 102, 1818–21. doi:10.2105/AJPH.2012.300857. Gavin, L. E., Catalano, R. G., & Markham, C. M. (2010). Positive youth development as a strategy to promote adolescent sexual and reproductive health. Journal of Adolescent Health, 46, S1–S6. doi:10.1016/j.jadohealth.2009.12.017. Grossman, M., & Markowitz, S. (2005). I did what last night?! Adolescent risky sexual behaviors and substance use. Eastern Economic Journal, 31(3), 383. http://col lege.holycross.e du/e ej/Volume31/ V31N3P383_405.pdf. Guilamo-Ramos, V., Bouris, A., Jaccard, J., Gonzalez, B., McCoy, W., & Aranda, D. (2011). A parent-based intervention to reduce sexual risk behavior in early adolescence: Building alliances between physicians, social workers, and parents. Journal of Adolescent Health, 48(2), 159–63. doi:10.1016/j.jadohealth.2010.06.007. Guilamo-Ramos, V., Jaccard, J., Dittus, P., Bouris, A., Gonzalez, B., Casillas, E., & Banspach, S. (2011). A comparative study of interventions for delaying the initiation of sexual intercourse among Latino and Black youth. Perspectives on Sexual and Reproductive Health, 43(4), 247–54. doi:10.1363/4324711. Guttmacher Institute. (2012a). Facts on american teens’ sexual and reproductive health. http://www.guttmacher .org/pubs/FB-ATSRH.html

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Hamilton, B. E., & Ventura, S. J. (2012a). Birth Rates for U.S. Teenagers Reach Historic Lows for All Age and Ethnic Groups (NCHS Data Brief 89). Hyattsville, MD: National Center for Health Statistics. http:// www.cdc.gov/nchs/data/databriefs/db89.htm Hamilton, B.E., Martin, J.A., & Ventura, S.J. (2012b). Births: Preliminary data for 2011. National Vital Statistics Reports, 61 (5). Hyattsville, MD: National Center for Health Statistics. Retrieved from http://www .cdc.gov/nchs/products/nvsr.htm#vol61 Harding, D. (2003). Counterfactual models of neighborhood effects: The effect of neighborhood poverty on dropping out and teenage pregnancy. American Journal of Sociology, 109(3), 676–719. doi:10.1086/379217. Huang, D., Murphy, D. A., & Hser, Y. (2011). Parental monitoring during early adolescence deters adolescent sexual initiation: Discrete-time survival mixture analysis. Journal of Child and Family Studies, 20, 511–20. doi:10.1007/s10826–010–9418-z. James, S., Montgomery, S. B., Leslie, L. K., & Zhang, J. (2009). Sexual risk behaviors among youth in the child welfare system. Children and Youth Services Review, 31(9), 990–1000. doi:10.1016/j.childyouth.2009.04.014. Jemmott III, J. B., Jemmott, L. S., & Fong, G. T. (2010). Efficacy of a theory-based abstinence-only intervention over 24 months: A randomized controlled trial with young adolescents. Archives of Pediatric Adolescent Medicine, 164(2), 152–59. doi:10.1001/archpediatrics.2009.267. Kan, M. L., Ashley, O. S., LeTourneau, K. L., Williams, J. C., Jones, S. P., Hampton, M. S., et al. & Scott, A. R. (2012). The Adolescent Family Life Program: A multisite evaluation of federally funded projects serving pregnant and parenting adolescents. American Journal of Public Health. Advance online publication. doi:10.2105/AJPH.2012.300836. Kirby, D. (2007). Emerging answers 2007: Research findings on programs to reduce teen pregnancy and sexually transmitted diseases. Washington, DC: National Campaign to Prevent Teen and Unplanned Pregnancy. Klerman, L.V. (2004). Another chance: Preventing additional births to teen mothers. Washington, DC: National Campaign to Prevent Teen Pregnancy. Kost, K., & Henshaw, S. (2012). U.S. Teenage Pregnancies, Births and Abortions, 2008: National Trends by Age, Race and Ethnicity. New York: Guttmacher Institute. http://www.guttmacher.org/pubs/USTPtrends08.pdf Lachance, C.  R., Burrus, B.  B., & Richmond Scott, A. (2012). Building an evidence base to inform interventions for pregnant and parenting adolescents: A call for rigorous evaluation. American Journal of Public Health, 102, 1826–32. doi:10.2105/AJPH.2012.300871. Macartney, S. (2011). Child Poverty in the United States 2009 and 2010: Selected race groups and hispanic origin (American Community Survey Brief ACSBR/10–05). Washington, DC: U.S. Census Bureau.

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http://www.census.gov/prod/2011pubs/acsbr10–05 .pdf Manlove, J., Terry-Humen, E., & Ikramullah, E. (2006). Young teenagers and older sexual partners: Correlates and consequences for males and females. Perspectives on Sexual and Reproductive Health, 38, 197–207. doi:10.1363/3819706. Markham, C.  M., Lormand, D., Gloppen, K.  M., Peskin, M. F., Flores, B., Low, B., & House, L. D. (2010). Connectedness as a predictor of sexual and reproductive health outcomes for youth. Journal of Adolescent Health, 46, S23–S41. doi:10.1016/j. jadohealth.2009.11.214. Martin, C. (2001). Screening for depression in pregnant teenagers. Journal of Pediatric and Adolescent Gynecology, 14, 129–31. doi:10.1016/S1083–3188(01)00130–9. Mathews, T., Sutton, P. D., Hamilton B. E., & Ventura, S. J. (2010). State disparities in teenage birth rates in the United States (NCHS Data Brief 46). Hyattsville, MD, National Center for Health Statistics. http:// www.cdc.gov/nchs/data/databriefs/db46.pdf Meade, C.  S., Kershaw, T.  S., & Ickovics, J.  R. (2008). The intergenerational cycle of teenage motherhood: An ecological approach. Health Psychology, 27, 419– 29. doi:10.1037/0278–6133.27.4.419. Monasterio E, Combs, N., Warner, L., Larsen-Fleming, M., & St. Andrews, A. (2010). Sexual Health: An Adolescent Provider Toolkit. San Francisco, CA: Adolescent Health Working Group, San Francisco. [Toolkit]. O’Donnell, L., Stueve, A., San Doval, A., Duran, R., Haber, D., Atnafou, R., & Piessens, P. (1999). The effectiveness of the Reach for Health Community Youth Service Learning Program in reducing early and unprotected sex among urban middle school students. American Journal of Public Health, 89, 176– 81. doi:10.2105/AJPH.89.2.176. Office of Adolescent Health, U.S. Department of Health and Human Services. (2012). Evidence-based programs (31 Programs). http://www.hhs.gov/ash/oah /oah-initiatives/tpp/programs.html Office of Population Affairs. (2012). History of Title XX. http://www.hhs.gov/opa/about-opa-and-initiatives /title-XX-afl/ Pear, R. (2012). Passions flare as House debates birth control rule. New York Times, February 16. http:// www.nytimes.com/2012/02/17/us/politics/birth -control-coverage-rule-debated-at-house-hearing .html Philliber, S., Kaye, J. W., Herrling, S., & West, E. (2002). Preventing pregnancy and improving health care access among teenagers: An evaluation of the Children’s Aid Society-Carrera Program. Perspectives on Sexual and Reproductive Health, 34, 244–51. doi:10.2307/3097823. Rapid Assessment for Adolescent Preventive Services (RAAPS). (2011). Products and Training. https:// www.raaps.org/products_training.php#1

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Rich, M. (2008). Virtual sexuality: The influence of entertainment media on sexual attitudes and behavior. In J. Brown (Ed.), Managing the media monster: The influence of media (from television to text messages) on teen sexual behavior and attitudes (pp. 18–38). National Campaign to Prevent Teen and Unplanned Pregnancy. http://www.thenationalcampaign.org /resources/monster/Media_Monster.pdf Rideout, V. J., Foehr, U. G., & Roberts, D. F. (2010). Generation M 2: Media in the lives of 8- to 18-year-olds. Menlo Park, CA: Kaiser Family Foundation. Rink, E., Tricker, R., & Harvey, S. M. (2007). Onset of sexual intercourse among female adolescents: The influence of perceptions, depression, and ecological factors. Journal of Adolescent Health, 41, 398–406. doi:10.1016/j.jadohealth.2007.04.017. Rounds, K. A. (2004). Preventing sexually transmitted infections among adolescents. In M. W. Fraser (Ed.), Risk and resilience in childhood: An ecological perspective. (pp. 251–280). Washington, DC: NASW Press. Saewyc, E. M., Magee, L. L., & Pettingell, S. E. (2004). Teenage pregnancy and associated risk behaviors among sexually abused adolescents. Perspectives on Sexual and Reproductive Health, 36, 98–105. doi: 10.1363/3609804. Santelli, J. S., Lindberg, L. D., Finer, L. B., & Singh, S. (2007). Explaining recent declines in adolescent pregnancy in the United States: The contribution of abstinence and improved contraceptive use. American Journal of Public Health, 97, 150–56. doi:10.2105/ AJPH.2006.089169. Schine, J. (1997). School-based service: Reconnecting schools, communities, and youth at the margin. Theory into Practice, 36, 170–75. doi:10.1080/ 00405849709543764. Sen, B. (2002). Does alcohol use increase the risk of sexual intercourse among adolescents? Evidence from the NLSY97. Journal of Health Economics, 21, 1085–93. doi:10.1016/S0167–6296(02)00079–6. Sexuality Information and Education Council of the United States (SIECUS). (2012). A brief history of federal funding for more comprehensive approaches to sex education FY10. http://www.siecus.org /index.cfm?fuseaction=page.viewPage&pageID =1341&nodeID=1 Sieverding, J. A., Adler, N., Witt, S., & Ellen, J. (2005). The influence of parental monitoring on adolescent sexual initiation. JAMA Pediatrics, 159, 724–29. doi:10.1001/archpedi.159.8.724. Simon, S. (2012). States slash birth control subsidies as federal debate rages. Reuters, March 5. March 5http:// www.reuters.com/article/2012/03/05/us-states-slash -birth-control-idUSTRE8240ZM20120305 Sipsma, H., Biello, K. B., Cole-Lewis, H., & Kershaw, T. (2010). Like father, like son: The intergenerational cycle of adolescent fatherhood. American Journal of Public Health, 100, 517–24. March 5doi:10.2105/ AJPH.2009.

Springer, D. W. (2008). Assessment of adolescents. Comprehensive handbook of social work and social welfare. Hoboken, NJ: Wiley. doi:10.1002/9780470373705. chsw003016. Suellentrop, K. (2011). What Works 2011–2012: Curriculum-based programs that help prevent teen pregnancy. Washington, DC: National Campaign to Prevent Teen and Unplanned Pregnancy. The National Campaign to Prevent Teen and Unplanned Pregnancy (2011). Counting it up: The public costs of teen childbearing. Retrieved from http://www .thenationalcampaign.org/costs/pdf/counting-it-up /key-data.pdf Tortolero, S. R., Markham, C. M., Fleschler Peskin, M., Shegog, R., Addy, R.  C., Escobar-Chavez, S.  L. & Baumler, E. R. (2010). It’s your game: Keep it real: Delaying sexual behavior with an effective middle school program. Journal of Adolescent Health, 46, 169–79. doi: 10.1016/j.jadohealth.2009.06.008. U.S. Census Bureau. (2010). State and County Quickfacts. http://quickfacts.census.gov/qfd/index.html. ——. (2011a). Intercensal Estimates of the Resident Population by Sex and Age for the United States: April 1, 2000, to July 1, 2010. [Data file]. http://www.census .gov/popest/data/intercensal/national/nat2010.html ——. (2011b). Intercensal estimates of the black or african american alone resident population by sex and age for the United States: April 1, 2000, to July 1, 2010. [Data file]. http://www.census.gov/popest /data/intercensal/national/nat2010.html U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics. (1995). Vital statistics of the United States 1991: Volume I—natality. Hyattsville, MD: U.S. Department of Health and Human Services. http://www.cdc.gov/nchs/data/vsus/nat91_1.pdf Ventura, S.  J., & Hamilton, B.  E. (2011). U.S. teenage birth rate resumes decline (NCHS Data Brief 58), Hyattsville, MD: National Center for Health Statistics. http://www.cdc.gov/nchs/data/databriefs/db58.pdf Warner, T. D., Giordano, P. C., Manning, W. D., & Longmore, M. A. (2011). Everybody’s doin’ it (right?): Neighborhood norms and sexual activity in adolescence. Social Science Research, 40, 1676–90. doi:10.1016/j. ssresearch.2011.06.009. Whitson, M. L., Martinez, A., Ayala, C., & Kaufman, J. S. (2011). Predictors of parenting and infant outcomes for impoverished teen parents.  Journal of Family Social Work, 14(4), 284–97. doi: 10 .1080/10522158.2011.587173. Wildsmith, E., Manlove, J., Jekielek, S., Anderson Moore, K., & Mincieli, L. (2012). Teenage childbearing among youth born to teenage mothers. Youth & Society, 44, 258–83. doi:10.1177/0044118X11398366. Xie, H., Cairns, B. D., & Cairns, R. B. (2001). Predicting teen motherhood and teen fatherhood: Individual characteristics and peer affiliations. Social Development, 10(4), 488–511. doi: 10.1111/1467–9507.00177.

cHaPter 11 bullying faye miSHna and meliSSa Van Wert

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ullying of children and adolescents is serious and pervasive. It compromises the well-being of individuals, families, and communities worldwide. Adults are obligated to intervene in situations of bullying, as the consequences of these experiences can be extremely damaging. defining and explaining bullying Bullying is a very complex phenomenon, difficult to understand and to determine how to respond. Accepted as a common schoolyard experience, bullying is often considered a predictable albeit painful part of childhood (Mishna, 2012). In recent years however, it has been increasingly understood that bullying is a public health issue that must be dealt with (Blosnich & Bossarte, 2011; David-Ferdon & Hertz, 2007). While a great deal is known about bullying behaviors and dynamics, many questions and controversies remain. Some consensus exists about certain elements of the definition of bullying, specifically, that bullying refers to a form of aggression that can be direct or indirect and includes physical, verbal, psychological, and relational acts; that it is intentional and occurs in a relationship characterized by a power imbalance; and that it is repeated over time (Mishna, 2012). Researchers consider direct and indirect forms of aggression to be distinct (CullertonSen & Crick, 2005), although similar risk factors are associated among children and adolescents involved in both forms (Herrenkohl et al., 2007). Overt aggression can be physical or verbal (Bauman & Del Rio, 2006) and may

include hitting, pushing, kicking, and making verbal threats or insults (Craig, Pepler, & Blais, 2007). Covert or indirect aggression is included in most definitions of bullying, although some of the most common forms such as exclusion are often not considered “true” bullying (Mishna, 2012). This lack of inclusion is highly problematic, as consequently these forms of bullying are overlooked (Craig, Henderson, & Murphy, 2000). A fast growing body of research has evolved on the recent phenomenon of cyberbullying (Berson, Berson, & Ferron, 2002; Mishna, Cook, Gadalla, Daciuk, & Solomon, 2010). Cyberbullying must be situated in the context of the cyber world, which offers young people unprecedented opportunities to communicate with others both in and out of their face-to-face social networks (Lenhart & Madden, 2007) and unparalleled opportunities for learning and self-exploration (Brown, Jackson, & Cassidy, 2006). The cyber world, however, has also provided new means through which children can bully and be bullied (Mishna, 2012). A universal definition of cyberbullying does not exist. Questions have been raised about the suitability of ascribing the label cyberbullying to online behaviors that do not appear to meet criteria for traditional bullying definitions (i.e., intention, power imbalance and repetition) (Wolak, Mitchell, & Finkelhor, 2007). It remains unclear whether to categorize cyberbullying as an electronic form of bullying or as a distinct phenomenon (Wang, Iannotti, & Nansel, 2009). Definitional clarity will assist in responding to and addressing cyberbullying. 227

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Broadly speaking, cyberbullying may be defined as the use of technology to bully another person, which results in harm or negative consequences for the individual experiencing the bullying (Patchin & Hinduja. 2012). Cyberbullying is not defined by any single identifiable behavior that occurs on any single technological device; the complexity of cyberbullying reflects the layered environments in which it takes place (Collier, 2012). With respect to both traditional and cyberbullying, the experiences and definitions of youth do not necessarily match the definitions of researchers (Vaillancourt et al., 2008; Vandebosch & Van Cleemput, 2008), or of parents and teachers (Mishna Scarcello, Pepler, & Wiener, 2005). Cyberbullying can encompass a variety of behaviors, including the use of electronic media to spread rumours, to hurt or threaten others, or to sexually harass (Hinduja & Patchin, 2008; Mishna et al., 2010). Some situations may involve young people receiving unwanted sexually explicit images or solicitation for such images, or situations in which private images are distributed publicly without consent (Willard, 2010). Given the lack of consensus on a definition, it is inappropriate to classify certain behaviors as always indicative of cyberbullying without consideration of the context in which these behaviors occur. When bullying, regardless of the form, is motivated by intolerance toward others based on actual or perceived membership in a particular group, such as gender, race, religion, sexual orientation, ability or socioeconomic status, it is known as “bias-based bullying” (Greene, 2006; Rigby, 2002). Bias-based bullying both results from and reinforces discrimination against minorities and marginalized groups within society (Greene, 2006; Rigby, 2002), and therefore has serious implications for marginalized communities and society as a whole. Children and youth may experience gendered harassment, defined as any action that polices the boundaries of traditional heterosexual gender norms, including sexual harassment and

homo- or trans-phobic harassment (Meyer, 2008). Young people may also experience racism, which can be covert or overt, and extends beyond the individual expressions of prejudice to include systematic and structural inequalities (Raby, 2004). Some children and adolescents are stigmatized based on negative weight-related attitudes and beliefs (Puhl & Latner, 2007) or based on prejudice against individuals with special needs (Dawkins, 1996; Mishna, 2003). Bias-based bullying may also comprise numerous intersecting aspects of a young person’s identity, with the consequence that the young person faces multiple intersecting forms of oppression (Daley Solomon, Newman, & Mishna, 2007). demographic Patterns Research indicates that bullying is a pervasive issue (Harel-Fisch et al., 2010; O’Connell, Pepler, & Craig, 1999; Olweus, 1994). Largescale surveys examining the prevalence of bullying in schools have been conducted around the world, including for example in Sweden (Olweus, 1994), Norway (Roland, 2000), the United States (Espelage, Bosworth, & Simon, 2000; Nansel et al., 2001), England (Whitney & Smith, 1993), Canada (Craig & McCuaig Edge, 2008), Australia (Rigby & Slee, 1991), Ireland (O’Moore & Kirkham, 2001), Turkey (Arslan, Savaser, & Yazgan, 2011), Korea (Kim, Koh, & Leventhal, 2004), Italy (Gini, 2004), India (Ramya & Kulkarni, 2011), and Japan (Rios-Ellis, Bellamy, & Shoji, 2000). Research in over forty countries involving over 200,000 adolescents revealed that approximately 11 percent of participants reported perpetrating bullying, 13 percent reported being targeted, and 4 percent reported being both a perpetrator and a target of bullying (Craig et al., 2009). Prevalence estimates for involvement in bullying varied considerably across countries, ranging from 9 percent to 45 percent for boys, and 5 percent to 36 percent for girls (Craig et al., 2009). The lowest prevalence estimates were reported in

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Sweden and the highest prevalence estimates in Lithuania (Craig et al., 2009). Children and youth cannot be easily categorized as a “perpetrator” or “target” based on any single factor (Espelage & Swearer, 2003). Research has identified certain characteristics, however, of children who are perpetrators and who are targets (Pepler Craig, Jiang, & Connolly, 2008), which warrant review. Understanding these characteristics can help to identify risk and resiliency factors, and ultimately help to develop prevention strategies and to respond in bullying situations. Evidence suggests that younger children are more likely to experience bullying, because although children are typically bullied by peers of their own age, younger children are also bullied by older children and are therefore at increased risk (Ziegler & Rosenstein-Manner, 1991). The research on gender and bullying is unclear. While some evidence indicates that boys bully more than girls (Craig & Harel, 2004; Nansel Overpeck, Haynie, Ruan, & Sheidt, 2003), other researchers note that differences in victimization between boys and girls are relatively small and have no clear pattern (Craig & Harel, 2004). Literature indicates that children and youth who are targets of bullying sometimes display characteristics that increase their vulnerability to victimization. Children who are chronically targeted are more likely to be shy, anxious, insecure, impulsive, and isolated as well as less empathic and popular (Bollmer, Harris, & Milich, 2006; Craig & Pepler, 2007; Owens, Shute & Slee, 2000). Targeted children may visibly show their distress when peers bully them and they may be less likely to retaliate (Bollmer et al., 2006). Some children who are targeted act in ways considered irritating (Miller, Beane, & Kraus, 1998; Olweus, 1993), which sadly can lead to adults and peers viewing these children as provoking the aggressor and therefore their own victimization (Owens et al., 2000). Studies suggest that children who bully may be stronger than their peers, assertive, and

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impulsive (Bollmer et al., 2006; Olweus, 1993; Ziegler & Rosenstein-Manner, 1991). Some findings suggest that their self-esteem is lower than children not involved in bullying (O’Moore & Kirkham, 2001), although other findings indicate that children who bully do not have poor self-esteem (Olweus, 1993). Approximately 10 to 20 percent of targeted children bully others and are victimized, and are described as provocative or aggressive “victims” (Olweus, 1978, 2001; P. K. Smith & Myron-Wilson, 1998), although as noted above, some research suggests a smaller percentage of children are both a perpetrator and a target of bullying (Craig et al., 2009). Research indicates that targeted children who bully others are the most severely rejected by peers and are particularly maladjusted (Fite & Colder, 2007). Targeted children may grow up in enmeshed or overly involved families (P. K. Smith, 2004) that do not allow them to speak for themselves, which may decrease their ability to be assertive and increase their vulnerability to being targeted (P. K. Smith & Myron-Wilson, 1998). These children are also more likely to experience maltreatment (Bowes et al., 2009) and to be victimized by school personnel (KhouryKassabri, 2009). Research suggests that families in which children perpetrate bullying are more likely to display poor functioning (Rigby, 1996), authoritarian or punitive parenting (Casas et al., 2006), a lack of warmth, excessive permissiveness (Casas et al., 2006; Olweus, 1994), and high conflict including violence (Bowes et al., 2009; Farrington, 1993; Olweus, 1994). Some studies suggest that bullying is transmitted through generations (Olweus, 1978), with longitudinal findings that boys who bullied at 14 years were likely, at age 32, to have children who bullied (Farrington, 1993). Cyberbullying prevalence estimates typically range from approximately 10 to 35 percent (Agatston, Kowalski, & Limber, 2007; Hinduja & Patchin, 2008; Kowalski & Limber, 2007; Li, 2007; Patchin & Hinduja, 2006), although according to some research the rates are

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significantly higher (Juvonen & Gross, 2008; Mishna et al., 2010; Raskauskas & Stoltz, 2007). Cyberbullying is difficult to escape, as most individuals are socially connected through technology, and the primary option through which to escape involves ending use of electronic communication completely (Brown et al., 2006). Technology is what connects many young people to their social world and therefore ending electronic communication is not a viable option. Evidence points to an association between cyberbullying and traditional bullying for both youth who are targeted and who perpetrate bullying (Hinduja & Patchin, 2008). Cyberbullying often occurs in the context of relationships (Hoff & Mitchell, 2008; Mishna, Saini, & Solomon, 2009), which challenges the commonly held assumption that it is anonymous (Hinduja & Patchin, 2008, 2009; Kowalski & Limber, 2007; Shariff, 2009) and corresponds with understanding bullying as a relationship issue (Craig & Pepler, 2007). Factors found to be associated with cyberbullying perpetration include low affective and cognitive empathy (Ang & Goh, 2010); aggression, exposure to violence, and low perceived social support (Calvete, Orue, Estevez, Villardon, & Padilla, 2010); poor parent-child relationship, substance misuse, delinquency, and poor academic performance (Ybarra & Mitchell, 2004). Parental support is associated with lower levels of cyberbullying involvement (Wang et al., 2009). High Internet use is linked both with experiencing (Vandebosch & Van Cleemput, 2008) and perpetrating cyberbullying (Li, 2007). Whether and in what ways gender impacts the involvement of young people in cyberbullying is unclear, as research findings on gender similarities and differences are mixed (Agatston et al., 2007; Ang & Goh, 2010; Dehue, Bolman, & Vollink, 2008). In a study involving children attending New York City public schools, over one-quarter of participants reported experiencing biasbased harassment (Sikh Coalition et al., 2009).

These students believed they were targets of this harassment due to their race or ethnicity, their religion, their nationality or immigration status, their gender or gender identity, their sexual orientation, or their disability status. A significant and concerning finding is that some students who reported experiencing bias-based harassment indicated that the perpetrator was a teacher or school staff member. Bias-based bullying of lesbian, gay, bisexual, transgendered, and questioning youth (LGBTQ) has been studied and identified across all school levels, including in elementary (Solomon, 2004), high school (Williams, Connolly, Pepler, & Craig, 2005) and university (Janoff, 2005) settings. Strong evidence indicates that homophobic bullying starts early and is pervasive (Solomon & Russel, 2004). Bias-based language, such as homophobic comments and labels, is often used against young people regardless of their membership in any particular marginalized group (e.g., “you’re a fag”) (Poteat & Espelage, 2005). LGBTQ youth are over-represented among those youth who are victimized by their peers, with up to 84 percent experiencing verbal harassment (Poteat & Espelage, 2005) and one-quarter experiencing physical harassment (Elze, 2003). Other research indicates that LGBQ students report higher rates of bullying, sexual harassment, and physical abuse by their peers than heterosexual youth, and also experience a more hostile peer context (Williams et al., 2005). Of particular concern, many studies indicate that homophobic language and harassment is often ignored or minimized by adults in authority positions (Kim, Sheridan, & Holcomb, 2009), or even perpetrated by these adults (Meyer, 2008). Other research on bias-based bullying indicates that children with special needs are more likely to experience peer victimization and harassment (Dawkins, 1996; Mishna, 2003). Children who are overweight are also at an increased risk of stigmatization (Gray, Kahhan, & Janicke, 2009; Hayden-Wade et al., 2005).

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Bias-based cyberbullying involves hateinspired electronic harassment, based on actual or perceived social identities (Blumenfeld & Cooper, 2010). In one study of middle school students in Canada, 95 percent of participants believed that students were more likely to be cyberbullied because of attributes such as ability or ethnicity (Cassidy, Jackson, & Brown, 2009). Other research on cyberbullying among middle and high school students found physical appearance to be the most commonly cited reason for cyberbullying; other reasons were ability, race, sexual orientation, and gender (Mishna et al., 2010). Limited research is available on bias-based cyberbullying (Blumenfeld & Cooper, 2010; Cassidy et al., 2009; Didden et al., 2009; Hoff & Mitchell, 2008). More research on bias-based traditional and cyberbullying is necessary in order to respond effectively at all levels of the ecological system both to prevent and to intervene with this damaging form of victimization. Societal context The dynamics of bullying are not contained within the relationship between the child who bullies and the targeted child. Individual factors, peer and family interactions, and societal and cultural conditions all contribute to bullying problems (Mishna, 2012). The ecological systems perspective is commonly viewed as the most suitable framework for understanding and addressing bullying among children and youth (Mishna, 2012). This perspective assumes that individuals are embedded in numerous social and environmental contexts, with multiple factors interacting over time to influence social behavior and development (Bronfenbrenner, 1979, 1992; Gitterman & Germain, 2008). In line with this perspective, bullying is viewed as occurring within the dynamic social context of the peer group, the classroom, the school, the family, and the broader community and society (Mishna, 2012). In response to the explosion of technology-mediated communication, scholars have

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proposed that the “techno-subsystem” (Johnson & Puplampu, 2008) and “techno-microsystem” (Johnson, 2010; Johnson & MacEwan, 2010) be included in the ecological systems framework. This adjustment extends a child or youth’s social ecology of home, school, and community environments to include the cyber world, which is thought to interact with all of the other levels to influence development (Johnson & MacEwan, 2010). Including the techno-microsystem or subsystem (Johnson, 2010; Johnson & MacEwan, 2010) in the ecological systems framework recognizes the ongoing reciprocal interactions among child characteristics, the use of communication technologies, and the home, school, and community environments (Johnson, 2010). The addition of the cyber world within the ecological systems framework is timely given the rapid and sustained increase of cyber interactions (Mishna, 2012). Bullying occurs within the context of the peer group, which can play a key role either by aggravating or alleviating the bullying problems (Atlas & Pepler, 1998; O’Connell et al., 1999; Salmivalli, 2010). Most bullying incidents occur in the presence of peers and the absence of adults with peers acting as observers, active participants, or interveners (Atlas & Pepler, 1998; Ttofi & Farrington, 2011). Most children express that they are against bullying and support the targeted child; peers are often reluctant however, to actually provide assistance to the targeted child (O’Connell et al., 1999). This discrepancy may be partly due to self-preservation concerns, the fear of retaliation, and difficulties inherent in challenging peer dynamics and the power of the perpetrator (O’Connell et al., 1999; Salmivalli, 1999). Bullying often occurs within the school context, and certain attitudes and responses to bullying by students, parents, teachers, and school administrators can be harmful (Hong, Cho, Allen-Meares, & Espelage, 2011), such as student and teacher tolerance of bullying (Brown & Merritt, 2002; Colvin, Tobin, Beard, Hagan, & Sprague, 1998). Schools that lack clear rules

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related to aggression as well as schools that have low principal involvement with students, weak staff cohesion, minimal teacher and student involvement in decision making, and inadequate supervision are more likely to foster bullying (Atlas & Pepler, 1998; Espelage & Swearer, 2003; Ziegler & Rosenstein-Manner, 1991). Discriminatory beliefs in society, such as homophobia and racism, may foster bullying among children and youth (Clarke & Kiselica, 1997; D’Augelli, Grossman, & Starks, 2006; Mishna, Newman, Daley, & Solomon, 2009). Socioeconomic conditions and attitudes toward violence in society may also contribute to bullying (Hong et al., 2011; Salmivalli, 1999), with bullying among young people mirroring societal violence (Atlas & Pepler, 1998). Vulnerabilities and risk factors Bullying can seriously impact the academic, social, emotional, and psychological functioning, as well as the physical health, of children and youth who are targets of bullying and who are perpetrators (Rigby, 2000). Children who perpetrate bullying and who are targeted are at risk of developing a number of psychosocial and psychiatric problems that may persist as they enter their adult years (Nansel et al., 2001; Olweus, 1993). Research indicates that victimization is associated with mental health problems (Rigby, 2000; Slee, 1995) and maladjustment (Hawker & Boulton, 2000). Compared to those who are not targeted, targeted children are more likely to report symptoms of depression, anxiety, and feelings of insecurity (Due et al., 2005); to have poorer self-esteem (Patchin and Hinduja 2010); and to describe themselves as unpopular, unhappy, powerless, afraid, and unsafe at school (Astor, Meyer, & Pitner, 2001; Colvin et al., 1998; Vaillancourt et al., 2010). Targeted children may also experience stressrelated physical symptoms such as headaches and stomachaches (Due et al., 2005; Williams, Chambers, Logan, & Robinson, 1996), sleeping difficulties (Due et al., 2005), and bed wetting

(Williams et al., 1996). These children may lack friends and be rejected by peers (Olweus, 1994), and may become less motivated in school, which can be accompanied by grade deterioration (Clarke & Kiselica, 1997). Individuals may suffer from the effects of bullying long after they cease (Carlisle & Rofes, 2007; Olweus, 1993; Staubli & Killias, 2011). Problematically, the effects of bullying often leave targeted children more vulnerable to further bullying (Crick & Bigbee, 1998). Young people who perpetrate bullying may be more likely to be unhappy at school (Nansel et al., 2001), to have attention deficit disorder (Kumpulainen, Räsänen, & Puura, 2001), to have lower self-worth (Undheim & Sund, 2010) and to be depressed as youth (Slee, 1995; Undheim & Sund, 2010) and as adults (Slee, 1995). Research suggests a reciprocal relationship exists between parental involvement and monitoring and perpetration of bullying, whereby increases in youth bullying behavior are associated with decreases in parental involvement and monitoring and vice versa (Georgiou & Fanti, 2010). Youth who perpetrate bullying are almost five times more likely than their peers to report using alcohol and approximately seven times more likely to report using drugs (Pepler, 2006). Other research indicates that youth who perpetrate physical or relational bullying display significantly more externalizing behaviors such as symptoms associated with oppositional defiant disorder and conduct disorder (Prinstein, Boergers, & Vernberg, 2001). Likewise, aggression in childhood often continues into adolescence (O’Connell et al., 1999), with bullying behaviors sometimes progressing into delinquency, gang activity, or criminal behavior (Farrington, 1993; O’Connell et al., 1999; Olweus, 1991, 1993; Undheim & Sund, 2010). Involvement in cyberbullying as a perpetrator or as a target affects the well-being of youth, over and above traditional bullying (Campbell, 2005; Hinduja and Patchin, 2009; Slonje & P. K. Smith, 2008). Cyberbullying may be more frightening than traditional bullying,

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particularly because it is hard to escape (Slonje & P. K., Smith 2008). Students who are cyberbullied report feeling sad, anxious, afraid, and unable to concentrate on school (Beran & Li, 2005; Juvonen & Gross, 2008) and may report social difficulties, drug and alcohol use, eating disorders, and low self-esteem (Dehue et al., 2008; Patchin & Hinduja, 2010; Ybarra and Mitchell 2007). Targeted youth are more likely to skip school (Ybarra, Diener-West, & Leaf, 2007), have detentions or suspensions, and to take a weapon to school (Mitchell, Ybarra, & Finkelhor, 2007). Bias-based bullying has serious consequences for victimized youth and society as a whole. Evidence suggests that LGBTQ youth who experience high levels of homophobic teasing or harassment report high levels of mental health issues (e.g., depression, suicidality, substance misuse), self-esteem issues, and school-related difficulties (Birkett, Espelage, & Koenig, 2009; Espelage, Aragon, & Birkett, 2008; Kim et al., 2009; Poteat & Espelage, 2007; Rivers & Cowie, 2006; Swearer, Turner, Givens, & Pollack, 2008). The use of homophobic and other biased epithets is often considered commonplace, although it is destructive and harmful even when this language is not directed at those who identify as LGBTQ (Athanases & Comar, 2008; Birkett et al., 2009). Research also indicates that girls who are targeted with sexually degrading language tend to feel anger, resignation, and depression, and tend to engage in self-destructive behaviors (Wessler & De Andrade, 2006). This research also reports that upon experiencing racist bullying, students feel angry, fearful, embarrassed, uncomfortable, and isolated, and begin to avoid school and may contemplate suicide (Wessler & De Andrade, 2006). Bias-based bullying motivated by weight-related prejudice is also associated with poor outcomes for the targeted child, including high levels of loneliness (HaydenWade et al., 2005), low self-esteem (Eisenberg, Neumark-Sztainer, Haines, & Wall, 2006), body dissatisfaction (Eisenberg et al., 2006), and

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negative health behaviors (Hayden-Wade et al., 2005). Bias-based cyberbullying toward youth with developmental disabilities is associated with both low self-esteem and high depression scores (Didden et al., 2009). Bullying motivated by bias is not simply a form of individual prejudice that children and youth perpetrate without actually meaning or understanding their actions (Aveling, 2007). Rather, involvement in biased-based bullying and harassment is related to more systemic and structural issues in society (DePalma & Jennett, 2010), which points to the need for systemic change in order to ameliorate this toxic form of bullying. resiliencies and Protective factors Throughout life, relationships are vital for optimal development (Corcoran & NicholsCasebolt, 2004). Positive and supportive relationships with peers, family, and other adults can be immensely protective for children and youth (Mishna, Wiener, & Pepler, 2008). Compelling evidence suggests that peer relations influence development (Bukowski & Adams, 2005), and that children of all ages benefit from friendship (Ladd, Kochenderfer, & Coleman, 1997). Being accepted by peers and having positive peer relationships is associated with good adaptation and can serve as a buffer for risks and adversity (Mishna et al., 2008). Having friendships is a positive source of protection for targeted children (Grotpeter & Crick, 1996), and can both ameliorate the negative effects of victimization and decrease the likelihood that a child will continue to be bullied (Hanish & Guerra, 2000). Positive relationships with adults have also been found to be protective against bullying. Supportive, nonpunitive approaches to parenting protect young people from bullying victimization (Baldry & Farrington, 2005), and maternal warmth, sibling warmth, and a positive home atmosphere are associated with children’s emotional and behavioral resilience (Bowes, Maughan, Caspi, Moffitt, & Arseneault,

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2010). Other research indicates that parental involvement and supervision protect young people from perpetrating bullying (Georgiou & Fanti 2010). In addition to parental relationships, the child-teacher relationship can significantly influence a young person (Burchinal, Peisner-Feinberg, Pianta, & Howes, 2002), with good relationships encouraging school involvement and academic achievement (O’Connor & McCartney, 2007). Positive relationships with teachers can also offer protection for students that have issues and risks associated with academic problems (Ertesvag & Vaaland, 2007). Other research points to a clear relationship between specific factors and a lower likelihood of bullying involvement, including individual factors such as positive self-concept and social sensitivity, as well as other factors such as positive and supportive family, community, and school environments (Donnon, 2010). When adults witness bullying incidents and intervene in some manner, this action may protect youth from victimization. In contrast, silence on the part of adults is a strong and destructive “statement” that tends to minimize the gravity of bullying and to further foster stigmatization of vulnerable young people. According to respondents in a study on bullying of lesbian and gay youth (Mishna, Newman, et al., 2009), inaction by adults is not only a missed opportunity for the adult to intervene, but also a message from that adult that “it is okay to keep bullying.” Alternately, respondents stated that if an adult responds by trying to stop the aggression and have a conversation, the adult provides support and protection for youth. One reason silence may arise is that adults may not consider certain behaviors or actions “serious” or bullying, whereas the young person does (Mishna, 2004). When such discrepancies occur, the child’s experience may be minimized or invalidated, which is among the factors that influence a child or youth’s decision to disclose being targeted (Mishna & Alaggia, 2005). A consistent and troubling finding is that a significant percentage of children and youth do

not tell adults about their victimization (CarrGregg & Manocha, 2011; Hanish & Guerra, 2000). Targeted children may be reluctant to tell adults for several reasons including fear of retaliation by those who bully them, shame and the belief that adults cannot help (Mishna & Alaggia, 2005). Young people who have caring, respectful, and interested adults in their lives may be more likely to disclose incidents of bullying and violence (Eliot, Cornell, Gregory, & Fan, 2010). Responding effectively to children and youth’s disclosures of bullying is an important protective factor. In contrast, ineffective responses by adults include minimizing concerns, disbelieving the victimized child, or reacting in ways that, although well intended, place the victimized child at increased risk (Mishna & Alaggia 2005). Adults must try to minimize the traumatic aspects of telling (Nagel, Putnam, Noll, & Trickett, 1996), validate the dilemma in disclosing, and avoid giving guarantees or promises of positive outcomes (Mishna & Alaggia, 2005). Disclosure should also facilitate timely intervention and healing for individuals who experience abuse, trauma, or victimization (Gries, Goh, & Cavanaugh, 1996). Despite their reluctance, children do turn to adults for help and adult intervention does help (Mishna & Alaggia, 2005). More research is needed on resiliency as it relates to all forms of bullying experiences. Understanding resilience in young people who have experienced bullying and determining factors that promote positive adjustment in the face of bullying can assist in the development of prevention and intervention strategies (Bowes et al., 2010). Programs and Social Work contributions School-based practitioners are in an ideal position to deal with all levels of the ecological context of bullying situations, through involving relevant groups such as school administrators, teachers, students, and parents (Vreeman & Carroll, 2007), and sustaining anti-bullying efforts, which is essential to maintaining change

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(Pepler, 2006). These practitioners may intervene in bullying situations by providing individual and group counselling for students, meeting with their parents and families, fostering communication and cooperation between parents and teachers (Drolet, Paquin, & Soutyrine, 2006), and connecting children and their families to resources in the community (Canadian Association of Social Workers [CASW], 2002). Although practitioners based in the community do not have easy access to the school context (Crothers & Levinson, 2004), they are still responsible for gathering information about bullying situations and attempting to work with all levels of the child or youth’s ecological system (Mishna, 2012). Exploring these systemic levels is critical when addressing bullying, in order to determine which measures in addition to meeting with the child or family are warranted. Failure to explore the issues and contexts of the bullying problems can leave the child or youth in a harmful environment and thus counteract therapeutic efforts (Mishna, 2012). There are countless anti-bullying programs, which must be selected based on evidence of their effectiveness, their fit with the individual or school, and their ecological context (Mishna, 2012). The prevailing viewpoint is that antibullying programs must take into account the multiple causes of bullying throughout the ecological system, rather than locating the problem with the children who perpetrate bullying or are targeted (Mishna, 2012). Anti-bullying programs vary considerably in their scope and aims, including: interventions aimed at children who are targeted or who are perpetrators (P. K. Smith, Ananiadou, & Cowie, 2003); interventions aimed at peers as well as students involved in bullying (Salmivalli, Kaukiainen, & Voeten, 2005); school curriculum-based programs to increase social competence and skills (Baldry & Farrington, 2004); and interventions aimed at the whole school including students involved in bullying, noninvolved peers, the curriculum, teachers, administrators and parents, and the school climate (Kilian, Fish, & Maniago, 2006;

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Olweus, 1994; Roland, 2000). Existing evaluation results are inconclusive regarding the effectiveness of anti-bullying programs (Merrell, Gueldner, Ross, and Isava, 2008; Rigby, 2004; Rigby & Slee, 2008; Vreeman & Carroll, 2007). At this point, research is unclear as to the specific elements of interventions that are effective and the specific elements that are essential for change (Pepler, P. K. Smith, & Rigby, 2004). Cyberbullying has emerged in recent history, and therefore the current knowledge base is small but growing. Intervening in situations of cyberbullying may be informed by prevention and intervention approaches used for traditional bullying (Cross & Walker, in press; Salmivalli, Kärnä, & Poskiparta, 2011). Keys to success in traditional bullying prevention and intervention include rigorous planning and development that involves identifying existing evidence; consulting with target audiences throughout the development process and conducting pilot testing; and careful and active monitoring during the delivery of preventive and intervention efforts (Cross & Walker, in press). Currently, several education strategies are employed to reduce cyber risks among children and youth, including personal and relationship safety, and media literacy, whereby the former focuses on online interactions and the latter focuses on youth’s capacity to critically examine content (Slane, 2009). Research is needed, however, to evaluate the effectiveness of these strategies in reducing the risk of cyberbullying. A systematic review of the literature (Mishna, Cook, Saini, Wu, & MacFadden 2009) identified only three cyber risk reduction programs that had been rigorously evaluated (Chibnall, Wallace, Leicht, & Lunghofer 2006). Two were programs for youth on Internet safety and the third addressed cyberbullying. Overall, this review suggested that although participation in cyber risk prevention and intervention strategies was associated with increased Internet safety knowledge, this knowledge may not be associated with a change in Internet risk attitudes and behaviors (Mishna, Cook, et al., 2009).

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assessment and intervention Given the prevalence and potentially significant short- and long-term effects of bullying involvement, practitioners should routinely inquire about bullying involvement even when a young person or parent does not raise bullying as an issue. In cases where there is bullying involvement, practitioners must comprehensively assess the degree of risk, vulnerability, and effects (Mishna, 2012). Practitioners must not dismiss or minimize the possibility that bullying can have serious effects and must be aware that some children and youth experience bullying as traumatic (Janson & Hazler, 2004; Mishna, 2007; Mishna & Sawyer, 2012). It is crucial to honor and validate a child or youth’s experiences and perceptions of bullying incidents, even if their perceptions differ from those of parents, teachers, or a practitioner (Craig, Henderson, & Murphy, 2000). Concerns about cyberbullying and other cyber risks have been met with attempts to protect youth from the dangers of the Internet through technological initiatives to block or limit access, and through education. Although blocking or limiting access may be helpful and necessary in some situations, this is not the only answer. A basic first step in responding to cyberbullying involves understanding the perspectives of youth, and the importance of technology to their social lives. Adults should take a nonjudgmental stance toward young people engaging with the cyber world, and should maintain open lines of communication about their technology use. Adults must be viewed as safe havens for youth, so that if young people experience troubling situations online, they feel comfortable discussing these experiences with trusting adults in their lives, without fearing nonacceptance, judgment, or loss of privileges (Young, n.d.). Another important initial step is recognizing that technology is not to blame for cyberbullying, but rather, appreciating that cyberbullying is embedded in relational issues and, for the contemporary generation, relationships

are embedded in the cyber world (Cross & Walker, in press). Disclosure of any form of abuse or trauma is complex and may not always result in desired outcomes (Vogel & Wester, 2003). Revealing something so private and significant can be so difficult that many individuals never tell anyone or do so only long after the fact (Cohen, 1999). Disclosing experiences of cyberbullying may be particularly difficult because of fear by the youth that disclosure will result in losing their technological privileges (Agatston, Kowalski, & Limber, 2007; Cassidy, Jackson, & Brown, 2009). In the absence of disclosure, practitioners who are working with individuals are missing invaluable contextual information that would aid understanding of the presenting issues (Mishna, 2012). Children should not be expected to easily volunteer information about their victimization, even with probing (Mishna & Alaggia, 2005). The practitioner’s responsibility is to uncover a child or youth’s involvement in bullying, by looking for clues of bullying involvement (Carr-Gregg & Manocha, 2011) and being attuned to signs of victimization such as a child’s reluctance to attend school, worsening self-esteem, or unexplained damage to his or her possessions (Mills et al., 2004). Key to helping children feel comfortable in disclosing is active listening and validating the child’s experience of the situation, rather than focusing on the adult’s perspective or on “objective” views (Mishna et al., 2005). Establishing an alliance with the young person is critical in promoting trust as is fostering the child’s ability to assert his or her voice (Marziali & Alexander, 1991). Young people who experience bias-based victimization may struggle with unique issues related to disclosure. In a national survey conducted in the United States, the majority of LGBT-identified youth reported that they would not tell a parent or guardian if they experienced bias-based cyberbullying, mostly out of fear that they would need to disclose their sexual identity in order to disclose the

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bullying. Youth also feared losing technological privileges. The Internet can act as a great source of support for LGBT youth, and thus the risk of having technology privileges removed by parents tended to outweigh the benefit of informing parents of cyberbullying (Blumenfeld & Cooper, 2010). Other research indicates that African American students are less willing to seek help for bullying and other violent situations (Eliot et al., 2010), which is important to consider in cases of racially motivated bullying. Pepler and colleagues (Craig & Pepler, 2007; Pepler, 2006) stress that to fully address the factors that influence bullying situations, the centrality of the relationship must be recognized. Relationships must be recognized as operative across all levels of the ecological context, and as underpinning all interventions, regardless of their nature, target, or goal (Mishna, 2012). Relationship issues must be addressed at each level, be it the individual, classroom/school, or societal/cultural. Within the interpersonal domain there are several significant relationships that must be considered, including the relationship between the child who perpetrates bullying and the child who is targeted; among the bystanders, the perpetrator, and the target; between the teachers and children; between the children and their parents; between the parents and teachers; and the relationships in the school milieu (Mishna, 2012). Labeling certain behaviors bullying sends a clear message that such behavior should not be accepted as “normal” and must be addressed. Paradoxically, including numerous behaviors within the term bullying can also minimize their gravity (Mishna, 2012). Within the inclusive bullying label, the intent of certain actions may be missed, such as assaults, hate crimes, and discrimination due to disability, gender, sexual orientation, religion, and race (Mishna, 2012). Attention to the underlying motivation of these behaviors is essential in order to intervene effectively (Greene, 2006; Rigby, 2002). Understanding bullying is made even more complex because of the overlap of

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bullying with harassment and the fact that in some cases bullying may come under the jurisdiction of the law and of human rights legislation (Greene, 2006). Determining whether to include civil and human rights violations within the umbrella term of bullying is a thorny and complex matter and has significant implications, such as whether to use the bullying (nonlegal) or the harassment (legal) definition (Greene, 2006). Advances in technology-based communication use have far outpaced policy and legal guidelines regarding cyber behavior. The legal ramifications of cyberbullying are often unclear, as there is rarely an obvious distinction between behaviors that are right and wrong (Campbell, in press). Research should be undertaken to explore questions such as: (1) how law attaches or should attach liability to the emotional harm caused by words or images (Shariff & Hoff, 2007); (2) how law attaches or should attach liability for participating in various capacities in bullying online or in offline incidents with online elements (e.g., participating as an instigator or bystander, participating by posting or distributing an image or video of an offline incident) (Auerbach, 2009); and (3) how law attaches or should attach liability for offline incidents instigated by online activities (e.g., suicide following cyberbullying involvement) (Ruedy, 2008). When developing policy and legal responses to cyberbullying, it is crucial to remember that technology is constantly advancing, and in turn, cyberbullying may be expressed quite differently in the coming years, months, and even weeks (Collier, 2012). The definition of cyberbullying included in legislation and policy must therefore be precise, but not restricted to a named set of behaviors that are expressed on a named set of technological devices (Butler et al., 2011). In dealing with the underlying motivations fuelling bullying, an intersectional approach focuses attention on the interactive relationships among the various systems of social identity and social location, including for example,

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race/ethnicity, gender, sexual orientation, ability, and newcomer/citizenship status (Daley et al., 2007). As with other systemic issues, the whole must be seen as greater than the sum of each part (Mishna, 2012). illuStrAtion And diSCuSSion

The following case example draws on an experience one of the authors encountered when conducting previous research on bullying.1 Erin is a bright and talented 11-year-old girl in grade 5, who had recently transferred to her current school. She was born in Canada shortly after her parents had emigrated from China and lives with them and her older brother in a large Canadian urban center. The school Erin attends is renowned for its all-around excellence and serves families that are mostly of moderate to high socioeconomic status. Indeed, one teacher expressed concern that the school’s excellent reputation lessened teachers’ and parents’ vigilance. He believed that the degree of bullying within the school “is just as much. It’s much more covert. I think because the majority of our bullying is not physical, most parents don’t perceive that we have a bullying problem. In fact many of them may have the same attitude that I heard from teachers when I first arrived saying, ‘oh our kids are nice to each other; there is no bullying.’” The teacher’s portrayal of the nature of bullying within this school matched Erin’s experience. Erin described having been “bullied physically” at her previous school. The extent of her victimization was such that Erin had come to expect and even “accept” being targeted by peers, which was evident in her depiction of herself as “a kid to be bullied.” After transferring schools, Erin felt relieved because the anticipated bullying did not occur. Rather, she thought, “oh wow, nothing bad is happening.” Completing the survey we administered changed Erin’s view, however. She explained, “There is a group of people I know and I thought they were my friends. But they tell secrets in front of me. And they’ll say, ‘Could you go away?’ and I would. I didn’t think it was my business. But now I remember the tone of

voice they used and they meant it meanly. So I reconsidered that and I thought, I guess they were bullying me.” Despite not having identified herself as being bullied in her current school, Erin nonetheless had been clearly affected. When discussing how she felt when excluded or told to go away Erin said, “It makes me really sad. I think it’s my fault. And well I don’t know why but I think that may affect me. Well, now when I make a mistake for some reason, I feel like I have to punish myself so I hit myself. And I think that could be related to the bullying.” Erin explained that when upset with herself she would hit her head with a book or pinch herself hard enough to draw blood. Erin most often dreaded going to school but for the most part forced herself to attend. Prior to participating in the research interview Erin had not discussed these experiences with anyone. After recognizing that this verbal and exclusionary behavior fit the definition of bullying that was provided in the survey questionnaire, and hence did not constitute “normal” expectable behavior, Erin realized that she did not have to accept such verbal taunts. Still, she felt confused about how to deal with this situation since some of the same children she considered to be her friends were among those excluding her. Clearly struggling with issues related to her exclusion, Erin was willing to see a school social worker to have help coping with her feelings and this problem. Erin and her mother each described their relationship as close, and Erin expressed feeling supported by her mother. She said, however, that in the past her mother didn’t always believe her when she told her about being bullied, for example about “being chased around the schoolyard by this kid waving his fists and saying ‘I’m going to hurt you.’” Erin explained that her mother “thought it was happening so often that she was thinking, ‘is Erin really telling me the truth because this is happening so often?’” Erin exclaimed “And of course I was!” She stated “To assume that it is true is much better than to assume that it’s not true. When my mom doesn’t believe me, it’s sort of hard because then you have no support.

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So when you have no support in dealing with the issue, it is not going to stop. Although kids can do something, children cannot always deal with this kind of situation. I mean we just can’t on our own. It is not as if we were born with some sort of sense of what to do here, what to do there. So we need help in that situation.” Erin’s mother had no idea that Erin was being excluded at her current school and explained that when approached to participate in the research, she had worried “it was something worse. I thought somebody was pushing her or hitting her or something like that.” She felt “relieved” when she heard that her daughter was being socially excluded because “this is what kids do.” Her mother corroborated Erin’s view that in the past she had not always believed Erin’s accounts of being bullied, which she attributed to her daughter’s tendency to be “dramatic,” and the associated “difficulty to sort of gauge, is she upset, is she exaggerating, what is going on?” Surprised that Erin reported being bullied, her teacher commented, “It never occurred to me that Erin would be bullied because she can stand up for herself and is liked and well adjusted.” Furthermore, Erin was a strong student, which was at odds with the teacher’s assumption that bullying “would affect your concentration and grades.” Several features of Erin’s experience of bullying left her vulnerable to feeling traumatized. These elements include the repetitive nature of her exclusion, not having been previously believed by her mother, the lack of awareness by both her mother and teacher of her current exclusion and her mother’s lack of appreciation for the seriousness of relational bullying. Several responses related to the interpersonal domain stand out. First, the social worker must appreciate the seriousness of indirect bullying, and validate and help Erin articulate her responses. The social worker may also provide information, in an appropriate manner and pace, for Erin and her parents and teacher(s), on the potentially devastating impact of bullying behaviors that are not obvious or that do not appear serious (Craig, Henderson, & Murphy, 2000). This education ideally should also occur on a broader level, for instance with the whole

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class or school. It appeared that the teacher’s assumptions about characteristics that targets of bullying would display—for example, that they would not be well adjusted or well liked or would not be able to concentrate on academics—might be one factor that prevented her from recognizing the possibility that Erin could be bullied and that it could have a traumatic impact on her. The social worker must balance information about the characteristics that targeted children may exhibit with the recognition that these characteristics need not be present in all bullying situations (Mishna et al., 2005). To confuse matters, Erin considered the children who bullied her to be friends. Having or desiring a friendship with the child who perpetrates bullying may complicate the situation and inhibit the targeted child’s ability to disclose (Mishna, 2004). The social worker therefore must balance her or his recognition that this behavior constitutes bullying with an understanding that Erin might be afraid of acknowledging, even to herself, or disclosing to others this problematic behavior, for fear of losing the friendship. Despite her newfound awareness that her friends should not exclude her, Erin was faced with the very real dilemma of whether and how to act on this recognition, as the potential loss of her friends may have felt too big to risk. Erin clearly needed support to not accept being bullied as part of her friendships. Ironically, because Erin appeared to be doing well, so much so that her teacher was surprised she would report being victimized, the social worker would have to be mindful not to minimize Erin’s concerns. Erin was already displaying negative effects of being bullied along with potentially traumatic effects of the experience, such as dreading and wanting to avoid school despite being a strong student, and blaming and hurting herself. Without support and interventions by trusted adults, Erin’s behavior could potentially escalate into sustained self-harming behavior and school avoidance, resulting in deterioration of her grades. Erin clearly had many protective factors, including individual characteristics as well as her positive relationships with

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her parents and teacher, upon which it was critical to build (Baldry & Farrington, 2005). Even after recognizing that she was currently bullied Erin did not tell her parents or teacher, although in the past she had told her mother about being physically bullied. Social workers can play an important role in helping parents and educators understand and respond to the children and youth’s perspectives and feelings. The social worker should also be alert to whether Erin’s victimization entailed racial bullying, since research has shown that disparagement of a person’s race is among the most typical forms of bullying (Nansel et al., 2001). The social worker should also assess Erin’s involvement in the cyber world, and determine whether any of her communications via e-mail, instant messaging, text messaging, or other forms of technology represented incidents of cyberbullying. The social worker may opt to engage in education regarding the cyber world and the difference between appropriate and problematic actions online. This case example illustrates several important issues and considerations discussed in this chapter. Erin endured bullying by her friends, which she did not recognize and which went undetected by her teacher and parents. Connecting with a social worker was an important step in helping Erin gain awareness of problematic interactions in her relationships and cope with her experience as a target of bullying.

conclusion Bullying dynamics demand a perspective that takes into account the inherent complexities involved—the individual, the social, and the

noteS

1. This case illustration was adapted from an example originally published in: Mishna, F. (2007). Bullying and victimization: Transforming trauma through empowerment. In J. Wise & M. Bussey (Eds.), Trauma Transformed: An Empowerment Response (pp. 124–141). New York: Columbia University Press. Pseudonym used to protect anonymity.

environmental context, including the newer cyber world. A number of factors influence how targeted children and the adults in their lives perceive and respond to bullying. Identifying such factors is critical in order to increase our understanding of how the targeted children, their parents, teachers, and school administrators view and react to bullying situations, and how adults interact with the children who report being targeted. Such understanding is essential in order to develop effective prevention and intervention (Smith, 1997). Although not all youth experience bullying as traumatic, research is needed to understand the individual, interpersonal, and ecological factors that lead to bullying being experienced as such. This knowledge would inform education and treatment programs to prevent the traumatization of children and to transform experiences of being traumatized (Mishna, 2007). Factors to examine include the frequency, nature, severity, and type of bullying (Janson & Hazler, 2004), as well as the responses of adults to the victimized children, such as whether they believe and validate the children or hold them responsible for the victimization (Mishna, 2004, 2007). Bullying is a significant issue in children’s lives, with short- and long-term mental health, academic, physical, and social problems for the children who perpetrate bullying and those who are targeted. Social workers must be aware of how confusing and difficult it can be for children and adults alike to deal with bullying behavior, and must work to raise awareness of the various and subtle forms of bullying, as well as clarify and correct assumptions and misperceptions.

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t

he quality of care of children concerns every society because children represent its future. Quality care for children ensures healthy physical and emotional development, culminating in successful transition to adulthood. In adulthood the grown-up children become productive members of society and provide care and nurturance to their own children. In most western nations there are legal standards that define minimum standards for the care and nurturance of children. When the minimum standard is not met, the child is defined as abused or neglected. Quality of care for children is determined by many factors. Cultural mores and norms; neighborhood resources and safety; family, educational, social, and economic resources; parental characteristics and deficits; and characteristics and special needs of children themselves all influence quality of care and nurturance for children. Each state in the United States has laws to identify and deal with the needs of maltreated children. In the twelve years since the second edition of this book, a virtual explosion of research about maltreatment has evolved. The ideal of scientifically validated practices, at its dawn in the 1990s, is more developed today. At the same time there is renewed attention to important determinants of child maltreatment such as poverty and inequality in American society, and to the voice of parents.

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defining and explaining child abuse and neglect Child abuse and neglect (also called child maltreatment) is defined in the laws of each U.S. state. There is no universal definition of child maltreatment. The definition of child maltreatment is based on three components: the occurrence of one or more instances of adult behavior (or omission of behavior) toward a child; harm or endangerment to the child that is a result of the adult behavior; and a clear causal link between the adult behavior and the danger or harm to the child (Stein, 1998). While there are model federal statutes upon which state laws are based, there is still considerable variation from state to state in how different types of child maltreatment are defined. Services and intervention are driven by the identification of one of four commonly accepted types of child maltreatment. These are physical abuse, neglect (with several subforms), sexual abuse, and emotional abuse. Table 12.1 defines these types of abuse as they are defined in the two model federal laws on child maltreatment, the amended Child Abuse Prevention and Treatment Act [CAPTA] (PL 93–247) and the Keeping Children and Families Safe Act of 2003 (PL 108–36). States are mandated to sponsor child protective service systems (CPS) including a system to receive reports of child maltreatment. Child abuse and neglect is identified when a call is

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Definitions of Major Types of Child Abuse and Neglect

Type

Definition

Physical Abuse

Non-accidental 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. Failure of a parent, guardian, or other caregiver to provide for a child’s basic needs. Types of neglect include physical, emotional, educational, medical, or abandonment. 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. Also called psychological abuse, a pattern of behavior that impairs a child’s emotional development or sense of self-worth.

Neglect Sexual Abuse Emotional Abuse

made to the CPS agency in any given state. A call may be made by anyone suspecting child maltreatment. Social workers are legally mandated reporters of child maltreatment. This means that if a social worker suspects or observes that a child is maltreated, he or she must report the suspected maltreatment to the hotline. Other professionals such as teachers and medical professionals are also mandated reporters. Intervention for abused and neglected children is provided to children who are determined to be victims of or at high risk for child maltreatment by the state CPS agency. When a credible call is received on the state child abuse reporting hotline, a CPS investigator conducts an investigation and makes a determination about whether the allegation of abuse or neglect has occurred (case is indicated) or not (case is unindicated). Research indicates that the parenting support and child care needs of unindicated families is similar to that of indicated families (Drake, Jonson-Reid, Way, & Chung, 2003). A criticism of the CPS systems’ definitions and responses to child abuse and neglect is that they are too focused on parental inadequacy and insufficiently focused on the societal factors such as poverty and societal inequality. Thus, parents are “blamed” for the socially unjust and disadvantaged positions that they are in.

demographic Patterns The U.S. Department of Health and Human Services is mandated by CAPTA to collect data on states’ reports of child abuse and neglect. The data reported in this section is drawn from Child Maltreatment, 2010 (NCANS; U.S. Department of Health and Human Services [DHHS], 2011) and from the 2010 National Incidence Study (NIS), which is a nationally representative sample of 122 counties (Sedlak et al., 2010). NCANS is a compilation of administrative data that are reported by all 52 states and the District of Columbia and Puerto Ricco. The NIS provides information about unreported as well as reported child maltreatment. NIS obtains data from CPS workers and other professional “sentinels” who provide information about their observations of abused and neglected children. In 2010, state child welfare authorities received a total of 3.3 million reports of suspected child maltreatment. Of these, 61 percent (more than 2 million) were determined to be credible allegations of maltreatment involving 3.6 million children. In 2010 CPS formally investigated 1,793,724 reports. Of these, 461,297 cases of child maltreatment were indicated and 1,262,118 were unindicated. In the remaining cases indication was unclear or ambiguous. The number of indicated cases based on the NCANS data is only about one-third of the 1.25 million children estimated in the NIS to be

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victims of child abuse and neglect. This suggests that only a fraction of maltreated children actually become involved with the CPS system. Professionals made 60 percent of alleged maltreatment reports, with teachers, social services professionals, and law enforcement professionals making the largest numbers of reports. Nonprofessionals including family, friends, neighbors, and anonymous reports made the remaining 40 percent of reports. Rates of substantiation of child maltreatment allegations are higher for reports made by professionals as compared to reports made by nonprofessionals. NCANS finds that nearly 1 percent of American children (9.2 victims per 1,000 children) are found to be victims of child abuse and neglect. Rates of child abuse and neglect are double for infants as compared to older children. Boys account for 49 percent of victims and girls for 51 percent. The race or ethnicity of child maltreatment victims is white (45 percent), African American (22 percent), Hispanic (21 percent), and other ethnicities including Native American, and Asian (12 percent). Ethnic minority children are overrepresented in substantiated child maltreatment; this overrepresentation is referred to as “disproportionality.” There is a vigorous debate about whether disproportionality is explained by racism in child maltreatment identification and investigation, or whether it reflects the disproportional social and economic disadvantages faced by minority families in the United States (Detlaff & Rycraft, 2010). Over three-quarters of substantiated child maltreatment reports (80 percent) are for child neglect. Eighteen percent are for physical abuse, 9 percent are for sexual abuse, 8 percent are for emotional abuse, and 10 percent for other forms of maltreatment including threats of harm and congenital drug addiction. Since multiple forms of maltreatment may be substantiated for a single case, the total percent tallies more than 100 percent. Child neglect and child abuse are the most common co-occurring types of maltreatment.

In 2010, 1,560 children died from child abuse or neglect (2.07 deaths per 100,000 population, or 0.002 percent of the population under 18 years of age). Eighty-one percent of the perpetrators of child maltreatment are parents of the child, with other relatives accounting for 6 percent. Forty-five percent of perpetrators are men and 54 percent are women. According to both NCANS and the NIS, rates of substantiated child abuse and neglect have fallen since 2006, with rates of child victimization falling from 11 children per 1,000 child population in 2006 to 9.2 children per 1,000 child population in 2010. Rates of child physical abuse and child sexual abuse have fallen, but rates of child neglect remain tenaciously high and stable (Chalk, 2012; DHHS, 2011; Sedlak et al., 2010). Societal context Child abuse and neglect is best understood in an ecological context. Figure 12.1 shows an ecological model for child maltreatment. In this model multiple system levels affect the child’s biological, psychological, and social safety and well-being. The society (macro-system), local community (mezzo-system), family (microsystem), and individual (person-system) all affect the child. Each system has direct risk and protective factors associated with maltreatment. Systems interact with each other to create transactions that affect the quality and safety of life for children. An ecological framework presumes that there are multiple influences on people and that these influences can be organized by the social systems in which the child is embedded. Systems can be identified and organized by their level, from societal to individual. Smaller systems are embedded in larger systems. Thus, Individuals are embedded in Families, which in turn are embedded in local Communities or neighborhoods, which are embedded in the national Society. Systems even smaller (such as human biological systems) and larger (the world economy) could be identified, but for the purposes

cHild abuSe and neGlect

Societal System

Community System

Family System

Child System

Poverty

Community Norms

Family Structure

Special Health Needs

Social Inequality

Social Connections

Parenting Knowledge

Special Behavioral Needs

Health Disparities

Neighborhood Cohesion

Parenting Skills

Temperament

Cultural Mores

Crime

Social Supports

Developmental Level

Social Policies

Violence

Health Problems

Intelligence

Social Institutions

Housing

Behavioral Health Problems

Schools

Extended Family Resources

Recreational Resources

Number & Ages of Children

fiGure 12.1

TRANSACTIONS

TRANSACTIONS

TRANSACTIONS

School Options Recreational Options Crime and Violence

Child Care Options Home Safety Non-familial Adult Support Figures

Coercive Interaction Patterns Stimulation and Development Attachment

]

Ecological Model of Child Abuse and Neglect

Source: Adapted from Belsky (1980) and Coulton et al. (2007).

of this chapter, we will focus on Societal, Community, Family, and Individual Child systems. A final assumption is that every system level transacts with other system levels. This chapter prioritizes empirical research– based knowledge about ecological systems and their influences on child maltreatment. Given the conceptual complexity of the ecological systems model and unevenly distributed focuses of research, we have only partial knowledge about the etiology and development of child maltreatment. To understand child maltreatment, societal conditions that affect the quality of life for children must be identified. Child maltreatment is increasingly recognized as a global social and health problem (Stoltenberg Van Izendoorn, Euser, & Bakermans-Kranenberg, 2012; WHO, 2010; Gray, 2010; Gilbert et al., 2012). Making direct comparisons among countries is difficult because cultural norms concerning adequate care for children and definitions of

maltreatment vary from culture to culture. One study finds that among six developed countries the United States has the highest rate of violent deaths of children (Gilbert et al., 2012). Other analyses show that among developed countries the United States has comparatively high rates of children living in poverty and social disadvantage (OECD, 2009). These are major risk factors for child maltreatment. The status of children in the United States is markedly lower in some respects than many other developed countries (OECD, 2009). This is due to dramatic wealth disparities in the United States, coupled with inequalities produced by a limited social safety net for children, especially in the areas of medical care and education (Gilbert et al., 2012). These inequalities are directly related to the incidence of child maltreatment. The data in this section of the chapter, unless reported otherwise, are drawn from the Annie E. Casey Foundation report, Kids Count Data Book 2011 (Annie E. Casey Foundation, 2011).

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Twenty-one percent of all American children live in families that earn less than the official federal poverty rate, $23,050 for a family of 4 (National Center for Children in Poverty [NCCP], 2011). Most poverty scholars and policy experts criticize the official poverty definition as out-of-date and a dramatically low threshold. Many families with incomes above the poverty line experience severe hardship in food and housing (Annie E. Casey Foundation, 2011; NCCP, 2011). A more accurate estimate of children living in severely limited economic conditions is 42 percent, nearly half of all children in America. Growing up in poverty affects every ecological level of a child’s life. A child growing up in poverty is more likely to live in a single-parent household, which not only contributes to the poverty status of the family due to having only one earner, but also means fewer parenting resources are available. Children in poverty may experience nutritional inadequacy, which can effect their neurological development. The disadvantages associated with poverty begin before birth. Infant mortality, a major indicator of well-being of children in a society, reflects income disparities in the United States and is thus bimodally distributed. Infants born to poor families as compared to middle-class families have dramatically higher rates of infant mortality. America ranks forty-sixth out of 222 nations in infant mortality, below almost every other developed nation in the world (Central Intelligence Agency, 2010). In poor families there is less money available for toys and enrichment activities, potentially blunting the education and cognitive development of children. Poverty creates stress for parents, increasing their likelihood of mental health disorders, addiction, and health problems of their own. These factors increase risk for child maltreatment. Children in poverty are more likely to grow up in unsafe and unhealthy neighborhoods, where violence is common, where norms for adequate care of children may be distorted, and where rates of child maltreatment are high.

The complex links between poverty, education, and child maltreatment deserve special mention. Parents who are poor tend to have less education and literacy themselves. Fewer words are spoken in homes affected by poverty. An abbreviated family vocabulary negatively affects a child’s language development and the ability of families to communicate and to resolve conflict. It also places children at educational disadvantage even before they begin school. Parents with inadequate educational backgrounds frequently do not appreciate and do not know how to support their children’s education, thus potentially contributing to educational neglect and truancy. The schools available to children affected by poverty are often underfunded and underperforming. Therefore, a child growing up in poverty faces serious educational disadvantage in the United States, and the same factors that contribute to educational disadvantage also contribute to child maltreatment through educational neglect and other pathways. There are disproportionate rates of poverty across different racial and ethnic groups in the United States. African American, Native American, and Latino families show the most disadvantages. These are the populations that have been historically oppressed in American society and today show disproportionately high rates of child maltreatment and placement into foster care (Sedlak, 2010; DHHS, 2011). Thus, societal structural factors affect every level of the ecology of childhood and create conditions of risk for maltreatment and social disadvantage for children growing up in poverty. Poverty is the single biggest risk factor for being abused and especially for being neglected as a child. Vulnerabilities and risk factors Vulnerabilities and risk factors for child abuse and neglect are typically understood within the ecological framework in figure 12.1. Societal risk factors have been discussed above. This section will focus on the mezzo, micro,

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and individual systems—the community, family, and child. Social structural features of society often touch families and children through their effects at the neighborhood level. At the neighborhood level, families and children experience the effects of poverty, economic segregation, poor schools, and inadequate health care. Social structural characteristics of a neighborhood predict child maltreatment rates (Korbin et al., 1998; Coulton, Crampton, Irwin, Spilsbury, & Korbin, 2007; Olsen & Stroud, 2012). Neighborhoods with higher rates of families living in poverty, unemployment, single-parent families, crime and violence, and infant mortality, and which are more socially disorganized and lack social connectedness, have higher rates of child maltreatment. Neighborhoods with a greater ratio of children to adults, labeled the child care burden indicator, also have higher rates of child maltreatment. Neighborhoods also influence family behavioral patterns through cultural mechanisms such as norms. Norms provide immediate contextual support or sanction for certain behaviors including family interactions and parenting behaviors. Examples of how neighborhood influence family behavior and interactions include tolerance of child physical punishment in public, norms about leaving children unattended, and norms about child care exchanges, whether neighbors care for each others’ children (Olsen & Stroud, 2012; Coulton et al., 2007). A recent example of an isolated and severely economically depressed Native American community with a norm tolerating the sexual abuse of children was published in the New York Times (Williams, 2012a, 2012b). Neighborhoods also differ in noting and reporting child maltreatment. Whether differential rates of child maltreatment reporting and substantiation reflect the availability of different social transactional resources between neighborhood and family or whether they reflect differential social control in the form of greater surveillance is always a question (Olsen &

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Stroud, 2012). Nevertheless, certain neighborhood factors elevate risk for child maltreatment. Research has identified family and parent characteristics that contribute to the occurrence of child abuse and neglect (National Research Council, 1993; Olsen & Stroud, 2012; Videka, 2008a, 2008b). Family risk factors include four or more children in a family, single-parent status, parental unemployment, parental stress, parental history of child maltreatment victimization, parental mental health or substance abuse disorders, parental conflict, and family violence (Widom, 1989; Young, Gardner, & Dennis, 1998). Parental risk factors can best be understood as factors that predispose a parent to negative parenting practices that lead to child abuse and neglect. These parent-child interaction patterns ultimately lead to acts that are abusive or neglectful. The transactions between the ecological systems in which the family and child are embedded provide useful knowledge for direct prevention and intervention (Coie et al., 1993; Videka, 2008b). Considerable research exists on parent and child interactions and risk for child maltreatment. The findings stand today as important bases for understanding child maltreatment and for targeting interventions. Burgess and Conger (1978) demonstrated that abusive and neglectful families have different interaction and emotional valence patterns when compared to non-maltreating families. Maltreating families have fewer numbers of verbal interactions overall when compared to non-abusive families. They also make fewer positive and rewarding statements to each other. Furthermore, they have a greater proportion of negative valence or aggressive, threatening statements to each other. These patterns create a climate of negativity and an absence of positive interaction, creating an interaction style that predisposes families to incidents of child maltreatment. Egeland and his colleagues (Egeland, Jacobvitz, & Srouf, 1988; Egeland, Yates, Appleyard, & van Dulmen, 2002) conducted a series of

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influential longitudinal studies on motherinfant interaction and long-term child development consequences. They found that early parenting practices were influential in predicting long-term child development and school success outcomes. They identified three destructive parenting styles: physical abuse, neglect, and emotional abuse. They found that emotional abuse was most deleterious to child development, resulting in children who failed at school, were prone to conduct problems and later delinquency, and had negative life outcomes many years later. Wahler and Dumas (1989) identified a “cycle of coercion” that characterized the interaction between maltreating parents and their children. This cycle begins when a child misbehaves. The parent responds with negative verbal or physical (punishment) responses. This response fails to guide the appropriate child response and fails in empathic response to the child. The child is resentful and misbehavior escalates. The parent’s negative and coercive behavior escalates and may include threats and physical and verbal aggression. Negative behavior and emotion escalate in parent and child. Over time the parent fails to empathize with the child and to effectively socialize the child. The child internalizes negative behavior patterns, displays antisocial behaviors, and does not respond to authority. Other research, using attachment theory as a base, finds that disrupted attachments are characteristic of families affected by child abuse and neglect (Cicchetti & Toth, 2005; Cicchetti, Rogosch, & Toth, 2006). They identify sequences that are consistent with the earlier findings of Egeland, Burgess, and Wahler, in which parental nonresponse or non-empathic response leads to disruption of parent-child attachment processes. This begins during infancy and results in neurobiological development disruption in infants and young children, leading to poor attachment behaviors and antisocial development in the child. Ambivalent or negative attachment leads to greater likelihood

of coercive parent-child interaction patterns and to the greater likelihood of identifiable incidents of child abuse or neglect. Dozier and his colleagues (Bernard et al., 2010; Olsen & Stroud, 2012) show that negative parenting practices, such as the ones described above, actually produce negative stress hormones and brain effects on abused and neglected children, producing short- and long-term negative effects such as changes in responses to people, behavior and attachment patterns, and long-term behavioral outcomes including mental health and addiction disorders. Importantly, this same body of research shows that these negative effects are reversible. They can be changed, especially at early ages, by parenting interventions designed to improve the quality of parenting a child experiences. Analysis of intergenerational effects and transmission of violent behavior patterns in families provides information about risk for child maltreatment. Some, but not all, parents who were child abuse and neglect victims become perpetrators of child maltreatment with their own children. Factors that are shown to discriminate parents who become perpetrators of child maltreatment from parents who break the cycle of child abuse and neglect include worse financial resources, severity of child abuse of the parent, poor attachment between parent and child, and weaker, smaller social networks for the family (Dixon, Brown, & Hamilton-Giachristsis, 2009; Zuravin, McMillan, DePanfilis, & Risley-Curtis 1996). A host of child risk factors have been associated with child abuse and neglect. These include birth prematurity and low birth weight, which may result in a lack of social responsiveness in the infant; child temperament and the match between the child’s and the parent’s temperament; attractiveness of the child; and special health needs of the child (National Research Council, 1993; Chalk, 2012). These factors are important because they play a role in the parent-child interaction patterns that put families and children at risk for child

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maltreatment. They play a role in the interaction by creating conditions that are especially challenging for any parent. They are difficult for highly stressed parents without sufficient financial and social resources to manage and thus set the stage for neglect, for negative interactions, and for coercive child-parent processes when the parent has low parenting skills and attachment capacity. Special health or biological needs of the child and lowered responsiveness to the parent, thus setting the stage for attachment disruptions. In the past decade the concept of trauma has been applied to situations of child abuse and neglect. Adverse childhood experiences (ACEs) research establishes that trauma is cumulative and puts children at high risk for health and mental health morbidity (Filetti et al., 1998; Chapman et al., 2004). This framework has been influential in pediatrics and child welfare and has influenced how we look at the consequences of child maltreatment. Many of the adverse childhood experiences defined in this line of research are consistent with the experiences of children who face child abuse and neglect. This line of research also points to the cumulative and long-terms effects of childhood trauma, including child abuse and neglect. These experiences include witnessing or being a victim of violence, having a parent with addiction or serious mental health problems, being exposed to violence as a child, and the experience of abuse or neglect as a child. In one study, abused and neglected children were shown to be at risk for depression and substance abuse is adulthood (Dube et al., 2003). resiliencies and Protective factors Protective factors exist at every level of the child’s ecological experience. At the societal level progressive economic structures, as well as tax and social policies and programs help blunt poverty and its negative effects. Neighborhoods can protect as well as create risk for child maltreatment. Neighborhoods with stronger neighbor-to-neighbor social

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bonds protect families from abuse and neglect through tangible resources such as informal child care, as well as the opportunity to observe and learn from neighbor parents providing positive parenting and care for their children. Physical and locational neighborhood assets are also important. The presence of a settlement house or community center provides space for child care classes, parental support groups, and primary prevention programs. Contacts and interaction across neighborhoods, especially when neighborhoods have different social resource levels, may also make a difference. Family protective factors include a parent’s knowledge about child development and level of parenting skills, a good marital relationship, parental health and mental health, financial resources, and a strong social support network. Resilient children are defined as those who have a healthy childhood outcome despite experiencing situations of grave risk, such as childhood abuse and neglect. Research on the concept of resilience in abused and neglected children identifies which protective factors are key in achieving resilience in maltreated children (Luthar, Cicchetti, & Becker 2000). Resilient children flourish despite severe and unnurturing conditions; they survive abusive and neglectful situations and become productive and well-balanced adults. Several factors appear to be important. Children with high cognitive abilities are more likely to be resilient to child abuse and neglect (Egeland, Jacobvitz, & Srouf, 1988; Egeland, Yates, Appleyard & van Dulmen, 2002). For survivors of abuse or neglect, forming a coherent inner narrative of the maltreatment experience and the adult(s) who perpetrated it helps survivors to function adaptively, to manage memories of past traumas, and not to generalize negative interaction patterns. Children with adult mentors or supporters outside of the maltreating parents are also more likely to escape the negative long-term effects of maltreatment (Munson & McMillen, 2009). Another study found resilience in children who had been maltreated

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consisted of positive academic performance, a positive attachment to one or more adults, and optimism or positive expectations about their own futures (Rajendran & Videka, 2006). Programs and Social Work contributions Child abuse and neglect has been a priority of the social work profession since its founding. Many social workers today are employed in serving abused and neglected children. Prevention and intervention for child maltreatment is a multidisciplinary field with medical professionals, psychologists, and social workers playing major roles. The child welfare service system and the associated not-forprofit and health agencies are major employers of social workers. Social workers work at many levels serving abused and neglected children. They are direct service workers and must know the latest evidence-based approaches to preventing and treating child maltreatment. They are supervisors and program directors; in these roles they have the leadership potential to provide progressive and state-of-the-art services and treatments to abused and neglected children and their families. As public policy analysts and specialists, social workers play a role in advocacy for responsive and just public policies for abused and neglected children and their families. As chief executives of the notfor-profit organizations that serve children, and commissioners and secretaries of major governmental agencies in the child welfare system, social workers have tremendous potential to reform governmental systems to better serve socially disadvantaged, abused, and neglected children and their families. As researchers, social workers create knowledge that leads to a better understanding of and intervention for child maltreatment. Perhaps the most important contribution that social workers can make to serving abused and neglected families is to bring a social justice (“just practice”) perspective to their work with families affected by abuse and neglect (Waldgreave, 2005; Finn & Jacobson, 2003). In “just

practice,” social workers integrate advocacy for social justice in their clinical work. This means taking on the responsibility to use oneself as a social change agent, advocating for social equality and for progressive policies and services. This means using your constant awareness of social injustices embedded in the child welfare system, such as blaming socially disadvantaged parents, lack of access to the cultural and educational enrichment experiences that middleclass families engage their children in, and use of discretion within the power of your position to address these injustices and inequalities. For example, social workers are often in a powerful position with respect to giving voice to the concerns of parents whose children are abused or neglected, and educating the parents about productive and positive parenting roles. assessment and interventions Careful assessment is important in serving abused and neglected children and their families. Assessment is multidimensional and requires evaluation by the CPS system to determine whether abuse or neglect has occurred, and if the child is in a situation of imminent harm. These assessments lead to decisions about whether to remove the child to out-ofhome care with extended family members, or regular foster care with licensed foster care providers (Videka, 2012). Assessment of abused or neglected children following the CPS investigation is multidimensional and multi-professional. In some locations Child Advocacy Centers (New York State Child Advocacy Resource and Consultation Center, 2012) have been created to respond to the multidimensional needs of the child and family through collocation of services and key staff who work as a team in serving families affected by child maltreatment. Child Advocacy Centers typically have specialized child sex abuse competency but may also respond to other forms of abuse and neglect as well. Child Advocacy Centers typically include police, health care, mental health, CPS, school, and

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other professionals. Social workers may occupy several of these roles. A multidimensional biopsychosocial assessment of the abused or neglected child and his or her family must be provided. Using the ecological framework presented in figure 12.1, the assessment of the child should include a physical examination, and developmental, learning, and mental health assessments. The siblings of the child identified as abused or neglected should also be assessed. A family assessment is important, and this includes parenting knowledge and skills. Parental health, mental health, and addiction should be assessed. The safety and developmental appropriateness of the home environment warrants assessment. A careful psychosocial assessment that evaluates the resources and risks in the family’s social network, community, and neighborhood are also important. This includes the nature of family interactions and the quality of parental relationship if two parenting figures are present in the family and of the foster family if the child is placed in foster care. The resources of the community and services systems should be evaluated. This includes awareness of the services that the child is receiving from other providers, schools, youth programs, and health and behavioral health centers. Johnson et al. (2008) have identified over eighty-five assessment instruments and guides for abused and neglected children and their families. Since families of abused and neglected children are often involved in multiple mandated or voluntary social services, a service coordination assessment is important. The assessment should be directly linked with the coordinated service plan. In recent years attention has turned to engaging families in assessment and service planning through family group decisionmaking approaches that give parents a role in the goals and service plan for the family (Pennell & Burford, 2000). This is an important trend in serving abused and neglected children. It puts empowerment to work, giving

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families a voice in their own service plan. This approach also improves the engagement and commitment of the family to follow through with the service plan. The public health prevention framework is widely used to deliver services and interventions to abused and neglected children and their families (Chalk, 2012). Prevention programs aim to reduce child maltreatment and can be thought of in the following three categories: universal or primary prevention, which aims to prevent child maltreatment in a whole population; selective or secondary prevention, which aims to prevent child maltreatment in a group that is known to be at risk; and indicated or tertiary prevention, which aims to prevent the recurrence of child maltreatment in a population that has been identified as abusive or neglectful. The field of child abuse and neglect is moving forward with the development of evidencebased prevention and intervention for child maltreatment. In the early 1990s, there were a handful of intervention approaches with scientific testing, usually in very limited settings with small numbers of clients. Today the California Evidence Based Clearinghouse for Child Welfare (2012) is the leading source for social work and other professionals who want to acquaint themselves with the prevention and intervention programs that are best supported by current available scientific evidence. This website organizes prevention and intervention approaches at all three levels by the level of scientific evidence available to support the approach, as well as the target population on which the program has been scientifically demonstrated. The database can be searched by program name, topic area, maltreatment type, strength of scientific evidence, and child welfare outcomes (safety, permanency, and well-being). The United States has historically been reticent to offer comprehensive universal prevention programs to prevent child maltreatment; most of the prevention programs available to children and families, such as Head Start and

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other early childhood intervention programs, and subsidized prenatal and well-child pediatric care (through Medicaid and Child Health Plus), are means tested and typically are not even available to all families who meet the means test. In recent years there have been a few fascinating examples of community-based universal prevention programs. Two examples include the Triple P—Positive Parenting Program, a program originally developed for children with oppositional-defiant disorder, but now adapted to five levels that address the needs of maltreating families including universal prevention (Sanders, Markie-Dadds, & Turner, 2003), and the Durham Family Initiative (Dodge, Murphy, O’Donnell, & Christopoulos, 2009). The Triple P—Positive Parenting Program Level 1 aims to create environments that promote positive parenting strategies and adequate health and educational care of children. The intervention is a universal media and communication strategy that builds on family strengths to overcome negative community influences, targeting the transactions between the family system and the community system (see figure 12.1). In a quasi-experimental outcome analysis, Triple P prevention counties demonstrated lower rates of growth of child maltreatment reports than control counties (8 percent versus 35 percent), and placements in foster care and other out-of-home settings decreased by 12 percent while it increased by 44 percent in control counties. The Durham Family Initiative (DFI) provides a community-wide, universal assessment and referral program that aims to link families with services depending on their level of need. Programs available to families in need are evidence based and address the risk factors and enhance protective factors to promote positive parenting. DFI also focuses on interagency coordination to improve social services delivery at the community level. The focus is before a family is identified as abusive or neglectful. In longitudinal analysis of the program’s effects, child

maltreatment reports and recidivism in the DFI county were lower those in the comparison county. Universal prevention is promising, but costly, and the United States has not shown the willingness of Northern European countries to invest tax dollars in universal prevention programs for children. Selective prevention focuses on families with known risk for child maltreatment. The full Triple P—Positive Parenting Program (Sanders et al., 2003; Prinz & Sanders, 2007; Petra & Kohl, 2010) includes selective prevention assessment and services as well as universal services and shows positive effects in terms of reducing child maltreatment compared to control counties. Home visiting is a widely implemented selective prevention approach that brings services to parents in their own homes, starting before or after the birth of a child to a family in high-risk circumstances, and lasting for the first three to five years of the child’s life. There are at least nine different evidence-based home visiting protocols that provide prevention services to high-risk families prenatally and post-birth for as long as five years (Daro & Dodge, 2009; Olds, Henderson, Kitzman, Eckenrode, Cole, & Tatelbaum, 1999; Howard & Brooks-Gunn, 2009). These nine programs were evaluated for program approach and outcomes in the HomVEE study, commissioned by the U.S. Department of Health and Human Services (Paulsell, Avellar, Sama, Martin, & Del Grosso, 2010). Programs varied in the curriculums they used as well as in whether home visitors were professional social workers, nurses or teachers, or paraprofessionals who were supervised by professionals (Newman, 2008; Paulsell et al., 2010). Healthy Families America (HFA), one home visiting program, (http://www.healthyfamiliesamerica.org/home/index.shtml), deploys home visitors who are selected because of their willingness and capacity to work with the target population. They are trained and supervised by social workers, and have a reasonable caseload. They visit high-risk family homes prenatally or after birth, on a weekly basis. Home visits

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are structured with a standardized assessment, with strong outreach, a nurturance-attachment focus, parent education, child development assessment and education, and an emphasis on the use of social supports in the parents’ social network and use of health and developmental services for the child. Cultural competence is stressed. Some HFA programs have built in screening for parental mental health and addiction problems with encouragement and assessment for parents to seek services that they need. In the HomVEE study, all nine home visiting programs showed evidence of effectiveness (Paulsell et al., 2010). The HFA program was most broadly effective, demonstrating positive and lasting outcomes in seven of eight measured domains: child development and school readiness, child health, family economic selfsufficiency, linkages and referrals, maternal health, positive parenting practices, and reductions in child maltreatment. Furthermore, gains lasted one year or more following the end of intervention. The only domain that did not show positive findings (and no home visiting programs produced positive results on it) was reduction in juvenile delinquency, family violence, and crime. More research needs to be done to strengthen evidence about which family characteristics are associated with best program outcomes. Howard and Brooks-Gunn (2009) conclude that home visiting programs are most effective with low income, first-time adolescent mothers. Services for families who are already known to child welfare authorities due to substantiated allegations of maltreatment fall under the purview of indicated prevention. These include interventions focused on addressing the sequelae of maltreatment as well as reducing future maltreatment risk. There are increasing numbers of indicated prevention (treatment) options that have scientific evidence to support their effectiveness. As practitioners and agencies turn increasingly toward more evidencebased practices, some principles are emerging about selecting indicated treatment for families

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t a b l e 1 2 . 2 Principles for Selecting Indicated Prevention for Child Abuse and Neglect Principles for Treatment

Use a social learning approach to improve parenting skills. Use a treatment that promotes parent-child attachment. Consider targeted intervention models to improve a critical aspect of the family problems. Promote a constructive, collaborative relationship between foster and biological parent if the child is in foster care. Use approaches that engage and involve the biological parents. Give them a voice. Advocate for social justice for the family. Pay attention to and contribute to service coordination across agencies.

affected by abuse and neglect. The principles are listed in table 12.2. Parent training using social learning principles is a component in most indicated prevention programs for child maltreatment. There is evidence that programs using this approach improve parenting skills and child behavior (Barth, 2009). Patterson’s Living with Children (1977) is a classic reference tool for practitioners and parents. Disrupted parent-child attachment is found in child abuse and neglect. Many evidencebased service models include interventions for improving attachment. These are useful with young child maltreatment victims and their parents. Cicchetti’s (Cicchetti, Rogosch, & Toth 2006) parent-infant interaction program is a good example of an attachment-based model. Despite the complexity of problems in families of maltreated children, research supports the use of targeted interventions that focus on child or parent mental health and behavior issues. The trauma-focused cognitive behavioral therapy (TF-CBT), discussed in the case example, is a good example of a targeted treatment that produces broad improvements for children who have experienced trauma. The case study below illustrates how services can be adapted to include biological and foster parents when a child is placed in out-of-home care. The collaborative relationship between the parenting figures has benefits for the child.

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Engaging parents in decision making about services for their family is one of the best ways to bring social justice into the counseling of families affected by child abuse and neglect. Family group decision making is one of the best methods to engage parents and to make sure treatment responds to their needs (Pennell & Burford, 2000). Finally, families of abused or neglected children are typically engaged in services in many different agencies. Ensuring good communication and collaboration among service providers will benefit child and family and will deploy services in a more efficient manner. Family privacy and confidentiality should always be considered. In the following sections selected specific intervention programs will be discussed. For a review of the comprehensive list of evidencebased programs available, see the California Evidence Based Clearing House for Child Welfare (2012). Trauma-Focused Cognitive Behavioral Therapy (TF-CBT; Deblinger, Lippmann, & Steer, 1996) a conjoint child and parent psychotherapy will be discussed in detail in the case example in this chapter. TF-CBT has been particularly successful in reducing PTSD symptoms and child behavioral difficulties among children who have been sexually abused (King et al., 2000). By teaching parents about child health care, Project SafeCare enhances the quality of parent-child interactions, and promotes home safety and accident prevention. Project SafeCare aims to reduce the future occurrence of maltreatment. Among a sample of parents referred by child welfare services due to substantiated reports of abuse and/or neglect, those participating in Project SafeCare were significantly less likely to be reported for re-abuse within two years, compared to parents involved in family preservation services. Three years post-treatment, 85 percent of Project SafeCare families had no further reports of child abuse, compared to only 54 percent of families receiving family preservation (Gershater-Molko,

Lutzker, & Wesch, 2002). A recent statewide trial implementing SafeCare also confirmed reduced re-reports of abuse/neglect compared to services as usual (Chaffin, Hecht, Bard, Silovsky, & Beasley, 2012). A number of evidence-based interventions designed to reduce child behavioral difficulties have also shown effectiveness in reducing child maltreatment risk among maltreating families. Developed for families with children experiencing behavioral and emotional difficulties (ages 4–12), Parent-Child Interaction Treatment (PCIT) focuses on modifying maladaptive parent-child interactions and disrupting escalating coercive cycles, which lead to further child behavior problems and maltreatment. Through the use of one-way mirrors and radio earphones, parents are directly coached in vivo by trained therapists during interactions with children in order to strengthen the parentchild bond, decrease harsh discipline practices, improve child social skills, and reduce child behavioral difficulties. Chaffin and colleagues (2004) found that physically abusive parents receiving PCIT were less likely to be re-reported for abuse, compared to parents receiving standard community-based parenting groups. Multi-Systemic Therapy (MST), which has had extensive success in treating delinquent youth ages 12–17 (Henggeler, Melton, & Smith, 1992; Timmons-Mitchell, Bender, Kishna, & Mitchell, 2006; Ogden & Halliday-Boykins, 2004), is an intensive, individualized family- and community-based treatment that intervenes directly with those systems and processes related to antisocial behavior, such as parental discipline, peer associations, school performance, and family relations. A recent randomized clinical trial found that MST modified for physically abused youth and their families resulted in greater reductions in youth mental health symptoms, parent psychiatric distress, parenting behaviors associated with abuse/ neglect, youth out-of-home placements, and changes in youth placement, when compared to outpatient mental health treatment

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(Swenson, Schaeffer, Henggeler, Faldowski, & Mayhew, 2010). The Incredible Years is considered one of the most effective interventions for reducing child conduct difficulties (Barth, 2009; WebsterStratton & Taylor, 2001). The Incredible Years has been recently implemented in child welfare settings (Letarte, Normandeau, & Allard, 2010; Marcynyszyn, Maher, & Corwin, 2011). Findings suggest that program participation is associated with reduced parental distress, dysfunctional parent-child interactions, child behavioral difficulties, parent stress, and harsh parenting practices among parents with substantiated maltreatment allegations. Child welfare services typically struggle to engage and retain indicated families into services (Yatchmenoff, 2005). As a result, those interventions that have been designed specifically to promote engagement and empowerment among families are particularly useful. To this end, the 4Rs and 2Ss (4R2S) service delivery model to reduce childhood behavioral difficulties may hold promise (McKay et al., 2010, 2011). Designed in collaboration with parent consumers of child mental health treatment, this model melds group therapy, family therapy, and parent management training into a series of multiple-family group meetings with six to eight families over a period of four months. Groups are co-facilitated by clinicians and parent advocates (parents who have previously navigated through the child mental health service system) and involve a combination of discussion, activities, and homework within a non-stigmatizing group environment that normalizes family difficulties and fosters mutual aid. Such features may be particularly amenable to child welfare–involved families. Parent advocate group facilitators represent an emerging strategy to promote family engagement and empowerment, as well as model successful resolution of family difficulties. Preliminary evidence from a recently completed effectiveness trial suggests families participating in the 4R2S manifest significantly reduced child behavioral

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difficulties and increased child social skills (McKay et al., 2011). Additionally, despite greater perceived barriers to treatment, child welfare–involved families are able to maintain attendance levels on par with non-child welfare– involved families (Gopalan et al., 2011). illuStrAtion And diSCuSSion

Ana M. is a 13-year-old girl of mixed Hispanic and African American descent who has been in and out of foster care for over five years. She is the second oldest child out of five siblings. She is tall and seems older than her 13 years. Her family presents a classic, complex case of dually indicated child abuse and neglect. The family first became known to the child welfare system when Ana was 5 years old. A neighbor witnessed Mr. M., Ana’s father, beating her and called CPS. The CPS investigation concluded there was extensive evidence of abusive treatment of all five children in the household by Ana’s father, and neglectful behavior by her mother who was overwhelmed and failed to get children to health appointments and to school, and who sometimes left the children unattended while she ran errands. After the initial maltreatment report and investigation, the family was mandated to receive preventive services. Subsequent additional reports of abuse and neglect, some made by the social workers serving the family, led to Ana’s eventual placement in kinship care, back home with her mother, and then in foster care. Ana moved back and forth from foster care to the care of her mother, who had separated from Ana’s father. She currently lives with her foster family. Ana’s family was affected by domestic violence, with the parents eventually separating, creating even more strain on the overwhelmed and disorganized Ms. M. Ana has had multiple assessments. In these several problem areas were identified, including the following: homelessness; extreme parenting stress and disorganization; Ana’s health problems (asthma, ADHD, and developmental delays); and

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her mother’s borderline developmental disability. Psychological evaluations determined that Ana had learning disabilities, and later she was referred for special education classes. An Individualized Educational Plan (IEP) was created to address her learning needs and speech delays. Ana is tall and seems older than her 13 years. Over the eight-year period since the first CPS call was made, Ana received home-based services, was placed in kinship care with an aunt, returned home to her separated mother, and was now in non-kin foster care. The initial removal and placement was traumatic for Ana. She was placed with her maternal aunt, who reported that she had difficulty sleeping, and she was prescribed a sleeping medication (Concerta 10 mg) at the age of eight. Ana also felt fatigued several days within the week, and needed the medication to function. She was a shy kid who complained that other children made fun of her at school and that she couldn’t concentrate. She also felt responsible for the care and well-being of her younger siblings. Ana worried about their welfare and about the conflict with her parents. The psychiatrist recommended therapy for her speech, mental health services, and medical care for her asthma. Ana received general psychotherapy while in the care of her aunt. During therapy she reported elevated anxiety; the worst anxiety was when she thought about her biological father. Early episodes of therapy addressed some of the issues related to regulating her sleep and provided initial psychoeducation on identifying different emotional states. After a year in care with her aunt, Ana was returned to the care of her mother, Ms. M. While in her mother’s care she did well for several months, but because of the lack of supervision she failed to attend school regularly and often missed medical checkups required to manage her asthma and ADHD. Ana and her two younger siblings, ages 7 and 6 at the time, came back into care due to educational and medical neglect. The children were placed with a non-kin foster parent because the aunt lost her apartment and couldn’t qualify as a kinship care home.

The adjustment to the non-kin foster care placement was very difficult for Ana. She felt responsible and often remarked that it was because of her that they were in care. She also took greater responsibility to support and care for her younger siblings. During the first few weeks, Ana and her two siblings often slept together in the same bed. She also took the responsibility of bathing her two younger sisters, and ensuring that they weren’t late for school. Ana believed that the reason they came into care is because of her inability to attend school regularly, which was also due to periodic asthma attacks that forced her to stay home. The girls attended family therapy during their second placement, and some of the parentification issues were addressed with Ana. She was able to develop a relationship with the foster mother, due to the consistency and support that she provided. The foster mother’s relationship with the biological mother facilitated engagement during family therapy and she became a resource. She would often babysit the other children and support Ms. M. with different parental responsibilities. Ana’s relationship became stronger with the foster mother because of the support and modeling she provided. Ana was again returned to the care of her mother. The family lost their apartment due to nonpayment of rent and the family lived in a homeless shelter. Ana’s mother often left Ana and her siblings unattended while she ran errands or spent time with her current boyfriend. It was during one of these prolonged absences that two other girls her age lured Ana to the shelter’s laundry room. The laundry room was in the basement and wasn’t monitored. In the basement a friend of Ana’s older brother, age 16, was waiting and he sexually assaulted her. Ana was 12 years old at the time. After the incident one of the shelter workers had noticed Ana limping out of the laundry facility and tried to reach her mother. When she realized that Ms. M. wasn’t in the residence, she called ACS and notified the child welfare agency of the incident. An investigation was conducted and Ana was immediately removed and placed with the previous non-kin foster mother. In addition, Ana’s school recently sent the foster care agency a report that listed multiple problems Ana was having such as

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tardiness, being disrespectful, causing disruptions, being unprepared, talking in class, getting out of her seat, and playing around. Because of the rape incident and Ana’s externalizing behavior at school, a new treatment modality was sought. The social work supervisor overseeing her case recommended that Ana begin TF-CBT (National Child Traumatic Stress Network, 2012) to help her deal with some of the past traumas including her rape and trauma produced by the foster care placements (throughout the five years Ana remained highly attached to her mother and wanted to live with her), and current behavioral problems of anxiety and disruptive school behavior. TF-CBT was utilized because it was designed to address both single and multiple traumas, including physical and sexual abuse. This model fits well within a child welfare framework because it addresses the multiple traumas that children experience, including the trauma of out-of-home placement. As part of TF-CBT, the mother and the foster mother were asked to participate. Both the mother and foster mother agreed to be active and present. The foster mother was consistent with bringing Ana to counseling on time; however Ms. M. was often late. Considering individual and systemic limitations, Ana’s mother participated sufficiently in the conjoint sessions with Ana and the foster mother. Ms. M. needed to participate because Ana has a strong and loving relationship with her, and Ms. M. would be a support resource as Ana got older. The foster mother also participated in the initial sessions and provided concrete support such as bringing Ana to the sessions. In Ana’s case, the physical abuse by her father, the three moves to different homes, and the sexual assault were the focuses of treatment. Ana had been in individual counseling since she came into care; however, she was still acting out in school and in danger of failing her grade. Ana had been absent from school for approximately two months and tardy almost half of the school year. Teachers noted that she often missed homework, didn’t participate,

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and was a distractive influence in class. Ana was also becoming more aggressive toward other children, and her behavior in school prompted a reassessment of past treatments and recommended a new treatment approach. Ana was evaluated for traumatic exposure and post-traumatic stress disorder (PTSD) via the UCLA PTSD Index (Pynoos, Rodrigues, Steinberg, Stuber, & Fredrick, 1998) and the Traumatic Events Screening Inventory – Child Version (TESI-C) (Ford et al., 1999). These screening instruments ask children to identify the severity of traumatic experiences and other disturbing thoughts. The identification of traumatic experiences includes the presence of three clusters of symptoms such as intrusive thoughts, avoidance, and mood changes. The assessment of symptoms and identification of problem areas determines treatment approach; for Ana the sexual assault was the most upsetting event at the onset of treatment. The TF-CBT model comprises eight different components that make up the PRACTICE (Psychoeducation, Relaxation, Affect regulation, Cognitive coping, Trauma narrative, In vivo mastery of traumatic responses, Conjoint parent-child sessions, and the Enhancing personal safety) phases. The Psychoeducation phase includes normalization of behavior, information about common behavioral responses to traumatic events, and development of parenting skills. There was emotional validation for both Ana and Ms. M. that these were common reactions to traumatic events and many other children experience similar traumas. Ana had relied on sleep medication since she was 8 and understanding that erratic sleeping patterns are part of the traumatic reaction gave Ana a sense of normalcy. This information allowed her to engage in treatment and provided reassurance that she can get better. The second component explains the physiology of relaxation and instructs both the child and parent in various Relaxation methods. The social worker assisted Ana in identifying various feelings with her learning to begin to regulate her affect. She often became angry in school and the relaxation techniques allowed Ana to identify stressful situations.

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The social worker taught Ana meditation and mindfulness techniques. She was encouraged to become attuned to her body’s reaction in stressful situations and employ some of the relaxation techniques to control her breathing and quiet her thoughts. Therapy proceeds to reviewing Cognitive skills and development of alternative thoughts. In this phase of treatment, the social worker reframes negative cognitions, such as Ana’s internalization of selfblame for foster care placement. She often remarked that it was because of her that the family came to the attention of Child Protective Services (CPS). When Ana was 5 years old a neighbor had made a report to CPS about potential abuse after they witnessed the father hitting Ana with a belt in the backyard. That report required the family to participate in mandated preventive services, and Ana blamed herself for all subsequent foster care placements. The therapist worked with Ana to address any cognitive distortions (e.g., about foster care placement) and regain control over her thoughts. Ana often had flashbacks to the rape and her removal from her mother during school, which affected her ability to remain seated and participate in class activities. The social worker worked with Ana to manage difficult affective states and implement positive self-talk and other problem-solving skills. She introduced Ana to the idea of a “cognitive triangle” (Cohen, Mannarino, & Deblinger, 2006, p. 108), that changing thoughts can also change feelings and behaviors. The social worker also provided Ms. M. with a sense of safety and allowed the mother to emote her fears and vulnerability. This allowed Ms. M. to create a sense of safety for Ana and provide the emotional support needed for the next phase of treatment. This phase includes the development of a Trauma narrative, processing the trauma and defragmenting each of the traumatic episodes. The narrative was adapted to include both verbal and visual components to allow for different avenues of expression. This mitigated some of the issues presented by Ana’s learning disabilities. The technique allowed her to make progressive changes to the narrative and make meaning out of past experiences. Ana enjoyed

creating the narrative; it allowed her to create something positive out of her many negative experiences. The narrative was changed to include a life course perspective instead of focusing only on the traumas. This approach allowed Ana to contextualize the sexual abuse, foster care placement, multiple movements in care, and her parents’ domestic violence episodes preplacement. During this phase of treatment the narrative is shared with the parent, inaccurate cognitions are identified, and new cognitive strategies are developed to address parental errors. During the In-vivo desensitization phase, the social worker works with the child to address avoidant behaviors. Ana’s displacement of her fear to the school setting was one of the reasons for the avoidance and tardiness. Ana’s learning difficulties and speech delays affected her ability to express herself; she also had difficulty reading out loud when asked by the teacher. During treatment she disclosed that other children often bullied her in her class. Students in the class made fun of her for attending speech therapy and not being able to talk properly. Ana’s way of dealing with the situation was being disruptive, getting out of her seat, or leaving class. Another fear that kept her from attending school was that other children will learn about her family situation or foster care placement. To address these issues, Ana’s individual education plan was amended and she was transferred to another school that had the appropriate services that she needed. She was placed in a smaller class that had the necessary support services and the individual attention to foster learning. Ana’s behavioral change was immediate; she no longer avoided attending school. The support of the foster mother was also vital in ensuring that Ana attended school on a regular basis. The foster mother was an educational advocate for Ana and worked collaboratively with the teacher to provide the support that was lacking when she was in her mother’s care. The Conjoint parent-child sessions with Ms. M., provided Ana with a venue to discuss the multiple traumatic events and lack of appropriate care by her mother. Ana often felt angry at Ms. M. for not being consistent with care, or providing the support

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that she desperately needed. The conjoint parentchild sessions provided Ms. M. with a contained space to deal with the hostility of Ana’s feelings and her inability to parent properly due to the multiple individual and systemic constraints. Ms. M.’s own developmental delays, her lack of education, and poverty made it difficult to take care of her five children. She often felt overwhelmed and lacked the insight needed to address her children’s multiple needs. Three of her children also had both medical and behavioral issues that prohibited her from being able to maintain appropriate parenting for an extended period of time. The stress led to multiple relapses and foster care entry for both Ana and her siblings. The conjoint sessions provided Ana with an opportunity to address the conflictual feelings that she felt for her mother. The last part of therapy is based on addressing a child’s sense of safety with an Enhanced safety plan. The purpose of the plan was to assure that Ana would remain safe in the care of the foster mother and that Ms. M. would be actively engaged in visitations. The second component of the safety plan included a detailed description of supervision that ensured that Ana wasn’t left unsupervised for a prolonged period of time. The last part included an action plan to help Ana identify dangerous situations and how to act. The safety plan provided Ana with a template and a contract to address past traumas and future situations. TF-CBT’s goal-oriented and short-term nature of involvement was attractive to both Ms. M. and Ana. Psychoeducation provided Ana and her mother information about common emotional, behavioral, and physiological responses to trauma. The clear description of these components, session structure, and treatment length assisted with engagement. Ms. M. and the foster mother found the parenting stills and affect regulation exercises helpful because it provided them with concrete tools to change their behaviors and emotions. As the helping process progressed both mothers and Ana were able to identify positive and negative feelings, and develop skills to actively manage difficult emotional states.

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TF-CBT goals were concrete and time limited. Ana and her mother adhered well with the protocols because they observed marked change in behavior that was sustained over time. Strong initial engagement by the social worker is vital for positive outcomes. Without proper engagement, progress through the different steps of the model is difficult to achieve. Equal participation by Ana and her biological and foster mothers were essential for a positive outcome. Ana’s internalizing and externalizing behaviors markedly improved. Ana experienced change in affect after twelve weeks; behavior was consistent and progressed to the end at sixteen sessions. Psychoeducation and identification of feelings assisted with behavioral identification and regulation. For clients like Ana, having concrete steps was useful for the progression of treatment. Breathing and relaxation exercises helped her lower and manage her anxiety, while allowing her to process traumatic information. Furthermore, the social worker helped her to track her progress on a weekly basis. The conjoint sessions with Ms. M., Ana, and the foster mother also fostered a sense of safety along with the safety plan at the end of service. Ana was able to take what she learned and apply those skills to her new school and home setting.

conclusion In this chapter child abuse and neglect is presented as a complex social problem that is affected by every level of the abused and neglected child’s ecosystem, ranging from macro social disadvantage to community and family systems to the biopsychosocial systems of the child. A public health prevention framework was used to present multidisciplinary intervention responses. With the extensive new base of empirical knowledge about prevention and intervention for child maltreatment, the social work practitioner has more resources than ever in responding to complex cases of child abuse and neglect. The newest evidencebased approaches emphasize clear prevention

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and service goals, structured interventions, engagement of the voice of biological parents, and service coordination across agencies. Child abuse and neglect will continue to be a major

employer of social workers at every level. Social workers are increasingly assuming leadership roles in the development and delivery of services to this vulnerable population.

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rom the earliest days of civilization, every society has had to develop some means of dealing with young children whose parents are unable or unwilling to provide adequate care. At various times in recorded history, children have been sold into slavery, donated to monasteries and convents under a process known as oblation, or left to die of exposure. Abandonment in public places was common from the days of imperial Rome until the end of the Middle Ages, when foundling hospitals were established in most European cities. Although this development marked a shift from reliance on the “kindness of strangers” to the allocation of responsibility to public institutions for the care of homeless children, the custom of abandoning children persisted. In Paris in the late eighteenth century, 20 to 30 percent of the recorded births resulted in abandonment (Boswell, 1988). Not surprisingly, we in the United States must still struggle with the task of finding appropriate solutions for children whose parents do not provide needed care. Early social provisions for dependent children in this country derived from the English Poor Law tradition and relied heavily on a combination of poorhouses or orphanages for young children in urban areas and indenture or farming out for youth who could be taught a trade. Although the number of orphanages expanded rapidly in the early nineteenth century, there was no significant change in the pattern of care for young children until Charles Loring Brace established the Children’s Aid Society in New York in 1853. Concerned about the need to protect poor children from the

evils of urban life, Brace recruited large numbers of families in upstate New York and the Midwest and sent trainloads of homeless or destitute children to homes in these localities. This program was closely paralleled by the Children’s Home Society, established by Martin Van Buren Van Arsdale in Illinois in 1883, and by the end of the century, free foster home care had become a well-established means of providing for dependent children. At the same time, many communities continued to place large numbers of children in orphanages or institutions, in part because of the concern of the Roman Catholic and Jewish leaders about protecting children’s religious heritage. Although most of the large children’s residential institutions have been converted in recent years to smaller facilities with more specialized functions, these two traditions of foster family care and residential group care continue today as the primary societal mechanisms for caring for dependent children. defining and explaining children in foster care Although the rearing of children by extended family members is a time-honored tradition in the United States as in most other cultures, kinship care was not considered part of the formal foster care systems until the mid-1970s. At that time, child advocates began to argue that relatives caring for children should be entitled to the same foster care benefits as nonrelatives; and in 1979, acting on a court case filed in Illinois in 1976, the U.S. Supreme Court ruled in Miller v. Yoakim, 440 U.S. 125 (1979) that 269

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children living in relatives’ homes were entitled to the same level of foster care benefits as children living with nonrelatives. Since then, the number of children living in what is usually termed kinship foster care, i.e., care provided by relatives that is licensed and supported by the state, has increased exponentially. However, there are still children living in informal kinship arrangements in which there is no state involvement. The term foster care is now commonly used to describe both family-based (relative and nonrelative) and congregate care settings, thus incorporating a wide range of substitute living arrangements for children whose parents are unable to provide adequate care temporarily or permanently. Formal foster care is distinguished from other types of temporary substitute care for children, such as informal care by relatives or friends, by the fact that it involves a change in legal custody and state sponsorship. Formal foster care is distinguished from adoption by that fact that adoption involves a permanent change of legal guardianship as well as custody. Foster care serves various functions, including crisis intervention, emergency shelter, ongoing assessment, case planning, reunification, preparation for independent living and preparation for adoption (Pecora et al., 2009). Moreover, it includes a wide range of placement options to meet the needs of children including emergency shelters, diagnostic centers, family foster homes, kinship foster homes, agency-operated boarding homes, group homes, group residences, child care institutions, and residential treatment centers. In the mid-twentieth century professional knowledge about the importance of the parentchild relationship and children’s need for continuity and stability expanded, and the costs of maintaining children in foster care increased. Consequently, public officials, researchers, and advocates alike began to criticize child welfare agencies for their tendency to allow children to drift in foster care, moving from one

placement to another with no clear plan for discharge, either to their own families or to an adoptive home. The first real challenge to foster care in this country was posed in 1959 in Maas and Engler’s study of children in foster care in nine communities. Their criticisms were echoed repeatedly and reached a crescendo in the late 1970s with the issuance of a number of influential reports. Foster care has since been redefined so that it is now commonly viewed, not as an open-ended option available until children reach majority, but as a temporary, planned service that should be used only when preventive services have failed and until more permanent living plans case be developed. Social work practice in foster care is now guided by the concept of permanency planning, which is defined as “a set of goal-directed activities designed to help children live in families that offer continuity of relationships with nurturing parents or caretakers and the opportunity to establish lifetime relationships” (Maluccio, Fein, & Olmstead, 1986, p. 5). The goal of child welfare services is to ensure the safety, permanency, and well-being of children and youth. Current law and policies guiding foster care services emphasize placing children in family-like settings and maintaining ties to family and community, whenever feasible. Federal legislation states that children must be placed in the least restrictive (most family-like) setting that is consistent with the child’s best interests and individual needs. Whenever possible, children should be placed in close proximity to their parents’ home and current school. The focus on permanency planning has been beneficial in forcing attention to the need for expanded services to biological parents, relatives, potential adoptive families, and youth without permanent families. However, there is still a long way to go to ensure permanency for all children and youth. While foster care is meant to be a temporary solution, too many children remain in care for long durations.

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Many children experience multiple placement moves, each disruption forcing them to adjust to a new living environment, and new schools, friends, community, and other important aspects of daily life (Perry, 2006). Older foster youth who lack permanent families need assistance in developing skills to successfully transition from foster care into adulthood. Without these supports, youth are at high risk for negative outcomes such as homelessness, unemployment, low educational attainment, teenage pregnancy, sexual and physical victimization, and imprisonment (Pecora et al., 2005; Courtney et al., 2007). In addition to the policy emphasis on safety and permanency for children in foster care, the Administration on Children and Families of the U.S. Department of Health and Human Services (DHHS) has recently issued a memorandum to all state and tribal agencies administering or supervising funding for child welfare services. This memorandum states that priority must also be given to the emotional and social well-being of children receiving child welfare services. “To focus on social and emotional well-being is to attend to children’s behavioral, emotional, and social functioning— those skills, capacities, and characteristics that enable young people to understand and navigate their world in healthy, positive ways.” (DHHS, 2012b). This new emphasis reflects recognition that the traditional emphasis on safety and permanency is not enough. Recent research has demonstrated that the adverse effects of maltreatment, which most, if not all, foster children have suffered, are “concentrated in behavioral, social, and emotional domains” (DHHS, 2012b, p. 2). Hence public policy is now emphasizing interventions that address the impact of maltreatment and trauma, as well as those that ensure safety and permanency. demographic Patterns The Children’s Bureau in the U.S. Department of Health and Human Services collects

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federal- and state-level data on child maltreatment, foster care, and adoption. In September 2011, there were 400,540 children residing in foster care nationally (DHHS, 2012a). The majority of children entered foster care due to parental inadequacies, mainly child abuse and neglect. In 2010, 78 percent were victims of child neglect, 18 percent were victims of child physical abuse, and 9 percent were victims of sexual abuse (DHHS, 2010). According to Barth, Wildfire, and Green (2006), a number of children also enter foster care due to behavioral issues or a need to be in state custody to ensure they receive necessary mental health or other related services. The gender breakdown of children in foster care is relatively even, with 52 percent male and 48 percent female. The racial/ethnic breakdown of children in foster care in 2011 was 41 percent white, 27 percent black, 21 percent Hispanic, 1 percent Asian, 2 percent Native American, and 5 percent two or more races (DHHS, 2012a). When comparing the percentage of children in foster care with the percent of children in the general population, it is evident that white and Asian children are under-represented in foster care, whereas black and Native American children are over-represented (Hill, 2006). Hispanic children are not over-represented in foster care in general, but are overrepresented in certain states and communities (Hill, 2006). Children between birth and one year are most likely to be victims of child maltreatment and are disproportionately placed into foster care. In 2011, a quarter of children entering foster care were between birth and one year old (DHHS, 2012a). According to Wulczyn, Ernst, and Fisher (2011), young children spend more of their time in foster care on average than adolescents, which is the second largest group represented in foster care, and are at high risk for developmental delays. However, younger children are more likely than older children to reside in foster homes and then be adopted. Older children experience more difficulty connecting with a permanent family.

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Most children in foster care reside in a family situation: a quarter (27 percent) in a kinship foster home, half (47 percent) in a non-kinship foster home and 4 percent in a pre-adoptive home (DHHS, 2012b). About half (52 percent) of children in foster care have a case goal of return to parent or principal caretaker, and a quarter (25 percent) have a case goal of adoption. A Children’s Defense Fund (CDF) Report (2011a) outlined some notable improvements and encouraging trends in foster care over the past decade. The total number of children receiving foster care services has declined 26 percent, from 552,000 children in care in FY 2000 to 408,000 children in FY 2010. In the past five years, there has been a decline in the number of children entering foster care, children are remaining for shorter durations, there is a decrease in the number of children waiting to be adopted, and an increase in the number of adoptions. Positive improvements such as these can be partially attributed to new federal policies, such as the Fostering Connections to Success and Increasing Adoptions Act of 2008. Although improvements have been made, some challenges still remain. One major challenge is the number of adolescents in foster care who do not connect with a permanent family. Approximately 26,000 youth were emancipated from foster care in 2011 and expected to live as independent adults (DHHS, 2012a). Youth who age out of foster care without familial supports are at high risk for negative outcomes, including lack of educational attainment, homelessness, unemployment, and financial instability. Societal context Foster care is by definition a socially prescribed phenomenon and can be understood only in this context. The stresses in family functioning that bring children to the attention of child welfare authorities are a direct reflection of socioeconomic problems and racial and gender

inequalities in the larger society. Moreover, the way children’s needs are defined and the types of legal and service protections they are offered vary over time in accord with the prevailing norms of the communities in which they reside. Parents and children’s rights are both relative concepts, as are definitions of adequate parenting. Consequently, social service agencies and courts have great latitude and are heavily influenced by structural variables in determining when and under what circumstances children should enter and leave foster care. What has not changed significantly over time is the fact that foster care is essentially a service for poor children. Although the specific reasons for children’s entering substitute care, and the types of care provided, have varied throughout history, the problems necessitating placement have seldom been child related. Instead, they have usually reflected the inadequacies in parental functioning commonly associated with poverty. Since there is little evidence that placement of children in foster care contributes to upward mobility for children or their biological parents, foster care may actually contribute to maintaining the status quo. The very availability of substitute care resources deflects attention from the structural problems such as poverty, unemployment, and homelessness that undermine parental capacity to provide adequate care. At the same time, history suggests that society will always need some type of substitute care provision for children who cannot remain with their own parents. Although increased efforts to reduce socioeconomic deficits would undoubtedly decrease the number of children requiring foster care, structural changes alone cannot ensure equitable distribution of the emotional, cognitive, and physical resources also required for adequate parenting. Thus, some need for foster care services must be anticipated as long as the country maintains even minimal standards for child nurturance and protection. And because foster care is different and necessarily implies some deficit in family functioning,

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children in placement and their biological parents will always present special service needs. Although social workers have traditionally assumed primary responsibility for the administration and delivery of foster care services, their practice is structured in large measure by (1) social problems in the larger society that shape the size and nature of the population entering care and (2) federal and state laws and regulations governing the conditions under which children can or must be placed in foster care and the actions taken on their behalf. Poverty and minority ethnic status have long been recognized as variables that contribute disproportionately to the risk of children entering and remaining in foster care. Hill’s (2006) synthesis confirmed the general hypothesis that foster care as an institution reflects prevailing patterns of social and economic disorganization, demonstrating the impact of poverty and race at every stage of the child protective decision-making process. These patterns reflect long-standing structural problems in this country that influence the delivery of foster care services. However, it is also important for social workers to recognize the ways in which recent social policy and economic trends shape the service needs of children entering foster care and their parents. The state of the economy always influences the number and needs of children requiring child welfare services. Due to the economic downturn in 2009, millions of children fell into poverty (Children’s Defense Fund, 2011b). In 2010, 16.4 million children in the United States were considered poor and 7.4 million children were considered extremely poor. More than 60 percent of poor children lived in a singleparent home, but 9 percent of all married couples were also considered poor and two-thirds of poor children lived in a home where one parent works. Children of color are impacted by poverty at a disproportionate rate. Children living in poverty are at significant risk for developmental, physical, and educational delays, as well as increased rates of entry into foster care.

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Unlike social workers in most other settings, those working with children in foster care have explicit legal responsibilities. These duties are imposed as a consequence of the transfer of legal custody from a child’s biological parents to the local state authority. In making decisions and taking actions on behalf of foster children, workers are acting as agents of the state. Therefore, they must observe the laws and regulations set out to ensure that the state will fulfill its obligations under the doctrine of parens patriae, which gives the state the ultimate responsibility for protecting the welfare of all children. State responsibilities for children are embodied in federal and state law, administrative regulations, and court decisions. All social workers in foster care must be familiar with the core components of federal laws that set the basic framework for the current provisions of foster care services: Child Abuse Prevention and Treatment Act of 1974 (PL 93–247); Adoption Assistance and Child Welfare Act of 1989 (PL 96–272); Adoption and Safe Families Act of 1997 (HR 867); and the Fostering Connections to Success and Increasing Adoptions Act of 2008 (PL 110–351). Although protective services for children were initiated in the late-nineteenth century with the establishment in a number of urban areas of Societies for the Prevention of Cruelty to Children, there were no federal laws guiding the provision of protective services until the passage of the Child Abuse Prevention and Treatment Act of 1974. A response to media exposés and agitation in the medical community about the newly identified “battered-child syndrome,” this act established the National Center on Child Abuse and Neglect. It also provided limited funding for demonstration projects to states that comply with a series of regulations related to the establishment of statewide systems for reporting and investigating reports of suspected child abuse and neglect. Although the title of this act implies legislative concern about prevention and treatment, the implementing regulations focus attention

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almost entirely on mandatory reporting and investigation. Moreover, the law fails to define precisely what is meant by child abuse and neglect or to specify the evidential standards for reporting. As a consequence, the primary effect of the law has been to enlarge the number of reports and investigations of child maltreatment, not to provide the resources or guidelines required for states to serve these cases more adequately. Despite its limited scope and funding, this law has had a tremendous impact on the delivery of child welfare services across the country. All states have some type of mandatory reporting law that requires social workers as well as many other human service professionals to report suspected incidents of child abuse or neglect and that grants immunity from civil or criminal liability to those who make such reports. Since its enactment, the number or reports of suspected child abuse increased dramatically. In 2010, there were approximately 3.3 million reports. One-fifth of the referrals were substantiated or indicated, thereby necessitating continuing intervention by child protective services in the lives of approximately 695,000 children (DHHS, 2010). The Adoption and Child Welfare Act of 1980 (PL 96-272) was enacted after several years of Congressional reform efforts aimed at addressing the well-documented problems in foster care mentioned earlier. Supported by a broad coalition of public officials, child welfare advocates and professionals, and client organizations, this act amended Title IV-B of the Social Security Law and instituted a new Title IV-E, Foster Care and Adoption Assistance Program. Passage of this act made prevention of placement and permanency planning explicit objectives of federal child welfare policy. Moreover, by requiring states to establish standards and procedures consonant with the law in order to be eligible for federal funding, PL 96–272 ensured that these objectives would become the explicit policy of the state agencies responsible for the delivery of child welfare services.

The standards required states to establish case review mechanisms, with judicial determination of need and opportunity for parental participation at specified intervals, to ensure that “reasonable efforts” are made to prevent placement, to arrange placement in the most appropriate setting, and to discharge children to permanent homes in a timely manner. Case planning must ensure that placement is arranged “in the least restrictive, most familylike setting available located in close proximity to the parents’ home, consistent with the best interests and needs of the child.” The law also required that the states establish statewide information systems. Great optimism surrounded the passage of this law, and a decline in the foster care population during the early 1980s pointed to its potential efficacy. However, numerous problems related to staff limitations and resource shortages—and perhaps even the viability of some of the assumptions underlying PL 96–272—limited the capacity of the states to implement the intent of this legislation. One difficulty has been that the increased demands for monitoring and accountability have resulted in an enormous expansion in reporting requirements. Many of the procedural protections designed to safeguard the interests of children and parents have been utilized in a pro forma way that increases workers’ paperwork but does little to enhance the quality of the services they deliver. A second, related problem derives from the need for multiple administrative and court reviews of the status of children in care. These reviews inevitably press toward standardization of decision making, thereby decreasing social workers’ sense of professional autonomy and their capacity to develop carefully individualized intervention plans. Finally, in a system in which success is measured in part by reduction of foster care, not by reduction of the familial and social problems leading to placement, social workers are confronted at times by situations in which they are ordered to implement discharge or adoption plans that

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they do not think are in the best interests of their clients. In 1997, Congress approved a bill designed to promote child safety and permanency, the Adoption and Safe Families Act [ASFA] of 1997 (PL 105–89). Reflecting some of the same political sentiments as those that led to passage of the Welfare Reform Act of 1996, PL 104–193, as well as increased concern about the rise in child maltreatment and the length of time children were remaining in foster care, this act makes the safety of children a clear priority in all child welfare decision making. The law reaffirmed the concept of permanency planning established under the Adoption Assistance and Child Welfare Act of 1980 and specified again the importance of making “reasonable efforts” to preserve and unify biological family units. However, it also defined circumstances under which states are not obliged to make reasonable efforts to maintain children with or return them to their biological parents because of an assumed threat to their safety, i.e., cases in which a child has been subject to abandonment, torture, chronic abuse, or sexual abuse; cases in which a parent has committed murder or voluntary manslaughter; and cases in which parental rights to a sibling have been terminated. Moreover, ASFA expedited consideration of termination of parental rights by requiring states to file a termination of parental rights petition for any child in foster care for fifteen of the preceding twenty-two months. The only exceptions are situations where the child is in the care of a relative, or the agency documents a compelling reason why such termination would not be in the child’s best interests, or the state has not provided the services deemed necessary to permit safe family reunification. In an effort to facilitate more timely decision making and to promote earlier adoption of children who cannot return home safely, this law mandates a “permanency hearing” by an administrative body appointed or approved by the court no later than twelve months after a child enters foster care and every twelve months

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thereafter until the child is discharged from care. It also requires caseworkers to engage in what is called “concurrent planning,” meaning that they should provide immediate family reunification services while also making plans for termination of parental rights and adoption in case the family reunification efforts are not successful. ASFA requires states to document their adoption efforts and authorized adoption incentive payments for states that increase their number of annual completed adoptions. A significant federal law enacted to address the problems and needs of youth aging out of foster care was the Foster Care Independence Act of 1999 (PL 106–169), which replaced the Title IV-E Independent Living Program with the John H. Chafee Foster Care Independence Program. The Foster Care Independence Act increased funding for independent living services to assist youth in transitioning out of foster care. Services include education, training, and employment, as well as financial support. The law also allows states the option of extending Medicaid coverage to former foster children between 18 and 21 years old. Although states are required to provide youth with independentliving services, they are also encouraged to have a concurrent plan of establishing permanent and/or adoptive homes. Older children in foster care are considered “hard to place” and therefore adoptive parents are eligible to receive additional funding and support. The Child and Family Service Reviews (CFSRs) were introduced in 2000 by the U.S. Department of Health and Human Services (DHHS). These reviews were the first effort to focus on the outcomes rather than the processes of the various child welfare programs supported by Title IV-B and Title IV-E of the Social Security Act. CFSRs are administered by the U.S. Children’s Bureau of the Administration for Children and Families (ACF) within DHHS in collaboration with the states. In addition to ensuring systems accountability, they are designed to help states improve child welfare services by achieving specific outcomes

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related to safety, permanency, and child and family well-being. These outcomes are defined as follows (Children’s Bureau, 2012): Safety: Children are first and foremost protected from abuse and neglect. Children are safely maintained in their homes whenever possible and appropriate. Permanency: Children have permanency and stability in their living situations. The continuity of family relationships and connections is preserved for families. Family and Child Well-being: Families have enhanced capacity to provide for their children’s needs. Children receive appropriate services to meet their educational needs. Children receive adequate services to meet their physical and mental health needs. These desired outcomes place child safety, family preservation, and child/family wellbeing on essentially the same level. The outcomes are measured by a two-stage process consisting of a statewide assessment using aggregate data provided by the Children’s Bureau on each state’s foster care and in-home services and an on-site review of service outcomes and service systems. There are a number of limitations to this review system, and efforts are underway to improve the review process. However, it lays out clear policy objectives for the states, placing balanced emphasis on child protection and family preservation. The Fostering Connections to Success and Increasing Adoptions Act of 2008 (PL 110–351) promotes permanent families for children through placement with relatives and adoption, as well as improving educational stability and health care coordination. It also provides Indian tribes access to IV-E-funded programs and financial support for technical assistance. Regarding relatives, states must “exercise due diligence” to provide notice to all grandparents and other relatives within thirty days of the child being removed from the home, thus increasing the opportunity for children to be

placed with family members. States have the option of providing kinship guardianship assistance payments under Title IV-E for children who have been residing with relatives in foster care for at least six months and plan to leave foster care to live with them permanently. The Kinship Navigator program offers funds to help relatives connect children with necessary services and supports. Finally, states may waive non-safety-related licensing requirements that previously created barriers to children living with relatives. States are provided increased funding to locate adoptive homes for children, especially those considered hard to place, including children with disabilities or special needs and older youth. There is also federally supported adoption assistance for children with special needs. For older youth who lack permanent families, there is federal assistance available to provide supports until age 21, and a requirement that ninety days prior to the youth’s emancipation the caseworker must develop a personalized transition plan as directed by the youth. There is also increased support for educational stability and health care coordination for all children in care. The most recent federal legislation related to delivery of foster care services is the Child and Family Services Improvement and Innovation Act of 2011, PL 112–34. Enacted in recognition of the trauma that derives from child maltreatment, the law reauthorized Title IV-B of the Social Security Act and “includes new language requiring states to develop plans for identifying and addressing ‘emotional trauma associated with the child’s maltreatment and removal from home’ ” (Samuels, 2011, p. 20). Vulnerabilities and risk factors All children in foster care, almost by definition, are children at risk. They generally come from low-income families with high incidence of socioeconomic, physical, and emotional problems. They have frequently been exposed to repeated physical and sexual abuse and/or

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neglect. And they may display serious developmental delays and behavioral problems. Compounding these disadvantages is the fact that these children have all been exposed to the trauma of at least one separation from a parent or parent figure and frequently more. Consequently, they often live in a state of limbo, uncertain who is going to be caring for them or where they will live in the future. In view of these enormous stresses, not surprisingly, former foster children are overrepresented among runaways, prisoners, welfare recipients, and other “problem” groups. The key risk factors for children in foster care identified below include poverty and its associated problems, disproportionate representation of children of color, the impact of trauma, and high-risk behaviors. As discussed above, the economic crisis that began in 2009 significantly increased the number of children living in poverty. Children living in rural areas and those in large cities are most likely to live in areas of concentrated poverty (census track areas with poverty rates of 30 percent or higher) (Children’s Defense Fund, 2012). This extreme poverty places children at much greater risk of the harmful effects of familial and neighborhood stress. Three problems associated with poverty—parental substance abuse, homelessness, and low educational attainment—are placing enormous demands on foster care workers today, especially in urban areas. The link between parental substance abuse and child maltreatment is well documented in the literature (Small & Kohl, 2012). Parental substance abuse is one of the main reasons children come in contact with the child welfare system and ultimately get placed in foster care (Breshears, Yeh, & Young, 2004). The proportion of children who enter foster care due to familial substance abuse is about 42 percent (Pecora et al., 2009). Parental substance abuse has both short- and long-term consequences for parents, children, and families. It impedes a parent’s ability to provide safety and security to children and places children at high risk for poor developmental outcomes (Small & Kohl,

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2012). In general, children of substance-abusing parents come into foster care at younger ages, experience more severe maltreatment, remain in foster care longer, and experience more placement moves than other foster children (Berger, Slack, Waldfogel & Bruch, 2010). Children of substance-abusing parents are also at greater risk for the recurrence of child abuse and neglect (Barth, Gibbons, & Guo, 2006). Children living in homeless families are at high risk of foster placement. Although the current number of homeless families is unknown, the total number has increased dramatically in recent years. The National Center on Family Homelessness (2011) reported that there are 1.6 million “or one in forty-five children” homeless in a year. While the dynamics between homelessness and foster care services have not been thoroughly examined, research indicates that housing instability, financial hardship, and psychological distress may lead parents to place their children with relatives or friends, or to the intervention of child welfare services. A prospective study of families in New York City found that children residing in homeless shelters were at greater risk for child welfare involvement than comparable peers who had more stable housing arrangements (Park, Metraux, Brodbar & Culhane, 2004). The authors proposed three possible explanations: (1) the lasting impact of homelessness on family stability and family functioning, even after families achieve stable housing, (2) the difficulty adjusting to shelter life, especially among older children, and (3) the heightened scrutiny from social services professionals who are also mandated reporters. Regardless, there is evidence that homelessness creates a large burden on the child welfare system and negatively impacts family stability and functioning. Children involved in foster care remain behind their peers in school performance, high school graduation rates, and general education development (GED) obtainment (Courtney, Roderick, Smithgall, Gladden, & Nagaoka

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2004). Education is an essential component of obtaining a job and experiencing upward mobility. There has been a decrease in the number of full-time jobs available for people with a high-school diploma or less, and college graduates now earn twice, if not more, than those with a high school diploma or less (US Department of Education [DOE], 2011). Among youth 18–24 years old in the general population, the poverty rate is significantly higher (31 percent) for young adults who do not complete high school than for those who completed high school (24 percent) and those who earned a college degree or more (14 percent) (DOE, 2011). Moreover, lack of academic success has been associated with adverse health and socio-emotional problems including unemployment, dependence on public assistance, teenage pregnancy, health and mental health needs, criminal activity, and homelessness (Courtney et al., 2005). The problem of disproportionality and disparity of children of color is not a new phenomenon. Andrew Billingsley and Jeanne Giovannoni (1972) in their seminal work, Children of the Storm: Black Children and American Child Welfare, wrote about it. In 2006, Robert Hill conducted a systematic review of forty-five studies and found that children’s experiences in foster care differ by race and ethnicity at all major child protective decision-making points, including reporting, investigation, substantiation, placement in foster care, and exiting from foster care. Hill reported that children of color were more likely to be reported to child protection than white children. Race alone, or interacting with other factors (i.e., severity of maltreatment, source of report, gender of perpetrator), was significantly related to rates of investigation. Race or ethnicity of the victim or family was also one of the four key predictors of substantiation. Black children were 36 percent more likely to be placed in foster care than white children. They remained in foster care longer and were less likely to be adopted compared to white children.

While there is clear evidence of disproportionality and disparity, the underlying causes are less apparent. Common factors reported in the literature include (1) disproportionate and disparate needs of children and families of color; (2) racial bias and discrimination in the child welfare system and associated systems such as hospitals, schools, and law enforcement agencies; (3) child welfare system processes and resources, including staff; and (4) geographic context (Fluke, Harden, Jenkins, & Ruehrdanz, 2011). Although each individual factor is important, the causes of disproportionality and disparity are multifaceted and likely operate at various levels, including individual, family, community, agency, child welfare system, and social policies. The longer children remain in foster care, the more likely they will experience placement disruption. The harmful effects of multiple moves for foster children are well documented (Oosterman, Schuengel, Slot, Bullens, & Doreleijers, 2007). When children switch placements, they have to sever social ties, establish new relationships, integrate into new communities and schools, connect with new service providers, and engage in activities that may hinder their developmental progress. Placement disruption may also lead a child to move farther away from biological family members, which may interfere with the reunification process. More frequent moves may also trigger administrative consideration of higher-level care, which has been associated with diminished outcomes for children in care. As discussed above, children who experience maltreatment often experience trauma, as do children separated from their parents and forced to enter foster care. Recent research has demonstrated that “children known to the child welfare system have strikingly similar experiences of trauma and display alarmingly high rates of trauma symptomatology” (Samuels, 2011, p. 21). To illustrate, 14,303 children aged 0–17 who entered the Illinois Department of Children and Family Services between July 2005

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and June 2011 were assessed by a standardized instrument within forty-five days of entry. Researchers discovered that 95.14 percent of the subjects had experienced some traumatic event and that 75.69 percent had experienced a significant event. Moreover, 28.12 percent displayed at least one trauma symptom. Based on these findings the authors projected that for any 1,000 children in a child welfare system, it can be anticipated that at least 95 percent can be expected to have experienced a traumatic event, and 75 percent can be expected to have experienced a significant event (Griffin et al, 2011, p. 82–83). The clear implication of findings such as these is the need for early intervention services for children in foster care to assess and address potentially trauma related symptoms. Foster care youth are at risk for engaging in high-risk behaviors, such as unprotected sex (Bilaver & Courtney, 2006.) This places youth at risk of becoming pregnant or contracting a sexually transmitted disease. Youth in foster care experience higher rates of teenage pregnancy compared to the general population (Carpenter, Clyman, Davidson, & Steiner, 2001; Bilaver & Courtney, 2006.) A prospective study of youth exiting foster care reported that almost half of the girls in the study were pregnant by the age of 19 (Courtney et al., 2005). Youth who become pregnant often drop out of school and become dependent on public assistance, which compromises their chances for future success. Research demonstrates that children who are victims of maltreatment are at increased risk for committing a delinquent act (Ryan, Herz, Hernandez, & Marshall, 2007). Poor minority children are more likely to be arrested and placed in detention than their white peers (Children’s Defense Fund, 2012). Youth who spend time in juvenile detention centers are removed from their families, communities, and schools. Their educational needs are often not met and they reenter society lacking the education and life skills necessary to become productive adults.

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resiliencies and Protective factors Given the vulnerability and multiple risks faced by children in foster care, social workers must be familiar with potential protective factors, a number of which are identified below. From the moment children and youth are placed in foster care, the focus should be on establishing permanency through reunification with family, adoption, placement with relatives, or guardianship. Lloyd and Barth (2011) compared developmental outcomes amongst a cohort of infants placed in foster care during their first year of life. After five years, children who achieved permanency through reunification or adoption faired better developmentally than their peers who remained in foster care. Developmental measures included items such as language, social competence, internalizing and externalizing behaviors, cognitive development, educational outcomes, adaptive behavior, and daily living skills. The study captures the importance of children’s residing in stable and permanent homes. It also highlights the importance of early screening and assessment of children in foster care for developmental delays. Due to the trauma of child maltreatment, removal from parents, and foster care placement, children in out-of-home care are at high risk for traumatic symptomatology, as well as developmental and mental health issues. Therefore, early identification and subsequent service delivery are crucial for achieving optimal development (McCrae, Cahalane, & Fusco, 2011, p. 1417). Congress created the National Child Traumatic Stress Network in 2001, whose Child Welfare Committee has developed a range of assessment and intervention tools designed to assist child welfare and mental health practitioners to identify and help children and families who have been traumatized. The Child Welfare League of America (2012) “calls for a comprehensive, multidisciplinary health, mental health, and developmental assessment within one month of the child’s placement.” The League also recommends developmental and mental health evaluations

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on a regular basis once children are placed in care. McCrae et al. (2012) recommend that agencies work collaboratively with professionals trained in childhood development, such as early intervention specialists, to screen children for developmental and mental health problems. They also suggest that agencies have specialized teams focused on identifying and providing appropriate services to children and families. In recent years, there have been increased efforts to involve parents in the development and improvement of child welfare programs, services, and reforms. An example of an active parents’ rights group is the Child Welfare Organizing Project (CWOP) in New York City. CWOP is a group of parent advocates with previous child welfare involvement who provide services to other parents, including support groups, parents’ rights training, and advocacy/ support during family team conferences and court proceedings. They also provide education and training to social work students and child welfare professionals through class lectures and presentations at child welfare trainings and conferences. On a policy level, they meet with and advise public and elected officials regarding child welfare system reforms. Efforts should be made to maintain contact with family members and place children with relatives. “Kinship care helps children maintain familial and community bonds and provides them with a sense of stability, identity, and belonging, especially during times of crisis. Kinship care also helps to minimize the trauma and loss that accompany parental separation” (Annie E. Casey Foundation, 2012b, p. 2). Placing children with relatives may avoid the stress associated with adapting to stranger foster care. Research indicates that children placed with relatives may experience fewer behavioral and mental health issues and greater educational stability compared with children in stranger foster care (Annie E. Casey Foundation, 2012b). Cultural sensitivity has increasingly been recognized as a critical component of effective practice in children’s services. It is essential

that child welfare agencies and workers recognize the impact of culture and community and design interventions that are attuned to the culturally determined expectations of the clients and communities they are serving. The CWOP project described above provides a good example of an effort to learn from the client community. Another important innovation is the Family to Family program by the Annie E. Casey Foundation that was implemented in multiple locations. In this program foster parents are encouraged and paid to develop mentoring relationships with birth parents (Chipunga & Bent-Goodley, 2004). With careful selection of foster parents from the same community as birth families, this program can provide culturally sensitive support to client families. Immigrant children and youth under the age of 21 who are under the jurisdiction of the juvenile or family court and who are not being returned to their parents may be eligible to receive Special Immigrant Juvenile Status (SIJS) (U.S. Citizenship and Immigration Services, 2011) if returning to their country of origin is not in their best interest. This qualifies them for lawful permanent residency or a “green card,” a governmental photo ID and work authorization. It is essential for child welfare workers to assess children’s eligibility for SIJS and apply in a timely manner. Those children who exit foster care without SIJS risk deportation and are not authorized to work or receive governmental services. Educational attainment is a key protective factor for children and youth in foster care. The McKinney-Vento program was developed to address the problems homeless children encounter in enrolling in and attending school. Homeless children include those waiting to be placed in foster care. Provisions specify that state educational agencies provide equal access to public school education for homeless children, that homeless children not be separated from the mainstream school environment, and that homeless children be provided the necessary supports and services in order to meet

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academic achievement standards. Child welfare workers should be familiar with the regulations governing implementation of McKinney-Vento in their respective states and the ways in which they can utilize this law to protect the education of children awaiting foster placement or a change of placement. Maintaining qualified child welfare workers is key to establishing permanency for children and families. It is well established in the literature that direct service staff are not adequately prepared for the demands of working with this high-risk population (United States General Accounting Office [GAO], 2003). They are not provided the necessary training, supervision, and support to carry out their job responsibilities (Ellett, Ellett, & Rugutt, 2003; Mor Barak, Nissly, & Levin, 2001; GAO, 2003). Consequently, staff turnover rates may run as high as 20–60 percent annually in different locations. Moreover, the average length of stay for beginning workers is under two years (GAO, 2003). These factors make it extremely difficult for foster children to develop long-term meaningful relationships with their workers. Fortunately, recent federal legislation extended federal support for training for staff working with children in foster care. Individual states and localities are increasingly focused on strategies to retain child welfare workers. Programs and Social Work contributions Foster care services are provided by both public and private child care agencies. Although any licensed agency can provide foster care for a child whose parents sign a voluntary placement agreement, court approval of the placement plan is required to secure public subsidy for the costs of placement. The local public department of social services or its equivalent is ordinarily responsible for determining whether involuntary placement is required and for securing the necessary court order. The public department may provide care directly through a foster home or other residence administered under its auspices, or it may contract for the provision of

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care with a licensed private agency. Since the vast majority of foster placements are ordered on an involuntary basis, it can be assumed that most placements are now arranged through a public agency. Moreover, all publicly financed foster placements are subject to periodic administrative and court reviews. This legal framework guides the way foster care programs are organized. Traditionally, the only service provided by many child welfare agencies was foster care. Starting in the 1920s, increasing numbers of these agencies began to offer adoption services, primarily for healthy white infants. Adoption services were expanded in the late 1960s as agencies began to seek adoptive homes for children formerly defined as “hard to place,” i.e., older children, minority children, and those with physical handicaps or developmental disabilities. It was not until the 1970s that many child welfare agencies began to offer in-home services to families in which children were at risk of placement as well as to those whose children were in care. PL 96–272 mandated that foster care be viewed as part of a continuum of services to families in which parents need help to fulfill their basic role responsibilities. This service continuum includes supportive, supplementary, and substitute care services. Supportive services, often referred to as preventive or home-based services, are designed to strengthen parent and child functioning. They include various types of individual, family, and group counseling and education as well as a range of community advocacy efforts and concrete services. Supplementary services are distinguished from supportive services by the fact that they are designed to fulfill at least part of parents’ normal role responsibilities. Instead of aiming solely to strengthen the family, these services actually take some role in the family system. The primary supplementary services are child care (full-day and after-school programs) and homemaker–home help aides.

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Substitute care services, which include both foster care and adoption, are designed to ensure that all parental responsibilities will be fulfilled in a setting apart from that of the birth parent(s). They include the wide range of placement options described earlier. Although current federal legislation mandates a full continuum of services to ensure that an appropriate package of services will be offered to each child and family at risk, such a continuum is easier to conceptualize than to implement. Because of the vagaries of historical tradition and current funding patterns, few social agencies provide the required range of services. Instead, most administer one or a few specialized service programs. As a consequence, families often must seek services from several agencies simultaneously and experience multiple changes of worker and agency as their service needs change over time. In this context, it becomes increasingly difficult for foster care workers to provide the services required to effect family reunification in a timely manner, and parents tend to become increasingly distanced from their children in placement. In recent years, there has been a push in the child welfare field to provide child- and familycentered services in communities where children and families reside, which is consistent with social workers’ focus on the ecological perspective (Pecora et al., 2009). An innovative example, highlighting the need to provide family-centered and neighborhood-based foster care services, is The Annie E. Casey Foundation’s (2012a) Family to Family Initiative. The goal of the initiative was to reform the foster care system to (1) reduce the number of children in congregate and institutional care and meet their needs in family foster care, (2) reduce children’s length of stay in care, (3) safely reunite children with families in a shorter time period, (4) increase the number and quality of foster homes, (5) develop a network of family foster care that is culturally sensitive, neighborhood based, and keeps children in their communities, (6) ensure all children in out-of-home care

receive the family foster care resources, and (7) decrease the number of children in foster care (Usher, Wildfire, Webster, & Crampton, 2010). Family to Family incorporates four core practice strategies, including (1) building partnerships with communities most affected by the child welfare system, (2) team decision making at critical child welfare decision points, (3) resource family recruitment, development, and support, and (4) building the capacity of states to evaluate Family to Family outcomes (Annie E. Casey Foundation, 2012a). An evaluation of the fifteen anchor sites identified as having potential to fully implement the core strategies revealed some positive changes for children and families (Usher et al., 2010). In many sites the number of children entering out-of-home care decreased. When children were placed, they were more likely to be placed with a relative or in a foster home and were more likely to maintain contact with their families. Additionally, early involvement of parents coupled with the support of friends, relatives, community advocates, and others led to faster rates of reunification. Several challenges were also identified in implementing Family to Family. One challenge was getting staff to adopt and maintain a commitment to the values and principles of Family to Family. Another was the high rate of turnover in foster care agencies. Another was getting agency and community leaders to provide continuous support for the initiative, especially when there was turnover in high-level leadership. Additionally, there were some financial constraints, most notably during the economic downturn in 2008. Not all states participated in the Family to Family initiative; however, many incorporated one or more of the four core strategies into their child welfare and foster care services. For example, Casey Services reported in 2009 that fortyfive states currently utilize some form of the family teaming approaches (e.g., family group decision making/family group conferences, family team conferencing, the permanency teaming process, and team decision making).

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assessment and interventions A primary objective of child welfare services is to sustain children in their own homes and strengthen family functioning. Both by law and by professional mandate, social workers are expected to provide in-home services to families in which children are at risk of placement prior to considering foster care as a service option. The decision to place a child prior to provision of the services that might alleviate the need for foster care can be justified only if there is evidence that a child has been harmed or is at imminent risk of such harm. In order to determine this, the worker must conduct a safety assessment (see the National Association of Public Child Welfare Administrators [2009] for in-depth information). Once it is determined that a child must be placed in out-of-home care, the worker must deal with three tasks. The first is to locate an appropriate placement. Federal legislation mandates that children be placed in the most family-like setting available in close geographic proximity to the biological parents that is consistent with the child’s needs. Children should be placed with siblings when feasible, and the availability of suitable relatives should be explored. The child’s language, race, ethnicity, religion, and other factors that influence a child’s sense of identity must also be considered. The second task, early in the life of a case and prior to placement if possible, is the development of a comprehensive service plan. An intervention used in several jurisdictions is to hold a family team decision-making conference, which enables families to collaborate with agency workers, service providers, and community supports to design a comprehensive service plan. The plan should specify the anticipated duration of placement, the changes that must occur prior to reunification, the actions that will be taken by each party (i.e., parents, child, agency worker, and foster parents), the role of other community agencies, visiting arrangements, and a schedule for periodic assessment

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of progress. The plan is generally reviewed and approved by the court. A third critical, early task is to provide supportive counseling and education and to facilitate ongoing contact between children and parents in order to decrease the trauma and pain associated with separation. Even when the parent-child relationship is very conflicted or there has been serious abuse, parents and children tend to experience a terrible sense of loss after placement. Children often feel sad, abandoned, angry, and/or guilty and may act out these feelings in dysfunctional ways in the new foster home. Parents are likely to feel similar emotions. Therefore, it is important that the worker view foster placement as a traumatic event that may precipitate a crisis response in the parent(s) and/or the child(ren) and plan accordingly. Drawing on principles of crisis intervention theory, the worker can help both parents and children (if age-appropriate) to gain cognitive mastery of the situation by involving them actively in planning the placement, providing anticipatory guidance and rehearsal, and sharing as much information and decision-making responsibility as possible. One important objective throughout the planning process should be to give the participants as much information as possible about what is happening, why, and what can be anticipated in the future. When children enter foster care, the worker should make continued efforts to diminish feelings of loss and separation by helping them understand what is happening and facilitating ongoing contact between the birth parents and the children. Parent-child visiting is crucial, as it provides a sense of continuity, diminishes fears of abandonment, and facilitates family reunification. The worker should adopt a family-centered approach to practice and view the family as the unit of attention. They should do everything possible to support the family system and enable the parent(s) and child(ren) to make the changes required to ensure that the family will be reunited. Service plans for

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children in foster care may include parent education, individual and family counseling, remediation for children’s developmental difficulties, vocational or educational counseling, coordination and advocacy with a range of community agencies, and/or efforts to strengthen the family’s natural support network. Workers should also make regular visits to children in their foster home or group residences, and have regularly scheduled appointments with parents to monitor their progress and provide support and encouragement. When foster care workers practice from a family-centered, ecosystems perspective, the therapeutic tasks they carry out may be very similar to those performed by workers providing services to at-risk families in their own homes. However, there are some important distinctions. One is the need to work specifically on issues related to separation and trauma. A second is that they must function as part of a service team, and often carry lead responsibility for orchestrating the activities of various team members. The social worker must actively monitor what is happening in the placement and work in a collegial manner with the foster parents and/or child care workers to enhance their transactions with the child and the biological parents. Foster care workers must also consult with agency attorneys and testify at frequent court hearings. To work effectively with the courts, workers have to learn how to obtain the type of evidence that will be admitted in court, document their own and clients’ activities precisely, and present their observations and recommendations persuasively. They must also learn to function comfortably in what can be an adversarial context and to answer questions that may be posed by the foster child’s attorney or lay advocates in a factual, non-defensive manner. The competent worker will try to use court processes to enforce the service plan of greatest benefit to the child and the family. The third and perhaps most critical difference between practice with or on behalf of

children in the community and those in foster care is that the worker must assume major casemanagement and life-planning responsibilities, including making recommendations regarding whether children should be returned to their parents, freed for adoption, or given an alternative permanency plan. The implementation of regularly scheduled family team conferences throughout the duration of the case has assisted workers in the child welfare decision-making process. When done properly, a group of individuals familiar with the case, including parents and children, work together to make crucial decisions, service plans, and permanency recommendations that are then presented to the court. While this intervention has demonstrated some promising results in terms of more comprehensive decision making, foster care workers remain responsible for providing ongoing case management support to children and families in order to accomplish case planning goals. illuStrAtion And diSCuSSion

The Tiana Ramsey case came to the attention of Child Protective Services (CPS) on September 19th due to allegations of child neglect, including inadequate guardianship and emotional and medical neglect1. Ms. Ramsey, an undocumented 38-yearold woman from the Dominican Republic, has three children, Jessica, age 15; Jeanine, age 6; and Jay, age 4. Jessica was disobeying Ms. Ramsey’s rules and frequently running away from home, so Ms. Ramsey decided to rent her an apartment, where she resided alone. When the CPS worker investigated the case, Ms. Ramsey stated that she believed she was protecting Jessica by providing her with a “roof over her head” so she wasn’t roaming the streets. During the investigation, Ms. Ramsey was reluctant to provide any information about her other two children, so all three children were removed and placed in foster care with Strengthening Families Inc. (SFI). Ms. Ramsey became distraught when told about the placement, collapsed on the floor, and was rushed to the hospital. The CPS worker recommended that Ms. Ramsey receive a mental health evaluation.

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A family team conference was held the next day at the agency to develop a service plan for the family. In attendance were Ms. Ramsey, Jessica, the CPS worker, the SFI social worker, the SFI supervisor, and the foster parent. A Spanish interpreter was also present because Ms. Ramsey had limited proficiency in the English language. Ms. Ramsey presented as depressed and helpless. She did not trust the child welfare workers and refused to sign a release for the agency to access her children’s birth certificates and Social Security records, or her medical records. She indicated that she had previously consulted with a physician and she was in perfect health. The SFI social worker, Ms. Seina, questioned the role of culture and language in Ms. Ramsey’s resistance. She felt Ms. Ramsey could benefit from a Spanishspeaking worker, but none were available. All three children were placed together in the foster home of Ms. Stevens, a middle-aged African American woman. Ms. Ramsey was upset because the children were not placed in a Spanish-speaking home, but the agency felt Ms. Stevens could best meet their needs. It was agreed that Ms. Ramsey would visit her children twice per week at the agency, supervised by Ms. Siena. The children’s medical and school needs were also discussed. The following day, Ms. Seina conducted a home visit to the foster home to meet with the children and conduct a safety assessment. Ms. Siena spoke individually with the children, in an age-appropriate manner, to determine how they were adjusting to the foster home and inform them of the plan for visitation with their mother. The younger children appeared safe and comfortable, but they desperately missed their mother and looked forward to seeing her. Jessica also appeared content, but was very angry with her mother and did not want to visit with her. Ms. Siena met with the foster mother to discuss the plan for the children’s school, medical appointments, and the visitation schedule. On the same day, Ms. Seina conducted a visit to Ms. Ramsey’s apartment, accompanied by a translator. Ms. Seina focused the meeting on establishing trust and rapport with Ms. Ramsey by explaining

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her role: to work with the family to ensure they received the support and services necessary to achieve the permanency-planning goal of reunification. Ms. Ramsey appeared relieved and slowly began to open up to Ms. Siena. She disclosed she left Jessica alone at home when she was 4 years old. A fire started and Jessica was caught inside the home alone until a neighbor rescued her. Jessica spent three months in the hospital and was left with scars all over her body. Two years later, Ms. Ramsey left Jessica with her father in the Dominican Republic and moved to the United States. A year later Jessica reunited with her mother in the United States to undergo a skin grafting operation. Her skin never fully healed so she wears long sleeves and fingerless gloves to cover her scars. A few years later, Jessica began acting out and demonstrating anger toward her mother. She blames her mother for the fire and for abandoning her for over a year when she moved to the United States. Additionally, Jessica resents that her mother had two more children. She believes her mother loves them more than her and is jealous of the care and attention they receive. The agency held another family team conference approximately twenty days later to review the service plan. The children had adjusted well to the foster home. The foster mother was observed to be caring and supportive. They were up-to-date with their medical appointments and regularly attended school and parent-child visits, where Ms. Ramsey was observed to have a close bond to her younger two children. Jessica did not attend the majority of the visits and when she did, it was apparent that the relationship was strained. Ms. Siena recommended that the younger children be returned home. However, the CPS worker refused to consider it until the mental health evaluation was conducted. It was recommended that Ms. Ramsey participate in parenting skills classes, individual therapy, and family therapy with Jessica. It was also recommended that Jessica participate in individual therapy. Because she was undocumented, Ms. Ramsey lacked health insurance, which made locating services very challenging. She was able to find free

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Spanish-speaking parenting skills classes, but could not locate free counseling. Ms. Siena was concerned that this would be a significant barrier to returning the children home. Using a strengths-based, familycentered approach, Ms. Siena provided Ms. Ramsey and Jessica with support surrounding their relationship. She encouraged Ms. Ramsey to empathize and understand Jessica’s perspective and encouraged Jessica to visit with her mother and work on letting go of her anger. Because Jessica was in foster care, she was able to enroll in individual counseling and began meeting with her counselor once a week. A few months into the case, Ms. Siena discovered that Ms. Ramsey was pregnant. Initially, she did not tell Ms. Siena because she was fearful that the agency would immediately remove the child once born. She asked Ms. Siena not to inform the CPS worker or the court. Ms. Siena told her that she was obligated to inform them but that she would continue to be there to support her and the family unit. The pregnancy allowed Ms. Ramsey to obtain Medicaid to enroll in individual counseling. Ms. Ramsey attended individual counseling on a weekly basis. Ms. Ramsey continued to visit with her younger children at the agency twice a week, under the supervision of Ms. Siena. Throughout, Ms. Siena visited the foster home twice per month to monitor the children’s progress at home and in school. She received regular updates from all service providers. Ms. Siena believed Ms. Ramsey was a loving mother to her two younger children and they should be returned to her care. Seven months after the children were removed, Ms. Siena advocated in court for the children to return home to their mother, under the condition she continue attending individual counseling and work on her relationship with Jessica. She was concerned that the judge would not agree with her recommendation because in previous family team conferences and in court appearances both the CPS worker and the judge disagreed with her recommendation. Each time, the children were ordered to remain in foster care. On this date, Ms. Siena provided documentation that Ms. Ramsey completed parenting skills

classes and was in compliance with weekly individual counseling. Ms. Siena also provided the court with a written and oral report on Ms. Ramsey’s compliance with social services. Ms. Ramsey was observed to have appropriate parent-child interactions and a strong bond with her younger children. After a lengthy court hearing, the judge paroled the two younger children home to their mother. Jessica continues to reside in foster care with Ms. Stevens. She attends individual counseling and has agreed to attend family counseling with her mother. This case situation illustrates the important work that can be accomplished, even by a beginning practitioner in a foster care program. The social worker quickly recognized the barriers she had to confront related to cultural and language differences, limited resources available to undocumented parents, the early trauma experienced by an estranged adolescent daughter, and the differences in practice objectives between the CPS and foster care workers. Unfortunately, she did not anticipate the ways in which court action could define and limit the actions of biological parents and her recommendations once children entered foster care. However, the children were placed with a very experienced and caring foster mother, the worker utilized a strengths-based, family-centered approach to develop positive working relations with both the teenager and her mother, and she was adequately prepared to advocate effectively for her clients.

conclusion Foster care, as it is known today, originated as a social invention of the mid-nineteenth century designed to protect children whose parents were unwilling or unable to provide adequate care. Over a century and a half later, long-term foster care has been redefined as a social problem, and federal legislation now mandates the provision of services designed to prevent or limit foster placement. Societal reassessment of the value of foster care, together with the administrative and court review processes developed to monitor and regulate its

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use, have created new decision-making dilemmas and stresses for many social workers in this field. But these changes have not eliminated the challenge and satisfaction inherent in providing effective services to children in foster care. Moreover, new policy directives on

the development of family-centered services, prevention and treatment of the trauma often experienced by children in foster care, and promotion of child and family well-being are creating opportunities for creative, sophisticated practice interventions.

noteS

Children’s Defense Fund. (2011a). The number of children in foster care continues to decline. Accessed August 5, 2012. http://www.childrensdefense.org ——. (2011b). The state of America’s children 2011. Accessed August 5, 2012 http://www.childrensdefense .org/child-research-data-publications/state -of americas-children-2011/ ——. (2012). A portrait of inequality 2012. Accessed August 8, 2012. http://www.childrensdefense.org/child research-data-publications/data/portrait-of -inequality-2011.html Child Welfare League of America (2012). Checklist of needed services for children in foster care. Accessed August 15, 2012. http://www.cwla.org/programs/health /checklist.htm Chipunga, S.S., & Bent-Goodley, T. B. (2004). Meeting the challenge of contemporary foster care. The Future of Children, 14(1), 75–93. Courtney, M. E., Dworsky, A., Cusick, G. R., Keller, T., Havlicek, J., Perez, A., Terao, S. & Bost, N. (2007). Midwest evaluation of the adult functioning of former foster youth. Chicago: Chapin Hall Center for Children at the University of Chicago. Courtney, M. E., Dworsky, A., Ruth, G., Keller, T., Havlicek, J., & Bost, N. (2005). Midwest evaluation of the adult functioning of former foster youth: Outcomes at age 19. Chicago: Chapin Hall Center for Children at the University of Chicago. Courtney, M. E., Roderick, M., Smithgall, C., Gladden, R. M., & Nagaoka, J. (2004).The educational status of foster children. Chicago: Chapin Hall Center for Children at the University of Chicago. Ellett, A. J., Ellett, C. D., & Rugutt, J. K. (2003). A study of personal and organizational factors contributing to employee retention and turnover in child welfare in Georgia. Athens, GA: School of Social Work, University of Georgia. Fluke, J., Harden, B. J., Jenkins, M., & Ruehrdanz, A. (2010). Research synthesis on child welfare disproportionality and disparities. Washington, DC: Center for the Study of Social Policy Alliance for Race Equity. Griffin, G., McClelland, G., Holzberg, M., Stolbach, B., Maj, N., & Kisiel, C. (2011). Addressing the impact of trauma before diagnosing mental illness in child welfare. Child Welfare, 90(6), 69–89.

1. We are indebted to Sireen Irsheid for providing this case material.

referenceS

Annie E. Casey Foundation. (2012a). Family to family. Accessed August 15, 2012. http://www.aecf.org /MajorInitiatives/Familypercent20topercent20Family .aspx ——. (2012b). Stepping up for kids: What government and communities should do to support kinship families. Accessed August 15, 2012. http://www.aecf.org/ Barth, R. P., Gibbons, C., & Guo, S. (2006). Substance abuse treatment and the recurrence of maltreatment among caregivers with children living at home: A propensity score analysis. Journal of Substance Abuse Treatment, 30(2), 93–104. Barth, R. P., Wildfire, J., & Green, R L.. (2006). Placement into foster care and the interplay of urbanicity, child behavior problems, and poverty. American Journal of Orthopsychiatry, 76(3), 358–66. Berger, L. M., Slack, K. S., Waldfogel, J., & Bruch, S. K. (2010). Caseworker-perceived caregiver substance abuse and child protective services outcomes. Child Maltreatment, 15(3), 199–210. Bilaver, L. M. & Courtney, M. E. (2006). Science says: Foster care youth. Chicago: Chapin Hall Center for Children at the University of Chicago. Billingsley, A. & Giovannoni, J.M. (1972). Children of the storm: Black children and american child welfare. New York: Harcourt. Boswell, J. (1988). The kindness of strangers. New York: Pantheon. Breshears, E. M., Yeh, S., & Young, N. K. (2004). Understanding substance abuse and facilitating recovery: A guide for child welfare workers. U.S. Department of Health and Human Services. Rockville, MD: Substance Abuse and Mental Health Services Administration. Carpenter, C., Clyman, B., Davidson, A., & Steiner, J. (2001). The association of foster care or kinship care with adolescent sexual behavior and first pregnancy. Pediatrics, 108, e46. Children’s Bureau. (2012). Child and family service reviews fact sheet. Accessed August 12, 2012. http:// www.acf.hhs.gov/programs/cb/cwmonitoring /recruit/cfsrfactsheet.htm

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Hill, R. B. (2006). Synthesis of research on disproportionality in child welfare: An update. Washington, DC: Casey-CSSP Alliance for Racial Equity in the Child Welfare System. Lloyd, E. C. & Barth, R. P. (2011). Developmental outcomes after five years for foster children returned home, remaining in care, or adopted. Children and Youth Services Review, 33(8), 1383–91. Maluccio, A., Fein, E., & Olmstead, K. A. (1986). Permanency planning for children: Concepts and methods. New York: Tavistock. McCrae, J. S., Cahalane, H., & Fusco, R. A. (2011). Directions for developmental screening in child welfare based on the ages and stages questionnaires. Children and Youth Services Review, 33(8), 1412–18. Mor Barak, M. E., Nissly, J. A., & Levin, A. (2001). Antecedents to retention and turnover among child welfare, social work, and other human service employees: What can we learn from past research? A review and metaanalysis. The Social Service Review, 75(4), 625–61. National Association of Public Child Welfare Administrators. (2009). A framework for safety in child welfare. Washington, DC: American Public Human Services Association. National Center on Family Homelessness. (2011). America’s youngest outcasts 2010: The new report card. Accessed August 13, 2012. http://www.homelesschildrenamerica.org/ Oosterman, M., Schuengel, C., Slot, N. W., Bullens, A. R., & Doreleijers, T. A. H. (2007). Disruptions in foster care: A review and meta-analysis. Children and Services Review, 29(1), 53–76. Park, J. M., Metraux, S., Brodbar, G., & Culhane, D. P. (2004). Child welfare involvement among children in homeless families. Child Welfare, 83(5), 423–36. Pecora, P., Kessler, J., Williams, J., O’Brian, K. A., Downs, C., English, D., . . . Holmes, K. (2005). Improving Family Foster Care: Findings from the Northwest Foster Care Alumni Study. Seattle, WA: Casey Family Programs. Pecora, P. J., Whittaker, L. K., Maluccio, A. N., Barth, R. P., DePanfilis, D., & Plotnick, R. D. (2009). The child welfare challenge. New Brunswick, NJ: Transaction Publishers.

Perry, B.  L. (2006). Understanding social network disruption: The case of youth in foster care. Social Problems, 53(3), 371–91. Ryan, J. P., Herz, D., Hernandez, P. M., & Marshall, J. M. (2007). Maltreatment and delinquency: Investigating child welfare bias in juvenile justice processing. Children and Youth Services Review, 29, 1035–50. Samuels, B. H. (2011). Introduction—addressing trauma to promote social and emotional well-being: A child welfare imperative. Child Welfare, 90(6), 19–28. Small, E., & Kohl, P. L. (2012). African American caregivers and substance abuse in child welfare: Identification of multiple risk profiles. Journal of Family Violence, 27, 415–26. US Citizenship and Immigration Services. (2011). Special Immigrant Juvenile (SIJ) Status. 2012. http://www .uscis.gov US Department of Education. (2011). America’s youth: Transitions to adulthood. Accessed August 7, 2012. http://nces.ed.gov/pubs2012/2012026.pdf US Department of Health and Human Services (DHHS), Administration for Children and Families. (2010). Child maltreatment. Accessed August 1, 2012. http://www.acf.hhs.gov/programs/cb/pubs/cm10/ index.htm ——. (2012a). Adoption and Foster Care Analysis and Reporting System (AFCARS). http://www.acf.hhs.gov/ programs/cb/stats_research/afcars/tar/report19.pdf ——. (2012b). Promoting social and emotional well-being for children and youth receiving child welfare services. Log No. ACYF-CB-IM-12–04. Children’s Bureau Information Management. US General Accounting Office (GAO) (2003). HHS could play a greater role in helping child welfare agencies recruit and retain staff. Log no. GAO-03–357. Washington, DC: US Government Printing Office. Usher, L., Wildfire, J., Webster, D., & Crampton, D. (2010). Evaluation of the anchor site phase of family to family. Baltimore, MD: Annie E. Casey Foundation. Wulczyn, F., Ernst, M., & Fisher, P. (2011). Who are the infants in out-of-home care? An epidemiological and developmental snapshot. Chicago: Chapin Hall Center for Children at the University of Chicago.

cHaPter 1 4 crime Victims Jacqueline corcoran

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ach year, perpetrators of violent crime physically, emotionally, and/or financially damage millions of crime victims. In the aftermath of a violent crime, victims often have to cope with physical pain, psychological trauma, financial loss, and court proceedings that all too frequently seem impersonal and confusing. Many victims and witnesses have their first contact with the criminal justice system as a result of being victimized. This first meeting can be frightening and confusing. To reduce the impact of crime on victims and witnesses, the victims’ movement has grown remarkably during the past three decades. In the mid-1970s, victim rights advocates and victim service and victim/witness assistance programs were rarely available in cities and counties throughout the United States. The proliferation of victim service and witness assistance programs, domestic violence shelters, rape crisis centers, and victim compensation programs that now exist nationwide is a direct result of the 1984 Federal Victims of Crime Act (VOCA) funding, the 1994 Federal Violence Against Women Act, state and county general revenue grants during the 1980s and 1990s, and the earmarking of a percentage of state penalty assessments and/or fines levied on criminal offenders (Roberts, 1995). defining and explaining crime Victims — Crime victim: An innocent person who experiences loss or damage to their personal property and/or physical injury, psychological trauma, or acute anxiety as a direct result of a criminal act.

— Protective factors: In the aftermath of a criminal victimization, the biopsychosocial factors that help buffer the negative impact of victimization. — Revictimization rates: Refers to the data indicating that a large number of crime victims have been victimized more than once. — Victims of Crime Act (VOCA) of 1984: This was the first significant federal legislation with a major funding appropriation that has resulted in the development and expansion of several thousand victim/witness, victim compensation, sexual assault, and domestic violence programs. — Victim blaming: Refers to the insensitive statements made by some criminal justice employees (i.e., police and court staff) indicating that crime victims’ actions had contributed to their own victim-related trauma and resulting mental health problems. — Victim service programs: Typically, these programs provide prompt intervention and a full range of essential services to crime victims, such as crisis stabilization at the crime scene, emergency financial assistance and food vouchers, transportation to the hospital or court, transportation to the local domestic violence shelter, repairing or replacing broken locks or windows, and referral to social service agencies. — Victim/witness assistance programs: These programs are affiliated with prosecutors’ offices and provide the following services: witness notification and case monitoring, transportation services and court escort, victim advocates during pretrial hearings 289

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and the actual trial, and child care for children of witnesses while they are in court. — Post traumatic stress disorder (PTSD): A diagnosis from the Diagnostic and Statistical Manual of the American Psychiatric Association (American Psychiatric Association [APA], 2000) characterized by symptoms of anxiety that follow exposure to a traumatic stressor. The three major symptom categories of PTSD include: 1. reexperiencing: the traumatic events are reexperienced through recurrent and/or intrusive thoughts or images, nightmares, and flashbacks. 2. avoidance and numbing: the person, because of the negative affect and arousal associated with re-experiencing, attempts to control or protect against these symptoms. 3. increased arousal: the person is in a state of arousal as indicated by hypervigilance, insomnia, inability to concentrate, and an elevated startle response. — Acute stress disorder: Another diagnosis related to trauma from the APA Diagnostic and Statistical Manual, characterized by intense anxiety symptoms that are experienced immediately after the traumatic event and that persist for less than four weeks (APA, 2000). demographic Patterns Since 1973, the U.S. Justice Department has published an annual report (the National Crime Victimization Survey [NCVS]) documenting the number of victimizations in the categories of rape, robbery, assault, theft, household burglary, and motor vehicle theft to U.S. residents age 12 or older. An estimated 18,725,710 crimes occurred to U.S. citizens in 2010: 3,817,380 violent crimes, 14,769,990 million property crimes, and 138,340 personal thefts were committed in 2010 (Truman, 2011). The NCVS also measures victimization rates—the frequency of crime among subgroups of the population. Violence against males, African Americans, and persons

age 24 or younger occurred at higher or somewhat higher rates than the rates of violence against females, whites, and persons age 25 or older in 2009 (Rand & Truman, 2009). Societal context For decades the courts ignored the interests of victims and witnesses. Millions of dollars were spent in the 1950s and 1960s on rehabilitation programs aimed at changing convicted felons into law-abiding citizens. Millions of dollars were also spent by the courts on processing and protecting the best interest of defendants. In sharp contrast to the offender, crime victims had to wait in the halls of dreary courtrooms while the defendant sometimes threatened or intimidated them. Separate waiting rooms for witnesses and/or their children were practically nonexistent until the mid-1980s (Roberts, 1990). Services were rarely provided to assist the victim and the family members, who were often shattered by the traumatic experience. By the mid1970s, when the first victim/witness assistance and rape crisis demonstration projects were initiated, the pendulum began to shift toward providing woefully needed services for vulnerable crime victims. The changed focus corresponded to how the crime victim was treated throughout the criminal justice system, from the first contact with a police officer or detective to the testimony in court. Historically, many crime victims had been victimized twice: first during the actual crime and then, again, when insensitive and unresponsive police and prosecutors ignored their calls or requests for assistance, and/or subjected them to harsh, repeated, and victim-blaming questions (McDonald, 1976). Society must have estimates of the costs of victimization as measured by loss of life, physical injuries, and economic cost (e.g., unrecovered stolen property, lower productivity and work absenteeism, medical expenses, and mental health costs) in order to have appropriate responses in place. Tangible criminal justice costs involve $105 billion, but intangibles are much higher at $345 billion (National Institute

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of Justice, 1996). Overall, rape is the costliest crime at $127 billion, which is higher than murder. The aggregate cost of domestic violence against adults is $67 billion per year. Vulnerabilities and risk factors Some beginning work on crime victimization has identified certain vulnerabilities that might make recovery from the victimization experience more difficult. In this discussion, “risk” is defined in relation to adaptation after a crime has already occurred rather than the risk of crime occurring in the first place, as a focus on crime prevention is outside the scope of this chapter. Additionally, restorative justice, also referred to as victim-offender mediation, will not be covered here as it is considered an alternative to the traditional court process rather than being offered as a service to victims. Post-traumatic stress disorder is a potential negative outcome of having been a crime victim (Riggs, Rothbaum, & Foa, 1995). Social influences have been found to play a large role in the development of PTSD. The results of two meta-analyses looking at predictors of PTSD after various traumas, including crime events, are relevant to this discussion. An aspect of the trauma event—its severity—as well as lack of social support of the person experiencing the trauma, posed the largest risks (Brewin, Andrews, & Valentine, 2000; Ozer, Best, Lipsey, & Weiss, 2003). In addition to severity, other features of the traumatic experience linked to PTSD involve the degree of exposure to the trauma (intensity, duration, and frequency) and the person’s subjective sense of danger (Ford, Stockton, Kaltman, & Green, 2006). Revictimization is unfortunately another possible deleterious outcome of being a crime victim (Finkehor, Ormrod, & Turner, 2007), and not surprisingly, prior victimization may also slow recovery (Denkers and & Winkel, 1998; Kamphuis & Emmelkamp, 1998). Finkelhor et al. (2007) looked at predictors of revictimization in youth who had been victimized (crime victims were included as well as other types of

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victimization, such as peer bullying and child maltreatment). Revictimization in this study was related mainly to family factors: living in a violent or maltreating household, alcohol abuse in the family, imprisonment of parents, unemployment of parents, and family disruption. For revictimization of intimate partner violence specifically, Cattaneo and Goodman (2005) reviewed studies that examined risk factors through longitudinal designs. The following variables were identified as predictors: low socioeconomic status (SES); absence of children; relationship factors, including length of the relationship and relationship dissatisfaction; severity of previous incidents; previous partner history of abusive behavior; and court involvement for previous episodes of abuse. Sonis and Langer (2008) examined poor, urban women who had been previously abused from the Chicago Women’s Health Risk Study. They found that recurrent intimate partner violence was related to the woman being pregnant; the number of violent incidents in the previous year; partner harassment; and the man’s higher score on the power and control scale. A protective factor against recurrence was leaving a partner or having him leave, which the authors acknowledge is in contrast to other research that has been done in this area. It may be that in their impoverished, mainly African American sample, risk and protection may play out differently. Another risk factor that has been explored at the individual level is people’s explanations for why traumatic events, such as crime, have occurred, called their attributions. Theories have developed as to why people make such attributions. In just-world theory (Lerner, 1971), people work to maintain the belief that they live in a just world in which good people are rewarded and bad people are punished. In this way, they may blame themselves for being victims of crime, or they have to find a way to recast the event as having some positive benefit. Other theories, such as control theory (Walster, 1966), postulate that people make

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attributions to feel that they have control over what has happened. For example, according to a review, victims of sexual assaults may blame themselves for having been sexually assaulted (Miller, Handley, Markman, & Miller, 2010). Unfortunately, selfblame is associated with “depression, anxiety, posttraumatic symptoms, avoidance coping, sexual dissatisfaction, and sexual revictimization” (p. 1121). A meta-analysis was conducted to examine these different theoretical constructs and to determine predictors of self-attributions following three traumatic events: sexual victimization, illness, and severe injury (Littleton, Magee, & Axsom, 2007). The results indicated that people do not routinely make attributions when they respond to trauma. Additionally, no single theory accounted for the pattern of findings. Other individual coping mechanisms have been studied in relation to the development of PTSD. Coping by avoidance or dissociation both appear to contribute to PTSD (Ozer et al., 2003). Finally, higher negative beliefs about the world, self, and others after physical or sexual assault in women were associated with higher initial trauma reactions (Zoellner, Feeney, Eftekhari, & Foa, 2011). resiliencies and Protective factors Resilience in the face of having suffered a crime event may take the face of expedited recovery, although another positive marker may be to not undergo repeat victimization. As discussed above, this seems to be a deleterious potential outcome. However, research has only started to identify protective factors that may help produce positive outcomes (Dutton & Greene, 2010). At the individual level, some people are able to rely on their own personal coping for recovery (Dutton & Greene, 2010). Sims, Yost, and Abbott (2006) found that psychological functioning was more related to victims’ use of day-to-day coping skills than it was to accessing victim services. Social support in

terms of family and friends is also helpful for recovery. We also have the availability of victim services programs for assistance, the topic of the next section. Programs and Social Work contributions The six different types of programs developed to assist crime victims in the aftermath of being victimized are listed here (Haynes, 2011). They are then briefly described. 1. Victim compensation 2. Prosecutor-based victim/witness assistance programs 3. Victim service or crisis intervention programs 4. Rape/sexual assault crisis centers 5. Domestic violence programs 6. Children’s advocacy centers Victim compensation programs provide monetary recompense, established by the 1984 Federal Victims of Crime Act (VOCA), to victims of crime for medical, property, mental health, and other specific hardships due to a crime, funded partially by penalties exacted from defendants. A nationwide survey of state compensation showed that programs were generally functioning well (Newmark, Liner, Bonderman, & Smith, 2001). Suggestions were made, including putting in place funding allocation policies; outreach to victim groups that are not represented among claims; examination of current caps for mental health services; and improving the timeliness of claims processing. A study from the Netherlands on PTSD in victims of violence filing for compensation found high rates of PTSD (one out of two) (Kunst, Winkel, & Bogaerts, 2010). The authors recommended that victim compensation programs could provide, in addition to compensation, a mental health screening and referral function to ensure that victims were receiving appropriate assessment and intervention. Prosecutor-based victim/witness assistance programs are usually located either within the

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local county prosecutor’s suite of offices, in the county court house, or across the street from the court building. These programs are designed to encourage witness cooperation in the filing of criminal charges as well as testifying in court. The program coordinator reports directly to the county prosecutor. Victim/witness advocates are responsible for accompanying the witness to the prefiling hearing, preliminary hearing, deposition hearing, and/or trial to ensure that the attorneys, court clerk, and the magistrate treat each witness fairly and compassionately. Victims and witness also are provided with transportation and a court escort when their appearance is required. The overriding purpose of prosecutor-based victim/witness assistance programs and units is to assist witnesses in overcoming the anxiety and trauma associated with testifying in court, while encouraging witness cooperation in the prosecution of criminal cases. Objectives of these programs are as follows (Roberts, 1990): 1. Providing victims and witnesses with the message that their cooperation is essential to crime control efforts and successful criminal prosecution. 2. Informing victims and witnesses of their right to receive dignified and compassionate treatment by criminal justice authorities. 3. Providing information to witnesses on the court process, the scheduling of the case, the trial, and the disposition. 4. Providing orientation to court and tips on how best to accurately recall the crime scene and testify. Evidence is accumulating that victim advocacy can help with the prosecution of domestic violence cases. For example, in a Missouri study of 405 state-level domestic violence cases, participants who had more assistance from victim advocates were more likely to cooperate (Bechtel, Alarid, Holsinger, & Holsinger, 2012). Victim cooperation was, in turn, related to more successful prosecution.

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Victim service or crisis intervention programs for crime victims are usually lodged in a police department, sheriff ’s office, hospital, probation department, or not-for-profit social service agency. Typically, these programs attempt to intervene within the first twenty-four hours after the victimization. They provide a comprehensive range of essential services for crime victims including responding to the crime scene; crisis counseling; help in completing victim compensation applications; emergency financial assistance and food vouchers to local supermarkets; transportation to court, the local domestic violence shelter, the hospital, or the victim assistance program office; repairing or replacing broken locks and windows; assistance in replacing lost documents (e.g., birth certificates, marriage licenses, wills); and referrals to the prosecutor’s domestic violence and sexual assault intake unit as well as community mental health centers and social service agencies for extended counseling and short-term treatment (Roberts, 1997). Internationally, there are three types of victim services programs (Wilson & Segrave, 2011): 1. Unit services: the most prevalent model of victim services in the United States and Canada, comprising a specialized unit dedicated to helping crime victims within a police organization 2. Dedicated liaison officer—the most prevalent model in Australia in which certain police officers are charged with specialized responsibility for victims of crime and are trained accordingly 3. Referral services—front line police officers refer crime victims to community-based and governmental services outside the police organization Evaluation of victim services is hampered for several reasons. Lack of funding and reliance on volunteers and underpaid staff means that organizations find it hard to collect the necessary data (Lauritsen, 2006). Another reason for

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the dearth of evaluation is due to sensitivity to victims of crime. They cannot be expected to complete assessment instruments to meet the needs of research when they are still reeling emotionally from their recent experience. Despite the proliferation of programs, the majority of victims (82 percent) do not avail themselves of services (Sims et al., 2006). When Fugate, Landis, Riordan, Naureckas, & Engel, (2005) investigated reasons for nonuse, respondents gave as explanations: (1) they didn’t think such services would help; (2) they turned to family and friends for support; and (3) they didn’t know about the existence of services. It is acknowledged that police officers have a great deal of latitude when it comes to involving victim services, either telling the victim about services or calling directly for assistance (Corcoran & Allen, 2005; Corcoran, Stephenson, Perryman, & Allen 2001). Other studies have found that age and type of crime were important reasons for victim services nonuse (Langton, 2011; Sims et al., 2005). Although younger people are more likely to suffer from crime, older victims tended to seek aid from victim services more often. People who were victims of violent crime were also more likely to seek services than victims of property crime. Violent crimes are generally more traumatizing than are property crimes. Langton (2011), in a study of victim services from 2000 to 2009, found that while males are more likely to be victims of crime, female victims are more likely to avail themselves of services. Studies have been mixed as to whether victims benefit from the use of services. Langton (2011) found that victims who received services were more likely to see an arrest made in the case and have contact with a non–law enforcement criminal justice official, such as a judge or prosecutor, than victims who had aid. In support of victim services programs, a study in the Netherlands found that the majority (60 percent) of victims who developed posttraumatic stress disorder three months post-crime had not

had contact with victim services (Wohlfarth, Winkel, & Van den Brink, 2002). Despite these positive findings, a review of studies concluded that victim services had little impact (Haynes, 2011). Haynes, however, conducted his own examination of victim resources, including victim services centers, crime victim compensation applications filed, and input on the criminal justice process, in the state of Pennsylvania. The availability of victim resources led to higher incarceration sentences. In another study conducted in Pennsylvania, victims who availed themselves of services were compared against those who had not. No statistically significant differences were found between users and nonusers of victim services on psychological functioning scores (Sims, et al., 2006). The authors explain that crisis intervention counseling offered in the programs may not offer much benefit. Short-term counseling may not provide the dosage that people may need for psychological assistance. If that is the case, then services could be offered over a longer period of time. The ineffectiveness of services may also be due to victim services workers being untrained. One recommendation, therefore, is that programs should ensure adequate training and supervision of their staff. Another recommendation, coming out of the finding that revictimization may be an unfortunate consequence of being a crime victim, is that providers put together information on crime prevention and present it to their clients (Finkelhor et al., 2007). Currently, that is not a usual focus of services. Rape crisis centers (now more commonly called sexual assault centers) and domestic violence shelters (what were then known as battered women’s shelters) were formed due to recognition by feminists in the 1970s that both sexual assault and intimate partner violence were perpetrated mainly by men against women, to their great harm. Through the years, these organizations have become more professionalized and traditional with government funding

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sources. Currently, 1,265 sexual assault centers exist nationwide as of 2009 (Maier, 2011). More research has been conducted on domestic violence programs compared to sexual assault centers, although challenges are inherent in this type of research in general (Sullivan, 2011). First, women seek services because of different needs and life circumstances, and a wide variety of possible services are offered. As a result, it is difficult to determine which outcomes are appropriate to study. Another barrier is that clients may wish to remain anonymous because of the sensitive nature of their problems, and questioning victims for evaluation purposes may make them feel unsafe or uncomfortable. Finally, outcomes seen as desirable, such as a reduction, are the result not of the victims’ behaviors but of her partners’. A systematic review on domestic violence programs was conducted (Ramsay et al., 2009). The review included only experimental designs and compared what was referred to as “advocacy interventions” against usual care. The authors found ten trials involving 1,527 participants but noted the variation of programs being studied in terns of program intensity, outcome measures, and the duration of the follow-up. Intensive advocacy, which was defined as a woman receiving at least twelve hours of intervention, was found to be more helpful in ending partner violence at one to two years after she had received services, but not prior to that time. However, neither depression nor psychological distress was affected. Brief advocacy interventions (defined as those less than twelve hours’ duration) increased safety behaviors at all follow-up periods. From an examination of possible outcomes in this area, Stein concluded that safety behaviors, as well as increased knowledge about available community resources, were appropriate ways to measure the effectiveness of programs. Children’s advocacy centers started in 1985 in Huntsville, Alabama, and now there are more than 700 such centers in the United States. (National Children’s Alliance, n.d.). Using a

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multidisciplinary team approach, involving police investigators, prosecutors, and mental health and medical personnel, CACs have as their purpose the coordination of the child abuse investigation (Smith, Witte, & FrickerElhai, 2006). The objectives are to reduce the number of times the alleged victim has to be interviewed, and to enhance: 1. 2. 3. 4.

interagency cooperation. accountability. case tracking. efficient use of community services and resources.

Parents report high satisfaction with children’s advocacy services, (Bonach, Mabry, & Potts-Henry 2010; Jenson, Jacobson, Unrau, & Robinson, 1996), even when compared to more traditional methods of child abuse investigations (Jones, Cross, Walsh, & Simone, 2007). However, parents also stated they still needed more communication about the status of the investigation and prosecution of the case (Jones et al., 2010). assessment and interventions Assessment, which involves an understanding of the impact of the particular crime on the victim and knowledge of the risk and protective factors involved, can be conducted through a clinical interview. The identification of possible trauma symptoms in victims is important to assess and monitor. Taking the implications of the previously explored studies and drawing on other literature that may inform intervention with crime victims, the following guidelines can be offered: 1. People who have been victimized come with a variety of needs, so an individualized approach is necessary. 2. Crisis intervention in which people’s feelings and experiences are explored, reflected, and validated, as well as in which they are provided with information on the law

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enforcement and legal process, appears to be indicated for crime victims, but to have more of an impact, it may be necessary to continue intervention past one session (Finkelhor et al., 2007; Sims et al,. 2005). The availability of social support for victims and their coping mechanisms needs to be assessed by the victim services counselor, as these are malleable. Social workers and other mental health professionals often use crisis debriefing to forestall the development of PTSD when people have undergone trauma. It involves meeting with people individually or, most often, in groups, educating them about the nature of trauma and its reactions, and encouraging their exploration of feelings. Unfortunately, there is no empirical evidence as of yet that crisis debriefing is helpful for either children or adults, and it may cause additional distress (Rose, Bisson, Churchill, & Wessely, 2002). Therefore, if people are to be given information about possible responses they may have, the practitioner should ensure that he or she is not prescribing symptoms for the client. Given the risk of revictimization for victims of crime, crime prevention should be an essential element of intervention. Cognitive behavioral therapy, featuring exposure, has received the most research attention for the treatment of and prevention of acute stress disorder (Roberts, Kitchiner, Kenardy, & Bisson, 2010) and PTSD, as well as other anxiety disorders (Dignan, 2005). Exposure is a process by which the client learns to face the feared object until the anxiety dissipates. Therapist competence in delivering cognitive therapy may be important for recovery (Strunk, Brotman, DeRubeis, & Melissa, 2010), however, and Sims et al. (2005) suggested that victim services counselors may not be adequately trained. Additionally, the briefest time period of CBT delivery is four sessions, which is generally longer than the amount of time victims are generally seen in victim services.

7. A solution-focused approach to crisis intervention with crime victims has been discussed in the literature (Greene & Lee, 1996). The focus is on times when the victim demonstrates successful coping. The resources that are used are elicited, reinforced, and amplified so that the client can employ these strategies to resolve current difficulties.

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Annette Miller, a white female in her early 30s, recently experienced a robbery during the night shift at her job as a convenience store clerk. Annette could only describe her assailant as a middle-aged white man as his face was concealed by a stocking cap. He had pulled a gun out of his jacket pocket, held it to her head, and said he’d kill her if she didn’t immediately hand over the money in her register. She reported that he became even more agitated when a car pulled up in the parking lot, and she thought he’d panic and kill her. As it was, he grabbed the money from her and fled without being caught. Annette has worked at convenience stores for the last three years. She usually worked the night shift since she had found this the best arrangement as a single parent raising three school-age children. This work had allowed her to be available to her children, not only in the morning when she got off work but also in the afternoons when they came home from school and into the evening. An older neighbor would then come over when Annette was to leave for work, and she would spend the night to watch over the children. Annette said this worked well since the neighbor would not charge much and Annette couldn’t have afforded the cost of regular child care if she worked during the day. She said she did not have family to help her as they lived out of state. Annette said although this has been an ideal arrangement, now she blamed herself for working the night shift. “Everyone knows that’s when the robberies happen. And I already had one happen to me. You’d think I’d learn.” She said she had been

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through another robbery before, approximately eighteen months ago, but that had not impacted her as much. She described that the previous incident had involved a teenager, who was obviously nervous himself. Although he had held a gun to her and tried to conceal himself from the store video equipment by pulling his sweatshirt hood around his face, she could at least see his face, and this made it less scary to her. He was also immediately apprehended, and the case against him was strong. However, this time the police had no suspects so she knew her assailant was still out there somewhere. Every time a middleaged white man walked in the door, she would begin to panic to the point of having to leave work. She was having a difficult time sleeping at night. She also kept replaying the incident in her mind, and she worried about how she would support her three children if she didn’t work on a regular basis. Regarding previous life stress, Annette had experienced a divorce nine months ago from her youngest child’s (age 7) father, who left her for another woman. Her ex-husband was not following through with child support payments. To explain all these events, Annette says, “There must be something wrong with me for all these things to keep happening.” Annette was referred to the police victim assistance program after talking to the robbery investigator. She had become tearful and upset, realizing that nothing more was to be done on the case since there were no suspects, and the investigator told her that maybe she could benefit from talking to someone. The assessment procedure in this case consists of a clinical interview, which identified a number of risk factors for Annette. First, the robbery involved a gun and threats were made on her life, so this represents a more severe type of crime. In addition, she had actually feared for her life, and life threat has been associated with increased distress for robbery victims (Kamphius & Emmelkamp, 1998). Further, Annette’s pre-crime functioning was less than optimal due to her financial problems, the stress of single parenting, a divorce in the last year, and another robbery eighteen months ago. Annette has suffered from an accumulation of prior

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negative life events, which contributed to her present level of high distress. Neither does Annette seem to have many protective factors to buffer against the effects of victimization. She also makes statements such as, “Everyone knows the night shift is when the robberies happen. You’d think I’d learn” and “There must be something wrong with me for all these things to keep happening,” indicating that Annette seems to be making self-blaming attributions for the occurrence of the robbery event. Another possible protective factor, social support, is low in Annette’s case. She had moved to this state for her ex-husband’s job, and she has no family in the area. She further says that she is so busy working and taking care of her children that she doesn’t have time for socializing. She says she doesn’t associate with her neighbors because they don’t work and are always “partying,” and she doesn’t want that kind of influence on her children. Like many victims, Annette has experienced many life events that have depreciated her sense of wellbeing (Denkers & Winkel, 1998). Therefore, crisis intervention efforts that concentrate only on bringing a victim’s functioning to pre-distress levels may not be adequate (Roberts & Burman, 1998). Efforts instead should focus on establishing more problemfocused coping strategies. For instance, cognitive behavioral techniques can redress the faulty attributions and beliefs in regard to Annette’s self-blame and can help Annette build her self-esteem and manage her anxiety. Annette can also be trained on problem-solving skills so that she can identify her options in terms of employment and child care arrangements (Roberts & Burman, 1998). Helping efforts should also focus on assisting Annette in building her supportive network. Examples of such a supportive network may include a singleparenting support group or a more informal circle of other parents in similar life circumstances who can assist Annette with child care responsibilities and emotional support.

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A further intervention strategy with Annette might be to identify more individualized protective factors that she has employed for coping. One method by which her unique strengths and resources can be assessed is through a solution-focused approach (e.g., de Shazer, 1988, 1994). For example, Annette is raising three children as a single parent. What are the strengths she uses to be able to do this? How is she able to negotiate her work schedule and child care arrangements, and balance the needs of her children? How was she able to cope with her husband leaving her and the previous robbery she experienced? These strengths and capacities Annette has employed in the past can be accessed and developed to help her cope with more immediate challenges. Social work practice methods are uniquely appropriate for work with crime victims because the major focus is on the interaction between victims and the criminal justice system and between other service delivery systems, e.g., health and mental health. The intervention services performed by victim advocates

referenceS

American Psychiatric Association (APA). (2000). Diagnostic and statistical manual of mental disorders (DSM-IV-TR). Washington, DC: American Psychiatric Association. Bechtel, K. A., Alarid, L. F., Holsinger, A., & Holsinger, K. (2012). Predictors of domestic violence prosecution in a state court. Women and Offenders, 7(2), 143–60. Bonach, K., Mabry, J., & Potts-Henry, C. (2010). Exploring nonoffending caregiver satisfaction with a children’s advocacy center. Journal of Child Sexual Abuse, 19, 687–708. Brewin, C. R., Andrews, B., & Valentine, J. D. (2000). Meta-analysis of risk factors for posttraumatic stress disorder in trauma-exposed adults. Journal of Consulting and Clinical Psychology, 68(5), 748–66. Cattaneo, L., & Goodman, L.  A. (2005). Risk factors for reabuse in intimate partner violence: A crossdisciplinary critical review. Trauma, Violence and Abuse: A Review Journal, 6, 141–75. Corcoran, J., & Allen, S. (2005). The effects of a police/ victim assistance crisis team approach to domestic violence. Journal of Family Violence, 20, 39–45. Corcoran, J., Stephenson, M., Perryman, D., & Allen, S. (2001). Perceptions and utilization of a police social work crisis intervention approach to domestic violence. Families in Society, 82, 393–98.

reflect the characteristics of generalist social work practice. Social work is concerned with the interactions between people and their social environment that affect the ability of people to accomplish their life tasks, alleviate distress, improve social functioning, and realize their values.

conclusion The focus of victim services—whether it is with domestic violence programs, sexual assault centers, children’s advocacy centers, law enforcement–based victim services, or prosecutorbased victim/witness—is compatible with the kinds of roles for which social workers are well prepared. Crisis counseling is emphasized, but other direct practice roles, such as case manager, advocate, and program planner, are also critical. The evidence basis for victim services programs has grown since the last version of this chapter, despite the challenges involved in conducting evaluation when people are in crisis.

Denkers, A., & Winkel, F.  W. (1998). Crime victims’ well-being and fear in a prospective and longitudinal study. International Review of Victimology, 5, 141–62. de Shazer, S. (1988). Clues: Investigating solutions in brief therapy. New York: Norton. ——. (1994). Words were originally magic. New York: Norton. Dignan, J. (2005). Understanding victims and restorative justice. ebrary, Inc: Maidenhead, England: Open University Press, http://site.ebrary.com.proxy. library.vcu.edu/lib/vacommonwealth/docDetail. action?docID=10161267 Dutton, M., & Greene, R. (2010). Resilience and crime victimization. Journal of Traumatic Stress, 23, 215–22. Finkelhor, D., Ormrod, R. K., & Turner, H. A. (2007). Re-victimization patterns in a national longitudinal sample of children and youth. Child Abuse & Neglect, 31(5), 479–502. doi:10.1016/j.chiabu.2006.03.012. Ford, J.  D., Stockton, P., Kaltman, S., & Green, B.  L. (2006). Disorders of extreme stress (DESNOS) symptoms are associated with type and severity of interpersonal trauma exposure in a sample of healthy young women. Journal of Interpersonal Violence, 21(11), 1399–416. Fugate, M., Landis, L., Riordan, K., Naureckas, S., & Engel, B. (2005). Barriers to domestic violence help seeking. Violence Against Women, 11(3), 290–310.

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Greene, G.  J., & Lee, M. (1996). Client strengths and crisis intervention: A solution-focused approach. Crisis Intervention and Time-Limited Treatment, 3(1), 43–63. Haynes, S. H. (2011). The impact of victim-related contextual factors on the criminal justice system. Crime and Delinquency, 57(2), 298–328. Jenson, J., Jacobson, M., Unrau, Y., & Robinson, L. (1996). Intervention for victims of child sexual abuse: An evaluation of the children’s advocacy model. Child and Adolescent Social Work Journal, 13, 139–56. Jones, L., Atoroa, K., Walsh, W., Cross, T., Shadoin, A., & Magnuson, S. (2010). Nonoffending caregiver and youth experiences with child sexual abuse investigations. Journal of Interpersonal Violence, 25, 291–314. Jones, L., Cross, T., Walsh, W., & Simone, M. (2007). Do children’s advocacy centers improve families’ experiences of child sexual abuse investigations? Child Abuse and Neglect, 31, 1069–85. Kamphuis, J. H., & Emmelkamp, P. M. (1998). Crimerelated trauma: Psychological distress in victims of bank robbery. Journal of Anxiety Disorders, 12(3), 199–208. Kunst, M., Winkel, F.  W., & Bogaerts, S. (2010). Prevalence and predictors of posttraumatic stress disorder among victims of violence applying for state compensation. Journal of Interpersonal Violence, 25(9), 1631–54. Langton, L. (2011). Use of victim service agencies by victims of serious violent crime, 1993–2009. Bureau of Justice Statistics. http://bjs.ojp.usdoj.gov/index. cfm?ty=pbdetail&iid=2432. Lauritsen, J. L. (2006). Assessing problematic research: How can academic researchers help improve the quality of anti-crime program evaluations? Journal of Experimental Criminology, 2(3), 363–73. doi:10.1007/ s11292–006–9015–8. Lerner, M. J. (1971). Observer’s evaluation of a victim: Justice, guilt, and veridical perception. Journal of Personality and Social Psychology, 20(2), 127–35. Littleton, H. L., Magee, K. T., & Axsom, D. (2007). A meta-analysis of self-attributions following three types of trauma: Sexual victimization, illness, and injury. Journal of Applied Psychology, 37(3), 515–38. doi:10.1111/j.1559–1816.2007.00172.x. Maier, S.  L. (2011). Rape crisis centers and programs: “Doing amazing, wonderful things on peanuts.” Women & Criminal Justice, 21(2), 141–69. doi:10.1080 /08974454.2011.558802 McDonald, W. F. (Ed.). (1976). Criminal justice and the victim. Beverly Hills, CA: Sage. Miller, A. K., Handley, I. M., Markman, K. D., & Miller, J.  H. (2010). Deconstructing self-blame following sexual assault: The critical roles of cognitive content and process. Violence Against Women, 16(10), 1120–37. National Children’s Alliance. (n.d.). Ending child abuse and neglect after disclosure. Accessed August 28, 2012. http://www.nationalchildrensalliance.org/index .php?s=24

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National Institute of Justice. (1996). The extent and costs of crime victimization: A new look. Washington, DC: U.S. Department of Justice, Office of Justice Programs, National Institute of Justice. Newmark, L., Liner, B., Bonderman, J., & Smith, B. (2001). The national evaluation of state victims of crime act compensation and assistance programs: Findings and recommendations from a national survey of state administrators. Research report. Washington, DC: Urban Institute. http://www.urban.org /pdfs/410142.pdf Ozer, E.  J., Best, S.  R., Lipsey, T.  L., & Weiss, D.  S. (2003). Predictors of posttraumatic stress disorder and symptoms in adults: A meta-analysis. Psychological Bulletin, 129(1), 52–73. Ramsay, J, Carter, Y, Davidson, L, Dunne, D., Eldridge, S., Feder, G., Hegarty, K., Rivas, C., Taft, A. & Warburton, A. (2009). Advocacy interventions to reduce or eliminate violence and promote the physical and psychosocial well-being of women who experience intimate partner abuse. The Cochrane database of systematic reviews, 2009(3), CD005043. Rand, M., & Truman, J. (2009). Criminal Victimization. Bureau of Justice. http://www.bjs.gov/index .cfm?ty=pbdetail&iid=2217 Riggs, D., Rothbaum, B.  O., & Foa, E. (1995). A prospective examination of symptoms of posttraumatic stress disorder in victims of nonsexual assault. Journal of Interpersonal Violence, 10(2), 201–14. Roberts, A. R. (1990). Helping crime victims: Research, policy and practice. Thousand Oaks, CA: Sage. ——. (1995). Victim services and victim/witness assistance programs. In R.  L. Edwards and J. Hopps (Eds.), Encyclopedia of social work (pp. 2440–44). Washington, DC: National Association of Social Workers Press. ——. (1997). The role of the social worker in victim/ witness assistance programs. In A. R. Roberts (Ed.), Social work in juvenile and criminal justice settings (pp. 150–59). Springfield, IL: Thomas. Roberts, A. R., & Burman, S. (1998). Crisis intervention and cognitive problem-solving therapy with battered women: A national survey and practice model. In A. R. Roberts (Ed.), Battered women and their families (pp. 3–28). New York: Springer. Roberts, N., Kitchiner, N., Kenardy, J., & Bisson, J. (2010). Early Psychological Interventions to Treat Acute Traumatic Stress Symptoms. Cochrane Collaboration Systematic Review. 10.1002/14651858. CD007944.pub2. Rose S., Bisson J., Churchill R., & Wessely S. (2002). Psychological debriefing for preventing post traumatic stress disorder (PTSD). The Cochrane database of systematic reviews, 2002(2), CD000560. Sims, B., Yost, B., & Abbott, C. (2005). Use and nonuse of victim services programs: Implications from a statewide survey of crime victims. Criminology and Public Policy, 4(2), 361–84.

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——. (2006). The efficacy of victim services programs: Alleviating the psychological suffering of crime victims? Criminal Justice Policy Review 17(4), 387–406. doi:10.1177/0887403406290656. Smith, D., Witte, T., & Fricker-Elhai, A. (2006). Service outcomes in physical and sexual abuse cases: A comparison of child advocacy center-based and standard services. Child Maltreatment, 11(4), 354-360. Sonis, J. & Langer, M. (2008). Risk and protective factors for recurrent intimate partner violence in a cohort of low-income inner-city women. Journal of Family Violence, 23(7), 529–38. Strunk, D., Brotman, M., & DeRubeis, R. (2010). The process of change in cognitive therapy for depression: Predictors of early inter-session symptom gains. Behaviour Research and Therapy, 48, 599–606. Sullivan, C. M. (2011). Evaluating domestic violence support service programs: Waste of time, necessary evil, or opportunity for growth? Aggression and Violent Behavior, 16(4), 354–60. doi:10.1016/j.avb.2011.04.008.

Truman, J.  L. (2011). National Crime Victimization Survey: Criminal Victimization, 2010. Bureau of Justice Statistics Bulletin. http://bjs.ojp.usdoj.gov/index. cfm?ty=pbdetail&iid=2224. Walster, E. (1966), Assignment of responsibility for an accident, Journal of Personality and Social Psychology, 3(1),73–79. Wilson, D., & Segrave, M. (2011). Police-based victim services: Australian and international models. Policing: An International Journal of Police Strategies & Management. 34(3), 479–96. doi:10.1108/13639511111157528. Wohlfarth, T., Winkel, F., & Van den Brink, W. (2002). Identifying crime victims who are at high risk for posttraumatic stress disorder: Developing a practical referral instrument. Acta Psychiatrica Scandinavica, 105(6), 451–60. doi:10.1034/j.1600–0447.2002.01099.x. Zoellner, L. A., Feeney, N. C., Eftekhari, A., & Foa, E. B. (2011). Changes in negative beliefs following three brief programs for facilitating recovery after assault. Depression and Anxiety. 28(7), 532–40.

cHaPter 1 5 death in the family nancy boyd Webb and linda oPenSHaW

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he Book of Ecclesiastes proclaims, that “to everything there is a season . . . a time to be born, and a time to die” (Eccles. 3:1). However, family members may not experience the death of one of their members with this attitude of quiet acceptance, but instead complain that the death occurred “too soon” (out of season). Clearly, the death of a person in young adulthood or midlife is untimely, as is the death of a child. A parent’s death often generates complicated feelings of pain and anger among family survivors because of the critical role of parents as indispensable nurturers and caretakers. Death arouses the attachment relationships that exist between family members and stirs up distressing feelings of anxiety, dependency, and vulnerability. According to Walsh (2006, p. 181), “Coming to terms with death and loss is the most difficult challenge a family must confront.” This chapter deals with the range of deaths that may occur in any family, from the “timely” deaths of elderly grandparents, to unexpected deaths that occur in midlife as a result of terminal illness or from accidental causes. When a child or adolescent dies, parents may be devastated and depressed, and siblings often develop an increased sense of anxiety and fear. Personal vulnerabilities and challenges related to the impact of any death depend on many different factors, and the unique circumstances of each case require that we take both a wide and a narrow view of each situation in order to assess whether help is needed and, if so, what kind. Webb’s Tripartite Assessment is a useful tool to weigh the varying meanings of a

death depending on its unique circumstances for each person and other contributing factors. The chapter cites and applies the growing literature on family bereavement, includes illustrative cases, and includes some suggestions for practitioners who are working with bereaved family survivors. Because a death can occur at any time or place to anyone, all practitioners, regardless of their practice specialty, must be prepared to deal with clients who are coping with bereavement issues. defining and explaining death in the family Although death is inevitable, people are often unprepared for it. A parent’s death has an impact, not only on the family, but also on the wider community, including service providers. For example, the death of a 45-year-old mother from ovarian cancer will be treated differently from that of a 45-year-old father who was shot while dealing drugs. The children in each case suffer the loss of a parent, but the shameful circumstances of the father’s death create complicated emotions that inevitably make the grief process more difficult for his family. In addition, services to each family will differ because of the unique circumstances of each death, one of which may involve law enforcement investigation. Other factors about a death in the family, whether that of a parent or a child, relate to whether the death was anticipated (as with terminal illnesses) or sudden and/or accidental, sometimes raising concerns about whether it might have been prevented. For example, when 301

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a mother diagnosed with metastasized uterine cancer has hospice services in the home, the children, relatives, and friends gradually come to realize that the woman is getting weaker, and that she requires increasingly more pain medication. Even young children may begin to wonder if their mother will ever get better. Relatives may struggle with the issue of adequate pain medication and sometimes with the dying person’s requests for assisted suicide. These matters reach far beyond the family and are under discussion by medical ethicists and religious and legal scholars. They ultimately have great political, religious, and community impact. Children’s ability to comprehend the reality of death depends on their age. Families may tell young children that the dead person has gone to Heaven, and is now with God. This can be very confusing, since the child who is very literal may wonder how long the person is going to stay in Heaven, and whether or when he or she will return to the family. Therefore, regardless of religious beliefs, children should be told that when people die they cannot talk, feel, breathe, or move, and that their body is “dead.” Children also need to be informed that they will be dead forever. The correct language must be used (i.e., “dead,” rather than other terms, such as “passed away”) in order to reduce possible misinterpretation on the child’s part. When a parent of a child or adolescent dies, a primary question for the surviving family and the community member is always, “Who will take care of the youngsters?” The parent’s previous role as a caretaker now has to be assumed by others. This can be quite complicated in many small ways that make life difficult and stressful for the child and for the survivors. For example, when a mother dies, and the father must leave for work by 6:30 AM and the child’s school bus does not come until 7:30, who will take care of the child during this one-hour period five days a week? Similarly, who will be responsible for the child after school until the father returns from work, sometimes as late as 7 PM. Although many day care programs

typically provide for very early drop-off, and some even serve breakfast, few public schools provide this option for school-age children whose single parents (whether widowed or not) have to struggle to arrange before- and afterschool child care. Need for the child’s care during school vacation periods and holidays when the parent has to work also highlight the failure of community services to deal adequately with significant numbers of children in oneparent families. Sometimes family members and friends of the deceased parent can provide assistance, but where these options are not available, the community should provide alternative resources. When a young child dies, the family is usually devastated. They will need much support to get through each day, and this support may come from the extended family, the religious community, parents’ work colleagues, or neighbors. Parents’ ability to continue functioning may be compromised, and if this continues over an extended period it may be appropriate to obtain mental health services. demographic Patterns According to Howarth (2011, p. 21) citing statistics from the Social Security Administration (2000), about 3.5 percent of children lose a parent to death before they reach the age of 18. This means that teachers and schools must be prepared to face the certainty that some of their pupils will become bereaved during the course of the school year. Schools must help teachers face this inevitable occurrence by offering training and guidelines to help them respond appropriately when a child’s parent dies. The U.S. Census Bureau statistics provide information about the comparative rates of male/female deaths of blacks and whites. The count for 2007 (U.S. Census, n.d.) was calculated per 1,000 people. The death rate for all ages was 8.5 for white males, 8.5 for white females, 7.8 for black males, and 6.8 for black females per 1,000. The overall death rate for males was 8.1 and for females 8.0 (U.S. Census, 2007a).

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This resonates with prevalent knowledge that males die at a higher rate than females. Statistics about parental deaths were not available, since the Census Bureau collates data by age, geography, race, and cause of death, but not with reference to the family status of the deceased. Of all 2,423,712 deaths reported in 2007 (U.S. Census, 2007b) the total deaths for children ages 1–4 years old is 4,703; ages 5–14 years is 6,147; and 15–24 years is 33,982. Societal context The responses of members of an individual’s surrounding environment can either facilitate or hinder his or her mourning process. When the family cannot openly discuss as in a suicide, some homicides, and in AIDS-related deaths, the family must cope with the strain of secrecy at the very time that their feelings of grief are surging within them. By contrast, when a parent dies a heroic death such as in fighting a house fire (see the case of the Turner family presented later), the outpouring of support from the community can be tremendously validating and comforting to the survivors. Of course, the pain of the loss of one’s parent is just as vivid whether he or she dies in a drug-related murder or as a hero in battle. However, the drastically different response of the surrounding community in each situation will have a very significant effect on the family members’ ability to express their grief openly, receive support, and come to some form of eventual acceptance of the death. Different religious practices also influence the mourning process. The Jewish religion, for example, prefers immediate burial, without viewing of the body, in contrast to the Catholic practice of a wake of several days, with an open casket, followed by a funeral. The process of remembering and honoring the person who died is accomplished in Jewish families through sitting shiva, a mourning ritual of several days following the burial, which can be considered analogous to the Catholic wake. Members of the Islamic faith meet together to pay respects and offer their collective prayers for forgiveness

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of the dead (the Janazah prayer). After the body is buried in the ground, the Muslims who are present pay their final respects and then offer a final collective prayer asking for forgiveness of the dead (Understanding Islam, 2000). The participation of children in rituals of this sort often is abbreviated because of children’s inability to tolerate long periods of sadness and of talking associated with the reminiscing process. Practitioners must help families understand that children’s short sadness span is no reflection of their lack of respect or love for the dead person. Vulnerabilities and risk factors The loss of a family member to death initiates a major confrontation and awareness about the fragility of life and an escalation of anxiety about additional future losses. The reasoning of both child and adult concludes that if the all-powerful parent or strong child cannot vanquish the unseen ghost of death, then everyone now must be vulnerable! Children do not have a mature understanding about death until about the age of 9 (Nagy, 1948; Howarth, 2011). They often become clingy after close exposure to death, seeming to fear that other family members will now also disappear. The surviving spouse who may be overwhelmed by his or her own grief and about the prospect of carrying on alone may be less aware and responsive to his or her children, and the children, in turn, who sense their parent’s withdrawal, feel as if they have “lost” both parents. Another unfortunate reality is that people may mistakenly minimize the grief of sibling survivors, tending to focus instead on the grief of the parents (Davies, 1999; Devita-Raeburn, 2004). These attitudes serve to “disenfranchise” the siblings (Doka, 1989; Horsley & Patterson, 2006). The underlying meaning of the death of a parent, child, or sibling is that one’s life has been drastically affected. This is intensely stressful and the individual’s ability to function may be negatively affected for a short or long period of time. This decreased functioning should be understood in

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the context of a major life transition, which will require time and patience to resolve. Every person in a family plays a unique role, and when that person dies, the loss causes not only emotional pain but also the necessity of compensating for the lost functions the deceased carried out. When the dead person is a parent, someone must fulfill that individual’s tasks in the family, i.e., that of breadwinner, person who pays the bills, person who handles the details of child care, and so forth. Even children have unique roles, such as that of “jokester” or caretaker of the family dog. Sometimes the deceased person represents a symbol or a hope for the future, such as the individual who will carry on the family name. The challenge of filling the void caused by a death will be proportional to the nature and scope of the deceased family member’s real and symbolic role. Walsh (2006) points out that the surviving members may experience very negative effects when families are unable to reallocate role functions. If a death occurs in violent circumstances, the responses of surviving family members may be complicated by the fact that they become preoccupied with the details of the death itself and this can be traumatizing. Adverse grief outcomes can also occur when the death represents another in a series of losses. This situation has been referred to as “bereavement overload” (Neimeyer & Holland, 2006). It is understandable that families that face multiple deaths may have more difficulty with their grief process or complicated grief than do those who are experiencing a single loss (Rando, 1983; Neimeyer & Holland, 2006; Webb, 2010). Symptoms of complicated grief include “intense yearning for the deceased, shock and disbelief, anger and bitterness, and intrusive or preoccupying thoughts for more than six months following the death” (Meert et al., 2011, p. 208). The risk factors for family members are significant for the biological mother, or female guardian. Bereaved parents suffering from complicated grief have a greater than normal risk for psychiatric hospitalization, and increased

mortality from three to eighteen years following the death of a child (Li, Precht, Mortensen, Olsen, & Lancet 2003). resiliencies and Protective factors Various factors contribute to resilience, and readers who want to understand this topic in depth may wish to consult Walsh’s Strengthening Family Resilience, now in its second edition (2006). Much of the following content has been adapted from Walsh’s book, beginning with her definition of resilience as “the capacity to rebound from adversity strengthened and more resourceful” (Walsh, 2006, p. 4). Family resilience involves coping and adapting as a functional unit. From a systems perspective, resilience includes how a family confronts negative experiences, buffers stress, reorganizes, and moves forward with life. Another definition of family coping refers to its “ability to manage a stressful event or situation with no detrimental effect on any individual in that family” (Boss, 2002, p. 79). The concept of managing, rather than eradicating, the stressful event or situation involves cognitive, affective, and behavioral processes. Factors that facilitate positive responses in the family include: • A positive outlook • Spiritual beliefs and practices • Friendships and community networks • Open communication Obviously, some types of death are more challenging for families and these include deaths by suicide, deaths in violent circumstances (Murphy, Johnson, Chung, & Beaton, 2003), and untimely losses. The Turner family case (below) describes the death of a father/ husband in a house fire. Programs and Social Work contributions The social work profession has played a pivotal role in establishing and staffing bereavement programs to assist bereaved individuals

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following the death of a family member. The range of these programs includes hospitalbased individual, family, and group counseling; home- and agency-based hospice programs to assist family members of terminally ill patients; and time-limited mental health agency (Ormond & Charbonneau, 1995) and school-based grief support programs to help children who have lost a parent to death (Tait & Depta, 1993). When a family member is hospitalized because of a life-threatening illness or accident, a medical social worker is usually involved in dealing with the patient’s immediate needs while also planning for discharge. Often, the discharge will be a referral to an extended care program or nursing home. The family members need support when facing a possible death of a member of their family, in dealing with guilt they may feel over placing a family member in a nursing home, or in dealing with advance directive decisions. Because death often occurs in hospital settings, medical social workers have a central role either in providing such services or in referring families to community-based programs suitable for their specific needs. For example, the American Cancer Society has a wide range of groups for patients and relatives affected by cancers of a specific type. Many of these groups are co-led by a social worker and a nurse. Families are usually so overwhelmed at the time of a death that they may not pay attention to recommendations from the hospital. Thus, medical social workers should prepare a handout that lists resources for surviving family members, such as parent support groups, support groups for children or adolescents, and other services in the community that assist grieving family members in the months after their loss. Twenty-nine percent of U.S. households have children with special medical needs (Looman & Lindeke, 2008), and many of these children are suffering from a terminal illness. Medical social workers are in a position to be advocates. There are barriers that keep these children and

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families from receiving adequate health care, and they need advocacy, such as increasing the responsiveness of institutions and breaking down the barriers that keep clients from being served (Boylan & Dalyrmple, 2011). For clients who are dying, palliative care should be incorporated into the mainstream of medical care. Likewise, social workers should set up respite care and support to assist families and caregivers from the stress of full-time care of a dying patient (Kane & Himelstein, 2002). The hospice movement, in which many social workers offer services, has grown from a single program in the United States in 1973 to more than two thousand programs at the end of the century (Kastenbaum, 2008). A variety of services specially targeted to family members are currently available. A number of services and programs have been developed especially for children utilizing art, storytelling, and play. This is due to the growing awareness in the professional community about effective interventions with bereaved children. Because hospice social workers usually work with dying patients in the family home or long-term care facility during the last days of the patients’ lives, the hospice social worker is able to assess the needs and condition of surviving family members. When a hospice social worker provides palliative care, the social worker should seek input from all family members and caregivers about the decisions that are being made for the patient. If it is a parent who is dying, the hospice social worker should spend some time during each visit talking to the children about the upcoming death and helping prepare them to face it. When the death is slow, the adjustment for the child afterward is more difficult. Or, the longer the child anticipates the impending death, the more difficult it is on the child emotionally (Hope & Hodge, 2006). If it is a child who is dying, the parents will need information on possible resources to help them after the death of the child. There is usually a chaplain who works with hospice teams,

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and the social worker together with the chaplain can help the family find spiritual as well as temporal support. Hospice social workers should ensure that follow-up visits with the grieving family are allowed following the death of the client. Through the use of advocacy a hospice social worker should strive to provide bereavement care as long as needed (Kane & Himelstein, 2002). According to the U.S. Census Bureau, accidents, homicides, and suicides are the leading cause of death among young people (1999). If the family has lost a child through suicide, homicide, or an accident, they will be dealing with many agencies, from police officers investigating the situation to insurance companies. These families are at risk of secondary victimization from the treatment they receive from these agencies (Murphy, Johnson, Chung, & Beaton, 2003). Social workers practicing in these agency settings need to ensure that the families are treated with respect. Family members may have contact with a social worker who is employed by the police department. Police department social workers often accompany the officer when he or she notifies a family about the death of a family member through a suicide, homicide, or accident. The social worker from the police department should create a resource directory that can be given to family members to let them know what resources and services are available in the community to assist them. Families who have lost a child may receive assistance from social workers at a child advocacy center or shelter. Social workers in homeless shelters may also be assisting families who have lost a child or parent. There are numerous settings serving families who need support through the grief process and possible follow-up on trauma. Even though grief becomes less acute through time, professional counseling can help resolve it more quickly. Social workers in any practice setting need to be aware of the grief process so they can assist clients who are grieving.

Child welfare social workers may be involved in finding alternative home environments for children whose parents are dead. Child welfare agencies in the United States follow the family preservation model, which focuses primarily on placing children with their natural or extended family members who will raise the children. In cases where the grandparents become the caretakers, there is a need for ongoing support to help the grandparents become aware of resources in their community and help link them to those resources. One of the biggest struggles grandparents face in raising grandchildren is a lack of finances. Social workers need to be sensitive to the needs of those who encounter the burden of raising another family later in life and anticipate the needs of the clients by offering them assistance and resources. School social workers may be called on to help children face a pending death or offer support after the death of a parent or sibling. The school social worker should make school staff aware that the social worker can provide assistance to help children and adolescents manage the grief process. The social worker should create a handout for teachers that will provide resources about how to help a grieving child in the classroom. One way a child can tell a teacher when he or she needs assistance is to develop a special signal for use when he or she needs assistance. Giving the child a signal, such as laying a pencil on the desk pointing the tip toward the child, can be used to alert the teacher when the child is feeling sad and needs help. Using a signal when the child is feeling overwhelmed or vulnerable may create a sense of control for the child and offer a sense of safety and security in the classroom. A signal could also help teachers be aware that the child is experiencing painful thoughts and that the child needs attention to help refocus when memories and sad thoughts are preventing him or her from doing schoolwork. When children express the need for help, the teacher should refer the child to the school

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social worker. The school worker can teach the child about thought pages, where the child writes down all his or her feelings, which can then be discussed with someone at a later time. This is illustrated in the Jimmy case below. Some examples of thought pages are included here. When the picture or thoughts have been discussed, the page belongs to the child, and he or she can keep it or tear it up after saying goodbye to the deceased. • “Write down all of the thoughts and feelings you have right now about the death of _______. We will talk about it together when you have finished. When we have discussed what is on this page, it is yours to keep or tear up as you say good-bye to _______.” (Openshaw, 2008, p. 244) • “Draw a picture of your feelings related to the death of _____.” (Openshaw, p. 245) • “Draw a picture of what you think happened to _____ at the time of his/her death. What do you want to know about the death?” (Openshaw, p. 246) • “Write a letter to _______. Tell him/her what you wish you had been able to say before he/she died. Say the things that you wish he/she knew, and how it feels to be without him/her. Say good-bye.” (Openshaw, p. 247) School social workers are the link between the child, the school, the home, and other professional counselors. The school social worker should contact the home and seek additional support from the surviving parent or parents in the case of the loss of a student’s sibling. Grief often prevents children from being able to focus on their schoolwork. Adding school failure would only make the situation worse, so preventive support from the school through a school social worker who works with the home, the child, and school staff will ease the burden the child feels (Openshaw, 2008). In their effort to respond appropriately to situations involving student suicides or traumatic

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deaths, many schools and colleges have created crisis teams consisting of counseling, social work, administrative, and guidance staff who have received training about how to respond following these events. Friends of the deceased are often targeted to receive special outreach, because clinical research documents the special vulnerabilities of peers whose immaturity and lack of ability to express their grief may lead them to imitate the self-destructive behavior in what have been called “copycat suicides.” Most school-based crisis teams assign special guidance counselors and/or social workers to help students who may need to discuss their complicated reactions following traumatic deaths, such as shootings, car accidents, and suicides. Guidelines for schools to help with prevention of suicides and to deal with reactions of faculty and students following such a death have been developed (Webb, 1986). Many schools now have trained crisis teams prepared to deal with the emergency of traumatic deaths. However, it seems ironic to us that most schools do not have similar staff training programs and response protocols for the far more common type of bereavement, that of the death of a parent. Many resources about death are available in the form of storybooks for young children, information and support books for teenagers, and textbooks and curriculum guides for teachers (Cassini & Rogers, 1996; O’Toole, 1998; Stevenson, 1996). The availability of these resources, however, does not mean that they are being used. Because of the discomfort of many adults in discussing the topic of death, classroom teachers may shy away from it. This is analogous to the discomfort of schools and communities in dealing with issues related to sex education. Teachers need help and guidance about how to help students following a death, and it is preferable that they receive some in-service training prior to the need to implement this. Nearly two million children have a parent in the military (National Military Family Association, 2011). The branches of the U.S. military

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all have procedures to assist families when a deployed military person is killed in the line of duty. The military also has a support network for family members of military personnel who are not currently deployed but are still considered active duty. Seventy percent of military families live in civilian communities and not on military installations (National Military Family Association, 2011). There are six categories of casualty for military personnel who are killed, get injured, become sick, or become hospitalized. These include deceased, duty-status-whereabouts unknown, missing, very seriously ill or injured, incapacitating illness or injury, or not seriously injured (National Military Family Association, 2006). Military social workers should work with the National Military Family Association to notify school social workers who could assist the children whose parent has been killed. Social workers practice in many settings where there are clients who are dealing with the death of a child or parent. The practicing social worker should be aware that the common tasks grieving families have are (1) a shared acknowledgment of the reality of death and shared experience of loss, and (2) reorganization of the family system and reinvestment in other relationships and life pursuits (Walsh & McGoldrick, 1991, pp. 7–11). Social workers should have a list of resources to provide to family members who are experiencing grief. In any setting, it is imperative that the social worker provide comfort, support, and resources to grieving families. assessment and interventions A useful framework for analysis and understanding of the dynamics of a bereaved family is that of the Tripartite Assessment (Webb, 1991, 1993, 1996, 1999, 2004, 2007, 2010, 2011). This conceptualization (see figure 15.1) was originally developed for application to children in crisis and bereavement, and is adapted here to inform our understanding of the experience

of the family as a group to a death within their immediate circle. It takes into account the following three groups of interacting factors: • Characteristics pertaining to the family itself • Factors specific to the death • Factors in the family’s support system Some of these represent vulnerabilities and risk factors, while others can be considered protective factors that may increase the resiliency of the family as a whole. All of these interact and must be evaluated in order to appreciate fully the bereavement experience of a given family. For example, in situations involving the death of a parent, child, or sibling, factors such as the family’s past history of death and loss may seriously complicate the grieving process. In other cases, the nature of the death itself may have repercussions that affect the responses of the different family members. This would be true, for example, following a suicidal death or in a situation of violent or traumatic death. Regardless of the specific factors related to either the family characteristics and history or to the death itself, the support from the extended family, friends, and community serves as a balancing/protective influence that can ease the pain of bereavement and thereby contribute to a family’s resiliency following a death. When this support is absent, the risk factors may prevail. Figure 15.1 illustrates the components and interaction among the three sets of variables. The assessment of a bereaved family begins with an overview of the history and current status of the family as a unit. Many of the elements in the assessment focus on the status of the family’s life prior to the death, such as its past coping and overall adjustment. The subcategories in the tripartite chart can be considered in assisting the bereavement counselor in organizing and summarizing the relevant personal information about the

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Family factors Number of children Age/Status of deceased Past history of deaths among family members Current health of family members Past coping/adjustment Attribution of meaning re the death Religious/spiritual practices Grief reactions Current or delayed

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Death-related factors Type of death Anticipated/or/Sudden “Timeliness” of death/preventability Degree of pain Presence of violence/trauma Element of stigma Contact with deceased Present at death Viewed dead body Attended ceremonies Visited grave/mausoleum Expression of “good-bye”

Family/social/religious/culture factors Reactions/responses to the death among others The extended family: Grief reactions The school/workplace Peers/colleagues/friends Religious affiliation Typical rituals after death Cultural affiliation Typical beliefs about death Extent of child inclusion

fiGure 15.1

Tripartite Assessment of the Bereaved Family

Adapted from Nancy Boyd Webb’s Helping Bereaved Children. Copyright 2010 by The Guilford Press. Reprinted with permission.

family. The eight subcategories in this assessment consist of the following: • Age and status of the deceased (parent/ child/grandparent) • Number of children in the family and their ages • The family’s past history of deaths among its members • The current health status of various members • The past coping and adjustment of the family

• How the family attributes meaning re the death • The family’s religious/spiritual practices and beliefs • The nature of the family’s grief reactions As already mentioned, the death of a parent usually has a very serious impact on the children and the surviving spouse. Most important is the loss of the person, which will be deeply felt by all family members. Young children may consider death as abandonment because they do not fully understand its finality and

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irreversibility. They also may incorrectly believe that something they did or did not do caused the death. They will need patient reassurances from loved ones that the death was not their fault. When a family member (parent or child) dies from a terminal illness, there is more time to prepare children than when the death occurs suddenly. There also tends to be greater acceptance of death when it occurs to older/elderly people such as grandparents, compared to a young child. Everyone in the family is aware when a grandparent becomes frail, and/or has to be hospitalized, and if death follows later, it may be considered inevitable and timely. This differs sharply from the responses of a parent to the death of a child, which is generally considered “untimely.” The response of a parent to a child’s death can vary due to factors including the presence of other children in the family (Dyregrov, Nordanger, & Dyregrov, 2003), the cause of the death, and the age of the deceased child (Winjngaards-de-Meij et al., 2005). As might be expected, parents who lose a child under violent circumstances have poorer bereavement adaptation than do those whose child dies from a chronic or terminal illness in which there can be an anticipatory bereavement process. Parents who lose their only child also have a difficult bereavement. Deaths of older or younger children may have a severe impact on parents (Rubin, 2001). There will be more discussion of how the family attaches meaning to any death in a later section. The social worker should take a history that includes the circumstance and timing of past deaths in the family. The experience of multiple past deaths can have a cumulative effect on the mood and psyche of family members that can cause adverse grief reactions among the survivors. They may have less energy or ability to mourn a new death and to adapt to the current loss. Some people become overwhelmed with grief and unable to cope. In situations of complicated bereavement, a referral for counseling and/or mental health treatment is often appropriate.

When some individuals in the family are themselves chronically or terminally ill, or suffering the effects of an accident, the family’s psychological and financial resources may become strained or depleted and this can seriously impact the individuals’ ability to engage in mourning a new death. This may result in a delayed grief response, or one of complicated bereavement. Again, it is relevant for the social worker to ask about and take into account the overall health status of different family members. Some families have a confident and positive approach to life, believing that they will be able to handle the cards that have been dealt them. This attitude may have resulted in a history of success under difficult circumstances. A family such as this will face a death with a range of feelings, but also with the assurance that they will confront the loss together, will support one another, and will work together to honor the memory of the deceased. This attitude is vastly different from that of a family with a history of failure and lack of capacity to function under stress. They may respond to a death with feelings of being overwhelmed and inconsolable. Their grief may be prolonged, causing them to be unable to carry on their usual roles. Most typically a family’s history will include elements both of successful and unsuccessful coping. An important aspect of this history for social workers includes the family’s willingness to reach out and accept help from others compared to a response in which the family turns inward and becomes closed to offers of help from the outside. These responses may be culturally based and/or related to the circumstances of the death itself that sometimes cause families to feel ashamed and unwilling to discuss with others. Bereavement counselors must be attuned to how a family makes sense of a death, including what they state as the reason for the death, and about any notions about preventability. For example when a father dies in a car accident

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with a high blood alcohol count, the family members may say outright, or believe silently that “he brought it on himself.” In all likelihood there will be feelings of anger associated with this, which can complicate the bereavement process. Compare this example with that of a child who dies at age 6 of a brain tumor. The child’s family may say, “It was the will of God,” or “We were fortunate to have her with us for six years.” Their beliefs will greatly influence the manner in which they express their bereavement. In contrast, it is usually hard for families to find meaning following a death caused by suicide. The questions of blame, guilt, and possible prevention make it difficult to accept a suicidal death. If the family feels shame associated with the manner of death, they may try to disguise or distort the truth about the cause of the death. They often cannot find meaning that is acceptable to them, and because of their attempts to hide the true cause of the death, their grief becomes disenfranchised (Doka, 1989). This means that they cannot receive support from others, because they avoid having others involved. Counseling should be available for all these family members, even the young children. Among the most difficult death situations are those in which the body has not been located, but the circumstances lead to a presumption that death must have occurred (Boss, 2006). This was the case following the World Trade Center bombings, after which many bodies were never found or identified and the families had to decide whether and when to have a memorial service, with the presumption that their loved one had perished. Many of these families also had to struggle with their “shattered assumptions” (Janoff-Bulman, 1992) about issues of good and evil in the world, trying to reconcile the reality of what happened with their worldviews and with their beliefs about how and why such a tragedy could occur. A young school-age child asked his teacher, “Why did they do that to us, when we taught them how to fly?” (Webb,

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2004). Even young children try to understand the contributing causes behind a death, and many people struggle indefinitely with the questions “Why?” or “Why him or her?” and “Why not me?” Religion and spirituality play a big role in guiding many families through funeral and burial practices. Religion can provide not only guidelines regarding expected behavior, but also great psychological and emotional support. When no one in a family can answer the why question, faith in a higher power can bring some assurance that there is meaning to a death, even when individuals cannot find it on their own. Religious leaders often provide very helpful bereavement guidance and counseling. The ritual of the funeral gives direction and structure to the family about expectations, even as it also provides solace. The religious members typically reach out to offer support to grieving individuals. Families without any religious affiliation may still have beliefs about life and death that encompass a worldview that “everything has a purpose.” Much of the professional literature discusses typical and varied responses to grief. Social workers can help parents understand that they have a right to be sad and to grieve, and children can be told that everyone is sad because of the death, and that sometimes even grown-ups cry, but that they will not cry forever, and that they still will be able to take care of them. Grief may be delayed, and no precise timetable exists for how long or what form the bereavement should take. (Webb, 2010) deals with the topic of distinguishing between “normal,” “disabling,” and “complicated” grief. The term disabling is used to refer to grief that seriously interferes with a person’s life. An assessment can determine the degree of intrusiveness into a person’s life caused by his or her grieving. When the grief becomes all-encompassing and detrimental, the person is “stuck” and may need professional help for assistance. The term complicated grief encompasses and goes beyond the expression disabling grief

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insofar as it includes bereavement associated with traumatic loss. Prigerson et al. (1995) used the term complicated grief to describe persons who are unable to return to their previous level of functioning following a bereavement experience (Webb, 2010, p. 26). Of course the time factor must be considered, since it can be viewed as natural for individuals to temporarily slow down or even cease to function for some time following the death of a family member. The issue really becomes one of the duration and intensity of the withdrawal. Professionals who work in the bereavement field can help distinguish normal grieving from chronic depression. As has already been mentioned, the circumstances of the death will have an impact on the family’s response. These factors interact with the family factors already discussed and with the social, religious, and cultural factors to be reviewed later. The two major categories under consideration are the type of death and the degree to which survivors had contact with the deceased. We have already considered several of the factors under the type of death. These include whether the death was anticipated or sudden, whether it would be considered “timely” or preventable, whether it occurred in circumstances of violence and trauma, and whether the nature of the death caused it to be tinged with stigma. One subcategory that was not yet mentioned is the degree of pain involved in the death. When a death is painful, the family feels helpless and upset, especially if they witness their loved one in distress. Most hospitals and programs such as hospice that provide palliative care attempt to prevent suffering at the end of life. However, even with this goal, pain sometimes is not preventable, and when the patient suffers, the family does so also. This memory of a loved one suffering can interfere with the grief process of survivors. Another important factor related to the family’s experience of a death involves the nature of their contact with the deceased. Were they present at the moment of death, and/or did they

view the dead body? It is also useful to know if they had the opportunity to say good-bye, either at the moment of death, shortly after, or through attendance at a funeral or memorial service, and whether they have visited the grave or mausoleum, or location where ashes were scattered. The rituals of all religions serve to help families understand the reality and finality of the death and to express their feelings about the person who died through eulogies, death notices, the support of friends and colleagues, and experiencing the condolences of their surrounding network. The recognition and reactions of others to the death of a family member can have an important influence on the family survivors. At a time when a person may feel very bereft because of his or her serious loss, it helps to know that others feel a similar loss and want to give comfort. Ideally, after a death the extended family will rally around the next of kin and share the mourning, even as they offer love and support. Similar condolences can come from the school and workplace, as peers, colleagues, and friends come together to express their concerns and affection for the survivors. Some religious groups refer to themselves as “the church family,” thereby emphasizing their close ties to one another, as expressed through gifts of flowers, food, tributes, and special favors for the mourning family. In addition to religion, a family’s cultural identity can influence the nature of its response to a death. For example, many African American families believe strongly in an afterlife, and the funeral rituals will include songs and prayers conveying this message. In some instances they may actually celebrate the death because it signifies that the bereaved will go to Heaven and be free of worldly cares. These deeply held beliefs also convey the message that the survivors will be reunited with the deceased person after their own deaths, and this belief can result in a blunting of the pain of loss. Similar attitudes about death exist among many Irish Catholics who tell stories and jokes about the deceased at the

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wake and funeral, displaying little or no apparent expressions of grief (McGoldrick et al., 1991; Webb, 2010). Social workers who may be unfamiliar with different cultural practices and expectations following a death should inquire about these in order to better understand the responses of any given family. Because reactions and responses to death are shaped by our cultural beliefs, it is essential for any bereavement counselors to appreciate the diversity they may encounter in working with families from different cultural backgrounds and with children who may be navigating the process of acculturation, causing them to have to straddle different cultural expectations regarding a loss. The inclusion of children in the various after-death rituals varies greatly among various religions and cultures, although there is a growing belief among death educators that children can and should be included as long as provisions are made to take care of them if they become restless and inattentive. Decades ago it was not uncommon for children to be excluded and kept uninformed about deaths in the family because of the prevailing belief that they were too young to understand and that the experience of attending a wake and seeing a dead body would be too upsetting. The result of this exclusion was resentment on the part of many of these children when they grew up and looked back on their experience. So the current best practice is to prepare the child for the fact that some adults will be crying at the services, and that the person in the casket cannot talk or breathe or feel anything because he or she is dead. The child will also be allowed to leave with a predesignated person who will stay with him or her until the end of the service when the family can be reunited. In conclusion, use of the Tripartite Assessment will help the social worker understand the many interacting factors that coexist and influence the various bereavement responses of a family following the death of one of their nuclear members. This assessment will help

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determine if the family is coping satisfactorily with the death, or if further counseling may be advisable. This counseling may occur individually, in groups, or with the family as a unit. illuStrAtion And diSCuSSion

The Turner family consisted of Betty (mother), age 34, part-time cashier; Greg (father), age 35, policeman and volunteer fireman who was killed in a house fire; Mary, age 12, seventh grade; Greg Jr., age 9, fourth grade; Brian, age 6, first grade, and Lisa, age 4, nursery school. Three months following Greg’s death, the policeman/MSW social worker who was on the “crisis debriefing team” that visited the family immediately after the death suggested to Betty that it would be a good idea for her to consult a play therapist for the children because of the traumatic nature of their father’s death. The policeman/social worker telephoned me to provide information and to alert me to expect a call from Betty. Mrs. Turner agreed to bring all the children for a family session. I explained that following this initial meeting I would like to see each family member, including her, individually. I said that depending on my assessment of their individual needs, we would then develop a plan of how to proceed. This gave me an opportunity to meet all the family, to acknowledge the terrible loss they had each experienced, and to explain some of the ways I might be helpful to them. I described my role as someone who “helps children and families with their troubles and worries, and that sometimes we talk and sometimes we play” (Webb, 1996, p. 68). I suggested that we begin by having everyone make a drawing of a happy memory of their family. The boys each drew a picture of an outing in the park, the mother helped Lisa draw a snowman, and Mary drew some flowers. The purpose of this warm-up exercise was to help the children begin to feel comfortable with me. I also used the drawings to refer to their father, asking his whereabouts in the scene each drew. I had suggested that Mrs. Turner bring some pictures of

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her husband with her to this session, and she shared them at this time, pointing out the individual children with their father when they were much younger. I was impressed by Mrs. Turner’s ability to focus on her children when I knew that she had suffered a great loss herself. While looking at the pictures, I commented that no matter what happens after death, we still miss the person and wish he were still with us. I said that I knew it was hard to think and talk about someone you loved who had died, but that I thought it would be helpful to them. I also mentioned again that we could play as well as talk. Comment. This family was fairly easy to engage. The challenge here was the wide age range of the children, between 4 and 12 years. Because of this I knew that there was a vast difference in Lisa’s and Mary’s understanding of death. I realized that in a family session such as this, it is difficult to meet the individual needs of different family members. Nonetheless, the family session served the purpose of engagement and beginning the therapeutic relationship with each individual. I knew that in future sessions with the individual children I would use play therapy techniques with the two younger children, mostly talk with Mary, and a combination of talking and playing with Greg. I used an individual session with Mrs. Turner to go over many of the points mentioned earlier in this chapter with regard to helping the spouse of someone who died. I made a referral to a bereavement group for Mrs. Turner, and we also discussed the status of each child individually. Mrs. Turner stated that Mary told her after the family session that she didn’t want to come back for individual sessions. The mother felt that Mary was “doing very well,” and that she didn’t really need help, in contrast to the other children. She was concerned about Greg, who had started to be aggressive with other children in school; also, his schoolwork was deteriorating. Brian had always been disorganized, according to Mrs. Turner, and she felt that now he was “in a daze.” Lisa

simply did not comprehend what had happened, according to Mrs. Turner. She would say, “My Daddy died in a house fire,” but then hearing someone enter the house the very next moment, she would say, “That’s Daddy!” I reviewed some of children’s expectable responses to a parent’s death, and helped Mrs. Turner understand that many of their reactions were normative. At the same time, I asked for permission to contact the boys’ schools and to confer with the school social worker about their academic and behavioral status. Mrs. Turner was glad to have me do this and she signed the necessary release forms. As planned, I saw each child individually for several play therapy sessions. Greg was able to admit that he was losing his temper “a lot lately.” We spoke together about how much stress he was under because of his father’s death, and I referred to the fact that many people, adults and kids, feel angry when someone they love dies suddenly. He made a picture of a volcano, at my suggestion, and we talked about when feelings are held in they can “explode like a volcano.” I also gave him clay to mold and twist as we talked about what it’s like now that his father isn’t home, and he reminisced about some of the things he used to enjoy doing with his dad. Within three weeks I noticed a visible relaxation of Greg’s tension. His mother said that there had been no more negative reports from school, and the school social worker said that he was spending time with Greg every week talking about their shared interest in basketball. Brian’s reactions and behavior in therapy were quite different. He typically brought an assortment of toys with him from home and dumped them in the middle of the office floor, creating a very chaotic scene. He would use my firemen dolls, trucks, and the whole array of police and medical dolls in my collection, together with an assortment of family dolls of all sizes, ethnicities, and ages. Brian re-created on my playroom floor the chaos he was feeling internally. I understood the symbolic meaning of his play

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and verbalized to him that “everything seemed all mixed up and confused.” His play came to no resolution or conclusion, and he would not permit me to “play out” any rescue efforts. About three months after I began seeing him, and on the last day before I was to go away on an extended leave, he played out a house fire, the deaths of many people, and the inability of the hospital to save the people. This was a very sad scene, and I verbalized feelings of sadness and helplessness. He permitted me to cover up the “dead bodies” (with Kleenex), and he joined me in doing this. After a quiet but intense interval I said something about missing those people very much, and trying to remember how much they loved us. This very active child became quite focused and serious during this play, which I believe had deep meaning to him.

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are dead, we don’t see them anymore and they don’t come back.”

When I first began seeing Brian I was concerned about his poor speech and encouraged his mother to request an evaluation at school. In the midst of the period of therapy, she reported to me that the school was arranging special help for him. I felt quite certain that these difficulties were independent of his father’s death. But it also seemed likely that his problems with speech and learning were increased by his anxieties about the death.

This case illustrates some important factors that must be considered when a parent dies. First, children comprehend and interpret the death according to their ability, based on their age and developmental level. Second, the anxiety and stress associated with a death will magnify preexisting conditions, or lead to acting out behaviors that require a therapeutic response that recognizes the underlying meaning of the behavior. Third, the ability of the surviving parent to focus on the children’s needs and to maintain structure and routine in the home will influence the children’s adjustment. Fourth, a parent’s ability to interact appropriately with the children depends strongly on the support the parent receives from the extended family, friends, and the community. In this case, there was a large extended family who rallied around and offered help. In addition, the community and the father’s work associates also provided ongoing support. Finally, this family appeared to have been functioning well prior to the crisis of the death. They were already resilient, and although the sudden death certainly was a drastic loss, the extensive support they received contributed to their ongoing growth and development.

Lisa also had a speech impairment, but it was not serious, considering her young age. In the play sessions with me, Lisa used only female adults in the dollhouse family. When I asked her to tell me who was in the dollhouse family, she did not name a father. I asked her “What happened to the daddy?” and she responded, “We can’t find him; he’s lost. The mommy told someone on the phone that she lost her husband.” This confusion is understandable in view of Lisa’s young age. On the one hand she has heard people say that her father is dead, but she does not understand that death is irreversible. That is why she can switch from saying that her father died in a house fire to announcing his arrival at the front door. My response (and one I later suggested that mother repeat to Lisa) was that “maybe the Daddy is dead, and when people

The Tripartite Assessment is a useful tool for professionals in helping the child, school staff, and parent understand what is going on or the multiple stresses of a bereaved child. The difference in ages of Lisa, Brian, and Greg helps explain the children’s varying abilities to understand the permanency of their father’s death (Gibbons, 1992). According to Thompson, et al., it is common for bereaved siblings to experience a wide range of “internalizing and externalizing” problems. These include “feelings of sadness, anxiety, guilt, and isolation from peers” (Thompson et al., 2011, p. 154). In this case, the use of play therapy helped all three children express their worries and concerns about their father’s death. The older child made the decision with her mother’s approval to attend a school-based bereavement group with her peers. All benefited from the different interventions.

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conclusion Parents cannot guarantee their ongoing survival throughout the life span of their children, nor can they guarantee their children’s health and longevity. Social workers, therefore, must be prepared to provide services to families following parental or children’s deaths and to assist schools and community agencies with the creation and provision of programs for bereavement counseling. Depending on the nature of the death and the age of the surviving relatives, services may be offered through hospice programs, schools, mental health clinics, religious organizations, and funeral homes, or by private practitioners. Regardless of the locale of the counseling, the bereavement counselor should make an assessment of the individuals, taking into account the various components of potential risk and resilience factors, as enumerated in the Tripartite Assessment. Special attention should be given

to the age and level of cognitive understanding of the survivors, as well as to the nature of the death and the quality of existing support. The outcome of this assessment will point to the type of intervention that is appropriate. A variety of treatment options should be considered, depending on the circumstances of each case. Among these are bereavement support groups, individual and family therapy, and a combination of different treatments. The social work value of client self-determination argues for participation of the client in the choice of the particular treatment modality. Whereas a death is the end of a life, it must not result in despair and depression for the families of the survivors. Social work can lend a vital service by setting up appropriate programs, referring bereaved clients to them, and providing bereavement counseling on an age-appropriate level. These can help convert the despair of grief into a transformative experience.

referenceS

Horsley, H., & Patterson, T. (2006). The effects of a parent guidance intervention on communication among adolescents who have experienced the sudden death of a sibling. American Journal of Family Therapy, 34(2), 119–37. Howarth, R.  A. (2011). Promoting the adjustment of parentally bereaved children. Journal of Mental Health Counseling, 33(1), 21–32. Janoff-Bulman, R. (1992). Shattered assumptions. Toward a new psychology of Trauma. New York: Free Press. Kane, J., & Himelstein, B. (2002). Palliative care in pediatrics. In A. Berger, R. Portenoy, & D. E. Weissman (Eds.), Principles and practice of palliative care and supportive oncology (pp. 1044–61). Philadelphia: Lippincott Williams & Wilkins. Kastenbaum, R. J. (2008). Death, society, and human experience (10th ed.). Boston: Beacon. Li, J., Precht, D.H., Mortensen, P.B., & Olsen, J. (2003). Mortality in parents after death of a child in Denmark: A nationwide follow-up study. Lancet, 2003(361), 363–67. Looman, W. S. & Lindeke, L. L. (2008). Children and youth with special health care needs: Partnering with families for effective advocacy. Journal of Pediatric Health Care, 22, 134–36. McGoldrick, M., Almeida, R., Hines, P. M., Rosen, E., Garcia-Preto, N., & Lee, E. (1991). Mourning in different cultures. In F. Walsh & M. McGoldrick (Eds.), Living beyond loss. Death in the family (pp. 176–206). New York: Norton.

Boss, P. (2006). Loss, trauma and resilience. therapeutic work with ambiguous loss. New York: Norton. Boss, P., & Mullican, C. (Eds.). (2002). Family stress. Classic and contemporary readings. Thousand Oaks, CA: Sage. Boylan, J., & Dalrymple, J. (2011). Advocacy, social justice and children’s rights. Social Work in Action, 23(1) 19–30. Cassini, K. K., & Rogers, J. L. (1996). Death and the classroom. A teachers guide to assist grieving students. Toledo, OH: Griefworks. Davies, B. (1999). Shadows in the sun. The experience of sibling bereavement in childhood. Philadelphia: Brunner/Mazel. Devita-Raeburn, E. (2004). The empty room: Surviving the loss of a brother or sister at any age. New York: Scribner. Doka, K. (Ed.). (1989). Disenfranchised grief. Recognizing hidden sorrow. New York: Free Press. Dyregrov, K., Nordanger, D., & Dyregrov, A. (2003). Predictors of psychosocial distress after suicide, SIDS, and accidents. Death Studies, 27, 143–65. Gibbons, M. B. (1992). A child dies, a child survives: The impact of sibling loss. Journal of Pediatric Health Care, 6(2) 65–72. Hope, R. M., & Hodge, D. M. (2006). Factors affecting children’s adjustment to the death of a parent: The social work professionals’ viewpoint. Child and Adolescent Social Work Journal, 23(1) doi:10.1007/ s10560–006–0045-x.

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Meert, K. L., Shear, K., Newth, C. J. L. Harrison, R., Berger, J., Zimmerman, J., . . . Nicholson, C. (2011). Follow-up study of complicated grief among parents eighteen months after a child’s death in the pediatric intensive care unit. Journal of Palliative Medicin, 14(2) 207–14. doi:10.1089/jpm.2010.0291. Murphy, S. A., Johnson, L. C., Chung, I. J., & Beaton, R. D. (2003). The prevalence of PTSD following the violent death of a child and predictors of change 5 years later. Journal of Traumatic Stress, 16(1), 17–25. Nagy, M. (1948). The child’s theories concerning death. Journal of Genetic Psychology. 73, 3–27. National Military Family Association. (2006). Resources for Wounded Service members and Families. Accessed August 22, 2012. http://support.militaryfamily.org/site/DocServer/Wounded_Servicemember7–06.pdf?docID=6703. National Military Family Association. (2011.). National Military Family Association Summit. When Parents Deploy: Understanding the Experiences of Military Children and Spouses: Summary and Recommendations. http://www.militaryfamily.org/publications /community-toolkit Neimeyer, R. A., & Holland, J. M. (2006). Bereavement overload. In N. J. Salkind (Ed.), Encyclopedia of human development. Thousand Oaks, CA: Sage. Openshaw, L. (2008). Social work in schools: Principles and practice. New York: Guilford. Ormond, E., & Charbonneau, H. (1995). Grief responses and group treatment interventions for five- to eightyear-old children. In D. W. Adams & K. J. Deveau (Eds.), Beyond the innocence of childhood: Helping children and adolescents cope with death and bereavement (pp. 181–202). Amityville, NY: Baywood. O’Toole, D. R. (1998). Growing through grief. A K–12 Curriculum to help young people through all kinds of loss. Burnsvillle, NC: Compassion Books. Prigerson, H. G., Frank, H., Kasl, S. V., Reynolds, C. F. III, Anderson, B., Zubenko, G.  S., . . . Kupfer, D. J. (1995). Complicated grief and bereavement-related depression as distinct disorders. Preliminary empirical test. British Journal of Psychiatry, 174, 67–73. Rando, T. A. (1983). An investigation of grief and adaptation in parents whose children have died of cancer. Journal of Pediatric Psychology, 8, 3–20. Rubin, S. S., & Malkinson, R. (2001). Parental response to child loss across the life cycle: Clinical and research perspectives. In M. S. Stroebe, R. O. Hansson, W. Stroebe, & H. Schut (Eds.), Handbook of bereavement research (pp. 219–40). Washington, DC: American Psychological Association. Social Security Administration. (2000). Intermediate assumptions of the 2000 trustees report. Washington, DC: Office of the Chief Actuary of the Social Security Administration. Statistical Abstract of the US. (2007a). Table 109. Deaths and Death Rates by Sex, Race, and Hispanic Origin:1970–2008. http://www.census.gov/compendia /statab/2012/tables12s109.pdf

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Statistical Abstract of the US. (2007b). Table 121. Deaths by Age and Selected Causes. http://www.census.gov /compendia/statab/2012/tables12s109.pdf Stevenson, R. G. (1996). Teaching students about death. A comprehensive resource for educators and parents. Boston: Charles. Tait, D. C., & Depta, J. (1993). Play therapy groups for bereaved children. In N.  B. Webb (Ed.), Helping bereaved children. A casebook for practitioners (pp. 169–85). New York: Guilford. Thompson, A. L., Miller, K. S., Berrera, M., Davies, D., Foster, T. L., Gilmer, M. J., . . . Gerhardt, C. (2011). A qualitative study of advice from bereaved parents and siblings. Journal of Social Work in End-of-Life & Palliative Care, 7(2–3), 153–72. http://dx.doi.org/10 .1080/15524256.2011.593153. Understanding Islam. (2000). Islamic rituals at death. Accessed September 7, 2012. http://www .understanding-islam.com/q-and-a/customs-and -symbols/islamic-rituals-at-death-5463 U.S. Census Bureau. (1999). Statistical Abstract of the U.S. Table 140. Deaths by Age and Leading Cause: 1996. Washington, DC: U.S. Government Printing Office. ——. (2012) Births, death marriages, divorces. http:// www.census.gov/compendia/statab/cats/es.html Walsh, F. (2006). Strengthening family resilience. New York: Guilford. Walsh, F., & McGoldrick, M. (1991). Living beyond loss: Death in the family. New York: Norton. Webb, N.B. (1986). Before and after suicide: A preventive outreach program for colleges. The American Association for Suicidology. 16 (4),469–480. ——. (1991). Play Therapy with children in crisis. Individual, group, and family treatment. New York: Guilford. ——. (Ed.). (1993). Helping bereaved children. A handbook for practitioners. New York: Guilford. ——. (1996). Social work practice with children. New York: Guilford. ——. (Ed.). (1999). Play therapy with children in crisis. Individual, group, and family treatment (2nd ed.). New York: Guilford. ——. (Ed.). (2004). Mass trauma and violence. New York: Guilford. ——. (Ed.). (2007). Play therapy with children in crisis. Individual, group, and family treatment (3rd ed.). New York: Guilford. ——. (Ed.). (2010). Helping bereaved children. A handbook for practitioners (3rd ed.). New York: Guilford. ——. (2011). Social work practice with children (3rd ed.). New York: Guilford. Winjngaards-de-Meij, L., Stroebe, M., Schut, H., Stroebe, W., van den Bout, J., van der Heijdan, P., *Dykstra, I. (2005). Couples at risk following the death of their child. Predictors of grief and depression. Journal of Counseling and Clinical Psychology, 73, 617–62.

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he gay and lesbian population in the United States has been, until fairly recently, largely an invisible one that emerged in varying degrees depending on the prevailing societal climate. However, even with recent changes in some states that have legalized same-sex marriage and civil unions, some stigma remains associated with being homosexual. Because the lesbian and gay identity is not marked by identifiable physical characteristics, gay and lesbian persons can be easily overlooked as a vulnerable and yet highly resilient population group. Bisexual and transgender persons have been omitted from this chapter because the recent understanding of these groups as distinct minorities seems to demand that they be discussed as unique minority populations. defining and explaining Gay and lesbian Persons in a nongay World Homosexuality is a socially constructed term that has recent origins, although same-sex relationships have existed in all cultures and during all eras (Altman, 1982). Originally coined by a Hungarian physician named Karoly Benkert (also known as Kertbeny), the term homosexual was introduced in 1869. It came into more current usage toward the end of the nineteenth century when it was used by psychiatrists and medical doctors to define it as an unacceptable alternative to the more “normal” heterosexual behavior. The definition of homosexuality has evolved over time, from the early 1700s, where same-sex behavior was merely a sin for which someone could atone, to the early 1900s, 318

when homosexuality became an issue of personal identity. Currently, gays and lesbians are defined in a variety of ways, depending on who is constructing the definition. Generally, two disparate views exist on homosexuality. Some individuals believe it to be an unnatural, abnormal, sinful, and pathologic variation of sexual expression; others believe it to be a natural, normal expression of sexuality along the sexual continuum (Bieber, 1965; Kinsey, Pomeroy, Martin, & Gebhard, 1953; Masters & Johnson, 1966, 1979; Nicolosi, 1991; Socarides, 1978). These polarized views are found both inside and outside the gay community and are the basis of homophobia, confusion, and myth. Although never as common as heterosexual behaviors, homosexual patterns have existed since antiquity. And it was not until after the acceptance of Christianity as a mainstream religion that same-sex sexual behaviors became a “sin” (Boswell, 1980.) The tolerance for this sin ebbed and flowed depending on the societal beliefs of the era. For example, there was an increased tolerance for same-sex relations during the mini-Renaissance of the ninth through eleventh centuries that gave way to open condemnation of it during the following two centuries. While this condemnation lasted well into the nineteenth century and reemerged during the latter part of the twentieth century, the middle of the nineteenth century and the first part of the twentieth century saw the construct of homosexuality as an identity issue (Walker, 1999). In the twentyfirst century, there appears to be more tolerance of same-sex relationships as more and

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more states permit same-sex marriages or civil unions and churches sanction the ordination of lesbian/gay clergy. However, there remains a large contingent of the population that sees same-sex relationships as sinful and pathological (Human Rights Campaign, 2012). Those who define homosexual behaviors as pathological believe that the sexual behavior is learned and therefore, because it is a chosen activity, can be made extinct. Proponents of the illness model of same-sex sexual behavior view homosexuality as abnormal and a mental illness to be cured through programs of psychological counseling, medication, conversion therapy, electroconvulsive (shock) therapy, aversion therapy, prayer, or a combinations of therapeutic approaches. Citing such religious dogma as canon law, the Bible, and historical religious proscriptions against homosexuality, and relying on interpretations of Freudian theory, reparative therapists attempt to cure the homosexual of her or his affliction (Bieber, 1965; Nicolosi, 1991; Socarides, 1978). Their success rate is unknown and usually considered extremely low, and the National Association of Social Workers (NASW) condemned its practice in the 1980s (National Association of Social Workers, 1981). This definition of same-sex behavior as pathological, and therefore curable, represents one end of the definitional continuum as related to homosexuality and homosexuals. The other end of this sexual continuum sees homosexuality as a normal and inborn expression of sexuality. This view is endorsed by the American Psychiatric Association, which in 1972 removed homosexuality from its diagnostic manual of mental illnesses. This view should guide the practice of social workers working with lesbian and gay clients. Since there is no known cause for either heterosexual or homosexual behavior, the social worker must accept gay and lesbian persons as they would their heterosexual clients—people in various biopsychosocial states transacting with a traditionally heterocentric environment who, for whatever reason,

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find it necessary to seek social work assistance or are approached by an agency offering its services. Current research continues to explore a multitude of issues related to lesbians and gay men. Three dimensions of sexual orientation have been identified: identity, attraction, and behavior (Bostwick, Boyd, Hughes, & McCabe, 2010). Researchers have also discovered the culturally diverse, economically disparate, and multiethnic heterogeneity of the lesbian and gay community. While early studies focused on white, well-educated, usually professional, young lesbian and gay samples, studies toward the end of the twentieth century explored a variety of issues in the gay and lesbian community, including such things as aging, racism, sexism, adoption, marriage, health, coming out, domestic partnerships, law, ethnicity, and child care (LeVay, 1991, 1996). Research related to gay and lesbian populations conducted since the 1990s has expanded to include such issues as parenting, family dynamics, resiliency, specific health issues, people of color, gays in the military, genetics, gays in the workplace, and a host of other topics so diverse that when “lesbian and gay research” is entered into a popular search engine (bing), more than 40 million results appear (Croom, 2000; Harper, Buhrke, & Doll, 2012). The majority of researchers in the field assume that a homosexual sexual identity is innate as opposed to learned, is natural for some portion of the general population, can be a healthy way of life, and is an acceptable lifestyle. However, there continue to be conflicting definitions, persistent stereotypes and myths, and homophobia that impact the larger (heterosexual) community, service providers (often in traditional agencies), and users of services (gay men and lesbians in need of such services). Stereotypes and myths continue to surround the lesbian and gay community and its inhabitants. Evolving from and perpetuating myths and stereotypes, homophobia—the irrational fear of homosexuals and homosexuality— continues. No doubt stemming from the persistent religious proscriptions against same-sex

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sexual behaviors and the sodomy laws that developed in a parallel fashion, homosexual behavior continues to be viewed as less than acceptable by many. demographic Patterns To get a general sense of how widespread homosexuality is, the following demographics may be interesting. As has been noted, a lesbian or gay person cannot be identified just by appearance. Therefore, gays and lesbians can hide in a population and society that are primarily heterosexual. So although the entire lesbian or gay population cannot be identified, it has not stopped researchers from trying to estimate what percentage of the general population of the United States fits into that population category. One of the earliest estimates came from the Kinsey data that were generated during the last part of the 1940s and early part of the 1950s (Kinsey, Pomeroy, & Martin, 1948; Kinsey et al., 1953). These data, collected on the sexual behaviors of both men and women, suggested that between 3 percent and 10 percent of the total population were gay or lesbian. Others who study such phenomena agree that these percentages are probably fairly accurate (National Opinion Research Center, 1989–1992; Rogers, 1993), but these are merely estimates. A Gallup Poll conducted in 2011 indicated that most Americans think that as many as twentyfive percent of the population is lesbian or gay, while a 2011 study (Badash, 2011) indicated that only 4 percent of the country is lesbian or gay. In the latest data from the U.S. Census Bureau (2012), in 2009 there were 113 million unmarried-partner households in the country, of which 280,000 were male/male households and 301,000 were female/female households. Whether or not gay or lesbian couples inhabited these households is unknown. In reality, there is no way to know the exact number of lesbian and gay persons living in the United States. Assuming the estimates to be somewhat accurate, and based on current census data that show approximately 307 million persons living

in the country (U.S. Census Bureau, 2012), it would mean that, in the first part of the twentyfirst century, a total of between 9.2 million and 30 million persons in the United States were lesbian or gay. Using the same percentages across ethnic or racial lines, data demonstrate there could be from 1.1 million to 3.9 million African American gay men and lesbians, from 213,000 to 710,000 Pacific Islander or Asian gay men and lesbians, and from 7.2 million to 24.2 million Caucasian gay men and lesbians living in this country. When examining these statistics by sex, data show that in 2008 the United States population is comprised of 154.1 million women (50.7 percent) and 149.9 million men (49.3 percent) (U.S. Census Bureau, 2012). Again, using the generally accepted percentages of lesbians and gay men (3–10 percent), possibly there are from 4.6 million to 15.4 million lesbians and 4.5 million to 14.9 million gay men in the country. But these numbers are purely speculative. The one thing these data do show is that even using the lowest estimated percentage of lesbians and gays (3 percent) the numbers of homosexual people in the United States is not insignificant. While social services are offered to all socioeconomic groups, those with lower income levels traditionally use them more. The census data present a graphic picture of annual household incomes in the United States. According to the most recent census data (U.S. Census Bureau, 2012), in 2010, there were a total of 117.5 million households in the country. Of those, 19.7 million households (17 percent) were living in a household with Supplemental Security Income, public assistance income, or food stamps. Of those 19.7 million households, there were 280,000 “nonfamily households” (households comprised of persons not related by blood or marriage) that included men living with a male partner, and 301,000 that included women living with a female partner. What these data do not capture is the number of households that opted not to self-identify as a same-sex household.

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The 2010 census did make some attempt to identify persons who were living together but were not married and were in same-sex households, but no data were gathered that specifically asked about sexual orientation. However, this census did go farther than any previous census in trying to identify same-sex couples. One may conclude that data on lesbian and gay households were captured in the “nonfamily” category, but even doing that is risky. Having so noted, if one assumes that data on gay and lesbian households are embedded in the general census data, and that between 3 percent and 10 percent of all families in this category are lesbian or gay, then it may be that of the 117.5 million total households, between 3.5 million and 11.7 million households are lesbian or gay households. For those families receiving some sort of public assistance, 9.9 million are in a female household with no husband present and 1.7 million are in a male household with no wife present. These data tend to demonstrate that somewhere between 297,000 and 1 million households in poverty might be lesbians and 51,000 and 170,000 households in poverty might be gay men. Caucasians in nonfamily households are more likely to live closer to poverty than those in family households. Members of ethnic minorities (African Americans, Hispanics, and Asian and Pacific Islanders) tended to live in family households as opposed to nonfamily households. However, whereas 7.2 percent of all Caucasian households (family and nonfamily) live with incomes below $15,000, 18 percent of African American households, 15 percent of Hispanic households, and 6.9 percent of Asian and Pacific Islanders did so too. And while it is unknown how many of these ethnic minority households are lesbian or gay, it seems logical to deduce that if one is a gay man or lesbian of color, then it is more likely he or she will be impoverished than if he or she were Caucasian. Significant numbers of gay men and lesbians may be living at or near poverty and are likely recipients of social services. Such services

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may be related to socioeconomic status, being a member of a despised and often misunderstood disenfranchised minority group, or other factors associated with a societal context that is heterocentric. Since gays and lesbians are generally invisible as adults, they are seen as virtually nonexistent as adolescents, aged persons, or persons of color. Research related to lesbian and gay youth is still evolving, and the topic has been and continues to be one of interest for social workers. Again, if one assumes that 3 percent to 10 percent of the adolescent population of 21.5 million persons (U.S. Census Bureau, 2012) is lesbian or gay, then there could be anywhere from 64,500 to 2.2 million lesbian or gay persons between the ages of 15 and 19 years old in the United States. Similarly, data related to older gay and lesbian persons have only been collected with any regularity since the late 1970s. And while in 2009 one could estimate there to be between 1.8 to 6.1 million lesbians or gay men in the overall population of 61.1 million Americans 65 years of age or older (U.S. Census Bureau, 2012), by 2050, with the increasing numbers of elders, the total number of gay or lesbian persons in this age range could be between 2.4 million and 8 million. Data related to lesbians and gays of color is also an emerging area of interest for researchers. In sum, demographics related to gay and lesbian persons in the United States are speculative at best. But, even so, lesbian and gay persons do exist in every socioeconomic, racial, and age group and because of this, social workers will, at some point in their careers, encounter someone who is not heterosexual. Therefore, having a good understanding of this minority group is essential. Societal context To be a member of an invisible and often despised minority within a overwhelmingly heterocentric societal context is a stressful experience. The larger society is permeated by homophobia, which has been defined as

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negative feelings about lesbians and gay men, their sexual activities, and their communities. The fear may be at the phobic level, indicating an irrational fear of homosexuality and homosexuals, and the term has been identified as a prejudice similar to anti-Semitism or racism (Herek, 1991). Generally there are three identified forms of homophobia: institutional, individual, and internal. Institutional homophobia derives from a general societal hostility toward gay men and lesbians that is manifested in a variety of ways: sodomy laws outlawing same-sex sexual activity, religious prohibitions against homosexual behaviors, and a general perception that lesbians and gay men are not a significant part of the population. Individual homophobia is demonstrated by nongays’ attacks on lesbians and gay men that come in the form of gay jokes, verbal taunts, physical assaults, and the assumption that all persons are heterosexual. Internal homophobia is self-loathing and fear manifested in the individual gay man or lesbian who, because of institutional and individual homophobia, has internalized the negative attitudes and feelings about homosexuality. The social construct of homosexuality as an identity is one of recent history (Walker, 1999), as mentioned earlier, and while there is no known cause for same-sex behavior, evidence points toward a genetic rather than a learned origin (LeVay, 1991, 1996). If one is genetically predisposed to a trait or condition (like being left-handed or blue-eyed), there tends to be less stigma attached to it. With reduced stigma comes more social tolerance and acceptance; with more acceptance of the behavior comes less discrimination and more legal protections. This seems to be what is happening with relation to gays and lesbians. National Opinion Research Center (NORC) data from 1989 to 1992 reveal more tolerance of homosexuals and homosexuality than previously noted; NORC data from the General Social Surveys, 1991–2010, show that acceptance of homosexual behavior had increased from 14 percent in 1991 to 41 percent

in 2010 (National Opinion Research Center, 2011). Laws are gradually beginning to reflect that change. Nevertheless, all lesbian and gay persons grow up and live in a society dominated by a majority whose sexual orientation is different from theirs. In doing so they are confronted with a social structure that does not support their lifestyle. The social structure includes legal, economic, religious, educational, and familial systems. In fact, homophobia exists in every major societal institution in each of these areas, and so each can be a source of stress. But just as each institution is homophobic, each, too, offers varying levels of support to its gay and lesbian members. The legal system is one where institutional homophobia and hence a potential for stress is readily apparent. Legal prohibitions against same-sex sexual activity trace their antecedent roots to early canon laws (Walker, 1999). However, the legal system, while still not totally protective of lesbians and gays, is slowly becoming more accepting and supportive of same-sex issues. State sodomy laws are gone, so same-sex sexual expression is no longer illegal. National statistics on hate crimes include information on hate crimes against lesbians and gay men (“Hate Crime Statistics,” 1996), and the Matthew Shepard and James Byrd, Jr. Hate Crimes Prevention Act (Federal Bureau of Investigation 2012), which includes gays and lesbians as a protected category, was passed in 2009. This law allows the FBI to investigate violent crimes perpetrated against the gay and lesbian community (and also the transgender and bisexual communities) solely on the basis of sexual (or gender) orientation. However, there are 1,018 active hate groups in the United States (up from 474 in 1998), and no state, except Hawaii, is spared from having one or more hate groups represented (Southern Poverty Law Center, 1998, 2012). Hate crimes against gay and lesbian persons continue to be a serious concern (Federal Bureau of Investigation, 2012; Leadership Conference, 1996).

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Workplace discrimination against lesbians and gays continues to exist, but more and more companies are providing policies that protect same-sex couples, and scores of businesses have expanded personnel policies to include benefits for same-sex couples. Federal law now allows gays and lesbians to serve openly in the military. Marriage laws and domestic partnership ordinances continue to be passed in several states, and scores of localities, municipalities, universities, and corporations have passed domestic partnership laws or policies. However, gays and lesbians do not have legal recognition of their relationships in a majority of states. Some states allow both members of gay or lesbian couples to adopt a child, and federal legislation designed to prohibit gay or lesbian couples from adopting children failed to pass. There have been several successful state initiatives to ban discrimination on the basis of sexual orientation, and openly lesbian and gay persons run for and are elected to public office (Human Rights Campaign, 2012). With all these changes, it seems only a matter of time before lesbians and gays are given full civil and legal rights. In the first part of the twenty-first century, gay men and lesbian women are becoming more visible and more demanding of their legal rights, and candidates no longer dismiss the importance of the gay vote. Members of gay and lesbian political organizations such as the Human Rights Campaign (HRC) and the National Gay and Lesbian Task Force (NGLTF) actively lobby federal and state legislators on issues related to gays and lesbians. Their influence is not without political clout as, in 2012, both the president and vice president of the United States came out in support of same-sex marriage (Human Rights Campaign, 2012). That there even is a national lesbian and gay political agenda is testimony to the reality that the legal and political systems can and do change. The economic sector also manifests elements of homophobia. Although gay men and lesbians have been making significant contributions to

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the economy since antiquity, many employers at the end of the first decade of the 2000s still have no policies governing domestic partners, it is still legal to discriminate on the basis of sexual orientation in the workplace, institutional homophobia is not uncommon among workers, and many gay men and lesbians continue to face unnecessary hardships in the workplace. Lesbians and gay men can be found employed across the socioeconomic spectrum, from chief executive officers of Fortune 500 companies to migrant laborers. Their contributions would, no doubt, be missed, yet many prefer secrecy and anonymity to possible job loss. For example, in 1999, an employee of the Cracker Barrel Restaurant chain in Atlanta was fired on the basis of her lesbianism, and an assembly-line worker in a large automobile factory was subjected to verbal taunts and threats of physical abuse because he appeared at a gay rally (“Out at Work,” 1999). But this form of discrimination in the workplace may be changing. Data demonstrate that most Americans do not believe gays or lesbians should be discriminated against in the workplace. In support of that, many U.S. corporations openly encourage lesbian and gay applicants, have domestic partnership policies, and help find suitable employment for partners (Human Rights Campaign, 2012; National Gay and Lesbian Task Force, 2011). According to a study by the Human Rights Campaign (2012), in 2011 there were 337 major companies who employ more than nine million people in the United States that have policies favorable to lesbian and gay employees. Of the Fortune 500 companies, 86 percent have nondiscrimination policies in place that include sexual orientation. These are reflections of changes since the 1970s and are encouraging indicators that these lesbian women and gay men will continue to find adequate employment opportunities within the nongay world. Just as the legal and economic arenas are still characterized by institutional homophobia, so, too, is the religious community. As mentioned, the first legal proscriptions against same-sex

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sexual behavior evolved from early canon law, and vestiges of these remain. These proscriptions can be seen in teachings and beliefs of the conservative Southern Baptists, Catholics, and in organizations like the Cramer, D. and A. J. Roach, John Birch Society, the Family Research Council, and the Ku Klux Klan. The Christian Right (called the Radical Right by some) continues to characterize homosexuality as a mental illness that is curable through reparative therapy and prayer. Many mainstream denominations see homosexuality as a lifestyle choice and therefore an optional behavior that is sinful and goes against all religious teachings. While some extreme right-wing groups call for the extermination of homosexuals (as in Nazi Germany), most profess to “love the sinner, but hate the sin.” Citing biblical scripture and reparative therapists, and ignoring professional admonitions against reparative therapy (National Committee on Lesbian and Gay Issues 1992), the Christian Right has included homosexuality as an issue for attack on its agenda for the new millennium (Christian Coalition Worldwide, 2012; John Birch Society, 2012; Ku Klux Klan, 2012). Because the religious community has historically been the source of homophobia, many lesbians and gay men shun religion altogether and are simply not part of any organized religion. But, as in the legal sector, incremental changes that favor same-sex relationships are occurring. Churches and synagogues for gay and lesbian persons have existed in this country since the 1970s. One of the first, the Metropolitan Community Church, founded by Reverend Troy Perry, now boasts churches in every major city in the United States and has thousands of members. But not all lesbians and gays opt to attend churches or synagogues defined by sexual orientation, and support systems for lesbian and gay parishioners now exist within even the most conservative denominations. Openly gay or lesbian clergy have ministries in nongay churches, and several Protestant denominations ordain lesbians and gays. More than 350 churches in the country voted to be included as “welcoming

churches” for the gay and lesbian community and created a publication called Open Hands to provide resources for ministries whose parishioners include lesbians and gays (Witt, Thomas, & Marcus, 1995). With the advent of the legalization of gay marriage in some states, the traditional religious community has had to rethink its position on same-sex marriages, and most churches will now perform same-sex marriages if sanctioned by state law. Increasingly, Christian and Jewish churches and synagogues are willing to perform commitment ceremonies for lesbian or gay couples, and while they may or may not be legally binding, such unions are religiously sanctioned. Catholic priests have officiated at unsanctioned ceremonies outside their churches (Cherry & Mitulski, 1990; Witt et al., 1995). Institutions of learning are designed to teach students about societal mores, values, and skills. In the United States it is the right of each child to receive an education. However, institutional homophobia is a significant issue in public elementary, middle, and senior high schools, with what can be devastating effects on the lesbian and gay students in attendance (Gay, Lesbian, and Straight Education Network, 2012). The thought that prepubescent adolescents are sexual or would have need of any kind of sexual information is often still ignored. And by the time children enter adolescence, when sexual information is a necessity, schools have limited sex education content and even less content about the realities of lesbian or gay lifestyles. School counselors may be banned from discussing sexual orientation because of existing laws, school libraries are not a source of accurate information on lesbian and gay lifestyles, and teachers are often ignorant about the topic (Grossman, 1997; Morrow, 1993). Despite these challenges, the educational system is slowly coming to terms with the reality of its gay and lesbian students. The Gay, Lesbian, and Straight Education Network (GLSEN), created as a public school-oriented group in 1990, participates in curriculum development

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for elementary and secondary level schools and works with parents, teachers, students, and concerned citizens to end homophobia in the school setting. With numerous chapters located in twenty-three states nationwide, GLSEN creates and develops curricula for in-school programs, community organizing, and advocacy. Their primary aim is to work with and create change in the homophobic belief systems of educational leaders and policymakers (Gay, Lesbian, and Straight Education Network, 2012). One public school initiative undertaken by GLSEN in 1998 was to challenge federal legislation prohibiting teenage children Internet access to gay- and lesbian-oriented materials through public school access networks. GLSEN believed that it was immoral and potentially damaging to deny teens access to honest, helpful materials that could bolster self-esteem and perhaps reduce suicide (Einhorn, 1998). Schools are an important source of social interaction as well as information for their students. For gay and lesbian youth, the school setting can be a source of significant stress. Coming to grips with a sexual orientation that differs from the norm is difficult under the best circumstances. It can be devastating in schools where there are no built-in support networks. And support networks for adolescent and underage gays and lesbians may not be easily found. If they do exist, they may be closely monitored to ensure that older lesbians and gays are not taking advantage of younger persons, and in some cases parental permission must be obtained before an underage teen is allowed to join such a group. Further, a 2009 study (Gay, Lesbian, and Straight Educational Network, 2012) indicated that 90 percent of gay and lesbian students are bullied. While data indicate that college-age students are becoming more tolerant of same-sex relationships, junior- and senior-high-age students are the most negative group in their hatred of same-sex relationships (Child Welfare League of America, 2012). There are some schools that offer groups for gay and lesbian students, and some high schools have

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allowed same-sex couples to attend junior or senior proms together, but for most gay and lesbian students, school can be a place of little support and considerable stress. Postsecondary institutions tend to be more liberal in their approach to same-sex behaviors and relationships. Many universities have nondiscrimination policies that protect gay and lesbian students, offer campus organizations for gays and lesbians, and provide housing for same-sex couples. Sororities and fraternities for lesbians and gays have been established, and some schools have tried housing lesbian and gay students on specific floors of dormitories. In the middle 1990s, “queer studies” emerged as a legitimate topic of scholarly pursuit, and lesbian and gay faculty can now openly act as mentors for gay and lesbian students. And, like the legal and religious sectors, primary, secondary, and postsecondary institutions of education are beginning to grapple with issues related to their lesbian and gay students and provide curricula designed around the realities of being a gay or lesbian person. In doing so, such educational institutions are providing some supports for lesbian and gay learners. Institutions of higher education are under no obligation to provide content related to gay men or lesbians, but the Council on Social Work Education (CSWE) does mandate that such content be included at both the baccalaureate and master’s levels of social work education (Council on Social Work Education, 1994). In 2009 CSWE and Lambda Legal provided data related to social work students’ preparedness to provide services to gay and lesbian clients (Council on Social Work Education, 2009). Even so, the inclusion of such content is spotty, and accreditation site teams routinely overlook how well content on lesbians and gay men is being provided. It seems the educational system is as guilty of institutional homophobia as the legal and religious sectors. Families can also function as a source of support or stress for gays and lesbians. Nongay parents who have to come to grips with the reality

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that a son or daughter has a sexual orientation that differs from the norm. Parents generally do not understand the developmental and coming-out processes faced by their children, and gay and lesbian youth are at risk of familial verbal abuse, physical abuse, rejection, emotional distancing, and isolation. Coupled with the institutional homophobia encountered at school, these possibilities can cause the young lesbian or gay to become depressed, quit school, run away, abuse alcohol or drugs, or commit suicide (Child Welfare League of America, 2012; Grossman, 1997). As in other areas, though, there have been some changes in the interactions between gays and lesbians and their families. Once considered such a stigma that the disclosure of a homosexual identity to a family member was deemed unthinkable, by the end of the twentieth century more and more gays and lesbians were sharing their sexual orientation with various family members. And although responses to this disclosure vary, more supports are now in place than ever before to help struggling family members with this information. The bestknown such organization is Parents, Families, and Friends of Lesbians and Gays (PFLAG). Comprised primarily of people with gay and lesbian family members, PFLAG is concerned with the rights of lesbian and gay children, adolescents, and young adults. PFLAG has a myriad of initiatives, including Safe Schools for All, Straight for Equality, and others aimed at ensuring that gay and lesbian family members are accorded equality (Parents, Families and Friends of Lesbians and Gays, 2012b). By supporting family members, PFLAG helps families provide support for their gay and lesbian children. And with chapters in every major metropolitan area, many families who want to be a support system for their lesbian or gay family member can do so. Vulnerabilities and risk factors Being lesbian or gay does not intrinsically place a person at risk; however, the social context

creates vulnerability for gays and lesbians. Lesbian and gay persons are vulnerable and at risk in the heterocentric society primarily because of their differing sexual orientation and society’s continuing efforts to disavow homosexual behavior and homosexuality; this struggle has been documented since antiquity (Boswell, 1980. Although some positive steps to ensure equal rights for gay and lesbian persons are being implemented, the population is still vulnerable and continues to be at risk. Lesbians and gays are most vulnerable primarily in the larger heterocentric society where they are likely to be employed, have family, and function within societal norms. However, gay men and lesbians may also be at risk in the smaller homocentric society where they seek refuge, create families of choice, and socialize. This section explores major vulnerabilities of the population and identifies pressing psychosocial needs. Gay and lesbian persons cannot exist totally outside the larger, heterocentric social order. This social structure is predominantly heterosexual, and norms and mores mirror those of the dominant members. At best, gay men and lesbian women are seen as productive members of society; at worst they are seen as mentally ill deviants. As there is no one prevailing view of lesbians and gay men, just knowing when it is acceptable to acknowledge a deviant sexual orientation or not can be a source of anxiety and risk. Generally, there are various points across a gay or lesbian life where one is more vulnerable and at risk than at other times. And while developing a lesbian or gay identity is not a linear activity, one way of highlighting these is to explore them from a life-span perspective within both the heterosexual society and the smaller gay subculture. The topic of sexuality as related to preadolescent children is still one that is infrequently discussed, and the topic of lesbian or gay sexuality among young children is generally ignored. The exploration of gay or lesbian adolescent sexuality began in the early 1980s and is still emerging. However, from the research that has been

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conducted, several vulnerabilities and risk factors emerge for young lesbians and gays. From the nongay society a young gay or lesbian faces possible verbal, physical, or sexual assault; sexual exploitation; or victimization simply on the basis of a differing sexual orientation. To be considered a member of a stigmatized minority causes victimization, scapegoating, oppression, and social isolation (Child Welfare League of America, 2012; Grossman, 1997; Parents, Families, and Friends of Lesbians and Gays, 2012b). Moreover, during adolescence many individuals become aware of their sexual orientation, so their identity is not yet consolidated. This is complicated by the fact that gay and lesbian youth “typically enter adolescence with no preparation for the social identity that comes with being a sexual minority person . . . GLBT youth commonly do not see themselves reflected in their families, among their neighbors, or within their faith communities. Positive role models are not nearly so easily visible and available for them as they are for heterosexual youth” (Morrow, 2004, p. 92). Gay and lesbian youth are vulnerable to victimization both in the school setting and within their families. One study found that gay and lesbian adolescents were more likely to experience parental physical abuse than their heterosexual peers (Friedman et al., 2011). Research has also documented higher rates of sexual abuse among young gays and lesbians (Friedman et al., 2011; Tyler, 2008). In addition to these traumatic experiences, many gay and lesbian adolescents are subject to bullying and homophobic victimization by their peers in school (Birkett, Espelage, & Koenig, 2009), which may result in truancy (Friedman et al., 2011). Not surprisingly, school victimization has been linked to other negative outcomes, including smoking, alcohol use, marijuana or cocaine use, and risky sexual activities (Bontempo & D’Augelli, 2002). Another significant risk for gay and lesbian adolescents is suicide. Many studies have documented the increased prevalence of suicidality

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among sexual minority youth as compared to their heterosexual peers (Hatzenbuehler, 2011; Silenzio, Pena, Duberstein, Cerel, & Knox, 2007; Zhao, Montoro, Igartua, & Thombs, 2010). This is true even for gay and lesbian youth of color, which is notable given that ethnic minorities generally have lower rates of suicide than whites (O’Donnell, Meyer, & Schwartz, 2011; Walls, Freedenthal, & Wisneski, 2008). Not surprisingly, experiences of victimization and a lack of social supports are associated with an increased risk of suicide (Hatzenbuehler, 2011; Liu & Mustanski, 2012). Social workers also must be aware that gay and lesbian youth are most vulnerable to suicidality when they are in the midst of disclosing their sexual orientation to their families (Igartua, Gill, & Montoro, 2003). In addition to suicide, there are several other risk factors for gay and lesbian adolescents. Sexual minority youth are more likely to engage in substance abuse; among college students, this is particularly true for lesbians (Marshal Friedman, Stall, & Thompson, 2009; Ridner, Frost, & LaJoie, 2006). Lesbian and gay youth are also disproportionately represented among the homeless, either because they have been evicted from their homes or because they have chosen to run away (Rosario, Schrimshaw, & Hunter, 2012). Once homeless, they may engage in sex work in order to survive, which places them at risk of HIV (Marshall, Shannon, Kerr, Zhang, & Wood, 2010). For young men of color who have sex with men, HIV/AIDS is a significant risk; among men aged 13 to 24, HIV diagnoses increased 45.8 percent among Latinos and 93.1 percent among African Americans between 2001 and 2006 (Phillips, Wohl, Xavier, Jones, & Hidalgo, 2011). Growing up gay or lesbian has its risks, but several risk factors also are associated with being an adult lesbian or gay person. As has been said, remaining myths and stereotypes associated with homosexuality still color the way many view gay men and lesbians. These, coupled with institutional homophobia, tend to create situations in which adult gays and

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lesbians may be vulnerable and at risk. Such situations include legal proscriptions that make same-sex sexual behaviors “unacceptable” and employment and other discrimination based on sexual orientation “acceptable.” Because no universal laws exist to provide civil rights for gay men and lesbians or protect them from discrimination, lesbians and gay men are at risk for civil rights violations and discrimination in employment or housing. As a result, often gay men and lesbians simply hide their sexual orientation and “pass” as heterosexuals. However, this secretive lifestyle takes its toll. The risk of victimization does not end at adolescence; many gay and lesbian adults continue to suffer from violence and other traumatic events. One study found that gays and lesbians reported higher rates of childhood maltreatment, interpersonal violence, trauma to a close friend or family member, and unexpected death of someone close than did heterosexuals (Roberts, Austin, Corliss, Vandermorris, & Koenen 2010). Unfortunately, gays and lesbians are also at risk within their intimate relationships. Perhaps because of the stresses associated with an unsupportive social environment, domestic violence is more prevalent in same-sex relationships than in heterosexual ones (Alexander, 2002; Burke & Owen, 2006). Moreover, victims may lack the social supports that would allow them to leave an abusive relationship (Peterman & Dixon, 2003). The risk of victimization is one reason that gay and lesbian adults tend to have higher rates of mental health issues than do heterosexuals (Burgess, Lee, Tran, & van Ryn, 2007). Gay men in particular are at higher risk of mood and anxiety disorders, in part because of issues associated with HIV infection (Bostwick, Boyd, Hughes, & McCabe, 2010; Cochran & Mays, 2009). Gays and lesbians also experience high rates of substance abuse; they are twice as likely as heterosexuals to have co-occurring mental health and substance abuse issues (Green & Feinstein, 2012; Hughes & Eliason, 2002; Lipsky et al., 2012). Again, the risk of substance

abuse appears to be directly linked to experiences of oppression and victimization, as well as internalized homophobia (Hughes, McCabe, Wilsnack, West, & Boyd, 2010; Weber, 2008). This is particularly true for gays and lesbians of color. One study found that individuals who experienced discrimination on the basis of three aspects of their identity—sexual orientation, race, and gender—had rates of substance abuse that were nearly four times higher than those of gays and lesbians who did not report any discrimination (McCabe, Bostwick, Hughes, West, & Boyd, 2010). Among Native Americans, rates of both substance abuse and mental health issues are higher for two-spirits than for heterosexuals, as are rates of childhood physical abuse (Balsam, Huang, Fieland, Simoni & Walters, 2004). A final risk factor that is especially salient for gay men is HIV infection. As noted above, the gay community continues to be disproportionately affected by HIV/AIDS, and men of color who have sex with men are at particularly high risk. This may be linked to high levels of internalized homophobia, which makes it difficult for them to discuss their same-sex behavior with others (O’Leary, Fisher, Purcell, Spikes, & Gomez, 2007). There is a constellation of factors associated with HIV risk behaviors among gay men, all of which are interrelated: sexual compulsivity, depression, childhood sexual abuse, intimate partner violence, and polydrug use (Parsons, Grov, & Golub, 2012). While a full discussion of the challenges of living with HIV/AIDS is beyond the scope of this chapter, HIV has important implications for the mental health of infected individuals (Cochran & Mays, 2009). Younger gays and lesbians are at risk because of their youth, adult lesbians and gays are vulnerable simply because they are often seen to lead a deviant lifestyle, and older gay men and lesbians are vulnerable and at risk because (like their adolescent counterparts) they are virtually invisible. In the almost forty years that lesbian and gay aging has been a focus of limited study,

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it has been determined that, like their nongay counterparts, older gay men and lesbians are a vulnerable and at-risk population. Like other populations of lesbians and gays, older gay men and lesbians find themselves at risk both in the larger heterocentric society and in the smaller gay and lesbian subculture. Doomed to potential invisibility in both the nongay larger social order and in the lesbian and gay community, aging gay men and lesbians are often assumed to be nonsexual beings whose issues and familial structures are similar to other groups of older women and men. This invisibility makes older gays and lesbians vulnerable and at risk simply because their needs are neither known nor cared about. But perhaps invisibility is preferable to prevailing myths and stereotypes in both the nongay and gay/lesbian worlds about older persons generally and older lesbian and gay persons specifically. By the time older gays and lesbians have survived to old age, most have adapted to their sexual orientation and dealt with members of their biological families. Family members who are supportive of the gay or lesbian relative remain as members of the family of choice; those who are not supportive are often ignored and not considered “family” (Tully, 1983). But for those older gays and lesbians who have hidden their sexual origin from their families of origin and who face providing care to parents or siblings, there are untold risks. Can the elderly parent of a gay couple move in with the aging couple? Should an older gay man leave his home and partner of forty years to move in with his father? What should the growing older couple do with a younger mentally ill brother? What are the consequences for the surviving member of an aging gay or lesbian couple when one partner dies? These and scores of other dilemmas face aging gay men and lesbians who have living family-of-origin members and can cause a number of consequences. Relationship stress, depression, anxiety, and guilt can lead to more damaging behaviors such as substance abuse and withdrawal.

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While families of origin can cause problems for the older gay man or lesbian, there may also be stresses associated with their families of choice. Because their relationships are often not legally recognized, it may be particularly challenging for gays and lesbians to negotiate many of the transitions of old age: declining health, the death and dying of a partner, and ensuring adequate financial reserves. When an aging gay or lesbian’s partner begins to experience declining health, for example, the services traditionally available do not usually consider sexual orientation. Such service organizations tend to overlook a partner as a source of support and information, preferring instead to call on legal relatives. It is also not uncommon for the surviving partner of a gay or lesbian couple to be the sole beneficiary of the partner’s estate only to have the will challenged legally by members of the deceased’s biological family. Too often, family-of-origin members, children, or other legal relatives will be seen as the lawful heir. Older gays and lesbians, then, face multiple challenges, and often they lack the supports that would help them to navigate the stresses of aging (King & Dabelko-Schoeny, 2009). These stresses are compounded by stigma, isolation, and invisibility (Kertzner, Barber, & Schwartz, 2011). Not surprisingly, all of these issues take a toll on the mental health of older gays and lesbians. Discrimination and internalized homophobia both are associated with mental health issues, including depression, suicidality, substance abuse, low self-esteem, and loneliness (D’Augelli, Grossman, Hershberger & O’ Connell, 2001; Frederiksen-Goldsen, Kim, Muraco, & Mincer, 2009). Lesbians in particular seem to have high rates of alcohol abuse throughout the life cycle, and continuing into old age (Boehmer, Miao, Linkletter, & Clark, 2012; Masini & Barrett, 2007). As described, significant risk factors are associated with being lesbian or gay, and they are all associated simply with a sexual orientation that differs from most of the population. As a result, this population is vulnerable to a variety

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of unhealthy possibilities. While all gay and lesbian persons face similar heterocentric societal challenges, not all gay and lesbian persons see themselves as either vulnerable or at risk. However, data indicate that at some point in every lesbian or gay life the individual has been vulnerable and at risk due to institutionalized, individual, or internal homophobia. resiliencies and Protective factors Resiliency and protective factors are seen as those things, both tangible and intangible, that enable gay men and lesbian women to exist and function in an often hostile environment. Just as the social context places gays and lesbians at risk, the social context concomitantly provides gays and lesbians with sources of support and resiliency. Across the life span, many gays and lesbians have coped with homophobia by assuming a cloak of invisibility. While some may argue that to be invisible is to deny a vital part of one’s identity, to not do so might be more injurious. But increasingly lesbians and gays are choosing to remain visible, and to share their sexual orientation in the workplace, at church, at school, and with family members. Sharing what has been defined as a deviant lifestyle may carry risks, but it also carries the reward of not denying part of the self. As more role models emerge in the media, are historically claimed, and are seen in major films, theatre, and television, more gays and lesbians will find it easier to come out. And as more legal, economic, religious, educational, and familial supports emerge, lesbians and gay men will find it less necessary to camouflage themselves to part of the world. However, decisions around visibility and invisibility remain an important source of protection for gays and lesbians. Another significant resiliency factor is the creation of supportive communities. Some gays and lesbians receive support in their families of origin, while others rely on the cloak of invisibility within their families. If camouflage is not possible, other coping mechanisms include

distancing from the family (which in teens may mean running away), denial of sexual orientation, or honesty and attempts to work things out. But many gays and lesbians turn to the gay community for instrumental and emotional support, creating families of choice that fill those needs that are unmet by their families of origin. Friendship networks provide the primary source of these familial configurations, and they can be as simple or as intricate as any traditional family structure and may or may not include members of the biological family of origin. These families of choice historically have been and continue to be the mainstay of lesbian and gay endurance. Gay and lesbian people have always existed and have always managed to find one another and to provide support for one another even in grim times (Appleby & Anastas, 1998; Mallon, 1998; 1998; Tully, 1995; Walker, 1999). Often, no legal marriage vows bind gay or lesbian couples, traditional heterocentrist society creates barriers for them, and yet in rural, urban, and suburban areas, lesbians and gay men exist and even flourish. For many gays and lesbians, invisibility and families of choice are important protective factors that operate across the life span. In addition, just as the factors contributing to vulnerability change across the life span, so too do the factors that support resiliency. Young gays and lesbians function primarily within two settings: school and family. Within both these settings, social support—from friends, peers, family, other adults, and social groups—is a major protective factor, and this support may be particularly critical for gay and lesbian youth of color (Rutter, 2008). Of particular significance is the reaction of others to a young person’s disclosure of his or her sexual orientation. Positive reactions can act as a protective factor against substance abuse, while negative reactions are associated with increased substance use or abuse (Rosario, Schrimshaw, & Hunter, 2009). While the elementary and secondary school systems are not often thought of as being an area

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of support for gay and lesbian students, some positive changes are starting to occur. As mentioned above, organizations such as GLSEN have been instrumental in promoting these changes. Gay-straight alliances and support from teachers are both valuable resources for gay and lesbian students (Murdock & Bolch, 2005; Saewyc, 2011; Walls, Freedenthal, & Wisneski, 2008). Just as gay and lesbian youth need support from their peers, they also benefit from the presence of supportive adults. The family is an area of critical importance for young people. As discussed above, families may have a range of reactions to the discovery that a child is gay or lesbian. PFLAG can be a helpful support for families struggling with this information. For gay and lesbian youth, family acceptance of their sexual orientation is linked to greater self-esteem and to decreased risk of depression, suicidality, and substance abuse (Ryan, Russell, Huebner, Diaz, & Sanchez, 2010). Support from adults outside the family is important as well, as it can protect youth from the impact of victimization (Darwich, Hymel, & Waterhouse, 2012). Remarkably, the majority of gay and lesbian adolescents seem to be able to find enough support—from peers and adults—to negotiate this challenging stage of life: More important, most LGB youth are “ok.” Of the 101 youth in this study, there were only 14 adolescents in the “Highly Vulnerable” group . . . These numbers are no different than what you would likely expect from a random sample of high school students. (Murdock & Bolch 2005, p. 167)

Adults live their lives in the context of a number of systems: legal, economic, religious, and family. As discussed above, there have been positive changes in all these systems that can provide important support to adult gays and lesbians. These developments vary significantly by geographical region, and urban centers often provide more opportunities for support to gays and lesbians. For example, in some areas, a gay and lesbian subculture has developed that

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includes gay-owned and -run businesses. All major cities in the country now boast openly lesbian- or gay-owned establishments that cater to gay and lesbian clientele. Adults also benefit from the support provided by families by choice. Another important resiliency factor is humor. One study found that seventy percent of the participants used humor as a means of coping with homophobia and heterosexism (Willard, 2011). It was helpful both in interaction with others and in managing personal stress. Humor represents a highly adaptive means of negotiating a stigmatized identity. Just as social support is critical for gays and lesbians in adolescence and adulthood, it is a major resiliency factor for older gays and lesbians as well. Again, it is the family of choice that is the primary source of support. One study found that support from friends, rather than family of origin, was linked to better quality of life, decreased internalized homophobia, and lower rates of depression and anxiety (Masini & Barrett, 2007). Among chronically ill older adults and their caregivers, the quality of the relationship appears to decrease the risk of depression (Fredriksen-Goldsen, Kim, Muraco, & Mincer, 2009). Older gays and lesbians continue to be at risk, but this will be less true as the social context changes. With more legal protections for same-sex relationships, and more acceptance generally of gay and lesbian lifestyles, gays and lesbians will face fewer stressors as they age. Moreover, older gays and lesbians have many years of life experience that can help them to negotiate the challenges of the aging process. Programs and Social Work contributions In discussing the role of social work with the gay and lesbian population, it is necessary first to acknowledge that, as part of a larger heterosexist environment, the social service system is permeated with homophobia. Institutional homophobia impacts social service agencies in terms of policies and procedures that tend

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to perpetuate myths and stereotypes about lesbian and gay clients. For example, gay or lesbian couples are prohibited in many localities from becoming foster parents. Likewise, lesbian or gay couples are prohibited in many jurisdictions from jointly adopting children (McClellen, 1998; National Gay and Lesbian Task Force, 2011). Often social service agencies still define families in a heterosexual fashion (perpetuating the myth that all persons are heterosexual) and fail to develop policies that are reflective of their entire caseload. Because many jurisdictions do not allow gay and lesbian couples to marry, those couples are not privy to some services available to heterosexually married couples. Older gays and lesbians may be particularly vulnerable to institutional homophobia; there are few services that address their specific needs, and one study found that providers were resistant to offering these services (Hughes, Harold, & Boyer, 2011). Offices in traditional social service agencies may not be seen as “homosocial” (accepting of lesbian and gay clients) because waiting areas are devoid of gay-friendly reading materials, intake forms are heterosexually biased, and personnel perceive all clients as heterosexual. These institutional issues, while slowly changing, are also reflected in the individual homophobia of many service providers, who through ignorance, insensitivity, or intent, may cause gay or lesbian clients to avoid services. Historically, social workers have been found to be just as homophobic, if not more so, than members of the general population and other helping professionals More recent studies tend to indicate that social work students may be more comfortable with lesbian or gay individuals vis-à-vis groups of nonheterosexuals, that race and socioeconomic status or religion may influence homophobia, and that social work students can be influenced by institutional homophobia (Cluse-Toar, Lambert, Ventura, & Pasupuleti, 2004; Krieglstein, 2003; Sun, 2002; Swank & Raiz, 2007). Those individuals who

actually provide services are in a position to soften institutional homophobic policies and procedures, but they are also in a position to further institutional homophobia by displaying individual homophobic attitudes. These attitudes become operationalized through an individual’s assumption that all clients are heterosexual (the heterosexual assumption), the belief that lesbian or gay clients require services because of their sexual orientation, or falling victim to believing any lesbian or gay myth or stereotype. Finally, internal homophobia can play a significant role in the ability of a gay man or lesbian to seek services in the first place. For people who grow up and live in a predominantly heterosexual world where institutional and individual homophobia are real, the symptoms of internal homophobia can range from mild anxiety to suicide. Certainly traversing the route to become a client in what may be viewed as a traditional institution filled with prevailing stereotypes about sexual orientation and being confronted with personnel who are homophobic could tend to justify internal homophobia. These forms of homophobia may be present at all levels of social work practice. Micro-level programs are customarily defined as those social work services and interventions designed to be used with individuals, couples, groups, and families. Such interventive strategies have been part of social work since the emergence of the profession. There are still few social service agencies whose services are aimed solely at members of the lesbian and gay community, although there are social work practitioners in private practice whose clientele are primarily gay or lesbian, and within traditional social service agencies programs for gays and lesbians may exist. Generally, the lesbian woman or gay man seeking social services will be confronted with the same array of service providers as their nongay counterparts. And, also like their nongay counterparts, services provided to gay

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or lesbian persons may be voluntary, suggested, or mandated. Because gay and lesbian people may voluntarily seek services for depression, anxiety, low self-esteem, relationship problems, substance abuse, health issues, sexual dysfunction, coming out, and having and raising children, social workers play roles similar to when working with nongays. Thus, it is appropriate for the social worker’s roles to include those of social broker, enabler, teacher, mediator, and advocate, as each of these interventive roles has its appropriate place when working with lesbians and gays. Although common presenting problems and interventive roles are similar for nongay and gay populations, the social worker must avoid both the “heterosexual assumption” (the assumption that all clients are heterosexual) and all forms of homophobia. Often gay men or lesbians seek social services for reasons totally unrelated to their sexual orientation, but when issues about coming out, sexual dysfunction, HIV/AIDS, or sexual identity issues are the presenting problem, social workers must know how to create a homosocial space that is safe for gay or lesbian self-disclosure. Micro-level social work roles that have been particularly evident since the outbreak of HIV/ AIDS include those individual and group services developed for persons who are HIVpositive. Since the early 1980s, social workers have played a key role in providing support services, caregiving, and finally hospice services to countless numbers of those affected by the AIDS pandemic. And, while HIV/AIDS is no longer considered the death sentence it once was, social workers must continue to play an active role in ensuring appropriate services for those with HIV/AIDS and help younger gays to be aware of the continuing risk of contracting HIV/AIDS unless they practice “safer” sex. Groups for gay and lesbian adolescents are another useful micro-level intervention, as they provide support to youth who may feel isolated

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in their schools or communities (Medeiros, Seehaus, Elliott, & Melaney, 2004). Mezzo-level programs that revolve around community have, like micro-level interventions, been part of professional social work since its beginning. They are concerned with advocacy, mobilization, service, and organization within communities and seek to promote change at the community level (Kahn, 1995). Social work professionals provide services on behalf of gay men and lesbians within both the larger heterocentric community and the smaller lesbian and gay community. Within the gay and lesbian community, social workers have created agencies dedicated to gay and lesbian youth, have mobilized gay and lesbian community members to demand appropriate funding for HIV/AIDS research and medications, have created elaborate political action committees to ensure their civil and legal rights, and have worked tirelessly to protect existing freedoms for gays and lesbians. Within the larger community, social workers working in local and state agency settings where homophobic policies and practices exist should work toward the institutionalization of a homosocial space that accepts diversity and avoids vestiges of institutional homophobia. They may also advocate for the creation of programs specifically for gays and lesbians within these larger agencies. Macro-level programs are those professional social work activities related to the social institutions with which persons must interact in the course of daily living. Social workers have participated in demonstrations for gay and lesbian civil rights, have helped create laws and policies aimed at eliminating discrimination on the basis of sexual orientation, and have worked toward erasing institutionalized homophobia. These kinds of interventions have lasting and significant impact on the lives of gays and lesbians. At all levels, social workers have an obligation to ensure the protection of lesbians and gays and to strive to eliminate institutional homophobia in all areas of practice.

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assessment and interventions Gay men and lesbians often seek services for similar reasons as their nongay counterparts. The constructs of assessment and interventions seem to be two sides of the same coin, and as such both need exploration to ensure appropriate services for gay and lesbian clients. The term assessment can mean the process of evaluating or appraising, or understanding and evaluating. In social work, assessment is usually conceptualized as the professional process undertaken by the social worker to reach an understanding of the presenting problem, the client, and the current situation in order that appropriate interventive strategies can be developed and utilized to alleviate or solve the problem (Gitterman & Germain, 2008; Wood & Tully, 2006). Because the lesbian and gay population is heterogeneous, it is impossible to detail assessment strategies for every social service need of the group. Rather, this section will present what have generally been seen as unique issues facing gay men and lesbian women—invisibility and the heterosexual assumption, homophobia and its impact, and developing a sexual identity and coming out. A key element in the assessment process is that of client and worker understanding of the current situation and the person in that unique situation. Being a lesbian or gay person is not unlike being left-handed—it is not readily apparent, may be extremely awkward at times, but is always part of the person. It may or may not be relevant to the reason a client is in need of services. For example, Cecelia, a 54-year-old lesbian who was the guardian of her 90-yearold hospitalized terminally ill mother, was referred to the hospital social worker to assess the mother’s pending death and the impact it might have on Cecelia. Her sexual orientation was not germane to the immediate problem, but it would be important to know that Cecelia’s partner of thirty years was the primary caretaker of Cecelia’s mother and more likely to need the services. But in the case of Bob, a 27-year-old married man who had recently had

his first sexual experience with a male lover and was confused about his sexual identity, knowing his sexual orientation would be critical to the assessment process. The reality is that many social workers still assume their clients to be heterosexual. This denies the opportunity for honest dialogue and assessment from the beginning of the client/practitioner relationship. To be skilled at assessing the sexual orientation of a client, social workers can make their offices and waiting rooms “homosocial.” Including gay- or lesbian-oriented journals, popular newspapers, or magazines is one simple yet effective means to convey acceptance. Similarly, intake forms should be designed to include routine questions about living situations that are not biased toward a heterocentric model—rather than asking about a “spouse” or “relatives,” one could ask about important people in the client’s life and let the client provide the nature of the relationship. Also, social workers need to listen closely when clients are sharing their unique situations. Possible keys to sexual orientation may (but not always) include long-term relationships with members of the same sex, living with a member of the same sex, being involved in lesbian or gay organizations, or referring to a same-sex relationship with such terms as significant other, partner, lover, mate, co-vivant, or good friend. Clues to sexual orientation may be provided if clients are known to frequent gay or lesbian restaurants or bars, or are frequently seen involved with activities in the gay or lesbian community, or subscribe to popular gay press publications. However, extreme caution must be used when following what may be seen as stereotypes and generalities because many nongay persons also use similar terminology, frequent similar establishments, and read similar publications. While it is acceptable to ask about sexual orientation, nongays may be put off by the suggestion that they were perceived as something else, and gays and lesbians may not be immediately forthcoming with the information. The discussion of anything sexual is still highly

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emotionally charged and must be handled with dignity and sensitivity. A huge hurdle is simply having the social work practitioner overcome personal fears of discussing sexual matters. Social workers must also realize that just because a person is lesbian or gay may or may not be the reason for the visit and that gay men and lesbians tend to reveal their sexual orientation (or come out to the worker) when there is some need to do so (Tully, 1989). Likewise it is understandable if clients inquire as to the sexual orientation of a social work professional. Although data indicate gays and lesbians do not tend to choose professionals on the basis of the professional’s sexual orientation (LeBlanc & Tully, 1999; Tully, 1989), revealing one’s sexual orientation to a client can have positive or negative effects (Anthony, 1981–1982; Woodman, Tully, & Barranti, 1995). The prevailing professional wisdom is for the practitioner to use discretion and have some compelling reason for sharing the information. For example, Rocky, an 18-year-old gay high school student living in a rural area, was involuntarily placed in therapy to “cure” him. His social worker, a 35-year-old successful gay man, accurately assessed Rocky as suicidal and shared with him possible coping strategies. But, Juanita, a 76-year-old lesbian who had lived with her partner for forty years, was horrified when her social worker shared her personal sexual orientation and then questioned Juanita about her sexual orientation. Her reply was that sexuality was a matter of privacy and that she and Anna simply shared a one-bedroom apartment to save money. The social worker must be aware of the impact of homophobia on gay and lesbian clients. Certainly not every gay or lesbian person has experienced every form of homophobia, and while some may deny having ever experienced homophobia, it is virtually impossible to grow up in a nongay world and be totally immune to some facets of homophobia. Further, social workers must be aware of the impact of homophobia on themselves. All

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these dynamics can play an important role in the assessment process. That homophobia has impacted a lesbian or gay client at some point in time is a reality, but whether or not homophobia is involved in a presenting problem may not be immediately clear. In overt cases of discrimination or abuse, homophobia may be easily identified in the assessment process. However, if the homophobia is subtle, even the client may not recognize it as such and overlook it as an issue. Clients may internalize homophobia and the resulting consequences of this may include low self-esteem, depression, suicidal ideation, substance abuse, isolation, self-loathing, heterophobia, or acting out. And while these symptoms are not symptomatic of lesbians and gay men exclusively, in the assessment process they must be considered as a possible consequence of homophobia. Internalized homophobia, like other issues associated with homophobia, may or may not be related to the need for interventive services. A discerning social work practitioner will be able to determine from the client’s narrative the extent to which homophobia relates to the situation of the client and the client’s present psychosocial environment. Another important issue in the assessment of gay and lesbian clients is the individual’s place in the coming-out process. For the gay or lesbian, the process of developing a sexual identity has been characterized as nonlinear and occurring at any chronological age. The coming-out process has been described as one of possible crisis, confusion, and disquiet (Morris, 1997; Savin-Williams, 1996). While there are several models for coming out, they have the following elements in common: • The coming-out process is not linear and is not related to chronological age. It is multidimensional and includes cognitive, behavioral, emotional, and sexual aspects. • At some point the individual feels different from nongays because of strong emotional attachments or sexual feelings for

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members of the same sex. These feelings can be ignored, repressed, questioned, denied, accepted, or acted on. • Having identified the awareness and accepted its reality, the individual defines the concept of homosexuality in an attempt to make it an acceptable part of the personality. This may include identity confusion, involvement with the gay and lesbian community, alienation from the heterosexual community, hetero- or homosexual experimentation, ambivalence, denial, or acceptance. • Having adopted a positive internalized acceptance of homosexuality, the individual tends to become more involved in the gay and lesbian community by developing intimate same-sex relationships, the internalization of a gay or lesbian identity, the disclosure of this identity to others, and a psychologically healthy view of the self in spite of institutional homophobia. Once a person’s sexual orientation has unfolded, it generally remains “stable, consistent, and endures throughout the life course, although changing social norms and opportunities for relationships might influence how that orientation is manifested” (Saewyc, 2011, p. 258). Coming out may or may not be the primary reason for intervention. However, it has been documented that the early phases of coming out are a time when gay men and lesbians may need intervention (Cass, 1979; Child Welfare League of America, 2012; McDonald, 1982; Morris, 1997). It is important for the social worker to assess the point in the coming-out process that the client is in, as appropriate interventive services for a teenager confused about her or his sexual identity will vary considerably from services developed to help an aging lesbian who has a positive sexual self-view but is dying. It is also important for social workers to be aware that issues of disclosure may be more challenging in the earlier stages of the coming-out

process. Workers need to respect clients’ decisions about how much and when to come out to others (Morrow 2004, p. 94). A thorough and sensitive assessment lays the foundation for effective social work intervention. The concept of intervention is usually described as those professional social work activities defined by interventive roles used to achieve the goals that emerge as the result of the assessment phase (Wood & Tully, 2006). While the assessment phase is used to identify and clarify problems and possible solutions, the intervention phase is designed to develop and operationalize a feasible scheme for addressing or solving those problems. The traditional interventive social work roles of social broker, enabler, teacher, mediator, and advocate (Pinderhughes, 1995; Wood & Tully, 2006) all have utility when dealing with gay men and lesbians; how each role can be applied is discussed next. Social brokering is linking those in need with existing services that may be of benefit. Gay men and lesbians have varying knowledge of what supportive services and community linkages are available. Those new to a lesbian or gay identity may have fewer resources available simply because their knowledge is limited. Social work practitioners have an excellent opportunity to link gays and lesbians to resources only if the social worker is aware of existing possibilities. A powerful tool available to the gay and lesbian community as well as the social work professional is the Internet. Abundant resources related to the gay and lesbian experience are easily accessed. Popular websites include those of HRC (http://www.hrc.org), NGLTF (http:// www.ngltf.org), GLSEN (http://www.glstn.org), PFLAG (http://www.pflag. org) and the It Gets Better Project (http://www.itgetsbetter.org). All provide links to other equally worthwhile sites and all provide a realistic glimpse into the gay and lesbian community. Coupled with a working knowledge of lesbian and gay resources available in the worker’s own community, an ability to link clients with the appropriate service will fulfill an important

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function. For example, Todd, a 28-year-old sexually promiscuous gay man, confides to his social worker that he has not been practicing safe sex and is fearful he may be HIV-positive. To be unable to tell him where to be tested and of available services would be untenable. Or if parents suspect one of their children to be gay or lesbian, they can be referred to the local PFLAG group. Another tool of intervention is the role of enabler. Enablers assist clients to discover within themselves strengths and resources to cope with and create changes necessary to accomplish the goals of the agreed-to service contract. The enabler allows the client to create the needed environmental changes by supporting client activities through encouraging articulation of issues, allowing for venting, providing encouragement, or providing logical discussion (Wood & Tully, 2006). This role can have utility when working with members of the gay or lesbian community. It is not uncommon for lesbians or gay men to have internalized aspects of homophobia that may lead to depression or lowered selfesteem. Coming out can lead to sexual identity confusion, and a perceived lack of generalized social support for their lifestyle can cause gays and lesbians to feel disenfranchised. However, as noted earlier, gay men and lesbians have a tremendous capacity for resiliency. This strength may be eclipsed by heterocentrism, however, and social workers may find it necessary to help gay and lesbian clients discover the power within themselves and within the gay and lesbian community. For example, the police referred Stella, a physician, to the social worker. She complained of being physically abused by her “friend.” Through the assessment phase it became clear that her live-in lesbian lover had beaten Stella. While she was angry, hurt, and upset at what had happened, Stella was not certain what to do next. After assessing that Stella was not in need of medical treatment and that she had a safe place to spend the night, the social worker encouraged Stella to verbalize her

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feelings and vent. This allowed for an examination of the relationship and began to provide steps for a possible solution. With encouragement and reassurance, Stella formulated an appropriate goal and steps by which to attain that goal on her own. A third interventive role that has profound implications for working with gay and lesbian clients is that of teacher. The teacher role is one where the social worker is in a position to provide new information needed for coping with or remedying situations faced by the client. There is a vast amount of misinformation, myths, and stereotypes associated with lesbian women and gay men. Both social work practitioners and clients may play the role of teacher. Social workers may look to their gay and lesbian clients for information related to the lesbian and gay experience, and social workers have a chance to provide information to gays and lesbians related to differing ways of addressing problems. The teaching role then becomes a reciprocal one where both the client and the professional provide and create new ways of thinking. Enabling and teaching have overlapping functions. Enabling encourages clients to use existing resources, and teaching encourages the introduction of new resources designed to help clients cope with and solve problems (Wood & Tully, 2006). A fourth interventive role appropriate for use with lesbian or gay clients is that of mediator. Mediation is that activity designed to resolve or settle disputes between the client and systems in which they operate. A social worker who is knowledgeable about the gay and lesbian lifestyle and resources available can provide countless services on behalf of clients who, because of legal or religious proscriptions, may have been silenced. Mediation can take many forms including disputes related to terminating gay or lesbian relationships, financial issues, monogamy versus non-monogamy concerns, sexual openness, domestic violence, property settlements, coming-out dilemmas, or parentchild arguments. Again, the caveat must be

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that the social worker understands the gay and lesbian condition in order to be successful at mediation. The fifth interventive role that can be successfully used with gay and lesbian clients is that of advocate. Advocacy is the process whereby the social worker becomes the client’s speaker and presents information on behalf of the client. For example, a young lesbian mother living in a conservative rural Louisiana town was engaged in a custody battle with her alcoholic ex-husband. The two children, both girls, were aged 5 and 7. Both wanted to live with their mother, but the father was unwilling to allow that because of his ex-wife’s lesbianism. The mother’s lawyer contacted a social worker to testify as an expert witness and advocate on behalf of the mother. Based in part on this intervention, sole custody was granted to the mother. Had the social worker not had a detailed knowledge of the realities of lesbian parenting and related research associated with homosexuals and homosexuality, the chances are good that the outcome might have been different. illuStrAtion And diSCuSSion

Gay and lesbian persons are as diverse as the society in which they live. They are not identifiable by race, ethnicity, socioeconomic status, age, religion, intellectual abilities, physical capacity, or sex. Moreover, the issues faced by gay and lesbians vary across the life span. Social workers working with this population, then, must be sensitive to the multiplicity of perspectives and experiences of their gay and lesbian clients. The presentation of a single case cannot capture this diversity. The following case discussion, of an adolescent girl struggling with her sexual orientation, illustrates some of the complexities of social work practice with gays and lesbians. Kay, a 16-year-old adolescent, was hospitalized because of a suicide attempt. She is one of four children who live with a single 40-year-old mother, Dana. Dana is a devout member of a strict Southern Baptist church and has raised her children following

strict biblical instructions. Kay had attended Sunday school and church-related activities three times a week as long as she could remember and considered herself a Christian. She also thought of herself as somewhat different from her peers at school and always had close best friends who were girls. As Kay went through puberty and became sexually mature, her emotional feelings for her best friends deepened and she began to have same-sex sexual fantasies. Knowing this was unacceptable, she hid her feelings from her friends and herself. However, one of her best friends wrote Kay what could only be described as a love letter and Kay responded in kind. The couple became inseparable, riding to school together, attending church-related activities together, writing poetry to one another, and talking on the phone daily. Dana paid no attention to these activities until one afternoon when she discovered one of Kay’s more passionate letters, which described in detail her same-sex sexual desires. This discovery caused Dana to confront her daughter, and when confronted with the evidence, Kay did not deny her feelings and said she felt relieved that her mother now knew the truth. Dana demanded that the relationship between the teenagers stop. To ensure Kay’s mental health, Dana contacted her pastor, who referred Dana and Kay to a reparative therapist who could cure Kay of any homosexual tendencies she might be developing. Kay had been in treatment with the reparative therapist for one year. In that time she had been placed on antidepressant medication, had been subjected to aversion therapy, and was forbidden contact with any of her old friends. Her mother had placed her in private school and kept a close watch on her activities. Despite prayer, various group and individual therapies, and medication, Kay still found herself sexually attracted to members of her own sex. Feeling utterly worthless and alone, she overdosed on her prescription medications and her mother’s sleeping pills. Her sister found her in time to save her life, and she is receiving services from the hospital social worker.

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The assessment phase of intervention began when the social worker met with Kay alone. The medical records indicated the attempted suicide but little else. The name of the reparative therapist was listed as a contact. Kay presented as a scared but intelligent young woman who said she wanted no contact with the reparative therapist. She also said she was not interested in seeing her mother at the moment because it was her mother’s fault that she was in her current situation. When asked to explain this, she stopped talking. The social worker had recognized the name of the reparative therapist as one whose practice centered on sexuality and questioned Kay about her association with this person. Through probing, Kay began to share information about her deep spirituality, interest in the church, and her “best friend.” She successfully managed to ignore her past relationship with the therapist. But she did weave a tale that included her mother’s intense dislike of the best friend, pastoral counseling sessions designed to rid the soul of sin, and finally of reparative therapy to “fix” her and make her “normal.” When asked what normal meant, she cried, “You know, not queer!” and burst into tears. Once the sexual orientation issue was identified, Kay was able to share her year of what she described as “torture” while the therapist worked with her to cure her of her sinful ways. Although she said she had tried, she was psychologically and sexually attracted to women and because she knew she could never change, she decided that she would be better off dead and that her family would be better off in the long run not having a queer in the family. She was still uncertain about how she would relate to her mother, because she believed strongly that her mother’s inability to accept her for who she really was had caused her to go through the horrors of reparative therapy and forced her to her suicide attempt. It was important to assess what goals Kay could define in relation to her situation. She had come close to death and found life to be the better option. She wanted to work on things that would make it possible for her to feel okay about herself. First, the social worker explored the relationship between Kay

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and her mother further and discovered a long-term bond between them had been severed because of Kay’s sexual confusion. This deeply saddened Kay and she wondered whether or not the bond could be recreated. She said she would like to work on that. The social worker was acquainted with the gay and lesbian lifestyle and community and asked Kay what she knew about them. The answer was clouded with stereotypes and myths, and they agreed to include a discussion about stereotypes and myths as a goal. A third goal revolved around Kay’s deep Christian faith and its compatibility with same-sex desires. The final goal was related to Kay’s continuation with reparative therapy. As her mother was responsible for the therapy, Kay agreed to the goal of working with Dana to cease this intervention. These goals will require the social worker to be an enabler, a teacher, a mediator, an advocate, and a social broker. As an enabler, the social worker will support Kay’s strengths and desire to live, and encourage her to achieve her goals. As a teacher, the social worker can teach Kay and her mother about the realities of the gay and lesbian lifestyle, and as a social broker, the social worker can link Kay with such resources as the Metropolitan Community Church or other Christian churches that welcome lesbians and gays. As a mediator, the social worker can help resolve differences between Kay and her mother around the issue of sexual orientation, and as an advocate, the social worker can speak to Dana on behalf of Kay in relation to the cessation of reparative therapy with the knowledge that the NASW condemns such therapies.

conclusion The values and ethics of professional social work are well articulated in the NASW’s Code of Ethics. The Code defines six core values that are central to the profession—service, social justice, dignity and worth of the person, importance of human relationships, integrity, and competence (National Association of Social Workers, 1996, 2008). Embedded in these are the central roots of the profession that

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historically defined social work: a belief in the inherent worth of the individual and an individual’s right to self-determination. Pursuant to the professional value stance related to the unique nature of the individual, the Code of Ethics states that “social workers should not practice, condone, facilitate, or collaborate with any form of discrimination on the basis of race, ethnicity, national origin, color, sex, sexual orientation, age, marital status, political belief, religion, or mental or physical disability” (National Association of Social Workers, 1996, 4.02). NASW views discrimination and prejudice directed at any minority as inimical to the mental health not only of the affected minority, but of the society as a whole. The Association deplores and will work to combat archaic laws, discriminatory employment practices, and other forms of discrimination that serve to impose something less than equal status upon homosexually oriented members of the human family. It is the objective of the

social work profession not only to bring health and welfare services closer to people, but also help alter the unequal policies and practices of health and welfare institutions. In 2008, NASW revised the Code related to cultural competency and social diversity by noting that “social workers should obtain education about and seek to understand the nature of social diversity and oppression with respect to . . . sexual orientation” (National Association of Social Workers, 2008, 1.05) and that “social workers should not practice, condone, facilitate, or collaborate with any form of discrimination on the basis of . . . sexual orientation” (National Association of Social Workers, 2008, 4.02). Whether or not sexual orientation has been the focus of the work, social workers have always worked with gay and lesbian clients. It is knowledge, as well as a commitment to social justice, that will allow social workers to practice effectively with this vulnerable and resilient population.

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cHaPter 1 7 Homeless People Jennifer mcclendon and SHannon r. lane

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omeless individuals and families are arguably among the most vulnerable populations helped by social workers. Individuals and families who have lost a safe place of residence are vulnerable to physical threats such as exposure and violence, and the psychosocial threats related to high stress associated with mental health problems and substance abuse. While chronically homeless adult males may be the face of homelessness for many Americans, homelessness and precarious housing affects men, women, and children, families and single persons, youth and adults. Poverty is inextricably linked to the problem of homelessness. In fact, homelessness might be the most visible manifestation of poverty in America, and is certainly one that attracts tremendous attention. On the heels of the recent mortgage crisis and widespread foreclosures, the plight of homeless families received additional media attention. Subprime mortgages allowed families with lower incomes and poor credit histories to achieve home ownership for the first time, but the loans were often poorly understood and unaffordable as interest rates rose over time and monthly payments ballooned for families already on the financial edge (Williams, Nesiba, & McConnell, 2005). In addition, predatory lending, the process of using aspects of the borrowing process to deliberately take financial resources away from borrowers (Gray & Villegas, 2012), targeted members of disadvantaged groups, including those with low incomes, members of minority ethnic groups, members of communities of color, and immigrants (Gray & Villegas, 2012).

The rising rate of foreclosures is also due, in part, to rapidly rising medical debt. Nearly half of all foreclosures have medical causes, and recent estimates suggest that out-of-pocket medical expenses put 1.5 million Americans at risk of foreclosure in 2007 alone (Robertson, Egelhof, & Hoke, 2008). Many Americans losing homes to foreclosure are not the owners of the property, but renters who are forced out when the bank reclaims the property (Downing Phillips, Sermons, Pelletiere & Wardrip, 2009). Nationwide, 79 percent of agencies serving the homeless reported serving clients who recently experienced foreclosure as either an owner or a tenant (Downing et al., 2009). The vast majority (86 percent) of families who become homeless due to foreclosure move in with friends or family, at least temporarily. Moving in with others, or “doubling up,” is often the only option besides emergency shelter for families who have been evicted or foreclosed upon. Without adequate credit, the possibility of securing independent, affordable housing is minimal. Affordable housing remains scarce, particularly in urban areas. Over the past decade, low-income families have seen their average wages decline as average rents have increased by nearly 50 percent (Bravve, Bolton, Couch, & Crowley, 2012). Many families pay more for rent than they can truly afford, putting them at risk of financial crisis and eviction. Others move into overcrowded apartments with other families, or find less expensive but substandard housing. These choices, which can be both illegal and unsafe, are similarly precarious and put families at risk of homelessness. 345

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Responses to homelessness include programs at the local, state, and federal levels and assistance from the public and nonprofit sectors. As support for public housing and housing subsidies has waned since the 1980s, programs to manage the homeless crisis have grown. Most notably, the McKinney-Vento Homeless Assistance Act of 1987 provides federal support for the homeless Continuum of Care programs that include emergency shelter, transitional living programs, and permanent supportive housing for disabled and highly vulnerable populations. Current efforts have been bolstered by new federal legislation such as the Homeless Emergency Assistance and Rapid Transition to Housing (HEARTH) Act, which funds both prevention activities and efforts that quickly find permanent housing solutions for recently homeless individuals and families (United States Department of Housing and Urban Development (USHUD), n.d.b.). With growing recognition that it is less expensive to keep a family housed than to rehouse a family that has been evicted or foreclosed upon, new initiatives are being developed to prevent homelessness by supporting “precariously housed” families and vulnerable individuals. But homelessness prevention programs are few, and the homeless population has not abated. Those who have lost their homes are reliant on emergency shelter services, which have varying availability depending on the geographic region. Individuals and families are often reluctant to use such services for a variety of reasons, including perceived disrespect from service providers, loss of autonomy, lack of adequate safety, and religious mandates (Hoffman & Coffey, 2008; Wasserman & Clair, 2011). Individuals and families experiencing homelessness may develop a fear of authority figures that becomes a barrier to seeking services. Homeless families, for example, might worry that social service professionals will place the children in foster care if they are “found out.” Teenagers who have fled abusive homes may avoid authority figures out of fear they will be

returned to their parents, or sent to a group home or foster care (De Rosa et al., 1999). Single homeless adults often endure repetitive harassment, arrest, and incarceration for breaking laws and ordinances designed to criminalize homelessness (National Coalition for the Homeless and National Law Center on Homelessness and Poverty, 2009a). With or without connections to social services, the vulnerabilities faced by homeless people provide ample opportunity for the resilience of the human spirit to emerge. Individuals and families without homes tap into their personal creativity for problem solving, develop strong personal ties and relationships that foster survival on the streets, show profound altruism, and demonstrate a remarkable work ethic. definitions and explanations of Homelessness No single criterion exists that defines whether an individual or family qualifies as “homeless.” Definitions are varied and could include everyone from the typically homeless vagrant sleeping under the overpass to a family with children sleeping under their own roof (but facing imminent eviction). According to federal law (Stewart B. McKinney Act, 42 U.S.C. § 11301 et seq. 1994), an individual who is homeless lacks a “fixed, regular, and adequate” nighttime residence. The definition also includes “persons who sleep in a public or private place not designed for use as a regular sleeping accommodation for human beings” (Stewart B. McKinney Act, 42 U.S.C. § 11301 et seq. 1994). This definition includes among the homeless population those sleeping on the streets, in cars, in homeless shelters, and in transitional living programs. It also includes much-harderto-identify individuals, such as those who are “couch surfing” or using short-term stays with friends and family members to get by, and those who are “doubled up” with relatives or friends, including individuals or entire families living in one room of someone else’s home. The common theme to all of these experiences is that

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the person has no home of his or her own, any available shelter is tenuous or unsafe, sleeping arrangements are precarious, and they have little to no safety or privacy. To further protect children and ensure eligibility for supports and programs, the federal definition of homelessness for children is even more broadly defined, and is helpful to understanding the rich and complex circumstances and trajectories associated with homeless families. The definition of homelessness as it pertains to children specifically includes “children and youth who are sharing the housing of other persons due to loss of housing, economic hardship, or a similar reason; are living in motels, hotels, trailer parks, or camping grounds due to lack of alternative adequate accommodations; are living in emergency or transitional shelters; are abandoned in hospitals; or are awaiting foster care placement” (McKinney-Vento Act sec. 725[2]; 42 U.S.C. 11435[2]). This definition allows children in a variety of settings to be eligible for services designed to mitigate the instability of their living conditions. Homelessness encompasses a wide variety of individual and family experiences, including families that lost their home to foreclosure and are doubling up with family until back on their feet; teenagers thrown out of their homes by exasperated parents; single mothers staying in cheap motels because they can’t afford a security deposit; children who run away from foster care placements; released prisoners unable to find a landlord or employer to take a chance on them; and older veterans with mental health and substance abuse problems. Due to the broad nature of homelessness and the unique experiences of homeless individuals, there is no single solution or intervention to fix the problem. Yet with every passing decade, appropriate and effective interventions are developed as we gain a better understanding of the nature and course of homelessness. Many successes reported in the literature and by practitioners stem from a solid and growing understanding of the relationship between

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poverty and homelessness. Individuals living in poverty are most at risk of becoming homeless, and demographic groups who are more likely to experience poverty are also more likely to experience homelessness (National Coalition for the Homeless, 2009a). demographic Patterns Determining an accurate count of homeless Americans is a daunting task. Many unhoused individuals and families remain invisible to authorities by sleeping in cars, on friends’ couches, or in hidden spaces. Despite these challenges, the federal government has made a concerted effort to approximate the incidence and prevalence of homelessness in the United States by tracking users of homeless services and by sending professionals out into the community to count homeless individuals on the street. The U.S. Department of Housing and Urban Development’s most recent Annual Homeless Assessment Report (AHAR) to Congress found that on one night in January 2010, 407,966 individuals were found in shelters, transitional living programs, or on the streets (USHUD 2011). These “Point-In-Time” counts provide estimates of the number of individuals using or needing services on a given night. Long-term data are available through HMIS (Homeless Management Information Systems), which requires homeless services providers that receive federal funds to report the number of clients they serve through shelter, transitional housing, outreach, and drop-in programs. According to HMIS data, over a one-year period from October 2009 to September 2010 more than 1.5 million individuals received emergency services for homelessness (USHUD, 2011). It is important to keep in mind that neither the Point-In-Time count nor the HMIS data collection system counts homeless individuals and families who are “couch surfing” or doubled up with friends or relatives, or the individuals and families who are precariously housed in other ways.

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The AHAR has consistently found that African Americans, men between the ages of 31 and 50, and people with disabilities are all at higher risk of becoming homeless. According to the HMIS count of shelter users, just over half of the homeless population is male (62 percent), and one out of every five shelter users is under the age of 18 (22 percent). Most homeless individuals are adults and middle aged, with 37 percent of the population aged 31–50. Less than 3 percent of the HMIS homeless population is over the age of 62. Shelter users over the course of a year are approximately as likely to be white as they are to be African American, representing 41.6 percent and 37 percent of shelter users, respectively. However, while their proportions in shelters are roughly equal, African Americans comprise only 13 percent of the U.S. population but 37 percent of shelter users, demonstrating a significantly disproportionate risk for homelessness. An additional 9.7 percent of HMIS service users are identified as white and Hispanic (USHUD, 2011). The Point-In-Time count found that one in four sheltered homeless persons had a severe mental illness, and just over a third were experiencing chronic substance abuse problems (USHUD, 2011). The Point-In-Time and HMIS data demonstrate that individuals cycle in and out of a need for homeless services over the course of a year. The classic model of describing time-based categories of homelessness divides the population into transitional, episodic, and chronically homeless (Kuhn & Culhane, 1998). For about 80 percent of shelter users, homelessness is a temporary state alleviated by employment, changes in relationship status, available housing, or achieving sobriety. In fact, the most common length of time for a person to be homeless is one or two days (Kuhn & Culhane, 1998), and the 2010 AHAR found that 34 percent of those in emergency shelters stayed for a week or less (USHUD 2011). Transitionally homeless individuals generally experience one or two shelter stays over

a three-year period, for a total of 58 days on average (Kuhn & Culhane, 1998). Episodic homelessness is defined as cycling in and out of homelessness and shelter services, but on a more frequent basis (Kuhn & Culhane, 1998). Only 10 percent of shelter users are estimated to experience episodic homelessness. Over a three-year period, episodically homeless individuals stayed in shelters on five separate occasions, on average (Kuhn & Culhane, 1998). But others experience chronic or longterm homelessness. The Point-In-Time count found that approximately one out of four homeless persons was a long-term service user. Over the year of the HMIS data report, 6.2 percent of homeless persons stayed in a shelter for six months or longer. Race clearly plays a role in chronic homelessness, as 85 percent of long-term shelter residents are black or Hispanic, compared to 46.7 percent of the total homeless population (AHAR, 2010). A study of long-term homeless individuals in New York City and Philadelphia found that the overwhelming majority were black males. In New York City, 92.9 percent were black and 82.3 percent were male. In Philadelphia, 92.9 percent were black and 71.1 percent were male (Kuhn & Culhane, 1998). Despite stereotypes to the contrary, recent data suggest that only one in three chronically homeless individuals has a mental health condition. Substance abuse problems are more common, with rates around 50 percent for this population (Caton, Dominguez, & Schanzer, 2005; Kertesz, Larson, Horton, et al., 2005; Padgett, Gulcur, & Tsemberis, 2006). Lifetime rates are higher: among longterm homeless individuals, 60 percent have experienced mental health problems in their lifetime and 80 percent have experienced a substance abuse problem (Burt, Aron, Lee & Valente, 2001). Between 64 percent and 77 percent of homeless people can be found in large cities (AHAR, 2010; Henry & Sermons, 2010), but the problem of homelessness extends to suburban and rural

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areas. As in urban areas, rural homelessness is caused by poverty and lack of affordable housing. But homelessness in rural areas may take on a different appearance, as shelter services are more limited and homeless individuals are more likely to live out of their cars or campers, or double up with friends and family. Family homelessness is nearly twice as common in rural areas as in urban areas (Henry & Sermons, 2010). In rural areas, homeless individuals are most likely to be white, female, married, and currently working (Fisher, 2005). In both rural and urban areas, chronically homeless individuals are mostly unsheltered, living in cars, in abandoned buildings, on the streets, or in other places not meant to be dwellings (Henry & Sermons, 2010). Societal context Although most authors trace the roots of the growing homelessness epidemic to the federal budget cuts of the 1980s, homelessness is not a recent development in America. Homelessness has existed in some form throughout much of our history, always viewed with stigma and suspicion (Hopper, 1991). Mary Richmond referred to tramps as “barbarian, openly at war with society” (as quoted in Hopper, 1991, p. 115). Industrialization brought families from the farms to the cities in the 1870s, and the poor conditions of family separation, cycles of employment and unemployment associated with factory jobs, and inadequate housing led to unprecedented family stress, poverty, and substance abuse. Individuals and families crowded into tenements, built and modified quickly to provide the housing stock needed by the new inhabitants of cities, and quickly degenerating into cramped, unhealthy quarters conducive to the spread of contagious disease (Riis, 1890/1967). At its height, the tenement district in New York housed 290,000 persons per square mile, in these conditions. Mediation attempts for this poverty included the first Salvation Army mission to offer “soup, soap, and salvation” in New York’s Bowery district in 1879, even then

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a neighborhood known for homelessness, substance abuse, and violence (USHUD, 2011). Wagner (2005) argues that the modern-day system that attempts to address homelessness plays the role that was taken by the poorhouse in early American history. Organizations such as Charity Organization Societies attempted to determine which of these poor were worthy of assistance (Riis, 1890/1967), working alongside other relief efforts such as workhouses, almshouses, poorhouses, and charity hospitals, which were doing the same. The Great Depression of the 1930s caused an unprecedented rise in homelessness, with many individuals pulling up stakes to move to cities or move west, becoming transient. Other families lived in shantytowns known as “Hoovervilles,” camping on public lands. Estimates suggest that nearly 2 million Americans were homeless during the Great Depression. Marginalized groups, including persons of color and women, were hit hard during the Great Depression. Their jobs were often the first to go, their options for employment were fewer, and many New Deal programs were designed for men and explicitly discriminated against women (Abelson, 2003). The New Deal and gearing up of manufacturing for World War II created job opportunities and economic growth that alleviated much of the homeless crisis of the Great Depression. Hobos, transient communities, and unemployed vagrants remained, but the improved economy allowed most Americans to think of homelessness as someone else’s problem throughout the next twenty years. The complex nature of modern homelessness began, in part, with the well-intentioned Community Mental Health Act of 1963. Lifetime psychiatric care, or “institutionalization,” had long been the standard for chronic mental health conditions. This was seen as an improvement on earlier days, when the poor and mentally ill were often imprisoned for extended periods of time (Gollaher, 1993). With the development of new psychotropic medications, it became possible for individuals with psychiatric disorders to

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live independently. State hospitals discharged their patients and closed their doors, referring their prior residents to single-room-occupancy hotels and their local community mental health clinic for further treatment. Problematically, the network of services envisioned by President Kennedy through the Community Mental Health Centers Construction Act signed weeks before his death never emerged (Edmondson, 2012). Without life skills or adequate support, many of these displaced individuals found themselves without access to care, losing their access to treatment and their ability to maintain housing (Feldman, 1983). The 1960s and 1970s saw the development of the first organized soup kitchens and emergency shelters in major metropolitan areas, including the widely recognized Pine Street Inn (1969) for alcoholic men, and Rosie’s Place (1974), the first emergency shelter for homeless single women, both in Boston. The 1980s were a decade of high unemployment and economic distress that resulted in our current understanding of the homeless population. In 1980, the federal government provided 22 percent of the money for the budgets of major cities in the United States, but by the end of the 1980s, the federal government provided only 6 percent of urban revenue, part of a 60 percent decrease in federal support of urban governments. Most of the cuts were to federally funded low-income housing programs, including the construction and maintenance of public and low-income housing as well as funds for the Section 8 program, the government’s voucher program for low-income families. According to the National Low Income Housing Coalition, federal support for low-income housing was cut in half between 1980 and 2003 (Wardrip, Pelletiere, & Crowley, 2005). Without government subsidies, landlords charged market rate for rental units, and home ownership became further out of reach as onceaffordable urban neighborhoods were impacted by a wave of gentrification in the 1990s. The result was an inadequate supply of low-rent

units available for low-income families. Particularly in urban areas, low-wage working families became increasingly unable to afford market-rate rents. As low-income families moved out of city centers, so did the problem of homelessness. Since 2007, the number of sheltered homeless people in major metropolitan areas has decreased by 17 percent, and the annual number of people using homeless shelters in suburban and rural areas has increased 57 percent (USHUD, 2011). Because homelessness is closely tied to economic conditions, housing availability, and metropolitan areas, this social problem is not evenly distributed throughout the United States. Instead, the homeless population clusters in particular states and geographic areas. Florida, California, New York, Texas and Michigan had more than half of all homeless people in the United States (USHUD, 2011). Vulnerabilities and risk factors Homeless individuals and families are coping with physical, emotional, and legal threats to their well-being. The physical risks include exposure, malnutrition, exacerbation of medical conditions, and the threat or reality of sexual and physical assault. Along with physical concerns, homeless individuals are at constant risk of arrest, family separation, and coercive psychiatric care. Homelessness often represents a state of profound loss: loss of not just home, but also family, community connections, status and position, health, safety, and well-being. These painful experiences can lead to the exacerbation or onset of mental illness and unhealthy coping mechanisms such as substance abuse (Didenko & Pankratz, 2007; North, Pollio, Smith, & Spitznagel, 1998). One of the primary functions of a home is to provide security from outside dangers and threats. Without a home, safety and health are seriously compromised. Frostbite, leg ulcers, and respiratory infections are some of the ailments commonly associated with homelessness (National Coalition for the Homeless, 2009b).

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Malnutrition is also common, both because of limited access to food, and also the inability to cook and prepare healthy foods. The conditions of life on the street can cause physical illnesses to worsen, particularly tuberculosis, diabetes, and high blood pressure (National Coalition for the Homeless, 2009b). Perhaps the greatest physical danger associated with being unhoused is the likelihood of experiencing violence. Homeless individuals are particularly vulnerable to muggings, beatings, and rape (Padgett & Struening 1992). Some attacks are random, while others are associated with survival activities such as exchanging sex for shelter. Individuals who are intoxicated or coping with untreated mental illnesses are particularly vulnerable to attack, a cause for alarm given the rates of mental illness and substance abuse in the population. Hate crimes are yet another rising threat of violence against homeless persons. Between 1999 and 2010, the National Coalition for the Homeless has found over 1,000 violent crimes against homeless people, resulting in 312 deaths (National Coalition for the Homeless, 2012). The crimes varied, from trying to burn a homeless person in a blanket soaked in flammable liquids to beating with a baseball bat. In most jurisdictions, homeless individuals are not included under “vulnerable populations,” which would make these crimes eligible for prosecution as hate crimes. But the evidence is mounting that homeless individuals are targets of harassment and violence because of their homeless status. The true number of attacks is undoubtedly higher than the reports indicate because many homeless individuals will not report victimization out of fear of engaging with law enforcement (National Coalition for the Homeless, 2012). Avoidance of law enforcement, even when one has been victimized, is a logical response for homeless individuals. Many communities have criminalized the daily activities of homelessness, including panhandling (asking for money), loitering (sitting in a public place),

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sleeping outdoors, and even possessing a grocery cart (National Coalition for the Homeless, 2008). People experiencing extreme poverty are also likely to be engaged in gray- and blackmarket economies on the street that often result in warrants (Metraux & Culhane, 2006). Seeking police protection could result in unwanted attention to one’s own criminal history. Danger, exposure, and lack of privacy quickly create conditions for chronic stress. When combined with the profound loss of safety, home, status, and control over one’s environment, mental health concerns are inevitable. Victimization associated with life on the streets is reflected in the high rates of post-traumatic stress disorder among the homeless population (Goodman, Saxe, & Harvey, 1991). Outside of clear victimization and trauma, whether the link between mental health and substance abuse problems and homelessness is causal or correlational is a hotly contested question. Symptoms of mental illness were found to abate when homeless women received cash support from the government (Liebow, 1993), suggesting a connection between the stressors of poverty and mental health. Poverty also relates strongly to substance abuse, given that finding oblivion from the chronic stress in the form of drugs or alcohol is far less expensive than securing shelter (North et al., 1998; Jencks, 1994). The risks and vulnerabilities of homelessness only increase for youth on the streets. Minors are often ineligible for services or financial support, and authorities are required to report unattached minors to their families or to social services, resulting in a return to the homes youth have run from or an entry back into foster care. Without any institutional supports, youth on the streets are likely to engage in high-risk survival behaviors such as survival sex (prostitution, or trading sex for shelter). Runaway and homeless youth are likely to experience problems such as school failure, substance abuse, delinquency, malnutrition, sexually transmitted infections, serious mental disorders, and premature death from suicide, murder, and drug

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overdose (Greene, Ringwalt, & Iachan, 1997; Haber & Toro, 2004; Robertson & Toro, 1998). Homelessness is expected to increase over the coming years due to the combined influences of the foreclosure crisis, an increasing number of Americans living in poverty, and a demonstrated pattern of growth in the number of homeless families (National Coalition for the Homeless, 2008). Importantly, some social groups are more vulnerable to the ebbs and flows of the economy. Certain life experiences increase one’s vulnerability not just to poverty, but also to homelessness specifically. The odds of experiencing homelessness in the course of a year are approximately one in two hundred for the general population in the United States, while the odds of homelessness for a person living in poverty are one in twenty-five, and the odds for a veteran of the armed forces are one in ten (Witte, 2012). Life experiences known to increase the likelihood of homelessness include domestic violence, service in the armed forces, disability (including mental health and substance abuse problems), incarceration, and aging out of the foster care system. Sexualminority youth are also particularly vulnerable (Ray, 2006). Families, primarily single mothers with children, are the fastest-growing segment of the homeless population, and half of all homeless families cite domestic violence as a reason for becoming homeless (U.S. Conference of Mayors, 2008). In 2003, 100 homeless mothers from ten locations were surveyed and 25 percent of them reported being physically abused by a partner in the last year (American Civil Liberties Union, 2004). Men and women experiencing intimate partner violence are often forced to choose between abuse and homelessness, as the abuser often limits access to support networks and financial resources. Survivors may have been cut off from their friends and family by the abuser, and often have little work experience or credit history that would enable them to find employment or pass a credit check for an apartment lease. Survivors are often coping with

serious trauma as well, suffering from symptoms of anxiety, depression, and substance use that can make securing and maintaining safe, affordable housing an impossible prospect. A survey of twenty-two metropolitan areas found that, on average, 15 percent of all homeless people were fleeing domestic violence (U.S. Conference of Mayors, 2008). Many survivors of domestic violence enter the system of domestic violence services rather than homeless services, and may be undercounted. Nearly all domestic violence shelters report assisting survivors of domestic violence in finding housing, and 83 percent of survivors entering domestic violence programs need help in finding housing (Lyon, Lane, & Menard, 2008). Survivors who do not have adequate access to housing may feel they have no choice but to stay in or return to abusive relationships. With ongoing military efforts in the Middle East and Afghanistan, the well-being of returning military veterans is gaining national attention. Veterans of the armed forces returning from combat are at risk for serious physical and mental disorders, particularly post-traumatic stress disorder (PTSD), traumatic brain injury (TBI), and substance use problems that can impact daily functioning and the skills necessary to maintain housing and employment. According to “Veteran Homelessness: A Supplement to the 2009 Annual Homelessness Report,” released in January 2011 by the U.S. Department of Veterans Affairs and the U.S. Department of Housing and Urban Development, one in ten homeless individuals is a U.S. veteran, and 160,000 veterans are homeless each year. Between 44,000 and 66,000 of these veterans are experiencing chronic homelessness. Point-In-Time counts find that between 75,000 and 107,000 veterans are homeless on any given night (Kuhn & Nakashima, 2010; U.S. Department of Housing and Urban Development, n.d). These Point-In-Time counts report that half of all homeless veterans can be found in four states: New York, Florida, Texas, and California.

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Homeless veterans tend to be single males, older than nonveteran homeless individuals, and are more likely to have a disability, including a mental health or substance use problem. About 45 percent of homeless veterans are coping with a mental illness, 70 percent are experiencing a substance use problem, and 53 percent have a physical disability (compared with 41 percent of nonveteran homeless individuals). This demographic is starting to change, however. The veterans most at risk for homelessness today are those between the ages of 18 and 30 who identify as African American, American Indian, or Hispanic. Women veterans living in poverty are three times more likely to become homeless than nonveteran women living in poverty. The number of female veterans in the homeless population has been increasing steadily, and recent estimates suggest that nearly one in ten veterans staying in a shelter will be female. Only 4 percent of homeless veterans are part of families, and these veterans tend to be younger, African American, and female (U.S. Department of Veterans Affairs and U.S. Department of Housing and Urban Development, 2011). According to the 2010 Annual Homeless Assessment Report to Congress (U.S. Department of Housing and Urban Development, 2011), nearly four in ten sheltered adults (37 percent) have a disability, compared to 25 percent of the poverty population and 15 percent of the total U.S. population. Thus, a homeless adult is nearly 2.5 times more likely to have a disability than an adult in the U.S. population as a whole. However, the definition of disabled used in the AHAR is broad, and includes disabling mental health conditions, physical disability, intellectual disability, and diagnosable substance use disorders. The AHAR 2010 reports a breakdown of disability types only for those living in permanent supportive housing. Among adult individuals in supportive housing, 15 percent have physical disabilities, 6.6 percent are HIV-positive, 3 percent have a developmental disability, and 55 percent have a

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mental health and/or substance abuse disorder (USHUD, 2011). Cognitive impairments are not uncommon in the homeless population, although prevalence estimates vary widely. Existing data suggests between 3 percent and 40 percent of the homeless population has a cognitive impairment, compared with between 1 percent and 3 percent of the general population (Cotman & Sandman, 1997; Spence, Stevens, & Parks, 2004). Although there is not a tremendous amount of research, preliminary evidence suggests that intellectual disability is a risk factor for homelessness (Bremner et al., 1996), and suggests that the prevalence of intellectual disability (onset prior to age 18) among the homeless population is 12 percent (Oakes & Davies, 2008). People with disabilities face additional challenges to employment, and are thus more likely to be living in poverty. Supplemental Security Income (SSI) payments, intended to provide a safety net for those with disabilities, do not provide enough assistance for individuals to retain permanent housing. In 2010, the average monthly SSI payment was $498 (or about $5,976 annually) and the poverty level for a single-person household was $10,830 (U.S. Social Security Administration Office of Retirement and Disability Policy, 2010). While 70 percent of those without disabilities are in the labor force, only 21 percent of those with disabilities participate in the labor force. The unemployment rate for those with disabilities is nearly twice that of those without disabilities (14 percent and 8 percent respectively) (Office of Disability Employment Policy, 2012). Jail, prison, or a detention center is identified as the last living situation by one in twenty homeless individuals at a shelter (Witte, 2012). More than half of homeless people (54 percent) reported experiencing one or more types of incarceration, and many of them reported spending five or more days in city or county jail (42 percent). Nearly one in five (18 percent) homeless adults reported spending time in

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juvenile detention prior to age 18 (Burt, Aron, Douglas, Valente, Lee & Iwen, 1999). Incarceration may be a risk factor for subsequent homelessness, due to disruptions in living situations and difficulties with employment and finding housing post-release. Yet homelessness is also a risk factor for incarceration: 15 percent of incarcerated adults experienced homelessness in the year before their incarceration, and 10 percent were homeless immediately prior to incarceration. Of incarcerated adults with mental illness, 20 percent experienced homelessness immediately prior to sentencing. Mental health problems, substance abuse, and histories of trauma were prevalent among inmates with a history of homelessness (Greenberg & Rosenheck, 2008; Malone, 2009). Most young people in America find that achieving independence is a gradual process. Recent reports show that more than half of American youth ages 18–24 (54 percent) live with their parents, and 29 percent of young adults between the ages of 25 and 34 live with parents as they gather the necessary employment and credit histories to strike out on their own (Parker, 2012). One estimate suggests parents provide, on average, $38,000 for food, housing, education, and cash assistance to their adult children between 18 and 34 years old (Schoeni & Ross, 2005). In contrast, youth exiting foster care often have no family support, and these young adults must manage on their own. As a result, youth exiting foster care are nearly as vulnerable to homelessness as veterans: the odds of becoming homeless are one in eleven over the course of a year for this population (Roman & Wolfe, 2006). Most studies estimate that 12–13 percent of foster care youth who age out of the system will be homeless within a year, but that number may be as high as 20 percent (Freundlich, 2007; Dworsky & Courtney, 2009). Foster care is also a risk factor for homelessness before a young person is old enough to “age out” of the system. Teenagers who use youth shelters and drop-in centers for street

youth often report histories of foster care or other institutional placements, with rates ranging from 21 to 53 percent (Cauce et al., 1998; Robertson & Toro, 1998). Some studies found as many as 20 percent of minors staying in youth shelters came to the shelter directly from foster or group homes (Bass, 1992). The number of homeless teenagers and adults with prior foster care placements clearly demonstrates that youth involvement with child welfare systems and homelessness are closely linked. Recent estimates suggest that between 20 and 40 percent of homeless teenagers identify as lesbian, gay, bisexual, or transgender (Ray, 2006). With national estimates of the LGBT population around 3–5 percent, clearly LGBT or sexual-minority youth are overrepresented among homeless youth. LGBT youth often report that their sexuality caused conflict with family or child welfare placements—conflict that led to violent physical assaults, being thrown out of a family home to foster care or the streets, or being denied care from a residential facility (Clatts, Davis, Sotheran, & Attilasoy, 1998; Thompson, Safyer, & Pollio, 2001; Remafedi, 1987). One researcher found that 50 percent of gay teens experienced a negative reaction from their parents when they came out and 26 percent were kicked out of their homes (Remafedi, 1987). LGBT youth also leave home due to ongoing physical, sexual, and emotional abuse, both by choice (running away) and when removed by child welfare. LGBT youth may be more likely to run away from foster care placements than their peers, preferring homelessness to the harassment and violence common in foster care placements (Desetta, 2003). resilience and Protective factors for the Population The experience of homelessness can foster profound altruism, compassion, community spirit, creativity, and resourcefulness. Within the homeless community, many help one another by sharing food, resources, knowledge of safe

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places, information about local services and agencies, and places to find refuge. These community networks can provide key assistance to help people move out of homelessness, sharing information on population-friendly employers and landlords. In addition to the strengths found within the community, those who are precariously housed often draw heavily on their kinship and social networks. These networks help them access available space for couch surfing and doubling up, access to community resources such as shelters and prevention/ intervention programs, and support from individuals, groups, and systems such as churches. Those who feel connected to social support systems have improved physical and mental health outcomes (Hwang et al., 2009). Keeping connected to a network of family, friends, and acquaintances is fundamentally important for the homeless, and becomes more difficult the longer an individual remains unhoused. Homelessness researchers have proposed a social estrangement model to explain the challenges faced by homeless individuals (Grigsby, Baumann, Gregorich, & RobertsGray, 1990; Piliavin, Sosin, Westerfelt, & Matsueda, 1993). This framework suggests that individuals often become more estranged from society upon becoming homeless. The longer they remain on the streets, the greater their entrenchment in homeless culture and disaffiliation from traditional/prosocial institutions. Experiences on the streets, unstable residence, substance use, involvement in illegal activities, and disconnection from educational/vocational settings lead to further estrangement, including disconnection from formal employment (Piliavin et al., 1993; Sosin & Bruni, 2000). Support networks and community exchange systems help homeless individuals on a daily basis, but may be particularly important in contributing to resiliency during a crisis (Donaldson, Ahearn, Fullerton, Gifford & Ursano, 2009). Homeless individuals may get emotional support from family, friends, and partners, as

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well as from church groups or support systems such as Narcotics Anonymous meetings. They also get useful information from networks of other homeless individuals. Homeless individuals have the capacity to use both internal strengths such as prayer and hope and external networks to meet their needs and function during crises. It appears that the emotional support that comes from interpersonal connections is more salient to resilience than any structural supports. Young children, for example, cannot provide a mother with much in the way of tangible support, yet mothers of homeless families consistently exhibit fewer psychosocial problems (Burt et al., 2001). It could be that being needed or relied upon is the protective factor, but the importance of meaningful relationships is clear. In light of this understanding, many agencies serving the homeless have encouraged the development of social support networks and mutual aid among their clients, using group empowerment as a tool to promote self-efficacy and economic independence. Maintaining connections to support systems can be challenging without a permanent address or landline telephone. Recent evidence suggests that social ties among the homeless population are maintained in large part by the new ubiquity of low-cost cell phones (EyrichGarg, 2010). A study published in 2010 found that 44 percent of homeless adults owned mobile phones (Eyrich-Garg, 2010). This number has likely increased as federal programs such as Link-Up and Lifeline, originally intended to offset the cost of landline installation and service for low-income households, are now subsidizing cell phone service in some areas (FCC, 2011). Homeless individuals are also finding creative ways to maintain social connections online. Nearly half of homeless adults in one study accessed the Internet during the course of a month (44 percent), and another study found that homeless young adults are using computers

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and accessing the Internet (specifically social network websites) at rates equal to their collegeenrolled peers (Eyrich-Garg, 2011; Guadagno, Muscanell, & Pollio, 2013). The Internet can be a resource for maintaining social connections, and also finding new sources of support and information through online support groups and virtual communities. Homeless individuals report using the Internet for social support and also for job searches, housing searches, locating health and social services, making appointments, and staying connected to faith communities (Eyrich-Garg, 2011). Faith, spirituality, and religion can also be resources that help homeless individuals deal with the negative affects of homelessness (Washington, Moxley, Garriott & Weinberger, 2009). These can be used to increase feelings of self-esteem, personal control, and motivation, and can be sources of self-help and mutual support. Given the lack of control many homeless individuals feel about their circumstances, spirituality can be an important resource in increasing their feelings of self-efficacy and empowerment. Homeless youth are extremely resilient as individuals and as a community. These youth use their experiences on the street to develop “street smarts,” a concept involving the ability to quickly identify others who are trustworthy and can be helpful. Homeless youth describe strategies in the development of street smarts that include observation of others, guardedness in revealing personal information, and strategic use of aggression or angry behavior when needed to establish credibility and respect (Bender, Thompson, McManus, Lantry & Flynn, 2007). Homeless youth are resourceful in navigating service systems, communities, and resources, and in solving problems. When asked, they credit their social, interpersonal, and cognitive abilities as factors that contribute to their resourcefulness. Homeless youth with pets found those pets to be a source of stability,

emotional support, pride, and accomplishment. Other sources of resiliency for this population are similar to other homeless populations, such as spirituality and peer networks (Bender, Thompson, McManus, Lantry & Flynn, 2007). Rural homeless face different challenges and may have different opportunities for resiliency (Hilton & DeJong, 2010). Shelter users in rural areas, like those in urban areas, may cope by learning how to navigate social service systems. Many find that faith-based organizations provide more positive interactions than public social services agencies. They can also use relationships with other homeless individuals to provide both support and information to navigate systems and situations. Many had strong connections to family or friends in their geographic areas, which can result in help such as temporary housing, transportation, small gifts, phone access, and mail access. Because of these ties, they may choose to stay in rural areas to maintain these connections. Young homeless in rural areas may benefit from larger networks of family and friends to use for couch surfing. Programs and Social Work contributions Homelessness prevention programs are common across the country, primarily targeting those at highest risk. Prevention programs typically target renters facing eviction due to economic hardship, and other specialized programs work with individuals around their time of discharge from institutions such as prison, foster care, or psychiatric hospitals. A review of programs in 2004 found that the most common homelessness prevention activities offered by agencies serving the homeless population included budget and credit counseling for at-risk families, advocacy and referrals to local resources and low-income housing, emergency assistance in the form of tangible items like food and transportation vouchers, and cash assistance for rent or utility payments (Burt, 2005).

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A 2005 report from the U.S. Department of Housing and Urban Development reviewed prevention programs across the nation and highlighted five effective strategies for preventing homelessness. Used alone or in combination, the evidence supported the effectiveness of programs providing housing subsidies, permanent supportive housing opportunities, mediation in Housing Courts between landlords and tenants, cash assistance for families at risk of foreclosure or eviction, and/or rapid exit from emergency shelter programs (Burt, 2005). Research has consistently demonstrated the cost-effectiveness of housing subsidies, which provide housing vouchers for low-income families exiting homelessness. These subsidies are an example of secondary prevention, targeting individuals and families who have become homeless in an effort to rehouse them and keep them from joining the ranks of the chronically homeless. Housing subsidy programs provide enough support that 80–85 percent of previously sheltered homeless individuals and families can maintain independent housing for at least eighteen to twenty-four months (Shinn, Baumohl, & Hopper, 2001; Stojanovic, Weitzman, Shinn, Labay, & Williams, 1999). Homelessness was initially conceived as a temporary crisis, and interventions developed accordingly. The earliest services for homelessness were short-term crisis shelters and emergency food programs. The belief of the early 1980s was that as economic prosperity returned, homelessness would no longer be a significant concern. But even as prosperity returned, the problem of homelessness became entrenched. Short-term, crisis responses were inadequate to meet long-term support and housing needs for a vulnerable segment of the population. The McKinney-Vento Homeless Assistance Act of 1987, federal legislation to address the needs of the homeless population, established guidelines for a three-level system of care referred to as the Continuum of Care,

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meant to meet the needs of various subgroups of homeless individuals and families (Culhane, 1992; Wong, Park & Nemon, 2006). The Continuum of Care was meant to provide specialized services to individuals and families as they transitioned from the streets into stable housing (Culhane, 1992). The continuum includes three distinct levels of program response, including emergency shelter programs, transitional housing, and permanent supportive housing. This three-tier structure provides a variable level of permanency and support depending on the client’s needs and circumstances (Couzens, 1997). Emergency shelters are the point of entry for most clients, and services are typically shortterm and low-barrier (there are few disqualifications for shelter services). The role of the emergency shelter is to stabilize an individual or family in crisis, and serve a gatekeeper to more supportive transitional housing programs (Hoch, 2000; Padgett, 2007). Emergency shelters serve a broad range of individuals and families, often in barracks-style accommodations, to clients with a diverse array of challenges. Specialized shelters for unaccompanied youth exist in many metropolitan and suburban areas (Culhane, 1992; Toro, Dworsky, & Fowler, 2007). Transitional housing programs, the second tier in the Continuum of Care model, provide interim housing for a predetermined length of time (generally in the range of six to twentyfour months) to individuals and families who have demonstrated need and commitment, but do not have access to permanent housing or are not yet ready for independent living. These programs generally provide intensive services including psychotherapy, job training and placement, and case management. The goal is that each individual or family will achieve independent housing (subsidized or unsubsidized) upon discharge (Hoch, 2000). Transitional housing programs will often target a specific population, such as recovering substance users,

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survivors of domestic violence, youth exiting foster care, or parenting teens (Hoch, 2000). Permanent supportive housing, the third tier in the Continuum of Care model, provides long-term housing opportunities to individuals with severe functional impairments who would otherwise be unable to live independently. These programs often serve previously homeless individuals with serious mental health problems, physical disabilities, or chronic health problems (Wong et al., 2006). By 1988, the majority of funding for homeless services and programs came from federal, state, and local governments (Wong et al., 2006), and thus the majority of homeless programs followed the Continuum of Care model. Within this programmatic context, the priorities for assessment included determining the client’s motivation to seek and maintain long-term housing (“the will to be housed”), and their ability to do so, including barriers to accessing and maintaining housing (“the skill to be housed”). The most common barriers to homeless services include substance abuse problems, mental health problems, physical problems, and infectious disease. For those seeking care from privately funded service providers, religious belief and sexual orientation can also be significant barriers to care (Hoch, 2000; Wong et al., 2006). Emergency shelter programs serve as a catchall for homeless individuals and families in immediate crisis, as well as those individuals with no will for further services or those who do not qualify for transitional housing support due to conditions such as ongoing drug or alcohol use. Considered the gateway into housing services, one would imagine emergency shelters would serve all comers. Indeed, it is not uncommon for people to wonder why homeless men and women choose not to access services when they appear readily available. However, Wong, Park, and Nemon (2006) found that emergency shelters commonly excluded clients with substance abuse problems (61 percent), severe symptoms of mental illness (43 percent), serious

physical problems (32 percent), and infectious diseases such as HIV or tuberculosis (27 percent). The exclusion of these individuals from emergency shelter care has serious implications for the availability of services to many—if not most—homeless individuals. For transitional housing programs, the admissions policies are even more restrictive than for emergency shelters—86 percent would not serve individuals with a substance abuse problem, and 40 percent would not serve individuals with an infectious disease. In addition, homeless individuals who disclose domestic violence concerns may be refused entry at shelters because of safety concerns. There is some concern that homeless services are serving only homeless individuals with the highest levels of functioning, leaving the sickest and most vulnerable to fend for themselves (Culhane 1992; Hoch 2000; Wong et al., 2006). assessment and interventions In recent years, the focus of homeless services has shifted from provision of emergency survival services, such as temporary shelter and soup kitchens, to more comprehensive service delivery models with the goal of achieving long-term, stable housing. Although emergency programs may be effectively serving the majority of individuals and families who are homeless for short periods of time, the chronic homeless continue to be underserved and present a significant and expensive social problem. Chronically homeless individuals use a disproportionate share of services, often including a revolving door of imprisonment, emergency shelter, emergency hospitalization, and drug and alcohol treatment programs (Caton, Wilkins, & Anderson, 2007). Chronically homeless people are often coping with challenges that make them ineligible to move forward through the Continuum of Care services described above. Problems like addiction and communicable illnesses such as HIV often make the long-term homeless ineligible for services at emergency shelters and

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transitional housing programs (Hoch, 2000). These boundaries are maintained in order to ensure the safety of other clients and staff, but send a clear message that long-term housing is available only for those individuals who are willing and able to demonstrate effective life skills, get sober, and access appropriate mental health treatment (Caton et al., 2007). Social workers and others have been developing new, evidence-based approaches to working with the chronically homeless population that achieve long-term housing and save taxpayer dollars. These creative approaches include low-barrier long-term housing opportunities, outreach programs that bring substance abuse and mental health services to the streets, and intensive case management programs, some that focus specifically on critically important transitions such as at discharge from hospital (Caton et al., 2007). Housing First recognizes that getting sober and maintaining compliance with mental health treatment are far less daunting tasks when one has a roof over one’s head. Thus, in the Housing First program, all homeless clients are housed immediately and provided with essential follow-up support services as needed. These programs are particularly effective at housing the chronically homeless, who are generally not able to demonstrate “proof of readiness” in order to receive housing services (Padgett, Gulcur, & Tsemberis, 2006). Housing First programs have met with widespread success in multiple cities, with one New York City program demonstrating a five-year housing retention rate of 88 percent among formerly homeless individuals with serious mental illness (Kenney, 2008). Other promising intervention strategies focus on reaching out to people living on the streets to reduce barriers to accessing housing and supportive services. Assertive outreach and shelter-based community outreach techniques focus on developing individualized, trusting relationships with clients, even if they choose to remain on the street. Clients set the pace of

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relationship development and assistance, and case managers do not enforce rules or pressure clients to receive care until clients request services. Shelter-based community outreach programs will bring professional assistance such as psychiatric support services to clients, rather than requiring them to come into a clinic. These methods are particularly effective with clients coping with mental illness and substance abuse disorders (Bradford, Gaynes, Kim, Kaffman, & Weinberger, 2005; Argeriou & McCarty, 1990; Fisk, Rakfeldt, & McCormack, 2006). Other effective intervention models that prevent and alleviate homelessness include teambased wraparound case management models such as Assertive Community Treatment (ACT) and intensive case management. These models put together teams of professionals to work simultaneously on addressing mental health, substance abuse, legal problems, housing, family supports, and employment concerns. Clients in these systems can generally receive supportive interventions on an as-needed basis any time of day, any day of the week. Assertive Community Treatment is a structured, directed intervention, while intensive case management generally refers to any program where case managers have a caseload of fewer than twenty-five clients. On average, ACT programs are more effective than traditional programs at maintaining positive outcomes for clients (Nelson, Aubry, & Lafrance, 2007). Critical Time Intervention (CTI) is a research-supported homelessness prevention program that provides time-limited case management services to individuals upon release from institutions such as psychiatric hospitals, homeless shelters, and prisons (Susser et al., 1997). CTI provides psychosocial support to clients, and works to help establish and strengthen ties to family and community during their transition from institutional care to independent living. In this model, social workers engage and assess clients while they are in institutional care so that an individualized support program can be in place immediately upon discharge.

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The following example shows one of the many faces of homelessness: that of a young person named Becky. Becky grew up in a rural county of Missouri and was sexually abused by her stepfather. When she told her mother about the abuse, her mother kicked her out of the house at age 15. Becky was too young to sign a lease and live independently, and was afraid to go to anyone for help—they might send her to a program that would send her back to her home, or into the foster care system, where she heard abuse was common. She first moved in with friends, staying for brief periods of time on the couches or in the spare rooms of friends and acquaintances. Since none of these living arrangements was sustainable for long periods of time, she eventually ran out of friends to help her. Before long, she was staying with people she had just met, often swapping sex for shelter. Becoming disillusioned, she managed to get a ride to a nearby city, where she found work as a waitress. A flyer advertised that four roommates were looking for a fifth person to sleep on the couch in a twobedroom apartment to help with rent. They were willing to take a chance on Becky even though she was young and didn’t have much cash. Over time, her tips improved and she made new friends at work who were in similar situations to hers. Given the physical nature of her job, it should be no surprise that not long after starting, Becky threw her back out and was in excruciating pain. Without health insurance and unable to work to pay her rent or other bills, Becky became desperate. An acquaintance she had met through her roommates was a small-time drug dealer, and he suggested she might want to buy a few painkillers from him. Over the next year, Becky managed to keep working by taking whatever pills she could buy—she didn’t always know what kind they were, but they helped with the pain. One day her dealer was unable to get a supply of pills. A few days passed and Becky started to get sick with opiate withdrawal—sweating, cramping, nausea, diarrhea, and anxiety. She missed days of

work, and her boss threatened to fire her. She called her dealer, and he still had no pills but suggested that if she was sick she should try heroin. Desperate for relief and to keep working, Becky injected heroin for the first time. Within a few months, Becky was addicted to heroin, fired from her job for showing up late if she showed up at all, and kicked out of her apartment when her roommates got tired of covering her share of the rent. Although Becky’s friends liked to party, hard drugs terrified them and they refused to see her until she “got help.” Becky wanted to get clean and stop using heroin, but she was back to swapping sex for a place to stay and usually the guy would offer her drugs. No stranger would let her stay with him or her if she was sick from withdrawal, so she kept using. Becky realized she needed a safe place to stay for a few days so that she could get through the worst of the physical withdrawal, and then maybe she could make a clean start. The local women’s shelter would not take Becky in because she was actively using drugs, so she went to the emergency room at the hospital to seek help with detox. Detox is not medically necessary for opiate withdrawal, so Becky was discharged from the hospital with referrals to drug treatment clinics. With no money or health insurance to pay for private drug treatment, she found that there was a four-month wait list for publicly funded drug rehab. Running out of options, Becky decided to seek help, with her need overwhelming her fear of “the system.” She had seen a presentation in school on the Safe Place program, a nationwide community initiative that designates schools, fire stations, libraries, and youth-friendly businesses as Safe Place sites where youth can access help and supportive resources. Becky had seen a gas station in her new city with the Safe Place logo and told the attendant she needed a safe place to stay. The attendant looked up the number he was supposed to call, and within an hour Becky was met by an outreach worker from a nearby youth agency. The agency had a specialized emergency shelter for youth where she could stay for a few days. During that time, Becky worked with the

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program’s social worker to find a detox program designed for young adults that could immediately take her. Once she completed the detox, she returned to the shelter and received one-on-one counseling. Although the agency reached out to her mother, Becky was not allowed to return home because her stepfather was still present and her mother showed no ability to keep Becky safe in the home. Her time-limited stay in the shelter was almost up, and Becky was terrified of being placed in foster care. Together with her social worker, Becky developed a plan to enter a transitional living program for teenagers until she turned 18. While she stayed there she could continue seeing her social worker, get a job, and complete her GED. Advocacy on the part of the agency staff helped her to qualify for state-subsidized health care to deal with the health problems left over from her back pain and the harm to her body from drug use and malnutrition. The agency found extra funds to help pay for additional medical costs that Medicaid wouldn’t cover. After twelve sessions with a physical therapist, Becky felt as good as new. Although it wasn’t always easy, Becky left the TLP at the age of 18 with $10,000 saved, a GED, and few college courses under her belt. She was a regular attendee of Narcotics Anonymous meetings, and was able to sign a lease on her own one-bedroom apartment and make plans for her future. Although she would probably disagree, Becky was homeless from the time her mother kicked her out of the house at 15 until she signed her first lease at 18. This vignette illustrates the following points: 1. Education of youth and the professionals with whom they will interact about services and outreach programs like Safe Place are crucial. While not every at-risk youth will take advantage of the programs, Becky might have made use of services earlier if they had been suggested to her more often, particularly by the shelter, hospital, and detox staff who were unable to help her through their programs. 2. Services for at-risk youth like Becky must be comprehensive. Becky has needs for medical care, substance abuse services, housing, education, and

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mental health services to help with past trauma. Her success is dependent upon her ability to access the full range of services to meet all her needs. 3. There are multiple barriers to youth obtaining services, including their willingness to ask for help, their fear of authorities, the negative reputation of the foster care system, the effects of trauma from existing abuse, the effects of poverty, and the stigma attached to all of these underlying issues. Practice with this population is difficult and requires services to be thoughtful, comprehensive, and tailored to the individual. Individuals who are affected by stigma and oppression related to minority sexual orientation, race, ethnicity, or socioeconomic class will need to be provided assessment, intervention, and services that appropriately address their experiences and needs and are culturally competent. In addition, youth are particularly disadvantaged in our society because their age prevents them from having the same options, rights, and eligibility as older adults.

conclusion While the phrase “homeless people” may conjure up images of older men and soup kitchens, homelessness and precarious housing situations are common to many social work practice settings and populations. As we have seen, understanding housing and homelessness is critical for work with low-income families, survivors of domestic violence, sexual-minority youth, children and teenagers in the child welfare system, and veterans of the armed forces. Social workers in every setting need to be aware of the prevalence of homelessness and precarious housing, the groups that are at most risk, and the range of options for prevention and intervention. In addition, social workers need to be actively involved in social change efforts that fight poverty; increase the availability of affordable, safe housing; and decrease the stigma associated with homelessness and the social problems that are often associated with and exacerbated by this significant issue in the United States.

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he pathways to immigrants’ migration journeys are significant as they influence the well-being, health, and mental health of newcomers. Some immigrants, for example, arrive in the United States as refugees after escaping war, political oppression, and/or persecution. They may have endured violence, torture, imprisonment, and/or extreme deprivation, and perhaps witnessed the death or killing of family or community members. If they reach a refugee camp, they commonly face problems of poor living conditions, meager allotment of food, limited medical care, camp violence, and hostility from segments of the citizenry living in the country of first asylum (Marsella, Bornemann, Ekblad & Orley, 1994; Mollica, 1994; Olness, 1998). Other immigrants leave their country of origin for better economic opportunity or better education for their children. They commonly plan for their migration and wait (sometimes for a long period) for authorization to reside in the United States. Many individuals migrate to reunite with family members who have settled in the United States at an earlier time. Some are children who rejoin parents from whom they have been separated for years. In addition to having been separated, the children may enter a different family structure that includes new sibling(s) born in the United States, a new stepparent, and new stepsiblings (Drachman, Kwon-Ahn, & Paulino, 1996). A sizable segment of the immigrant population includes unauthorized or undocumented persons. Due to economic privation in their country of origin, many migrate either to support themselves or to feed and house 366

their families. The journey may be hazardous and violent as they trek through dangerous terrain. Some are assaulted or exploited when smuggled across national borders. Some, however, arrive with legal documentation to enter the United States but overstay the permissible time period to remain in the country, which ultimately shifts their status to undocumented immigrant. Since undocumented persons are subject to deportation, their lives are framed by this persistent threat. Other immigrants who are described as transnationals represent a contemporary form of migration and settlement. They commonly engage in activities with persons and organizations in both the sending and receiving countries (Drachman & Paulino, 2004). They are described as living “dual lives,” living “here and there,” and keeping “two feet in two worlds.” Although the pathways that frame the migration journey are varied, the experience of stress is common (Falicov, 1998; Suarez-Orozco, 2004; Beiser, 2006; Basoglu, Jaranson, Mollica & Kastrup, 2001). The stresses involve leaving family, friends, community and homeland and arriving in a new country where immigrants need to find housing, obtain employment, secure education for their children, learn a new language, negotiate new systems such as health care or transportation, and familiarize themselves with the customs and practices of people in a new land. The stresses are many and cumulative and their interaction with one another can generate a combined effect. Taken together, the accumulation of adversity, the constellation of risks, and their combined

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effect can jeopardize the well-being, health, and mental health of those who experience the life event of migration (Sameroff, Gutman, & Peck 2003; Yates, Egeland, & Sroufe 2003; Rutter, 2003; Beiser, 2006). On the other hand, many immigrants adapt and cope successfully, through the accumulation and combination of protective processes that enhance resistance to stress and promote resilience (Sameroff, et al., 2003; Rutter, 2003). defining immigrants and explaining migration Migration studies as a field of scholarship provides knowledge from a range of disciplines. The disciplines differ in their explanation of migration, their perspectives, the unit of study, and level of analysis. Scholars consider its interdisciplinary nature, stating a “full understanding of contemporary migration processes will not be achieved by relying on the tools of one discipline alone or by focusing on a single level of analysis because their complex multifaceted nature requires a sophisticated theory that incorporates a variety of perspectives, levels and assumptions” (Massey, Arrango, Hugo, Kouaouci, Pellegrino, & Taylor, 1993, p. 432). In keeping with this idea, knowledge derived from a mix of disciplines informs this discussion. Micro- and macroeconomic theories, for example, explain reasons for immigrants’ departure from their country of origin and explain forces that draw them to the destination country. The ways in which social networks channel migration and provide support for newcomers are described in sociological discussions. The lives of transnational migrants, which are rooted socially, politically, and economically in more than one nation-state are described and explained in the interdisciplinary field of transnational studies. Finally, analysis of a nation’s legal structure that examines immigrants’ rights and service eligibility can explain in part the nature of immigrants’ reception in the new country. These subjects are examined, as they provide

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a context for understanding the phenomenon of migration while taking into account new developments in the field. Everett Lee (1966) crystallizes demographic treatises on the movement of people written in the 1880s and furthers the push/pull theory of migration. This classical explanation assumes there are “push” forces in the sending country and “pull” forces in the receiving country that generate migration. As an economic theory, individuals are viewed as rational actors who examine alternatives on whether to move or stay. Opportunities and gains as well as personal and structural obstacles to migration are considered. Both monetary and nonmonetary costs and benefits are included in the calculations (Haug, 2008). Decision making is based on a cost/benefit analysis. Migration is viewed as an investment in human capital and the unit of attention is the individual who has an opportunity for securing a better wage in the destination country. Although a decision to migrate is viewed as an individual’s rational choice, which implies a micro explanation for migration, the sum of the many persons who decide to migrate suggests the theory can be conceived as both a micro and macro explanation for population movements (Schelling, 1978). Migration is also created by geographic differences in the supply and demand for labor. The differences in wage rates between countries generate the movement of workers from low-wage nations to high-wage nations. The high-wage country benefits from the added labor, and workers from poorer countries secure employment. Supply and demand is a macroeconomic theory that assumes labor markets are primary mechanisms for generating migration (Massey et al., 1993). The theory also explains how the migration flow can occur in the opposite direction—from wealthy countries to poor countries. For example, businesses from wealthy countries invest capital in poor nations, as the rate of economic return is high. The capital investment generates a migration flow of highly skilled persons who follow the

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capital anticipating they will secure the economic benefits of their skills. According to the “new economy of migration,” the family or household is the centerpiece for decision making on migration. In lieu of the individual, the family/household considers which member(s) could move in order to maximize household income and minimize the risks associated with migration (Massey et al., 1993; Stark & Lukas, 1988). Thus, some members could work in the home country while others could seek work abroad. The diversification of labor within families is a risk-reduction strategy that takes into account the possibility of loss of employment in either the home or destination country due to economic downturns, market changes, natural events, crop failures, or personal difficulties that could reduce household income (Haug, 2008; Massey et al., 1993). According to world systems theory, the “penetration of capitalist economic relations into peripheral noncapitalist societies creates a population prone to migrate abroad” (Massey et al., 1993, p. 444). With the aim of greater profit and wealth, businesses from capitalist countries enter countries on the periphery of the world economy in search of land, consumer markets, raw material, and labor. For example, several businesses may enter a developing country and with the support of a sympathetic government, the businesses mechanize the production of farming. As a result, the traditional manual labor used for farming eventually disappears. Since workers become redundant, a nation’s unemployment rises; workers’ persistent search for jobs evolves; and migration becomes a plausible response. These are among the conditions that underlie economic globalization. Social network activity offers another explanation of migration. It assumes that networks or “sets of people linked by acquaintance, kinship and work experience” provide the channels for the migration process (Tilly, 1990). To diminish the risks associated with migration, individuals rely on their interpersonal networks in both the sending and receiving countries for

information and assistance about moving and resettling. Networks in the home country, for example, provide information regarding migration decisions, including whether to move or stay. They provide information on the means of transportation, financial costs, and potential contacts with people in the destination country. In the receiving country, networks guide newcomers on housing, transportation, and jobs, as well as provide continuous social support and economic information (Vertovec, 1999; Boyd, 1989; Haug, 2008). Network activity is also reproduced and extended by the new immigrants who supply information and assistance to the next group of newcomers. Furthermore, networks are transformed and new networks are created. For example, a business owner may delegate responsibility to an immigrant for the hiring and supervision of employees. Since the immigrant has access to a labor supply from his community, he or she hires people from that community for employment in different divisions or areas of the workplace, and new networks form within the different divisions. Therefore, local labor markets can become linked through specific networks of interpersonal and organizational ties surrounding migrants (Vertovec, 1999). As proposed by some, migration is a “process of network building which depends on and in turn reinforces social relationships across space” (Portes, Guarnizo, & Haller, 2002, p. 279). The multiplier effect of social networks can also generate a migration chain process and pave the way for establishing transnational networks (Haug, 2008; Boyd, 1989; Faist, 2000; Pries, 2004). Although the theories presented differ, they are not incompatible. One theory can predominate as an explanation for the migration of a population, while several theories can explain aspects of a population’s movement. “Push” forces, for example, predominate in the migration of numerous populations—Southeast Asians during the Vietnam War, Cubans during political changes in Cuba, current Syrian flight into Turkey due to political turmoil,

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Bosnians during the war in Kosovo. As apparent, the “push” phenomenon is commonly associated with people fleeing persecution, war, or oppression. Economic issues also push people to move. Large groups of Mexicans, Salvadorans, Hondurans, and Guatemalans move from the global south to the global north for economic reasons. The “pull” force is common in family reunification. A child who remains with relatives in the Caribbean responds to the “pull” of a parent to rejoin the family who migrated to the United States. A husband or wife living in Mexico responds to the “pull” of rejoining the family in the “north.” When Russian adults living in the United States sponsor their parents who cared for the grandchildren in the home country, the grandparents respond to the “pull” and often migrate to the new land. Several theories outlined above can explain the migration of people who cluster in global cities where there is a demand for low-wage service workers. The global cities have sizable populations of highly paid professionals (lawyers, experts in finance, technology, accounting) who are employed by large firms that coordinate and manage the global economy. Both the firms and the lifestyles of the professionals generate a demand for low-paid service workers (for building maintenance, hotel housekeeping, child care, domestic work, care for the elderly) (Sassen, 2002a, 2002b). Households living in the developing world whose countries are deeply in debt and have pools of unemployed and underemployed persons decide to send one or more family members abroad to save the family from slipping into greater poverty (Ehrenreich & Hochschild, 2002; Pyle, 2006a; Parrenas, 2005; Dreby 2006; Schmalzbauer, 2004). Thus migration to the global cities is in part a response to a supply-and-demand dynamic. Adding to the explanation are households that orchestrate decisions on migration while taking into account individual and collective needs (Pries, 2004; Stark & Lukas, 1988). Support networks further the explanation. In

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the sending country they provide information on issues surrounding departure, risks of the journey, contacts along the way, and border crossings; and in the receiving country they assist in housing and employment and ease the process of adaptation (Garcia, 2005). Since the social work literature on transnational migration is in an early phase of development and since social workers are likely to encounter individuals who are transnational migrants, an explanation of the phenomenon is relevant. Transnational migration refers to the “processes by which immigrants forge and sustain multi stranded social relations that link together their societies of origin and settlement” (Basch, Glick-Schiller, Basch, & BlancSzanton, 1992). Transnational migrants are distinguished from “traditional” migrant types who over time discontinue movement across nation-states and resettle in the receiving country. According to some scholars, they represent a new category of contemporary migrants (Vertovec, 1999). Rather than focusing on traditional concerns about immigrants’ origins and their adaptation to the receiving countries, the transnational migration perspective “concentrates on the continuing relations between immigrants and their places of origin and how the back and forth traffic between home and new country build complex social fields that straddle national borders” (Portes, 2002). Some, however, question the existence of transnational migration (Waldinger & Fitzgerald, 2004). Critics claim immigrants of the past maintained familial, social, economic, and political ties to their home countries and also developed connections and ties to the new land. They, therefore, contend that transnational migration is an old U.S. immigration story retold through a different lens. However, differences exist between previous immigrants and contemporary transnational migrants that are linked to the development of time- and spacecompressing technologies of communication (e-mail, cell phones, fax) and transportation (air travel) (Levitt, Dewind, & Vertovec 2003;

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Faist, 2000; Foner, 2001; Portes, Guarnizo, Landolt, Autler, & Baires, 1999). These technologies, which were not available to immigrants of earlier times, enable current transnational migrants’ regular and routine cross-border contact. Thus, a mother employed in the “new” country as a child care worker can have regular and routine contact and conversations with her children living with a grandparent in the home country. Also, a committee comprised of migrants currently working in the “new” country can travel over a weekend to oversee a homeland community project that members sponsored and funded, and return to work by the following Monday (Smith, 2006). Transnational activities are varied and are expressed at different levels, which range from states, institutions, and communities to individuals and families. They also take place in different arenas—political, economic, sociocultural, and religious. The following examples of transnational activities are presented within micro, mezzo and macro domains to illustrate their different forms and to highlight their relevance for the broad range of social work practice. The examples include a transnational family (micro practice); a hometown community project (mezzo practice); and remittances (macro practice). The “micro example” below focuses on mothers and their children. Many women, including many mothers, are driven to a decision to move internationally so that their families can survive (Sassen, 2002a). These women commonly leave countries that are struggling with debt, poverty, high unemployment, and low wages. They migrate where there is a demand for “care work,” often in cities of the global north. Many are employed as livein housekeepers/nannies, or persons caring for the elderly. Due to economic circumstances and/or the admission policy of the receiving country, many mothers leave their children with relatives or “other mothers” in the home country. Nonetheless, they maintain contact with their children through e-mail, texting, phone

cards, letters, videos and gift giving (Schmalzbauer, 2004; Parrenas, 2005; Hondagneu-Sotelo & Avila, 2003; Ehrenreich & Hochschild, 2002). Despite the distance from their children in both space and time, the mothers continue a nurturing role as portrayed in parent-child correspondence and in their queries about children’s health, schooling, activities, and relationships (Hondagneu-Sotelo & Avila, 2003; Parrenas, 2005). They also assume the role of breadwinner as the remittances they send home support the family. Some enhance the children’s future as they support their education. The mothers’ time away from children can span years. There are also constraints around visiting the children that include the expense of travel and/or the undocumented status of some mothers. For undocumented women, crossing a border is not only a safety risk but also a risk for deportation and job loss as they may encounter U.S. immigration officials. The mothers’ separation of time and space from children leads to a change in modes of interaction from direct at-home exchanges to indirect contact through technological devices situated far from home. They develop new child care arrangements shifting from the “at-home” mother living with her children to grandmother or “other” mothers residing with and caring for the children. They construct new meanings of motherhood. For many women, the latter entails forsaking cultural views and individual beliefs regarding the importance of “at-home solo motherhood.” In so doing, they cope with stigma, guilt, and criticism from others (Hondagneu-Sotelo & Avila, 2003). They are on an immigration journey as they leave their children, their community, their homeland, and, in some cases, husbands. The example illustrates the significance of cross-border contact between mothers and children, changes in family roles that evolve out of transnational migration, changes in views of motherhood, and the contributions of mothers to the survival of their families.

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The following “mezzo example” is drawn from an ethnography on the transnational lives of new immigrants (Smith, 2006). It describes activities between members of a village in Puebla, Mexico, and emigrants from the village living in Brooklyn, New York. In the basements of Brooklyn homes, the village committee of New York initiated fund-raising activities to develop a potable water system for the Mexican village. The new water system would be able to handle the pressure needed to pump water into different parts of the village. Thus, villagers could “shower any time of day or night, plant trees in the backyards and water them” (Smith, 2006). Committee members also traveled over a weekend to Mexico to meet with villagers and consult with contractors on the work they funded and returned to their jobs on the following Monday. Although the New York committee eventually became involved in the political life of the village and helped to fashion a set of rules and practices for participating in transnational public life, community acceptance of the committee’s political role took years to establish as villagers exerted control over their community. The example portrays cross-border activity between a homeland community and an emigrant network in the new land. It also reflects the connection between transnationalism and community development. The remittances (“macro example”) sent by individual migrants to their families, relatives, or friends in the sending country represent their ties and commitment to those who remain in the homeland. However, the volume and stability of these individual monetary transfers are transformed from an “intimate transaction” into a global economic force (Guarnizo, 2003; Orozco, 2004). The remittances have a major positive effect in developing countries. There is compelling evidence that they reduce poverty, improve a nation’s creditworthiness for external borrowing, and drive investments. They also support

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community projects like the potable water system cited in the previous example. The stream of remittances in developing countries totaled $75 billion in 1989; they increased to $125 billion by the mid 2000s and reached more than $350 billion by 2011 (Sirkeci, Cohen, & Ratha, 2012). Since remittances transferred by hand carriers are not captured in the data, governments in the sending and receiving countries consider policies that would increase their flow and promote transfers through formal channels. In the remittance-receiving countries, suggestions include tax exemption on remittances, as well as improved access to banking services and foreign exchange. In the remittance-source countries, suggestions are similar but also include support for migrant groups. Clearly, the collective economic power of transnational families and groups has engaged the interest and actions of governments and banking institutions in both sending and receiving countries. Although remittances have declined since the global recession, they nonetheless cushioned the financial crisis for developing countries and have been more resilient than private capital flows (Sirkeci, Cohen, & Ratha, 2012). The discussion of transnational migrants highlights their common activity of crossborder contact between receiving and home countries, as well as their different type transnational practices. The phenomenon of transnational migration also implies a contextual shift in social work practice from one that primarily revolves around understanding migrants’ experiences in the receiving country to a dual focus on the experiences in the country of origin and the country of destination. Therefore, a broader frame for assessment and helping that includes a two-country perspective on families, communities, and institutions as well as familiarity with international practice is implied. Immigration law and immigration status influence the reception newcomers experience. The statuses carry different rights and

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different service entitlements, and reflect different policies among newcomers (Drachman, 1995). The different immigrant statuses include legal permanent resident, refugee, undocumented/unauthorized person, and mixedstatus family. A legal or lawful permanent resident (LPR) is a foreign-born individual who is legally admitted to live permanently in the United States by qualifying for an immigrant visa abroad or through adjustment to permanent status in the United States. Family members or employers sponsor many LPRs to come to the United States (Fortuny, Capps, & Passel, 2007). A refugee, as defined in the Refugee Act of 1980, is a person who is outside of and unable or unwilling to avail himself or herself of the protection of the home country because of persecution or fear of persecution on account of race, religion, nationality, membership in a particular social group, or political opinion (PL 96–212). The individual who requests refugee status makes an application from abroad, often from a country of asylum. After one year in the United States, the individual can apply for permanent residence. An asylee is distinguished from a refugee as the individual enters the United States without authorization and requests asylum after arrival. If granted asylee status, the individual can apply for permanent residence after one year. Since refugees and asylees are admitted into the United States for humanitarian reasons, they qualify for public benefits. An undocumented/unauthorized immigrant does not possess a valid visa or other immigration document, as the individual either entered the United States without inspection, stayed beyond the time permitted on a temporary visa, or violated the terms under which the person was admitted to the United States (Fortuny, Capps, & Passel, 2007). An unauthorized immigrant is ineligible for federal means-tested programs. A mixed-status family includes one or more noncitizen parents, many whom are

undocumented, and one or more children who are United States citizens. The family could also include a noncitizen parent(s) and one or more children who are U.S. citizens as well as one or more children who are undocumented. A citizen child in a mixed-status family qualifies for means-tested benefits while any undocumented children and undocumented parent(s) in the same family do not qualify for meanstested benefits. demographic Patterns The foreign-born population in the United States increased from 31 million in 2000 to 38.5 million in 2009. Currently the foreign-born population represents 12.5 percent of the total U.S. population. In 2006, the foreign-born population included 11.5 million naturalized citizens (31 percent), 10.5 million legal permanent residents (28 percent), 2.6 million refugees (7 percent), and 1.3 million (3 percent) temporary legal migrants, many of whom are students or temporary workers (Passel, 2010). The undocumented/unauthorized population living in the United States has recently declined. In 2007, the undocumented population reached 12 million. By 2009, the population decreased to 11.1 million. The decline represents the first reversal in the growth of the unauthorized population over the last two decades. The reduction occurs among individuals arriving from Latin American countries (other than Mexico). The Mexican unauthorized population, which accounts for 60 percent of the undocumented population, reached 7 million in 2007 (Passel & Cohn, 2010). Although this number has not significantly changed, the inflow from Mexico has also fallen in recent years (Passel & Cohn, 2010). Despite the decline in the unauthorized immigrant population, there is an overall increase. In 1990, the undocumented population reached 3.5 million; by 2000 it was 8.4 million; and by 2009 it reached 11.1 million (Passel & Cohn, 2010). The timing of the decline is notable as it coincides with the economic downturn in the United

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States and the country’s enforcement strategy aimed at the removal of undocumented persons and other noncitizens convicted of major or minor offenses. Immigrants are heavily concentrated in six states—California, New York, New Jersey, Illinois, Texas, and Florida. During the 1990s and 2000s, the foreign-born population spread to new growth states, new metropolitan areas, and suburban counties—communities that have had little or no history of immigration (Lyman, 2006; Capps & Fortuny, 2006; Roberts, 2006). For example, in New Rochelle, a suburban community outside of New York City, the share of foreign-born residents rose to 32 percent of the population by 2006 (Roberts, 2006). In Danbury, Connecticut, the Asian immigrant population rose to 11 percent of the population. An 11 percent increase occurred in second-tier growth states such as Georgia, Massachusetts, and Washington; and the largest percentage of increase occurred in the third-tier growth states including Alabama, Kentucky, South Carolina, Missouri, Ohio, and Pennsylvania (Lyman, 2006). The largest growth rate of children of immigrants occurred in many states that had small immigrant populations twenty years ago—North Carolina, Georgia, Nevada, and Arkansas (Fortuny & Chaudry, 2011a). Metropolitan areas (metros) across the country have large concentrations of immigrant populations. In 2007, the foreign-born population was over one million in each of the following metros: Los Angeles (3.6 million); New York (3.4 million); Chicago and Miami (over 1.4 million (Fortuny, Chaudry, & Jargowsky, 2010). Foreign-born populations in thirteen other metros ranged between 500,000 and one million; and in twenty other metros the population was at least 200,000. By 2007, fifty-two of the top one hundred metropolitan areas had foreign-born populations of 100,000 or more (Fortuny, Chaudry, & Jargowsky, 2010). Immigrants are therefore rapidly dispersing to many regions across the country and settling in many metropolitan areas.

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Children of immigrants are a sizable population, and their well-being is significant since they represent the future of the country. Most of the increase in children of immigrants occurs among citizen children—i.e., children born in the United States. Citizen children comprise more than 80 percent of the children with foreign-born parents (Fortuny & Chaudry, 2011a). Between 1990 and 2000, the population of children of immigrants increased from 8.3 million to 13.3 million; and grew to 16 million by 2007 (Fortuny & Chaudry, 2011b). In contrast, the growth rate of children of native-born parents was less than 1 percent between 1990 and 2000. Due to the higher numbers of children of immigrant parents, the U.S. child population increased from 63 million in 1990 to 74 million during the 2000s (Fortuny & Chaudry, 2011b). The large majority of children of immigrants (84 percent) live in metropolitan areas of the United States. Half the population live in ten large metros, and the other half is dispersing to fast-growing metros in the Southeast and Midwest. While the number of children of immigrant parents living in metros increased 26 percent between 2000 and 2009, children of native-born parents decreased by almost 1 percent. Similar to the national increase in the child population, the 5 percent growth of the child population in metropolitan areas of the United States is attributable to children of immigrants. Prior to the economic downturn in the United States, an overwhelming majority of immigrants was employed. In 2008, participation in the workforce among unauthorized immigrants was 80 percent; and for legal permanent residents it was 72 percent. Over 90 percent of both legal and unauthorized immigrants worked full-time (Capps, Rosenblum, & Fix, 2009). Despite immigrants’ high level of employment, many immigrant families have low incomes—i.e., below 150 percent of the federal poverty level (Capps, Rosenblum, & Fix, 2009). The low family income is largely explained by the low-wage jobs in sectors of the economy where immigrants are commonly

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employed, e.g., agriculture, construction, garment industry, meat packing, leisure, hospitality, and services (Passel & Cohn 2010; Capps et al., 2005). Other factors also contribute to the low income among immigrants, such as limited English language skills; less than ten years residence in the United States, and the absence of high school education. Compared to native-born low-income families, immigrants’ use of public benefits is also lower. The reasons for their low service utilization are previously discussed in the context of the devolution of immigrant policy. Diversity of immigrants along ethnicity, race, and national origin is one of the defining characteristics of the current wave of immigration in the United States. More than half of all immigrants in the country come from Latin America, and a sizable proportion (29 percent) come from Mexico (Jones-Correa, 2012). Individuals from countries in Central America, South America, and Spanish-speaking countries in the Caribbean are a part of the mix within the Latino immigrant population. Individuals from Asia comprise 28 percent of immigrants. There is also broad diversity in national origin among the Asian immigrant population who arrive from different countries including India, Philippines, China, Vietnam, and Korea, which are among the nations with high immigrant percentages in the country (Jones-Correa, 2012; Chaudry & Fortuny, 2011). Racial diversity is additive to national origin diversity. The children of immigrant parents illustrate the nature and degree of population heterogeneity among immigrants and foretell the composition of the U.S. population in the coming years. For example, Latino, Asian, and black children comprise a majority of children in nine states (Fortuny & Chaudry, 2011a). When racial and ethnic group populations are aggregated among the top one hundred metropolitan areas in the nation, nonwhite children represent the majority (Fortuny & Chaudry, 2011). The racial and ethnic shifts in the child population are due to the decline in the

number of white children and the large number of Latino and Asian children, with most of the growth among children of immigrants (Fortuny & Chaudry, 2011a). Societal context A humanitarian view that supports the inclusion and integration of people from different parts of the globe into United States is reflected in the country’s immigration history. As argued by Daniel Kanstroom, the United States is also a “deportation nation, which lives in equipoise with the country’s openness to legal immigration” (Kanstroom, 2007, p. 3). These opposing views are embedded in the historic swings between immigrants’ inclusion and exclusion in United States. They are also visible in the current societal context with exclusion and deportation predominating. Two laws enacted in 1996—the Personal Responsibility Work Opportunity Reconciliation Act (PRWORA—welfare reform) and the Illegal Immigration Reform and Immigrant Responsibility Act (IIRIRA)—change the social and economic landscape for newcomers. Prior to the 1996 legislation, legal permanent residents were generally qualified for the same public benefits as citizens and were required to meet the same eligibility criteria as citizens. The 1996 welfare law, however, restricts legal permanent residents’ access to means-tested benefits for five years after arrival. During the first five years in the United States, they are ineligible for Temporary Assistance for Needy Families (TANF), Supplemental Nutrition Assistance Program (SNAP, formerly food stamps), Social Security Income (SSI), and Medicaid. After the five-year bar, eligibility for means-tested benefits is based on their income plus the income and resources of their sponsor. The sponsor’s income, which is required by the 1996 IIRIRA is lifted once the immigrant completes forty quarters of work or becomes a citizen. The IIRIRA also raises the sponsor’s income level to 125 percent above the poverty line for a family member’s admission into the United

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States. Since sponsors are required to sign an affidavit of support, this requirement is legally enforceable. Thus, federal and state agencies that provide means-tested benefits can sue sponsors for failure to provide the promised support; and to recover monies spent on an immigrant in the event the individual received public assistance (Stickney, 1997; Drachman & Ryan, 2001). The 1996 laws ultimately dismantle the safety net for legal permanent residents as they are ineligible for federally funded assistance should they become disabled, aged, or poor prior to the five-year bar. Family reunification is also more difficult to accomplish due to the higher sponsorship rate for a relative’s admission into the country. Under the 1996 welfare law, immigrant policy (i.e., government rules and investments aimed at promoting immigrants’ social integration) shifts from federal authority to state authority (Padilla, 1997; Fix & Tumlin, 1997. The law creates block grants for states to assume the powers for determining who receives public benefits, the conditions of the benefits, and duration of benefits (Drachman & Ryan, 2001; Hagan et al., 2011 Fix & Tumlin, 1997). What had previously been uniform national rules set by Congress regarding noncitizens’ eligibility for public benefits is currently variable across the states. Since states are granted greater power than before to either bar, limit, or provide full access to benefits for noncitizens, welfare reform “deepens the differences between how citizens and noncitizens are treated and redefines noncitizens’ membership in society” (Fix & Tumlin, 1997, p. 1). Studies undertaken after passage of the 1996 laws indicate a decline in the use of benefits among citizen children in mixed-status families (Fix & Zimmerman, 1999), and a significant decline in legal immigrants’ use of TANF, SNAP, SSI, and Medicaid (Capps et al., 2002; Capps, Rosenblum, & Fix, 2009). Although the decline in the use of public services is in part attributable to eligibility restrictions, it is also

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a result of other barriers to services, such as undocumented parents’ fear of deportation if they access services on behalf of their citizen children (Pine & Drachman, 2005). Confusion about eligibility requirements, problems with documents required to support eligibility, limited English language skills, and the complexity and variability across states on eligibility rules are among the barriers (Fortuny & Chaudry, 2011b). Ultimately, the restrictions on immigrants’ eligibility for public benefits, the obstacles to family reunification, the variability among the states in determining who receives public benefits, and the regulations that distinguish citizens from noncitizens reflect the devolution of immigrant policy. The steady increase in the number of persons deported from the United States since 1997 reflects a restrictionist immigration view. Although the restrictionist perspective is aimed primarily at undocumented persons, legal permanent residents are also among the many individuals removed from the United States. In 2001, the yearly number of deportees, which includes noncitizens with criminal and noncriminal offenses, totaled 189,026. By 2009, the yearly number almost doubled and reached 395,165 (United States Department of Homeland Security, 2011). A Human Rights Watch report uses data from Immigration Customs and Enforcement (ICE), an agency within the Department of Homeland Security, which estimates that 897,099 noncitizens were deported between 1997 and 2007 after having served their criminal sentences. The report also estimates at least one million spouses and children have faced separation from their family members due to deportation (Human Rights Watch, 2009). Although the U.S. debate on immigration assumes a prominent place among the country’s national concerns, there is limited attention in the debate on the experiences of children and families that derive from interior enforcement actions of arrest, detention, and deportation of undocumented persons. The enforcement

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actions have fragmented families and created extreme economic hardship due to the deportation of a primary breadwinner. It has created housing instability and food insecurity, precipitated a change in family structure from a twoparent family to a single-parent family, and generated psychological and behavioral difficulties for children who suddenly lost a parent or parents through detention and deportation (Kremer, Moccio, & Hammell, 2009; Chaudry, Capps, Pedroza, Castaneda, Santos, & Scott, 2010; Capps, Castaneda, Chaudry, & Santos, 2007). For children who experienced a parent’s arrest and detention during a work site or home raid, their common reactions of fearfulness, sleeplessness, loss of appetite, withdrawal, frequent crying, anxiety, behavioral difficulties, school absences, and deteriorating school performance are documented (Chaudry et al., 2010; Capps et al., 2007). Furthermore, many of the children who lost a parent through detention and deportation are U.S. citizens (Kremer, Moccio, & Hammell, 2009). In addition to the deportees’ experience of banishment, human suffering is spread when considering the many husbands, wives, mothers, fathers, brothers, sisters, and children that are affected by the deportation of a family member. Members of the community in which the deported person lived also suffer as entrepreneurs lose business partners, shops close, and tax revenues are lost (Human Rights Watch, 2009). Two laws passed in 1996, the Anti Terrorism Effective Death Penalty Act (AEDPA) and the IIRIRA, reflect recent post-entry socialcontrol laws and a hardening of the deportation system. The IIRIRA expands the offenses for which noncitizens could be deported by adding to the list of aggravated felonies that are grounds for deportation (Kanstroom 2007). The list, which includes major offenses such as a crime of violence, also includes minor offenses such as possession of a substance (Hagan et al., 2011). Individuals could also be deported for a Cappsretroactive law. In other words, a crime that was not considered an aggravated felony at

the time of the offense and is now defined as an aggravated felony is currently deemed a deportable act. Thus, a 30-year-old noncitizen living in the United States since he was 4 years old and employed for years as a store manager while supporting his mother is now deportable to his country of birth due to a minor crime he committed when he was a teenager. The IIRIRA also establishes “expedited removal,” which permits the Department of Homeland Security (DHS) to order the removal of individuals who do not have proper documents for U.S. entry (Drachman, 2001). These individuals are removed from the country within days without a further hearing. Therefore, persons who fear persecution if returned to the home country may be barred from applying for asylum due to the fasttracking process of “expedited removal.” The September 11, 2001, attacks on the United States fortified the 1996 laws as terrorism became a national concern. The USA Patriot Act was passed shortly thereafter, emboldening the government to arrest, detain, and deport persons viewed as a threat to national security. In 2003, the Department of Homeland Security was established. The Immigration Customs and Enforcement (ICE) was created as a department within Homeland Security with the stated goal of “removing all removable aliens by 2012” (DHS, 2003). ICE escalated its interior enforcement actions, which include the highly publicized work site and home raids and the 287(g) program that sweep undocumented immigrants from the families and communities in which they live and work. As an example, a Honduran couple, the parents of two young children, are arrested and detained in a work site raid in Massachusetts (Preston, 2007). While the wife remains in detention, the husband is released on humanitarian grounds to care for the children, ages 2 and 5 years old. The younger child is a U.S. citizen and the older child is undocumented. The couple migrated to the United States for the family’s safety as criminal gangs were using the Honduran streets as a combat

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zone (Preston, 2007). Rival gangs shooting in and around a public bus killed the wife’s sister and twenty-seven passengers. The husband states “we walked over dead bodies in Honduras. The children see that and they don’t grow up well” (Preston, 2007, p. A1). Although the wife petitions for U.S. asylum, her petition is denied. In detention, she is awakened early one morning, driven to an airport by immigration agents, and deported to Honduras. Telephoning her husband as soon as she could place an international call, she says, “I am more afraid in Honduras than the American jail. I have no home, no job” (Preston 2007, p. A1). Although the example portrays the circumstances and experiences of one family, it reflects the tens of thousands of families who are torn apart by deportation as parents and children are separated; children develop psychological and behavioral difficulties, children’s school performance deteriorates, and parents are faced with the wrenching decisions cited in the example. In addition, citizen children who accompany their deported parents are effectively deported from their home country and deprived of their right to a U.S. education and the social rights of a citizen. The home countries to which the deported parents and their children generally return (Mexico, Guatemala, Honduras, El Salvador, Haiti, Dominican Republic) also face difficult economic and social problems of low wages, low educational attainment levels, poor educational conditions, child labor, and violence (Kremer, Moccio, & Hammell, 2009). Thus, prospective opportunities for children and adults are likely to be limited. Although the discussion focuses on the present social context of immigration restriction and exclusion, the humanitarian view that supports immigration inclusion and integration is currently gaining strength. For example, a recent executive order by President Obama permits undocumented young persons who came to the United States as children to remain in the country, to work in the country, and to obtain a driver’s license and other documents without

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fear of deportation. Although temporary, the order could benefit more than 800,000 young people (Preston & Cushman, 2012). In addition, the large Latino vote, which influenced the outcome of the recent U.S. presidential election, has shifted the political and social landscape so that comprehensive immigration reform is possible in the near future. Vulnerabilities and risk factors The word stress refers to the psychosocial discomfort or distress people frequently experience in daily life, especially while adapting to new environments. The immigration literature suggests that the process of adaptation to the host culture can be stressful enough to threaten the psychosocial well-being of many immigrants (Hull, 1979; Tran & Ferullo, 1997), whether admitted to the United States for economic advancement, reunification with their families, or humanitarian reasons. Studies reveal that the newcomers’ stressful life experiences seem to have contributed to their psychosocial problems. The most prevalent problems include domestic violence, alcoholism, juvenile delinquency, alienation of the elderly, marital and intergenerational conflicts, and mental disorders. The term culture shock was coined to characterize severe anxiety-provoking situations experienced by those who must act under unfamiliar social norms and behavior cues (Oberg, 1960). It implies that the experience of a new culture is an unpleasant surprise—a shock—partly because it is unexpected and partly because it may lead to a negative evaluation of one’s own culture. Researchers have seen culture shock as a normal reaction, part of the routine process of adaptation to culture stress, and the manifestation of a longing for a more predictable, stable, and comprehensible environment (Furnham & Bochner, 1986). Some have also suggested that the greater the difference between the culture of origin and the host culture, the higher the rate of psychosocial dysfunction (Berry, Kim, & Mok, 1987).

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Since members of any cultural group are not all alike, the differences within a cultural group may be greater than the differences between the dominant culture and a minority culture. One major difference among members of various ethnic and cultural groups is the degree to which they have immersed themselves in the culture of the United States. Acculturation can be defined as a process that begins when individuals from different cultures come into continuous firsthand contact, leading to changes in the original cultural patterns of either or both groups. The task faced by new immigrants is to adapt to the host society. Not surprisingly, the stress of adapting—i.e., acculturation—may result in anxiety, depression, psychosomatic symptoms, and identity confusion (Williams & Berry, 1991). For some immigrants, cultural conflicts continue to cause inner confusion and stresses even after many years of settled lives in their new environment Our conduct is dictated by the predictions that we make about our physical and social environments. Consider an immigrant family that leaves its village or town in an underdeveloped country one day and finds itself the next day in one of the most advanced industrial countries in the world. The members of the family are instantly plunged into an unpredictable new environment that, given their ignorance of the social structure, the norms of behavior, and the timetable of natural events. They are unprepared to survive, let along thrive in. Most of us deal with our environment, recognizing cues and automatically responding, without daily reflection upon social expectations and regulations. Immigrants, however, cannot take this nonverbal language for granted. They need to consider each situation individually and reflect quickly on their own role in it. For immigrants whose contacts with others were once limited to their own family and extended family, to live in a new land means to reorganize, restructure, and re-predict their lives on a daily basis. This is stressful.

Immigrants often sustain multiple losses. The loss of social status and social roles may create a sense of deprivation and insecurity. Among immigrants, the discrepancy between anticipated and actual social status, namely, goal-striving stress, seems to exert substantial negative effects on their mental health. Some immigrants continue to experience lower social status throughout their lives. Female immigrants generally suffer more dramatic changes in role status than do their male counterparts (Freidenberg, Implivale, & Skovron, 1988), and role reversal is a major stress in the families of several immigrant groups (Brown, 1982) in which the wife can find employment more easily than the husband. When she becomes the breadwinner while the husband stays home and does the housework, many immigrants—particularly men who come from countries where traditional families are the rule—find the reversal of roles intolerable. Migration, however, may also result in a deterioration of women’s positions for those who do not work outside the home. The roles that they have been socialized to fulfill are no longer viable in their new land. Wives and mothers who do not speak the language may be more dependent on their husbands and children, as well as either more overworked or more isolated than they were in their home country (Rhee, 1996). As mothers, they are confronted with primary responsibility for their children’s schooling. Yet they are unprepared to understand and cope with an institution such as the school. Thus, children and husbands, experienced in schools and in workplaces, become the interpreters of this new culture and its institutions for the homebound mothers and wives, causing further role strain. As primary providers for the families’ immediate needs, women worry a great deal about the shifting dynamics between parent and child that accompany a migration experience (Rhee, 1996). Extreme differences between Western, Asian, African, and Latin cultures with regard

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to family values, authority patterns, and degree of individualism sharpen this conflict. The search for identity and/or the re-creation of identity are complicated processes for immigrants. They must reexamine and change their attitudes toward themselves, toward other ethnic groups, and toward the dominant culture—an experience stressful enough to create repeated crises of identity. Most immigrants, particularly children and adolescents, must sort out and decide which parts of their cultural heritage to retain and which aspects to modify or replace in order to function effectively in their new country (Le, 1983). Immigrants, particularly refugees, often have experienced profound loss, not just in terms of status and material goods, but also in seeing their native land transformed politically and culturally. Losses also are associated with separation from members of their families and other social support networks. These multiple losses add up to a stressful, if not traumatic, experience. Persons living below the poverty level in the United States include an inordinate number of ethnic/racial/cultural group members, many of whom are immigrants. Factors such as housing, employment, educational opportunities, and life expectancies are often associated with poverty among members of culturally diverse immigrant populations. For those immigrants who are vulnerable to social distress because of genetic or psychological factors, the added stress of poverty can lead to symptom manifestations and mental health problems. Social class and environmental risk factors have negative effects on the immigrant’s adaptation. The negative effect may largely derive from the congested, low-income, and depressed neighborhoods where immigrants reside. Residence in inner cities exposes the immigrant to overcrowded and unsafe buildings, as well as to too-frequent environmental changes that require quick adaptation. Innercity living may present immigrants and their

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children with multiple stresses that, cumulatively, may be more damaging to healthy functioning than a single acute stressor would be. Migration may not be a labor migration, but if immigrants want to survive, to attain an independent income, and to regain or achieve a desirable socioeconomic status, they have to rely on employment. Gender adds another dimension to the stratification of immigrants within both the workplace and the larger society. Immigrant women experience the restrictions of a sex-segregated occupational structure, in which women’s jobs are characterized by lower wages, fewer opportunities for advancement, and less job security (Philzacklea, 1983). Immigrant women’s jobs are located disproportionately in the poorly paid labor-market sectors where they work as domestics, sewing machine operators, waitresses, and so on. Immigrants often suffer the frustration of being unemployed and regarded as fringe wage earners. Many immigrants willingly accept menial or semiskilled jobs in order to survive. They share the problems of unskilled workers throughout this country: double workloads, repetitive and fatiguing jobs, unhealthy working conditions, an absence of benefits, and the like. Many immigrants held professional or white-collar jobs in their countries of origin. Some are able to maintain their former occupational and social status, but many cannot find similar or comparable occupations in the United States. In spike of their economic mobility, they have not resolved the problem of status inconsistency. How generous should this country be to those who do not speak standard English? This question has been asked with increasing urgency within the dominant culture. Certain white Americans perceive language as the one mutable feature of culturally diverse groups; therefore, the place to take a stand and demand assimilation (Hurtado & Rodriguez, 1989). To them, the ability to speak English serves as a symbolic measure of assimilation.

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As a corollary, many of these same Americans hold in contempt individuals whose spoken language is noticeably different from what they perceive as standard English. Far from serving as a simple vehicle for describing an objective world, language is the key facet of a person’s self-concept and active shaper of the way people think and act (Rubin 1981). Learning a new language is a gradual process, for a shift from one language to another requires a change of thought processes, cultural attitudes, and self-concepts. Immigrants to the United States often feel lost and disoriented when they cannot achieve a level of proficiency in English that makes them comfortable in their environment. Many of the behaviors considered problematic by teachers are, in reality, characteristics of students who are in the process of second-language acquisition. Often, a child undergoing acquisition of a second language is diagnosed incorrectly as learning disabled. Evidence has shown that much of the history of culturally diverse groups in the United States has often been unpleasant, with racism and prejudice fueling the oppression of minorities. Certainly, many immigrants have experienced racism and negative stereotyping. Not surprisingly, these have in some instance led to emotional distress and social dysfunction. The current political environment is characterized by strong anti-immigrant feelings. There is a growing concern among the indigenous population that newly arrived immigrants are taking away jobs from the native-born lowest-paid workers. Many immigrants come from homogeneous nations, where they were not accustomed to racial and ethnic diversity, and are unfamiliar with the kind of racism, both overt and covert, so often experienced in this country. The existence of so many unfamiliar cultural and ethnic groups, particularly in cities, where they live in close proximity to one another, often leads to stress that is exacerbated by crisis situations, such as social violence, racial profiling, and police brutality. Obviously, these experiences and the fears they generate lead to stress.

resiliencies and Protective factors Coping has been identified as a mediator of social stress (Pearlin, Lieberman, Monoghan, & Mullin, 1981). Some immigrants withdraw from stress, whereas others try to diminish it by finding creative and adaptive solutions. Some immigrants approach stressful situations with optimism and confidence; others look to surrogates to resolve them. At the core of immigration lies the issue of cultural identity. Its formation involves finding a place within that larger social world. For immigrants and refugees, this means giving up some components of their previous identity and establishing a new self in a social world whose dimensions may be vague or unknown. In the process of changing behavior, values, attitudes, and identity, immigrants face two general questions: whether to retain the cultural identity and characteristics of the country of origin and/or whether to participate in the larger society (Berry et al., 1987). Four types of acculturation are possible: (1) assimilation, in which the original cultural identity is rejected and only participation in the larger society is accepted; (2) integration, in which the original cultural identity is retained and participation in the larger society is accepted; (3) separation, in which original cultural identity is maintained and participation in the larger society is rejected; and (4) marginalization, in which both original cultural identity and participation in the larger society are rejected (Pawliuk et al., 1996). Researchers investigating the process of acculturation have suggested that an integrated, or bicultural, style is associated with better psychological functioning in adults (Berry et al., 1987). People who can maintain a balance between two cultures have fewer psychological disorders than the groups at the extremes—the least or the most acculturated (Ramirez, 1984). Studies have shown that more acculturated individuals who have become alienated from their own ethnic support systems are more likely than less

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acculturated individuals to suffer psychological disorders. Immigrants have both positive and negative perceptions of the United States. Though they may see it as a land of opportunity, particularly for their children, many feel lost without a sense of community and fear losing their identity. They use differing strategies to cope with their geographic and cultural loss: nostalgically recreate past association; idealize the home country; criticize the new culture; and superficially adjust to the new reality. Since not all members of any given cultural group are alike, the acculturation pattern or style will differ from person to person. Age, gender, and social class are among the variables to be considered in relation to vulnerability, as well as adaptive behavior, in coping with cultural conflicts. Immigrants can show resilience, as well as vulnerability, and not all immigrants will be traumatized by their experiences. Immigrants who positively perceive the place of their ethnic culture tend to preserve it in their identity, either fully or partially, whereas those who perceive it as inferior tend not to identity with it (Berger, 1997). The employment status of immigrants and refugees in the host society is an important indicator of their adaptation (Tran, 1991). For sure, immigrants and refugees who arrive in the United States with a knowledge of English, good educational background, social skills, manageable family obligations, and good health status will achieve a higher rate of employment than those who lack these characteristics. Resources made available through interrelationships with significant others provide both emotional and tangible benefits to individuals. These include a sense of meaning, belonging, and acceptance; affection and nurturing; and information, transportation, and help with daily living. Research has found that social supports directly affect immigrants’ adaptation with respect to job satisfaction, depression, health outcomes, and life satisfaction (Payne & Jones 1987; Turner, 1981).

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Immediate family members, as well as extended family, play key roles in many immigrant families’ lives. Family support is a widely appreciated aspect of many cultures. Family support moderates stress, and the mobility of family support systems acts as a preventative measure, alleviating stress. In immigrant families, differences in acculturation style of parents and children may create family conflict. Such conflicts may also arise when some members represent the values of the country of origin and others represent the values of the new society. A family’s ability to adapt to life in the new country—such as maintaining contact with formal or informal institutions and peers without giving up ethnic identity— serves as a strong protective factor. Parents who speak the language of the host culture or who have friends in the host culture may be more likely to enroll their children in team activities and organizations, activities that will result in higher levels of social competence. Newly arrived immigrants depend on their own ethnic communities for a social support system to reduce the stress of immigration. Immigrants express their culture through their own social and institutional community networks, and it is the community as a whole that integrates them with the larger society. By setting up, in the host country, social networks based on both kinship and friendship, and by establishing ethnic associations and religious institutions, immigrants are able to respond adequately to their most important sociocultural needs within a community that mediates between them and the larger society. These organizations provide a place for social relationships to develop that satisfy the immigrants’ need for communication and enable them to avoid isolation. For such networks and organizations to provide social support, the immigrant community must have within it a relatively large proportion of well-integrated and educated individuals able to serve as mediators. These men and women usually share deeply ingrained core

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cultural values and/or support from the host society. Immigrant groups with support and funding from federal and state governments are able to express their culture and identity through their own social networks and community organizations. Programs and Social Work contributions Voluntary agencies have taken a major role in the resettlement process of refugees in this country as well as other Western countries (Tran, 1991When refugees began to arrive from Southeast Asia, the government established several refugee camps in this country to receive, process, and resettle refugees in American communities. The second-wave refugees from Southeast Asia and refugees from Latin American countries, the Soviet Union, and other Western countries came to the United States either directly or after spending a period of time in their first asylum country. Once refugees received a visa for entry to the United States, they were assigned to one of the voluntary agencies, known as VOLAGs. The VOLAG agencies included the United States Catholic Conference, the Lutheran Immigration and Refugee Service, the International Rescue Committee, Church World Services, Hebrew Immigrant Aid society, and others. The VOLAGs were responsible for finding sponsors for refugees who were allowed to leave camps only when sponsorship in the communities was obtained (Tran, 1991). The VOLAG agencies, which continue to provide services to refugees throughout the world, have had cooperative agreements with the Bureau of Refugees Programs of the Department of State to resettle the new refugees. When no sponsors are found by the VOLAGs, local voluntary agencies, such as the New York Association for New Americans (NYANA), directly assume responsibility to settle refugees. The goal of sponsorship is to assist the refuges to be integrated in the host country and to become economically self-sufficient. These international and local agencies are responsible for initial food, shelter, and clothing needs and for

counseling the refugees and immigrants about health, employment, and social services. Each state has a federally funded program for assisting newly arrived refugees and immigrants. These programs, through contacts with voluntary agencies, provide services such as English-as-a-second-language training, job development, employment placement, information and referral, interpreters, and socialadjustment programs. With the establishment of settlement houses in the late 1800s, educated middle-class individuals moved into poor neighborhoods to work directly with immigrants and other poor populations to bring about community and social changes (Iglehart & Becerra, 1996). The settlement house workers saw a part of their goal as assisting immigrants in adapting to American life. At present, many settlement houses continue to provide immigrants with social services, and educational and vocational programs. During the early 1900s, the mutual aid and self-help activities of ethnic communities began to flourish. This practice was much influenced by African Americans’ belief that their survival was strongly linked to self-reliance in the face of exclusionary and separatist practices (Martin & Martin, 1985). Black communities began to take on the task of addressing their own community needs. Other ethnic communities organized their own self-help programs. For example, early Chinese immigrants developed benevolent associations for their communities, and Mexican American organizations emerged to address their community needs. The goal of the early ethnic community organizations was to deal with problems identified by the community and provide services that were endorsed by the community. Today, ethnically run services for ethnic communities continue to grow and flourish. As the population becomes more diverse in complexion and culture, more attention is directed toward the need for social service agencies to provide culturally sensitive and competent services. The ethnic agencies became a model for the provision of such services

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Phases of Migration: Critical Variables

Factors that Influence Each Migration State Age, family composition, urban/rural background, race, education, culture, socioeconomic background, occupation, belief system, social support

Country of Origin Premigration/Departure

Social, political, economic, and educational factors Separation from family and friends Decisions regarding who leaves and who is left behind Abrupt departure Leaving a familiar environment Life-threatening circumstances Experience of violence and persecution Loss of significant others

Transit/Intermediate

Perilous or safe journey of short or long duration Refugee camp or detention center stay of long or short duration Awaiting a foreign country’s decision regarding final relocation Loss of significant others

Country of Resettlement

Cultural issues Reception from host country Opportunity structure of host country Discrepancy between expectations and reality Degree of cumulative stress throughout migration process Different levels of acculturation among family members Intergenerational conflict and family structural changes Language differences

Source: D. Drachman & A. Paulino (Eds.). (2004). Immigrants and social work: thinking beyond the borders of the United States. Binghamton, NY: Haworth.

(Iglehart & Becerra, 1996). Some of these ethnic agencies, with the help of governmental funding, became multiservice centers. These centers usually are capable of providing culturally and linguistically appropriate services to the community. Services provided by these multiservice centers often include information and referral, case management, efficacy and networking services, as well as counseling, youth, health, mental health, protective, and vocational services. Some also provide housing, employment services, and services for families and children. These agencies and those in other ethnic communities are active in developing programs for the empowerment of the communities and the new immigrants. assessment and interventions The migration framework includes several phases: premigration and departure, transit or

intermediate country/place, and resettlement. There are critical variables associated with each phase and common factors that influence all phases. Table 18.1 outlines the phases of migration, the phase-specific variables, and the common factors that influence all phases. Social, political, economic, and educational factors in the premigration and departure state are significant. This phase may involve abrupt flight, exile, or a situation in which individuals choose to depart. It may entail a short wait prior to departure or years of waiting and living in limbo before leaving. Some of the issues individuals face in this phase include separation from family, friends, and community; departure from a familiar environment; decisions regarding who leaves and who is left behind; expectation for a better future; and experiences of persecution, violence, and loss of significant others. Among the issues that

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emerge from this stage during resettlement are concern for those left behind, depression associated with the multiple losses, incongruity between expectations and the reality of life in the new land, posttraumatic stress disorder for people who experienced or witnessed violence, and survivor guilt. In the transit phase, experiences may range from a perilous sea journey on a fragile boat, or a long trek by foot through dangerous terrain, to an uncomplicated arrangement for travel on a commercial flight. The duration of the transit phase may vary from hours to years. An individual might live in limbo in a refugee camp for years while awaiting a final destination. The transit phase could also involve a long stay in a detention center while awaiting the decision of a receiving country regarding entry or deportation. On the other hand, an individual may leave the country of origin and, within hours, connect with family or friends in the new country. Common issues in the resettlement phase include the degree of cumulative stress experienced by the individual, the discrepancy between expectations and actual quality of life in the United States, the reception in the new country (e.g., policies about inclusion or exclusion), and the opportunity structure of the receiving country. Reunification in a different family structure with new members, such as stepparent and half- or stepsiblings, may generate conflict. Changes in power relationships between parent and child also may foster conflict. Cultural issues are numerous and include the degree of consonance or dissonance between the country of origin and the receiving country. They include different views on health, mental health, help-seeking behavior, education, child-rearing practices, gender-role behavior, and different levels of acculturation among family members. Cultural issues also surface in the interactions between service personnel and immigrant families. Depression, suicide ideation and suicide attempts,

substance and chemical abuse, parent-child conflict, and wife and child abuse are among the commonly reported problems. As men and women shift in their traditional marital roles (particularly when wives are employed and husbands are unemployed or earn less than the wives), marital conflict or dissolution may surface even among cultures where divorce is rare. Several principles for intervention are suggested below: 1. Helping should aim toward the reduction of stress, symptoms, and disability. 2. The discussion of traumatic events should occur at the individual’s pace. Catharsis and venting are not encouraged as they can exacerbate individuals’ symptoms and discourage client participation. 3. Support individuals’ strength in the person and in the environment. 4. Attention should be paid to physical, social, economic, housing, food, and medical needs. 5. Explore the value of group services as it may reduce isolation and preserve cultural values. 6. A significant part of helping involves an understanding of immigrants’ cultural views on health and illness, their cultural healing practices, and cultural help-seeking and receiving behavior. Despite differences in history, language, and culture, Asian nations tend to view health and illness from a comprehensive perspective that links the body with the mind and the spirit. Thus, the treatment of illness includes medicines and herbal remedies; diet, such as the balancing of foods; and physical treatment, which may include acupuncture, yoga, massage, and meditation (Dhooper, 2003). In contrast, U.S. health care practices and treatments are organ specific. Medical specializations are also organ specific. Mental health practice is separate from physical health practice.

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illuStrAtion And diSCuSSion

The couple described in the following example emigrated from Russia to the United States. The case illustrates the intermingling of experiences in the different migration stages and their cumulative effect. The role age plays in the migration process, the client’s vulnerability and resilience, and the supports provided by a service organization and the couple’s family are also portrayed. Anna (63) and Yacov (74) were well educated. Anna had been employed as an engineer in Russia; Yacov was a mathematician. In addition to Russian, their native language, both were fluent in German. Upon arrival, they could not speak English. Both were Jewish, and not religious. Resettlement and counseling services were provided by a family service agency. Their worker was a Russian émigré who had recently completed graduate social work training in the United States. Many crises occurred shortly after the couple arrived. Anna, who became ill, was hospitalized and diagnosed as having heart and liver disease and gastrointestinal problems. Following hospital discharge, her psychological functioning declined. She cried often and couldn’t sleep or eat. She stared out the window most of the day. Yacov told the worker he had never seen her behave this way. He also said she threatened to kill herself. When questioned about a history of depression, the couple indicated there was none. Shortly thereafter, Anna was rehospitalized for depression. While in the hospital, she wouldn’t talk to the psychiatrist. It was discovered later that she feigned taking the antidepressant medications prescribed by the psychiatrist because she was suspicious of them. In the first few months, Anna’s moods alternated between depression and anger. The mood shifts were associated with the following issues, which were prominent in the client/worker discussions.

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Anna was angry at Yacov for pressuring her to leave Russia. She had worked her whole adult life and was a highly respected professional in her native country. She was active in her community. Her family was together, and she had friends. Here she had no one. She couldn’t work; she couldn’t speak English. She believed there was no time in her life to rebuild what was lost. Their son Alexei and granddaughter Natasha, with whom she was close and who had lived with Anna and Yacov for years, were still living in Russia. Their other son Ivan, his wife, Katya, and their two sons, who also had emigrated, were detained in Rome. No one knew if they would be allowed to come to the United States. Although Anna was concerned about them, she also blamed Katya for their problems, as Katya initiated the decision to leave. Katya’s desire to emigrate grew out of a rise in antiSemitism. Although the Soviet government at the time supported more openness, the openness also permitted overt anti-Semitic expression. Thus, virulent attacks against Jews by grassroots organizations increased. Concerned about the future for her sons, Katya therefore wanted to leave the country. Since Yacov was close to Ivan and his grandsons, he supported their decision to emigrate. He also wanted to accompany them and pressured Anna into agreeing that they, too, should leave. Anna discussed her disappointment in U.S. life. She criticized the U.S. hospitals and doctors. In Russia, she said one has time to recuperate in a hospital or recuperate in a dacha (country home). Doctors in Russia made house calls. Medicines were paid for. Their streets were clean and safe. She ruminated over the past—the losses of her parents and brother during World War II, and the years of starvation at that time. Yacov, however, was overwhelmed by concern that Ivan and his family would not be able to come to the United States. He insisted the worker pressure the “bureaucrats” to admit them. Although the worker explained she had no power over immigration

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matters, Yacov persisted in his request. The worker agreed to explore the issue. The following outlines the results of the worker’s exploration and the issues discussed with Yacov regarding the detention of Ivan’s family. Yacov knew that prior to the late 1980s, few people were permitted to leave the Soviet Union. He was also aware that emigration regulations in the Soviet Union were relaxed as a result of the new policies of openness (glasnost) and restructuring (perestroika). Thus, many people were permitted to emigrate and many arrived in the United States. The reasons for the detention of many, the worker explained, was due to U.S. law, which involved a per-country limit for the number of persons permitted to enter the United States. Since so many émigrés from the Soviet Union had arrived in the United States, the Soviet Union country quota was exhausted. Also, the United States no longer considered the émigrés as refugees because of their newly acquired freedoms in the Soviet Union. Thus, they could not enter the United States as refugees. The exhausted country quota and the denial of refugee status, therefore, left many individuals from the Soviet Union stranded and living in limbo in Rome. The worker’s explanation of the detention, however, was met with distrust and skepticism as Yacov said, “You sound like a Russian bureaucrat.” Since the worker was bicultural and bilingual, she sensed Yacov’s response was rooted in the different views held by Russians and Americans on institutions and their employees. Specifically she knew it was common in Russia to view institutional personnel as “bureaucrats” who followed government rules and procedures and who ultimately blocked the requests of people. She also knew Russians commonly manipulated “bureaucrats” and persisted in their requests in order to receive what was needed. Although she explained that many organizations in the United States were not government controlled, Yacov’s distrust persisted as he pressured her to “pull strings” so that Ivan’s family could come to the United States. Yacov’s lack of information regarding

Ivan’s situation, which made him anxious, and his lingering skepticism of the worker’s reason for the detention led the worker to pursue other avenues to help. Ultimately she found a group of émigrés in a neighboring state who were participants in a Jewish organization that was pursuing the situation of Russian detainees. The worker connected Yacov to this group. She also connected him to an émigré family in the community whose family members were also detained. The agency provided transportation for Yacov, Anna, and the other family to attend the group meetings. Yacov welcomed the connection to the group and was actively involved in it. The advocacy efforts of this group (and others) led to the eventual release of many detainees. Ivan’s family was among them. Upon the arrival of Ivan’s family, the agency assisted them in locating housing close to Anna and Yacov’s apartment. Anna assumed the caretaking of her grandsons, which enabled her son and daughter-inlaw to attend English language classes and pursue employment. Anna also began to learn English and her depression began to subside. Eight months after Ivan’s family arrived, Yacov experienced severe headaches, which were the precursor to a stroke. He died from the stroke two and a half years after arrival in the United States. Anna relapsed into another depression. She accepted the worker’s referral to a psychiatrist. She was able to discuss her concerns with him and took the antidepressant medications he prescribed. Anna’s grief from the loss of Yacov was intense, as it was intertwined with the other recent losses. Nonetheless, she was able to regain functioning in a few months. She continued to learn English. She took care of her grandchildren, and she became active in a Russian émigré community. Although immigrants commonly experience losses of family, friends, community, work, and natural support systems, these losses often have a different

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meaning for the aged. As Anna indicated, “there was no time to rebuild what was lost.” Thus, the sense of time and hope to build a new and better future— a view commonly held by younger immigrants—is muted for Anna, as well as for other older newly arrived individuals. Health and mental health issues affect all immigrants. Older immigrants, however, are particularly vulnerable. Anna experienced both health and mental health problems that occurred shortly after her arrival. She was hospitalized for physical ailments of heart and liver diseases and she suffered from depression. Yacov, who arrived in the United States at age 74, died of a stroke at age 76. Anna, who arrived at 63, was a widow living in a new land at 65. Thus, it is reasonable to assume the interaction between the age of the couple and the losses and stresses associated with their migration placed them at further risk. The cumulative effect of experiences in the different migration phases are apparent in the case. In the premigration phase, the couple struggled with numerous issues that revolved around the pros and cons of emigration. Based on a desire to be with their son’s family, the couple decided to leave their country. However, in the transit phase, one family was detained in Italy and the other arrived in the United States. Paradoxically, the desire to maintain one’s family led to family separation. In resettlement, the separation of the two families was a major problem. The case also illustrates how immigrants’ lives may be caught between the governments of different countries. When this occurs, it is necessary for workers to explore and understand the complex immigration issues that create clients’ personal problems. The understanding leads to different types of interventions, such as helping a client obtain legal assistance or connecting a client to another system that addresses the immigration issue relevant to the client’s situation. The latter was the intervention used by the worker as she connected

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Yacov to an organization that was advocating on behalf of Russian detainees. Cultural issues surfaced in several areas of the work. Anna’s refusal to talk to a psychiatrist during her hospitalization was in part due to her life in Russia, where psychiatrists were often used as a form of social control. Moreover, having an open discussion about one’s feelings and thoughts with a psychiatrist, a stranger, led Anna to be suspicious. The suspiciousness led her to feign taking the prescribed antidepressant medications. Yacov’s expectation of the worker’s power with regard to the release of Ivan’s family was culturally based. His skepticism and distrust of the worker’s rationale for the Russian detainees was also culturally based. Since the worker was bicultural, she was able to recognize the roots of the cultural misunderstanding and intervene in accordance with this understanding. The mediators of stress included the couple’s strengths, the support of the family, and the provision of services by the agency and the Russian émigré community. The couple’s high level of education was helpful background for adapting to the complexities of U.S. life. Anna’s fluency in two languages facilitated the learning of English. The caretaking of grandchildren that Ann assumed provided her with a sense of contribution to the family and increased her social interaction. Yacov’s persistence enabled him to become active in pursuing the reunification of the families and increased his social interaction as well. Needless to say, Ivan’s family was a support for Anna and a Yacov, and Anna and Yacov were supports for Ivan’s family. The agency acted as a buffer of stress by connecting the family to medical facilities and medical personnel, assisting in family reunification, locating housing, and providing counseling. The strong Russian émigré community where the families resettled enabled Anna to pursue her future life without Yacov.

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conclusion The chapter presents background knowledge for social work practice with immigrant and refugee populations, describes new developments in the field of immigration and social service, and highlights specific immigrant groups. The forces that underlie the movement of populations are explained by different theories that provide background for an understanding of migration. Although the explanations differ, the discussion illustrates how several theories can inform an understanding of the migration of a single population. To familiarize social work practitioners and students with the migration process and the significant variables associated with stages in the process, a conceptual framework is introduced. The framework, which is a vehicle for assessment, also serves

as background. It is applicable to practice with immigrant communities, families, individuals, and groups who vary in their countries of origin. The background also provides information about the different immigrant statuses, demographic patterns, the unique stress associated with migration, supports that buffer stress, and service programs. The emergence of transnational migration is a relatively new development. This phenomenon is introduced and amplified by examples of transnational activities, which are differently expressed in families, communities, and institutions. There is also a significant change in the U.S. reception toward legal permanent residents and undocumented persons. The change is examined in an analysis of the U.S. deportation system.

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cHaPter 19 intimate Partner abuse Jonel tHaller, Jill tHereSa meSSinG, and bonnie e. carlSon

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lthough violence within intimate relationships has existed for centuries, intimate partner abuse has only recently been considered a social problem. Since its entry into public consciousness in the 1970s, much has been learned about the nature of this phenomenon as well as its associated risk factors and consequences. A comprehensive approach to understanding intimate partner abuse also considers protective factors that may buffer risk and inform prevention and treatment. This chapter examines the social problem of intimate partner abuse, specifically how it is defined, its prevalence, the physical and mental health consequences, associated risk and protective factors, and services and interventions to ameliorate it. defining and explaining intimate Partner abuse From the time it first emerged as a social problem, defining and explaining violence within intimate relationships has been surrounded by controversy. Although most commonly referred to as domestic violence, violence toward female intimate partners has acquired a wide variety of other labels, including wife battering, spousal abuse, marital violence and, most recently, intimate partner violence or intimate partner abuse. As research has identified violence in cohabiting couples and in dating couples as early as junior high school, scholars have been less inclined to label this phenomenon marital violence or spousal abuse unless they are referring specifically to abuse in the context of 392

marriage. Similarly, the term domestic violence connotes violence that occurs in a domicile, thereby excluding some intimate relationships and including some relationships that are not intimate (e.g., child abuse). The term intimate partner violence is increasingly preferred by federal agencies addressing this problem, such as the Centers for Disease Control and Prevention. The term intimate partner abuse will be used in this chapter; intimate partner refers to a broad range of intimate relationships, such as a spouse or ex-spouse, current or former boyfriend or girlfriend, or a current or former dating partner, and abuse encompasses physical and sexual violence and also a broader range of hazardous behaviors (e.g., psychological abuse). Although the term intimate partner abuse is gender neutral, women are more likely than men to be survivors of violence in intimate relationships, as will be discussed. Intimate partner abuse can be defined as a pattern of behavior involving the threat or use of physical or sexual violence or emotional or psychological abuse perpetrated by an intimate partner with the potential to cause physical or psychological injury, harm, or death. Physical violence may consist of pushing, shoving, slapping, punching, choking, kicking, beating up, cutting someone with a knife, and other acts of physical aggression. Examples of sexual violence include sexual coercion (e.g., threats to leave or withhold resources if certain sexual acts are not performed) as well as forcing an intimate partner to have sex or to engage in

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degrading and unwanted sexual activities. A wide range of behaviors also constitute emotional or psychological abuse, such as ridicule, isolation from one’s family and friends, the cultivation of economic dependency, stalking, and threats to harm one’s children, pets, or property. More recently, abuse might also include cyber stalking or cyberbullying, wherein an abuser uses technology to terrorize or humiliate a partner. Control of sexual and reproductive health can also be part of intimate partner abuse and includes forced condom nonuse, birth control sabotage, and/or pregnancy coercion. A long-standing controversy has existed regarding the nature of intimate partner abuse, resulting in two different perspectives. The feminist perspective frames intimate partner violence as a problem of violence against women, in which men victimize women in a pattern of escalating violence and abuse that will not stop on its own. Within this perspective, intimate partner violence is associated with the broader gender relations within a patriarchal society and has its origins in men’s need or desire to control their female partners. In contrast, the family violence perspective has described intimate partner violence as behavior initiated by either men or women that is not necessarily frequent or escalating in severity, and not always motivated by the desire to control an intimate partner. Johnson (2008) has attempted to resolve this debate by asserting that these two points of view have emerged because they are essentially describing different phenomena. He describes them as such: In order to understand the nature of an individual’s use of violence in an intimate relationship, you have to understand its role in the general control dynamics of that relationship . . . In intimate terrorism, the perpetrator uses violence in the service of general control over his or her partner . . . In situational couple violence, the perpetrator is violent (and his or her partner may be as well); however, neither of them uses violence to attempt to exert general control. (Johnson, 2008, p.5)

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Johnson’s (2008) statistical findings support the idea that men are more likely than women to be the perpetrators of intimate terrorism, while both men and women are likely to perpetrate situational couple violence. Stark (2007) contributes to our understanding of the mechanisms used by intimate terrorists in his description of coercive control, a pattern of controlling behaviors, similar to kidnapping or indentured servitude, used to subjugate another person. In regard to whether this phenomenon is gendered, he asserts that men are most likely to perpetrate coercive control because their dominant position in society affords them the opportunity to do so. Indeed, women tend to suffer greater mental health consequences from intimate partner abuse than men (Black et al., 2011) and are consistently more likely than men to be severely injured or murdered by an intimate partner (Fox, 2005). How we define and conceptualize intimate partner abuse is important because these definitions will communicate what we see as the nature of the problem, who is affected by it, and what we should do about it. If our definition of abuse is narrow, for example, consisting only of physical violence, we may overlook indicators of emotional or sexual abuse in the context of an intimate relationship. Additionally, to the extent that the problem is framed as men abusing women, heterosexual men and individuals in same-sex relationships who experience intimate partner abuse may be rendered invisible. As more recent studies regarding gay and lesbian couples reveal rates of overall intimate partner abuse similar to, or even higher than, those for heterosexual couples (Messinger, 2011), it is important to consider the impact of intimate partner abuse on this vulnerable population. demographic Patterns The National Intimate Partner and Sexual Violence Survey (NISVS) provided recent data on the prevalence and consequences of intimate partner abuse. This telephone survey was

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conducted by the CDC’s National Center for Injury Prevention and Control with the support of the Department of Defense and the National Institute of Justice. A representative national sample of 9,086 women and 7,421 men were interviewed between January 22, 2010, and December 31, 2010 (Black et al., 2011). This study found that nearly one in three women (35.6 percent) and one in four men (28.5 percent) had experienced rape, physical violence, or stalking by an intimate partner in their lifetime. Severe intimate partner violence (e.g., being hit with a fist or something hard, beaten, slammed against something) was experienced by approximately one in four women (24.3 percent) and one in seven men (13.8 percent) in their lifetime. Approximately one in seventeen women (5.9 percent) and one in twenty men (5.0 percent) reported experiencing rape, physical violence, or stalking within the past twelve months, approximately 42 and 32 million women and men respectively (Black et al., 2011). According to the NISVS, 9.4 percent of women have experienced intimate partner rape in their lifetime, while too few men reported experiencing intimate partner rape to produce reliable estimates (Black et al., 2011). Intimate partner rape often co-occurs with severe physical violence and has been linked to intimate partner femicide (Campbell et al., 2003; Messing, Thaller, & Bagwell, in press). In small community samples, intimate partner rape is commonly reported by women who are also concurrently experiencing severe physical abuse, with prevalence rates up to 50 percent (Messing, Thaller, & Bagwell, in press). An estimated 16.9 percent of women and 8 percent of men in the NISVS survey reported experiencing intimate partner sexual violence other than rape, such as sexual coercion and unwanted sexual experiences (Black et al., 2011). Individuals who suffer intimate partner abuse may also experience a lack of control over their reproductive and sexual health. Women whose male partners are controlling may face difficulty in convincing their partner to use

a condom, which results in higher rates of sexually transmitted diseases and unintended pregnancy (McFarlane et al., 2005). Moreover, pregnancy coercion and birth control sabotage are two strategies used to control an intimate partner. Results from the NISVS found that 4.8 percent of women and 8.7 percent of men reported having an intimate partner who tried to get them pregnant, or become pregnant, against their will. The prevalence of pregnancy coercion and birth control sabotage in community samples of adult women and female adolescents experiencing other forms of intimate partner abuse has ranged from 26 percent to 74 percent (Miller et al., 2010; Miller et al., 2007; Moore, Frohwirth, & Miller 2010). Other studies have found that abusive men are more likely than non-abusive men to report being involved in pregnancies ending in abortion (Silverman et al., 2010). To a large extent, it appears that physical violence is accompanied by emotional abuse or psychological aggression, which can include expressive aggression, such as acting dangerous, name calling, insults, and public humiliation, as well as coercive control, which includes behaviors intended to monitor and control an intimate partner, such as threats, interference with family and friends, and limiting access to money (Black et al., 2011). A roughly equal number of men and women (nearly half, or 48.4 percent and 48.8 percent, respectively) reported experiencing at least one of these acts of psychological aggression from an intimate partner over the course of their lifetime (Black et al., 2011). However, women (43.7 percent) were more likely than men (28.3 percent) to report that their partner tried to keep them from seeing family or friends. Women were also more than twice as likely as men to report that their intimate partner threatened to physically hurt them, their pets, or the people they love (Black et al., 2011). Approximately one in six (16.2 percent) women and one in nineteen men (5.2 percent) reported experiencing at least one incident of stalking by an intimate partner in a way that caused them to be

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fearful that they or someone they loved would be harmed in their lifetime (Black et al., 2011). Female survivors were most likely to be stalked by current or former intimate partners, while men were most likely to be stalked by current partners or acquaintances (Black et al., 2011). Like intimate partner rape, stalking has been linked to intimate partner femicide (Campbell et al., 2003; McFarlane et al., 1999). Intimate partner homicide is the most serious form of intimate partner violence, and is generally the result of an escalating pattern of abuse. Nearly half of all murdered women are killed by an intimate, or formerly intimate, partner (Brock, 2003; Campbell et al., 2003; Catalano, 2009; Frye, Hosein, Waltermaurer, Blaney, & Wilt, 2005), compared with 5 to 7 percent of murdered men (Fox, 2005). Between 65 percent and 80 percent of intimate partner femicide victims were previously abused by the partner who killed them, making this the single largest risk factor for intimate partner femicide (Campbell et al., 2003; Campbell, Glass, Sharps, Laughon, & Bloom, 2007; Sharps et al., 2001). Since 1993, women have comprised approximately 70 percent of all victims killed by an intimate (Catalano et al., 2009). Moreover, although there has been a steady and significant decline in the rate of male victims of intimate partner homicide, the decrease in the intimate partner femicide rate has been less substantial (Greenfeld, Rand, & Craven, 1998; Rennison & Welchans, 2000), and the number of women killed by male intimate partners has not decreased since 2002 (Fox & Zawitz, 2010). In addition to differences in gender, several sociodemographic trends in intimate partner abuse have been noted. First, research has consistently found that individuals become susceptible to intimate partner abuse at a young age, with a majority of female and male survivors experiencing their first incident of relationship abuse before 25 years of age (Black et al., 2011). Additionally, studies have consistently found that individuals with lower income and lower educational attainment are more likely to

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experience violent victimization by an intimate partner than those from higher socioeconomic classes (e.g., Cho, 2012). It has been theorized that women with higher income and educational attainment will have more opportunities to leave an abusive relationship (Powers & Kaukinen, 2012). Moreover, women who are employed are generally less isolated than those who are not. However, Fox Benson, DeMaris, and Van Wyk (2008) also point out that a woman’s involvement in the workforce, especially if her partner is unemployed, may indicate economic stress in the relationship, or may lead to increased jealousy and an abuser’s perceived need to assert his dominance, also referred to as the “backlash effect.” Powers and Kaukinen (2012) found that employment status worked differently according to race; employment was linked to increased rates of intimate partner violence for white women, but not for nonwhite women. The underrepresentation of severe violence, or intimate terrorism, in this sample may overlook the function of female employment status in relationships where gendered power dynamics are perhaps most salient (Powers & Kaukinen, 2012). Numerous studies have compared rates of intimate partner abuse across racial and ethnic groups, with some inconsistency (Powers and Kaukinen, 2012). Native American and African American women have generally been found to experience intimate partner violence at higher rates and in different ways than white women (Potter, 2008; Smith, 2005). However, studies finding higher prevalence of intimate partner abuse in samples of ethnic minorities might be detecting the effects of poverty or lower educational attainment rather than ethnicity. Thus, racial and ethnic comparisons should control for socioeconomic differences; studies often find little difference in the prevalence of intimate partner violence according to race when controlling for socioeconomic factors (Cho, 2012). There are also difficulties in measurement, as definitions of violence or abuse may vary according to cultural differences,

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and women from some ethnic minority backgrounds may be less willing to report experiencing intimate partner abuse. Moreover, within different racial and ethnic groups, the risk factors for and the consequences of abuse may differ, as well as the perceived options for addressing violence. Nevertheless, a recent analysis of NISVS data, which did not control for socioeconomic status, revealed significant differences according to race and ethnicity in the prevalence of physical violence, rape, or stalking by an intimate partner. Lifetime prevalence was highest among multiracial non-Hispanic women (53.8 percent), American Indian or Alaska Native women (46 percent), and non-Hispanic black women (43.7 percent). Reported rates were lower for Hispanic women (37.1 percent) and non-Hispanic white women (34.6 percent), and lowest for women who identified as Asian or Pacific Islander (19.6 percent) (Black et al., 2011). For men who were victims of intimate partner abuse, the highest lifetime prevalence of physical violence, rape, or stalking by an intimate partner was reported by those who identified as American Indian or Alaska Native (45.3 percent), followed by multiracial non-Hispanic men (39.3 percent) and nonHispanic black men (38.6 percent). White men (28.2 percent) and Hispanic men (26.6 percent) reported lower rates, and too few men who identified as Asian or Pacific Islander reported abuse to provide reliable estimates (Black et al., 2011). In summary, intimate partner abuse has been described in various ways, with the greatest point of contention over whether this phenomenon is gendered. Research has found gender symmetry in the perpetration of minor acts of physical violence within intimate relationships. However, women are significantly more likely than men to experience severe violence, rape, and death as a result of intimate partner violence. Results of research on race/ethnicity and intimate partner violence vary depending on whether socioeconomic status is considered.

Societal context Violence against women in the context of intimate relationships has existed for centuries, and was legally sanctioned by governments from the time of the ancient Romans through the early history of the United States (Dobash & Dobash, 1977–1978). From a historical perspective, violence against women in the family has been tolerated by our legal system for centuries and has had strong social support. It is against this backdrop of patriarchy that feminists first began to bring the issue of “wife abuse” to public attention in the 1970s (Messing, 2011). Since this time, there has been a proliferation of legislation and social services designed to help ameliorate intimate partner violence against women. Abusive men are more likely to be arrested and convicted than ever before. Shelters and social support services are available to victimized women in every state, and increasing numbers of health and mental health professionals are recognizing the impact of victimization on women’s well-being. Although progress has been made, many issues still need to be addressed. For example, some women have found it difficult to access the resources and services that would enable them to terminate an abusive relationship (Dichter & Rhodes, 2011). Despite the work that has been done to address this social problem over the past four decades, many women continue to encounter significant barriers on their journey to safety, including a proliferation of victim-blaming myths that may communicate to victimized women that they are responsible for their abuse and should accept their plight (Thaller & Messing, under review). These contextual factors might also contribute to the perpetration of intimate partner abuse. Feminists have long considered societal factors to be primary explanations for intimate partner abuse. However, there is evidence that other factors play a contributing role. For example, although men as a group are exposed to patriarchal values and traditional gender roles

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in our society, most men do not become abusive toward their partners. And, although studies find that abuse festers in a climate of poverty and deprivation, many men who grow up in poverty are not abusive toward their partners. Researchers have found the prediction of intimate partner abuse to be extremely complex, influenced by factors on the micro, mezzo, and macro levels. Vulnerabilities and risk factors There is a substantial literature on the subject of intimate partner violence vulnerabilities and risk factors. Outcomes of concern discussed in this chapter are homicide, violence-related injuries, physical health outcomes, and psychological or mental health consequences. National surveys have shown that female murder victims are substantially more likely to be killed by an intimate partner, such as a husband, ex-husband, or boyfriend, than are male victims of homicide (Catalano et al., 2009; Fox, 2005). Significant risk factors for intimate partner homicide, or attempted homicide, include prior intimate partner violence, stalking, nonfatal strangulation, access to firearms, threats to kill, forced sex, and recent estrangement (Campbell et al., 2003; Campbell, 1995; Glass et al., 2008; McFarlane et al., 1999; Wilson & Daly, 1993; Wilson, Johnson, & Daly, 1995). A woman’s danger of fatal violence increases significantly upon separation from her partner, particularly when that partner is controlling (Campbell et al., 2003). The Danger Assessment (www.dangerassessment.org) assesses risk of intimate partner homicide for women in abusive relationships (Campbell et al., 2003), and has recently been adapted for immigrant women (Messing et al., 2012) and women in same-sex relationships (Glass et al., 2008). Approximately one in seven women (14.8 percent) and one in twenty-five men (4 percent) in the 2010 nationally representative sample reported physical injury as a result of intimate partner rape, physical violence, or stalking (Black et al., 2011). Although injuries

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are common in the aftermath of intimate partner violence, many injured survivors do not seek treatment. Approximately 7.9 percent of women and 1.6 percent of men who reported intimate partner rape, physical violence, or stalking sought medical care as a result of an injury (Black et al., 2011). Head, neck, and facial injuries tend to be the most common injuries observed in women seeking emergency room care as a result of intimate partner violence (Wu, Huff, & Bhandari, 2010). Other injuries experienced as a result of intimate partner violence include bruising, abrasions, lacerations, fractured bones, concussions, burns, evidence of attempted strangulation or choking, and contusions to internal organs. In addition, traumatic brain injury resulting from strangulation and blows to the head, especially when repeated over time, may cause substantial disability, but this is only beginning to be understood as an effect of intimate partner violence (Kwako et al., 2011). Beyond injury, the physical health consequences of intimate partner violence have been extensively studied in recent years, with the emerging consensus that abused individuals, especially women, are likely to experience compromised health related to their victimization. More severe emotional, physical, or sexual abuse will result in more physical symptoms, suggesting a cumulative effect. These findings are not surprising in light of what we know about the association between trauma, stress, and physical health (Scott-Storey, 2011). A variety of nonspecific symptoms are associated with intimate partner abuse, such as poor appetite, low energy, chronic fatigue, headaches, difficulty sleeping, breathing problems, gastrointestinal problems, muscle tension or soreness, and gynecological problems (Bonomi et al., 2006; Campbell, 2002). Difficulty sleeping was the most common physical health outcome, reported by both women (37.7 percent) and men (33 percent) who had experienced intimate partner rape, physical violence, or stalking (Black et al., 2011).

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With regard to mental health or psychological outcomes resulting from partner abuse, a wide range of outcomes has been observed (Afifi et al., 2009). Depression is a common response to intimate partner abuse. Women who experienced intimate partner abuse were between two and three times more likely to report major depressive disorder than those who had not been abused (Beydoun et al., 2012). Risk of suicide is also elevated for women victimized by intimate partner violence (Cavanaugh et al., 2011; Leone, 2011). Studies suggest that intimate partner forced sex is at least, if not more, emotionally harmful to women compared to rape by a stranger (Bergen 2006). Women who have experienced intimate partner forced sex report higher levels of perceived stress and dissociation than those assaulted by an acquaintance or stranger (Temple et al., 2007). When compared with women who have experienced physical violence but not sexual violence from an intimate partner, women who have experienced physical and sexual violence in combination were more likely to suffer depression, shame, and post-traumatic stress disorder (PTSD) (Feinstein et al., 2011; Messing, Thaller, & Bagwell, in press). PTSD is an appropriate diagnosis for many survivors of violence; a meta-analysis of U.S. studies found that the weighted mean prevalence of PTSD among women who experienced intimate partner violence was 63.8 percent across eleven studies (range: 31 percent to 84.4 percent) (Golding, 1999). Women who are at risk for homicide, have poor overall health, have pain due to abuse, expect future injurious violence, feel unsafe, or experience feelings of shame may be more likely to experience PTSD symptoms (Wilson et al., 2011). This diagnosis assists in conceptualizing the symptoms as a normal response to abnormal circumstances, thereby depathologizing characteristic survivor response patterns. In addition to the intrusion and avoidance symptoms that are central to the PTSD diagnosis, other responses indicative of PTSD include dissociation, increased arousal,

irritability, angry outbursts, hypervigilance, and sleep disturbances. Widely varying estimates of the extent of PTSD in samples of abused women can be attributed to the use of different samples (e.g., sheltered survivors versus those seeking help from counseling agencies) and varied instruments used to measure PTSD. Another explanation for these differences may be due to differential exposure to trauma and to variations in vulnerability and coping as discussed later. Substance abuse has also been associated with perpetrators and survivors of intimate partner violence. Among men and women, alcohol and illegal drug use were associated with increased odds of perpetration and victimization (Afifi, Hendriksen, Asmundson, & Sareen, 2012). For survivors of intimate partner abuse, substance misuse may be a way of coping with the trauma of living with abuse (Fazzone, Holton, & Reed, 1997). In a study of 71 treatment sites across the nation, nearly one in two women and one in ten men entering substance use disorder treatment reported having been victimized by an intimate partner (Schneider, Burnette, Ilgen, & Timko, 2009). Longitudinal studies have found a reduction in intimate partner violence perpetration and victimization following treatment and remission of alcohol and substance abuse (Stuart et al., 2009). The literature on psychological after effects associated with intimate partner abuse indicates a wide variation in outcomes. One explanation for this variation pertains to the abuse itself. Survivors experience differences in the types of abuse to which they are exposed (physical, emotional, and/or sexual), as well as variation in the frequency, severity, and duration of each type. It appears that there is an increased risk for more adverse outcomes with exposure to cumulative trauma, that is, multiple experiences of abuse that may involve different types of abuse, repetition of the same type of abuse, or both (Scott-Story, 2011). For example, a history of childhood victimization typically makes women more vulnerable to various forms of re-victimization as an adult and is commonly

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associated with increased risk for poor mental health outcomes among survivors of intimate partner abuse. Research findings indicate that women who experienced childhood abuse may be two to six times more likely to experience adult intimate partner abuse than those who did not (Bensley, Van Eenwyk, & Simmons, 2003; Coker, Smith, McKeown, & King, 2000; Schaaf & McCanne, 1998); the resulting combination of childhood and adult trauma can further exacerbate the severity of mental health outcomes (Becker, Stuewig, & McKloskey, 2010). It has been suggested that PTSD mediates the relationship between childhood and adult intimate partner victimization (Engstrom et al., 2008; Messing et al., 2012; West, Williams, & Siegel, 2000) and that particular symptoms of PTSD (such as numbing, arousal/ hyperarousal, or disassociation) may be what increases the vulnerability for re-victimization (Cloitre, Scarvalone, & Difede, 1997; Krause, Kaltman, Goodman, & Dutton, 2006; Risser et al., 2006; Wilson, Calhoun, & Bernat, 1999). However, variation in the nature and extent of abuse does not explain all variation in mental health vulnerability, suggesting that there are mediating or moderating factors beyond those associated with the abuse itself that might account for the diversity of outcomes observed. Some women appear to function quite well despite being abused, whereas others function very poorly. In some cases, survivors who exhibit serious problems while being abused improve dramatically shortly after abuse ceases; however, in other cases, women continue to exhibit mental health problems after abuse ends and require much support and professional assistance (Ford-Gilboe et al., 2009). For many survivors of abuse, psychological difficulties may be initially greater upon ending an abusive relationship than they were when the relationship was intact (Anderson & Saunders, 2003). Women experience many stressors and losses upon leaving an abusive intimate relationship (e.g., Amanor-Boadu et al., 2012; Mohr, Messing, & Durfee, under review); for example, the

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stress associated with financial dependency may exacerbate symptoms and hinder recovery (Carlson et al., 2002). In summary, the possible detrimental outcomes that can result from intimate partner abuse are numerous, with the most serious outcomes being homicide and suicide. A substantial subgroup of women who are victimized by intimate partners experience physical injury, and some of these injuries require medical care that is most often received in an emergency setting. Other health problems are even more common sequelae of abuse, such as gastrointestinal problems, chronic fatigue, difficulties breathing and sleeping, and other stress-related somatic complaints (Campbell, 2002). As a result, abused women tend to experience poorer health than their non-abused counterparts. Mental health consequences include depression, PTSD, and substance abuse. Although some of these problems remit when abuse ceases, in other cases abuse-related problems continue long-term. Variability exists in abuse-related physical and mental health problems, in part related to the range of types of abuse experienced as well as their severity, frequency, and duration, but the seriousness of abuse itself cannot account for all the variability seen among abuse survivors. resiliencies and Protective factors Protective factors may help to explain diverse mental health outcomes in the aftermath of intimate partner abuse. These factors buffer individuals from the harm normally associated with stressful or traumatic experiences. Some individuals, despite exposure to multiple risk factors, fail to succumb to the expected harmful effects and remain well functioning. Indeed, many survivors of intimate partner abuse, despite experiencing serious traumatic violence and other forms of abuse, function remarkably well (Briere & Jordan, 2004). Little research exists regarding specific factors known to buffer survivors from the harmful effects of intimate partner abuse. However, there is a growing literature on factors that buffer adults from the

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harmful effects of stress in general. Numerous factors are associated with resilience in the face of exposure to high levels of stress: social support, positive self-regard, cognitive appraisal strategies, the perception of control, maintaining a positive outlook, self-efficacy, spirituality, good health, and type of coping strategies used (Carlson et al., 2002). Although some of these factors may be aspects of personality or temperament, and thus relatively fixed, others are quite malleable and have implications for intervention. Cognitive appraisal refers to the process by which people attach meaning to potentially challenging or traumatic events via their subjective perceptions (Lazarus, 1991). People may not be aware of the meanings they attach to overwhelmingly stressful or traumatic events, such as the different components of intimate partner abuse, and becoming aware of these meanings allows for the possibility of altering them. Cognitive appraisal can be particularly useful for survivors of intimate partner abuse who engage in self-blame. Understanding patterns of abuse and their reactions to them can be empowering, leading to an increase in confidence when making important decisions. Social support commonly functions as a stress buffer and a protective factor; one of the tactics of intimate partner abuse is isolation, however, and many survivors of intimate partner abuse lack social support because their abusers have successfully isolated them from friends and family. In a sample of help-seeking heterosexual women, social support did not serve as a protective factor for those experiencing the most severe violence. However, for all other participants, those with the least amount of social support were more likely to experience re-abuse over the course of the following year (Goodman et al., 2005). Social support is thought to buffer stress in several ways, such as through enhancing self-esteem, affecting perceptions of stressful events, providing concrete assistance, and increasing knowledge of coping strategies (Carlson et al., 2002). Merely having a

supportive person in which to confide has been shown to be beneficial for survivors of abuse (Cohen & Hoberman, 1983). The value of tangible resources to a survivor of intimate partner abuse cannot be underestimated. Financially independent individuals with access to material resources, such as housing and reliable transportation, have more options for becoming and remaining safe. Education and employment status play a large role in the attainment of these resources. Women who were employed or living with family or on their own were less likely to report re-abuse after formally seeking help (Goodman et al., 2005). Immigrant women perceive greater risks and barriers to leaving an abusive intimate relationship, including greater financial risks associated with leaving (Amanor-Boadu et al., 2012). These findings support the notion that assisting survivors of abuse in achieving economic independence is critical in preventing future violence. As a group, individuals who experience intimate partner abuse tend to lack many of the factors that may be protective against negative outcomes. In addition to lacking social support, they tend to possess limited material resources; intimate partner abuse is often associated with poverty, and abusive partners may limit access to material resources and/or prohibit their partners from working. Survivors of intimate partner abuse often have physical and mental health problems as a result of the abuse, and this can also interfere with coping. The needs of abused individuals may also vary depending on their stage in relation to the change process (Dienemann, Glass, Hanson, & Lunsford, 2007). Change behavior can be understood in terms of the Transtheoretical Model (TTM) of Change, which identifies five primary change stages: (1) precontemplation, (2) contemplation, (3) preparation, (4) action, and (5) maintenance (Prochaska & DiClemente, 1984). Abused individuals in the precontemplation stage are not yet considering change and may need information about what

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constitutes abuse, while those in the contemplation stage are considering action in response to abuse and may need information about different legal, financial, or housing options. In the preparation stage, the individual begins actively preparing for change, gathering and drawing upon resources. The next stage is characterized by active change, and maintaining this change is the final stage. The Domestic Violence Survivor Assessment (DVSA) has been developed for program evaluation and tracking a client’s progression through these stages (Dienemann et al., 2007). When applying the stages of change model to women in abusive relationships, it is important to recognize that the idea of “change” is commonly conceptualized as readiness to leave an abusive partner. Separation can be a particularly dangerous time for a survivor of abuse, and women in all stages are continually using strategies to maximize safety for themselves and their children. As such, an inability to “change” may actually represent the best safety strategy for the survivor at that time (Hamby, in press). Further, individuals who have left an abusive relationship may have different needs, depending on how they respond to their feelings of grief upon ending the relationship (Mohr, Messing, & Durfee, under review). Several critical psychosocial needs must be addressed, regardless of a survivor’s readiness to leave an intimate partner or feelings of grief. These include support, validation, respect for decision making (i.e., self-determination), information about abuse and risk factors for homicide, protection from violence and homicide, and concrete services. Gondolf and Fisher (1998) have theorized that, as violence increases, women utilize additional coping strategies. Indeed, women are continually engaging in informal protective strategies, and may be more likely to seek formal services once the violence has escalated and/or they have come to the realization that the abuse will not stop. In samples of heterosexual women seeking formal services for intimate partner abuse, women had utilized many

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strategies prior to seeking services (Goodkind, Sullivan & Bybee, 2004; Goodman, Dutton, Weinfurt, & Cook, 2003), and women were more likely to use informal strategies than formal strategies (Goodman et al., 2003). For example, 94 percent of women had tried to talk with their partner about his violence, 90 percent had tried to avoid their assailant at times, 73 percent had spoken with friends or family about the abuse, and 67 percent had stayed with friends or family to avoid abuse (Goodkind et al., 2004). The strategies most likely to make the situation better or to be rated as helpful were informal networking strategies, contacting police, safety planning, staying at a shelter, or contacting specialized victim services (Goodkind et al., 2004; Goodman et al., 2003). Although women reported using strategies to placate or resist their partner most frequently, these were reported to be the least helpful (Goodkind et al., 2004; Goodman et al., 2003). Survivors of intimate partner abuse are active in their coping and have substantial strengths that they bring to bear upon their situation. It is important to remember that abused women are typically coping not only with the abuse itself and its effects on their own and their children’s well-being, but also with many other stressors such as financial problems, their partner’s extreme possessiveness, substance misuse, and chronic conflict and tension. Through all of this, several strengths are evident in individuals victimized by intimate partners; some of the characteristics of abuse survivors that are often viewed as liabilities can be reframed as strengths, such as loyalty to their partners, a desire to maintain a two-parent household for the sake of their children, and sensitivity to the needs and desires of other family members. Although these characteristics have been viewed as barriers to the termination of an abusive relationship, they can also be seen as indicators of strength and resilience. Despite the common mental health consequences of intimate partner abuse, a majority of survivors continue to function as partners,

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parents, employees, family members, and friends. They are resilient in every sense of the word. It is important to remember that many studies of intimate partner abuse use clinical samples of sheltered or help-seeking women who have specifically sought help with coping. The majority of abused individuals, particularly those who experience “minor” acts of violence, do not seek help from professional service providers, though they are active in their coping and help seeking through informal networks. Although some survivors of abuse are socially isolated, others receive social support, validation, and practical assistance from friends and family members. Although some survivors may struggle with effective problem-solving and coping skills, many are extremely resourceful and creative about maintaining their safety and well-being. Professional counseling or therapy, while not needed by all survivors of abuse, is necessary for a subgroup of survivors who do not improve after the abuse has ended. This is especially true for women with symptoms of PTSD, depression, or substance abuse. Cognitive behavioral techniques can be useful in developing positive coping strategies and reducing cognitive distortions. Programs and Social Work contributions Over the past four decades, awareness of intimate partner abuse and the needs of survivors have grown dramatically in the mental health, criminal justice, health, and social service sectors. Programs and services for abused women, their abusive partners, and their children have expanded exponentially. Research has shown that abused women may be more likely to disclose abuse to social workers than any other practitioners (Trabold, 2007), and the National Association of Social Workers has recommended that social workers be prepared to work with clients who disclose intimate partner abuse (Thackeray, Stelzner, Downs, & Miller, 2007). Several studies have indicated the usefulness of universal screening in detecting hidden cases

of intimate partner abuse; this practice can also be utilized to remove prejudice from the assessment process and to educate the public (Spangaro, Zwi, Poulos, and Man, 2010; Todahl & Walters, 2011). Screening is most effective when practitioners demonstrate sensitivity, nonjudgment, and respect for privacy (Thackeray et al., 2007; Tower, 2006). In order to create the opportunity for a client to disclose, screening should always be done in private; this is particularly important when a client’s intimate partner is nearby (Toohey, 2008). Social workers can provide support and information that will assist their client in determining the best course of action in the client’s unique situation. Developing relationships with victim advocates and/ or shelter workers prior to contact with such clients facilitates the referral process. Domestic violence shelters, which first opened in the mid-1970s, have been in the forefront of programs designed to serve survivors of intimate partner violence. In addition to providing services to abused women and their children, shelters have been especially important because of the role they have played in pressing for social change on behalf of survivors (Stark, 2007). The Violence Against Women Act (1994) and its reauthorizations (2000, 2005, 2013) have been instrumental in the establishment of services for victims of abuse. Under this Act, states have played a key role in the development and support of services and are often the conduit for federally supported domestic violence services. It was estimated that in 2010 there were over 9,500 unfulfilled requests for services nationwide in one twenty-four-hour period (NNEDV, 2011). Many survivors of intimate partner abuse will eventually leave their abusive intimate relationship. However, leaving is a difficult process that takes time and resources; survivors who choose to leave need both formal services and informal help to end their abusive relationship. The majority of abused women who sought help from law enforcement, shelter, or victim advocates had previously spoken with family

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members, friends, health care providers, clergy, and employers about their situation (Goodman et al., 2003). These same women rated shelters, victim advocates, the police, and family and friends as the most helpful resources, followed closely by doctors, nurses, and mental health counselors (Goodman et al., 2003). The most helpful kinds of professionals were those who had been trained to understand the plight and constraints of survivors of intimate partner abuse. Those professionals who utilize a singular approach with all survivors of intimate partner abuse will not be effective; for this reason, clergy were identified in one study as more harmful than helpful (Bent-Goodley & Fowler, 2006). Few controlled evaluations exist regarding the effectiveness of services for abused women. A review of advocacy interventions intended to reduce or eliminate violence and promote the health and well-being of survivors of intimate partner abuse found that physical abuse was significantly reduced one to two years after the intervention (Ramsay et al., 2009). Advocacy as an intervention can occur in health care or shelter settings and consists of education regarding intimate partner abuse and community resources as well as assistance with goal setting. Advocacy interventions hinge upon empowerment: rather than prescribing treatment goals, clinicians encourage clients to reflect upon their strengths and decide upon meaningful goals. Recently, advocacy interventions involving the use of technology have been developed and are in the process of being rigorously tested (Glass, Eden, Bloom, & Perrin, 2010); these interventions hold promise for reaching women who are not accessing traditional social services. Services for abusive partners have been controversial for a host of reasons, not the least of which is their effectiveness. Since the mid-1970s, batterer intervention programs (BIPs) have proliferated. Court-mandated programs have increased since many states passed pro-arrest policies in the late 1980s. Several social workers have played a prominent role in the development of programs and policies to address the

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needs of abusive partners, most notably Jeffrey Edleson, Daniel Saunders, and Richard Tolman. There is a strong consensus in the field that group interventions are most effective, but there is less agreement regarding format, length of treatment, content of treatment (e.g., education versus therapy, cognitive behavioral versus psychodynamic), and the extent to which concomitant mental health and substance abuse concerns are addressed. One common approach to perpetrator intervention has been a gender-based, cognitive behavioral modality (the Duluth model) where men are held responsible for their abuse and taught alternative behaviors. However, a review of interventions using cognitive behavioral therapy (CBT) for male perpetrators of intimate partner violence was not able to determine whether this type of intervention yielded significantly better results than no treatment (Smedslund, Dalsbo, Steiro, Winsvold, & Clench-Aas, 2011). The Transtheoretical Model of Behavior (TTM) has also been applied in BIPs to assess for perpetrator change and accountability, with mixed results (Costa, Canady, & Babcock, 2007). Numerous issues exist regarding effectiveness of BIPs. For example, dropout rates tend to be very high—60 to 90 percent for men who could be considered intimate terrorists (Eckhardt, Samper, & Murphy, 2008). Additionally, the early effects of interventions may lessen with time (Taylor, Davis, & Maxwell, 2001). Concerns also exist regarding the extent to which survivors may have a false sense of safety when their abuser participates in a BIP, and few programs exist specifically for abusive men from ethnic minority groups. Nonetheless, there is the need for intervention programs designed to assist abusers in changing their abusive behaviors, and there is some evidence that programs can be successful in helping certain types of perpetrators desist from violence (Buttell & Carney, 2006). A large body of literature now documents the deleterious effects on children of witnessing partner abuse between their parents (Carlson, 2000; Evans, Davies, & DiLillo, 2008).

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To summarize briefly, problems linked to witnessing violence can be identified in virtually all areas of development: cognitive, behavioral, and socio-emotional. Both internalizing (e.g., depression, withdrawal) and externalizing (e.g., aggression toward peers or family members, noncompliant behavior) problems have been documented. In extreme cases, children manifest symptoms of PTSD after observing adult intimate partner abuse (Evans et al., 2008). However, the negative effects of witnessing intimate partner abuse can be ameliorated by therapeutic interventions after exposure to violence (Carlson, 2000). Several well-documented group-intervention models have been described in the literature to address the problems of child witnesses to intimate partner abuse (e.g., Jouriles et al., 2009; Sullivan et al., 2002). Group therapy for these children has been found to be effective. In this setting, children are allowed the opportunity to talk about their experiences and learn that they are not alone. They learn more about intimate partner abuse and who is responsible for it, as well as new coping behaviors and safety skills. These groups may run concurrently with support groups for parents who are survivors of intimate partner abuse, and parent involvement is highly recommended (Poole, Beran, & Thurston, 2008). Where group interventions are not available, practitioners may wish to see children who witnessed intimate partner abuse on an individual basis. Assessment should include an evaluation of the extent of violence and abuse to which children have been exposed, whether they have been abused or neglected themselves, their behavioral adjustment, posttraumatic symptoms, coping mechanisms, perceptions of the abuse and whether they feel responsible for it, and access to social support beyond the immediate family. assessment and interventions As mentioned earlier, intimate partner abuse intervention encompasses other groups as well, in particular abusers and children exposed to

violence between their parents. Female survivors of male violence are the group most frequently seen by social workers. However, many of the interventions for intimate partner abuse summarized in this section may be applied to women and men in same-sex relationships, as well as heterosexual men, if sensitivity to unique needs and concerns is maintained. The theoretical framework adopted will determine the direction of assessment and intervention. For this reason, the social worker must understand the dynamic of power and control within the intimate relationship. If intimate partner abuse is used to control an intimate partner, that is, violence is instrumental rather than expressive, the dynamic may be similar to intimate terrorism, and couples counseling is contraindicated (Jacobson & Gottman, 1998). Because detection of intimate terrorism can mean the difference between life and death, social workers are advised to first assess for severe violence, risk for homicide, and coercive control, regardless of how the couple presents. Social workers should also assess for the use of violence in self-defense, as this may contribute to risk of injury and death (Johnson, 2008). If abuse is detected but can be categorized as situational couple violence, where it is clear that neither partner is using violence to exert control in the relationship, the social worker can move toward couple-focused interventions, such as the development of healthy communication and anger-management skills. The majority of individuals who experience intimate partner abuse tend to encounter their first helping situation not with a specific domestic violence program, but through more generic therapeutic or counseling services. Indeed, research has shown that victims of intimate partner abuse are more likely to disclose their situation to social workers than any other practitioners (Trabold, 2007). Clients may first seek help for their own or their children’s mental health issues until either the social worker or the victimized individual recognizes that intimate partner abuse is the problem that needs

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attention. Assessment and intervention tools frequently used by victim advocates, such as the Danger Assessment, should be integrated into social work practice in mental health settings (Campbell, 2001; Campbell et al., 2003). In settings funded largely through third-party payments, the social worker may need to provide a formal diagnosis for an abused woman. Thus, issues pertaining to psychiatric diagnosis also are discussed in this section. In working with survivors of intimate partner abuse, assessment and intervention often occur simultaneously. In fact, the assessment process itself may be a powerful intervention for victimized individuals. For many, it may be the first time that anyone has asked about whether they have been physically, sexually, and/or emotionally abused by an intimate partner. Acknowledging that intimate partner abuse is a serious problem and validating their experience can be a source of support for abuse survivors. They also learn that they are not alone in the struggle and that help is available, allowing them to feel less shame, guilt, and self-blame about the abuse. The first and most important area of assessment must address the safety of the client and children present in the household (Davies, Lyon, & Monti-Catania, 1998). Each individual defines violence and safety differently; thus, the social worker should remember that the client is the expert regarding her or his own situation. Client-centered intervention is especially important for survivors of intimate partner abuse because it can impart a sense of power (Dutton, 2000). In dealing with safety, the clients’ right to self-determination must be respected. However, a social worker can communicate the belief that abuse may occur in the future by strongly encouraging the development of a safety plan; this recommendation can also be helpful in penetrating the denial of some survivors who believe that the abuse was a one-time or rare event. Except in cases of child abuse or threats to self or others, the social worker needs to respect clients’ decisions

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in regard to their intimate relationships irrespective of the worker’s opinion, which can be challenging in some cases. The need for social support can first be discussed in the context of finding a safe place to stay in the event that violence appears imminent. Abused clients may not have support readily available or may not want to jeopardize the safety of supporters. In that case, the social worker should introduce a domestic violence shelter as a safety option. Though shelter services may be more difficult to locate for lesbian women and gay and heterosexual men as well as survivors living in rural areas, efforts have been made to increase services and decrease discrimination against these populations. The social worker can explain the array of services that a shelter can provide. Positive (safety, support, information) and negative (less privacy, following shelter rules) aspects of going to a shelter should be discussed with strong emphasis on the importance of safety. Many shelters allow visits or have scheduled tours, and this may help to instill confidence and familiarity for a client concerned about the negative aspects of shelter. The content of any safety plan should be specific to the needs and situation of the client, and should be founded on autonomy and empowerment (Campbell, 2001). Attention to immediate safety or safety in an emergency should yield an escape plan that includes the means of escape and access to any resources necessary to put the escape plan into action. This may include packing a hidden suitcase that includes important documents and medication, an extra set of keys, and extra cash. If a shelter stay is possible, the shelter contact information, location, and eligibility requirements should be noted ahead of time. Safety planning might also include the participation of children, neighbors, friends, or family members if a code that signals an emergency and/or the need for police intervention is established. A generic safety plan can be found on the website of the National Domestic Violence Hotline—www.thehotline.org.

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Developing an emergency safety plan is equally important for survivors who are not ready to leave, do not see a reason to leave at the present time, or have already left. This safety plan should be reviewed (and updated as necessary) at every point of contact during the duration of the intervention. Legal status is another area that can affect an individual’s safety. In some cases the abusive husband might use his wife’s immigration status—or her uncertainty about her immigration status—to exert control over her; due to unfamiliarity with her legal rights and protective laws, an immigrant woman may fear deportation for herself or her loved ones and/ or separation from her children, and may feel forced to stay with her abusive husband (Abraham, 2000; Crandall, Senturia, Sullivan, & ShiuThornton, 2005; Erez & Hartley, 2003). In this case, the social worker needs to educate the woman about the provisions of the Violence Against Women Act, which allows survivors of abuse and their children to petition for permanent residency. A plan to obtain necessary documentation of the abuse must be developed in these cases. Many survivors of intimate partner abuse may be unaware of their own strengths and resilience. Violence may occur regardless of what they do, contributing to feelings of powerlessness. Counseling focused exclusively on clients’ deficits should be avoided in favor of social work models that utilize a strengthsbased perspective, beginning with the assumption that even the most troubled survivors have strengths. Social workers must engage in the assessment of survivor strengths and frame psychological symptoms as attempts at coping (Dutton, 2000). For instance, staying in an abusive relationship may appear to be masochistic, but it can also be seen as persistent, family oriented, and resilient. One of the primary goals in survivor counseling is to empower survivors of intimate partner abuse to gain control over their lives. In conducting a strengths inventory, clients are assumed to be experts on their own

strengths and must be actively involved in their identification. The social worker offers perceptions of client strengths only after the client has had the opportunity to articulate them. Post-traumatic stress disorder occurs in response to a traumatic event, or series of events, where extreme fear is induced. Because of the high proportion of women who experience posttraumatic stress in response to intimate partner abuse, social workers should assess and recognize these posttraumatic reactions and follow up with appropriate interventions. Providing support and focusing on problem solving without also specifically addressing the trauma is less effective in alleviating trauma symptoms (Koss et al., 1994). Standardized testing or questionnaires (e.g., the Trauma Symptom Checklist authored by Briere & Runtz, 1989 or the PTSD Checklist authored by Weathers, Litz, Herman, Huska, & Keane, 1993) should be used so that a client’s PTSD might not be mistaken for other psychiatric disorders such as personality disorders. Educating victimized individuals about the reasons behind their reactions is important in helping them understand how their symptoms are “normal” in the context of the “abnormal” situation of trauma. This can allow individuals to gain a renewed sense of control over their reactions. Explaining to the client the course of the treatment, including possible difficulties during the process, is empowering. The client can control the pace of treatment, reducing anxiety and providing a feeling of control. It is important to create a safe environment for clients before encouraging them to remember the past or discuss continuing trauma related to violence and to avoid revictimizing clients (Dutton, 2000). For clients who are out of the abusive situation and in a safe environment, the therapeutic process should consist of helping the client to gradually reexperience the trauma in a safe environment, manage stress, reduce shame and rage, facilitate expression of grief, find meaning in the victimization, and rebuild a new life (Dutton, 2000). For many survivors of intimate partner abuse, substance use can be a way of self-medicating.

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For some, use of alcohol and/or other substances is due to the abuser’s influence (Fazzone et al., 1997). Substance impairment can adversely affect problem solving and the survivor’s ability to keep herself and her children safe. When substance abuse is determined as a result of assessment, the social worker needs to discuss the client’s use of the substance in relation to the abuse and point out the importance of substance abuse treatment. For example, many shelters have rules requiring residents to be sober in order to receive services. If the treatment priorities of the counseling agency and the substance abuse treatment program are different (safety versus abstaining from alcohol or drugs), it will be important to work with a substance abuse counselor who is familiar with intimate partner abuse and understands the importance of safety. Safety should continue to be a focus during substance abuse treatment. Safety-related issues, such as not involving the abusive partner in the treatment process, should be discussed with the substance abuse treatment counselor, especially because family involvement in treatment is typically a component of substance abuse treatment. When survivors of abuse are using substances to self-medicate for depression, anxiety, and other emotional problems, it is important to consider a referral for medication. A thorough medical and psychiatric checkup is necessary before providing appropriate psychotropic medication. Close monitoring of the survivor’s use of prescribed medication is necessary to prevent possible relapse involving misuse of the medication (Fazzone et al., 1997). The social worker should function as a case manager to integrate all different treatments and services the woman is receiving. Some survivors of abuse have developed psychiatric disorders in need of medication, treatment, and even hospitalization. The social worker should document symptoms in the context of the violence. For example, depression is a common diagnosis with survivors of intimate partner abuse, and using a tool such

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as the Beck Depression Inventory (Beck, Rush, Shaw, & Emery, 1979) can be useful in assessment and treatment. Techniques such as cognitive restructuring can be useful in helping the survivor challenge distorted beliefs, and referral to a psychiatrist may be needed for medication therapy. In the case of suicidal ideation, means and intent must be assessed, and hospitalization may be necessary to ensure the client’s safety. illuStrAtion And diSCuSSion

Orlanda is a 28-year-old Mexican woman living as an undocumented immigrant in the United States. She arrived at an outpatient mental health clinic without an appointment to discuss her son’s behavioral problems in school. She explained that her 6-year-old son had been getting into fights with other children, throwing things in the classroom, and swearing at other children and at his teacher. She told the social worker that his teacher recommended counseling for him. To get a better understanding of the factors that might be affecting Orlanda’s son’s behavior and to observe the interaction among family members, the social worker asked Orlanda to bring the whole family in for the next session. With hesitation, Orlanda reported that her husband, Luis, who is also from Mexico, did not know she was seeking help, and it would be difficult to get him to come to counseling. The social worker was able to gather more information about family dynamics and conflict resolution and learned that Luis frequently beat Orlanda, sometimes in the presence of their children. She advised Orlanda to return to the clinic for individual counseling. In subsequent counseling sessions, Orlanda reported that Luis did not seem like a violent person when they first met in Mexico where he was visiting family members. They married after only two months of knowing each other, and she moved to the United States, where he lived, to be with him. However, none of her family and friends lived in the United States, and she felt very isolated. Orlanda was very

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close to her mother and sisters, but she could not speak with them regularly while in the United States. Although Orlanda had several years of work experience in Mexico, she spoke limited English and did not feel competent to seek employment outside of the home in the United States. Plus, Luis had stated on several occasions that he did not want her to have a job. Luis beat her for the first time when he saw her talking with a male classmate at the adult school where she was learning English. Subsequently, he forbade her to attend school and would become very upset when she attempted to learn English at home. Luis became more controlling, often following her even when she was just going to the grocery store. Still, despite his violence, jealousy, and controlling behaviors, Orlanda did not consider leaving him, in part because she was afraid of being deported and also because she was pregnant with their first child. She also explained her concern that divorce would bring shame upon her family. Luis’s beating continued during her two pregnancies, often because she was “not paying enough attention to him.” He also beat her for reasons such as the food’s being too salty, dust on the TV stand, or the children’s being too noisy. If the children were around when Luis got angry, he beat her in front of the children; this happened about once a week. Orlanda reported that she felt sad and lonely much of the time and did not want to get out of bed in the morning, but that she was able to get up when she thought about her children and how much they needed her. Orlanda said that she did not sleep well because of nightmares. She also reported starting to feel nervous each day around the time Luis came home from work because she did not know what kind of mood he would be in. She would try very hard to make sure that the house was clean, dinner was prepared, and the children were playing quietly when he walked in the door, but this was difficult and he could always find something she had not done adequately. Her nervousness often led to headaches and stomach pains.

In this situation, assessment and intervention themes included Orlanda’s need for validation and support, the family’s safety, the need for information about intimate partner violence, her immigration status, and mental health consequences. In the first session, the social worker acknowledged the seriousness of the situation and labeled what Orlanda was experiencing as intimate partner abuse, validating Orlanda’s experience and complimenting her desire to help her son. She also pointed out the courage Orlanda showed in discussing the abuse. Safety was an immediate concern. The social worker conducted a risk assessment, using the Danger Assessment for Immigrant Women (DA-I; Messing et al., 2012) to determine whether Orlanda and her children were at risk of severe violence or homicide. The presence of prior intimate partner violence, beatings during pregnancy, and her husband’s jealous, controlling, and isolating behaviors all placed her at increased risk. The worker shared these findings with Orlanda. Additionally, after determining that Orlanda was not suicidal, the worker questioned her in detail regarding the children’s well-being to determine whether they had been neglected or physically or sexually abused by either parent and the extent of their exposure to the violence between their parents. The social worker persuaded Orlanda to develop an emergency safety plan and an age-appropriate emergency safety plan for her children; these plans described what each family member could do when violence occurred (e.g., preparing escape routes and emergency telephone numbers). The social worker also informed Orlanda about local domestic violence shelters as well as services and support groups in the area with cultural and linguistic sensitivity to the needs of immigrant women. In subsequent sessions, psychoeducational interventions were used to assist Orlanda in understanding the nature and dynamics of intimate partner abuse, its effects on victims, and the effects on children who witness such abuse. The social worker linked the presenting problem of Orlanda’s son’s problematic behavior at school to the effects of abuse on

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child witnesses. Oftentimes, explicit awareness that exposure to chronic conflict and abuse can be harmful to children helps increase women’s readiness to take steps toward ending abuse. The social worker noted several strengths, including Orlanda’s obvious concern about her children, the importance of family in Orlanda’s life, her willingness to follow through with the school’s recommendation for counseling, and her resilience thus far. Because Orlanda and her family are from Mexico, the social worker needed to be both sensitive to and knowledgeable about Mexican culture. Such awareness includes understanding common religious beliefs and cultural norms around marriage and gender roles. Moreover, the social worker was knowledgeable about immigration law and was prepared to use this knowledge to advocate for this client with Immigration and Customs Enforcement. The worker informed Orlanda that if she ever decided to leave her husband, she could be successful in seeking legal status on her own, via U-Visa, assuming she could document her abuse. This would mean contacting the police the next time she was beaten to begin documentation of the abuse. Obtaining an order of protection (called a restraining order in some states) would be another way of documenting her husband’s violent behavior. Social workers, however, must be knowledgeable about the many valid reasons for a survivor’s reluctance to contact law enforcement or seek an order of protection. Women may be afraid of what their abusers will do if they call the police. They may also believe police will be unable to help, or they do not want their husbands to be arrested, especially if they are sole financial providers for the family or are undocumented immigrants. Orlanda stated that she wanted to stay married to Luis, despite the abuse, and she was unwilling to involve law enforcement. Practitioners should use caution in urging clients to separate from abusive partners if they are in an early stage of change where leaving is not being contemplated, especially in light of the danger

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associated with leaving. Terminating an abusive relationship can be very complex, especially when there are children involved. Planning for leaving may take months or even years. Additionally, the empowerment model of social work practice includes encouraging clients to assess their strengths and needs and to set their own goals. The social worker was careful not to pressure Orlanda to leave her husband, taking into account her early stage of change at the initial session. She did not want to alienate her client, nor did she want Orlanda to leave her husband if she felt that the timing was not safe. The social worker also acknowledged the presence of strong cultural norms regarding family unity and privacy in the Latino community. The social worker addressed Orlanda’s mental health concerns by administering a depression inventory and by evaluating Orlanda for PTSD symptoms, concluding that Orlanda was in the moderate range for depression but, while she was experiencing some symptoms of PTSD, she did not screen positive for PTSD. Because of her score on the depression measure, the social worker chose to use cognitive behavioral techniques, such as cognitive restructuring and reframing, to deal with Orlanda’s depression and cognitive distortions, which should eventually improve her self-esteem. In addition, the social worker taught Orlanda relaxation techniques to help with anxiety. Other interventions included helping Orlanda to see that the abuse was not her fault and that she did not deserve to be mistreated. The practitioner also worked with Orlanda to help find resources to achieve goals around family planning, because Orlanda did not want more children, and learning to speak English despite her husband’s objections. Orlanda met with the social worker for several weeks, creating a safety plan and brainstorming ways to learn English. She was able to improve her mood slightly and feel comfortable using the relaxation techniques the social worker taught her. Orlanda’s son also met with a social worker during that time. However, Orlanda stopped attending these meetings after four weeks, and the worker was unable to get

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back in touch with her. While the social worker was disappointed that Orlanda did not continue treatment, she had provided services consistent with social work values by allowing Orlanda the space to make her own decisions. The social worker also felt confident that Orlanda had new knowledge of safety planning, immigration options, available resources, and coping strategies.

conclusion Intimate partner abuse is increasingly recognized as a common problem often seen by social

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Buttell, F. P., & Carney, M. M. (2006). A large sample evaluation of a court-mandated batterer intervention program: Investigating differential program effect for African-American and Caucasian men. Research on Social Work Practice, 16(2), 121–31. Campbell, J. C. (1995). Assessing dangerousness. Newbury Park, CA: Sage. ——. (2001). Identification and intervention with women victims of abuse in the health care system. Aggressive Behavior, 27(3), 259–60. ——. (2002). The health consequences of intimate partner violence. The Lancet, 359, 1331–36. Campbell, J. C., Glass, N., Sharps, P. W., Laughon, K., & Bloom, T. (2007). Intimate partner homicide: Review and implications for research and policy. Trauma, Violence & Abuse, 8(3), 246–69. Campbell, J. C., Webster, D., Koziol-McLain, J., Block, C. R., Campbell, D., Curry, M. A., . . . Wilt, S. (2003). Assessing risk factors for intimate partner homicide. National Institute of Justice Journal, 250, 14–19. Carlson, B. E. (2000). Children exposed to intimate partner violence: Research findings and implications for intervention. Trauma, Violence & Abuse, 1(4), 321–42. Carlson, B. E., McNutt, L. A., Choi, D. Y., & Rose, I. M. (2002). Intimate partner abuse and mental health. Violence Against Women, 8, 720–45. Catalano, S., Smith, E., Snyder, H., & Rand, M. (2009). Bureau of Statistics. Female Victims of Violence (NCJ 228356). U.S. Department of Justice. Cavanaugh, C. E., Messing, J. T., Del-Colle, M., O’Sullivan, & Campbell, J. C. (2011). Prevalence and correlates of suicidal behavior among adult female victims of intimate partner violence. Suicide and Life-Threatening Behavior, 41(4), 373–83. Cho, H. (2012). Racial differences in the prevalence of intimate partner violence against women and associated factors. Journal of Interpersonal Violence, 27(2), 344–63. Cloitre, M., Scarvalone, P., & Difede, J. (1997). Posttraumatic stress disorder, self- and interpersonal dysfunction among sexually retraumatized women. Journal of Traumatic Stress, 10(3), 437–52. Cohen, S., & Hoberman, J. M. (1983). Positive events and social supports of life change stress. Journal of Applied Social Psychology, 13, 99–125. Coker, A. L., Smith, P. H., McKeown, R. E., & King, M. R. (2000). Frequency and correlates of intimate partner violence by type: Physical, sexual and psychological battering. American Journal of Public Health, 90(4), 553–59. Costa, D. M., Canady, B., & Babcock, J. C. (2007). Preliminary report on the Accountability Scale: A change and outcome measure for intimate partner violence research. Violence and Victims, 22(5), 515–31. Crandall, M., Senturia, K., Sullivan, M., & Shiu-Thornton, S. (2005). “No way out”: Russian-speaking women’s experiences with domestic violence. Journal of Interpersonal Violence, 20(8), 941–58.

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Wilson, M., & Daly, M. (1993). Spousal homicide risk and estrangement. Violence and Victims, 8(1), 3–15. Wilson, M., Johnson, H., & Daly, M. (1995). Lethal and nonlethal violence against wives. Canadian Journal of Criminology, 37, 331–62. Wu, V., Huff, H., & Bhandari, M. (2010). Pattern of physical injury associated with intimate partner violence in women presenting to the emergency department: A systematic review and meta-analysis. Trauma, Violence, & Abuse, 11(2), 71–82.

cHaPter 2 0 older Persons in need of long-term care t o b y b e r m a n - r o S S i 1 a n d t i m o t H y b . k e l ly

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he population of the world is becoming older. In 1998, older people in the more developed countries outnumbered children for the first time in recorded history and by 2045 the United Nations predicts that this balance will tilt for the world as a whole (Department of Economic and Social Affairs, 2009). Without question, the lives of older persons reveal significant gains and accomplishments, and this pattern is expected to continue. Yet, a large portion of our older population, particularly women, ethnic minorities, and the oldest old, live lives of unnecessary hardship, hardship created and secured by unresponsive, oppressive, and exploitative social systems. There are profoundly different beliefs regarding how a society should provide for older persons. These differences of opinion are heightened by a growing percentage of older people within the population, and the controversies are seen across the world. Many of the global welfare systems developed in the twentieth century designated older people as a special category of persons that needed some form of protection. Yet, these systems were developed in very different demographic times (Quesnel-Vallée, Farrah, & Jenkins, 2011). How does a society today care for its older citizens when their numbers become larger than the number of children? Increasingly, older people are being seen as a drain on economic resources and a block to economic development (Isaacs, 2009). The controversies expose a potential backlash against older people, and daily there are popular stories that reflect a growing conservatism, a rising negativity toward older persons, and an

increase in injustice. These issues are brought into sharp focus when examining older people who are in need of long-term care. defining and explaining older Persons in need of long-term care The focus of this chapter is on older persons who need long-term care. By long-term care we mean care in home, institutional, and noninstitutional settings. The numbers of older persons receiving paid long-term care in the United States will more than double from 2000 to 2040—from 2.9 to 6.0 million (Johnson, Toohey, & Wiener, 2007). A similar picture emerges in other countries. For example, in the UK, between 2004 and 2050 the number of residential nursing home beds will need to increase 150 percent, and the number of hours of home care will need to increase by 140 percent in order to meet expected demographic increases (Wittenberg, Comas-Herrera, Pickard, & Hancock, 2004). The population of older persons in need of long-term care is often called the frail elderly. The term frail is used to suggest fragility, weakness, infirmity, brittleness, things easily broken, and a quality of being easily crushed, destroyed, or wanting in power (Oxford English Dictionary, 2012). The concept of frail elderly contains a strong deficit orientation centering on incapacity. Thus, older persons are often viewed not in their wholeness as individuals, but in their limitations and dependence on others. Consider, for example, the following definitions: “Older persons with mental, physical, and/or emotional disabilities that limit their independence 415

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and necessitate continuing assistance; persons 75 years or older” (Harris, 1988, p. 75), or “. . . biologic syndrome of, decreased reserve and resistance to stressors, resulting from cumulative declines across multiple physiologic systems, and causing vulnerability to adverse outcomes” (Hicks & Millar, 2011, p. 89). These definitions of frail elderly suggest an individualistic, medical orientation as well as a linearity of approach. “Personal attributes” are viewed as primary factors in the older person’s situation. The environment serves principally as backdrop, rather than as principal player in the creation of the “condition.” “Disabilities” become intrinsic to the individual and not a function of social creation and an inadequate person:environment fit. Thus, the individual, not the environment, becomes the target for change. And yet, we know that when resources are available and coping capacities are strengthened, “frailty” declines and resiliency is most likely to be realized. A narrow medicalization does not adequately describe frailty; rather it is better understood as a complex interaction between older persons and their environment. When the environment is responsive to longterm need, the older person’s strength will be more likely to meet its environmental demands. An unresponsive or menacing environment requires even greater strength to simply maintain the status quo. In such circumstances, needs increase and greater personal resources are required to maintain oneself. The need for long-term care or what others call frailty results not from attributes of older persons alone, but from a lack of congruence between their needs and capacities and the environment’s demands and resources. As Kane and Kane (2005), Luppa, Luck, Matschinger, König, and Riedel-Heller (2010) note, institutionalization in a long-term care facility is brought about by the interaction between social circumstances and individual characteristics, not solely the individual. Further, Luppa, Luck, Weyerer, and colleagues (2010) found in their systematic literature review that the existence of functional

limitations, and not the presence of a chronic medical condition, increased risk for nursing home placement. Functional limitations occur within an environmental context. Given the proper environment, medical conditions need not be disabling and the “need” for long-term care may be avoided or delayed. demographic Patterns Older people are living longer and are more financially secure, better educated, more content with their lives, and more politically active than ever (He & Muenchrath, 2011; Hungerford et al. 2001/2002). Yet, there are older persons who, for a variety of reasons, have become increasingly dependent on others for assistance in managing their lives or coping with significant life stressors. It is these older persons whose resiliency is strained by the weight of significant personal, interpersonal, and environmental stressors in the face of insufficient protective forces. To understand the risks and vulnerabilities of those requiring long-term care, sociodemographic, economic, health, physical, and mental health characteristics must be examined. These elements are closely interdependent, and their combined effects constitute critical elements of the aging experience. The awareness that aging is affected not only by what occurs to those 65 and older, but also by experiences of a lifetime, makes knowledge of the ongoing effects of gender, race, and class upon older persons central to our understanding. Gender, race, and class determine the quantity and quality of economic and service resources available to older persons and inform our understanding of which older persons are most at risk. The scarcity of essential environmental resources necessarily requires us to focus on those in greatest need. Around the world, the numbers of persons over 65 are growing more rapidly than those younger. In the United States, the aging of the population is not as drastic as in Europe; however, the aging of the U.S. population is increasing significantly. For example, only 4 percent

older PerSonS in need of lonG-term care

of the total population at the beginning of the twentieth century was over 65; by 2050 the percentage of those over 65 will be 20 percent (DHHS, 2010). By 2050, those 90 and over will represent 10 percent of those over 65 (He & Muenchrath, 2011). Fertility rates, decreased mortality, and immigration patterns have all contributed to the growth of older persons at a rate faster than that of any other population group (DESA, 2009). Concomitantly, there has been a striking increase in those over age 75, and those above 85 have doubled each decade since 1940. In the 2010 U.S. census reports we began to see figures for those over 90 years of age, rather than the traditional old-old cutoff of 85 years of age. Not only is the American older population becoming proportionally older, it is also becoming more diverse. For example in 2008, older people from minority ethnic backgrounds accounted for approximately 20 percent of the older population. By 2050 the percentage of older people from minority ethnic backgrounds will increase to 41 percent. Hispanic older people will be the largest older minority ethnic group by 2050. In 2008 they accounted for 7 percent of the older population, but by the mid-point of the twenty-first century they will account for 20 percent of the older population (Federal Interagency Forum on Aging-Related Statistics, 2010). Gender and minority status remain critical variables in life expectancy. Women continue to live longer than men, and gender disparities increase with age (DHHS, 2010). For persons born in 2006, there is a five-year life expectancy advantage for white Americans over African Americans (Arias, 2010). White women have an eleven-year advantage over black men. While the life expectancy for black women is slightly greater than for white men, racial comparisons between white and African American males still favor white men by 6.4 years. White women have an advantage of 4.2 years in comparison with African American women (Arias, 2010). Theories of cumulative advantage and disadvantage help to explain these differences.

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Advantage and disadvantage are structured around race and class in America, and the initial inequalities experienced in childhood become heightened across the life course, while initial advantages become accentuated. However, now that life expectation figures are calculated on people of Hispanic origin, the picture becomes more complex. Life expectancy for Hispanic persons born in 2006 is 2.5 years longer than non-Hispanic white persons and nearly 8 years more than non-Hispanic black persons (Arias, 2010). Generally, both black and Hispanic children are born into families with fewer advantages that their white counterparts (Mutchler & Burr, 2011) and yet, we see very different life expectancy rates. Immigration patterns may explain some of the difference in Hispanic populations. There may also be cultural protective or risk factors at play. The living arrangements of older persons are directly affected by life expectancy, marital and childbearing practices, and economic status of countries. Worldwide about 14 percent of older people live alone, but in more developed countries older people are more likely to live alone (DESA, 2009). Those who live alone are more likely to need assistance if illness or disability occurs, are more likely to be poor, and as such those living alone have become a social and policy concern (Casey & Atsuhiro, 2002). In the United States significant differences exist between men and women. In 2010, only 42.3 percent of older women lived with their spouse, compared to 69.9 percent of older men. This disparity increases with age; when we look at women over 75, only 30.4 percent live with a spouse (DHHS, 2011). The portrait of older persons living alone varies by ethnicity. For example, older black, Asian, and Hispanic women lived with relatives other than a spouse more often than non-Hispanic white women. White and black women were more likely to live alone than older women from other ethnic minority groups. Older black men were more likely to live alone then men from other racial or ethnic groups (Federal Interagency Forum

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on Aging-Related Statistics 2010). Though a relatively small percentage of older people live in institutional settings, the percentage increases with age. In 2009, only 4.1 percent of Americans over 65 lived in an institution. However, before the age of 74 only 1.1 percent of older people are living in an institution, but at 85+ the percentage increases to 13.2 percent (USDHHS, 2011). The majority of these residents are widowed, older women. Social isolation is positively correlated with increased age, a single or widowed status, few nearby informal supports, poor transportation, living alone, poverty, being a caregiver, retirement, mental illness, and decreased physical capacity (Findlay & Cartwright, 2002). Social isolation can lead to serious emotional, cognitive, physical, and social difficulties (George, 1996; Kirkwood, 2005). Associated poverty and decreased social supports clearly place this population of single women living alone at increased risk of increased morbidity, neglect and abuse, institutionalization, and death. The much smaller percentage of older men living alone with few social supports are also at risk. Compared to widowers and married older men, never-married and divorced men living alone have decreased functional social support and are most vulnerable to social isolation (Arber & Ginn, 2005). The poverty index, as developed in 1964 by the Social Security Administration, established that older people, female-headed households, and farm families spent less on food and therefore had a higher poverty threshold. Femaleheaded households and farm families were removed from this calculation, but the assumption that older people have lower nutritional needs or spending remains (Atchley & Barusch, 2004). The poverty threshold for a single older person in 2011 was $10,799 compared to the $11,702 used for single householders aged 15 to 64. For a two-person elderly household with no related children, it was $13,596, compared with $15,063 for younger households (U.S. Census Bureau, 2011). There is no justification for

establishing this lower standard, and it should be abolished (Rogers, Brown, & Cook, 1994). The Supplementary Poverty Measure (SPM) was introduced in the 2011 census, and it includes regional differences, as well as nondiscretionary expenses such as out of pocket medical expenses or noncash benefits, thereby providing a more realistic view of poverty. Using the SPM, we see a sharp jump from 9 percent of older people officially in poverty to 15.9 percent of older people in poverty (DHHS, 2010). All economic indicators for older persons must be read with this reality in mind. Over the last 75 years, there have been major gains in the economic status of older persons in America. The poverty rate for older persons was 75 percent in 1936, but from 2000 to 2010 it has hovered around 8.9 percent to 10.4 percent (DHHS, 1985–1986; DHHS, 2011). While the overall reduction in the poverty rate for older persons is certainly encouraging, a more detailed analysis reveals considerable cause for concern, particularly for women, ethnic minorities, and those oldest. First, older persons are poorer than are other adults. Data from the 1990 census (U.S. Census Bureau, 1996) indicated that the percentage of older persons living below 150 percent of the poverty rate was 27.6 percent in comparison to 23.6 percent for all other adults. By 2003, the rates of adults younger than and older than 65 who were 125 percent below the poverty threshold were identical at 16.9 percent. However, nearly 20 percent of those over 75 were 125 percent below the poverty threshold (U.S. Census Bureau, 2004). Second, poverty for females at all ages is greater than poverty for males. In 2010, the poverty rate for older women was 10.7 percent, compared to 6.7 percent of older men. Third, race, ethnicity, and living arrangements were important variables in poverty. Older Hispanic women (40.8 percent) and older black women (30.7 percent) who lived alone had the highest poverty rates (U.S. Census Bureau, 2011, 2010). Further, poor older persons are highly dependent on federal, state, and local programs for their minimum

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standard of living and have little opportunity to move beyond a poverty level through their own efforts. Approximately one-third of older people rely on Social Security for 90 percent or more of their income (He et al., 2005; DHHS, 2010). Purchasing power for resources that can buffer against stressors is limited. While poor older persons are the most disadvantaged, lower- and middle-income persons in need of long-term care also experience disadvantaging economic conditions. The costs of long-term care places lowerand middle-income older persons at risk of impoverishment. This is especially true for older Americans, compared to older people from other developed countries as the cost of long-term care is more likely to be paid for by individuals in the United States (Eskildsen & Price, 2009). In 2006, the average medical expenditure was $57,022 among residents of long-term care facilities and $12,383 for those older people living in the community (Federal Interagency Forum on Aging-Related Statistics, 2010). Though there are some protections for community-living spouses, the amount of spend down required to be eligible for Medicaid greatly reduces a couple’s finances and can severely impact the community-living spouse. Older persons will eventually have decreased possibilities of purchasing long-term care and will become more dependent on means-tested programs. The control of long-term care facilities by the for-profit market in the United States is firmly cemented. In 2010, 67 percent of nursing homes were for-profit (Centers for Medicare and Medicaid Services, 2010). In Europe and Canada we also see increasing privatization of long-term care. This trend is particularly concerning as for-profit facilities have been found to have lower-quality care (Comondore et al., 2009). Between 2006 and 2008, 75 percent of older people rated their health as good, very good, or excellent, and chronic illness and disability have declined among older persons (Federal Interagency Forum on Aging-Related

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Statistics, 2010). Nonetheless, advanced age brings with it an increased probability of a greater number of chronic illnesses and a greater need for assistance with activities of daily living (George, 1996; Federal Interagency Forum on Aging-Related Statistics, 2010; He et al., 2005; U.S. Census Bureau, 1996). Chronic conditions, rather than acute disease, tend to generate the limitations in self-care of greatest concern (Federal Interagency Forum on Aging-Related Statistics 2010; He et al., 2005; Maldonado 1987; U.S. Census Bureau, 1996). Disability associated with chronic health conditions is frequently increased for low-income persons owing to poorer housing, health care, and nutrition. Ethnicity also impacts health status. While 42.8 percent of older non-Hispanic white persons reported their health as very good or excellent, only 26 percent of older African Americans, 24.3 percent older American Indians/Alaska Natives, and 28.2 percent of older Hispanics (28.2 percent) also rated their health as excellent or very good (Federal Interagency Forum on Aging-Related Statistics, 2010; U.S. Census Bureau, 1996). Blacks 65 and over have a significantly higher rates of functional limitations than whites and those from higher Socio-Economic-Status SES (He et al., 2005; U.S. Census Bureau, 1996). Reduced capacity for self-care becomes associated with chronic disease, and a significant decrease in the functional or cognitive capacity for self-care in the following areas increases the need for long-term care services: (1) home management activities, including preparing meals, shopping for personal items, managing money, using the telephone, doing light housework, and doing heavy housework; (2) personal care activities, including bathing, dressing, using the toilet, getting in and out of bed or a chair, and eating; (3) mobility status; and (4) continence status (Gaugler, Duval, Anderson, & Kane, 2007; Luppa, Luck, Matschinger, et al., 2010; National Center for Health Statistics, 1989). The distinction between personal care tasks and household management tasks

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is important. Evidence suggests that the likelihood of institutionalization increases in accordance with increases in the degree of personal care tasks required, especially when assistance is needed with three or more activities of daily living (Gaugler et al., 2007). At the same time, twice as many older persons with similar health and functioning live in the community than in an institution (Olson, 1994b). The literature suggests that the critical variable increasing the likelihood of institutionalization is not physical need but whether family and community care supports are available and sufficient (Garner, 1995; Luppa, Luck, Weyerer, et al., 2010). While getting reliable estimates is difficult (Mathews & Savva, 2011), varying rates of mental disorder in older people are reported. Actually, of all the psychiatric disorders noted in the Diagnostic and Statistical Manual IV-TR (APA, 2000), age-related cognitive decline is the only diagnosis specifically associated with aging. Yet, a significant number of older people do experience depression, dementia, or paranoia. Estimates range between 6 and 25 percent for depression (Fiske & Jones, 2005). Less than 2 percent of people in North America between 65 and 69 have dementia, but nearly a third of those over 85 have dementia (Alzheimer’s Disease International, 2008). Paranoia rates range from 0.5 percent to 11 percent (Gurland, 1991), though paranoia may be caused by other physical or mental conditions. The numbers of older persons with a mental illness will increase as the older population grows in general. Older persons with mental illness have great vulnerability, risk, and needs. Their vulnerability and risk increase without appropriate mental health services, and there is substantial evidence that older people are underrepresented in service utilization, especially those in nursing homes (Knight & Lee, 2007). Depression dementia, and paranoia, the three most prevalent laterlife mental health conditions of concern, make hopefulness and a feeling of control difficult to sustain. Alzheimer’s disease makes independent living an improbability. Decreases in attention

span, learning, memory, language, judgment, and relational skills, coupled with a depressive reaction to the disease itself, can increase the risk of institutionalization. Functional limitations can be measured and quantified once they occur; however, they often cannot be foreseen. A broken hip, the death of a spouse, the loss of sight, the loss of an apartment, or the closing of a neighborhood store, for example, can dramatically change the lives of older persons who had once managed quite independently. Intellectual acknowledgment of the possibility does not prepare one for the actuality. The need for informal and formal supports can arise instantaneously, propelling the individual into previously not experienced role relationships with families, friends, neighbors, and formal service organizations. Under such circumstances mental health needs do increase. Societal context We must understand that the private troubles of our clients reflect public issues in society and that all public issues are lived in private lives (Mills, 1959; Schwartz, 1969). Understanding this connection is particularly important in working with older people, especially those needing long-term care. The cumulative impacts of advantages and disadvantages afforded different classes of people across the life course converge in old age. No issue is more imposing on the lives of those needing longterm care than the public policy that specifies need, creates the conditions under which need comes about, and sets up the service systems to meet the very need it has helped create. As an embodiment of values and philosophy, public policy expresses a point of view about the proper role of government in the lives of its citizens, about the varied beliefs and interests of those governed, and about the powerful groups that govern and create social services. Thus, public policy is both proactive in creating the social context of older persons and reactive to the social context in which it finds itself. Those in power almost always establish definitions of

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need, rarely including views of the recipients of such decisions. The term ageism was coined by Butler (1969) to convey a prejudicial societal context that results in stereotyping and bias toward older persons. These biases have profound effects on how society behaves and are especially oppressive when internalized. Ageism is an insidious process that creeps into every aspect of private and public life. Within public life the most devastating and far-reaching effect of ageism is social policy that enacts the view that older persons constitute a class apart from the mainstream of society, where they are less worthy of social investment and less capable of acting in their own behalf. The belief that older persons are well off and profiting at the expense of children is at the center of debates concerning how society should distribute its resources (Hewitt & Quadagno, 1997; Isaacs, 2009; Marche, 2012). Negative views of older persons support policies that diminish opportunities for the older persons to make the most ordinary choices about their own lives. Devaluation of older persons is exacerbated by such views, and the creation of responsive social policy is constrained. When ageism is internalized by older persons, as it inevitably is, the price paid is lowered self-esteem and a negative self-concept. When not countered by protective forces, an emotional state of helplessness and hopelessness can induce and maintain disease itself (Gaigin & Pargament, 2011; Mercer & Kane, 1979). These feelings profoundly affect a person’s level of assertiveness, a high level of which is believed to be necessary to survival (BermanRossi, 2005). The sense of oneself as potent has direct bearing on the ability to cope successfully with life events as we age (Resnick, 2011; Neeman, 1995). Estes (2011), Estes, Linkins, and Binney (1995), Neugarten (1982), and Olson (1982, 1994a, 1994b) are unequivocal in advocating the view that old age itself does not create the disadvantage. Aging and old age are socially constructed and cannot be understood separately

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from societal forces and characteristics. The major problems older persons face are the ones we create for them. Ageist social and economic policies, which perpetuate and institutionalize negative definitions of older persons, combine to produce the environment older persons must contend with. Individualistic public policy does little to mitigate inequities. The failure to correct past abuses limits the lives of older persons and frames the central challenge of social policy and planning for older persons (Estes, 2011; Estes, Swan, & Gerard, 1982). Vulnerabilities and risk factors Originating in the fields of commerce and insurance, the concept of risk has evolved from its earliest definition concerning the categorical probability of a negative outcome occurring in a particular population (Cowan, Cowan, & Schulz, 1996). This original idea shifted as researchers tried to make sense of the reality that similar outcomes did not necessarily occur even when persons were similarly situated in the same risk category. Rutter (1987) proposed that it was not the risk and vulnerability factors themselves, nor the protective factors alone, but rather the vulnerability and protective processes and mechanisms that connect risk and adverse outcome that critically influence whether risk results in negative outcomes. Risk, then, is what predisposes “individuals and populations (identifiably groups of people) to specific negative or undesirable outcomes” (Cowan et al., 1996, p. 9). What is important is that a predisposing risk is not a guarantee of an adverse result. We must ask, what links risk and negative outcome? Cowan et al. (1996) offer that “vulnerability increases the probability of a specific negative or undesirable outcome in the presence of a risk” (p. 10). What is most important here is that vulnerability only has viability and potency when risk is present. Vulnerability can be located in individual persons, in the external environment, or in the relation between the two. The relevant question is always: to what risk is the vulnerability linked,

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and what are the vulnerability processes and mechanisms that increase the probability of negative outcomes in the face of risk? Ryff and colleagues (1998) add two additional concepts that are especially useful to our understanding of vulnerability and resilience in later life: accumulation of adversity and accumulation of advantage. Accumulation of adversity has two distinguishing features: (1) the notion of “pileup” of hardship, and (2) the enduring or chronic nature of problems. Accumulation of advantage speaks to the pileup of advantage, which has protective benefits and may be central to an understanding of resilience. Later life is a time when individuals bring with them a lifetime’s accumulation of adversity and advantage, as well as being a period in which there is a natural accretion of life challenges. The following presentation of the risks and vulnerabilities for older persons is organized around the material previously presented in the categories of demographics and social context. Occupying status in more than one of the preceding categories increases overall risk and illustrates the concept of accumulation of adversity. The greater the accumulation of disadvantages, the greater the need for protective factors and processes/mechanisms to mitigate or nullify the negative outcomes associated with risk. Age. The oldest old are at greatest risk for a negative view of their capacities, living alone, increased poverty, social isolation, chronic illnesses, the fewest social supports, needing assistance with activities of daily living, decreased physical and mental capacity, loneliness, depression, late-life dementia, neglect and abuse, morbidity, mortality, and institutionalization. Gender. Males are at risk for the following: shortened longevity, acute illnesses, completing suicide (particularly white males 85 and over), and poverty (especially older minority males). Females are at risk for living alone, fewer income sources, lifetime poverty that increases with aging, widowhood, chronic illnesses,

social isolation, attempting suicide, inadequate or inappropriate mental health treatment, and institutionalization. Minority. Older persons are at risk for the following: shortened longevity; living alone (notably if an African American woman); extreme impoverishment (particularly African American and Native American women and recent immigrants); inadequate housing and environmental resources; fewer long-term care services; increased chronic illnesses; higher functional limitations; and racism in the provision, availability, and adequacy of necessary services. Poorer persons are at risk for shortened longevity, poorer health, poor nutrition, increased disability and the need for assistance with activities of daily living, chronic stress, fewer available physical and mental health services, more limited access to all services, and poorer quality of all services and benefits. Lower- and middleclass older persons are at risk for impoverishment with institutionalization. Cutting across all populations irrespective of age, class, gender, and minority status is that insufficient and inadequate social supports place all older persons at risk for increased morbidity, abuse and neglect, institutionalization, and death. The risks identified in the preceding are those that are primarily person based, though some system-based risks are included. The risks are all associated with being situated in a particular demographic category. The case is made, once again, that these categories of age, gender, minority status, and class become risk categories because the larger societal context creates them as such, and therefore the environmental context itself operates as a constellation of risk factors. On a societal level, ageism, sexism, classism, racism, and homophobia act to predispose older persons to negative outcomes. Public policy, which emerges from these conditions, institutionalizes disadvantages for older persons and increases their vulnerability. Public policy that generates these conditions also increases vulnerability. The case has been made that personal risks and societal risks are intertwined and

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both must be addressed if the lives of older persons are to significantly improve. Once again, poverty and low income are the most powerful risk factors for older persons, substantially predisposing them to notable disadvantages, the effects of which are increasingly more difficult to nullify or lessen as one ages. resiliencies and Protective factors The demographics and societal context of aging combine to present a bleak picture for a large portion of older persons. How is it, then, that older persons manage well, are able to sustain meaningful lives, and, in the main, believe that life is worth living? On the positive end of the continuum are protective factors, processes, and mechanisms, as well as resilience. Protective factors, processes, and mechanisms are those that act as a buffer or decrease the probability of a negative outcome in the presence of adversity (Cowan et al., 1996; Daniel, Wassell, & Gilligan, 2010). Rutter (1987) cautions that a situation high in protective mechanisms is not a situation of low risk; rather, it describes the processes by which risk does not result in the probable negative outcome. Such a caveat is important because it points to the necessary separation of risk and protective factors and protective processes and mechanisms and, as such, opens up multiple routes to lessening the impact of risk, for example, reducing risk, and/or strengthening protective factors, processes, or mechanisms. Three categories of protective factors include (1) sociological, (2) psychological, and (3) social/relational (Mlinac, Sheeran, Blissmer, Lees, & Martins, 2011; Ryff, Singer, Love, & Essex, 1998). Sociological buffers include sociodemographic resources; psychological protections point to how individuals cope with and react to the events and challenges before them, and social/relational includes the arena of social supports. Resilience operates as a process and represents the outcome of a process. The concept includes the notion of resources that can be called upon in periods of need and that operate

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to facilitate, at minimum, the return to the stability of the prestress state (Daniel, Wassell, & Gilligan 2010). At times, the prestress state can be surpassed, as when individuals, families, or groups achieve even more positive outcomes. In such instances, crises have been turned into opportunities for emotional or physical growth (Cowan et al., 1996; Ryff et al., 1998). Allen and colleagues (2011) expand the definition of resilience beyond adverse events and suggest that it also includes the coping processes in the face of everyday life struggles. On a certain level there are obvious protective factors for older people needing long-term care. For example, economic resources protect against poverty, psychological well-being protects against depression, health protects against illness and depression, social supports protect against isolation and depression and thus increase physical well-being, and so on. The greater the number of protective factors, the more likely it is that protective processes will be fortified. Income and resources dramatically increase options and freedom in life. By aiding in survival, stress is decreased and physical and psychological well-being is increased. Social supports promote resilience by linking personal resources and resources of the larger environment (Clark et al., 2011; Netuveli et al., 2008). In this sense, these supports function as “conduits” fostering connections between individuals and social systems of importance to them. A sense of group membership, whether familial or peer, is particularly sustaining and can buffer the pain of loss. Self-concept also has a profound effect on how older persons cope with, and adapt to, life challenges. A strong, continuous self-concept operates as a resilience mechanism by organizing life experience and by preserving a sense of coherence over the life span (Bergeman & Wallace, 1999; Clark et al., 2011; Staudinger et al., 1999). Moreover, a sense of coherence is based in one’s sense that life is comprehensible, manageable, and meaningful (Clark et al., 2011; Korotkov, 1998; Resnick, 2011).

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Comprehensibility fosters resilience by increasing the older person’s sense of an ordered world in which experiences can be anticipated and planned for. Planning fosters mastery and decreases stress. Manageability promotes resilience by increasing the older person’s view that he or she has sufficient resources to cope with life’s challenges. A sense of meaningfulness is most central to resilience and the perpetuation of a sense of self. In addition, “. . . if individuals’ experiences are characterized by participatory decision making in which they are free to select their own outcomes, a strong sense of meaningfulness develops. However, when individuals have no say in any matter, they tend to see life as devoid of meaning” (Korotkov, 1998, p. 55). For older persons in need of long-term care, where so much is beyond their control, the ultimate right to participate in their own life and to express themselves is directly linked to the preservation of the self. The literature on resiliency in later life is beginning to develop at pace (e.g. Resnick, Gwyther, & Roberto, 2011). Ideas concerning the preservation of a sense of self and a sense of coherence, that is, a self that finds expression with others and maintains meaning and a sense of purpose, appear particularly compelling. Adding the power of resourceful environments links older persons to their community and to the society at large. These ideas are at the heart of resilience and provide a persuasive conception of successful aging. Taken together, these ideas about resilience provide a direction for policy, planning, and practice. Programs and Social Work contributions Estimates are that family and friends to older people living in the community provide 71 percent of all long-term care in America (Whitlatch & Noelker, 2007). In the UK it is estimated that family caregivers save the UK governments £87 billion per year by providing care (Buckner & Yeandle, 2007). These figures confirm that family caregivers provide the bulk of longterm care to older people. As such, supporting

caregivers should be an important social work activity. Unfortunately, all too often caregivers feel less than supported by professionals. It should also be noted that the desire to be a caregiver and the ability to be a caregiver do not always coincide. Though formal long-term care services are commonly thought of as institutionally based, actually they are one among three categories of services provided: noninstitutional and nonhome community-based; home-based; and congregate, residential- and institutionalbased. These services take place through agesegregated programs for older persons (e.g., nursing homes, multipurpose senior settings, Meals on Wheels, and sheltered residential facilities), as well as through age-integrated programs (e.g., acute hospitals, community mental health centers, and outpatient health services). Both demonstrate the flexibility and resourcefulness of social workers as they respond to the needs of older persons. The following areas of service delivery are illustrative. Nursing homes have been the main type of long-term care facilities since the Medicare era (Zimmerman & Sloane, 2007). These settings provide skilled nursing care, supervision, assistance with activities of daily living, medication management, and rehabilitative services. Social workers provide a wide range of services aimed at helping residents with their life transitional concerns, with the interpersonal tensions that normatively arise within a congregate setting, and with environmental obstacles to a more satisfying life. Life stressors can be addressed through individual, family, and group services. Group services decrease isolation, foster a sense of belonging and well-being, and mitigate feelings of loneliness and helplessness by increasing experiences in which control over the environment can be exercised (Berman-Rossi, 1990, 2005; Kelly & Berman-Rossi, 1999). Families also do well in groups, where the pain brought on by the crisis of institutionalizing a loved one can be shared with others experiencing similar feelings, and families can use each other’s

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strengths to assist in negotiating the nursing home environment (Berman-Rossi & Gitterman, 1999; Ebenstein, 2006). The acute care hospital is inextricably linked to the future lives of older persons in need of long-term care. Diagnostic related group (DRG) treatment and managed-care discharge policies frame the organizational context in which social workers practice. Poised at this critical decision-making juncture, social workers provide a major contribution to the lives of older persons by attending to the social, behavioral, and emotional concerns of patients and their families/caregivers (Gehlert & Browne, 2011). This may entail providing information about health conditions to the patient and family, planning discharge, finding and/or arranging community resources to support care and rehabilitation in the community, assisting with advance directive decision making, providing information to other medical staff members about the patient, and mediating between hospital staff and the family. In addition to their direct practice role, social workers sometimes assume leadership roles in multidisciplinary teams and other hospital committees. Without the buffering efforts of hospital social workers, it is likely that an even greater number of older persons would require institutionalization. The services of social workers are also imperative for older persons experiencing long stays in an acute care hospital as they wait for long-term care community facilities. Rehabilitation programs, whether attached to nursing homes or acute care hospitals, provide short-term rehabilitation care (Zimmerman & Sloane, 2007). These programs are designed to enable older persons to cope with specific medical traumas so that they have the option of returning to the community. The social worker provides service links during hospitalization and upon release, and helps older persons and their families cope with the current medical trauma. Most important, the social worker holds, for all to see, a vision of the possibility of the older person’s returning to the community.

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Though there is often a fine line between personal care and nursing care, residential-care home or assisted living facilities do not provide skilled nursing care. They do, however, provide a range of other supports from room, board, supervision, and assistance with activities of daily living, and medication management. These facilities may provide individual apartments for residents, single rooms, or shared accommodations. The social worker, who often administers the program, provides help with all problems experienced by the participants: familial and interpersonal concerns, financial matters, health worries, negotiation of the service environment, loss, and change. Group meetings for members provide a supportive medium in which members help one another with similar troubles. Adult day care centers provide an alternative to institutionalization for many vulnerable older people. They are typically group-based services providing a planned program of activity during the day. Designed to serve those who wish to remain independent, adult day care tends to serve those older persons who often fall outside the “safety net” of other programs. The social work, rehabilitation, recreational, transportation, nursing, and medical services combine to provide a comprehensive program that eliminates the splintering of services found elsewhere. As the older person improves and is meaningfully engaged during the day, families often feel less need of institutionalization. Toward that end, group services provide a means for preserving human connection and increasing a sense of well-being and independence (Kelly 2005, 1999; Sakadakis & MacLean, 1993; Wescott, 2011). Home care refers to a range of health and social care services delivered at the home of those receiving services. For example, this may include nursing care, rehabilitation services from occupational or physical therapists, personal care, friendly visiting, or housekeeping. Social workers have a coordination role in home health care as well as supporting the older

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person’s adjustment to needing the plethora of “strangers” in his or her life. They also have a key role in supporting the caregiver or family involved with the older person (Gehlert & Browne, 2011). Were it not for home care services, remaining at home in the community would not be possible for many older persons. In 2008, nearly 12 million people in America received home care services (National Association for Home Care and Hospice, 2010). Administered by the forprofit, not-for-profit, and public sectors, these services are provided through home care agencies, community agencies serving the aged, or institutions with community-based home care services. In 2008, 33,000 home care agencies were identified in the United States, up from 15,027 in 1994 (National Association for Home Care and Hospice, 2010; Kaye, 1995). Medicare, Medicaid, and local governments paid for 80 percent of the home health delivered, with Medicare paying the largest share (41 percent). Given the short-term and medical treatment emphasis of Medicare, those who need nonmedical home care services are forced to pay or go without. Once again, class is a critical factor in the receipt of services. The lack of a wellintegrated system for the provision of home health care services creates significant problems for providers and significant hardship for receivers of service—thereby increasing risk for institutionalization. assessment and interventions Hundreds of instruments have been developed for “assessing the older persons” in need of long-term care services (e.g., Kane & Kane, 2000). These instruments include singledimensional tools measuring physical, mental, and social functioning, as well as multidimensional measures inquiring into more than one performance area. Assessment of need centers on the functional limitations of the older persons and their resulting dependence. These instruments quantify attributes located within the individual and believed stable enough to

measure. In the main, they represent a snapshot of the older persons, extracted from a field of interacting forces. Kane and Kane (2000) suggest that assessment and these instruments can be used to diagnose, evaluate care, or determine eligibility for services. Such linear approaches use a medical model of study, diagnosis, and treatment. Of course, how the tools are actually used in practice with older persons is the critical question for practitioners. This is where the payoff lies. Unfortunately, the measurements themselves are often the ends of their own utilization. In social work, assessment and practice with older persons are better served by a tradition in which the process of “knowing” and moving from “knowing to doing” is a complex, sometimes puzzling, often difficult, nonlinear enterprise. Knowledge does not carry its own prescriptions for action (Millikan, 1959; Schwartz, 1962). The properties of individuals, families, groups, and communities are not rigid and fixed but adapt and vary in interaction with the environment through a process of reciprocal adaptation (Gitterman & Germain, 2008). While certain functional measures can be achieved, the totality of an older person’s life and its potentiality in a responsive environment do not hold still for easy measurement. It is this potentiality that social workers must understand as they work with older persons. Better suited to our work are the Interactionist Model (Schwartz, 1994) and Life Model (Gitterman & Germain, 2008). These models suggest that the character of an entity is created by the interaction of its parts. To understand individuals, families, groups, and communities, we must understand them in interaction with their environment. The ecological concept of person:environment fit is particularly useful in understanding older persons and their ever-changing needs (Gitterman & Germain, 2008; Gitterman, 1996). Gitterman’s (2001) distinction between life conditions, life events, and life circumstances fosters clarity in assessment. Identifying these

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stressors provides a possible entry point for beginning work with clients (Gitterman & Germain, 2008). The first, life conditions, includes those conditions commonly attributed to the person, for example, aphasia as a result of a stroke, a disease such as Alzheimer’s, or loss of mobility because of arthritis. In these instances, individual attributes are relatively fixed and “knowable” and are viewed as independent of the external environment. The second, life events, can include events occurring to an individual, for example, a stroke, a broken hip, or loss of a spouse or partner, and can also include situations commonly defined as originating in the larger environment, for example, poverty, the loss of an apartment with gentrification, or the discontinuation of income benefits as a result of changed eligibility requirements. In these instances, environmental factors are viewed as measurable and independent of the individual. Understanding the third source of disequilibrium, life circumstances, poses the greatest challenge to the social worker. This source includes those events, situations, or circumstances where a clear separation between person and environment is difficult to establish. An example would be a decline in cognitive functioning precipitated by depression associated with social isolation and fewer orientation cues, or a weight loss instigated by ill-fitting dentures associated with poor health care benefits, or low benefit utilization associated with cognitive and physical loss. What is distinctive about this third arena is that clients’ situations and their experiences with them are not “knowable” by measuring the person and the environment separately. Rather, they can only be understood through comprehension of the reciprocal interaction between the person and the environment. The flow of energy and experience between the older person and his or her environment actually creates the phenomenon itself. It is the degree of congruity between the needs and capacities of the individual and the demands and resources of the environment that ultimately determines the nature of

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the consequences for the individual. To be of help, we must understand both the degree of congruity and the person:environment reciprocal transactions so that this understanding informs our helping strategies. Achieving such an understanding is difficult and challenging for social workers practicing with the older persons in long-term care. Complexity is a distinguishing feature of such an effort. The effects of quickly changing physical, social, economic, psychological, cognitive, and organizational forces make achieving an assessment of any particular phenomenon, no less an entire situation imbedded in a life, difficult and subject to change. Adopting the view that assessment is an ongoing, continuous process will strengthen practice with older persons. Assessment does not stand apart from practice with older persons. From the initial moment of contact between worker and client, the helping process itself is invoked. Practice with older persons begins with worker and client(s) searching for a shared definition of need. Whether the “units of direction” are large or small, whether they entail where to live, what to wear, or what to eat, the older person must be placed, once again, in the director’s chair. Ownership of the problem generates and releases energy for the tasks at hand. Agreement on what the problem is also provides the driving force and guiding spirit in determining what data must be collected in assessment. The fullness of older persons’ lives does not permit the gathering of a lifetime of information, yet the complexity of defining problems requires a breadth of knowledge. Purposefulness strengthens physical and psychological energy, particularly when that energy is limited. Finally, it is more possible to live in the here and now when the present, at least some of the time, is subject to one’s own influence. From the beginning of the working relationship, the worker fosters autonomy by providing information and helping clients to make their own decisions. These ideas about the relation between assessment and practice are particularly fitting

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for older persons in need of long-term care. Severely disenfranchised by our political, economic, and social system; severely discriminated against as a result of ageism, racism, classism, and homophobia; and coping with a wide range of disheartening life conditions and circumstances, many older persons do not enter helping relationships imbued with their own power (Bhatti-Sinclair, 2011). This is particularly true for older minority clients. A practice strategy that maximizes strengths, provides for choice, and encourages self-direction is the preferred strategy—even when the client seems to have “accepted” a high degree of dependence on others. Not to encourage self-direction is to deny the older person the right and opportunity to exert influence. The following older person:environment fit assessment tool is proposed to practitioners. It allows salient data to be organized in keeping with the concepts of balance between older persons and their environment and incorporates the distinction between informal and formal social supports. It incorporates risk, vulnerability, protective factors and processes, and resiliency. Such a tool can be used by workers alone, or with clients. It is they who can find the pathway to their own resiliency. Using these concepts is much more challenging than thinking linearly and categorically, for example, directly linking risk and outcome. But the knowledge that few risk outcomes are preordained should be encouraging to social workers. Resiliency theory’s hopefulness emerges, not from a denial of risk or vulnerability, but from a recognition that protective factors and processes can protect against risks inherent in the aging experience. Centered in the client’s initial concerns, this tool helps the worker to generate salient background information and information on significant life conditions, circumstances, and events. The initial formulation of need provides the beginning impetus and direction for the assessment. As the problem shifts, changes, or is expanded upon, and other facets of the work become revealed, worker and client can

then search for other relevant information and protective processes. When used at different points in time, the tool can identify the changing person:environment fit and inform changes to helping strategies. Gitterman and Germain’s (2008) Life Model informs this assessment tool. 1. Definition of the problem. What is it? When and under what circumstances did it develop? How has the client dealt with it? How much stress has been generated by it? What inferences can be made about the problem and the client’s way of coping with it? 2. Client’s expectations of agency and worker. Under what circumstances did the client’s need come to the attention of the agency? What is the client’s degree of choice? What are the client’s expectations of the agency and the worker? What kinds of experiences has the client previously had with social workers or organizational helpers? What inferences can be made about the client’s expectations of the agency, the worker, and the helping situation? 3. Knowledge about the client’s life condition, life event, or life circumstance. What is generally known about the condition, event, or circumstance with which the client is struggling? What are the predominant associated risks and vulnerabilities that predispose and increase the probability of the problem’s perpetuation? What are the predominant associated protective factors, forces, and mechanisms that mitigate probable negative outcomes and increase resilience on the part of persons experiencing this life condition, event, or circumstance? 4. Client’s strengths and limitations. What are the client’s strengths and limitations in dealing with the problem? How able is the client to negotiate organizational systems? What inferences can be made about the client’s strengths and limitations in dealing with her or his problem(s) in the past and currently? 5. Environmental supports and obstacles. What is the client’s physical environment, including

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the home, neighborhood, and organizational environment? What social supports are available, including informal and formal supports? What inferences can be made about the client’s environmental supports and obstacles and their relevance to problem resolution or problem persistence? 6. Degree of congruity between personal and environmental resources. What personal and environmental factors promote perpetuation of the problem? What personal and environmental factors promote problem resolution? What is needed to establish a better person:environment fit? 7. Practice direction. What additional data would be helpful? What will be your approach to the problem? What will you do to help? How will you and the client work together? The assessment process embodied within the tool is built upon strategies of partnership, mutuality, and encouraging a strong voice on the client’s part, coupled with an understanding of older persons in interaction with their environment. These strategies are all equally important during the ongoing phase of work. It is during this phase that the worker becomes most tempted to “do for” clients, rather than painstakingly involving clients in their own lives. While the temptation is understandable, doing so can only undermine clients’ growing sense of confidence in their ability to influence those around them. When they are encouraged to make their own choices and are “lent a vision” of their own possibilities, then the potential of the helping relationship is being fulfilled. This portends the clients’ potential in other relationships as well. Of course, at times social workers must assume a protective role in work with older persons (Horner & Kelly, 2007). The decision to act paternalistically must be carefully thought through (Kelly, 1994). Schwartz (1994) and Shulman’s (2009) discussions of skills are helpful in highlighting how social workers strengthen

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clients’ voices. Workers prepare to receive client communication by “tuning in” to the meaning of clients’ struggles and their ambivalence about expressing strong sentiment, especially toward those on whom they are dependent. Elaborating skills help older persons tell their story, moving from the general to the specific, containing the worker’s instinct to solve everything. Workers reach inside of silences and ask questions to learn more. Empathic skills encourage clients to attach affect to the work at hand by reaching for feelings, displaying understanding of clients’ feelings, and putting clients’ feelings into words. The same set of values and principles that guide our “doing with” clients should guide our “doing for.” These include the principle of the least restriction, a strategy of “partnership,” and honoring the client’s wishes, to the extent possible without endangering their well-being. Even persons with Alzheimer’s disease can communicate preferences, and we must learn to listen, hear and respond. Ensuring the place of all older persons in the helping process demands a great deal of the social worker. The press of myriad demands pushes us quickly on and urges us to avoid attention to detail, to process, to feeling, to the complexity of the person:environment, and to the strength of the relationship that can develop when we and older persons work closely together. However, such avoidance fosters unnecessary dependency, stifles autonomy, perpetuates the passivity associated with withdrawal and a failure to thrive, and ultimately becomes oppressive. illuStrAtion And diSCuSSion

The following practice example illustrates service to a group of older persons living within Metro Home and Hospital for Aged (MHHA), a not-for-profit, long-term care facility that has a 140-year history of serving older persons within the institution and within their homes. As funding priorities changed, and as ideas shifted toward serving older persons in less restrictive environments, MHHA developed an even wider range of noninstitutional home-based

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services. A broad range of programs and services, allowing older persons and their families a range of options, is one of MHHA’s distinguishing features. The Floor Group was designed to provide an ongoing opportunity for residents who lived on the same floor of MHHA to work together on shared matters of importance concerning the broad arena of their lives as older persons and the more specific domain of their lives as older persons within an institutional setting. All personal, interpersonal, and environmental issues were deemed to be important to the members. The group was conceived as a system of mutual aid wherein the worker’s attention was directed toward individual participants, toward strengthening the group as a whole, and toward developing a network of helping relationships (Schwartz, 1961). As an open-ended group that met weekly, the members, the worker, and the Floor Group as a whole would face certain challenges. These developmental challenges are normative for open-ended groups (Galinsky & Schopler 1985). The amount and frequency of member turnover are key elements affecting group development. Open-ended, institutionally based groups for older persons are especially challenging (Kelly & Berman-Rossi, 1999). In this Floor Group a central core of four residents consistently attended. It was they who carried forth the developing culture and work of the group. As time passed, they assumed greater leadership and brought new members on board. Members who attended came from a pool of 31 residents living together on the same floor. The average age of residents was 86 years, and 90 percent (n = 28) were female. Only 10 percent belonged to an ethnic minority group. The worker was a 27-year-old, white, Jewish female who was new to MHHA. At the time of this group practice example she had been at MHHA for about two months. The following practice example is fleshed out from the worker’s practice log. She kept this journal so that she could study her practice

with her supervisor and colleagues at MHHA. The worker writes: As a social worker for three floors, I was struck by the fact that the appearance of residents on one of my floors looked significantly more unkempt than the appearance of residents on my other floors. I noticed messy hair, lipstick applied in a crooked manner, ties on crooked, and a general lack of attention to physical appearance. As a new worker I thought the differences might be associated with the fact that these residents, who were sicker, might be less inclined and less able to “fix” themselves up. When I realized that healthier residents, who used wheelchairs for transportation, also had an unkempt appearance, I felt confused and was unsure of what to do with my impressions. Our first two-floor group meetings had been spent in getting acquainted. Though group members lived together, they felt they knew little about each other personally. Not only did they need to get to know me, they needed to learn more about each other as well. At our third group meeting eight residents were present. After greetings and the sharing of refreshments I asked group members how their week had been. Four residents spoke. The sentiment was the same: nothing special had occurred. They said life was pretty much the same; nothing changed. I said I had the sense that they felt pretty resigned in their lives at MHHA. Silence. I waited a bit and when no one responded, I said I noticed how quiet they were and wondered if they could share a little of what they were thinking. No one responded. I waited. Mrs. Bauer was the first to speak. Very slowly she said that her life was over and little mattered to her. I was surprised by her remarks. It was only our third meeting and we hardly knew each other. I had not expected such strong feelings to be expressed so early in the life of the group. I waited, to give others a chance. No one said anything. The silence was heavy again. Looking at Mrs. Bauer I said I thought she had shared some pretty strong feelings and I wondered if anyone else felt so resigned, as if their lives were over too and that little mattered to them.

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Hesitatingly, Mrs. Domingo said she felt the same way. Ever since her husband died and she had to come to MHHA, she didn’t care about much. She said she used to enjoy dressing up each day, but now there was no one to appreciate how she looked. Her children were far away, and people in her family were all old, too. Mrs. Schwartz said she felt the same way. Her appearance didn’t matter to anyone else and certainly didn’t matter to her. Mr. Smith, who had never spoken before, said that, anyway, even the Home didn’t care about them and didn’t think of them as people. Hearing his words, I felt very startled and disturbed. I felt so optimistic about my work and suddenly saw myself so out of tune with the residents. I couldn’t imagine that this was really how the Home felt. Mrs. Bauer said she thought they had done enough talking about depressing things and wanted to know what else I wanted to talk about today. I said I hoped maybe we could spend a few more minutes talking about what they had raised. Mrs. Bauer said if we did, she would leave. She didn’t want a group just to talk about upsetting things that would never change. The others who had spoken shook their heads in agreement. I said I was sorry. I didn’t mean to push them to talk if they didn’t want to, but I hoped the group could be a place where we could discuss things that were important to them. Mrs. Bauer said this wasn’t important. It was just how things were. She again asked what else I wanted to discuss with them. There was an air of expectancy. I said I thought we were just getting to know each other and I hoped we could continue that process and that we could think about what they might like to discuss in the group . . . any issues, topics, or matter of interest to them. Mrs. Bauer was called for a bath and suggested we discuss this next week. Others said they had enough as well and began to leave. I asked if they wouldn’t be willing to talk for just a few more minutes since I sensed that some of them were disturbed by our discussion. They said no and left. Only Mrs. Archer, who had slept through the meeting, was left. As I left the room I saw that residents were getting ready for lunch even though lunch was an hour away. I wanted to approach group members but didn’t know what to say. I left the floor feeling very bad, as if I had encouraged too much

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self-revelation too quickly in the life of the group. I feared that residents would not return and that they had been hurt by the experience. During the ensuing week I resolved to try and get a better feel for what the residents were saying by observing life on the floor. In addition, I decided to reach out to group members who had expressed such disturbing sentiments. I came on the floor very early the following morning to better understand how residents were assisted in getting ready for breakfast. As I came on the floor I noticed Mr. Smith sitting in his wheelchair, looking straight ahead into the hall, and putting on his tie. I was struck by how he did this without ever looking in a mirror. The result was a disheveled appearance. Next I came upon Mrs. Bauer who, also sitting in her doorway, was combing her hair. As I approached her, I instinctively took a mirror out of my purse and offered it to her. She looked up and said, “I used to be able to use one of those.” Naively I asked what she meant. Lifting her hands she said her arthritis was so bad she could no longer hold a mirror. I said I was sorry, I didn’t realize. A nursing assistant came and wheeled Mrs. Bauer to breakfast. My confidence as the floor social worker was plummeting quickly. It was then that I realized what should have been perfectly obvious from the start. What I had originally attributed to depression was really related to the fact that all residents could not negotiate small, handheld mirrors, and other residents who used wheelchairs could not see the mirror over the sink in the bathroom. A walk through the Home’s three buildings confirmed my hunch. There were no floorlength mirrors in the hallways of two of my three floors. Residents in the two other buildings had hall mirrors, and residents in this building did not. I felt embarrassed by my psychologizing of the issue. Though the problem clearly had a depressing effect on residents, the matter before us was undoubtedly environmental in origin. Certainly I couldn’t be the only one to think that full-length mirrors were in order. I spoke with a floor head nurse and a floor-nursing assistant with

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whom I had a good working relationship. The nursing assistant said she had difficulty encouraging residents to take an interest in how they looked and anything that helped with that would be great. In contrast, while the head nurse agreed that residents didn’t always look as well groomed as they might, she feared that they would be upset with what they saw and therefore it would be better to be without mirrors. Besides, the residents weren’t really pushing for this addition. Sensing a veiled criticism I said, “Are you thinking that this is really ‘my thing’?” She said, “I know you mean well but you are new here and young. Maybe you don’t quite understand what it is like to be old.” I said perhaps she was right. I knew I had a lot of learning to do and I hoped she could help me learn. Working with older persons was new to me. As she left to care for a resident she said, “Besides, the residents had their ‘time of attractiveness.’” She also said, “I’m sure you will figure this all out.” I must admit to being quite surprised. It never occurred to me that a staff professional would want to “protect” older persons from dealing with the visual impact of their physical changes. I had no doubt that my colleague had not “caused” the problem, but rather, she had a rationale as to why it would be better not to work for change. Once again, I felt at a loss about what to do. I thought it prudent to better understand the problem. The organization’s view was as yet unknown to me. What I perceived as a problem had gone on for a long while. I would have to learn why. I assumed that understanding the organization’s stake in the status quo would help me develop a strategy for change. I was strengthened by my belief that hallway mirrors would not be a startling addition and surely seemed to be in the residents’ self-interest. It was shortly after a team meeting that I learned what was probably the reason mirrors were not installed. The head nurse and nursing assistants were speaking about their frustration with not having bathrooms in each of the resident’s rooms. They said they knew the Home was applying to conduct a major renovation of the Tower Pavilion and that the construction would probably be completed within

two years. They added that they knew the Home didn’t want to make any changes now that might be undone by the new construction. While I was tempted to comment about the mirrors, I realized that raising the issue prematurely might risk a negative response that might be hard to undo. Determining how to proceed in the development of my strategy was not clear. Brager and Holloway (1978) recommend a “force field analysis,” which, like all assessments, considers the forces for and against change. Analyzing the strengths and limitations of the organizational environment would be an integral component of this organizational assessment. As a new staff member, I was unknown to most and my efforts alone would not bring about change. Even if they could have, I wasn’t sure that my timing was correct. I reasoned I had more to lose through my “rightness” if my team did not support the change than if the problem persisted for a while longer. It was more important to move with the team in relation to residents’ needs than to press for change only I valued. Importantly as well, I didn’t know how the group members felt about hall mirrors. While the Home did not need the residents’ permission to add mirrors, it seemed important to tap the members’ thinking. Including group members in the process could only serve to strengthen residents’ sense of their own potency. In addition, doing so would strengthen the group as a whole, thereby strengthening connections among members and between residents and the team. As I thought about my working relationships in the facility, I realized that my strongest relationships were with the nursing staff on my floors, the other team members, and my social work colleagues. If there were to be any change I would need to think in terms of an alliance of interests. And certainly, the head nurse and I were not necessarily on opposite sides. The head nurse was worried that residents would be too upset—too upset for their own good. While I did not have that concern, I could appreciate that she did. Several others thought it might be better to leave well enough alone. I would need to find ways to align with her caring and her interest

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in the residents as well as attend to her fear that the residents might become too upset. Engaging other team members seemed easier. I thought locating each discipline’s stake in the change would increase their support for the change. I knew the nursing assistants were supportive of the change. Involvement with grooming and appearance fell directly to them. Gaining support from physical and occupational therapy seemed possible, too. I could present hair brushing as an upper-body range-ofmotion exercise, in the same way wheeling oneself to the mirror would strengthen upper extremities. The doctors certainly were interested in their patients’ general well-being and knew there was an important connection between mind and body. Certainly, the psychiatrist in particular would support most things that countered alienation and depression. The recreational therapist, too, might be excited by either specific programs she could provide pertaining to appearance or just the additional ways in which residents might involve themselves in activities when they looked and felt better about themselves. I defined the steps in my strategy as follows: 1. Developing consciousness about the problem among residents and floor staff. 2. Developing a base of support within the floor group and among my team members. 3. Working on the change strategy with the head nurse, determining points of tension between us, as well as ways to lessen her worries and increase her support. 4. Talking with the social workers from the two other floors in the Tower Pavilion to determine their assessment of the problem, their view of the possibilities of change, and whether they would lend support to the effort toward gaining mirrors. 5. Garnering the enthusiasm of the director of social services so that she might support the effort with administration, with whom she had a close working relationship. I began by testing out my ideas with the head nurse. Our conversation meandered toward our earlier

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difference, and I said I was planning to bring my observations and ideas to the floor meeting next week and wondered what she thought about that. She said she guessed that was okay. I said, “You don’t sound so sure.” She replied, “Well, it’s just that because you think the mirrors are a good idea you might pressure the residents to think the same way and besides, the residents aren’t used to being asked about what they think about floor matters.” I said I could see she really had a lot of questions about my group work on the floor. What would she think of our meeting some time so that I could tell her more about the group service and what the Social Work Department was hoping to achieve? I said I had wanted to sit down with her but had only managed a brief conversation about the group because she was so busy and I was so new. I said, “It just occurred to me that perhaps you might like to join me for the portion of the group when I raise the matter of residents’ appearances and no hall mirrors.” She laughed and said, “Believe me, I have enough to do.” I persisted a bit saying, “that’s a real invitation.” She smiled and said no . . . it was ok, she wasn’t opposed and didn’t feel the need to be there. I smiled and said, “Okay, thanks. I’ll let you know how it goes.” At the next floor meeting Mrs. Bauer, Mrs. Domingo, Mrs. Archer, Mr. Smith, and eight additional residents were present. After refreshments were served, Mrs. Bauer asked what I wanted to discuss with them. After reaching for their agenda and finding them fixed on my raising matters, I said that I had some observations and an idea I wanted to share with them. I said that when I came on the floor I frequently noticed residents trying to groom themselves in the morning without having any mirrors to look in. I cited several examples and then noted that Mrs. Bauer had taught me that many of them found it too difficult to use a little mirror and so they did the best they could. I said I also knew many of them could not stand long enough to use the mirror over the sink in the hall bathroom. The room was quiet. No one said anything. Mrs. Bauer, who in only five meetings was emerging as a floor leader, said, “So?” I smiled and said, “Well . . . I was wondering whether you might like to have mirrors in

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the hallway so that you can see yourselves when you are getting ready in the morning.” Silence. I waited. More silence. I waited. Mrs. Domingo was the first to speak. She said, “A mirror is not important to me. I told you already, I don’t care about that stuff  .  .  . there’s no one to dress up for anymore.” Waiting thirty seconds felt like eternity. Just as I was about to speak, Mrs. Carver said, with a big smile, “You could get dressed for me! We could get dressed for each other.” Mrs. Carver pointed out that because they were roommates they were always helping each other. Mrs. Domingo looked at Mrs. Carver intently but said nothing. I said, “Mrs. Carver, I have the sense that you are saying that things are not the same as they used to be but life continues.” She said, “Right, honey, if we have to be here and have to look at each other, why shouldn’t we look as nice as we can?” Slowly other members began to discuss the idea of hall mirrors. Most denied their importance for them but were willing to support the idea if others wanted them. I shared with them the support of nursing staff and my intention of speaking with other team members. I also noted that I would like to bring to them, each week, how the matter was developing. Many acknowledged that they would like to hear. Mrs. Domingo was quiet throughout the meeting. Before summarizing the consensus of the group, I turned to Mrs. Domingo and said that I noticed how quiet she was. She was quiet and then began to cry. She said this conversation only helped her miss her husband more. Mrs. Carver took her hand and said, “I know, I miss my husband too and my daughter.” Others lent support. It was a tender, intimate moment in the group. We agreed I would bring feedback on the mirrors each week, and in response to my invitation a few said maybe in the future they might want to talk about missing people. People lingered together after the meeting. Once I felt secure with the support of my team, I planned to talk with the social workers on the other floors. I was mindful of the fact that neither of them had raised the issue for their residents. I wasn’t sure that moving beyond the bounds of my floor would be a wise thing to do. Once others became involved I would lose a measure of control, but I knew my

efforts could and should not be secret. Besides, a broader base of support might be useful, and I was self-conscious about raising an issue for change for only the residents on my floor. The social workers were enthusiastic. In the hustle and bustle of all their work, hallway mirrors felt like a low priority. They suggested that because I was new and not yet involved with all the problems they were charged to address, I still had time to devote to “extras.” We agreed that I would carry the major responsibility for engaging the change and theirs would be a supportive role. When I had spoken with enough people individually, and had a sense that most supported the change, I decided to bring the matter up in team. The head nurse seemed willing to go along since everyone else seemed to want them. The team, as a whole, seemed to enjoy the idea of working together on this project. Once raised, there was consensus that mirrors were important. Team members felt especially strongly that since there were mirrors in the newly remodeled buildings, their patients should not be discriminated against. All along I had been using a parallel strategy with staff and residents. As the issues were discussed in team, they were discussed in weekly floor group meetings. These meetings were new to residents and having “an issue” provided a kind of galvanizing force. Residents were becoming connected to each other through their collective interest in getting mirrors on the floor. Even the more hesitant residents seem to be captured by the energy on the floor. Eventually the team and residents decided to invite Administration to a team meeting and to a resident floor group meeting to discuss the problem and to present the request for mirrors in the hall. By this time, the heads of social work, nursing, physical therapy, occupational therapy, and recreational therapy all supported the change. The director of social work informally cued in the Home’s administrator, so she was prepared. As we planned, both meetings occurred in the same week for maximum effect and support to residents.

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The residents were eloquent in their presentation. In team, the head nurse took the lead. She began her presentation by appealing to the administrator’s sense of furthering the goals of the institution and her sense of fair play as other floors had mirrors. A few days after these meetings, the other floors made the same request. Shortly after, the mirrors were purchased and installed. There was a great deal of excitement on the floors the day the mirrors were installed. The team and residents shared a sense of pride in having been effective. Residents peeked out of their rooms as the workers hung the mirrors. When all was cleaned up there was a quiet on the unit. It was as if residents were privately deciding who would go first. Ms. James, the head nurse, was watching, too. Mrs. Bauer, who had emerged as a leader in the floor group, slowly wheeled herself to the mirror closest to the nursing station. Staff members “hung” in the background, knowing that residents should be allowed sufficient space to decide when, how, and if they approached the mirror. Mrs. Bauer finally arrived and sat in front of the mirror. She turned to staff and just looked at us without words. I quietly smiled in return. She continued to view herself, not moving at all. I had no idea of how long it had been since she had really seen herself. This was her moment. Residents and staff seemed to sense that and didn’t intrude. After a few more minutes Mrs. Bauer began to sob quietly. Ms. James immediately moved toward her. I suggested she wait a moment. Mrs. Bauer and the staff were only a few feet away from each other. She began to cry a little more. Ms. James and I walked over to her. Ms. James looked at me. I put my hand on Mrs. Bauer’s shoulder and smiled gently at her. She smiled and said, “It’s o.k. I’m all right. It’s been a while since I’ve taken a good hard look at myself and I suppose I wasn’t prepared.” Ms. James held her hand. I said it seemed that she was a little upset and I wondered what she was feeling as she looked at herself. She smiled again and said, “Well, I certainly have wrinkles, and I certainly am not a ‘young chippy,’” but laughing she added, “I’m o.k. This is who I am and it is nice to know.” I smiled and said, “Yes, I can imagine.” I moved

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away a little and by this time Ms. James and Mrs. Bauer were hugging each other. Many of us had watery eyes. As I looked up I noticed that residents had quietly wheeled themselves to where we were. Mrs. Bauer invited others to come up to the mirror. Residents and staff shared the experience. It was a moving time. The floor was never the same. The preceding example demonstrates many themes. These themes are about the salutary value of groups, the importance of professional skill, the symbiosis between private troubles and public issues, the power of the group to strengthen individual and collective resilience, the professional’s obligation for social change, and the possibility and process of social change. We see a social worker encouraging group members to engage with life, to risk the possibility of disappointment, and to risk expressing their voice after being quiet for so long. We hear a social worker fostering connections among members, asking them to taste remembered pleasures from when they had friends and were part of a hub of activity. We watch a social worker encouraging caring about each other and about themselves. The social worker has developed a slow, nurturing, partnership style with the group members. She understands well that loneliness and alienation prompt caution and uncertainty. More important than the mirrors was the worker’s relationship with the members and their relationships with each other. After all, they were now family and community to each other with the potential for affectional ties. Receiving the mirrors would be meaningless if in the process the members felt violated and oppressed. While the mirrors had intrinsic value, the risk of oppressing the residents far outweighed any good that might have come from adding an environmental resource. The worker also understood the group members’ underlying fear that their assertion would cause institutional retaliation. Her careful attention to the process and the pains she took to attend to the dialogues between the residents and all facets of the institution, for example, nursing staff and administration, served as a protective factor diminishing the risk. With the staff and institution, too, the worker was guided by the desire to establish a close working partnership centered on

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the Home’s relationship with the group members. Moving too quickly and risking alienating the team and administration would ultimately do a disservice to the floor residents. Jeopardizing her position within MHHA would not have served the residents well. Here too, the residents had more to gain from enhancing the tie between them and the institution. Securing the mirrors paled in comparison with diminishing this connection. The social worker’s belief in the possibility of change emerged from her belief in the symbiotic connection between the residents and the institution. She held to the idea that greater than the objective of the mirrors was strengthening the dialogue among the residents and their floor and institutional community. Her emphasis on the connection between clients and their environment reflected her definition of professional function between client and community.

conclusion The subject of this chapter has been serving older persons in need of long-term care. The demographics of aging provide a dramatic picture of the social, economic, and political context in which such older persons live. Social workers must heed this picture as they plan, organize, and deliver social services to a population made vulnerable by public policy insufficiently responsive to its needs. Of the older persons in need of long-term care, older women, particularly older minority women living alone, are especially disadvantaged by poverty. These older persons are most at risk of abuse and neglect, morbidity, institutionalization, and death. Older white men living alone are at risk for suicide. The notion that these persons are at risk because of personal attributes rather than society’s failure is an example of societal ageism, in which older persons are blamed for their problems in living. Viewing the individual as independent of the environment is consistent with the medicalizing of aging. The transformation of older persons’ needs into social problems pushes older

persons further to the margins of society and pits their interests against the interests of others. Frailty, as in the “frail elderly,” is socially defined and socially created. It comes about when we separate older persons from the environment and fail to provide the resources necessary for a satisfying life. The incongruity between older persons’ needs and capacities, on one hand, and society’s demands and resources, on the other, taxes diminishing and difficult-to-renew personal and environmental resources. Under such conditions, weakened voices are created. An unresponsive social context produces inadequate resources and fragmented services. It also produces isolating, age-segregated policies, the very situation long-term care services are designed to mitigate. The task for social workers is a difficult one. Though it is beyond our profession’s capacity to bring about the redistribution of economic resources, it is not beyond our ability to advocate for responsive public policy centered on an adequate economic standard. Similarly, though it may be beyond our capacity to integrate fragmented long-term care services, it is not unrealistic to undertake to plan integrative programs to serve the whole of our clients’ lives by connecting them to services that our own agencies cannot provide. Moreover, though we cannot ensure the responsiveness of others, we can bring the plight of the most vulnerable older persons to center stage in our own work and professional activities. Practice with older persons in need of longterm care requires a helping strategy directed toward assisting older persons in making the strongest claim possible on society, through the strengthening of their voices. Placing older persons at the head of this effort, to whatever extent possible, maximizes their strengths. At least within our relationships, self-determination and a better balance of power should prevail. Under these conditions of partnership, the resiliency of older persons is most likely to be realized.

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endnote

1. Professor Toby Berman-Rossi, a beloved and respected friend, died in 2004. Her graceful, courageous and resilient spirit lives on in many of our hearts. referenceS

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n the military, servicemembers face unique challenges and rewards in navigating predictable moves, separations, and reunions throughout their lives in the military.1 With the additional complexity and unpredictability of deployment, or multiple deployments and exposure to combat, new layers of stressors face these servicemembers and their families. As our troops are returning home from Afghanistan now and during this upcoming “draw-down” period between 2013 and 2014, clinical social workers need to be adequately prepared to support these servicemembers and their families as they renew their attachments with partners, their children, parents, other family members, friends, and colleagues. Although women are in the minority in terms of our military, they comprise more than 14 percent of the active-duty force (Department of Defense [DoD] 2012, 2007; Institute of Medicine [IOM] 2010). Servicemembers (both male and female) typically encounter exceptionally high level of workplace stress, yet women in the military address some unique stressors and traumatic events that affect their health and mental health. Even while drawing upon noteworthy resilience, many have a higher burden of medical illness, poorer quality-of-life outcomes, and earlier psychological morbidity than do men who are exposed to comparably intense traumatic events (IOM, 2010). Following homecoming, new family and work roles will be negotiated, especially if they are transitioning out of the military to veteran status, leaving behind an active social identity as a warfighter.

This comprehensive textbook aims to provide an overview of various social work practice approaches with vulnerable and resilient populations. Servicemembers (or warfighters, as many prefer to be called) typically do not view themselves as vulnerable or oppressed. In contrast, they, as members of our volunteer military corps, often embrace a strong sense of loyalty, pride, and dedication to serving the country while also demonstrating noteworthy resilience (MacDermid & Riggs, 2010). Vulnerable is not the adjective that leaps to mind as we hear about outstanding competencies, skillful performance, and a collegial esprit de corps. Even so, many servicemembers respond to the pressures of deployment to a war zone with consequent health, mental health, and psychosocial effects. In addition, there are subpopulations that face unique stressors. Women in the military constitute one of these important subgroups. Many have expressed the importance of attaining equality and receiving the same opportunities as their male counterparts. Although identifying gender differences involves a potential risk of stereotyping, ignoring the differences may lead to culture blindness. A balance is required between recognizing the commonalities for men and women in the military and highlighting some of the unique issues relevant especially for servicewomen and veterans. explaining and defining returning Servicewomen and Veterans What do issues of gender have to do with women’s experiences in the military? 441

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Often, the role of gender, in the masculinized culture of the military, remains invisible during the psychosocial transitions facing servicemembers and their families during and following deployment. First, in order to practice effectively with servicemembers, veterans, and their families, values, customs, mores, procedures, and hierarchy of the military must be understood. A focus on responsibility, duty, courage, self-sacrifice, loyalty, and an “esprit de corps” guide the day-to-day lives of our troops. Any Military Occupational Specialty (MOS) involves more than a set of tasks—it also involves committing to rules and order while assuming responsibility for the safety and wellbeing of others as well. As the military privileges the universality of such values, a purposeful focus on “oneness” fosters a world view of homogeneity— the antithesis of heterogeneity, or diversity (Basham, 2012a). As servicemembers bond with each other and stress their common goals, they experience a sense of sustaining and comforting brotherhood and sisterhood, and for many, patriotic allegiance. This unit cohesion also has a strong positive effect on one’s effectiveness in theater. During a mission, this is not the time to amplify differences, when mutual support and commonalities of objectives are essential to safety and efficacy. Although this perspective remains coherent during operations, does the “sameness” persist at the end of the day when servicemembers share meals and return to their sleeping quarters? Is there flexibility to recognize individual differences based on gender, between men and women? Thinking of gender beyond a binary view seldom occurs. For example, although transgendered individuals may well be serving in the military, little discussion focuses on their experiences. Given the scope of this chapter, the visibility or invisibility of this binary notion of gender will be addressed, while also recognizing the limitations of a narrowed perspective. During and following deployment, is the uniqueness of each individual servicemember

minimized or overlooked when viewing the world with a universalistic perspective? Is there room to embrace military values during a mission while also embracing a space that involves sound timing, thoughtful pacing, and validating of expressed feelings during periods of duress? Does gender dictate one stereotypical masculinized way to contend with distress and intense emotions? Another question arises. Why should it matter then that there are differences as well as commonalities in relation to gender, among other factors, not only during deployment but especially upon homecoming? A social worker, Simpson (2011) noted in a paper on the phenomenology of “othering” that the “imperialism of sameness” that may be adaptive during active military operations yet might prevent us from responding to the unique biopsychosocial-spiritual needs of our servicewomen and veteran clients. Gender shapes worldviews, contributes to stereotypes, and affects engagement with and responsiveness to behavioral and mental health interventions. In fact, gender plays a central role, albeit implicit, in shaping different responses to combat and deployment stressors and in seeking help for physical and mental health problems. Gender also influences a servicewoman’s receptivity toward current best practice models that are grounded in a strong evidence base as well as those developing practice models with emerging evidence of efficacy (e.g., family therapy and complementary/alternative healing methods). Finally, servicewomen may experience unique barriers to accessing useful social work services (Silva, 2008). For example, imagine how a female soldier who has suffered military sexual assault might feel as she approaches a waiting room filled with male soldiers and identified with a large bold sign noting “BEHAVIORAL HEALTH/SEXUAL ASSAULT SERVICES.” Instead, gender-specific services for women who have survived military sexual trauma may be situated in a clinic setting staffed exclusively by women and identified as

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“HEALTH SERVICES.” Procedures might also be initiated to ensure that the victim is separated from the offender in terms of residence and unit assignment. Deployment to a war zone involves inevitable destruction, fighting, and witnessing horrors frequently contrasted by a strong sense of camaraderie and reconstruction. Servicemembers often respond to combat with normal responses to abnormal events. Even when some servicemembers and their families rely upon noteworthy resilience, others face many transitions with greater difficulty. The Operation Iraqi Freedom (OIF), Operation Enduring Freedom (OEF), and Operation New Dawn (OND) troops are presenting with a constellation of what is referred to as the signature injuries of these conflicts. Or, some officers and enlisted soldiers reported, these recent wartime conflict zones feature signature weapons (i.e., improvised explosive devices, or IEDs) that directly cause traumatic brain injury, hearing loss, and mental health injuries. Each war produces a different set of signature injuries, in this case clearly associated with a distinctive weapon that inflicts specific damage. With our current troops, research data support a high incidence of co-occurring conditions including posttraumatic stress or post traumatic stress disorder (PTSD), depression and suicidal thinking, traumatic brain injury (TBI), substance abuse (SU), and intimate partner violence (IPV) (Basham, 2012b; IOM, 2012, 2010; MHAT, 2011; Tanielian & Jaycox, 2008; Weinick et al., 2011). demographic Patterns Since women represent a minority cohort in the Armed Forces, this discussion begins with a review of demographics in relation to women in the military. Women now comprise over 14 percent of the active-duty force, with 17 percent in the National Guard/Reserve and 20 percent new recruits (Basham, 2012a; DoD, 2012, 2007; Pew Research Center, 2011). This percentage needs to be understood in the context of more than 2 million servicemembers who have been

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deployed to either Afghanistan or Iraq during the past decade of military operations in these areas (DoD, 2012) with 1.4 million troops active duty (DoD, 2012; Pew, 2011). Of activeduty troops, 69.8 percent self-define as white (including Hispanic), while 16.9 percent are African American (also including Hispanic). Among officers, 77 percent are white, while 9.5 percent are African American. A recent demographic report of what the Air Force looked like in 2011 revealed a total number of 330,057 active-duty personnel (65,866 officers and 264,171 enlisted personnel). Average age of service members, both male and female, is 35 years old, and women represented 19 percent of the personnel, higher than in the other branches of the military. Approximately fifty-nine percent of the male and female service members are married, while demographics of race and ethnicity parallel the general statistics for Armed Forces (14.5 percent African American, 2 percent Asian, 7 percent Native American, 1.06 percent Pacific Islander, and 5 percent Latino) (DoD, 2011). While women are now allowed to serve in a wider range of military occupations than in the past, they are often negatively affected by stereotypes that affect job performance and career paths. For example, Weiss and de Braber (2012) discuss the notion that female leadership is often associated with emotion-based characteristics, a bias that may limit a servicewoman’s access to higher ranks. Although women were admitted to military academies in the 1970s, more than thirty years passed before a woman was promoted to four-star general. In a recent DoD report, only 3 percent of female military officers were high ranking (e.g., including brigadier general, rear admiral, or higher). The glass ceiling effect is palpable in the military when servicewomen are often evaluated based on their ascribed stereotypical traits (e.g., sympathy, kindness, and nurturance). Other servicemembers may feel that women still threaten an established male culture. Even though servicewomen may struggle to excel and advance in

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the military, the military culture can also be empowering for servicewomen in promoting physical and mental strength, leadership, and tough goal-oriented problem solving. Twenty-three million veterans live in the United States, yet only 8 million currently receive services through the Veterans Administration Health Care System. U.S. women veterans reached the 1.8 million mark, translating into 7.7 percent of the veteran population. Younger, on average, compared with male veterans (48 vs. 61 years), women veterans are less likely to seek health care at the Veterans Administration Medical Center (VA) settings as compared with male veterans (15 percent vs. 22 percent in 2007) (Weiss and de Braber, 2012). A daunting percentage (46 percent) of veterans have not sought VA services at all. However, the percentage of veterans who are women is expected to increase steadily; women are projected to make up 10 percent of the veteran population by 2018 and 13.3 percent by 2033 (Yano et al., 2010). Most of our female veterans today obtain all or most of their medical care outside the VA (IOM, 2010; Murdoch et al., 2006). Societal context Barriers to accessing VA services include lack of information about eligibility, benefits, and available women’s health care services (Basham, 2012b; Hoge, Auchterlonie, & Milliken, 2006; Washington, Kleimann, Michelini, & Canning, 2007; Yano et al., 2010). Those women veterans who typically use services at the Veterans Administration Medical Centers or the VET Centers have low income, no medical insurance, major health problems, minimal social supports, and a disability connected to their military service. Their mental health issues and chronic diseases are similar to those presented by male clients including PTSD, hypertension, depression, and chronic low back pain (Basham, 2012; IOM, 2010b). Although before January 2013 when the ban on women service combat was lifted women were technically barred from serving in combat

specialties, such as armor or infantry, a growing and unprecedented number of female soldiers are deployed to combat areas where their lives are at risk. This is a relatively new phenomenon (IOM, 2010; Hoge, Clark, & Castro, 2007). They serve in a range of support positions (such as piloting aircraft, intelligence, mental and behavioral health, transportation, emergency medical care, and mechanics) that involve traveling outside military bases, coming under direct fire, and working alongside combat soldiers. In the compelling biographical text titled Band of Sisters, Lieutenant Mathwirk of the 9th Communications Battalion Motor Transport wrote in an e-mail from Iraq: “I am proud to run convoys through some of the most dangerous roads in Iraq and so are the rest of my female counterparts. Women in the military are in combat operations. We get blown up and shot at just like the guys . . . the insurgents and terrorists do not differentiate. Stop pretending that we are not out there risking and sacrificing our lives like our male counterparts” (Holmstedt, 2007, p. 313). Vulnerabilities and risk factors The rates of pre-military trauma (i.e., childhood sexual, physical, and emotional abuse) for both men and women are higher than in the general population (Basham, 2012b; IOM, 2010). Yet, women veterans are more likely than male veterans to have experienced interpersonal trauma prior to military service (Smith et al., 2008). Caulfield et al. (2005) note that 38 percent of Marine Corps servicewomen and 27 percent of servicemen reported childhood physical or sexual abuse. Along similar lines, Rosen and Martin (1996) noted that 35 percent of active-duty male and female Army soldiers and 58 percent of active-duty female soldiers reported childhood abuses. Additional research findings support high rates of preexisting childhood trauma. For example, Merrill et al. (1999) reported that 57 percent of a sample of 1,093 Navy recruits had been abused; of those, 18 percent experienced physical abuse,

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17 percent experienced sexual abuse, and 22 percent experienced both physical and sexual abuse. In general, women are more likely to have experienced complex trauma. Although preexisting childhood trauma is considered a risk factor for vulnerability to mental health problems, a study conducted by Yehuda et al. (2006) revealed that those servicemembers who had successfully resolved trauma-related symptoms, including attachment and relationship issues, related to their childhood experiences navigated better in combat situations without suffering negative mental health outcomes. Although earlier research data supported the notion of universality in relation to gendered responses to stress, including traumatic stress, Taylor (2006) conducted a study to explore physiological responses to stress. They discovered that part of the stress response for women involves the release of oxytocin, a hormone that induces desires for connection, calm, tenderness, and prosocial behavior. This process correlates with bonding, an enhanced sense of trust, and reduction in fear and anxiety. As a neuromodulator that affects brain function, oxytocin also reduces cortisol and is associated with increased estrogen. These data provide alternative explanations to the widely understood depiction of the “fight-flight-or-freeze” response as elaborated by many contemporary researchers in neurobiology (van der Kolk, 2003; Siegel, 2007; Schore, 2003). An alternative response based on these physiological changes might be to “tend and befriend” (Taylor, 2006). For example, while serving as a medic in Iraq, Sgt. Oliva, whose wartime experiences will be discussed later in the chapter, ran toward her injured colleague who was trapped in a burning vehicle that had been exploded by an improvised explosive device (IED). Even though her Military Occupational Specialty (MOS) as a medic directed her to help and rescue, not only did Sgt. Oliva try to contain the flames surrounding her friend, she also risked her life trying to extricate her friend from the rubble. Her efforts were

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unsuccessful. Yet, Sgt. Oliva did not fight, flee, or freeze; instead she ran toward the danger. Is this a “tend and befriend” or a “pause and collect” response to trauma? For many women who are reared to care for others, could it be possible that such early socialization in childhood reinforced this neurobiological response to the traumatic stress of combat? In other research data related to the role of ethnicity in response to stress, cultural mores that view the self as interconnected with family and community are introduced as different from an autonomous and individualistic self. The “we” self is distinguished from the “I” self (Mattei, 2011). Some individuals reared in collectivist “we-self ” cultures react to stress with “tend and befriend” or “pause and collect” patterns as a result. They are inclined to reach out to others to provide care and connection in times of duress. Disturbing rates of military related sexual harassment and assault are higher than in the general population (Kimerling et al., 2010; Martineau & Wiegard, 2005; Suris & Lind, 2008; Suris, Lind, Kashner, Borman, & Petty, 2004; Williams & Bernstein, 2011). Current data from the Department of Defense (2012) estimates that during the course of military service, female servicemembers have a one in four chance of victimization by sexual assault. An earlier report revealed that 4.7 percent of rapes in the military result in pregnancy (Stewart & Trussell, 2000, p. 228). However, the Department of Defense (DoD) does not provide current data on how many assaults result in pregnancy for these female victims. Considerable attention has been focused recently on reports of military sexual assault within the Air Force. In 2012, Staff Sgt. Walker was sentenced to twenty years in prison for “rape and sexual assault” on Lackland Air Force Base in San Antonio, Texas (Weissert, 2012). This particular base has been the subject of scrutiny and investigation involving sexual misconduct perpetrated against thirty-one female trainees. Along similar lines, Gradus

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et al. (2008) revealed that 72.5 percent of women and 41.6 percent of men in their research samples experienced sexual harassment during service. A study of a nationally representative sample of women in an outpatient Veterans Administration Hospital setting discovered that 25 percent of women have suffered sexual assault (Hankin et al,. 1999), supporting earlier findings of 78 percent and 38 percent in women and men, respectively (IOM, 2010). Lower rates of assault are typically reported by active duty service members to the Department of Defense as compared with the higher rates reported in the Veterans Administration Medical Center programs utilized by service members who have left the military and transitioned into Veteran status. Many Veterans reported increased comfort and safety in reporting. Women’s exposure to sexual stress in the military has been determined to be much more prevalent than previously believed and is strongly associated with the development of PTSD (Gregg & Miah, 2011; IOM, 2012). Tragically, rape is not just a problem in combat but exists during peacetime in military academy settings as well. For example, a study of 658 U.S. Marine recruits revealed that “sexual harassment, performance stress, and unit cohesion mediated the relationship between egalitarianism and mental health symptomatology” (Weatherill et al., 2011, p. 348). Several controversial questions arise. Could these women recruits minimize their reporting of sexual harassment to ensure good evaluations of their performance in training? Are they concerned that reporting might affect promotion and/or have other negative consequences? Or, are they perceived as less of a “sexual object,” by fellow service members as they reported feeling more confident succeeding in a male-dominated environment? In contrast, a survey poll of military academies revealed that 50 percent of 1,906 female respondents and 11 percent of 3,107 male respondents indicated some type of sexual harassment during their tenure at school. In addition, 64 women reported rapes, 30 women

reported oral or anal sex against their will, and 55 men reported being victims of sexual assault (Sidoli, 2005). Military sexual assault presents some unique circumstances. The victim usually knows the perpetrator, often someone the victim depends upon. The risk often involves continuing exposure to the perpetrator and victimization. The same positive values promoted in the military of self-sufficiency, loyalty, and protection of the group can sometimes interfere with a victim’s capacities to report an assault. In general, rates of PTSD, depression, and substance abuse are higher for women who were assaulted as compared with those who were not assaulted (IOM, 2010). In the study by Himmelfarb, Yarger, and Mintz (2006) examining relationships between military sexual trauma and nonmilitary sexual trauma (before and after military service) and PTSD in female veterans, they discovered military sexual trauma was more strongly associated with PTSD as compared with pre-military trauma or post-military trauma (IOM, 2012; IOM, 2010). Wartime conditions impose unique challenges in relation to physical health and wellbeing for both male and female servicemembers. In particular, inadequate hygiene increases bladder infections. Many women servicemembers are unable to receive routine gynecological exams. They also frequently report a range of physical health problems (e.g., lower back pain, headaches, pelvic pain, gastrointestinal pain and symptoms, sexual dysfunction, gynecological symptoms, and chronic fatigue) (IOM, 2010; Tanielian & Jaycox, 2008). The majority of women servicemembers are childbearing age. Goyal (2005) conducted a study of servicewomen that revealed 20 percent reporting reduced use of contraception and unintended pregnancy. This finding contrasted with the general population rate of unintended pregnancies of 7.1 percent within a comparable age group. A more recent study conducted by Grindlay, Holt, and Grossman (2011) revealed that 63 percent of servicewomen used birth control, although many of

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them expressed difficultly accessing contraception during deployment overseas. Servicewomen reported concerns in another study that revealed restrictions on abortions at Department of Defense facilities, except in the case of rape or incest (Grindlay, Yarrow, Jelinska, Gouparts, & Grossman, 2011). When pregnancy is confirmed, a servicewoman is nondeployable; yet she may choose the option of completing active duty, which usually involves less physically demanding work (e.g., office work.) Since she may have withdrawn from a unit that involved specialized training (e.g., marksmanship, field exercises, and aircraft flying), other servicemembers may resent losing the extra support. In addition, they may need to fill in for this colleague while the pregnant servicemember’s MOS is adjusted to accommodate her health needs. After the birth of the baby, the new mother/ servicemember may also struggle to regain fitness and experience conflicts in fulfilling work roles within her unit. She is expected to pass physical fitness guidelines six months following childbirth—a daunting task for many new mothers of infants. The absence of consistent procedures to facilitate nursing also complicates early bonding between mothers and their infants. Beel and Ritchie (2003) assert that successful breast-feeding is preferable for infants over bottle feeding, yet a work environment needs to provide time and support. Disparities in rank affect lower-ranking enlisted mothers, who have less control over their work environments as compared with their higher-ranking female officers. In relation to mental health, women, in general, reveal higher rates of depression and anxiety, including PTSD, than men (Crowley, Bender, Chatigny, Trudel, & Ritchie, 2011; IOM, 2012; Tanielian and Jaycox, 2008). In fact, PTSD affects twice as many women as men. Female trauma survivors, compared with male trauma survivors, typically endorsed more self-blame for the event and expressed stronger beliefs that they are damaged, that they have suffered

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relational violations, and that the world is a dangerous place (Tolin & Foa, 2006). In a recent poll of 85 female veterans, 22 percent reported a PTSD diagnosis vs. 15 percent in 2009. Retired Colonel Ritchie notes that servicewomen are more likely to take psychotropic medications as prescribed (e.g., SSRIs for depression) and are less burdened by notions of stigma in reporting distress. As a result, it is unlikely that these troops have been overreporting mental health symptoms (Standifer, 2012). Studies of military populations posted at permanent bases are similar, yet current studies of the deployed military populations are inconsistent. There are significant gaps in the study of women and PTSD, yet as noted earlier, there seems to be a direct association with incidence of PTSD among deployed women and military sexual assault (IOM, 2010). Although there are new programs that specifically address military sexual assault, as well as research to explore effective methods of treatment for PTSD (IOM, 2012), attention is still needed to expand such services and to address co-occurring conditions of substance abuse, depression, traumatic brain injury, and intimate partner violence (IOM, 2012). For those servicemembers who suffer physical and or mental health injuries, caregivers in the family or the community often rally to provide support and care, often for indefinite periods of time, given the severity of the injury or disability. In spite of the daunting responsibilities involved in providing caregiving for an injured family member, many express fulfillment and satisfaction that counterbalance experiences of burden. Deployment affects marital stability of men and women soldiers differently (Sayers, Farrow, Ross, & Oslin, 2009). Angrist and Johnson (2000) found a statistically significant increase in divorce rates in women but not men. Military wives on bases receive more support from their communities than husbands do, since “military wife” has been a traditional role that has received important attention throughout the years. Military husbands fulfill a less typical

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role, often experiencing isolation and a dearth of supports and services (Basham, 2012a). In a similar vein, families of reservists and the National Guard typically access fewer behavioral and mental health services since they return to their hometown communities rather than to a military base or post that generally provides a full range of reintegration services. Consistent reports of high rates of intimate partner violence post-deployment are revealed in various research projects exploring the reintegration of returning OIF, OEF, and OND servicemembers and the veterans of these conflict zones (Fonagy, 1999; Jakupcak et al., 2007; Marshall, Panuzio, & Taft, 2005; Taft, Vogt, Marshall, Panuzio, & Niles, 2007; West & Tinney, 2011). For example, a comprehensive study dedicated to exploring the prevalence of intimate partner violence in a representative U.S. Air Force sample reported widespread prevalence of partner maltreatment compared with civilian samples. Lower rank was considered a risk factor for offending and victimization (Foran et al., 2011). Several explanations are offered to understand this heightened volatility. First, the hyperarousal cluster of a posttraumatic stress response, and a PTSD diagnosis, involves affect dysregulation, alternating numbness and hyperarousal, and intermittent rage outbursts. A physiologic traumatic stress response can be triggered by stimuli reminiscent of the original traumatic event, leading to a flashback. Second, when a servicemember is trained to protect and kill, when necessary, and operates on waves of peak adrenaline, it is impossible to automatically switch off the stress response needed to survive in combat. Yet, when these factors intersect, an incendiary climate activates. Fear, threats of abandonment, hurt, and anger erupt with intensity. In response to this threatening environment, family members are challenged to reach some equilibrium. Women in the military may experience unique stressors in relation to their multiple roles as servicemember, mother, spouse,

and caretaker of aging parents. To provide some context for this topic, 55 percent of the troops are married and 1.0 million have at least one parent who serves in the military (IOM, 2010). As of 2010, one million children have experienced the deployment of a parent, and 65 percent of servicemembers have the direct responsibility to care for children and/or or parents (IOM, 2010). A survey of actively deployed servicemembers noted that 50 percent believed that deployment negatively affected their partners and children (Patten & Parker, 2011; Sayers et al., 2009). Several substantive research projects confirm these findings, adding that children affected by parental deployment display heightened emotional and behavioral problems (Chandra et al., 2011; Chandra et al., 2010; Rentz et al., 2007). Several theorists suggest that secondary trauma functions as an emotional process whereby family members begin to experience symptoms of posttraumatic stress in the context of living with a servicemember who actively suffers with acute symptomatology (Bride & Figley, 2009). Although the focus in this section highlights gender as a central factor in shaping a servicewoman’s adaptation to all phases of the deployment cycle, the ways that she experiences her military identity influence her worldview and affect coping and adaptation as well. As servicemembers return home and anticipate separation from the military, they experience keen losses of the uniform, service to country, participation in a mission, and camaraderie. For those women who identify as lesbian or bisexual, most have been required to remain closeted about their sexual identity under the “Don’t Ask, Don’t Tell” policy (DADT) (Craig, 2007). In fact, the threat of discharge based on a general perception of differing from the normative gender or sexual orientation has been grounds for dismissal (Craig, 2007). Although women constitute a small percentage of the military, a disproportionate number of female servicemembers as compared with men were discharged under DADT (Glauser, 2011). Women

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who identify as lesbians also run the risk of victimization through bullying, antigay remarks, and threats of violence, as well as military sexual assault. With the repeal of DADT, one hopes that the climate of transparency will mitigate the pernicious effects of secrecy inflicted on these servicemembers throughout their service. Yet, for many, the damage has already been done with years of hiding and concealment necessary to protect one’s status and job in the military. As we consider the confluence of many sociocultural factors that shape intersecting social identities, it is important to be attuned to ways that ethnicity, religion, and socioeconomic status influence this complex process as well. For many, but not all, a military or veteran identity assumes a central position in this complex nexus. resiliencies and Protective factors The majority of servicewomen complete their military service without suffering negative mental health outcomes. Yet, even those women harness resilience to adapt to the many deployment- and combat-related stressors as they reintegrate back home with new family roles, changed relationships, growth spurts in their children, and many other adaptations. Identifying and accessing protective factors strengthens resilience. Resilience is usually characterized by the following features: (1) a capacity to experience and balance negative and positive emotions; (2) utilizing an adaptive task-oriented coping style; (3) flexibility in thinking and problem solving; (4) ability to make meaning or take a reflective stance; (5) maintaining fitness and safety (Meichenbaum 2011, p. 330). In a recent study conducted by the RAND Corporation, Meredith et al. (2011) published an extensive report focused on ways to facilitate the development of resilience in the U.S. military. Findings included the presence of intrinsic factors that promote resilience in an individual along with extrinsic factors that involve other individuals who are a part of one’s life and environment (e.g., family, organization, and community).

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First, in relation to individuals, the authors identified factors that promote resilience in the military, including positive coping, positive affect, positive thinking, reclaiming behavioral control, physical fitness, and altruism (Meredith et al., 2011). Second, at the level of the family, the following factors promote resilience: emotional ties, communication, support, closeness, nurturing, and adaptability. Third, the unit-level factors include positive command climate, teamwork, and cohesion. Finally, the community-level factors include a sense of belonging, cohesion, connectedness, and collective efficacy. In spite of these various challenges, the major sources of resilience throughout the deployment cycle include social supports and meaning making related to their deployment (IOM, 2010). Research supports the influences of cohesive unit support, sound military training, and solid leadership as major protective factors in preventing negative mental health outcomes as well (Baker et al., 2012; IOM, 2010; Tanielian and Jaycox, 2008). In addition, the ongoing constructive support from families, friends, and faith-based communities provide invaluable assistance. Although many men assume a caretaker role, more women than men still tend to be the primary caretakers of children and providers of housework. Deployment also involves separation from children and families for months at a time, requiring leaving children behind with spouses or alternative caregivers (Armstrong, Best, & Domenici, 2006; Matsakis, 2007). Knowing that her children are well cared for by nurturing alternative caregivers serves as a protective factor for deployed mothers in mediating adverse consequences of combat. Many single mothers experience more stress given the absence of additional supports during and following deployment. They may need to exercise even more creative planning efforts to ensure continuity and loving parenting for their children during deployment. Once again, the centrality of facilitative social supports emerges as a major protective factor.

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For those servicemembers who suffer physical and or mental health injuries, caregivers in the family or the community often rally to provide support and care for indefinite periods of time, based on the severity of the injury or disability. In spite of the daunting responsibilities involved in providing caregiving for an injured family member, many express fulfillment and satisfaction that counterbalance experiences of burden. In fact, servicewomen and female veterans often experience caregiver satisfaction as opposed to caregiver burden. Each branch of the Armed Forces has a separate version of resilience-building interventions for servicemembers, partners, and frequently for children and families as well. For example, The FOCUS project sponsored by the National Child Traumatic Stress Network along with UCLA is a public health model that relies on a prevention and collaboration intervention implemented at the project sites of the U.S. Marine Corps (Camp Lejeune, Camp Pendleton, MCB Hawaii, MCB Okinawa, and Twenty-Nine Palms); Naval Special WarfareCoronodo Island and Little Creek/Dam Neck and Navel Seebees in Gulfport and Naval Base Ventura (Saltzman et al., 2011). Components include: (1) trauma-informed developmentally appropriate education; (2) family resilience skills—goal setting, problem solving, and emotional regulation; (3) family deployment timeline—link skills to family experiences. create a family narrative, and manage combat/deployment reminders; (4) enhancing social support; and (5) dealing with new challenges. During the past several years, the DoD implemented a number of programs to build resilience in warfighters and their families. The Army’s Battlemind program was utilized for several years and steadily researched through the Walter Reed Army Medical Center to boost resilience in soldiers, their partners, and caregivers during the predeployment, deployment, and post deployment periods (Basham, 2012a; Tedeschi & Calhoun, 2004).

The program includes self-development training modules in four main areas: emotional, social, spiritual, and family well-being. More recently, the heightened concern about a high incidence of suicides in the military led to the development of a new Army program titled the Comprehensive Soldier Fitness (CSF) program, (U.S. Army, 2009). Goals of this program are to strengthen mental and physical fitness for soldiers and families (http://www .cnn.com/video#army-comprehensive-soldier-fitness.cnn) (Meichenbaum, 2011). The National Guard has also launched a program titled H-SLIDER to identify what aspects of military life can be transferred back to civilian life, (www.warfighterdiaries.com—interactive website; Meichenbaum, 2011). The acronym refers to the following character traits and combat-related mind-sets: H for honor, hard work, honesty, hardiness; S for soldier service, sacrifice, subordination to the group; L for loyalty, brotherhood, commitment to one’s unit; I for integrity, leadership, patriotism; D and E for dedication and discipline; and R for respect, readiness, responsibility, and resilience. In summary, the Department of Defense has prioritized the development of several different resilience-building programs that aim to promote strength, flexibility, and resilience for servicemembers and their families throughout repeated deployment cycles. They also support post-traumatic growth, a concept that refers to the positive psychological change experienced as a result of the struggle with highly challenging life circumstances” (Tedeschi & Calhoun, 2004, p. 1; Johnson, 2002). Programs and Social Work contributions Social workers play a central role in providing a full range of services available to servicewomen, veterans, and their families in a wide array of settings. For active duty and reservists, health and behavioral health services are often provided by clinical social workers in inpatient, outpatient, intensive outpatient, and residential settings (Basham, 2012b; Sneath & Rheem, 2010

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Wain & Gabriel, 2007; Weinick et al., 2011). Following the transition to veteran status, a plethora of services opens up for servicemembers who have separated from the military (Basham, 2012a; Tanielian & Jaycox, 2008). Social workers occupy the majority of the direct service positions in all Veterans Administration Medical Center settings, including behavioral and mental health, psychosocial rehabilitation, dual diagnosis, domiciliary services, and hospice. In addition, for those servicewomen and their families who seek help outside the system, TRICARE-approved clinical social workers in the private sector provide a wide range of services to servicemembers and their families. Since many servicewomen and veterans choose to pursue advanced education or reenter the job market following deployment, social workers at the bachelor’s and MSW level may assist with school-based and job counseling. Since women have become the fastest growing segment of potential clients at the Veterans Administration Medical Centers, research needs to attend to the needs of women as well as servicemen. As late as 2001, federal agencies started to require their funded researchers to include women in their research in sufficient numbers to enable valid analyses of differences in intervention effects, when relevant. Given the increasing and pressing needs from our troops, social workers in turn need to advance their knowledge, awareness, and clinical skills in providing quality mental health and psychosocial services to these women in the military. Gender plays an important role in understanding and coping with various stressors throughout the complex deployment cycle. In spite of constructive efforts by various commanding officers in all branches of the military to reduce stigma, persistent negative views and stereotypes about mental health and psychosocial services interfere with accessing and engaging with social work services (Basham, 2012a; Hoge et al., 2006; MHAT, 2011). Regrettably, stigma prevails and reinforces the shame and fear experienced by these female

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warfighters. As they recognize their needs, they also notice the pervasive negativity associated with seeking help. Vulnerability is often considered a sign of “weakness” and “failure to perform one’s duty.” Many women in the military express strong views that they do not want to be treated differently nor viewed differently by their superiors or colleagues, based on gender. This stance is both positive and admirable in terms of expecting social justice, yet represents an additional pressure to “work even harder and more fiercely” to maintain discipline and self-constraint. assessment and interventions As we consider the most effective ways to provide optimal social work services, several questions arise. First, how can social workers be most useful in facilitating ways for servicewomen to integrate into their families and communities following homecoming? Second, what values, knowledge, and clinical skills are central to our social work practice? Third, what are the central principles that guide our practices? In the past decade, I have systematically distilled central principles that undergird clinical social work practice and have arrived at a working mantra that guides my approach to the work (see Box 21.1). Optimally, social workers should provide “relationship-based, culturally responsive, theoretically grounded, and research informed” clinical social work practice (Basham, 2009, 2008). Social workers are obligated to abide by our Code of Ethics, which promotes the values of respect, self-determination, and a nonjudgmental, accepting stance. Valuing relationship is an important principle in providing high-quality social work services (Basham, 2012b). Most social workers recognize the importance of relationship in establishing a sufficiently trusting therapeutic alliance as well as serving as a source of social support in the lives of our clients. Traumatic events readily disrupt connections and attachments with significant family members and friends, setting the stage for disengagement and estrangement.

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box 21.1

I.

Phase-Oriented Therapy with Military Couples

SAFETY, SELF-CARE, STABILIZATION, AND ESTABLISHING A CONTEXT FOR CHANGE 1. Assessing and establishing safety 2. Strengthening self-care • Physical health • Mental health • Sleep, nutrition, and fitness • Substance use, abuse, medications • Communication skills • Biobehavioral strategies for stress reduction/affect regulation • Knowledge regarding deployment-related stressors 3. Exploring relevant sociocultural influences (e.g., military culture, gender, race, religion, ethnicity, sexual orientation, socioeconomic status, ability, age, and primary language) 4. Strengthen support systems (e.g., family, community, and religion/spirituality) 5. Determining partnership status (e.g., continuation? stasis? dissolution?)

II. REFLECTION ON TRAUMA NARRATIVES AND GRIEVING 1. Exploring and reflecting on the meaning of traumatic experiences 2. Grieving of multiple losses and bereavement 3. Exploring the intergenerational legacy of the “victim-victimizer-bystander” pattern 4. Developing shared empathy 5. Developing mentalization 6. Creating bereavement and healing rituals III. CONSOLIDATION OF NEW PERSPECTIVES, ATTITUDES, BEHAVIORS, AND SOCIAL VINDICATION 1. Remediating presenting concerns and symptoms 2. Re-establishing connections (e.g., family, faith-based community) 3. Enhancing sexual relationship 4. Strengthening co-parenting 5. Developing complex social identities (e.g., gender, military, ethnicity, etc.) 6. Developing opportunities for social vindication

In an effort to engage a returning female servicemember in a helping alliance, a reparative therapeutic relationship must be established as grounding for the difficult work of repairing disrupted connections with partners, children, and other family members. The “mantra” that guides the provision of high-quality clinical social work practice also relies heavily on a synthesis of social and psychological theory models. A broad range of theory models provides a clinician with conceptual scaffolding (e.g., attachment and family theories), while also drawing from select theory models that resonate with a client’s presenting issues. illuStrAtion And diSCuSSion

Sgt. Ana Oliva, a 35-year-old Mexican American Army reservist soldier with an AA degree, has served

in the military for the past thirteen years, including an eight-month tour of duty in Iraq. She has been married for fifteen successful years to her husband Paulo, a college-educated 37-year-old accountant, and she and her husband are delighted to be rearing two children, Jorge, age 14, and Sonja, age 5. Prior to deployment, the family was experiencing economic stability and satisfaction between the partners and among the parents and children. While deployed, Sgt. Oliva worked as a medic as her Military Occupational Specialty (MOS). She was exposed to many warfighters who suffered devastating physical and psychological injuries. On one occasion, Sgt. Oliva failed to “save” the life of a young 18-year-old private, killed in an IED blast, whom she had “taken under wing” (her perception) since the arrival of some additional troops assigned to her unit.

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Although she sustained pride in her accomplishments during the remainder of her tour, four months following homecoming she experienced acute distress. She could not sleep and suffered flashbacks, nightmares, and crying jags. Plagued with guilt and hopelessness, she felt that she “deserved to be dead.” Codeine and several glasses of wine emerged as her salve for severe headaches and distress. Fights ensued between Sgt. Oliva and her husband; their adolescent son, Jorge, started to skip classes and defy limit setting. Little Sonja refused to go to kindergarten and complained of headaches and stomachaches every day. Sgt. Oliva felt bereft and guilt ridden about witnessing the violent death of a fellow soldier and continuously worried about “feeling estranged” from her two children. In spite of the secure attachment that this couple experienced before deployment, instability, pervasive anxiety, and estrangement characterized family interactions for these many months. Relationships had been disrupted and attachments disturbed by the separation during pivotal developmental time periods for everyone combined with intense traumatic combat exposure for Sgt. Oliva while in theater. When her family practitioner suggested to Sgt. Oliva that she meet with a social worker for counseling, she was very wary of taking this step, worrying that any behavioral health treatment could affect her career negatively. Clearly, she needed to talk with a professional who could help her address the suffering and alienation that she was experiencing. Once a therapeutic alliance is crafted with a culturally attuned clinician, a clinical social worker proceeds to work within a multi-theoretical framework. At the phase of engagement, attachment theory helps to address the anxieties and fears expressed by the children as they adjust to a “changed, sometimes frightening” mother. In addition, the clinician invited Mr. Oliva to attend an assessment session as well to explore ways that this couple could deal with their reunion, shifting of family roles, and recognition that everyone had changed during the past eight months. Based on Sgt. Oliva’s presenting issues of concern,

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the clinician could also utilize psychodynamic and family theories to understand Sgt. Oliva’s unresolved grieving. Trauma theory provides understanding of her symptoms of posttraumatic stress, which may benefit from psychopharmacology, while cognitive behavioral theories may address the symptoms of depression with cognitive behavioral methods (CBT) and the posttraumatic stress symptoms with Cognitive Processing Therapy (CPT), two evidence-based models that reveal a high level of research rigor. What is the rationale for using the term culturally responsive rather than culturally competent, which is our clear mandate required by our professional practice guidelines (Basham 2012a, 2008)? Cultural responsiveness moves beyond and enhances definitions of cultural competence. It implies a dynamic interchange between the client and clinician to explore the meanings and meaning making that are attached to various sociocultural factors. Rather than assuming a static model of competence, a culturally responsive approach presumes that an individual defines herself with a complex intersection of meanings related to themes of gender, race, ethnicity, religion, sexual orientation, socioeconomic status, ability, and language of origin. During the establishing of a therapeutic alliance, a clinical social worker needs to demonstrate the knowledge, values, and skills defined as cultural competence and also explore a shared understanding of how cultural themes have shaped the client’s worldviews. Although the Department of Defense has adapted training and preparedness for troops with an inclusive stance toward women in the military, many servicemembers continue to report a “masculinized” culture that values individual self-sufficiency, physical and psychological strength and prowess, as well as emotional constraint. On the other hand, social workers must be reminded of the tendency to overgeneralize and perpetuate stereotypical assumptions about gender differences. The culture of the military, shared Mexican ethnic heritage, a Roman Catholic belief system, and bilingualism emerged as central influences in the lives of

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the Oliva nuclear and extended family. Reared in a patriarchal structure, Sgt. Oliva learned to embrace the primacy of caregiving for children and other family members, a value that transferred readily to her MOS in the military—helping and rescuing injured servicemembers. Her military identity is very positive, yet shaken by her “perceived error” in “losing the life of her young buddy.” Although Sgt. Oliva embraces her role as a mother, wife, daughter, and loyal family member, she is also very loyal to her unit and her fellow soldiers. These relationships must be honored and attended to, especially following the ruptures related to combat. If a social worker attended solely to symptoms of post-traumatic stress or posttraumatic stress disorder, she would be ignoring Sgt. Oliva as a total person, intricately involved with her immediate and extended family, her colleagues at her workplace—a local nursing home—and her fellow soldiers in her unit. Discussion of ways for her to reconnect with her buddies as well as her family and church members affirms the nurturing influences of these individuals, groups, and communities. Social workers should utilize best practices based on research-informed evidence that is preceded by a rigorous and thorough biopsychosocial-spiritual assessment that sets the stage for crafting a practice plan. In a phase-oriented model, issues of acuity, risk assessment, identification and building of resources, as well as liaison and collaboration with other professionals, must be attended to first, before shifting focus to reducing problematic symptoms. Although Sgt. Oliva presented to her clinical social worker with distinct symptoms of depression and PTSD, a complete biopsychosocial-spiritual assessment needed to be conducted initially to first rule out traumatic brain injury, substance use, other physical problems, potential suicidality, and psychosocial issues. Coordination with the various professions within her treatment plan expanded to include collaboration with a family therapist and the counselors at her children’s schools. EMDR,

a research-informed model, was utilized to reduce the intensity of Sgt. Oliva’s visual memories of the improvised explosive device (IED) that killed her colleague. Only after stability was established were Sgt. Oliva and her husband able to engage in couple therapy and more in-depth evidence-based treatment models for trauma-related symptoms. Many clinicians recognize the importance of a relationship-based treatment model, especially in light of the disruptions to attachment caused by exposure to traumatic stressors during deployment. Valuing the centrality of resilience, empowerment, and cultural responsiveness is vital for effective engagement. Most servicemembers and veterans express a wish for their treatment to be customized to them as individuals, rather than following prescribed, manualized protocols, exclusively. A one-size-fitsall treatment approach further alienates returning servicemembers, reinforces objectifying people, and perpetuates disengagement. In contrast, a flexible, multi-modality, integrative clinical social work approach draws upon a synthesis of social and psychological theory models and research data to guide the assessment and treatment course with a couple/family (Basham, 2008; Basham & Miehls, 2004; Clulow, 2001; Fredman, Monson, & Adair, 2001; van der Kolk, 2003; Siegel, 2007). This work can be very challenging considering the potential effects of secondary trauma and countertransference responses based on enactments of the “victim-victimizer-bystander” relationship template (Basham & Miehls, 2004; Staub, 1989). As a result, the social worker needs to avoid becoming an overly zealous rescuer or a detached bystander. Yielding either to a passive, futile victim stance or an aggressive and victimizing condemnation of clients remains an ongoing risk for the clinician as well. Phase I focuses on a biopsychosocial-spiritual assessment, safety, self-care, and stabilization (see Box 21.2). As couples enter therapy, each partner may approach the work with long-standing secure or insecure attachment patterns of relating. Combat

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Phase-Oriented Therapy with Military Couples

Biopsychosocial-Spiritual Assessment I.

INSTITUTIONAL/SOCIOCULTURAL (grounded in social constructionist, feminist, and critical race theories) 1. Clinicians’ attitudes and responses (e.g., countertransference and secondary trauma) 2. Social supports (e.g., family, community, faith-based organization, unit, command) 3. Military and VA context (e.g., branch, rank, status, era of service, and MOS) 4. Service delivery context (e.g., social policies, finances, and political context) 5. Previous and current health and mental treatment 6. Intersecting diversity factors (e.g., race, ethnicity, religion, socioeconomic status, ability, sexual orientation, and gender)

II. INTERACTIONAL (grounded in intergenerational and narrative family theories) 1. Relational dynamics (including “victim-victimizer-bystander” themes) 2. Power and control struggles 3. Distancing and distrust 4. Sexuality and physical touch 5. Boundaries 6. Communication 7. Dearth of rituals 8. Intergenerational patterns III. INDIVIDUAL/INTRAPERSONAL 1. Individual cognitive, affective, and behavioral functioning (grounded in trauma and cognitive behavioral theories) • Indicators of resilience • Complex PTSD symptomatology and FEARS (Goodwin 1990, 62) Fears (nightmares, flashbacks, intrusive thoughts) Ego fragmentation (dissociation, identity distortion) Affective changes (hyperarousal/numbness, compulsive/addictive/antisocial behaviors) Reenactment Suicidality/Somatization (insomnia, hypervigilance, startle response, bodily complaints) 2. Intrapersonal/intrapsychic (grounded in attachment, object relations, and contemporary relational theories) • Working models of attachment, affect regulation and capacity for mentalization • Capacity for whole? Part? Or merged object relations? • Role of projective identification • Internalized “victim-victimizer-bystander” dynamic Source: Adapted from Basham, K. K. & Miehls, D. (2004). Transforming the Legacy: Couple Therapy with Survivors of Childhood Trauma. New York: Columbia University Press.

exposure can often destabilize a servicemember’s working model of attachment and “circle of security,” so entry into therapy can be experienced as threatening (Basham, 2008). While conveying knowledge, cultural responsiveness, and benign authority, a delicate therapeutic alliance is forged. A major focus during this phase is affect regulation, often disrupted for one or both partners during a post-deployment transition. Cultural relativity must be considered here since different cultural worldviews shape responses to stress in many different ways. Finally, a thorough biopsychosocial-spiritual assessment is central to designing a multi-modality clinical social work practice plan.

Serving both as an anchor and compass for directing the couple/family intervention plan, the social workers needs to address various relevant themes. Similar to assessment models that focus on the client in social context, this approach reviews the client’s presenting issues through three domains: the institutional/sociocultural, the interpersonal, and the individual intrapersonal. In each of these domains, the clinician should assess both strengths and vulnerabilities and compose a complete summary at the end of the initial assessment process. In the institutional/sociocultural realm, the following six areas are explored: (1) social supports (e.g., family, community, faith-based organizations, unit

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command, workplace, friendships); (2) military or VA context (e.g., branch, rank, status, eras of service, and MOS); (3) service delivery context (e.g., social policies, finances, political contexts, barriers to care); (4) previous and current health and mental health treatment; (5) intersecting social identities (e.g., race, ethnicity, age, religion, sexual orientation, socioeconomic status, ability, and gender); and (6) clinician’s attitudes, responses, and worldviews (e.g., cultural countertransference and secondary trauma). In the interpersonal realm, the following seven areas are explored: (1) relational patterns (including the “victim-victimizer-bystander” scenario); (2) power and control conflicts; (3) distancing and intimacy; (4) sexuality and physical touch; (5) communication skills; (6) presence of absence of healing rituals; and (7) intergenerational relational patterns. Finally, in the individual/intrapersonal realm, the following four areas are considered: (1) physical health, including illnesses and physical and cognitive injuries (e.g., traumatic brain injury, burns, amputations, mental health issues including cooccurring conditions such as PTS or PTSD, panic disorder, depression, substance abuse, intimate partner violence); (2) internal working model of attachment and circle of security; (3) capacities for affect regulation an mentalization; (4) internalized relational templates. In conjunction with an in-depth face-to-face interview, a range of assessment tools can be used as well. For example, in order to assess PTSD, the following approaches are used regularly: structured clinical interview, Clinician-Administered PTSD Scale (CAPS), the Impact Event Scale (IES), the Mississippi scale for Combat-PTSD and the PTSD checklist (IOM, 2012). The frequently co-occurring conditions of depression, other anxiety disorders, and substance abuse are assessed by a combination of interview and structured assessment tools as well. Given the scope of this chapter, a fuller discussion of these other conditions will be addressed in other chapters of this text. Typically, the summary of the strengths and vulnerabilities in these three arenas— institutional, interactional and individual—sets

the stage for a cocreated treatment plan attuned to the client’s needs. In many practice settings, the indepth nature of such evaluations is undermined by productivity requirements that often interfere with providing adequate time for the task. Many social workers are unrealistically expected to arrive at a useful differential assessment within one fifty-minute meeting. The Oliva family continues to furnish us with a clinical example of this phase-oriented couple/family clinical social work practice model. They entered Phase I of this trauma-informed therapy with goals to engage in a thorough ongoing biopsychosocialspiritual assessment. A review of the assessment reveals a summary of strengths and vulnerabilities in the sociocultural, interpersonal, and individual arenas. Within the sociocultural/institutional realm, the Oliva family revealed distinct resilience (e.g., strong shared commitment to family, bilingualism, successful careers, stable finances, education, and earlier commitment to their faith-based community). Vulnerabilities included socioeconomic differences between the partners, conflicts with extended families and faith-based community, distance from her Army unit, and exposure to racial and cultural trauma. On an interpersonal level, the couple experienced strengths in problem solving and co-parenting along with vulnerabilities characterized by harsh verbal exchanges, distancing, poor communication, and disengaging from emotional and sexual intimacy. Finally, within the individual arena, Sgt. Oliva experienced a range of mental and physical health issues, including traumatic grief, symptoms of PTS/PTSD, depression, and TBI. Mr. Oliva suffered deep sadness about “losing his wife” to what he referred to the “ravages of war.” Individual strengths for each partner included strong commitments to caregiving of their children, and extended family members and stable values fortified their shared resilience. In this first phase of the couple/family therapy, stabilization of the crisis was needed along with setting goals to ensure safety; improve communication; and

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activate mental health, rehabilitation, and health referrals for Sgt. Oliva, her husband, and children, as indicated. Both children collaborated with school counselors to assist them with transitioning to reuniting with their mother and the family. Sgt. Oliva was also engaged with an OIF veterans support group and individual psychotherapy in addition to couple therapy with her husband. Safety, stabilization, and establishing a context for change are major features of this phase, which they accomplished within three months of weekly interventions benefiting from a full range of modalities. Once stable scaffolding has been reestablished, Phase II of the couple/family therapy model involves a cognitive reflection on ways to temper the legacies of trauma, including the “victim-victimizer-bystander” pattern in their day-to-day relationships with each other, their children, their friends, and other family members. Grieving major losses often occurs within this phase, along with narrating and reflection on trauma narratives. From an attachment theory perspective, Bowlby anticipated stages of grief, including intermittent protest, despair, detachment, and reorganization following a disrupted attachment (Bowlby, 1969/1982). Addressing attachment injuries facilitates the re-emergence of the “circle of security” (Basham, 2008; Bowlby, 1969/1982; Fisher & Crandell, 2001; Hazan, Gur-Yaish, & Campa, 2004; Marvin, Cooper, Hoffman, & Powell, 2002). For example, after completing Phase I tasks of phase-oriented treatment, Sgt. Oliva started a structured treatment protocol of Cognitive Processing Treatment, an evidence-based method that focuses on instilling hope and resources while also revisiting the significant traumatic events through narration in writing and verbal expression. The evidencebased practice model could only be effective within the context of this family’s overall adaptation to reintegration following homecoming. As Sgt. Oliva and her husband, Paulo Oliva, shared their experiences of loss and grief during and following deployment, each partner was able to listen attentively to and witness the profound grief expressed by the

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other. Enhanced empathy clearly strengthened their bond and promoted a deeper understanding of the complexity of their respective situations. Finally, Phase III of the couple/family therapy model involves tasks to focus on consolidating new perspectives, attitudes, and behaviors. In attachment theory language, this is the territory of “exploration.” As both partners experience greater empathy toward each other and increased capacities for mentalization, they report feeling more joy, a sense of connection, and enhanced sexual exchanges (Basham, 2008). Many partners use this opportunity to discuss their values and worldviews and reshape their multiple social identities (e.g., gender, race, and ethnicity). New ways to reconnect within the community are also discussed, and moves toward social vindication are explored. Returning to the Oliva family, Sgt. and Mr. Oliva during Phase III talked about ways to expand their relationship to renew friendships that had been lost during deployment and reconnect with their spiritual community. As the children experienced more stability and connection within the family, they were better able to expand their horizons as well. Although Sgt. Oliva originally had no interest in accepting a Purple Heart award for her bravery during combat, she changed her mind after reconnecting with her unit and talking extensively about their shared experiences. Gradually, she recognized the value of her overall efforts to provide medical crisis assistance in the midst of danger. When her entire family and unit attended this ceremonial event, she expressed deep gratitude for the validation shared among this admiring group of supporters. Toward the end of this therapy, which lasted a total of four months, both Sgt. Oliva and her husband, Mr. Oliva, decided to volunteer regularly with a local chapter of the National Military Families Association to assist returning servicemembers and their families. Each partner expressed deep gratitude for the service provided by these troops and their families, along with a profound sense of meaning attached to their shared public military service as military families.

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conclusion In summary, the influence of gender can be transparent or invisible depending on a range of factors. This chapter examined the ways that servicewomen and their families cope with the challenges of deployment and postdeployment. More specifically, the demographic and biopsychosocial-spiritual needs of women in the military have been addressed. Current research data provide documentation of the risk factors and vulnerabilities including (1) pre-military trauma; (2) responses to trauma; (3) military sexual harassment and assault; (4) health and mental health; (5) caregiver burden vs. caregiver satisfaction; (6) marriage/ partnerships and divorce; (7) intimate partner violence; and (8) complex social identities. Focusing on the centrality of resilience provides an analysis of the complex individual, family, and community factors that shape the building of resilience and posttraumatic growth for servicemembers and their families. Various prevention and resilience-building programs crafted by the Department of Defense are

introduced, followed by a general description of a plethora of social work interventions aimed to assist with the health, mental health, and psychosocial needs of servicewomen and their families. In order to attend to the nuanced complexity of these adjustments and transitions, a phase-oriented trauma-informed clinical social work practice model is introduced, illustrated with clinical vignettes. By recognizing the commonalties and uniqueness among servicemembers based on gender, we can only hope that both women and men serving in the military will benefit from a customized, thoughtful, collaborative approach to high-quality care. In addition to promoting enhanced health and mental health, attention to the needs for secure employment, education, and access to veterans’ benefits are vitally important to advance the well-being of this population. Moving beyond micro practice to a focus on the workplace, community, and health and mental health organizations, each clinical social worker needs to move from “case to cause” regularly in our work with our troops and their families.

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combat marines: Methods of the Marine resiliency study. Prevention of Chronic Disease, 9, E97. Basham, K. (2008). Homecoming as safe haven or the new front: Attachments and detachment in military couples. Clinical Social Work Journal, 36(1), 83–96. ——. (2009). Commentary on keynote lecture presented by Dr. Jonathan Shay 6/27/09. The trials of war: Odysseus returning from Afghanistan and reflections. Smith College Studies in Social Work, 3/4, 283–86. ——. (2012a). Couple therapy with post-deployed couples. In J. Coll, A. Rubin, & E. Weiss (Eds.), Handbook of military social workers. Hoboken, NJ: Wiley. ——. (2012b). Facilitators and barriers in effective clinical practice with redeployed military and veteran couples. Military Behavioral Health Journal, 1. Los Angeles: Center for Innovative Research with Military and Veteran families (in press). Basham, K., & Miehls, D. (2004). Transforming the legacy: Couple therapy with survivors of childhood trauma. New York: Columbia University Press. Walter Reed Army Institute of Research (WRAIR), (2008). Battlemind Training. http://www.battlemind .army.mil

1. The term servicemember refers to individuals who serve in a particular branch of the military (i.e., Army, Navy, Marines, Air Force, and Coast Guard) who are either active duty or members of the Reserves or National Guard. The terms soldiers, seamen, and airmen are used in popular discourse, yet currently, the frequently preferred terms for those persons who serve in the military include servicemembers (i.e., servicemen and servicewomen), troops, warfighters, or warriors. These terms are regularly used throughout the chapter. referenceS

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——. (2012). Assessment of Ongoing efforts in the treatment of PTSD. Washington DC: Institute of Medicine Press. Jakupcak, M., Coneybeare, D., Phelps, L., Hunt, S., Holmes, H. A., Felker, B., . . . McFall, M. E. (2007). Anger, hostility, and aggression among Iraq and Afghanistan war veterans reporting PTSD and subthreshold PTSD. Journal of Traumatic Stress, 20, 945–54. doi:10.1002/jts.20258 Johnson, S. M. (2002). Emotionally focused couple therapy with trauma survivors: strengthening attachment bonds. New York: Guilford. Kimerling, R., Street, A., Pavaro, J., Smith, M.  W., Cronkite, R.  C., Holmes, T.  H., & Frayne, S. M. (2010). Military-related sexual trauma among veteran health administration patients returning from Iraq and Afghanistan. American Journal of Public Health, 100(8), 1409–12. MacDermid, S. M., & Riggs, D. (Eds.). (2010). Risk and resilience in military families. New York: Springer. Marshall, A. D., Panuzio, J., & Taft, C. T. (2005). Intimate partner violence among military veterans and active duty servicemen. Clinical Psychology Review, 25, 862–76. Martineau, P., & Wiegard, C. (2005). Women at war: Sexual combat. Sacramento, CA: Sacramento Press. Marvin, R., Cooper, G., Hoffman, K., & Powell, B. (2002). The circle of security project: Attachmentbased intervention with care pre-school child dyads. Attachment & Human Development, 4, 107–24. Matsakis, A. (2007). Back from the front: Combat trauma, love and the family. Baltimore, MD: The Sidran Institute. Mattei, L. (2011). Coloring development: Race and culture in psychodynamic theory. In J. Berzoff, L.  M. Flanagan, & P. Hertz (Eds.), Inside out and outside in: Psychodynamic clinical theory and psychopathology (pp. 258–83). Lanham, MD: Rowman & Littlefield. Meichenbaum, D. (2011). Resilience-building as a means to prevent PTSD and related adjustment problems in military personnel. In B. A. Moore & W. F. Penk (Eds.), Treating PTSD in military personnel: A clinical handbook (pp. 325–344). New York: Guilford. Mental Health Advisory Team 7 (MHAT). (2011). Mental Health Advisory Team (MHAT) Iraqi Freedom. Washington, DC: Office of the Surgeon Multinational Force-Iraq, Office of the Surgeon General United State Army Medical Command, Mental Health Advisory Team. Meredith, S., Sherbourne, C., Gaillot, S. J., Hansell, L., Ritschad, H. V., Parker, A. M., & Wrenn, G. (2011). Promoting Psychological Resilience in the US Military. MG-966-OSD. Santa Monica, CA: Rand. Merrill, L. L., Newell, C. E., Thomsen, C. J., Gold, S. R., Milner, J. S., Koss, M. P., & Rosswork, S. G. (1999). Childhood abuse and sexual re-victimization in a female Navy recruit sample. Journal of Traumatic Stress, 12(2), 211–25.

Murdoch, M., Bradley, A., Mather, S. H., Klein, R. E., Turner, C. L., & Yano, E. M. (2006). Women and war: What physicians should know. Journal of General Internal Medicine, 22(3), 5–10. Patten, E., & Parker, K. (2011). Women in the U.S. military: Growing share; distinctive profile. Washington DC: Pew Research Center. Pew Research Center (2011). The military-civilian gap: War and sacrifice in the post 9/11 era. Washington, DC: Pew Research Center. Rentz, D.  E., Marshall, S.  W., Loomis, D., Casteel, C., Martin, S. L., & Gibbs, D. A. (2007). Effect of deployment on the occurrence of child maltreatment in military and non-military families. American Journal of Epidemiology, 16, 1199–1206. doi:0.1093/aje/kwm008 Rosen, L. M., & Martin, L., (1996). The measurement of childhood trauma among male and female soldiers in the U.S. army. Military Medicine, 161(6), 342–45. Saltzman, W., Lester, P., Beardlslee, W. R., Layne, C. M., Woodward, K., & Nash, W. P. (2011). Mechanisms of risk and resilience in military families: Theoretical and empirical basis of a family-based resilience enhancement program. Clinical Child Family Psychological Review, 14(3), 213–30. Sayers, S.  L., Farrow, V.  A., Ross, J., & Oslin, D.  W. (2009). Family problems among recently returned military veterans referred for a mental health evaluation. Journal of Clinical Psychiatry, 2, 163–70. Schore, A. N. (2003). Early relational trauma, disorganized attachment, and the development of a predisposition to violence. In M. F. Solomon & D. J. Siegel (Eds.), Healing Trauma: Attachment, Mind, Body and Brain (pp. 107–67). New York: Norton. Sidoli, L. (2005). Assaults concern military academiesmore than 300 women victimized, survey reports. http://inforweb.newsbank.com. Siegel, D. (2007). Mindful brain: Regulation and attunement in the cultivation of well-being. New York: Norton. Silva, J. M. (2008). A new generation of women? How female ROTC cadets negotiate the tension between masculine military culture and traditional femininity. Social Forces 87, 937–60. Simpson, G. (2011). Diversity and the cultivation of wellness. Greater Washington Area Society for Clinical Social Work, Alice Kassabian Memorial Lecture, Washington D.C. Smith, T.C., Ryan, M.A.K., Wingard, D.L., Slymen, D.J., Sallis, J.F. & Kritz-Siverstein, D. (2008). New onset and persistent symptoms of post-traumatic stress disorder self-reported after deployment and combat exposures: Prospective population-based US military cohort study. BMJ, 336, (7640), 366–371. Sneath, L., & Rheem, K. (2010). Use of emotionally focused couple therapy with military couples and families. In R. Blair Everson & C.  R. Figley (Eds.), Families Under Fire: Systemic Therapy with Military Families. New York: Taylor & Francis.

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Standifer, C. (2012). Military women’s lawsuit—alleges rape, assault. Army Times. Retrieved 2012-05-30. Staub, E. (1989). The roots of evil: The origins of genocide and other group violence. New York: Cambridge University Press. Stewart, F., & Trussel, S. (2000). Preview of pregnancy resulting from rape: A neglected public health issue. American Journal of Preventive Medicine, 19(4), 228. Suris, A., & Lind, L. (2008). Military sexual trauma: A review of prevalence and associated health consequences in Veterans. Trauma, Violence and Abuse, 9, 250–69. doi:10.1177/1524838008324419 Suris, A., Lind, L., Kashner, M., Borman, P. D., & Petty, F. (2004). Sexual assault in women veterans: An examination of PTSD risk, health care utilization and cost care. Psychosomatic Medicine, 66, 749–56. Taft, C. T., Vogt, D. S., Marshall, A. D., Panuzio, J., & Niles, B. L. (2007). Aggression among combat veterans: Relationships with combat exposure and symptoms of posttraumatic stress disorder, dysphoria, and anxiety. Journal of Traumatic Stress, 20, 135–45. Tanielian, T., & Jaycox, L.  H. (2008). (Eds.). Invisible wounds of war: Psychological and cognitive injuries, their consequences, and services to assist recovery. MG-720-CCF. Santa Monica, CA: RAND Corporation. Accessed January 11, 2011. http://www.rand.org /pubs/monographs/MG721.html Taylor, S. F. (2006). Tend and befriend: Bio-behavioral bases of affiliation under stress. Current Directions in Psychological Science, 15(6), 273–77. Tedeschi, R. G. & Calhoun, L. G. (2004). The foundations of post-traumatic growth. Psychological Inquiry: American International Journal for Advancement of Psychological Theory, 15(1), 93–112. Tolin, D. C., & Foa, E. R. (2006). Sex differences in trauma and PTSD diagnosis: A quantitative review of 25 years of research. Psychological Bulletin, 132(6), 959–92. Van der Kolk, B. (2003). Posttraumatic stress disorder and the nature of trauma. In M. F. Solomon & D. J. Siegel (Eds.), Healing Trauma: Attachment, Mind, Body and Brain (pp. 168–95). New York: Norton. Wain, H. J., & Gabriel, G. M. (2007). Psychodynamic concepts inherent in a biopsychosocial model of care of

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traumatic injuries. Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry, 35(4), 555–73. Washington, D.  L., Kleimann, S., Michelini, A.  N., & Canning, M. (2007). Women veterans’ perceptions and decision-making about VA health care. Military Medicine, 172(8), 812–17. Weatherill, R., Vogt, D., Taft, C., King, L., King, D., & Shepherd, J. (2011). Training experiences as mediators of the association between gender-role egalitarianism and women’s adjustment to Marine recruit training. Sex Roles 64, 348–59. Weinick, R., Beckjord, E.  B., Farmer, C.  M., Martin, L. T., Gillen, E, . . . Scharf, D. M. (2011). Programs addressing psychological health and traumatic brain injury among u.s. military servicemembers and their families. Santa Monica, CA: RAND Corporation. Weiss, E., & de Braber, T. (2012). Women in uniform: Triumph and challenges. In I. Allen, J. Coll, & E. Weiss (Eds.), Handbook of military social work. Hoboken, NJ: Wiley. Weissert, W. (2012). Luis Walker, Air Force Staff Sgt., Sentenced to 20 Years for Rape, Assault. http//www .huffingtonpost.com/2012/luis-walker-airforce-stan 1691690.html West, K. M., & Tinney, G. (2011). Safety on the homefront: Adequately addressing violence in families impacted by military service. Los Angeles: University of Southern California Center for Innovation and Research on Veterans and Military Families. Williams, I. & Bernstein, K. (2011). Military sexual trauma among female veterans. Archives of Psychiatric Nursing, 25, 138-47. Yano, E.  M., Hayes, P., Wright, S., Schnurr, P.  P., Lipson, L., Bean-Mayberry, B., et al. & Washington, D. (2010). Integration of women veterans into VA quality improvement research efforts: What researchers need to know. Journal General Internal Medicine, 25(1), 55–61. Yehuda, R., Flory, J.  D., Southwick, S., & Charney, D. (2006). Developing an agenda for translational studies of resilience vulnerability following trauma exposure. Annals of New York Academy of Science, 1071, 379–96.

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uicide and suicidal thoughts, impulses, and behaviors are among the most challenging client conditions facing social workers. In the year 2010, the latest for which data is available, 38,364 people died by suicide in the United States, representing a rate of 12.4 per 100,000 and the tenth leading cause of death (McIntosh & Drapeau, 2012). Globally, a million people per year die by suicide at an overall rate of sixteen per 100,000 (CDC, 2012b). These numbers, while startling, do not take account of the many people who also struggle daily with the despair and challenges associated with the mental health conditions which are implicated in 90 percent of completed suicides. Some of these people make nonfatal attempts; in the United States alone in 2009, there were nearly one million attempts (McIntosh, 2012). In addition, while suicide is the tenth leading cause of death among all Americans, homicide, arguably a more high profile public health problem, ranks much lower as the sixteenth leading cause of death. In addition, Rockett (2012b) reported that deaths by suicide had outranked those by motor vehicle accidents in the United States in 2012 and that this holds true in the European Union, Canada, and China as well. Social workers provide a large proportion of overall services to people with mental health conditions in settings as diverse as schools, psychiatric hospitals, homeless shelters, and a range of public and private agencies. Social workers must develop skills in suicide prevention, intervention, and postvention with people of all ages. It is more likely than not that in the course of one’s career, a social worker will be 462

faced with the experience of a range of client suicidal behaviors and in some cases, with the death of a client by suicide. In addition, suicide leaves many devastated and stigmatized survivors in its wake and these individuals and families often seek help from social work agencies. Finally, in keeping with the dual mission of the profession, it is imperative that we play an active role in the amelioration of social conditions that may increase the likelihood of individuals’ seeing suicide as a means of escaping intolerable life conditions. defining and explaining Suicide and Suicidal behaviors In September 2012, the U.S. Surgeon General released the 2012 National Strategy for Suicide Prevention (NSSP), a product of ongoing collaboration with the National Action Alliance for Suicide Prevention, a private-public partnership of 200 representatives of public and private organizations, established in 2010. The major goals of the alliance are to establish suicide prevention as a national priority, coordinate efforts to implement high-value objectives, and develop necessary resources for sustainability of these efforts (U.S. Department of Health and Human Services [HHS], 2012). Simply put, suicide is a “death caused by selfdirected injurious behavior with any intent to die as a result of the behavior” (HHS, 2012). The NSSP also includes definitions for variants of suicidal phenomenon including the following: ȣ Suicidal ideation involves thoughts of engaging in suicide-related behavior.

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ȣ Suicidal intent implies that at the time of the injury the individual intended to kill him- or herself or wished to die and that the individual understood the probable consequences of his or her actions. ȣ Suicidal plan requires a thought regarding a self-initiated action that facilitates selfharm behavior or a suicide attempt; often including an organized manner of engaging in suicidal behavior such as a description of time frame and method. ȣ Suicide attempt is a nonfatal self-directed potentially injurious behavior with any intent to die as a result of the behavior. A suicide attempt may or may not result in injury. ȣ Suicidal behaviors are acts and/or preparation toward making a suicide attempt, suicide attempts, and deaths by suicide. ȣ Suicide crisis, suicidal crisis, or potential suicide is a situation in which a person is attempting to kill him- or herself or is seriously contemplating or planning to do so. It is considered a medical emergency, requiring immediate suicide intervention and emergency medical treatment (HHS, 2012, p. 142) However, in order to fully understand both prevailing definitions and the prevalence of suicide, the social worker considers the stigma attached to mental illness in general, and to suicide specifically. Remarkably, in 2013 although suicide is recognized as a major public health problem, the study of suicide is relatively new. It wasn’t until the 1950s that formal suicide prevention efforts began in the United States, through the work of a group of clinicians in Los Angeles. During the following decades, organizations at both the private and public levels began to focus attention and resources on the reduction of deaths by suicide, resulting in part in the first-ever national strategy in 2001. The stigma that kept the issues related to suicide “in the closet” for so long has also negatively impacted the development of our ideas about

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suicide, from the development of unambiguous definitions to the identification of those at risk, to the accurate “counting” of suicide attempts and deaths. The Centers for Disease Control (CDC), in 2011, in collaboration with the Department of Veteran Affairs, developed definitions designed to help standardize the collection of data on what they term “fatal and non-fatal self-directed violence” (CDC, 2012a). In addition to the definitions listed above, Crosby, Ortega, and Melanson (2011) include the following terms and definitions: non-suicidal self-directed violence—behavior that is selfdirected and deliberately results in injury or the potential for injury to oneself. In these instances, there is no evidence, whether implicit or explicit, of suicidal intent; and suicidal selfdirected violence—behavior that is self-directed and deliberately results in injury or the potential for injury to oneself, with evidence, implicit or explicit, of suicidal intent. Crosby, Han, Ortega, Parks, & Gfroerer, (2011) also provide a broader definition of suicidal behaviors than that put forth in the NSSP. In addition to the definitions provided above, they include the clarification that the preparatory behaviors to suicide may include things like gathering materials to be used in an attempt (e.g., pills, firearm, hose for asphyxiation) or giving things away, writing a will, etc. The considerations of these definitions are critical from several standpoints. Clinically, they allow practitioners a common language that is critical in all phases of prevention and intervention. They also help clinicians and clients to distinguish between a range of suicidal spectrum problems and their associated phenomenology and, importantly, risk. For example, some clients who have self-injurious behaviors also have what can be termed serious suicide attempts. These clients are often able to ascribe different motivations, precipitants, and meanings to the non-suicidal and suicidal violent behaviors. Consider the client on an inpatient psychiatric unit who describes having superficially cut herself with a light

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bulb following a contentious family meeting. Sally reports having been “so furious, no one is listening to what I am saying. I can’t take it anymore. I knew that after I did it, I would feel better. Sometimes I just need the physical pain to be worse than the emotional. I did initially feel much better, almost a sense of relief. I knew I would feel better.” In this instance, the client, though engaging in a self-directed violent act, did so, clearly, with the intent of shifting her affective state, rather than of dying. At another time, however, this same client, during a period in which she experienced a great deal of helplessness and hopelessness following a painful breakup, took a significant overdose of prescription medicine (in quantities sufficient to kill herself), in what she later characterized as a suicide attempt. Fortunately, a family member unexpectedly stopped by her house, discovered her in time, and called emergency services. In the aftermath of both the self-injury and the suicide attempt, Sally reported not being able to “take it anymore.” However, in the former situation, the “couldn’t take” referred to her feeling state; in the latter, it was her very life she “couldn’t take.” The social worker working with Sally needed to be clear about the different definitions, conditions, and associated motivations and circumstances in each of these events. In both, careful assessment, screening, and provision of safety measures are warranted. However, ongoing interventions may differ, as the degree of risk and the function of the behaviors are different. At the same time, understanding the relationship between self-injurious behavior and suicide attempts is vital; one of the highest and most stable risk factors for suicide is a prior attempt (Beghi & Rosenbaum, 2010). Standardized, carefully constructed definitions of the range of suicide-related terms are also important in the development and implementation of suicide research. Early attempts at documenting the prevalence and trends of suicide and suicide behaviors have been complicated by the reluctance of practitioners, researchers, and family members and others to

acknowledge that an individual’s death was in fact, a suicide. For example, tracking cause of death in “untimely” deaths has been difficult, as professionals have often wanted to “protect” survivors from the stigma of a loved one’s suicide. We have recently seen improved methods for surveillance of data through education and funding to medical examiners and coroners. In the past, for example, it has not been uncommon for certain single-car accidents to be erroneously classified as motor vehicle accidents rather than a suicide, in spite of evidence supporting the latter finding. The use of the psychological autopsy procedure, developed by the American Association of Suicidology (AAS), is a means of identifying both distal and causal factors in individual or cluster suicides. For individual cases, these findings can help to establish causes and correlates to death. In the case of cluster suicides (more than one in a short time in a small geographic area or among people known to each other), the psychological autopsy can also help to identify troubling social and age cohort trends and “contagion” on a broader level. While psychological and micro etiological factors dominate the contemporary suicide discourse, the influence of economic, social, and related macro issues are worth another look. Durkheim, a French sociologist, writing in the early twentieth century, challenged the dominant view that suicide was invariably caused by psychiatric illness. Durkheim asserted that anomic suicide results in a lack of regulation of man’s activities and suggested that “deviant” behaviors such as homicide and suicide would result. According to Graeff and Mehlkop (2007), Durkheim argued that suicide should be considered a social phenomenon that requires explanation from social facts. In contrast to the psychological approach to understanding suicide, he argued that changing rates of suicide themselves should be the focus of attention. In the contemporary arena, then, looking at the rising rate of suicide deaths in middle-aged men, for example, would require

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the search for an explanation based upon societal structures and change rather than solely upon rates of psychiatric illness. Durkheim also introduced the term anomie to suicide studies. Anomie occurs in the context of rapid social change when social norms are confused and individuals feel disconnected from community. As in the Great Depression, this sociological approach to understanding current suicide rates and trends may be particularly relevant in an age of global recession, polarizing politics, a changing employment landscape, and the concentration of economic resources among the upper 1 percent of the population. Of note, the term or phenomenon of assisted suicide does not appear in the 2012 National Strategy for Suicide Prevention. Assisted suicide is an emerging social, legal, and ethical issue facing social workers, particularly those working in medical and geriatric settings. Csikai and Manetta (2002) argued for a “call to action” for social workers in the aftermath of the Oregon Death with Dignity Act of 1994 and the National Association of Social Workers (NASW) issued a policy statement titled “Client Self-Determination in End-of-Life Decisions” in 2000. Though beyond the scope of this chapter, the issue of assisted suicide is an emerging one that has great legal, ethical, and medical implications for social workers and their clients. Regardless of one’s position on the issue, there seems to be some consensus that many of those people considering assisted suicide may have psychiatric or other conditions that could be amenable to treatment. Therefore, careful screening of clients with psychiatric and debilitating and/or terminal physical illnesses is critical in determination of suicidal risk, assisted or not. There has also been some debate among clinicians and researchers regarding the appropriate terminology for the act of suicide itself. Social workers have tended to endorse “peoplefirst” terminology (Heller & Gitterman, 2011) and this is particularly important when referring to those with mental illness and or other stigmatized conditions. In the past, a suicidal

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act has been referred to, most unfortunately, as either “successful” or “unsuccessful.” Clearly, this is unfortunate language. Suicides were then referred to as “completed” or “uncompleted” but the recent spike in military and veteran deaths has raised our consciousness about the unintended associations with this terminology. In the military, “completed missions” are referred to as those actions with positive outcomes. Therefore, there is now some gathering consensus that the simple terms “death by suicide” or “died by suicide” are clear, direct, and without unintended ambiguity or meaning. demographic Patterns According to the Centers for Disease Control (2012b), in the United States, one person kills him- or herself every 13.7 minutes, or 100 times per day. In the time it takes to read this chapter, two more lives will have been lost to suicide. Suicide data is typically reported as rates per 100,000; the total rate in the United States in 2010 was 12.4; and suicide accounted for 1.6 percent of all deaths in 2009. However, as noted, obtaining accurate accounts of deaths by suicide has historically been a monumental task, so it is likely that the numbers listed below are conservative estimates. In 2010, 38,364 people in the United States died by suicide (all statistics are for the year 2010, the latest year for which comprehensive data is available at the time of press, unless otherwise noted). This number represents an increase from the previous year, continuing an upward trend since 2000. Suicide statistics are ever changing, and individuals and groups who are at a relatively low risk at one point in time may be at an elevated risk at another point. Social workers must remain apprised of shifts in demographic risk in order to appropriately screen and identify both populations and individuals at risk. Also, as noted, suicide rates are reported in several ways; by rate per 100,000, ranked cause of death, and total number of deaths. These differences are important to the understanding of relative risk. For example,

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white men over the age of 85 had an alarming 47.33 rate of death by suicide in 2010, but the total number of men in this category who die by suicide is relatively small because of the overall small number of men in that category. Likewise, suicide is the tenth leading cause of death among all Americans, but the third leading cause of death for people ages 15–24 in 2010 (McIntosh & Drapeur, 2012), who are less likely to die from a range of other leading causes of death than their older counterparts. While we focus here primarily on suicide deaths, it is critical to note that each year 8 million adults report having serious thoughts of suicide, 2.5 million make a suicide plan, and 1.1 million report an attempt (McIntosh & Drapeau, 2012). There are significant differences according to gender; men die by suicide at a significantly higher rate (20.00) than women (5.2 percent). However, women make three times as many suicide attempts as their male counterparts. Method of suicide also differs by gender; men are more likely to die by firearm than women; women are more likely to die by overdose (National Vital Statistics Reports, 2012). However, these proportional differences shift and generational cohort effects may account for this. For example, the number of women dying by firearm has increased significantly over the past decade. African Americans as a whole have a suicide rate of 5.1 per 100,000, roughly equal to that of all women. Within the group, however, there are significant gender differences; black men have a rate of 8.7, while black women have a rate of 1.8, the lowest of any identified subgroup. Nisbet (1996), in a review of the literature, found strong support for the idea that strong social support, especially from family members, is a strong protective factor for black women. Fernquist (2004) found perhaps that single motherhood itself, among black women, is related to the lower rates in this group. He further confirmed that these relatively low rates for black women are due in part to “strong social and emotional support

systems that offer needed help to single black female parents (e.g., child care, emotional support, confidantes, etc.)” (p. 169). The African American youth suicide rate has fluctuated since 1981. Between that time and 1994, the rate increased 78 percent; however, since then the rate has decreased significantly. Indeed, in a review of the research literature on African Americans and suicidal behavior, Joe and Niedermeier (2008) found that young black males complete suicide at rates comparable to their white counterparts and, disturbingly, that firearm suicide in this group has increased more precipitously. The authors caution social workers against adopting the misconception that African Americans “do not commit suicide” and of not being aware of the specific patterns in trends in suicidality in this racial group, at all age points. The authors conclude that the results of their review “clearly refute conventional beliefs about negligible rates of suicide among this population” (p. 255). The reasons for some of these demographic shifts are not well understood. Regardless of gender and age, firearms were the predominant method of suicide for African Americans. AAS (2012a) suggests common myths regarding protective factors against suicide in this population are pervasive and perpetuate dangerous ideas about relative risk. For instance, AAS identifies these myths as (1) there is a religious stigma of suicide as the “unforgiveable sin,” (2) African American men are macho and do not take their own lives, and (3) African American women are always strong and resilient and never crack under pressure. Additionally, barriers to treatment must be addressed and access to treatment increased (Das et al., 2006). Indeed, cultural differences in the expression of suicidal behaviors exist; this population is less likely to use drugs in a suicidal crisis, manifestations of depression may be more pronounced, and some do not express suicide intent during the crisis. (AAS, 2012a). Greater involvement and liaison between mental health and faith communities may be helpful in terms of decreasing stigma and barriers, and

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increasing awareness (NOPCAS, 2012). Compton, Thompson, and Kaslow (2005), in a sample of low-income African Americans, found that social supports and family relationships did indeed confer some protective factors, and further research is needed to clarify these. Hispanics account for 17.8 percent of the U.S. population (AAS, 2012b), and the suicide rate for Hispanics of all ages was 5.3 per 100,000, compared to 12.63 for non-Hispanics of all ages (AAS, 2012b). In virtually all categories, the suicide rate for Hispanics is lower than for nonHispanics. According to the AAS (2012b), the following prevalence rates are reported; among Hispanics, the highest risk was for those males ages 80–84, at 21.9 per 100,000 compared to 37.64 for their non-Hispanic counterparts. The suicide rate for theses adolescents aged 15–19 was 6.0, compared to 8.1 for all non-Hispanic adolescents. However, importantly, 31.6 percent of Hispanic high school students report higher rates of feeling sad and hopeless than their non-Hispanic classmates; female Hispanic adolescents reported this at rates of 39.7 percent. According to the Youth Risk Behavior Surveillance (CDC, 2012b), there are some alarming trends in suicide-related thoughts and attempts. According to this national surveillance study, 15.4 percent of Hispanic adolescents report having seriously considering attempting suicide in the previous twelve months, a higher rate than reported by non-Hispanics. Finally, in terms of suicide attempts, Hispanic female high school students report a rate of 11.1 percent, compared to their white non-Hispanic counterparts (6.5 percent) and black non-Hispanic girls (10.4 percent). Thus, the range of suicidal behaviors and underlying conditions (feeling of hopelessness and depression) should be reviewed when considering relative risk among subgroups of the population. In this instance, while Latino youth have lower-than-average deaths by suicide, the self-reports of other suicidal thoughts, feelings, and behaviors are substantially higher than their non-Hispanic counterparts. This has significant implications for prevention, identification of

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risk, and intervention. Goldston et al. (2008) provide an excellent discussion of the importance of cultural considerations in the assessment and intervention related to suicide among ethnic adolescents. This includes hypotheses about family and social norms, risk, and protection, as well as the influence of immigration status, to be discussed further. Native Americans (NA) and Alaskan Natives (AN) have a roughly comparable rate of suicide (11.84, compared to 12.4 for the overall population). Suicide in this group is the eighth leading cause of death overall, but importantly, the second leading cause for people ages 10–34. Indeed, a pressing concern is the data on suicidality among the children and adolescents of this ethnic group; 10–29-year-olds have the highest rates of suicide of all non-NA and non-AN of all races. For example, those in the 20–24-year-old group had a twenty-three per 100,000 rate of death by suicide, compared to twelve per 100,000 rates for their non-AI/AN counterparts. In addition, their rate of death by firearms in the group of 20–34-year-olds was substantially higher. Rates of firearm deaths are particularly important data because of the high likelihood of death ensuing from a firearm attempt. Freedenthal and Stiffman (2004) conducted a first study of suicidal behaviors in Native American adolescents in urban areas and compared them with those who had remained on reservations. They found that the urbanraised youth had a lower rate (21 percent) of suicidal ideation than did those on the reservation (32.6 percent). However, there was far less discrepancy on the rate of attempted suicide (urban at 14.3 percent and reservation at 17.6 percent). It is important to note that many psychosocial circumstances that may contribute to suicidality, such as conduct disorder, alcohol dependence and abuse, substance abuse, gang involvement, police or court history, and reporting discrimination related to native status were significantly higher in the adolescents living on the reservation. Interestingly, both groups reported high numbers of having had

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a friend attempt to die by suicide (urban at 31 percent and reservation at 41.8 percent). These numbers alone provide evidence of the degree to which suicidality is a critical issue for the Native American population and tribes. Overall, all of these findings must be considered in the context of the broader emerging literature on the complex psychosocial, historical, and sociocultural factors related to Native American populations. In terms of protective factors, Asian Americans had a rate of 6.2 suicides per 100,000 in 2010 (McIntosh & Drapeau, 2012) according to the 2010 CDC statistics. Cheng et al. (2010) used data from the National Latino and Asian American Study (NLAAS) to examine the demographic, psychiatric, and culturally relevant factors associated with a range of suicidal behaviors in four distinct subgroups of American Asians. They found an overall rate of 8.8 percent for lifetime suicidal ideation and 2.5 percent for lifetime suicide attempts. Prevalence rates for suicidal ideation differed by being U.S.-born and by age (18–24-year-olds had a rate of 13.3 percent) but not by gender, ethnic origin, level of education, or poverty level. Those who were never married had substantially higher rates of suicidal ideation (17.9 percent) than those who were married (5.7 percent) or those and those who were divorced/separated/ widowed 9 percent. In terms of actual suicide attempts, here too 18–24-year-olds had significantly higher rates (at 12.36). Additionally, females had higher rates of attempts, and married individuals had a lower rate of attempt than those never married or those divorced/ separated/widowed. Importantly, Cheng et al. (2010) found that “high levels of family conflict and perceived discrimination were independently associated with suicidal ideation and suicide attempts” (p. 13). Furthermore, the authors suggest that family conflict may be associated with issues related to acculturational differences within families. However, they also found that high levels of ethnic identity were associated with lower rates of suicide risk; ethnic identity may serve as a buffer.

Immigration status must be considered when evaluating the statistics and research about ethnic/racial groups and suicidality. Borges, Orozco, Rafful, Miller, & Breslau, (2012) found that within ethnic groups “risk for suicidality was low among immigrants prior to migration compared to the U.S. born, but equalized over time after migration” (p. 1175). The authors argue for an increased public health focus upon prevention aimed at second-generation immigrants who may have “lost all protective factors.” In earlier research, Fortuna et al. (2007) found that for Hispanics, there was also a higher risk for suicidality in second-generation immigrants and, importantly, also for those who arrived in the United States at earlier ages. The fact that for some of these people immigration actually increases risk for suicidality is a sobering one that merits further investigation. These data have important implications for both prevention and intervention efforts at both micro and macro levels. When immigrants are also refugees, premigration experience often includes the experiences of terror, abuse, and involuntary migration. For these immigrants, survival and escape from intolerable situations in their native lands may have required life-affirming and lifesustaining perspectives and actions. However, there is no evidence available that confirms or disconfirms the possibility that this may have conferred any protection from suicidality. In fact, Ferrada-Noli et al. (1998), in their study of 149 refugees from many countries, found that only 5 percent did not meet criteria for psychiatric illness and 79 percent were diagnosed with post-traumatic stress disorder (PTSD). Because psychiatric illness is a significant risk factor for suicide, it is not surprising that 40 percent of this sample who met the criteria for PTSD had made a prior suicide attempt. The authors suggest that the high degree of psychiatric illness in this population provides some explanation for the overrepresentation of immigrants in the suicide statistics of countries with relatively high numbers of what they call “refugee-immigrant flow.” At the same time, help-seeking for psychiatric

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care is typically low in refugee populations, so those at risk may not receive treatment for their PTSD or suicidality. The early literature on suicidal risk for gay, lesbian, bisexual, and transgendered people suggested an elevated risk, but early on there was little research devoted to research and intervention and suicide prevention. Haas et al. (2011) undertook a massive effort, with the support of many private and public organizations, to evaluate the existing literature and make recommendations for research and practice. In addition to the usual problems with the means of securing accurate data regarding suicide as a cause of death, efforts are also hampered given that death certificates do not identify a person’s sexual orientation and furthermore, as with many things, there may be a presumption of heterosexuality. Using other methods to determine suicide death and sexual orientation, several studies (Rich, Fowler, Young, & Blenkush, 1986; Shaffer, Fisher, Hicks, Parides, & Gould, 1995; Renaud, Berlim, Begolli, McGirr, & Turecki, 2010) have determined that samesex orientation is not disproportionately represented among suicide deaths (as cited in Hass et al., 2011). However, Hass et al. (2011) note limitations of these studies in terms of sample size and the focus on adolescents and young adults. However, there appears to be ample and convincing evidence that suicide attempts are significantly higher in LGBT people. King et al. (2008) in a meta-analysis of twenty-five international population–based studies, found that gay/bisexual males had a four times higher rate of lifetime suicide attempt than their heterosexual counterparts; lesbian women had twice the rate as their heterosexual counterparts. Interestingly, Gilman et al. (2011) found that suicidal ideation does not appear to be a stable predictor of LGB suicidal behavior. This is in contrast to the relationship between the two for non-LGB populations. In sum, Haas et al. (2011) stress that the literature since the 1990s reveals significantly higher risk of suicidal behaviors among LGBT people, in comparison

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to their heterosexual counterparts and that this requires increased research and clinical attention to this population. Importantly, King et al. (2008) see gay-related stigma leveled at LGB people as implicated in the high rates of suicide attempts in this population. The situation for transgendered people may be even more dire, although insufficient research exists. The 2009 U.S. National Transgender Discrimination Survey (National Center for Transgender Equality and The National Gay and Lesbian Task Force, 2009) provided critical data which demonstrate the range of difficulties encountered by transgendered people, much of which may impact relative suicide risk. For example, a full 97 percent reported mistreatment or harassment on the job. In nonrandom samples, up to one-third of transgendered people report having made one or more suicide attempts (Haas et al., 2011). In one international study, Pfafflin and Junge (1998) found sixteen possible suicide deaths in 2,000 persons who had had gender reassignment surgery, which would be a rate of 800 per 100,000, an almost unimaginable risk. It may well be that the heightened stigma toward this subgroup of LGBT people is related to increase rates of suicidal risk. The rates of U.S. veteran and military deaths by suicide are particularly troubling. In August 2012, Secretary of Defense Leon Panetta reported that in the first 155 days of 2012, 154 active-duty troop members died by suicide (U.S. Department of Defense [DoD], 2012). This represented a 22 percent increase over the number from the same period in 2011. Secretary Panetta reported to the House Senate Committee that military death was an “epidemic.” Furthermore, the numbers concerning veterans are no less disturbing; according to a Pentagon report in January 2012, approximately 950 veterans under VA care attempted suicide each month between October 2008 and December 2010. According to the CDC, veterans now account for fully 20 percent of all deaths by suicide in the United States, and veterans of the conflicts in Afghanistan and Iraq are at higher risk than those from

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other wars. According to Kaplan, McFarland, Huguet and Valenstein (2012) in their study of suicide risk in veterans, veterans were at higher risk for suicide than nonveterans except for those over age 65. Furthermore, they report that of the veteran suicide deaths between 2003 and 2008, 69 percent of veterans died by firearm, a method that is associated with high fatality. In recognition of the alarming data, the Department of Veteran Affairs has made suicide prevention a high priority, given that by their own report, as many as 5,000 veterans die by suicide each year. Also, given that the United States has an all-volunteer army and service members are disproportionately from minority and lowerincome groups, these people are at higher risk of exposure to a current risk factor for suicide. In the United States, substantial variations in deaths by suicide are evident by region and by state and district. For example, suicide rates range from a low of 4.8 per 100,000 in the District of Columbia to a high of 22.5 in Montana; these numbers are best understood in reference to the national rate of 12.0 per 100,000. In terms of divisions, the Middle Atlantic has the lowest rate and the Mountain area has the highest at 17.9. (McIntosh & Drapeau, 2012). Societal context Proximate causes are more commonly identified and understood in relation to suicide, but distal factors such as “social position, economic factors, social isolation and integration, and cultural factors” are also implicated in the etiology of this major public health issue (Li, Page, Martin, & Taylor, 2011, p. 608). Blake et al. (2002) found that lower socioeconomic status has tended to be related to lower suicide risk. According to Li et al. (2011), this may be related to theories of social integration, and they argue that because the literature on distal risk (such as socioeconomic status) has been limited, public health and policy initiatives have focused more on proximate risk factors such as psychiatric disorders. Rehkopf and Buka (2006), in a systematic study of the literature on the

relationship between poverty and suicide, identified highly divergent findings regarding area socioeconomic characteristics and area suicide rates. Some studies demonstrated higher rates of suicide in higher socioeconomic areas, while others found the inverse, lower rates in high SES areas. Other studies found no differences. However, in other respects, the relationship between suicide/suicidal behaviors and the social context can be understood through the examination of several life circumstances. Schneider et al. (2011), in their examination of the impact of work-related factors, found that unemployment (particularly over an extended period of time), early retirement, and homemaker status conferred additional risk. The role of unemployment is particularly important to consider in the context of worldwide economic recession. Work conditions also play a role; tedious tasks and high job-related stress were also implicated in the full range of suicidal behaviors according to Schneider et al. Logan, Hall, and Karch (2011) analyzed postmortem records of nearly 30,000 suicide deaths and determined ten distinct patterns of risk factors, two of which included mental health–only factors and one substance abuse–only. Five patterns include a combination of mental health conditions and psychosocial risk factors, while the remaining two related only to relationship problems. The relationships among psychiatric diagnosis, demographics, and stressful life events/circumstances are highlighted below in terms of their relative vulnerability and protective factors. Vulnerabilities and risk factors Risk factors for suicide are typically grouped into three categories: demographics, noted previously, and psychiatric diagnosis and stressful life events/circumstances. The demographic factors discussed above highlight the groups of people who are at elevated risk for the full range of suicidal behaviors, including ideation and/or preoccupation, planning, attempts, and fatal injury. The primary demographic risk factors include age, gender, race/ethnicity,

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sexual orientation, generational cohort, and geographic region. Psychiatric diagnosis is implicated in an overwhelming number of deaths by suicide. Rihmer (2007) reports that “more than 90 percent of suicide victims and attempters [italics mine] have at least one current DSM-IV axis I diagnosis (mainly untreated) major mental disorder, most frequently major depressive episode (MDE) (56–87 percent), substance use disorders (26–55 percent), and schizophrenia (6–13 percent).” Furthermore, a prior suicide attempt is the single best predictor of an eventual death by suicide (Beghi & Rosenbaum, 2010). These statistics have important implications for social work practitioners and form the basis for responsible risk assessment. Finally, stressful life events/circumstances from an ecological perspective reside in society, community, and relational arenas (Dahlberg & Krug, 2002). As cited in the NSSP (HHS, 2012), Dahlberg and Krug include the “availability of lethal means of suicide, unsafe media portrayals of suicide, lack of supportive relationships, barriers to health care, high conflict or violent relationships, and family history of suicide” (p. 15) in their ecological model of risk. Additionally, having lost a loved one to suicide precipitously raises one’s risk for dying by suicide (Jordan & McIntosh, 2011). The role of psychosocial factors may be particularly important in the small proportion of people who die by suicide and do not have a psychiatric condition. Judd et al. (2012) in a study of this population found that in the absence of a mental health condition, relationship and financial problems figured prominently. Attempts to identify “high risk professions” in terms of death by suicide have been equivocal according to the American Psychiatric Association (2001), though historically, dentists, doctors, and police have been considered at elevated risk. According to Pompili et al. (2011) there appears to be elevated risk for people with medical conditions such as cancer (particularly those of the mouth, throat, and lung) in the first few months post diagnosis, but also during the first five years. Three

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degenerative diseases of the central nervous system, multiple sclerosis, Huntington’s disease, and Parkinson’s disease, all of which may manifest in part in psychiatric symptoms, also confer higher risk. Finally, spinal cord injury, epilepsy, migraine, HIV/AIDS, chronic kidney disease, arthritis, and asthma (in adolescents) may predispose individuals to a higher rate of suicidal behaviors (HHS, 2012). When considering the role of physical disease in suicidality, it is critical to take a comprehensive approach, which takes into account factors such as comorbid psychiatric conditions and psychosocial conditions that may be a consequence of the illness. For example, the person with advanced Parkinson’s disease may suffer unemployment, financial uncertainties, and stressed relationships in addition to a loss of sense of “agency,” hopelessness, and feelings of being a burden to others. While many of these risk factors pertain to the population at large, some studies have identified factors specific to certain populations. For example, the following risk factors have been identified for youth suicide: low self-esteem, exposure to a friend’s or family member’s suicide (Borowsky, Ireland, & Resnick, 2001; Resnick et al., 1997), and firearms in the household (Brent et al., 1999). resilience and Protective factors Resiliency is commonly understood as the ability to “bounce back” from life’s adversities. Sources of resiliency include optimal neurobiological factors, sufficient and responsive environmental resources, and certain psychological attributes. Resiliency is a particularly important concept in our understanding of suicidal behavior in terms of both assessment of risk and in interventions aimed at “shoring up” adaptive capacities. Johnson et al. (2011) describe resilience to suicide as “an ability, perception, or set of beliefs which buffer individuals from the development of suicidality in the face of risk factors or stressors” (p. 264). In an introduction to their report on an extensive review of seventy-seven studies investigating

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resilience to suicidality, Johnson et al. note the variance in the literature regarding conceptual definitions of resiliency to suicide. Osman et al. (2004) describe resiliency as having the ability, the resources, and the competence to regulate suicidal thought, while Rutter, Freedenthal, and Osman (2008) conceptualized resilience as an internal factor defending against suicide. Johnson et al. (2011) also focused instead on the role of positive self-appraisals which buffer against the “pernicious impacts” of stress. Johnson et al. (2011) found that the “buffering hypothesis” of resilience has particular value in understanding resilience to suicidal behaviors and intents. This hypothesis has three major components: (1) resilience should be considered as a separate construct from risk, one which may moderate risk; (2) both risk and resilience have bipolar dimensions; and (3) the resilience should be viewed as internal psychological constructs (Lundman, Strandberg, Eisemann, Gustafson, & Brulin, 2007, as cited by Johnson et al., 2010). In their exhaustive review of seventy-seven studies that investigated resilience and suicidality, Johnson et al. (2011) found strong support for the mediating effects of the following psychological buffering factors: overall positivity of attributional style and higher levels of agency, or the belief that one has the power and ability to effectively direct one’s own actions. Conversely, they found strong support for the amplifying effects of higher levels of perfectionism and for hopelessness. In addition, more moderate buffering effects were found for problem-solving ability, self-esteem, problem-solving confidence, general social support, family support, significant other support, attachment, and suicide-related beliefs. These findings provide significant guidance for practice and highlight the importance of considering both psychological/individual and environmental factors as crucial in understanding resilience to suicidality. Interventions targeted at increasing those internal and external capacities can provide a buffer to suicidality and could enhance other aspects of psychosocial functioning.

In examining the demographic trends, being a member of certain gender, age, generational cohort, and racial/ethnic groups confers some protective factors. For example, black women have a particularly low rate of suicide at 1.9 per 100,000 (McIntosh, 2012). In consideration of why this might historically be so, one might consider such variables as reasons for living, i.e., one’s sense of responsibility for others, and the role that spirituality and community may play in these women’s lives. Because psychiatric conditions are implicated in 90 percent of people who die by suicide, clearly early identification and intervention can provide protection. For example, depression is often comorbid with suicidal thoughts and behavior. It is important to understand this in the context of the findings cited above by Johnson et al. on factors related to resilience. In addition, Gitterman and Germain (2008) noted, “Exercising foresight and taking active steps to cope with environmental challenges are critical factors” (p. 65) in the development of resilience. Exercising foresight may be particularly challenging for people living with depression as they often have a negative attributional style, a diminished sense of agency, and high perfectionism and hopelessness. The early identification and treatment of depression then can potentially confer some protection. The interventions, such as cognitive behavioral strategies that target feelings of hopelessness and negativity, may be helpful in dealing with suicidality as well. Finally, the massive efforts made as a result of increasing concern among federal and state agencies toward prevention cannot be underestimated. The Garrett Lee Smith Grant Program, for example, provides funding for prevention on college campuses, and many private organizations, including the Jedd Foundation and the Jordan Matthew Porco Memorial Foundation, also target college-aged populations. Prevention efforts at both the public and private levels focus upon public health messaging, prevention activities, and screening and intervention. There is continued need for both wide-scale public

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health initiatives and “case-based” prevention interventions. Programs and Social Work contributions Social workers provide services at the levels of prevention, intervention, and postvention to a broad range of populations in an equally broad range of settings. Prevention, as a cornerstone of the NSSP, is a critical function, and prevention efforts have increased substantially through the efforts of such organizations as the National Action Alliance for Suicide Prevention (NAASP), the Suicide Prevention Resource Center (SPRC), the American Federation of Suicidology (AFS), and the American Association of Suicidology (AAS). Prevention, while aimed primarily at the eradication of deaths by suicide, also includes prevention of suicidal behaviors. This is particularly important given the fact that people who make a nonfatal suicide attempt are at significantly increased risk of dying by suicide from a subsequent attempt. Social workers are increasingly providing services to youth in school settings. Singer and Slovak (2011) surveyed 311 school social workers from an eleven-state region and found that fully 88 percent had worked with suicidal students within the previous two-year period; for those social workers at the high school level, that number reached nearly 100 percent. While a large majority reported feeling confident in their work, relatively few reported having received training in their graduate programs. Social work degree programs at the bachelor’s and master’s levels must provide comprehensive education on working with suicidal clients. This education should not be limited to the classroom. Field instructors and their agencies have a vital role to play in the development of skills and knowledge in social work students. Collaborations between field instructors, agency personnel, social work faculty, and public mental health and child protective services are critical in the preparation of the social work workforce.

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In spite of the reported high number of suicidal behaviors in corrections settings, where many social workers are employed, an electronic search of “social workers” and “suicide” and “corrections” yielded few “hits.” This is unfortunate given the high number of risk factors that many inmates have for suicidal behaviors, in the absence of the usual supports that are considered to be protective. Hayes (2005), cited in Alexander (2011), reported that over 400 suicides occur per year in corrections settings, most of which occur in jail settings by white males in the first twenty-four hours of incarceration. Indeed, Baillargeon et al. (2009), in a study of psychiatric disorders and suicides in Texas, the state with the largest state prison system, found a rate of eighteen per 100,000 deaths by suicide; of the forty-one deaths in the one-year period studied, twenty-one had a diagnosis of serious mental illness. They further report that in the United States, fully one-half of prisoners have at least one mental health condition. Alexander (2011) argues for the importance of comprehensive mental health assessment and intervention and has found that cognitive behavioral treatment is found to be the most effective with both juveniles and adults. Availability and effectiveness of aggressive treatment of prisoners with mental health conditions will likely play a significant role in the reduction of prison suicides. Social workers on psychiatric units, who provide a good deal of the discharge planning, need to be particularly vigilant regarding patient safety. According to a systematic meta-analysis conducted by Large et al. (2011), the rate of suicide in the months following discharge is several hundred times higher than that of the general population, with 5 percent of these occurring within a week of discharge. This greatly elevated risk highlights both the tenacity of suicidal thought in these clients and the enormous challenges facing those who work with them. The authors in this study concluded that about “3 percent of those characterized as highrisk can be expected to commit suicide in the

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year following discharge” but that “60 percent of the patients who commit suicide are likely to be categorized as low-risk” (p. 627). While the authors note several limitations in their study, they conclude that there exist severe limitations in categorizing this group of patients by their risk of suicide. This concern, while sobering, should serve as a strong motivator for the profession to increase our understanding and use of effective risk assessments. Many practitioners in both inpatient and outpatient settings have employed no-suicide contracts, now generally referred to as suicide prevention contracting (SPC), with clients at high risk, but there exists some controversy about their effectiveness. Edwards and Sachmann (2010) report that 76 percent of surveyed mental health professionals report having used verbal no-suicide agreements and 37 percent reported using written agreements, with less-experienced respondents using them more frequently. Goin (1998) and Kroll (2000) caution against their use in lieu of the development of the therapeutic alliance, detailed risk assessment, removal of lethal means, or consultation. Indeed, these skills and activities are essential to good social work care of the suicidal client in any setting. assessment and interventions Detailed risk assessment, safety planning, and lethal means restriction (identification and removal of any items a client could use to kill him- or herself) are central to both assessment and intervention stages in the work with clients who have any level of risk (demographic, psychiatric, or due to life stressors) for suicidality. In addition, this work requires that the social worker not “tread lightly” when working with these clients. Many practitioners fear that asking a client whether they ever “think of hurting” themselves will result in non-suicidal people becoming suicidal. Nothing could be further from the truth. Clients struggling with what they believe are insurmountable problems, whether it be mental illness, a degenerative

illness, a disrupted relationship, or overwhelming environmental stresses, often have thoughts of suicide. The task of the social worker is to “connect” with the client, who is often feeling alienated from his or her own life and the supports that may be available to him or her. Usually, risk assessment involves a combination of comprehensive assessment by clinical interview and standardized risk instruments. The comprehensive assessment should include the investigation of both the absence and presence of both the risk and protective factors identified above. The Suicide Prevention Resource Center (2012) has developed a Best Practices Registry (BPR), which lists evidence-based practices for suicide prevention that have undergone rigorous evaluation and demonstrated positive outcomes (SPRC). Section I (evidence based) is derived from the National Registry of Evidence-Based Programs and Practices (NREPP) developed through the Substance Abuse and Mental Health Services Administration (SAMHSA) and from the SPRC/AFSP (American Foundation for Suicide Prevention). This extensive resource is available online and includes general guidelines for screening and intervention as well as guidelines for specific settings and populations such as hotlines, emergency departments and primary care for adolescents and the elderly. Additionally, several theoretical approaches are on the registry, including Dialectical Behavioral Therapy (DBT) and multisystemic family therapy. In order to be included on the registry, programs must meet strict criteria, including the demonstration of positive outcomes, and peer-reviewed publication. Generally, social workers are well advised to use universal screening in many of our settings and most particularly in those that serve potentially high-risk clients. Suicide assessment should be considered ongoing; it is not sufficient to ask only at intake. Clients who are at elevated risk should be evaluated on a regular basis, and consultation with family members may be necessary as well. A good evaluation will include (in addition to a comprehensive clinical evaluation)

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questions about ideation (frequency, intensity, duration, passive or active, intrusive or controllable), intent (degree of severity), presence of a suicide plan (the degree to which it is feasible, well thought out), the availability of means to kill oneself, the likelihood of being found after an attempt, and whether preparations have been made (making a will, saying good-byes, giving things away). In addition to risk factors, the client should be asked about any protective factors or reasons for “living.” For example a young mother may feel preoccupied with thoughts of killing herself, and have a plan in mind, but identify that “it’s a sin in my church, so I’ll go to hell if I kill myself and I don’t want that” or “if it weren’t for my children I’d kill myself right now.” While determining the existence of any of these deterrents is very important, caution should be taken to understand them in the context of the whole picture as part of the risk/protective factor balance. Furthermore, the social worker should understand that particularly with those clients whose mental status fluctuates, deterrents may not have as much power at one time as at another. Obtaining a very detailed history about any prior suicidal behaviors (including attempts, plans, ideations, other forms of self-harm) can be helpful in terms of understanding the present crisis. In the event that there have been previous suicidal behaviors, answers to questions about how those were resolved can be helpful in terms of both evaluating risk and making use of prior deterrents. In the case of prior attempts, the potential lethality of those attempts must be evaluated, what accounted for its not being a fatal attempt, and how the client felt about surviving it. Ideally, these risk assessments will involve both extensive face-to-face discussions and a screening tool, providing two sources of assessment, which are more powerful when used together. The Columbia-Suicide Severity Rating Scale (C-SSRS) was found by Posner et al. (2009) to have high validity and reliability in both clinical and research settings. The Beck Suicide Scale for Suicide Ideation (BSI) (Beck, Steer, & Ranieri, 1988) is a self-report

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instrument, and the Beck Scale for Suicidal Ideation (Beck, Kovacs, & Weissman, 1979) is a clinician-administered instrument; both are also used widely in a range of clinical settings. If assessment reveals that the client is at risk for suicide, the social worker should determine, preferably in consultation with the client and, if possible, with the family, the level of intervention required. Clearly, the first goal is to keep the client from self-harm; in instances in which the client is “an immediate risk to himself ” hospitalization may be necessary. If the client is not willing to be voluntarily admitted to the hospital, the social worker, in accordance with agency policy and state law, may need to pursue an involuntary hospitalization. In these instances, the social worker must be clear with the client about why he or she is pursuing this course of action. If the worker has determined that the client, though actively suicidal, has any degree of ambivalence about acting on those wishes, it is very useful to try to engage with the client about the reasons for the ambivalence. That will probably not, in itself, reduce the likelihood of an attempt, but may make the admission to the hospital less traumatic, and may preserve the therapeutic alliance as well. If the client is not in immediate danger of suicide, a range of supports should be put into place, including additional sessions, safety planning, means restriction, and mobilization of family and community supports. Additionally, referral to other forms of care may be necessary, including intensive outpatient services and/ or access to emergency mobile services. In all cases, consultation with a supervisor, colleague, or other agency staff is merited. Assessment and interventions are closely linked in the work with the suicidal client. In addition to taking necessary steps to assure the client’s safety, the worker will, as demonstrated in the following case illustration, work with the client on underlying mental health conditions and adverse life circumstances in order to decrease symptoms and increase adaptive functioning, all of which are intended to decrease suicidal risk.

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The following case illustrates the multifaceted work with a client who demonstrates many indications of risk for completed suicide: Ronald is a middle-aged male struggling with financial uncertainty secondary to economic recession, and is struggling with suicidal thought, overwhelming depression, interfamilial stress, and the complications of bereavement. The work with the client involves the critical tasks of both screening and assessing for suicidal risk and for “reasons for living, all within the context of an understanding of actual and potential internal and external resources and stressors. The worker demonstrates the importance of understanding the complex circumstances that give rise to an individual’s preoccupation with suicide and the need for interventions at several levels of the client’s world—the intrapsychic, the interpersonal, and the environmental. The worker highlights the affective, cognitive, and behavioral manifestations of the client’s despair, and intervenes at each of these levels.” Ronald is a 47-year-old white married father of three, who was referred to the community mental health center by his primary care physician. Ronald was a “reluctant” client at best; his wife, Linda, had struggled with him for months before succeeding in having him even agree to see their family doctor. Linda had begged, cajoled, and even threatened him with a marital separation, though she had no intention of separating from the man she loved. This last threat, however, seemed to work and Ronald, accompanied by his wife, kept his appointment with the family doctor. The previous six months had been challenging ones for Ronald and his family. He was quite close to his mother, who had died a year earlier after a prolonged battle with cancer. Following her death, his father, who had relied heavily on his wife emotionally and for even the basic tasks of daily living, even during her illness, “fell apart.” According to Ronald, this was not unexpected as his father had a long history of episodic “dark moods.” Ronald was the oldest

child in his working-class family, and the caretaking of his father fell to him. A younger sister lived nearby but was under-functioning herself, secondary to her alcohol abuse. Ronald’s younger brother lived across the country and had been estranged from the family for decades, claiming that he had been physically abused as a child by his father, a charge that Ronald refused to discuss. Unbeknownst to Ronald, during this time his father fell behind on his mortgage payments and was being threatened with foreclosure on the house Ronald had grown up in. Ronald was furious about this and increasingly fearful that he would have to assume the entirety of his mother’s caretaking function for his father. He confided in Linda that he felt trapped, by his father’s demands, but, more important, because his mother had extracted a death-bed promise from him to “take good care of Dad, so I can die in peace.” Because Ronald was now making daily sixty-mile round trips to check on his father after work, the couple agreed that though it would create its own problems, having his father live in their basement bedroom would be a better solution. Ronald negotiated with the bank that held his father’s mortgage and his father, George, angrily moved in with the family. At the same time, Ronald’s three children presented challenges of their own. The second-oldest, Kevin, was a senior in high school and had been picked up by the police for driving under the influence. Ronald was mortified. However, rather than becoming angry, he berated himself for “not being a good enough father.” He was also certain that Kevin’s behavior was related to having been “dislodged” from his room; Kevin had previously lived in the basement apartment but had to move back upstairs to share a room with his 13-year-old brother once his grandfather moved in. Ronald obsessed about the impact that having his father move in was having on his family and on Kevin in particular. The 13-yearold, always a loner, seemed to Ronald to be isolating further. Sarah, the oldest, a freshman in college, was living away from home for the first time and Ronald missed her enormously. She expressed worry about

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both her mother and father and came home every weekend. Like her maternal grandmother, she assumed responsibility for everyone around her and the comparison was not lost on Ronald. Things were not easy at work either. Ronald was a machinist and had been making a “good salary . . . not a lot, but I can take care of my family . . . I don’t need any handouts.” However, around the time that his mother died, a large international company bought out the company where he’d worked most of his adult life. New management reduced the workforce by 30 percent and sharply reduced employee wages and benefits. Ronald’s salary was now less than it was ten years earlier and his pension benefits were no longer secure. He felt that all of a sudden, “the rules to the game all changed.” To make up for part of the loss of this income, Linda increased her hours at the muffler shop where she had worked “mother’s hours.” This troubled Ronald, who, having seen the effects of his mother “overdoing” for his father, did not want Linda to have to work so hard at a job and take care of the home too. His ambivalence and resentment about her having to work full-time became a source of conflict between them. Having enjoyed a very satisfactory and low-conflict marriage, the couple was ill equipped to manage and resolve their mutual resentments. Linda felt she was “doing everything I can to help” but that Ronald was increasingly angry, frustrated, and isolative. It was at the point of a particularly difficult verbal exchange that Linda told him that if he would not keep an appointment she had made for him with the family doctor, she was leaving. Seeing Linda uncharacteristically angry convinced Ronald that at least to “keep the peace,” he’d keep the appointment. Fortunately, Ronald had been a patient of Dr. Langley for many years. It was readily apparent to the doctor that Ronald was not doing well. Ronald had lost twenty-five pounds since his physical a year earlier and he appeared drawn and downcast. Linda had insisted on accompanying Ronald to the appointment and was able to fill in the history of the previous six months. Ronald was somewhat guarded about the degree to which the family was

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experiencing difficulties. However, when the doctor mentioned that he’d remembered how close Ronald was to his mother, Ronald began to cry. Linda, who had never before seen her husband of twenty-five years shed a tear, became tearful herself. At this point, Ronald sobbed uncontrollably, stating that “I’m sorry, I’m a terrible husband. I have ruined our lives. I can’t live with myself. You’d be better off without me.” Dr. Langley expressed his concern for Ronald and gently suggested that he might be depressed. Ronald responded that he was not crazy and “I’m nothing like my father.” After further discussion, Dr. Langley consulted with the mental health worker at the clinic and was able to arrange for Ronald to be seen the next day. Dr. Langley shared his concern about Ronald’s condition with the couple and asked Ronald if he ever “thought about hurting himself.” Ronald said “not really.” The doctor assessed that he was not at immediate risk and asked that Linda “keep a close eye on” Ronald until the appointment the following morning. The following morning Ronald met with the social worker, Ms. M. He and Linda had talked a great deal the previous evening and he reported “this helped.” The social worker began by saying that she’d gotten the background information from Dr. Langley and acknowledged that there had been changes in nearly every area of Ronald’s life during the past year. Ms. M.’s immediate concern was for Ronald’s safety. Initially taken aback by the directness of her questions about any thoughts about suicide or hurting himself, Ronald soon appeared relieved. He indicated that increasingly he felt that “Everybody would be better off without me and while I still have a job, my life insurance benefits are good. With that money, Linda could make sure that Sarah could stay in college and Linda wouldn’t have to work as much. Also, there would be the Social Security survivorship benefits for Linda and each of the kids, even for Sarah because she’s in college. I don’t know what would happen about my father, though; I haven’t yet figured that out. I do feel bad about leaving Linda with that mess though. Maybe then my brother and sister would have to step up.” He paused and then added, “And I want to be with my mother.” The social worker

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was clearly right to have been concerned about Ronald’s safety. In addition to the clinical interview, Ms. M. used the agency’s suicide screening tool to further assess Ronald’s suicide ideation, intent, intensity of ideation, degree of planning, psychological pain, hopelessness, helplessness, perceived burden on others, and prior suicidal behaviors and substance use. In addition, his high score on the Beck Depression Inventory confirmed her suspicion that he was suffering with severe depression. On the positive side, Ronald had no prior history of suicidal or self-harming behaviors or intemperate use of substances. Though his marriage was currently strained, Ron and Linda were mutually supportive and satisfying and each considered the other “my best friend.” Currently socially isolated, the couple had, in fact, a group of long-term friends who could be potential supports. Prior to this time, Ronald had had no psychiatric problems, though there was a strong family history of both substance abuse and undiagnosed depression. In terms of access to means, Ronald had no firearms in the home. However, Ronald’s sense of hopelessness and helplessness was high and he felt that he was increasingly a burden to his family. He felt trapped in every direction: the situation with his father, the tenuousness of his job and income, and his unrelenting grief over his mother’s death. His cognitions were characteristic of depression; he was overwhelmed and obsessed with guilt and had lost any sense of selfefficacy. While he had made no suicide attempts and had not formulated a “plan,” he clearly had thought through at least the financial “benefits” of his death for his family. Disturbingly, these thoughts had formulated outside his consciousness; he appeared somewhat surprised himself at the degree to which he had considered the financial impact on his family. At the same time of course, he had either ignored or minimized the very deleterious effects his suicide would certainly have on Linda and his children. At that point, he had difficulty identifying any “reasons for living,” an important protective factor for suicidal clients.

Having made a connection with Ronald, the social worker obtained his permission to have Linda join them to talk about next steps. Ms. M. conveyed to the couple her concerns about Ronald’s depression, his suicidality, and the tremendous life challenges the couple were facing. Ms. M. felt it was important at this point to fully engage Linda; while Ronald was the identified client, Linda was going to play a critical role in his recovery. Furthermore, Linda herself was struggling as she too had been close to her mother-in-law and missed her support. Linda revealed that “if this were going on while Mother G. was alive, she’d be the first person I’d go to for help.” Linda was also enormously concerned about her husband and hearing the social worker ask about suicide frightened her. However, she acknowledged that this was “the elephant in the room. I realize every night and morning I say a prayer that Ronnie will be safe. I’ve never worried about his safety before. Somehow I knew that I might lose him. He’s always been so steady. My worry about his staying safe isn’t about his safety as a machinist, or about him driving or anything. I was just afraid he couldn’t take it anymore. And I don’t know what I’d do without him. He is the love of my life.” Ronald reached out to her at this point. It was clear to Ms. M. that the couple had the capacity to take refuge in each other and that that would be an important component of Ronald’s recovery. In work with suicidal clients, safety is always the first consideration. On the basis of her assessment and in consultation with Ronald and Linda, Ms. M. recommended an appointment with the agency psychiatrist for evaluation for antidepressant medication as soon as possible and twice-weekly sessions with Ms. M. and Ronald. Linda would accompany Ronald as needed. Initially, Ronald balked at missing any time from work to meet with Ms. M. Fortunately, she was able to offer at least one evening appointment. Ms. M. shared her risk assessment with the couple and asked Ronald and Linda to evaluate this as well. Ronald responded, “I feel a little more hopeful, but I don’t know if that will stay. I do know that I don’t want to hurt Linda.” Linda noted that she now didn’t feel “so alone” with this. Ms. M. reviewed with them

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warning signs that his risk level might be increasing and went over the crisis numbers and procedures. She gave them this material in writing as well, knowing that following an emotional evaluation assessment, it might be hard to remember everything that was recommended. Overall, Ms. M. did not feel that Ronald posed an immediate suicide risk, but the level of his depression and his current life challenges were concerning. She also recognized that suicidality could be fluid, particularly in someone who is very depressed. Thus, her recommendations included ongoing support and ongoing risk assessment (by her and the couple), as well as treatment of Ronald’s depression. Ms. M. conceived of her role as social worker on several levels. Trained in the delivery of mental health services, she was quick to identify the depression Ronald was struggling with and refer him for medication evaluation. As important as she considered the risk side of suicide assessment, she also knew that protective factors and the more dynamic conception of “reasons for living” would be important in both assessment and intervention. She also understood that this 47-year-old man’s sense of himself as provider and caretaker was being seriously undermined by his unexpected job and income instability. His unresolved issues with an abusive, depressed, and under-functioning father had been held at bay until his mother’s death. At that point he was faced with the challenge of fulfilling his beloved mother’s wish that he assume her caretaking role with his father. In order to honor her memory, he had had to repress both his old and his reactivated anger at his father, which only served to increase his sense of guilt. He was worried about his children as well. He silently worried that he’d not be able to afford to send Sarah back to college for her sophomore year and that she was taking on too much adult responsibility, as he had done. The legal issues facing Kevin were also weighing on him and he felt, perhaps rightly, that his son’s acting out might be related to his father’s uncharacteristic unavailability to him. Finally, he was afraid that his younger son, Carl, was just “getting lost in the shuffle.” These paternal concerns and responsibilities weighed particularly heavily on him,

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given that he had developed his own sense of fatherhood in a counter-identification with his own father. At the same time, the environmental stressors and transitions he faced were untenable. Clearly, his capacity to manage his psychological pain and the demands of his multiple roles was diminished in the face of too many environmental stressors and too few supports. Ms. M. recognized that while the amelioration of psychological symptoms was critical and the acquisition of insight useful in terms of resolving the crisis Ronald faced, environmental interventions were equally important. She referred the couple to their state’s office on aging in order to help them access resources for their care of his father. In the conjoint couple’s sessions, they identified family and friends who could provide emotional and social support to Ronald, Linda, and their children. In the individual work, Ms. M. used a variety of interventions aimed at reducing suicidal risk, decreasing depressive symptoms, and increasing adaptive functioning. Ms. M. hypothesized that as Ronald’s depressive symptoms abated, his suicidal risk would significantly decrease. She used an integrative model, which included cognitive behavioral interventions and psychodynamic theory (Heller & Northcut, 2010). By targeting his dysfunctional thoughts, e.g., “I am no good, everyone would be better off without me,” Ms. M. was addressing both his depressive symptomatology and his suicidal risk. She routinely assessed for suicidal thought and intent. She also systematically worked with Ronald to identify and examine disconfirming evidence of this “belief ” and others, so that he could achieve a more balanced and accurate view of his situation and his value to others. Ms. M.’s understanding of cognitive schemas and object relations theory was helpful in her understanding why these particular cognitive distortions were prominent for Ronald at this time. Ronald revealed that as a child, he became accustomed to his father’s accusing him of being “pretty useless” and a “bother.” As a child, however, this was balanced by his mother’s covert repudiation of that perspective; while she was careful of contradicting her husband, she effectively communicated to

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Ronald her belief that he was both important and valuable. Now, in the absence of his mother and the presence of increased pressure and negativity from his father, those early maladaptive schemas were reactivated. In order to recalibrate these negative self-appraisals, it was important for Ronald to address the “here and now” issues in the context of understanding both the genesis of these schemas and the dynamics that had reactivated them. At the same time, Ronald was able to begin to appreciate that the life he had constructed for himself, until this recent episode, had in fact helped to ameliorate some of those early maladaptive beliefs. For example, within the context of his marriage and as a previously highly valued employee, Ronald had in fact, lots of disconfirming evidence to the belief that he was “useless” and a “bother.” This realization was important too; it disconfirmed his related belief that “I’m no good, I’ve never been any good and that’s not going to change”—beliefs that now underscored his sense of helplessness and hopelessness.

incapacity has resulted in his no longer experiencing him as such a threat. He visits him once weekly at the facility. According to Ronald and Linda, the children have “settled down” and he has been doing a lot of fishing with his two sons, something he hadn’t done since his mother became ill. Sarah became fully engaged at school, coming home only on the occasional weekend.

Six months later, Ronald had made significant progress on all fronts. A trial of an antidepressant was effective and thoughts of “being gone” had disappeared. His company offered a fairly generous buyout option to employees with twenty-five years’ or more service. He was eligible and took it. Both he and Linda had some trepidation about his not working, but a month into retirement he was approached by an old high school buddy who had a small welding operation. He’d just lost his assistant and wanted Ronald to join him. It turned out this was a good fit and provided extra income. Linda was then able to attend a night course to become a medical billing specialist, something she had always wanted to do. This allowed her to eventually work from home on a contract basis with small medical groups. The couple faced an additional crisis early on when Ronald’s father, George, was diagnosed with WernickeKorsakoff ’s syndrome, an organic brain disorder related to his chronic alcoholism. This required intensive care, which the family was not able to provide at home. They made arrangements for admission to a nearby long-term care facility. While Ronald still has resentments toward his father, George’s relative

The outcome in the work with Ronald was positive. It required a range of skills on the part of the worker, a willingness and ability on Ronald’s part to explore many painful topics, and the availability of his wife to support the process. Through the work, Ronald not only re-embraced his life, but also developed skills that would help him to identify any future warning signs of depression and suicidality. For Ms. M.’s part, while she was pleased with the outcome, upon reflection, she was quite forthright about how frightened she was when she first understood the depth of Ronald’s despair. She noted that working with Ronald and his suicidal thoughts gave a whole new meaning to providing a “holding environment” with a client and family.

Ronald and Linda continued to miss his mother. He came to see his finding suitable care for his father as meeting his promise to his mother. He and Linda started gardening together in what they fondly termed the “Lorraine Memorial Garden” in their backyard, in honor of his mother who “was never happier than when tending her flowers.” In reflecting on his depression and the suicidal crisis Ronald still found it hard to believe that “things could get that bad,” but feels that in the process, “I learned a lot about myself and my family  .  .  . it’s good to be alive.”

conclusion Work with suicidal clients is very challenging for social workers and the agencies in which we work. Given that fully 90 percent of people who complete suicide have a diagnosable mental health condition and that social workers provide the bulk of mental health services in

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the United States, it is critical that the profession and individual social workers meet the challenge to commit ourselves to suicide prevention and intervention at all levels. Studies by Jacobson et al. (2004) and Heller and Parks (unpublished data 2011) indicate that 32 percent of social workers may have a client die by suicide and many more will have clients who attempt suicide or struggle with related suicidal behaviors and thoughts. The work with suicidal clients and their families requires several things: an awareness and use of the evolving literature on suicide risk, shifting demographics and effective interventions, excellent social

work engagement and intervention skills, and a commitment to suicide prevention at micro and macro levels. Furthermore, one of the hallmarks of the experience of the suicidal person is the experience of “being alone in the world”; the social worker must be willing to meet the client as a human being as well as a professional. This experience may give new meaning to the importance of “meeting the client where the client is.” Through the use of self-reflection, self-care, and supervision and consultation, the social worker must be willing to “go to the dark places” with the suicidal client, while balancing hope and despair.

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hen terror strikes, it leaves a path of destruction in its wake—a path that extends beyond the immediate victims and survivors. The impact of terrorist threats and attacks is often widespread, reaching throughout the society and changing life as we know it. The terror attacks of 9/11, for example, resulted in the deaths of nearly 3,000 and the displacement of another approximately 4,000 people. Many more accessed local services in New York City. For example, the crisis hotline of the NYC Mental Health Association received calls from more than 80,000 people, and Safe Horizon, a care management clearinghouse, was contacted by more than 170,000 (Waizer, Dorin, Stoller, & Laird, 2005). Social workers were called into action to respond to those in need in New York City and throughout the United States. Increasingly, a public mental health approach to responding to terrorist attacks is advocated (Friedman, 2005). Such an approach focuses on providing broadly targeted prevention efforts as well as early identification and intervention services for those deemed to be at highest risk for developing significant distress. The emphasis is not on treating illness but rather on promoting wellness. While most people exposed to mass violence or terrorism experience extreme distress immediately following such events, the majority of survivors are ultimately resilient (Bonanno, Westphal, & Mancini, 2011), with only approximately 30 percent developing a psychiatric disorder (Friedman, 2005). Efforts to normalize psychological reactions to terrorism and reduce the stigma of using mental 484

health services were made in the wake of 9/11, as well as efforts to provide appropriate training for clinicians (Amsel Neria, Marshall, & Suh, 2005). More work in these areas is needed and social workers are well placed to contribute their expertise to these efforts. defining and explaining terrorism No single definition of terrorism is universally accepted (Amnesty International, 2012). A central component of most definitions of terrorism is that it involves deliberate attacks on civilians or does not distinguish between civilian and non-civilian targets (Scheinin, 2010). Amnesty International views terrorist attacks as human rights abuses, serious violations of national and/or international criminal law, and war crimes in the context of armed conflicts (Amnesty International, 2012). The act of defining and offering an explanation for terrorism and terrorist acts is controversial and political. Several key areas of debate revolve around (1) what behavior is considered an act of terrorism, and (2) whether the term terrorism should apply to the actions of states (governments) as well as to the actions of nonstate actors. Most governments have defined terrorist acts to exclude governmental actors. Efforts to agree on a definition of terrorism that is legally binding and to adopt an international convention on terrorism are impeded by the lack of consensus on these issues (Brennan, 2011). Terrorists are considered criminals by governments that are victimized by their actions or plots. One’s perspective defines who is classified as a terrorist versus a freedom fighter.

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The United Nations (UN) Security Council views terrorist acts as a threat to international security and peace. Such acts include actions carried out by individuals or by groups that may be sponsored by a state (Brennan, 2011). In 2001, after 9/11, the UN Security Council unanimously adopted an anti-terrorism resolution (Resolution 1373) and made it mandatory for all UN member states (UN Security Council, 2001). The UN Security Council (2004) Resolution 1566 provided a nonbinding definition of terrorism as: “criminal acts, including against civilians, committed with the intent to cause death or serious bodily injury, or taking of hostages, with the purpose to provoke a state of terror in the general public or in a group of persons or particular persons, intimidate a population or compel a government or an international organization to do or to abstain from doing any act” (p. 2). Despite this UN definition, states are still left to come up with their own definitions of terrorism, a situation that has led to contradictions and ambiguities (Brennan, 2011). Terrorist acts have occurred throughout the world for centuries. Some examples from recent history include the Oklahoma City bombing in 1995; the 9/11 attacks of 2001 in New York, Virginia, and Pennsylvania; the 1998 bombing of U.S. embassies in Kenya and Tanzania; the 2005 bombing of the London transit system; and the 2003 Jemaah Islamiyya bombing of the Marriott Hotel in Jakarta, Indonesia. Social workers in the United States should be aware that some refugees, asylum seekers/asylees and immigrants that they encounter might have survived terrorist attacks and/or other forms of severe human-perpetrated trauma in their homelands years earlier. These prior traumas may continue to affect their mental health functioning and as a result inevitably influence their reactions to new terrorist threats or attacks they may experience in the United States. The U.S. Code of Federal Regulations defines terrorism as “the unlawful use of force and violence against persons or property to intimidate

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or coerce a government, the civilian population, or any segment thereof, in furtherance of political or social objectives” (28 C.F.R. Section 0.85). The FBI classifies acts of terrorism as either domestic or international (DOJ, n.d.). The U.S. Criminal Code defines terrorism as “an activity that (1) involves a violent act or an act dangerous to human life that is a violation of the criminal laws of the United States or of any State, or that would be a criminal violation if committed within the jurisdiction of the United States or of any State; and (2) appears to be intended to intimidate or coerce a civilian population, to influence the policy of a government by intimidation or coercion, or to affect the conduct of a government by assassination or kidnapping” (18 U.S.C. 3077). For purposes of this chapter, we will focus on acts of terrorism and their consequences that have taken place within the United States. We address the impact of terrorist acts on those who survive and the broader community and society rather than on the perpetrator. No matter how one defines terrorism, the consequences and impact on individuals, family, communities, and society are considerable. demographic Patterns Clearly, the impact of terrorist acts cuts across geographic region (e.g., Oklahoma City 1995; 9/11 attacks in New York, Virginia, and Pennsylvania 2001) and group memberships (e.g., age, gender, race, ethnicity, religion, sexual orientation, and social class), and has severe immediate and long-term consequences. As observed in the aftermath of the terrorist attacks in Oklahoma City, 9/11, and other such tragic and traumatic events, “No one who witnesses the consequences of mass criminal violence is unaffected by it” (HHS, 2004, p. 31). The cost of terrorist actions is often debilitating, creating mass casualties and numerous victims (HHS, 2004). Such deliberate acts of sudden and widespread damage violate the social order and have far-reaching and devastating physical and psychological consequences.

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A: Community victims killed and seriously injured Bereaved family members, loved ones, close friends B: Community victims exposed to the incident and disaster scene, but not injured C: Bereaved extended family members and friends Residents in disaster zone whose homes were destroyed First responders, rescue and recovery workers Medical examiner’s office staff Service providers immediately involved with bereaved families, obtaining information for body indentification and death notification D: Mental health and crime victim assistance providers Clergy, chaplains Emergency health care providers Government officials Members of the media E: Groups that identify with the target-victim group Businesses with financial impacts Community-at-large fiGure 23.1

While researchers have noted that physical proximity to traumatic events increases the likelihood of experiencing traumatic symptomatology (Schlenger Caddell, Ebert, Jordan, & Batts, 2002; Schuster et al., 2001); the findings of several studies indicate that even those who do not experience the event directly can be affected negatively (Galea & Resnick, 2005; Pfefferbaum et al., 1999; Pfefferbaum et al., 2001). The population exposure model (see Figure 23.1) (Burkle, 1996; Tucker Pfefferbaum, Nixon, & Foy, 1999; Wright, Ursano, Bartone & Ingraham, 1990) posits that those individuals

most personally, physically, and psychologically exposed to the traumatic events following terrorist actions are the ones most likely to be affected (HHS, 2004). At the same time, this model recognizes that beyond the direct victims/survivors (i.e., those killed or injured) and their bereaved family members and social networks (including loved ones and close friends), there are others who are also deeply affected to varying degrees, such as disaster and trauma professionals (e.g., health care providers, emergency service personnel) who care for survivors (Palm, Polusny, & Follette, 2004).

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Finally, the population exposure model argues that in order to provide effective interventions after a terrorist attack, service providers must consider both the community perspective and the individual psychological impact in order to promote recovery and well-being (HHS, 2004). Societal context The societal context, including the social and physical environment, is a potential source of support and/or stress for survivors of terrorism. The societal context is multifaceted, and different components of it may transact to affect the well-being of survivors. The societal context is particularly relevant to the discussion of terrorism because the target of terrorism is society— and society is forever changed through terrorist threats and acts. These events may lead to an escalation of ongoing conflicts such as in Israel and Palestine, or to the start of a war (e.g., post9/11). Terrorist acts often result in multiple casualties, including those who are injured or killed, damage to buildings and infrastructure, and the evacuation or displacement of the nearby populace. The primary targets of the act of terrorism, however, are generally not those who may be killed or the direct target—those are rather the means toward a larger goal (Schreiber, 1978). The real targets are the survivors, and the ultimate aim is to instill fear and terror in society (Friedman, Hamblen, Foa, & Charney, 2004). Terrorists seek to intimidate and coerce civilians and governmental policy makers, or influence a government’s conduct through acts such as kidnapping or assassination (U.S. DOJ, n.d.). Terrorism is often defined in terms of its intent of inducing terror and eroding “the very fabric of a society” (Hamaoka, Shigemura, Hall, & Ursano, 2004, p. 531). The fact that terrorism is human perpetrated and intentionally inflicted makes a huge difference in the response, including often damaging the survivor’s ability to trust in others. People may question whom they can trust and if they are or ever can be safe again. Some may become

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hypervigilant, remaining on guard for another threat or attack. Given the wide scope and everchanging targets of terrorism, it is difficult for a society to ever fully protect or prevent all further attacks. In the United States, we have seen increased resources devoted to homeland security and building local, state, and national programs and policies to protect us from and respond to these threats. Some of these efforts (e.g., body scans and tighter security at airports, The Patriot Act and other legislation that expanded government intrusion into our lives and enhanced presidential authority, stricter immigration laws) have become part of the new norm of society. Terrorists strategically seek to invoke feelings of shock, horror, and fear in members of the targeted society in order to achieve their aims (Ayalon, n.d.; Hamaoka, Shigemura, Hall, & Ursano, 2004; Friedman, Hamblen, Foa, & Charney, 2004). According to Hamaoka et al. (2004), “Terrorism can be thought of as a psychological assault that challenges the society’s sense of safety, security, and cohesion” (p. 531). The terrorist act typically provides a clear demonstration of the perpetrator’s power of a destructive nature and can serve as a form of blackmail (Ayalon, n.d.). Terrorists do not always select specific victims. Rather, the direct victims are sometimes arbitrarily chosen on purpose, in part to make a point that the terrorist acts can and may occur anywhere at any time (Ayalon, n.d.). This is an insidious aspect of some acts of terrorism. It means that large groups of people (including civilians) or the society as a whole can be potential victims of terrorism—and this threat, in and of itself, can be traumatizing, inducing intense fear and taking a psychological toll. A given individual or community/society may experience a one-time unexpected terrorist act where the circumstances are such that they are unlikely to expect another attack from the same perpetrator in the future (e.g., individual acting alone who dies). Alternatively, under different circumstances (e.g., act was

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conducted by a group that remains active and able to continue to inflict harm), an individual or members of a community/society may begin to live in fear of future terrorist attacks, and live with chronic fears of a diminished future. Residents of and visitors to New York City had pronounced feelings of being on guard following 9/11. The level of fear and apprehension was exacerbated for some New Yorkers by the color-coded Homeland Security Advisory System (HSAS) established six months after 9/11 (CNN Wire Staff, 2011). Many tuned into media broadcasts, some on a daily basis, to learn of the current color-coded risk level. The levels ranged from green (low risk of a terrorist attack) to red (severe risk) and varied from area to area (being higher in some areas, especially highprofile public areas). The level of tension in the populace was particularly heightened around holidays and at anniversary dates of 9/11. “‘The old color coded system taught Americans to be scared, not prepared,’ said [House Homeland Security Commission] ranking member Rep. Bennie Thompson, D-Mississippi. ‘Each and every time the threat level was raised, very rarely did the public know the reason, how to proceed, or for how long to be on alert’” (CNN Wire Staff, 2011). The National Terrorism Advisory System (NTAS) finally replaced the color-coded HSAS system in 2011. This new system was designed to provide more detailed and timely information to governmental agencies, transportation hubs, first responders, and the public. No longer were there to be constant alerts or a “blanket warning that there is an overarching threat” (U.S. DHHS, 2011). Hopefully, that change will make a difference in the impact on the wellbeing of Americans. The circumstances of terrorist events, as well as individual and societal responses, influence the resulting sequelae. The social and physical environment may be compromised in the case of a terrorist attack, such that resources that may have proven to be supportive prior to the attack are no longer

available or able to adequately attend to the survivors’ and society’s needs. The environment may become a source of stress as images of destruction, death, or injury may serve as a trigger, reminding of the terrorist attack and leading to associated distress. Often these images are shown over and over on television or in print and other media sources. Graphic television images of the planes crashing into the Twin Towers, for example, people jumping from the towers, images of the rubble, and people searching for their loved ones transfixed many Americans in the days and weeks after 9/11, including those far from “ground zero.” Some children were also exposed to these images as parents, teachers, and others struggled to try to explain to them what they were witnessing. For those who had experienced other traumas earlier in their lives, direct or indirect exposure to a terrorist event often is re-traumatizing. Kinzie and colleagues (2002) studied secondary traumatization from media images of 9/11 in a diverse group of previously traumatized refugees from five war-torn countries. They found significant reactivation of PTSD symptoms and recommended that clinicians anticipate this in refugees who are reexposed to significant trauma, even if indirectly through the media (Kinzie, Boehnlein, Riley, & Sparr, 2002). The way the media portray terrorist events may also have an impact on the assumptions (positive or negative), prejudice, stigma, and fear of some members of the public toward those they perceive to be connected with or similar to the perpetrator(s) in some way (DHHS, 2004). Television and other media may also be used in a positive way, however, as part of a public mental health approach targeting the community or broader society (Friedman, 2005). The enormity of the terrorist attack, level of destruction, grotesqueness of the images of those killed or maimed in the attack, and the implication or assumption that one’s own community or neighborhood could be targeted

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adds to the level of distress felt by individuals and communities (Hobfoll et al., 2007; Reissman, Klomp, Kent, & Pfefferbaum, 2004). Another important aspect of the societal context is the level of depletion of psychosocial or economic resources as a result of the attack (and/or due to prior traumas or economic disadvantages) and the concomitant negative impact on individual and societal coping (Hobfoll et al., 2007). The extent to which a society is prepared or able to respond to a terrorist act also can have a deep impact on the outcomes for individuals, families, and communities. Often, trained and experienced responders and service providers who are from the area hit are also affected. This may include emergency responders, health and mental health professionals (including clinical social workers), social service providers, faith communities, and governmental, nonprofit, and voluntary groups from the area who may be struggling to cope and attend to their own immediate and longer-term survival needs. Providing services to others in their community may trigger their own reactions and/or compromise their ability to be most effective in their response (Bills et al., 2009; Perrin et al., 2007). Much work has been devoted in recent years by governmental and nongovernmental agencies around the world to developing guidelines and resources for preparing in advance for responding to terrorist attacks and other public health disasters (Ben-Gershon, Grinshpoon, & Ponizovsky, 2005; Reissman, 2004). Such efforts will hopefully make it easier for communities to respond quickly to identify and assist those who are most at risk and vulnerable. Vulnerabilities and risk factors While “the level of exposure to the traumatic events and the stressors associated with that event are highly correlated with mental health outcomes, especially in ‘most exposed’ groups, not all traumatic events and stressors are equal

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in their potential for psychological impact” (DHHS, 2004, p. 12). Green (1993) has posited eight dimensions of traumatic exposure associated with posttraumatic stress: 1. 2. 3. 4. 5. 6.

Threat to life and limb Severe physical injury Receipt of intentional injury Exposure to the grotesque Violent/sudden loss of a loved one Witnessing or learning of violence to a loved one 7. Learning of exposure to a noxious agent 8. Causing death or severe injury to another In the aftermath of terrorism, many of these dimensions are present. Additionally, the level of community trauma increases when there are both a large number of victims relative to non-victims and large numbers of fatalities and serious injuries (HHS, 2004, p. 12; Tierney, 2000). A range of biological, genetic, personality temperament, and socioeconomic factors as well as prior traumatic life events have been shown to contribute to the survivor’s vulnerability to traumatic events (HHS, 2004). Examples of survivor risk factors include a prior, preexisting, or family history of psychiatric disorder or substance abuse (psychological factors); neuroendocrine vulnerability; early and prior traumatization; family instability; age (very young and very old more at risk); female gender; low education level; poverty; severity of post event stress; and lack of social support (Norris et al., 2002; Watson, Brymer, & Bonanno, 2011). Women have a higher prevalence of depression, anxiety, and PTSD and may have increased vulnerability to the impact of trauma due to sociocultural and biological factors (HHS, 2004; Watson, Brymer, & Bonanno, 2011). Other factors documented to influence mental well-being following a terrorist event include: intensity of the impact, extent and

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nature of the event, availability of community resources, prolonged recovery/rescue efforts, multiple additional deaths, and missing physical remains of the deceased. Terrorist acts that result in a significant number of deaths and serious injuries can be expected to have profound and long-lasting physical, emotional, and financial effects on many survivors and family members (HHS, 2004). Aldrich and colleagues (2010) studied approximately 13,000 fire department rescue workers who responded to 9/11 in New York City and found that their exposure to dust from the World Trade Center led to significant declines in their lung functioning and that most did not recover over the following six years. Residents, workers, and students in lower Manhattan and surrounding areas exposed to poor air quality and toxic dust also experienced health in addition to mental health problems (WTC Medical Working Group, 2011). Those far from the site of a terrorist attack may also develop symptoms of distress. This may be due to such phenomenon as the impact of media exposure and/or knowing others who were directly exposed. Schuster and colleagues (2001) conducted a survey three to five days after 9/11 with a nationally representative sample comprised of 560 adults in the United States accessed through random-digit dialing. They found high levels of distress in adults throughout the country. Ninety percent had one or more symptoms of distress, 44 percent reported at least one substantial stress symptom, and 36 percent viewed terrorism as a somewhat or very serious problem where they lived or worked. These adults reported that 35 percent of their children had at least one symptom of stress, and that nearly half (47 percent) of their children were anxious about the safety of themselves or loved ones. The authors recommend that communities and clinicians far from the geographic site of the attack needed to be prepared to respond to the aftermath of terrorist disasters.

resiliencies and Protective factors Bonanno (2004) has defined resilience as “the ability of adults in otherwise normal circumstances who are exposed to an isolated and potentially highly disruptive event such as the death of a close relation or a violent or lifethreatening situation, to maintain relatively stable healthy levels of psychological and physical functioning” (p. 20). A growing body of evidence suggests that most people are resilient, reporting little or no psychological distress, continuing to meet their responsibilities and engaging in the world around them (Bonanno, Galea, Bucciarelli, & Vlahov, 2007). In fact, the majority of individuals who experience terrorism are resilient, with only about a third developing mental health problems, with the biggest negative impact being fear (Friedman, 2005). Researchers have pointed to a number of factors that serve to enhance resiliency during and after traumatic events. Among these are individual personality traits and the absence of psychiatric problems or substance abuse problems. In addition, individual, attributional styles, family stability, social support and resources, coping self-efficacy, and a range of biological factors also serve as protective factors (Ehlers & Clark, 2000; Kaniasty & Norris, 1999; HHS, 2004; Watson, Brymer, & Bonanno, 2011). Table 23.1 (HHS, 2004, p. 15) highlights key risk and resiliency factors. The ability to evaluate these risk and resilience factors in consideration with the survivor’s degree of trauma and loss exposure (as outlined by the population exposure model described earlier) can serve as a way to identify the survivors who are most vulnerable and those most likely to be resilient (HHS, 2004). Programs and Social Work contributions Social workers are ideally suited to build on the strengths and resilience of individuals, families, and communities affected by terrorism given the strengths base of the social work profession. Social workers can and do play vital

SurViVorS and VictimS of terroriSm ta b l e 2 3 . 1

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Survivor Characteristics

Survivor Groups’ Characteristics [sic]*

Resiliency Factors

• Prior or pre-existing mental health or substance abuse problems • Prior traumatization or unresolved losses • Female gender • Low socioeconomic status, low education • Family instability, conflict, single-parent household • Perceived or real lack of social support, isolation • Overuse of coping strategies such as avoidance and blaming self or others

• Relative mental health, absence of history of diagnosable psychiatric problems • Capacity to tolerate emotions and cope flexibly with symptoms associated with trauma and bereavement • Self-perception of having ability to cope and control outcomes • Higher socioeconomic status, higher educational level • Immediate and extended family providing practical, emotional, and financial support • Effective use of social support systems

Vulnerability Factors Source: U.S. Department of Health and Human Services. (2004). Mental Health Response to Mass Violence and Terrorism: A Training Manual. DHHS Pub. No. SMA 3959. Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, 11, 15.

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roles across the spectrum of services related to terrorism (Gitterman & Malekoff, 2002; Miller, 2012). They are among the professionals who work closely with individuals, families, and communities providing crisis intervention, psychological first aid, and a range of preventive and psychotherapeutic interventions, as well as engaging in community-organizing efforts. They serve as administrators of health, mental health, social service, and civic organizations that serve survivors of terrorist events. Social workers engage in social policy both from within and outside of governmental institutions. They help to shape policies in a variety of arenas such as in schools, clinical or social service agencies, and local, state, and national governmental bodies to better prepare these entities for preventing or responding to the impact of terrorist events. In the 212th U.S. Congress, there were seven social workers serving in House of Representatives and two in the Senate (Manning, 2011). The Congressional Social Work Caucus (CSWC) was inaugurated during the 11th Congress. Its mission, in part, is to represent the interests of the 600,000 social workers and their constituencies and evaluate and monitor legislation and programs designed to assist communities, individuals, and families faced with social, health, and economic

problems (see http://socialworkcaucus-towns. house.gov/about-me/purpose-mission-goals). A wide range of programs has been developed in the United States to prepare for and respond to terrorist events. Project Liberty, a federally funded crisis intervention program that was established in New York City following 9/11, is a good example of a large specialized effort to meet the needs of survivors of that terrorist event in New York City. Its services included, in part, a targeted media public education campaign, outreach, efforts to link survivors with services, community support groups, and crisis intervention. Many communities, however, particularly those in less urban or prominent locations, have very few if any specialized programs to respond. Most must rely on less-specialized general governmental and private health, mental health, community, and social services whose staff may not have training or experience regarding trauma, not to mention terrorist attacks. Concerted efforts have been made to train and support mental health providers who work with individuals and communities affected by terrorism (Amsel, Neria, Marshall, & Suh, 2005; Norris, Watson, Hamblen, & Pfefferbaum, 2005; Pawlukewicz, 2003). In addition, the efforts of volunteers, including preexisting or newly

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formed interfaith or community groups, have been significant. Social workers play key roles in efforts to reduce the stigma, misinformation, and prejudice that exist in society toward those who are different from oneself that, in some cases, may fuel acts of terrorism or acts of violence toward those perceived to be similar in some way to those who engaged in terrorist acts. In the aftermath of 9/11, for example, acts of violence and threats based on religious bias were made toward Sikhs who wore turbans (the perpetrators misperceiving them to be Muslims) and women who wore headscarves throughout the United States. Hate crimes against Muslims and Islamic institutions increased between 2000 and 2001 according to FBI statistics (from twenty-eight to 481 incidents with 554 victims; U.S. DOJ, 2001). All those who share the characteristic with the victims that led them to be stereotyped and targeted are affected. Some of the authors’ torture survivor clients from these groups were targeted and attacked after 9/11. The authors, along with their and other torture treatment organizations, were among the broad-based interdisciplinary, governmental, and community efforts following 9/11 to promote greater understanding and acceptance across diverse groups and support peaceful resolution to conflict following 9/11. Social workers have long embraced diversity and not condemned whole groups or peoples because of the actions of a few. This orientation and commitment is embedded in and supported by the Social Work Code of Ethics (NASW, 2008). Interfaith community efforts to promote peace and greater understanding, with participation from social workers, emerged in New York City, Los Angeles, and other parts of the country post 9/11. Social workers can help to be a catalyst for these efforts, and work in a collaborative interdisciplinary way in affected communities. Outreach to allied professional groups and individuals and diverse parts of society is valuable (Brymer et al., 2006; Watson et al., 2011) in

increasing access to needed services following a terrorist event as well as in preparedness efforts. While firefighters, paramedics, and police officers often prefer to talk to one of their peers if they seek assistance after a traumatic incident, many employee assistance programs (EAPs) also include social workers on their staff. While some emergency service personnel, among others, have traditionally been known to be concerned about the impact of accessing EAP services on their jobs and careers, efforts to destigmatize seeking help and normalizing distressing reactions to terrorism and other traumatic events has increasingly made EAP services a viable option (J. Brakeman, personal communication, July 15, 2012). In addition, the pervasive nature of the impact of 9/11 on organizations and their staff has made it more acceptable to focus on the well-being of employees, further supporting the important role of EAPs (Haaz, 2011). EAPs also typically provide an affordable and accessible avenue of care for their employees. Given that the majority of those who survive a disaster, including a terrorist attack, do not seek services (Watson et al., 2011), social workers can play an important role in identifying those most in need of services and in increasing outreach and access to appropriate and effective services. More widespread and specialized training in empirically supported treatments is needed to develop a core of social workers (and other mental health professionals) around the country who can respond appropriately and effectively to the physical, psychological, spiritual, and communal/societal needs of terrorist survivors and the broader society. Some social workers are already specialists in this area and may be well suited to conduct this training. To be most effective, training should be accompanied by ongoing supervision and consultation. This combination has been shown to be effective in training community providers to deliver services that are empirically supported and in improving practitioners’ fidelity in delivering them (Hansel et al., 2011; Ruzek, Friedman, &

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Murray, 2005; Watson et al., 2011). Some multidisciplinary teams that provide training and consultation to other behavioral health specialists are headed by social workers. Such training and ongoing consultation efforts are vital in making appropriate and specialized services available to survivors of terrorism as well as expanding access to care for those who may not otherwise pursue or obtain mental health services (Watson et al., 2011). In 2004, the U.S. Centers for Disease Control’s Senior Advisor for Disaster, Terrorism, and Mental Health advocated for mental and behavioral health specialists to take on new roles to enhance community preparedness for and responses to terrorist and other public health disasters (Reissmann, 2004). The potential role for social workers in this work is thus conceptualized broadly and calls for strong assessment and intervention skills across domain and level. assessment and interventions Understanding the factors that put individuals, families, groups, and communities at risk of maladaptive coping or functioning, and/ or other problems following a terrorist threat or attack is valuable in guiding assessments and shaping interventions. This must be done within an ecological person:environment perspective, including assessing the fit or lack of fit of the person and his or her capacities, characteristics and needs with the physical, social, and cultural environment, as well as his or her adaptedness and adaptation (Gitterman & Germain, 2008). The complexity of the relationships between people and their environments, broadly considered, including their impact on the survivor’s coping must be attended to as well. The transactions between the person and his or her environment are continually occurring and most people experience periods when there is not a fit, even more so after such a disruptive event as a terrorist threat or attack. The Life Model approach to social work practice (Gitterman & Germain, 2008) provides a valuable approach for understanding

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the biopsychosocial-cultural-spiritual factors that affect survivors of terrorism and offers a framework for working with them. This model draws on an ecological systems’ perspective that models practice “on life itself, its processes of growth, development and decline, its methods of problem-solving and needs-satisfaction as understood in the trajectory of the life span” (Bandler, 1963, pp. 42–43, as cited in Gitterman & Germain, 2008, p. 71). The model facilitates and supports the client’s potential for growth and social functioning, at the same time working to make the environment more responsive to the client’s goals, needs, and rights. It aims to improve the level of fit between persons and their environment by social work practice that promotes the reduction or elimination of life stressors by (1) assisting persons to activate and utilize environmental and personal resources, and (2) exerting influence on environmental entities (both physical and social) to be more responsive to the needs of people. Social workers and other professionals must understand that distressing reactions to terrorist attacks or threats should not be viewed or labeled as pathological and not all survivors exhibiting symptoms of distress will go on to develop a mental health disorder (Hobfoll et al., 2007). In the face of such a potentially life threatening event, it is “normal” (one might say expected) to develop difficulty sleeping, traumatic memories, and efforts to avoid situations or places (e.g., tall buildings post 9/11) that remind them of the attack or other distressing symptoms. Current approaches to intervention in the field of disaster mental health are increasingly directed toward those identified to be in particular need, compared to past efforts that were targeted toward the overall population (Watson et al., 2011). Effective assessment approaches are vital to identify those most in need. When assessing individuals exposed to terrorist events, social workers should include the dimensions of traumatic exposure outlined earlier in this chapter that appear to be

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associated with post-traumatic stress (Green, 1993). In addition to risk factors specific to the survivor, the characteristics of the stressor also contribute to the type and extent of posttraumatic symptoms experienced by a survivor. The survivor’s response to trauma is also shaped by the extent and nature of the resources, support, and social response they receive (Briere & Scott, 2006). Typically, social workers have a lot of experience in conducting needs assessments to identify and deal with a wide range of needs of individuals and communities. Some of the most common significant needs of survivors of terrorism include: • Emergency and longer-term medical care for those injured or whose health has been affected (e.g., by breathing toxic dust from collapse of World Trade Center that has been linked to cancer) • Emergency shelter and food, as well as longer-term support to meet basic needs for those displaced by a terrorist act • Grief support for those who lost loved ones—this can take many forms (e.g., support groups, religious or spiritual support, community memorial services, grief counseling) • Resumption of normal routines (especially for young children) In 2004, a collaborative effort by multiple U.S. governmental agencies resulted in the publication of a training manual for mental health responses to terrorism (DHHS, 2004). The development of this manual was a joint project of the U.S. Department of Justice (DOJ), Office for Victims of Crime (OVC), and the Center for Mental Health Services (CMHS) of the Substance Abuse and Mental Health Services Administration (SAMHSA). The manual has a host of relevant training materials and checklists that span screening, assessment, intervention, and cultural considerations with different affected subgroups that can serve as a valuable

resource for social workers and allied mental health professionals working in this field. It includes work with children, adults, older adults, families, and communities as well as organizational preparation and response. The materials are modified for different age and cultural groups. The screening and assessment checklist for adults affected by terrorism includes the following areas: exposure to trauma and loss, identification of risk and resiliency factors, current psychological distress, how they coped with prior significant stressors, the extent and availability of social support, and present urgent concerns (HHS, 2004). Assessment of traumatic bereavement is also recommended. The survivor’s physical health must also be assessed. Some additional areas of screening and assessment of older adults include current living situation; history of medical conditions prior to the terrorist attack; current physical and psychological distress; and the older adult’s cognitive, sensory, and behavioral needs and abilities (DHHS, 2004). Social workers who screen and assess children and adolescents exposed to terrorist attacks need a strong grounding in developmental phases and the different ways that trauma impacts this population. In addition, the person:environment and social ecological models provide a valuable framework to examine the multiple effects and interrelatedness of various relevant social elements in an environment. Bronfenbrenner’s (1979) Ecological Systems Theory examines the micro- (individual or interpersonal level), meso- (family or organizational level), exo- (community level), and macro- (intercultural level) factors and influences and the continual interaction between the person and the environment. The context in which people experience a terrorist attack is always a relevant factor that can impact their reactions and the course of their recovery. For children and adolescents, the context would include such elements as their stage of psychosocial development, their family and

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life situation, and the makeup and quality of their caretaking relationships (HHS, 2004). Social workers may find valuable supports and resources in the family, school, and/or community. With young children, it is particularly important that the assessment of exposure to trauma and loss as a result of terrorist attacks must take into account both objective and subjective factors (given their limited developmental ability to understand what is happening and distinguish fact from fantasy). In addition to covering the same set of factors one would with adults of any age, there are a few other areas to pay particular attention to, including changes in behavior, emotions, and social and academic functioning; ongoing stressors at school in addition to home; and the impact of traumatic reminders in their school or home environment (HHS, 2004). For all age groups it is important to obtain a thorough history of past exposure to other traumas, particularly recent or unresolved traumas. While it has long been observed that exposure to trauma is associated with increased substance use and comorbid substance use and mental health problems such as PTSD and depression in some survivors, limited literature exists examining the relationship between terrorist or other disasters and substance use (Pfefferbaum et al., 2002; Reijneveld, Crone, Schuller, Verhulst, & Verloove-Vanhorick, 2005). An increased use of substances following 9/11 was detected in one study conducted five to eight weeks after the attack (Vlahov et al., 2002). The authors found that depression was more commonly associated with an increase in the use of cigarettes, alcohol, and marijuana post 9/11 and concluded that the increased use of different substances may be associated with comorbid mental health conditions, including PTSD and depression. A complete assessment of those who survive terrorist attacks should include a thorough examination of substance use history. Further study is needed to determine the factors associated with post–terrorist

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attack substance use, whether increased use in the immediate aftermath of such an attack is a short-term response aimed at adapting to the disaster or related to other mechanisms, and the longer-term course of substance use post– terrorist attacks (Pollack, 2009). In addition to assessing the impact of a terrorist attack on individuals and identifying their individual needs, it is important to do a broader contextual assessment. Do the survivors and the larger systems they are embedded in (including family, community, society) have the internal and external resources they need to cope and function adequately (or be resilient). With terrorist attacks, sometimes the infrastructure (including the resources needed to help survivors and the community in the immediate aftermath and longer term) are rapidly depleted or wiped out. A public mental health strategy to responding to a terrorist attack would involve intervening at multiple levels (e.g., societal, community, family, and individual) at the same time. Friedman (2005) presents an inverted psychosocial pyramid that conceptualizes such a strategy and includes the following types of interventions: building safety, capacity building, public education, training, self-help, counseling and other clinical interventions, and policy coordination. Bonanno, Westphal, and Mancini (2011) argue that interventions aimed at large groups of or all survivors of a disaster may not be beneficial and may work against the natural coping strategies and abilities of survivors. Most survivors of disasters are resilient and not all need services (Watson et al., 2011). There are many approaches that have been used to intervene following terrorist and other public health disasters. Some, such as Critical Incident Stress Debriefing (initially developed for debriefing first responders such as police, firefighters, and paramedics in groups), gained early popularity, but current thinking in the field has shifted away from these approaches for use with survivors of terrorist attacks (Brymer et al., 2009; Gray & Litz, 2005; Watson et al., 2011).

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Practical help (e.g., obtaining food and shelter), psychoeducation, and psychological first aid (PFA) are currently thought to be more useful than debriefing approaches following a disaster (NCPTSD, 2010). Evidence-based PFA is most commonly endorsed for early intervention with distressed families, adults, and children following mass violence and disasters (e.g., Bryant & Litz, 2009; National Commission on Children and Disasters, 2010). PFA aims at meeting the immediate practical and psychological needs of survivors, promoting safety and stabilization, supporting coping, and linking survivors with needed resources (Brymer et al., 2006). For the purpose of this chapter, we will only discuss those interventions that have a strong evidence base. We will highlight some of those most supported in the literature at present and encourage readers to access the sources cited here for more in-depth coverage of these approaches. Interventions need to be individualized to the unique characteristics and circumstances of the individual, family, or community. One size does not fit all. No matter the particular approach taken, adherence to the principles of trauma-informed care is recommended (Briere & Scott, 2006; Herman, 1997). The Substance Abuse and Mental Health Services Administration’s National Center for Trauma-Informed Care (SAMHSA’s NCTIC), a technical assistance center that promotes trauma-informed care, is a good source of information (see their website at http://www.samhsa.gov/nctic/). Among the most commonly used and/or promising interventions with this population that are appropriate for use by social workers (some with strong evidence base) are Trauma Focused Cognitive Behavioral Therapy (TFCBT) (with variations developed for different populations), crisis intervention (Waizer et al., 2005), psychological first aid, brief family therapy (Wells, 2006), psychosocial support and therapy groups, and case management. Cognitive behavioral therapy (CBT) is action oriented and represents an integration of

cognitive restructuring and behavioral modification. CBT assumes that maladaptive behavior and emotions that interfere with effective daily functioning are caused by flawed and unhealthy patterns of thought. The intervention focuses on changing the person’s thought patterns in order to change his or her emotions and behavior. CBT is a relatively short-term form of therapy, typically delivered in a series of sessions lasting up to sixteen weeks. It has been found to have positive effects on terrorismrelated PTSD in uncontrolled studies, similar to the findings with other disaster survivors (Gillespie, Duffy, Hackmann, & Clark, 2002). Among the components of CBT often delivered post-disaster are gaining knowledge about one’s symptoms of post-disaster distress, journaling, learning a breathing technique to control one’s anxiety, systematic desensitization, building a repertoire of positive coping activities and skills, behavioral homework assignments, cognitive rehearsal, and restructuring one’s thoughts to be more positive and supportive of healthy functioning. School-based delivery of CBT interventions with children and adolescents who have experienced mass trauma is supported by several studies (e.g., Berger & Gelkopf, 2009; Berger, Pat-Horenczyk, & Gelkopf, 2007; Jaycox et al., 2010). Variations to the traditional CBT model of treatment have been made tailored to postdisaster response. Three of these approaches, all found to result in significant improvement in post-disaster symptoms, are briefly described here (Brewin et al., 2008; Brewin et al., 2010; Hamblen et al., 2009; Levitt et al., 2007). Readers are encouraged to consult the sources for more details. Hamblen and colleagues (2009) utilized a manualized disaster-specific intervention with adults. This intervention did not focus on adults with a specific diagnosis (such as PTSD), but more broadly on behavioral, emotional, and cognitive reactions to the disaster. Levitt and colleagues (2007) modified a prolonged exposure model of intervention, adding skills training in patterns of interpersonal relating and

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affective regulation. After the London bombings in 2005, Brewin and colleagues (2008, 2010) employed a screen-and-treat approach that was effective in increasing the detection and referral of individuals affected by the disaster compared to usual referral processes. In addition, social workers and allied professionals have employed various interventions targeted at the community level. For example, community interventions may include organizing rituals, memorials, anniversary commemorations, community gatherings, and symbolic gestures (HHS, 2004). The psychosocial capacity building approach to responding to disasters advocated for by Miller (2012) engages local members of the affected community in all stages of disaster response and has been effectively applied in diverse communities around the world. Miller defines psychosocial capacity building as “intervention, provided by professional and nonprofessional people, both local and from the outside, that constitutes a multisystemic, culturally grounded, empowermentand resiliency-oriented approach designed to help individuals, families, social groups, and communities recover from a disaster. Psychosocial capacity building seeks to be sustainable over time and builds on the foundation of local capacities and resources” (p. 191). Efforts to understand what factors support community resilience following trauma have been challenged by conceptual difficulties in identifying key components and in implementing and evaluating communitylevel interventions (Watson et al., 2011). Miller (2012) identifies eleven key practice principles of psychosocial capacity building, including the following: outside disaster responses must be careful to do no harm; understanding the social ecology of the disaster is vital; building the capacity of the local people, institutions, and community supports is essential as they will be there long after the outsiders have left; meaningmaking is an important task for survivors and their communities; the process and conclusions of meaning-making vary across cultures; groups

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are helpful in promoting much-needed social cohesion and connectedness post-disaster; multisystemic interventions are most effective and link individual and family healing with the recovery of the community; psychosocial healing helps to promote social justice and peace (and social justice and peace promote healing); fostering resilience, stressing efficacy, and encouraging individuals and communities who have experienced disaster to tap into their strengths promotes recovery; organizations should include and support selfcare efforts for their disaster response members; evidence-based interventions should be used when possible; and local people should be involved in determining what is evidence and in the development and implementation of evaluation of the interventions. This approach is well suited to the ethical foundation and practice principles of social work interventions with individuals and communities affected by terrorist events. Social workers also have an important role to play in helping to shape policies to address the needs of survivors and their communities and to prepare for possible future attacks. In doing so, social workers are exerting influence over the social and physical environments in order to shape them to be more responsive to the needs of survivors of terrorist attacks. Hobfoll and his colleagues (2007) identified the following five key intervention principles that have been empirically supported for use in cases of ongoing mass violence and disaster (for early and midterm interventions): (1) promoting a sense of safety, (2) promoting calming, (3) promoting a sense of community efficacy and self-efficacy, (4) promoting connectedness, and (5) instilling hope. These principles have been acknowledged internationally as useful for both intervention and to guide research. As there is a lack of sufficient randomized controlled trials to date for interventions with mass violence and disaster, these principles are considered “evidence informed” (Hobfoll et al., 2007).

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In the immediate aftermath of 9/11, an international expert consensus group was formed by six federal agencies (National Institute of Mental Health, 2002) to address early-intervention issues after mass violence. Various products came out of this group’s efforts and a number of international and national consensus documents were written. Watson and colleagues (2011) summarize the commonly agreed upon recommendations and guidelines developed by these expert groups regarding behavioral health interventions following disasters such as terrorist attacks. Rather than being reactive, experts agreed that it is important to be proactive, making preparations before the disaster strikes. Practitioners need to be flexible, willing to reevaluate and make changes to their plan or intervention as needed. Emphasis is placed on being practical and realistic. Attention is paid to phases of recovery and making sure that the services offered are appropriate to the phase. In keeping with the principles outlined by Hobfoll and colleagues (2007), interventions at every level must be delivered in such a way to promote calming, a sense of safety, hope, connectedness, and efficacy. Health and mental health professionals have at the heart of their professions the mandate to “do no harm.” The experts agreed that this principle, as applied to the realm of interventions in situations of disasters, included the importance of coordinating the efforts of the various groups to avoid duplication of response and fill gaps in services; keeping in mind demand and available resources when planning interventions; remaining updated on and using effective evidence-based interventions; making sure that one’s interventions are culturally sensitive and supportive of human rights; integrating evaluation of one’s interventions; and remaining open to external review and evaluation (Watson et al., 2011). As much as possible, social workers should include the locally affected population in their intervention response and build on and work with locally available resources

and capacities. These may be friends of survivors, their family, or members of their school or larger community. The experts agreed that stand-alone services should be minimized as much as possible. Instead, they favored integrating services into larger existing service systems in order to maximize the number of affected people that can be served as well as promoting less stigma and enhancing the sustainability of the services. The experts recommended that interventions be multilayered and engage the media and make use of the Internet to target and support the larger affected community. People should facilitate efforts to promote various approaches to communal healing that attend to cultural, memorial, spiritual, and religious practices relevant to those affected. A wide range of services are needed (Watson et al., 2011), including in part: • Making sure that basic needs are met (e.g., housing, food, safety)—social work’s expertise in needs assessment and case management are valuable here • Individual-level assessment that includes immediate triage, screening to identify those at high risk, monitoring the functioning and distress of survivors over time, and in-depth assessment of individuals who exhibit more severe signs of distress or more compromised functioning • Intervention at the community level to assess and monitor community needs and conduct evaluation of intervention programs • The provision of psychological first aid and support that is geared to enhance resilience • Outreach activities and providing information • Training, ongoing consultation, and technical assistance to local providers • Evidence-based treatment of individuals who are not functioning well or who

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exhibit ongoing distress (e.g., Trauma Focused Cognitive Behavioral Therapy— see http://tfcbt.musc.edu/ for more information) Finally, the experts concurred that disaster interventions required a “stepped care” approach (Watson et al., 2011). Such an approach offers early practical help and support widely while saving more intensive and specialized interventions for the minority who require additional services. Recent literature highlights the benefits of employing interventions tailored to the stage of recovery and length of time since a terrorist attack, as well as being sensitive not to push those who demonstrate resilient trajectories into interventions (Watson et al., 2011). To date, early psychological intervention in the first month following a disaster has very little research evidence (Brymer et al., 2009; La Greca & Silverman, 2009; Ruzek et al., 2008). With time, most people affected by disasters, including terrorist attacks, will recover without professional intervention. This process can be made easier with the right kind of help (NCPTSD, 2010). In the immediate aftermath of a disaster, people need to feel safe, calm, and connected to other people. Crisis intervention programs, such as the Crisis Counseling Program of the Federal Emergency Management Agency (FEMA) for those who have survived federally declared disasters, is one approach that aims to address this. FEMA programs have been the targets of much criticism, particularly following Hurricane Katrina (Morris, 2006; DHHS, 2006), yet have provided much needed (if insufficient) federal resources for individuals, families, and communities affected by disasters. Practical assistance to ensure that survivors have the basic resources (e.g., safety, food, shelter) they need that will enable them to cope and, in some cases, rebuild their lives, is vital at this stage. Support from family, friends, school, and community can serve as valuable

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resources as well. Providing practical assistance is at the core of many disaster response programs and typically comprises the core of immediate intervention services. Vernberg and colleagues (2008) lay out the guiding principles and core intervention actions of the evidence-informed PFA approach in their Psychological First Aid Field Operations Guide (PFA Guide). PFA is considered a best practice for use with children, adults, and families in the immediate aftermath of a terrorist event or other disaster. The eight core actions of PFA are designed to be tailored to the individual and context, and include contact and engagement, safety and comfort, stabilization, information gathering (e.g., regarding problems that require immediate attention, monitoring those most at risk, and identifying risk and resilience factors to work with), practical assistance, connection with social supports, information on coping, and linkage with collaborative services (Vernberg et al., 2008). Detailed information and guidance on these actions and useful handouts are included in the PFA Guide, and practitioners seeking to implement PFA are encouraged to thoroughly read this resource. More research is needed, however, to evaluate PFA interventions. The provision of public education to promote resilience in the community is also a common intervention approach. Such education may be provided on the Internet (e.g., materials on the websites of organizations such as the National Center for PTSD or the International Society for Traumatic Stress Specialists), through the media, or by disaster recovery professionals, including social workers. Typically, this education covers such topics as common reactions to disasters, strategies to strengthen positive coping and resilience, how to provide support to loved ones and one’s community, and when and how to find health and mental health services if needed. PFA is geared to providing survivors of disasters with assistance in the immediate days or

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weeks after the disaster during the crisis phase and sometimes in the early part of the recovery phase. In contrast, Skills in Psychological Recovery (SPR) provides services and aid during the recovery phase, after the initial crisis period has receded, the immediate basic needs of the survivors have already been met, and the person needs more intensive intervention than PFA (Berkowitz et al., 2010). SPR is a training program developed by the National Child Traumatic Stress Network/National Center for PTSD. It is an evidence-informed flexible skillsbased approach to serving families, adults, and children with moderate distress that is solution focused (Berkowitz et al., 2010). SPR is a type of secondary prevention and is not intended to be a model of mental health treatment. It is an intermediate form of intervention aimed at reducing survivors’ distress and the need for professional mental health treatment through identifying and building on coping skills to enhance their functioning. At the heart of SPR is the teaching of skills to develop more effective problem solving, ways to cope with stress and disaster reactions, a plan for healthy and meaningful activities, more effective and positive patterns of thinking, and healthy social networks and community supports. This skill building is intended to promote resilience post-disaster. SPR is an example of a training program that has been developed for teaching interventions that can be delivered by paraprofessionals following disasters and other traumas (Watson et al., 2011; Berkowitz et al., 2010). Social workers are among those who deliver these trainings. Interventions aimed at the community and building its resilience are often provided at these early or intermediate stages (Miller, 2012; NCPTSD, 2010). These interventions may include various spiritual, religious, memorial, cultural, and/or other communal practices aimed at healing. Such community-based activities often assist in making meaning of the event and grieving the losses of the community and its members. Efforts are made to use

already existing resources or those that develop naturally after a terrorist attack or other disaster. Community interventions also support the members’ returning to normal routines as quickly as possible and building a positive and hopeful outlook on the future. Even if they receive PFA, crisis intervention, or SPR, some survivors of terrorist attacks may still exhibit serious distress and be in need of more in-depth treatment for anxiety (including panic or PTSD), depression, or guilt. In terms of mid- to long-term interventions, the aim is to treat and prevent psychopathology (Bryant & Litz, 2009). CBT has the most empirical support compared to other intervention approaches at this stage for both adults and children who have experienced a disaster or an incident of mass violence (Brymer, Steinberg, Watson, & Pynoos, 2012; Watson et al., 2011), although it is not the treatment of choice for everyone. Miller (2012) cautions that CBT and other Westerndeveloped models of intervention are most consistent with a Western orientation toward pathologizing reactions to disasters and targeting recovery services toward the individual as opposed to the community or collective. The National Association for Social Workers (NASW), like most professional health and social service organizations in the United States, has established a set of standards for its members related to cultural competence. There are ten NASW standards related to cultural competence aimed at improving social work services for diverse clients and communities covering the following domains: ethics and values, self-awareness, cross-cultural knowledge, cross-cultural skills, service delivery, empowerment and advocacy, diverse workforce, professional education, language diversity, and cross-cultural leadership (NASW, 2001). Social workers are tasked with, in part, remaining ever conscious of the uniqueness of each client within their larger social context. Social workers are called upon to recognize their own cultural biases, confront the effects of discrimination and racism, and continually reevaluate their

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experiences with and attitudes toward people of different social classes, genders, sexual orientations, ages, physical and mental abilities, and spiritual and religious beliefs. The American Psychological Association has a similar set of standards (APA, 1993). Both professions stress the importance of not using a Eurocentric or monolithic lens when working with clients, as well as being aware of one’s countertransference and how that affects the lens with which we view the population and clients we work with. NASW’s standards stress that, for a service system to be culturally competent, it must manifest all of the following at every level of the system: “(1) value diversity, (2) have the capacity for cultural self-assessment, (3) be conscious of the dynamics inherent when cultures interact, (4) institutionalize cultural knowledge, and (5) develop programs and services that reflect an understanding of diversity between and within cultures” (NASW, 2001, p. 12). Ethnocultural issues have not been extensively addressed in the post-disaster intervention literature, with some notable exceptions (Marsella et al. 2008; Norris and Alegria 2006; Watson et al., 2011). Among the recommendations made by these authors for working with minorities who have survived disasters are making sure to provide services in the best language of the survivor, gathering adequate information about the survivor’s concepts of recovery, and addressing his or her basic needs and the barriers he or she may have to accessing care. In 2003, the U.S. Department of Health and Human Services published a set of guidelines and recommendations for the development of cultural competence for disaster mental health programs. Nine principles were included that advocated for respecting diversity and recognizing the importance of culture; a profile of the community’s cultural composition should be developed and kept up-to-date; disaster workers should be recruited to be representative of the area served; staff should be provided with cultural competence training on an

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ongoing basis; services must be appropriate, accessible, and equitable; the role of traditions and customs, help-seeking behaviors, and natural support networks should be recognized; community leaders and organizations that represent the diverse cultural groups in a community should be involved as “cultural brokers”; information and services must be linguistically and culturally competent; and the level of cultural competence of the program should be evaluated (DHHS, 2003). Despite these guidelines, there is the danger that some practitioners may stereotype or reify the culture of others. Some advocate for cultural humility rather than competence to help to address this danger (Tervalon & Murray-Garcia, 1998; see also Miller & Garran, 2007, regarding racism and the importance of looking at the racism within as well as outside). Cultural humility involves the practitioner’s engaging in a process of self-critique and self-reflection of his or her worldview throughout his or her lifetime. Practitioners are to start by examining their beliefs and assumptions about their interactions and goals with their clients. This approach differs markedly from that of cultural competence, which aims instead to identify and respond to the “culturally specific traits” of someone from a given culture. The practitioner operating from a standpoint of cultural humility actively seeks to disrupt the traditional power imbalance between provider and client and enter into a partnership built on respect where the client is recognized as the expert of his or her own experience. The practitioner is to maintain an open, accepting, and respectful attitude toward diverse perspectives. In this model, it is the relationship between two different perspectives that comprises the cultural difference. Rather than reserving this approach only for use with those who are culturally other than oneself, it is recommended that the reflective attentiveness of the cultural humility approach should be used in all interactions. Cultural responses must be considered when planning interventions. The 2004 DHHS

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training manual recommends attending to the following: the meaning of the disaster and emergency response to members of the affected cultural group(s); the influence of culture on practices and beliefs regarding trauma, healing, death, mourning, and burial; history of exposure to violence and other trauma in the United States and their country of origin (if applicable); impact of culture on the expression of signs and symptoms of posttraumatic stress and other types of anxiety, grief, and depression; impact of culture on views about mental health providers and mental health; and cultural norms regarding greetings, family composition, and other professional courtesies (DHHS, 2004). Providing the necessary multifaceted services to survivors of terrorist attacks can place numerous competing stressors on helping professionals and result in their developing symptoms of traumatic stress and physical health problems (Bills et al., 2009; Palm et al., 2004; Pawlukewicz, 2003; Perrin et al., 2007). Social workers who choose to engage in this work need a robust support system and attention to self-care in the organizational (e.g., structured ongoing opportunities for supervision to process the impact of the work on themselves), professional (e.g., training), and personal (e.g., maintaining adequate sleep patterns, physical exercise, and good nutrition, and scheduling time to debrief) realms (Amsel, Neria, Marshall & Suh, 2005; Bell, Kulkarni, & Dalton, 2003; Danieli, 2005; Herman, 1997; Norcross & Guy, 2007; Palm et al., 2004; Pross, 2006; Trippany, Kress, & Wilcoxon, 2004). illuStrAtion And diSCuSSion

In order to effectively meet the many needs of victims and survivors of terrorist attacks, social workers must be able to work within different levels of the various systems within which their clients function (i.e., the individual, family, and community levels). For young people, the school setting is one of the most influential service systems, as schools can provide

a safe and stable environment within the extensive chaos that terrorist acts can create. Social workers working within educational systems can provide direct interventions for this population, including teaching effective ways to handle stress and providing support and guidance around issues of loss and traumatic reactions. An example of such an intervention is a school-based psychoeducational group developed for vulnerable students with a history of refugee trauma, war, and human rights abuses who were further traumatized by the 9/11 terrorist attacks (Akinsulure-Smith, 2009). The goals of this particular brief group intervention were to provide emotional and behavioral stabilization and symptom relief through trauma education and training in stress-management skills. The group is composed of “Jesse,” “Maria,” and “Markus” (not their real names). It illustrates some of the benefits of group following a terrorist attack. Jesse lost several members of her immediate family as a result of terrorist attacks in Columbia; Maria was separated from her family and fled the brutal civil war in Sierra Leone; and Markus and one sibling fled to the United States from Yugoslavia. All of these young people were devastated by the events of 9/11. Teachers and guidance counselors in their schools identified them, like the others referred to this group, when their grades began to slip dramatically and they reported a range of emotional difficulties post-9/11. Each described in detail where they were when the planes crashed into the towers and described a resurgence of a deep fear of “Here too? I thought I was safe now . . .” All had experienced extensive losses as a result of their prior traumatic events that were exacerbated by 9/11. Markus reported that his first fear was for the well-being and whereabouts of his brother. Jesse resigned herself to a belief that she would never see her parents again (even though she had left them at home when she went to school that morning). Maria reported wandering around in a daze. In the group sessions, all participants were able to mourn the abrupt loss of their newfound sense of safety and the resurgence of old symptoms

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(nightmares, exaggerated startle responses, hypervigilance). Markus and Maria reported that the increased military and police presence brought back terrible memories of the war scenes in their home countries. Witnessing the deaths of so many through the media also served to heighten all their traumatic responses. All group members reported that the emotional and practical support from other group members comforted them in their grief. They felt understood as the other teenagers in the group from other countries also had reactions to 9/11, meaning that they “weren’t crazy.” While the group facilitators provided coping strategies, they also learned healthy coping techniques from each other and built a strong support network that helped to reduce the growing sense of isolation that they had described to the facilitators during the assessment phase. The group leader facilitated this discussion, building on the strengths of the group (e.g., Markus’s meditation practice and problem-solving skills, Jesse’s strong support from extended family, Maria’s deep sense of faith); all elements that they reported helped them during their prior traumatic experiences. The leader provided trauma education and taught stress-management skills to support the members’ emotional stabilization and symptom relief. The leader connected the group members and their families to practical resources. When working with individuals, families, or communities in the aftermath of a terrorist attack, group services can serve as an effective intervention as it offers multiple therapeutic benefits, including normalizing the range of reactions, reducing isolation, building social support networks, and teaching new and healthy coping skills; most important of all, it can offer all of these benefits to several survivors and affected populations at the same time (Gitterman & Shulman, 2005). Social workers working in such settings can provide group services, emphasizing survivor strengths and improving coping skills. In developing a group

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service for this population (as with any other), social workers must have a clear sense of the purpose and objectives of the type of group service they plan to offer (i.e., Will the group be for direct survivors or for affected populations? Will it be for children, youth, or adults?), thoughtfully manage assessment procedures (i.e., group member screening—inclusion and exclusion and selection process), make clinical decisions regarding group structure and format (short- or long-term group) and interventions (psychodynamic, cognitive behavioral, or integrative), manage group dynamics, and make decisions regarding co-facilitators. Finally, the clinician must have a solid understanding of the principles of trauma therapy and clinical care (Briere & Scott, 2006; Herman, 1997).

conclusion In the more than a decade that has passed since 9/11, we have learned a great deal about the psychosocial impact of terrorism, what response strategies show promise, and the importance of becoming better prepared for the possibility of future terrorist attacks (Felton, 2004; Stein et al., 2004; Watson et al., 2011). Much more, however, needs to be done. Further refinement and development of intervention strategies for this population are needed along with the expansion of resources available to ensure that services are more accessible. Further research and evaluation of responses to terrorism are also needed (Watson et al., 2011). Terrorist attacks and threats have a profound effect on individuals, families, and societies—even those who are far from the immediate target zone. Most survivors are resilient, however, and only a minority will develop serious mental health problems. The impact of such events depends on the multifaceted person:environment transactions and a person’s level of fit with his or her environment as well as a variety of risk and vulnerability and protective and resiliency factors. Social workers have the training and orientation to provide early identification of those survivors who are

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most vulnerable, assess the multiple risk factors and effects, and provide a wide range of interventions matched to the needs and characteristics of the affected individuals, families, and communities. They are often valuable members of interdisciplinary teams providing services to affected survivors and communities. Social workers are well suited to build on the strengths and resilience of survivors of terrorist events given the profession’s strengths-based

approach and orientation. Increasingly there is a role for social workers and allied professionals to contribute to a preventive public mental health approach to terrorist events as well as to shaping new and more responsive policies. Social workers should continue to help move the evidence base forward to better assist survivors of terrorist events and work with communities to prepare for future possible attacks or threats.

referenceS

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cHaPter 2 4 Survivors of torture S. meGan bertHold

“Life has not been easy for us The war has brought us and our families untold suffering But the suffering has not broken our spirits It has only strengthened our resolve to succeed at life as we start over again” Sudanese Women’s Refugee Group of Salt Lake City, Utah 2003, p. 25.

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fficially sanctioned or perpetrated torture flourishes in many countries around the world, in times of war and in times of peace (Amnesty International, 2012; Engstrom & Okomura, 2004). Torture is used to suppress those who are deemed to be a threat to those in power, instilling fear in society and suppressing opposition. Members of political opposition parties working for democratic elections in their country or those who advocate for the rights of women and girls are targeted. Torture is directed toward those who fight against the persecution and murder of LGBTQ people or who are trying to freely practice their religion. People are also tortured for being from a particular ethnic group or nationality, or due to mistaken identity or because the person is in the wrong place at the wrong time. Women selling street food in a zone frequented by rebels have been accused of supporting the rebels and tortured by the military, when in reality they were apolitical and just trying to feed their family. Regardless of the reasons, torture has profound affects on the individual, family, and community. Amnesty International documented torture in 101 countries in 2011 (Amnesty International, 2012). Torture is a widespread practice despite the fact that international law has established that all humans have the right to be free from

cruel, inhuman, and degrading treatment (UN General Assembly, 1984). Torture violates the fundamental freedoms and human rights contained in the United Nations’ Universal Declaration of Human Rights (UN General Assembly, 1948), and most domestic legal systems around the world prohibit torture. In ratifying the United Nations Convention Against Torture (UNCAT), the United States agreed to abide by the following proscription: “No exceptional circumstances whatsoever, whether a state of war or a threat of war, internal political instability or any other public emergency, may be invoked as a justification of torture” (UN General Assembly 1984, Article 1). Torture is always illegal with no exceptions. Torture can never be justified, yet not everyone defines torture in the same way. Social workers in the United States practicing in a wide variety of settings may encounter refugee, asylum seeking, and asylee1 or immigrant survivors of torture. Specialized knowledge and skills are needed to ask the right questions and provide effective services to torture survivors. defining and explaining of torture Definitions matter. What is deemed to be stateinflicted or -sanctioned torture or other forms of official persecution and what is not can 509

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make the difference between who is eligible for asylum in the United States and who is not. It can mean the difference between whether the torture survivors are allowed to remain in the United States or whether they will be deported to their home country where they may be in danger of being tortured again and possibly murdered by the authorities. Various definitions of torture exist, including those in the World Medical Association’s (WMA) Declaration of Tokyo (1975) and the United States’ Torture Victims Relief Act (TVRA) (1998). The most widely accepted definition of torture internationally, however, is that contained in Article 1 of the United Nations Convention Against Torture and other Cruel, Inhuman or Degrading Treatment or Punishment (UNCAT): ‘Torture’ means any act by which severe pain or suffering, whether physical or mental, is intentionally inflicted on a person for such purposes as obtaining from him or a third person information or a confession, punishing him for an act he or a third person has committed or is suspected of having committed, or intimidating or coercing him or a third person, or for any reason based on discrimination of any kind, when such pain or suffering is inflicted by or at the instigation of or with the consent or acquiescence of a public official or other person acting in an official capacity. It does not include pain or suffering arising only from, inherent in or incidental to lawful sanctions (UN General Assembly 1984, Article 1.1).

Most definitions of torture include the concepts that torturers intentionally harm others, pain or suffering is always inflicted, and the relationship between the torturer and the tortured is one of power vs. defenselessness (Basoglu, 1992). The perpetrators are government officials or someone who has the consent of the authorities. The perpetrator may also be someone whom the authorities cannot or will not control (e.g., a guerilla group or the militia who may be torturing someone who the government wishes

to be harmed or with the acceptance of the authorities). In countries where torture occurs, perpetrators commonly are found amongst members of the military, police, detention or prison officers, paramilitary forces, or statecontrolled counterguerilla forces. The reasons for torture can be many. Torture is often used as a means to persecute, punish, or coerce someone into making a confession or providing information. Frequently people are targeted for torture by the authorities due to their political opinions, nationality, race, religion, or membership in a social group (these are the same grounds for persecution found in the definition of refugee; United Nations Protocol, 1967). The United States is a signatory to the UN’s Convention Against Torture; however, a federal statute provides more details regarding how the United States defines torture independent from UNCAT: ‘torture’ means an act committed by a person acting under the color of law specifically intended to inflict severe physical or mental pain or suffering (other than pain or suffering incidental to lawful sanctions) upon another person within his custody or lawful control (18 U.S.C. 2340(1) 1998).

This statute (the Torture Victims Relief Act) defines “severe mental pain or suffering” as: “(1) the intentional infliction or threatened infliction of severe physical pain or suffering; (2) the administration or application, or threatened administration or application, of mind-altering substances or other procedures calculated to disrupt profoundly the senses or the personality; (3) the threat of imminent death; or (4) the threat that another person will imminently be subjected to death, severe physical pain or suffering, or the administration or application of mind-altering substances or other procedures calculated to disrupt profoundly the senses or personality” (18 U.S.C. 2340(1) 1998).

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The definition of what constitutes severe physical or mental pain has been contentious (Basoglu, Livanou, & Crnobaric, 2007). Some draw the boundary more broadly in terms of what they define as torture, to include such acts as domestic violence or torture in the context of child abuse. The focus of this chapter will be on officially sanctioned or state-sponsored torture. demographic Patterns The task of determining with any precision how many torture survivors there are worldwide or in the United States is impossible. The fact that torture is generally conducted clandestinely, away from public scrutiny, complicates the task. Furthermore, the way in which torture is often inflicted leaves survivors feeling fearful and ashamed and unlikely to report the abuse for fear of repercussions from the torturer or their community. Even for those survivors who manage to escape to a different country, many keep the fact of their torture closely guarded, living in fear of being detected and deported to their homeland where their lives may be in jeopardy. The best prevalence estimates come from the United Nations and human rights watchdog groups such as Amnesty International. According to the 2012 Amnesty International Report of 155 countries and territories worldwide, systematic torture and ill-treatment occurred in 101 countries in 2011 (Amnesty International, 2012). The United Nations High Commissioner for Refugees reported that in 2011 there were more than 42 million forcibly displaced persons worldwide for the fifth year in a row (UNHCR, 2012). More than 800,000 people became refugees for the first time in 2011, the highest number since 2000. By the end of 2011, there were 15.2 million refugees, 26.4 million internally displaced persons (IDPs), and 895,000 seeking asylum worldwide. Afghanistan (2.7 million), Iraq (1.4 million), Somalia (1.1 million), Sudan (500,000) and the Democratic Republic of the Congo (491,000) produced the most refugees in 2011. UNHCR had 25.9 million persons on its refugee and IDP caseload in 2011 (these are

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the latest annual figures available at the time of this writing). Refugees have withstood and survived multiple traumas and stressors, including such experiences as war, deaths of family and friends, starvation, dislocation, loss of country and culture, and the challenges of adjusting to a new country. In addition, many have been subjected to torture, with studies in western countries of relocation finding a prevalence range of 5 to 35 percent of torture survivors among refugees (Wentzel, Kastrup, & Eisenman, 2007). The Office for Refugee Resettlement (ORR) utilized this prevalence range in 2000 when it initially called for proposals to serve torture survivors, further estimating that there may be as many as 500,000 torture survivors in the United States. Torture treatment experts around the United States believe that this is an undercount. Most refugees and asylum seekers/asylees in the United States come from Sub-Saharan Africa, the Middle East, Asia, Eastern Europe, and Latin America. According to the Department of Homeland Security’s (DHS) Annual Flow Report, in 2011 the greatest number of refugees admitted to the United States (out of a total of 56,384 persons) came from Burma, Bhutan, and Iraq (Martin & Yankay, 2012). Texas (10 percent), California (8.8 percent), New York (6.3 percent), and Pennsylvania (5.3 percent) had the highest percentage of newly admitted refugees in 2011. This was the first year ever since state-level residence data were collected that California did not receive the most new refugees. An additional 24,988 individuals were granted asylum in the United States in 2011, with the leading countries of nationality being China (34 percent), Venezuela (4.4 percent), Ethiopia (4.3 percent), Egypt (4.1 percent), and Haiti (3.5 percent), accounting for over half of all those granted asylum. Seventy-six percent of those granted asylum by the DHS (as opposed to grants by an immigration judge for which these data are not yet available) were between 18 and 44 years old, and the median age was

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28 years. More than half (51 percent) were male and 43 percent were married. The leading states of residence for these asylees, representing approximately two-thirds of the total, were California (38 percent), Florida (17 percent), and New York (15 percent). More information about refugees and asylees in the United States can be found on the U.S. Office of Immigration Statistics website at http://www. dhs.gov/ immigrationstatistics. Torture is inflicted upon people of all classes, races, ethnicities, genders, ages, and sexual and religious/spiritual orientations, although the patterns of who is oppressed and at risk for torture varies from country to country and sometimes from one region to another within a given country. While anyone can be subjected to torture, human rights defenders, politicians and members of opposition political parties, union leaders, journalists, health professionals, student leaders, and members of ethnic and religious minorities are common targets. Reports from groups such as the U.S. State Department, Amnesty International, and Human Rights Watch document torture and other abuses around the world on an annual basis; however, ta b l e 2 4 . 1

their findings are only as accurate and complete as their sources. Some acts and types of torture never make it to the pages of these reports. For example, this author recalls being questioned as an expert witness on the stand in an asylum hearing some years ago about a male applicant who claimed to have been sodomized in prison in Iran. The judge referred to the recent State Department report that made no mention of such acts in Iranian prisons. The author apparently satisfied the judge on this point (he granted asylum), referring to the extensive medical and psychological evidence related to this applicant’s claim in the record, the author’s and her colleagues’ professional experience in treating scores of other Iranian males who had been sodomized in prison, and providing ample psychological and cultural evidence as to why the applicant (and others similarly situated) would not want to reveal sexual torture to authorities (he had only revealed it to the author after extensive therapy). Table 24.1 summarizes the most common types of torture. Beatings and threats are two of the most widespread forms (Quiroga & Jaranson, 2005, 2008). Generally a person is

Summary: Most Common Types of Torture*

1. Blunt Trauma: crushing injuries, whipping, beatings 2. Penetrating Injuries: gunshots, shrapnel, stab wounds, slash cuts 3. Suspension (e.g., by their wrists or ankles for several hours or days) 4. Burns: chemical, thermal, and electric burns (inflicted with cigarettes, electricity from power outlets or stun guns, hot irons, gas torches, ice, hot liquids, acids) 5. Asphyxiation: wet (submerging face in fluids such as filthy water, urine, or excrement), dry (covering face with plastic bag), and chemical (forcing their victims to inhale chemicals or dust) 6. Electric Shocks (often electric probes are placed on sensitive organs, such as earlobes and genitalia) 7. Forced Human Experimentation (by health professionals) 8. Traumatic Removal of Tissue and Appendages such as earlobes, hair, and nails 9. Extreme Physical Conditions (e.g., forced body positions and prolonged constraint, extreme heat/cold conditions without shade, water, or appropriate clothing) 10. Sexual Torture: sexual humiliation, trauma to genitalia, rape 11. Mental or Psychological Torture: direct threats (including death threats), sensory deprivation, isolation/solitary confinement, mock execution of the individual or their loved ones, witnessing torture or death of others, uprooting Adapted from Boston Center for Refugee Health and Human Rights (2009). Caring for victims of torture: A free online course. Copyright © 2005, 2009. http://www.bu.edu/bcrhhr/pro/course/course_index.html.

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Sources: American College of Physicians, 1995; Forrest, 1995; Goldfeld Mollica, Pesavento & Stephen, 1988; McIvor & Turner, 1995; Petersen & Rasmussen, 1992; Rasmussen, 1990; Shrestha & Sharma, 1995; Skylv, 1992; Sommier Vesti, Kastrup, & Genefke, 1992; United Nations, 2001; Weinstein, Dansky, & Iacopino, 1996.

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subjected to multiple types of torture, a practice designed to evoke in them a sense of hopelessness and lack of control. Nearly all torture involves some type of psychological torture. Most torture victims are subjected to physical and psychological torture simultaneously, and rape and sexual assault of both males and females (minors and adults) also occur frequently as part of the overall torture. The International Criminal Court, as well as the International Criminal Tribunals for Rwanda and the former Yugoslavia, found that rape constitutes a crime against humanity (Rome ICC Statute, Article 7[1][g] [§ 1564]; ICTY Statute, Article 5[g] [§ 1576]; ICTR Statute, Article 3[g] [§ 1577]). Rape is often used to terrorize entire communities. In the context of war and torture, girls and women are sometimes raped in front of their families or community members. This effectively results in their being ostracized and sometimes renounced by their husbands and/ or other relatives. Societal context The societal context is important in helping to shape the meaning and practice of torture, and there have been significant changes in these regards over time. Torture was a common and sanctioned component of legal proceedings throughout much of Europe from the midfourteenth century to the end of the eighteenth century (Skoll, 2008). The Inquisition also approved of the use of torture for cases of heresy. In present times, torture is generally considered to be unacceptable (even heinous) and is typically inflicted under conditions of secrecy (Rasmussen, 1990). Torture deeply harms the individual, his or her family, and the entire community. The authorities often go after the loved ones of their primary target—threatening, torturing, killing, or “disappearing”2 them to put pressure on or punish the one they are really after. Statesponsored or -inflicted torture impacts communities by creating and perpetuating a culture

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of terror and silence within society. Perpetrators rarely kill their torture victims. Often the perpetrators return the damaged survivor to society, mind and body broken, as a symbol of what will happen to others if they speak out or challenge their power. It becomes dangerous to protest against the authorities or to seek justice. Torture makes it abundantly clear that basic human rights are not respected or assured. Torture is an example of extreme humanperpetrated violence that results in health and mental health disparities. It matters: where you live; what your nationality is and your political, religious, ethnic, racial, and social affiliations are; what your perceived level of threat is to the powers that be; and what your connections are. Acts of torture are often secretly rather than openly committed, as it is generally in the interest of the perpetrators to escape detection and prosecution for crimes against humanity or other charges. Torturers generally hold their victims for some time, waiting to release them until their bruises and other physical signs of the torture have healed. Visible scars and corpses make for very incriminating evidence during criminal proceedings. For these reasons, methods of torture have been developed that do not leave lasting physical marks. There are always exceptions. This author has worked with survivors with very visible marks from their torture left on their faces such that looking in the mirror in the morning (or having people ask them what happened) is a daily reminder of the horrors they were subjected to. Often governments suppress the publication of accounts of torture. For example, authorities in some countries have shut down newspapers and television stations. Access to the Internet has been restricted or blocked by some authoritarian regimes. Journalists who investigate or leak accounts of atrocities by the authorities are often targeted for torture or murder or are disappeared. Given the suppression of the media and the danger that human rights activists and organizations sometimes face in documenting

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such abuses, we often learn about acts of torture from survivors who have fled their homeland as refugees or asylum seekers when they seek services. Even so, survivors often don’t report their torture unless they are applying for asylum or in context of a trusting relationship with a social worker, health or mental health professional, or attorney. The social and physical environments can provide supports for torture survivors (e.g., extended family and social networks; practical, ideological, and/or spiritual support from members of the person’s political group or religious community; the existence of specialized holistic services if they live near a torture treatment center). At the same time, the environment can generate or exacerbate stress. Torture is a human-perpetrated trauma, and tends to damage (at least initially) the survivors’ ability to develop a trusting relationship, including initially within a therapeutic relationship (Fabri, 2001; Kanninen, Salo, & Punamaki, 2000). Sometimes survivors are not sure if they can trust their own countrymen and -women in exile, which can result in further isolation and compromise their healing process. This author has worked with survivors who have seen their torturers or close associates of their torturers on the streets in the United States, a situation that left them terrified and panicked, triggering a temporary deterioration in their condition and functioning. Suddenly, the country where they had sought refuge and asylum no longer felt safe. ta b l e 2 4 . 2

• • • • • • • • •

Vulnerabilities and risk factors In countries where torture is rampant, such as Burma (Myanmar), citizens who are not members of the power establishment or closely affiliated with those in power are often at risk for torture. In particular, those who are members of opposition parties or from denigrated and condemned minority groups, such as homosexuals in Uganda, are at risk. Some people are targeted randomly or due to mistaken identity. For a summary of factors that historically put individuals at risk, see table 24.2. In addition to the factors noted above, the context of torture and cruel, inhuman, and degrading treatment (CIDT) (including the level of distress associated with the stressors and its perceived level of uncontrollability) appears to contribute to determining the severity of its impact (Basoglu, 2009; Basoglu, Livanou, & Crnobaric, 2007). In a study of 432 torture survivors in Turkey and the former Yugoslavia, contextual factors were found to mediate the level of traumatic stress (Basoglu, 2009). More than one method of torture used in combination was found to have maximum effect. PTSD was related to deprivation of essential needs, isolation, forced stress positions, war-related captivity, exposure to extreme temperature, and sexual (but not physical) torture. The risk of developing PTSD increased by 71 percent for those who experienced CIDT. CIDT as well as the helplessness and fear-inducing effects of captivity were the key determinants of psychological impairment

Historical Risk Factors for Torture*

Person is a refugee, asylum seeker, or asylee History of living in a refugee or displaced persons’ camp Leader (or relative of a leader) of an opposition organization in country of origin Family members died as a result of trauma and/or relatives experienced torture or other form of systemic violence History of arrest or detention, and/or being a prisoner of war From country where violence erupted and was uncontrollable (e.g., Bosnia, Rwanda) Immigrant from a country ruled by a military regime or totalitarian government From a minority group in the home country (e.g., religious, sexual orientation, ethnic, or political) Country of origin had civil war when the person resided there

Adapted from Table 1 (p. 113). Historical Risk Factors for Torture. Weinstein, H. M., Dansky, L., and Iacopino, V. (1996). Torture and war trauma survivors in primary care practice. Western Journal of Medicine, 165, 112–18.

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and the perceived severity of torture for the detainees (Basoglu, 2009). Torture is associated with severe and debilitating physical and psychological sequelae among native-born populations (Basoglu & Paker, 1995; de Jong et al., 2001; Rasmussen, Rosenfeld, Reeves, & Keller, 2007), voluntary migrants (Eisenman et al., 2003), and involuntary migrants (Carlsson, Olsen, Kastrup, & Mortensen, 2010; Kinzie 2011; Marshall, Schell, Elliott, Berthold, & Chun, 2005; Mollica, Wyshak, & Lavelle, 1987; Silove, Steel, McGorry, Miles, & Drobny, 2002; Shrestha et al., 1998). A meta-analysis of epidemiological studies of torture survivors and refugees in the United States and their home countries found consistently high rates of mental health problems (Steel, Chey, Silove, Marnane, Bryant, van Ommeren, 2009). Common conditions are PTSD, depression, comorbid PTSD and depression, psychotic disorders, and panic, phobias, and other anxiety conditions typically associated with PTSD and/or depression (Kinzie, 2011; Kinzie, Jaranson, & Kroupin, 2007). Central to the diagnosis of PTSD is exposure to a traumatic event and the presence of symptoms of reexperiencing of the trauma, avoidance of traumatic triggers and/or psychological numbing, and hyperarousal. For details of the diagnosis of PTSD and other psychiatric conditions mentioned here, please refer to the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders DSM-IV-TR (APA, 2000). Many people around the world have experienced some trauma in their lives by the time they are adults. PTSD and depression are two of the most common of many possible psychological sequelae found in trauma survivors. While approximately half of the U.S. population has been exposed to one or more traumatic event(s) that would qualify as a trigger for PTSD, only about 8 percent go on to develop PTSD (Stamm, 2002). There are relatively low past-twelve-month prevalence rates of PTSD and depression in the general U.S. population

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(3.5 percent for PTSD and 6.7 percent for major depression) (Kessler, Chiu, Demler, Merikangas, & Walters, 2005). Higher rates of PTSD and depression have been found in refugees and torture survivors (Steel et al., 2009). A review of the literature revealed that refugees who have resettled in Western countries may be approximately ten times more likely to have PTSD than their age-matched counterparts from the general population in their country of residence (Fazel, Wheeler, & Danesh, 2005). A high prevalence of psychiatric disorders (14 to 74 percent) has been found in studies of torture survivors, with diagnoses of PTSD, depression, and comorbid PTSD and depression being the most prominent (Kinzie, Jaranson, & Kroupin, 2007). These rates were generally higher than the rates found in matched trauma survivors who had not been tortured. High rates of suicidality are associated with torture and refugee experiences, especially among those with PTSD. One review of refugees with PTSD found that 40 percent had made suicide attempts (Ferrada-Noli, Asberg, Ormstad, Lundin, & Sundbom, 1998). Survivors may also have complex presentations that include any or all of the following: identity and affect regulation and other personality difficulties, tension reduction behaviors (Briere, 2002) (e.g., substance use, self-mutilation, suicidality, binging and purging, other problems with impulse control or forms of externalizing anxiety-reduction strategies), psychosis, dissociation, somatic symptoms, sexual problems, cognitive distortions, and self-blame, guilt, and/or low self-esteem (Briere & Scott, 2006). When trauma is human perpetrated, such as in the case of torture, the survivor’s capacity to retain a positive sense of identity, form healthy interpersonal bonds, trust others, maintain his or her faith in a system of justice, and sustain existential meaning and hope may be greatly compromised. Enduring personality changes have also been noted in some torture survivors and others who have been cumulatively exposed to interpersonal

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traumas, and may manifest as symptoms of avoidant behavior and/or extreme social withdrawal (Kinzie, 2011; Briere, Hodges, & Godbout, 2010). Recent literature has reported dementia in U.S. veterans with PTSD (Yaffe et al., 2010) and in elderly refugees (Kinzie, 2011). Torture survivors frequently are subjected to prolonged stress that has been found to be associated with functional and structural changes in the brain. Dysfunction in their central nervous system may manifest as PTSD and/ or depression (Kinzie, 2011; see also Southwick & Friedman, 2001). Exposure to new traumas or stimuli that trigger reminders of past traumas can cause an exacerbation of their mental health (Kinzie, Boehnlein, Riley, & Sparr, 2002; Piwowarczyk & Keane, 2007). Risk factors identified for psychological sequelae following torture include: female gender, previous history of psychological trauma, personality traits, length of imprisonment, and mental preparedness for the torture (Basoglu, 1992). Practitioners need to take into account cultural variations in how individuals express symptoms of distress (e.g., somatic complaints, culture-bound syndromes) and conceptualize problems (e.g., cultural bereavement versus PTSD; Eisenbruch, 1992); the causes and meaning they ascribe to their trauma and related distress; and their coping efforts and healing practices (Berthold & Gray, 2011). Furthermore, they should be sensitive to and aware of what is and is not considered to be a mental disorder in the person’s culture. Caution should be taken not to use formal diagnostic tools that have not been validated for members of the client’s culture. There is a growing body of evidence that has found high rates of serious chronic health problems in torture and other trauma survivors and an association between PTSD and depression from significant trauma and chronic physical health problems in U.S. veteran and other populations (Coughlin, 2012; Grigg-Saito, Och, Liang, Toff, & Silka, 2008; Mollica, 2011; Southeast Asian Subcommittee, 2006; Wong et al., 2011).

Family members of the torture survivor and their communities are typically negatively affected as well. Some of the manifestations of this may be distrust in other community members and those in authority, social withdrawal, a constriction of social networks with accompanying loss of cultural and social support, intergenerational or marital conflict, compromised parental functioning and role reversal with children, silence about the traumatic experiences and low level of tolerance for the expression of distress, and pressure for the younger generation to succeed (Center for Victims of Torture, 2005). Given the risks and vulnerabilities outlined here, torture survivors arriving in the United States commonly have pressing needs for health, mental health, social, and family services. They also often need legal assistance with such things as obtaining asylum or family reunification with their loved ones left behind when they escaped. Beyond the need for healing from the immediate impact of their torture, survivors may need assistance with adjusting to a very different society, coping with new stresses, and navigating such things as enrolling their children in school, obtaining access to health care and adequate food supplies (Piwowarczyk, Keane, & Lincoln, 2008), learning how to use the public transportation system, and finding a job, housing, and child care. Often they find themselves far from their traditional/natural support networks that provided practical support with such things as child care and emotional support, and it may take them time to build a new network. resiliencies and Protective factors Despite the significant risk of harmful consequences following torture, survivors are, by definition, resilient. The lives and identity of survivors are not wholly defined by their torture. They are multidimensional beings. They possess enormous strengths that enabled them to endure and survive their torture (Guskovict, 2012; Moio, 2008). Many persevere despite considerable ongoing stressors and thrive in their

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lives. Resilience is frequently conceptualized as a defense mechanism, one that people use when confronted by adversity that makes it possible for them to thrive (Masten & Coatsworth, 1998). Masten and Obradovic (2008) define individual resilience as involving the capacity for, processes of, or patterns of successful adaptation during or after traumatic or threatening situations. Effective strategies of coping and adaptive processes that are relational and developmental in nature have been seen to contribute to enable some people to be resilient in the face of trauma (Walsh, 2003). What may be protective in one context, however, may not be healthy or adaptive in another. Bonanno (2004) clarifies that resilience is not the same as recovery, and defines resilience as “the ability of adults in otherwise normal circumstances who are exposed to an isolated and potentially highly disruptive event such as the death of a close relation or a violent or life-threatening situation, to maintain relatively stable healthy levels of psychological and physical functioning” (p. 20). It is important to understand that the most common outcome of potentially traumatic events (PTEs) is resilience, according to recent research (Bonanno, Westphal & Mancini, 2011). Most survivors demonstrate a steady trajectory of healthy functioning following exposure to PTEs. Rather than being an outcome of several dominant factors, recent research suggests that there are a number of independent predictors of resilient outcomes following traumatic events (Bonanno et al., 2011). Among these protective factors are: relative mental health and the absence of a history of diagnosable psychiatric or substance abuse problems; individual personality traits and attributional styles; greater family stability; the presence of immediate and extended family who provide practical, emotional, and financial support; greater and effective use of social support and other resources; higher socioeconomic status; higher level of education; coping self-efficacy (i.e., self-perception of having the ability to cope

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and control outcomes); the capacity to tolerate emotions and cope flexibly with symptoms associated with trauma and bereavement; and a range of biological factors (Ehlers & Clark, 2000; Kaniasty & Norris, 1999; HHS, 2004; Watson, Brymer, & Bonanno, 2011). Research on resilience conducted specifically with torture survivors suggests that strong commitment to a cause (Basoglu et al., 1997), preparedness for one’s torture (Basoglu, Paker, et al. 1994), having strong support (Basoglu, Paker, Paker, et al. 1994), and spirituality (Holtz, 1998) may protect survivors from or mitigate some of the harmful effects of their torture. Women torture survivors at one treatment center transformed their women’s group into a community for mutual support and sharing of gender-specific knowledge (Moio, 2008). Resilient torture survivors this author has worked with from many countries have continued to engage in their political activism, including at times speaking publicly to the media, after they were tortured. They continued to fight for their cause knowing full well that they were at great risk of being picked up and tortured again or possibly murdered for their actions. Their beliefs, strong spirituality, and support from family, friends, and fellow activists strengthened their resolve and supported them in their healing process. Survivors of torture and other traumas often search for a sense of meaning and coherence in their lives. The author has worked with survivors who were picked up and tortured randomly or because of mistaken identity. It was much more difficult for them to understand why they were tortured or make sense of their experience compared to those who had a clear sense of why they were targeted and were prepared ahead of time for the possibility that they would be tortured. The literature on post-traumatic growth also has a lot to teach us in terms of how people and communities around the globe cope with enormous stress and achieve growth following trauma (Tedeschi & Calhoun, 1996; Weiss & Berger, 2010). One of the areas of post-traumatic

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growth that is relevant for some torture survivors is that of spiritual growth (although it is important to recognize that some survivors struggle with spiritual crisis or loss of faith as well). Spiritual growth can result in an increased sense of meaning and purpose in one’s life (Calhoun & Tedeschi, 1999). Spirituality is one important source of recovery from adverse life experiences for many people around the world, and an important area to be explored in the treatment of torture. Piwowarczyk (2005) writes By recognizing the depths of despair in the most existential of terms, we also give validation to the depth of understanding of human existence that can only come about through personal suffering. For some torture and trauma survivors, spiritual understanding is the only possible pathway to recovery. Trauma by its very nature is isolating. For some, connecting with communities of faith can be the first step in restoring trust in humanity and alleviating the painful situation of isolation (7).

Another aspect of the isolation that many torture survivors in the United States initially face is isolation from their loves ones. The majority of survivors escape from their homeland alone given the great difficulties, expense, and the danger that escape typically involves. If they are successful in obtaining asylum in the United States, they can begin the lengthy process of reunifying with their spouse and minor children (it is a much longer and complex process to sponsor other immediate family members). Support from family and strengths-based family interventions can be an important resiliency factor for many (Fabri, 2011). Therapeutic family work that incorporates the use of cultural and religious rituals was found to provide an important source of strength for survivors and facilitated their maintaining a connection to their beliefs and traditions from home (Woodcock, 1995). Refugee parents found it helpful when they were able to give their children a sense of permanency and optimism (Panos & Panos, 2003). Knowledge of these resiliency

factors is important in shaping social work and other services for survivors of torture. Programs and Social Work contributions At the time of this writing, a consortium of over 30 specialized torture treatment and legal programs are spread across the United States, providing an array of services to survivors of officially sanctioned or state-sponsored torture who have left their homelands and are in the United States. Among the most common services available are counseling, psychiatric services and medication, family interventions, group work, case management, and forensic psychological assessments and expert-witness testimony in survivors’ asylum hearings. A relatively small number of these specialized centers have the capacity to provide in-house medical (including forensic medical) or legal services. Many, however, have developed extensive networks in their areas to collaborate on or refer for these and other services. Clearly there are torture survivors living in parts of the United States without a specialized center. Federal technical assistance made available through the ORR has provided training to mainstream health, mental health, and social service providers in recent years. More training and ongoing consultation are needed to prepare these providers as well as educators and religious and other social institutions to be able to better detect and serve survivors of torture. Surveys of foreign-born patients seen in large urban medical centers in the United States found that 5 to 10 percent had suffered some form of torture in their countries of origin (Randall & Lutz, 1991; Eisenman et al., 2003) but only 3 percent had told their health care providers (Eisenman et al., 2003). In practice, it can be challenging to operationalize who has been tortured. Rasmussen and colleagues (2012) developed the Torture Screening Checklist (TSCL), a narrative coding tool to assist practitioners in classifying who has been tortured based on client histories. Health and refugee service providers frequently do not feel

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prepared to appropriately serve these survivors (Rafuse, 1993; Sonis, Gorenflo, Jha, & Williams, 1996). Social workers historically have also not received specialized preparation in graduate school to work with torture survivors, although some schools have relevant graduate curricula on trauma and human rights issues. Professional conferences and training programs offer continuing education opportunities for specialized training to prepare social workers for the tasks of serving survivors of torture and other gross human rights violations. Social workers can and do play a vital role in conducting training and outreach, providing consultation, engaging in community organizing, providing individual and family counseling, leading groups, collaborating as an interdisciplinary team with other providers, providing case management, and coordinating care. In addition, social workers are among those who conduct forensic psychosocial evaluations of torture survivors and provide expert-witness testimony in Federal Immigration Court in the asylum proceedings. They also serve in leadership roles in agencies and legislative bodies, and help to build programs through grant writing, fund development, and program planning. Social work researchers can generate meaningful data to inform treatment and advocacy for expanded services and prevention efforts. The NASW (2006) has been a vocal advocate against torture. Social workers can play a meaningful role in putting a human face on the need for reform of human detention conditions and other policy and legislative change. Fighting for social justice and an end to impunity provide powerful pathways to healing the harm done by torture and other human rights violations (Mollica, 2006, 2011). Healing from the physical and psychological sequelae of torture and the ability to achieve optimal functioning are supported when survivors’ basic needs are met, they have adequate support networks, and they feel safe in their communities. Social workers have much to contribute in these areas. They are trained to

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conduct thorough needs assessments; provide case management and care coordination to deal with the array of concrete needs of survivors and their families (e.g., housing, education, employment, food security, English language acquisition); build social supports; facilitate family reunification (e.g., connecting with resources needed to apply, preparing the survivor and family, addressing challenges after reunification); address community safety concerns; and attend to issues of spiritualty (e.g., connecting with religious and/or spiritual resources, and addressing spiritual crises, opportunities, and transformations). Many torture survivors may come into contact with social workers when they are in the process of applying for asylum in the United States and thus generally are not yet eligible for the range of social services available to refugees, permanent residents, and citizens. Depending on where the survivor is residing in the United States, it may take anywhere from six months to many years to complete the asylum process, depending on many factors, including how busy the Immigration Court is in that area. The author still has a number of cases pending in the Los Angeles Federal Immigration Court that she is waiting to testify in (the oldest case has been in the system for eleven years and the next hearing is scheduled for a year from the time of this writing). In the meantime, social workers have utilized creative means of ensuring their clients’ basic needs are met, including networking within ethnic and religious communities. assessment and interventions Social workers should approach assessment and intervention with survivors of torture from other countries with cultural competence and humility (Betancourt et al., 2003; Tervalon & Murray-Garcia, 1998), holistically, and with a trauma-informed lens (see http://www .samhsa.gov/nctic/). Cultural humility involves social workers’ engaging in a lifelong process of self-critique and self-reflection of their own

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worldview. Practitioners strive to put their beliefs and assumptions aside about the experiences, goals, and needs of their clients and their interactions with them. The practitioner operating from a standpoint of cultural humility aims not to identify and respond to “culturally specific traits” of their client, but rather to disrupt the traditional provider-client power imbalance and enter into a partnership built on respect. The client is acknowledged as the expert of his or her own experience, and the practitioner strives to maintain an accepting and respectful attitude toward differing perspectives. Working from an ecological person: environment perspective, social workers should assess the level of fit or lack of fit of the survivor and their characteristics, capacities, and needs with their social, cultural, and physical environment, as well as their adaptation (Gitterman & Germain, 2008). The complexity of the relationships and transactions between survivors and their environments must be assessed as well, and those that promote healing and resilience identified and built upon. Gitterman and Germain’s (2008) Life Model approach to social work practice (as briefly described in the chapter in this volume on terrorism) is equally relevant to practice with survivors of torture. Grounding in strengths-based and narrative approaches is also invaluable and supports the natural resilience and strength of survivors (Hanscom & Ray, 2012; Saleebey, 2006; Wade, 1997). These approaches are empowering and do not pathologize. They assume that people already inherently have the ability to effectively respond to their difficult situations and involve working with individuals to recognize and build on their existing resourcefulness and strengths—often the very qualities that enabled them to survive their torture. The Istanbul Protocol, developed in 1999, is the first set of international guidelines used to document torture and its consequences and report these findings to investigative bodies, including courts (United Nations, 2001). It is widely used by health and mental health

professionals around the world to guide their detailed assessments of the scope and impact of torture on survivors and by legal professionals for investigative and prosecution purposes. Assessments should include history of torture and ill-treatment, pre- and post-torture history, current psychological complaints, medical and psychiatric history, history of substance use and abuse, mental status exam, and assessment of social functioning. Social workers should be prepared to assess the full range of the client’s trauma experiences. Many torture survivors have a long history of cumulative trauma predating their torture. Some survivors continue to be exposed to violence and other traumas in exile. Cultural variations in how clients express their distress and what is considered to be normal functioning must be taken into account. Rather than focusing only on the challenges or deficits, the social worker should include a thorough assessment of the survivor’s strengths, both internal and external. The most thorough assessment of a torture survivor should be conducted by an interdisciplinary team that may involve a social worker, neuropsychologist, internist or other medical doctor, and other specialists, as needed, depending on the particular condition of the survivor. Survivors who have a history of head trauma should be evaluated for possible traumatic brain injury (TBI), as different treatment protocols are needed and mild TBIs are often overlooked (Vasterling, Bryant, & Keane, 2012). Careful attention to evidence of dissociation (prior to, during, and after the torture) is important, as well as the impact of trauma on the survivor’s memory and ability to give a coherent, consistent narrative account of his or her experiences (Berthold & Gray, 2011). Chronic pain is a common complaint and must be appropriately assessed and attended to (Quiroga & Jaranson, 2005, 2008). Social workers can play a pivotal role in making sure that these (and other) important needs of the survivor do not fall through the cracks, something that is a real possibility given the state of health care in the United States today

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and the fact that most torture survivors do not have health insurance for quite some time after they arrive in the United States. Survivors’ legal status should be assessed. Insecure immigration status can have a substantial negative impact on survivors’ mental health and well-being, especially if they fear they may be deported back to where they were tortured (Berthold, 2012; Chantler, 2012; Raghavan, Rasmussen, Rosenfeld, & Keller, 2012; Steel et al., 2006). If survivors do not have legal status, the social worker must know that.3 If they do not already have legal status and do not have an attorney, they should be referred to one with immigration expertise. Social workers and other professionals may be in a position to conduct forensic assessments and provide evidence (sometimes including testimony) in a survivor’s asylum hearing. The forensic psychosocial assessment can be conducted in a therapeutic fashion (Gangsei & Deutsch, 2007). Some torture survivors come from countries with very different laws regarding child abuse and domestic violence than in the United States, and have different perspectives of what is considered to rise to the level of abuse. People convicted of certain crimes in the United States, including violent crimes that harm other people, may be barred from asylum and some other forms of immigration relief (Lundsford, 2012). The social worker has an opportunity to engage in valuable preventive work by educating survivors new to United States about these laws as a way of orienting them and empowering them with knowledge to avoid legal troubles (not to mention the consequences of the abuse itself). All of the areas identified previously in the vulnerability section of this chapter should be a focus of the social worker’s assessment. Kinzie (2011) argues that particular attention should be paid to the possibility of PTSD, depression, and psychosis. Social workers can collaborate with physicians who may prescribe medication to provide immediate relief for such distressing symptoms as difficulty sleeping, persistent nightmares, and irritability that interferes with

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daily functioning and interpersonal relationships. Attending to these common complaints can go a long way to establishing a therapeutic relationship with torture survivors. There is widespread recognition that the impact of childhood trauma can be present decades later (Dube, Felitti, Dong, Giles, & Anda, 2003). PTSD and depression in torture survivors of all ages often follow a chronic fluctuating course (sometimes lasting for decades), with periods of remissions and exacerbations (often in response to traumatic triggers) that call for long-term interventions (Berthold & Gray, 2011; Boehnlein & Kinzie, 2011; Kinzie, 2001, 2011; Marshall et al., 2005). Social workers and others who work with torture survivors should keep in mind a number of foundational considerations as they prepare to interact with survivors (Boston Center for Refugee Health and Human Rights, 2009). Social workers should seek to make their torture survivor clients as comfortable and feel as much in control as possible. The overriding principle is to avoid re-traumatizing survivors and to create an environment that provides the opportunity for healing (e.g., when they relive their trauma in session it is in a disparate environment that does not feel dangerous or threatening; Briere, 2002). The social worker should eliminate common triggers (e.g., paintings with violent images) and ensure that his or her office does not resemble a cell. In the author’s experience, however, it is not always possible to predict what will be experienced as re-traumatizing for a given survivor, especially in the early days of your professional relationship. The author had a painting of open lotus blossoms in her office (a Buddhist symbol of enlightenment and self-awareness), and over the years many torture survivor clients from diverse backgrounds remarked that they found the painting soothing and inspiring. One client, who had been detained for several years, had a different reaction. He found the center of the lotus blossoms reminded him of the eyes of his guards monitoring him. Social workers

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should remain attentive to signs of distress in their clients. During torture, victims tend to be stripped of all control. Whether they live or die is in the hands of the torturer. Finding opportunities to give control back to survivors is therapeutic. Simple ways of establishing this in session are by letting survivors know that they can take a break when they want to, decline to answer any or all questions, and stop the session at any point. In addition, the social worker can give survivors the choice of having the door left open or closed. While the vast majority of survivors will prefer the privacy of a closed door, a closed door may be a trigger for others. One torture survivor who the author worked with was tortured on one occasion by soldiers who locked her into a very small pantry in her kitchen. For several years she was not able to tolerate being in relatively small rooms with shut doors without hyperventilating and having a panic attack. One of the signs that she was getting better was her ability to tolerate having the door closed during sessions with her social worker some months into the work. The social worker should also avoid having a demeanor or using styles of questioning (e.g., rushing the survivor or asking a series of closed-ended questions in rapid succession) that resemble or remind the survivor of interrogation, a technique that is a frequent part of torture (Randall & Lutz, 1991). The social worker begins by assessing clients’ strengths and their life before they were tortured rather than jumping into the details of their torture or other traumas (BCRHHR, 2009). Many survivors will feel anxious when they first meet with a social worker or other helping professional, particularly because there is often not a tradition of seeking professional help in their country of origin unless a person is “crazy.” In some communities around the world, seeking counseling may be a foreign concept as there may not be any social workers or others who perform these roles. While some torture survivors may be ready to talk and want to make sure the social worker knows about their torture

experiences in the first session, others may not be able to discuss details of their torture for quite some time. Some survivors may never be able to talk about some aspects of their experiences. Help can proceed without gathering a full torture history (in some cases, conducting a full history may be contraindicated)4 (Briere, 2002; Briere & Scott, 2006). Regardless of the intervention approach, the social worker’s use of self and the therapeutic relationship are vital to healing. Core social work interventions, such as beginning where the client is, meeting concrete survival needs, negotiating complex organizations, and combating emotional and social isolation are essential. The self-trauma model, developed by Briere (2002) for treating adult survivors of severe childhood neglect and abuse, provides a valuable framework for conducting appropriate assessments and interventions with survivors of torture and other types of complex trauma. The approach blends elements from CBT and psychodynamic therapy with mindfulness practices. Key elements of this therapeutic approach include an overarching positive and respectful approach to the survivor (i.e., the provision of validation and support, and the processing of relational issues, within the context of a positive therapeutic relationship); providing psychoeducation about trauma and associated symptoms; the incorporation of stress reduction and affect regulation training; cognitive interventions (targeted at debilitating or damaging trauma-related assumptions, perceptions, and beliefs); processing of the traumatic memories and development of a coherent narrative of the trauma over time; and focus on increasing the survivor’s self-acceptance and self-awareness. Social workers are taught to always work within the therapeutic window (Briere, 1996, 2002), making sure that they do not psychologically overwhelm the client with traumatic material that they do not have the ability to tolerate or regulate, while at the same time ensuring that the counseling does not support excessive avoidance that would hamper progress being

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made. It is a delicate balance that requires clinical attentiveness, experience, and judgment. The concept of the therapeutic window is important to keep in mind when conducting trauma assessments. Prior to conducting an assessment of survivors’ trauma experiences, it is advisable to assess their mental status, their level of functioning, whether they have had episodes of flashbacks and/or dissociation and what triggered these episodes (if known), and identify with them what helps them to calm down and feel in control when they become flooded with traumatic memories. In addition, it is beneficial to build on any effective strategies they may already have and develop a plan that you can use together to calm them down and bring them back to the present in the event that they become very distressed, dissociate, or have a flashback during the session. The strategies may involve such things as engaging in slow deep breathing, reminding them that they are in a safe place with you in the United States far from the country where they were tortured, utilizing guided imagery of a safe place, and/or naming three (nonthreatening) things in the therapy room. It is often quite helpful to work with survivors on enhancing their self-awareness of early signs that they are beginning to be distressed (often somatic sensations) and to practice using the tools you have developed together to reduce their distress and prevent an escalation of their symptoms. In the author’s experience, not only will this approach be very helpful in your trauma work together, but survivors may also be able to use some of these tools to good effect on their own outside of the session. The social worker should continually monitor the level of arousal and distress of clients throughout assessment and intervention, particularly during portions of the sessions that deal with traumatic material or particularly sensitive topics (staying within the therapeutic window described earlier). If survivors start to develop signs of distress the social worker can

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intervene and practice their coping strategies with them. At times it may become necessary to cut short an exploration of a particularly distressing topic or come back to it later if and when the survivors are ready. It is not necessary to gather the trauma history all in one setting and it is generally not recommended to do so, particularly if the history is extensive, although there are individual differences in survivors’ ability to tolerate providing a trauma history. Survivors should be given as much control as possible, including guiding the timing and scope of what they share with the social worker. The questions should be phrased in such a way to normalize clients’ experiences with torture so that they do not feel alienated or ashamed (BCRHHR, 2009). Some aspects of their experiences may be particularly difficult for them to talk about (e.g., sexual torture, being forced to provide information that could be used to hurt loved ones) and should be approached cautiously and with compassion. If the social worker is conducting a forensic assessment for survivors’ asylum cases or other purposes, it is recommended to explain clearly and fully how the information they share will be used, who will see it (limits to confidentiality), and why it may be important for the social worker to understand more about their experiences. Regardless of how important the social worker may feel that it is to have a complete account of the torture and its consequences, it should always be the survivors’ choice as to what they share. They may feel able or want to share more over time. It often can be therapeutic to make note of signs of the survivors’ strengths and resilience during and after their torture and ask them to reflect and elaborate on this. Although many refugees have experienced torture, the literature on treatment outcomes for these survivors is quite limited (Fabri, 2011; Jaranson & Quiroga, 2011; Kinzie, 2011; Sjölund, Kastrup, Montgomery, & Persson, 2009). Methodological challenges complicate the conclusions that can be drawn from the

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studies that have been conducted. Most of the early literature in this field was comprised of narrative accounts of clinical lessons drawn from case examples and practice experience. These accounts were valuable and contributed to the knowledge base. In more recent years, increased attention has been paid to conducting empirical research with and evaluating programs that serve torture survivors. Various approaches to work with torture survivors and other refugee groups have been studied to date, including interventions by lay counselors in Africa (Neuner, Onyut, Erti, Odenwald, Schauer, & Elbert, 2008), cognitive behavioral therapy (CBT) (Hinton, Pham, Tran, Safren, Otto, & Pollack, 2004; Hinton & Otto, 2006; Palic & Elkit, 2009; Hinton, Hofmann, Pollack, & Otto, 2009), narrative expressive therapy (Halvorsen & Stenmark, 2010), traumafocused therapy (Kruse, Joksimovic, Cavka, Woller, & Schmitz, 2009), group therapy (Drozdek, de Zan, & Turkovic, 1998; Kira, Ahmed, Mahmoud, & Wasim, 2010), psychoanalytic therapy (Varvin, 1998), and psychopharmacology (Smajkic et al., 2005; Boynton, Bentley, Strachan, Barbato, & Raskind, 2009). Most of these studies struggle with problems related to lack of treatment controls, sampling problems, participants with multiple diagnoses, differing effectiveness criteria, and lack of significant follow-up over time. Meta-analyses of trauma-focused therapy (Nickerson, Bryant, Silove, & Steel, 2011) and cognitive therapy (Crumlish & O’Rourke, 2010) provide preliminary evidence of their benefit with asylum-seeking and refugee populations. In a meta-analysis of sixty-four intervention studies with survivors of torture and related traumas, Fabri (2011) concludes that there is sufficient empirical evidence from wellconstructed and -implemented studies to classify CBT-guided interventions as a best practice with diverse populations of trauma survivors warranting further study. The combination of counseling and psychiatric medication treatment was classified as a promising practice with

torture survivors; and interventions with families, psychosocial community-based interventions, and narrative approaches were found to be emerging practices given the state of empirical literature in those areas. Fabri (2011) cautions that such interventions must be adapted to be appropriate for the diverse cultures, ethnicities, religious/spiritual orientations, worldviews, life experiences, and range of unpredictable stressors faced by torture survivors being treated in host countries such as the United States. Narrative approaches often focus on creating a sense of meaning or utilizing testimony as a political and therapeutic act in the context of historical construction and the pursuit of justice and reparations. Torture survivors have testified in their asylum proceedings and in various legal proceedings prosecuting their torturers (e.g., in the International Criminal Court, the Extraordinary Chambers in the Courts of Cambodia, the Inter-American Court of Human Rights, and in the cases of torturers residing in the United States prosecuted by the Center for Justice and Accountability). As empowering and healing a process as this may be for some survivors, it is important to keep in mind that providing a narrative or testifying is not therapeutic for everyone (McKinney, 2007). Not all trauma survivors need or are able to tell their story, even in therapy (Briere, 2002). Multidisciplinary care of torture survivors utilizing a biopsychosocial model was supported in the literature (Fabri, 2011). Winter (2011) summarizes the best and promising social service practices in the field of torture treatment. The literature on social work and other social service interventions with torture survivors, asylum seekers traumatized by war, refugees, and immigrants supports a comprehensive approach that includes an emphasis on addressing practical needs and reducing everyday stressors (Potocky-Tripodi, 2001; Winter, 2011). Winter (2011) reviewed twenty-nine articles that include case studies, descriptive reports by clinicians, program evaluations, small cohort studies, and a

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randomized controlled trial examining social services for torture survivors or asylum seekers fleeing war. One key conclusion from this review is that interdisciplinary approaches to helping torture survivors that contain a robust social service arm are considered to be a best practice and most effective. These social service interventions focus on such things as housing, employment, and social supports. Supporting these avenues for self-sufficiency and enhanced functioning is thought to promote healing and resilience in torture survivors (Winter, 2011). In addition, strengths-based case management (SBCM) (Brun & Rapp, 2001) and case management intervention principles from Assertive Community Treatment (ACT) (Allness & Knoedler, 2003) have been recognized as best practices in the field of social work (Brekke, 2012) and are relevant to work with torture survivors. Case management is among the services provided by social workers working with torture survivors. It aims to improve the continuity and coordination of services, is client-centered, and is ideally suited for work with individuals who have multiple complex needs such as survivors of torture. Case management can involve many components and functions, including assessment, planning, advocacy, linking the client to needed resources in the community, monitoring, and ongoing supportive care (SAMHSA, 2002). It also can include direct counseling services that, in part, focus on building skills, crisis intervention, and consultation with family or other supports. The SBCM model starts with the belief that individuals have abilities, strengths, and inner resources that enable them to cope with life’s challenges (Brun & Rapp, 2001). Torture survivors typically have enormous strengths and are resilient. Practitioners utilizing an SBCM approach promote the self-determination of their clients while engaging in active outreach and assisting them in identifying and attaining their goals (Arnold, Walsh, Oldham, & Rapp, 2007). Social workers build on the strengths and resilience of the torture survivors they

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serve as they regain control of their lives after torture and rebuild their lives in a new society and culture in the United States. The SBCM model encourages the use of informal helping networks, an approach that is in keeping with the ethnic community and informal networking that naturally arise in many communities of torture survivors. This approach is also practical given the realities of the economic downturn in the United States and the fact that torture survivors who arrive in the United States without legal status typically are not eligible for work authorization and most social services until such time as they obtain asylum or another form of legal status, something that may take a number of years. The SBCM approach is also compatible with supporting interventions that are informed by the culture and trauma experiences of diverse torture survivors and attend to their cultural traditions and needs. The SBCM and ACT approaches can be used to facilitate the process of survivors’ healing from their traumas and attaining self-sufficiency in the United States, thereby promoting the ability of torture survivors to make valuable contributions to their new society. Two other important topics social workers should become familiar with if they plan to work with torture survivors are working with interpreters and secondary or vicarious trauma. Space limitations prevent a full exploration of these issues here. Torture survivors come to the United States from many parts of the world. Frequently social workers and other professionals who serve survivors of torture need to work with interpreters. It is essential that providers work with an appropriately trained interpreter (Akinsulure-Smith, 2007), yet many providers struggle to find professionally trained interpreters, particularly in certain languages. 5 Some resort to using family or friends to interpret, a practice that can have very negative consequences for the client. Social workers who serve torture survivors should prepare themselves for the possibility that hearing their clients’ trauma stories and witnessing their severe distress may

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personally affect them and put them at risk for developing vicarious trauma. In addition, however, social workers and other professionals may experience vicarious resilience from working with trauma survivors, including gaining improved skills to reframe and cope with negative events.6 illuStrAtion And diSCuSSion

The life situation presented here is complex, given the realities and multiple layers of trauma, loss, and adaptation torture survivors typically face when forced to flee their countries along with the challenges inherent in transitioning into a new, often radically different, society. A competent social worker serving torture survivors must be knowledgeable about trauma-specific and transcultural approaches to assessment and intervention, as well as have a solid foundation in relevant theoretical frameworks. The practice guidelines presented here are not intended to be comprehensive or address all aspects of the case, but will illustrate some of the early interventions to be considered. Alternative approaches and starting points may also be effective. All names are disguised and identifying information altered. Alisa is a 15-year-old refugee girl from a rural village in the Democratic Republic of Congo (hereafter referred to as the DRC) who came to the United States a little over one year ago after fleeing her wartorn village. Alisa is living with her foster parents Sarah and Paul Nolan and their two children (Mark, age 17, and Kathy, age 12) in an inner-city neighborhood with a high crime rate. Alisa’s school grades have recently improved since she has become more fluent in English. Her teachers are concerned that she appears socially withdrawn, particularly around males, and has appeared to have difficulty adjusting to the social norms of her peers. Alisa is extremely attractive and her male classmates have been giving her a lot of unwanted attention. Recently, the Nolans requested help from a community counseling agency after Alisa ran away from their home. Just before she ran away, Mr. and Mrs. Nolan were arguing

with her after she refused to have a routine medical checkup. Alisa spent the night at her friend’s house without informing the Nolans where she was. The Nolans were very worried, made worse by the fact that a few weeks earlier, two teens had been shot a mile from their home. During the initial appointment at the counseling center, Mr. and Mrs. Nolan told the assigned social worker that they were concerned about Alisa. They shared that Alisa is so different from their children and they did not know how to handle her anymore. Alisa was quite guarded toward the social worker in the first session. Alisa gradually shared with her social worker over the next several weeks how lonely and fearful she felt and how strange things seemed to her in the United States. Eventually, Alisa revealed some details about her life back in the DRC and bits and pieces of the story of her escape from the DRC. Alisa shared that for several years before she escaped, her village was the site of periodic clashes between government soldiers and the Lord’s Resistance Army rebel forces. Both sides suspected her father, an elementary school teacher, of spying for the other. One night, a group of armed government soldiers burst into their home and interrogated her father at gunpoint. Alisa and her siblings were restrained by the military and forced to watch as her mother was raped and her father was beaten in front of them. Her father begged the soldiers not to hurt his wife but the soldiers shot him in the head and he died. Alisa’s mother and younger siblings managed to run away but the soldiers took Alisa with them when they left. Alisa was held at a military barracks and raped and interrogated by several soldiers over a two-week period. The soldiers kept asking her for information about her father’s involvement with the rebels and threatened to kill her when she repeatedly told them that he wasn’t involved with the rebels. One soldier cut her stomach with a knife when she struggled with him as he was raping her. Eventually the soldiers released Alisa and she made her way back home, only to find it deserted. Her neighbor urged her to flee before the rebels or government forces returned, and helped her to escape from the DRC.

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Alisa has had no contact with her family since the soldiers took her to the barracks. She does not know if her mother and siblings are dead or alive. She is Christian and has been going to church in the United States. She is very distressed that she was not able to perform the proper prayers and communal rituals for her father after his murder. She also feels guilty for not staying in the DRC to find her mother and siblings and has been thinking that she might try to return to the DRC to look for them. The social worker learns that Alisa does not have any legal status in the United States and, after some research, discovers that Alisa might be eligible for asylum. Alisa is haunted by images and nightmares of what she experienced in the DRC. She tries to avoid thinking or talking about these traumas. Alisa tells her social worker that she ran away because she was afraid that the doctor would see the scar on her stomach and ask how it happened. She also didn’t want anyone to touch or examine her private parts given the memories of her rape and the taboo associated with this. She cries and tells the social worker that she is terrified that she might have “gotten AIDS” when she was raped and that she has seen others in her community die from AIDS. Furthermore, when her foster parents yelled at her, she was reminded of being interrogated by the soldiers and was flooded with memories of what the soldiers did to her and her family. Drawing on relationship building, basic social work interviewing skills, CBT, the self-trauma model, and narrative and strengths-based approaches, the social worker focused on helping Alisa deal with the multiple traumatic experiences, her complicated grief over her multiple losses, and the current factors in her life that are triggering reminders of the violence in the DRC that she fled from (e.g., her reactions to her foster parents’ yelling at her and the community violence in her neighborhood). Alisa was engaged as the expert on her life. Alisa and her social worker explored the impact of her society and culture’s views of rape on the shame and stigma she felt, and how this, along with her strong avoidance symptoms (a common effect of trauma), were

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accentuating her fear of being examined by a doctor. Alisa had never had a gynecological exam and the social worker provided her with information and psychological preparation that enabled her to undergo one. Alisa revealed that she considered an HIV-positive diagnosis to be a death sentence given the high incidence of AIDS in her country. This appeared to be exacerbated by the conditions of war and the inadequate state of treatment availability and options in her country. Pre-test STD counseling was conducted that incorporated the realities of Alisa’s life, and she decided to be tested for the HIV virus and other STDs. The social worker drew on basic social work principles and narrative therapy, asking questions to draw out Alisa’s experiences, the history of the problem and the factors that have influenced its development, and the meaning these had for her. A strengths-based approach was used to help Alisa explore whether she wanted to return to the DRC or not and other avenues to search for her family (e.g., through the Red Cross and family friends still in the DRC). Alisa decided to apply for asylum and the social worker was able to write a report and provide expert-witness testimony in Federal Immigration Court that helped her overcome the one-year bar to asylum (e.g., her severe psychological distress and difficulty functioning made it impossible for her to apply for asylum within her first year in the United States). Alisa and the social worker collaborated in uncovering Alisa’s competencies, talents, abilities, and resources (recognizing and building on her strengths and resilience, including what helped her survive the civil war, escape, and eased her initial adjustment to a radically different culture). They worked together to reconnect Alisa with her pre-trauma self and transform the label given to Alisa by others (a “defiant loner”) into a description she gave herself as an independent, strong, and resourceful young woman. Family work was also provided that helped Alisa’s foster parents and foster siblings better understand her culture, life experiences, and traumas. The family’s social worker increased the Nolans’ understanding of the meaning of having a medical evaluation for Alisa while protecting her privacy and control

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over what and when she chose to disclose to the Nolans. Part of the family work focused on deconstructing the problem and examining unstated cultural assumptions held by each member that appeared to be perpetuating the conflict and lack of understanding in the family system and exploring new ways of relating to one another. Alisa shared with her social worker that she is from a communal society, and she welcomed connecting with the local Congolese community as a support for her and to provide consultation for the social worker. In facilitating Alisa’s connection with the local Congolese community, her social worker was careful to make sure that Alisa felt comfortable with the community members (recognizing that she might not feel safe and may have difficultly trusting others from her refugee community, particularly if she perceived that members of the community might have links to the DRC government or the rebels). The community leaders offered to conduct a communal ceremony and ritual to grieve and pray

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1. Asylum seekers must demonstrate that they have been persecuted by the authorities in their country based on at least one of five grounds: political opinion, religious beliefs or practices, nationality, race, or membership in a social group. (For more information about asylum, see U.S. Citizenship and Immigration Services, 2011a, 2011b.) Asylum is a form of immigration relief that affords the person the right to remain and work legally in the United States, a pathway to U.S. citizenship, and the right to sponsor his or her spouse and minor children. Individuals who are granted asylum are referred to as “asylees.” Torture survivors sometimes are granted one of two alternative forms of legal relief: withholding of removal or relief under the United Nations Convention Against Torture (CAT). To be granted withholding, an applicant must establish that his or her life or freedom would be threatened in the future in the country of removal. Under CAT, those in removal, deportation, or exclusion proceedings may claim that they “more likely than not” will be tortured if removed from the United States. Unlike asylum, withholding of removal and relief under CAT does not permit the sponsorship of a spouse or minor children, nor is the recipient allowed to

for Alisa’s loved ones.7 Alisa found this very meaningful and helpful as she struggled to cope with the death of her father and the traumatic disappearance of her other family members. Alisa was able to connect with other Congolese teens and adults through community events and activities, enabling her to feel less alienated and ease her transition to the new country.

conclusion Social workers have significant roles to play within the broader societal plague of torture even while intervening with the survivors. The social worker’s use of self and the therapeutic relationship remain the most important ingredients, regardless of the applied approach. Survivors of torture are resilient, attesting to the strength of the human spirit while greatly contributing to society. With vision, we can put an end to the suffering, the dying, and the forced flight from their homelands due to torture.

adjust his or her status later to that of permanent resident or U.S. citizen. 2. When people are “disappeared,” the authorities or a rebel, guerrilla, or militia group that the authorities cannot or will not protect them from, kidnaps them. Their families, friends, and associates are unable to locate them. Months and years may go by with no news about them. Rarely, a person resurfaces, usually with evidence of abuse or torture. More commonly, a disappeared person is eventually assumed to be dead (murdered), although the lack of bodily remains and the uncertainty about the person’s fate is agonizing for the loved ones left behind. 3. At the time of this writing, a person must apply for asylum within the first one year of arriving in the United States in order for the merits of his or her case to be heard (although exceptions to the one-year rule are allowed based on changed or extraordinary circumstances). Examples of changed or extraordinary circumstances include changed country conditions resulting in increased risk of persecution, and severe physical or mental health problems that made it impossible to apply for asylum within the first year. 4. There are constraints on trauma processing, such that it may be contraindicated to expose clients to

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trauma memories in treatment if they experience severe depression, high risk of suicide attempts, acute psychosis, very high anxiety (including easily triggered panic attacks), substance intoxication or some instances of substance dependence, overwhelming guilt and shame associated with the traumatic event, especially impaired affect regulation capacity, and/or very recent and substantial trauma exposure (Briere & Scott, 2006). 5. A new five-day training program for interpreters who work with torture survivors (“Healing Voices”) was piloted in August 2012. Information about this training program and upcoming trainings for providers who serve torture survivors about working with interpreters can be found at http://www.volinterpreting.org. 6. A continuing education course regarding vicarious trauma and resilience and self-care (Berthold, 2011) can be found at http://www.netce.com/course overview.php?courseid=744. 7. If there hadn’t been a local Congolese community in Alisa’s area, it might have been possible to connect her with the broader community and organize a ceremony to support her grieving through her church. Torture treatment or refugee resettlement agencies may be able to facilitate a link to the Congolese (or other ethnic) community elsewhere in the United States, if desired. referenceS

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Wade, A. (1997). Small acts of living: Everyday resistance to violence and other forms of oppression. Contemporary Family Therapy, 19(1), 23–39. Walsh, F. (2003). Family resilience: A framework for clinical practice. Family Process, 42(1), 1–18. Watson, P. J., Brymer, M. J., & Bonanno, G. A. (2011). Postdisaster psychological intervention since 9/11. American Psychologist, 66(6), 482–94. doi:10.1037/ a0024806. Weinstein, H.  M., Dansky, L., & Iacopino, V. (1996). Torture and war trauma survivors in primary care practice. Western Journal of Med, 165(3), 112–18. Weiss, T., & Berger, R. (Eds.). (2010). Posttraumatic growth and culturally competent practice: Lessons learned from around the world. Hoboken, NJ: Wiley. Wenzel, T., Kastrup, M. C., & Eisenman, D. P. (2007). Survivors of torture: A hidden population. In P. Walker & E. Barnett (Eds.), Immigrant medicine (pp. 653–63). Philadelphia: Saunders Elsevier.

Winter, A. M. (2011). Social services: Effective practices in serving survivors of torture. Torture, 21(1), 48–55. Wong, E. C., Marshall, G. N., Schell, T. L., Elliott, M. N., Babey, S. H., & Hambarsoomians, K. (2011). The unusually poor physical health status of Cambodian refugees two decades after resettlement. Journal of Immigrant and Minority Health, 13(5), 876–82. Woodcock, J. (1995). Healing rituals with families in exile. Am J Fam Ther, 17(4), 397–409. World Medical Association Declaration of Tokyo. (1975). Guidelines for physicians concerning torture and other cruel, inhuman or degrading treatment or punishment in relation to detention and imprisonment. Adopted by the 29th World Medical Assembly. Tokyo, Japan: World Medical Association. Yaffe, K., Vittinghoff, E., Lindquist, K., Barnes, D., Covinsky, K. E., Neylan, T., . . . Marmar, C. (2010). Posttraumatic stress disorder and risk of dementia among U.S. Veterans. Arch Gen Psychiatry, 67(6), 608–13.

cHaPter 2 5 young men of color b r u c e J . a r m S t r o n G , a lW y n t. c o H a l l , and renee mayer coHall

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ost adolescent and young adult men are “healthy” according to traditional indicators of health (e.g., mortality rates). Health issues of infancy and childhood are distant memories, chronic illnesses of later life are beyond imagining, and “health” may simply mean “doing life and enjoying it” (Baizerman, 1979). “Health” however, is an elusive concept that defies simple explanation. A more holistic conceptualization that considers mental and social well-being is most appropriate during young men’s journey through adolescence and young adulthood. The World Health Organization defines health as “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity” (WHO, 1946), and the Alma-Ata International Conference on Primary Health Care (WHO, 1978) affirms that attaining the highest level of health requires responses from “social and economic sectors in addition to the health sector.” These landmark documents emphasize a holistic, assets-based understanding of health and mental health that includes consideration of income, education, and employment disparities, and “social morbidities.” These documents also highlight the importance of comprehensive, coordinated, and continual collaboration that reaches across health, mental health, education, employment, legal, and social service systems. This chapter discusses social work practice with 10- to 24-year-old males in the United States, with a focus on young black and Latino males (young men of color). The authors do

not view health, mental health, and well-being through the narrow lens of a medical model focused on deficits (i.e., young men of color are not labeled as “careless risk takers” who are “hard to reach”). Instead, the authors celebrate young men’s assets and their resiliency in coping with environments that often are not supportive. Social workers are encouraged to craft interventions that empower young men to take action in resolving challenges, and to shape community, institutional, and structural environments that promote health and development. Focusing on social work practice with young men of color is timely and reflects a growing national interest. The role of young men in preventing unintended pregnancy and STIs and in improving the health of families and communities has been increasingly recognized (Bonhomme, 2007). More attention has also been paid to addressing men’s health needs “in their own right” (Alan Guttmacher Institute, 2002). Legislation proposing an Office of Men’s Health has been introduced (but not adopted) in Congress (S. 1028, 2003). The Youth Risk Behavior Survey (YRBS) and other studies have built a robust body of knowledge about young men’s health, including their social and mental health (e.g., Eaton et al., 2012). Public (e.g., the Office of Family Planning) and private (e.g., the Robin Hood Foundation) stakeholders have invested in health, mental health, and social services for young men of color. Addressing young men’s physical, social, and mental health needs is urgently needed. 535

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On average, males in the United States live five fewer years than females. The mortality rate for 10- to 24-year-old males is declining but is far too high (CDC, 2012a). Life expectancy for black males is lower than for Latino and white males (Murphy, Xu, & Kochanek, 2012). Mental health morbidity is high (almost 25 percent of young adult males report some form of mental illness), yet males are less likely than females to receive treatment for their mental illness (Substance Abuse and Mental Health Services Administration [SAMHSA] 2011). Young males have higher rates of absenteeism and grade retention, and are more likely to drop out of high school than their female peers. Black and Latino males have higher dropout rates than white males (Chapman, Laird, Ifill, & Kewalramani, 2011). Disparities are most disturbing for young men who are marginalized by poverty, low educational attainment, unemployment, undocumented immigration status, incarceration, and discrimination because of sexual orientation. Social workers must play key roles in redressing these disparities. defining and explaining young men of color The World Health Organization (WHO), the United Nations Children’s Fund (UNICEF), and the United Nations Population Fund (UNFPA) define “young people” as persons between 10 and 24 years of age (WHO, 1946). During this transitional period, youth experience profound physical, cognitive, emotional, and social changes, form beliefs and attitudes, develop cognitive and interpersonal skills, and engage in behaviors that have immediate and long-term consequences. Youth development is shaped through interactions with peers, family members, and non-parental adults. “Teachable moments” that help young people cope with life’s challenges are abundant when services are accessed in clinics, schools, workforce development (WFD), GED, prison reentry, and other community-based organizations (CBOs).

In recent years there has been a shift in how researchers, practitioners, and policy makers think about healthy youth development, and new questions have been asked. What do young people need to achieve successful adulthood? What outcomes should be expected? How can communities support development? What role do young people play in shaping their own development? Development and prevention science researchers have reached the consensus that key characteristics of youth development are • Ongoing—a continuous process from childhood to early (9–13), middle (13–17), late (17–21) adolescence, and young adulthood (21+) • Uneven—variations between and within youth (e.g., some 14-year-old males shave, others don’t; an 18-year-old male can have excellent social skills but poor decisionmaking skills) • Complex—physical, cognitive, social, emotional, and moral growth • Influenced by environment—physical (e.g., safe schools); access to services, opportunities, and supports • Mediated through relationships—connections with parents, neighbors, peers, teachers, health and social service professionals influence the direction and pace of development • Triggered by participation—youth development is catalyzed when youth are actively engaged and asked to contribute (Pittman, Irby, Tolman, Yohalem, & Ferber, 2003). Positive youth development (PYD) is a profound paradigm shift away from one that focuses solely on preventing or fixing problems. It is a perspective that is resonant with a strengths-based approach to social work practice. PYD principles suggest that all youth, even those bruised by stressful life experiences and noxious social environments are capable of healthy development if they are connected

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to resources and opportunities. PYD acknowledges that all young people need help at some point in life, and that all share common needs, e.g., to feel connected to caring adults, to feel safe at school. PYD emphasizes that all young people have assets and that engagement is the most effective road to achieving a sense of competence (Pittman et al., 2003). A key tenet of PYD is the notion that it is not enough for young people to just stay out of trouble. Young people also need to prepare for adulthood (“problem free is not fully prepared”) (Pittman, Irby, & Ferber, 2000). Few issues better illustrate the impact of shifting to a PYD paradigm from a deficitsbased model than Juvenile Justice (JJ) policies and interventions over the past century. Shifts in understanding have had a particularly significant impact on young men of color, a group that is treated more harshly at every step along the JJ “pipeline” (Annie E. Casey Foundation, 2012) and one that is disproportionately harmed by disparities in arrests, prosecution, and incarceration (e.g., exclusion from tuition assistance; loss of voting rights). In the early nineteenth century, for example, the doctrine of “parens patriae” (i.e., granting the state authority to protect persons deemed unable to act on their own behalf) was applied to “delinquent” youth who “needed” to be protected in “reform” institutions. In the early twentieth century, as young people flooded out of factories onto the streets, the focus shifted to one that assessed the moral character of “troubled” youth, and those determined by judges and child advocates to be in need of care were assigned to rehabilitation outside the home. In 1967, the Supreme Court Gault decision established that children facing delinquency proceedings had a constitutional right to legal counsel equal to the rights of adults. The “adultification” of youth intensified and turned sour in the 1980s as crack-related arrests exploded (“adult time for adult crime”) (Schwartz, 2005). Principles of “restorative justice” attempted to strike a balance between “rehabilitative” and “retributive”

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approaches (Bazemore & Umbreit, 1994), but sensational incidents like the Columbine shootings led to youth (especially young men) being labeled as “superpredators” (DiIulio, 1995) who needed to be prosecuted and sentenced as adults. A growing body of neuroscience research in recent years, however, has challenged the notion that adolescents are as culpable as adults (e.g., Geidd, 2008). MRI studies, for example, have confirmed that the human brain continues to mature well into the 20s. Since adolescent brains are still “under construction,” their capacity for impulse control, long-term planning, consequential thinking, and other executive functions associated with prefrontal cortex development is different from adults’. Table 25.1 illustrates how a paradigm shift away from a traditional model of JJ to one based on PYD principles dramatically alters the way young people are understood and treated. According to a PYD perspective, “problems” of young men in the JJ pipeline are understood as indicators of a poor “fit” between their basic needs (e.g., to feel part of a group, to have a defined role and purpose), and the qualities of their physical, social, and interpersonal environments (e.g., few employment opportunities, isolation from caring adults, biased policing practices). demographic Patterns The current generation of 10- to 24-year-olds is the largest in the history of the world; 1.8 billion youth comprise one-quarter of the world’s population (U.S. Census Bureau, 2012b). In the United States, 10- to 24-year-olds constitute onequarter of the male population. Latinos comprise 21 percent of 10- to 24-year-old males, and blacks comprise 16 percent (U.S. Census Bureau, 2012a). In 2009, 13 percent of males lived below the poverty level, with black and Latino males more than twice as likely as white males to be poor (DeNavas-Walt, Proctor, & Smith, 2011). The Youth Risk Behavior Survey (YRBS), Monitoring the Future (MTF), the National Longitudinal Study of Adolescent Health

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ta b l e 2 5 . 1

Traditional Juvenile Justice (JJ) vs. Positive Youth Development Traditional Juvenile Justice

Positive Youth Development

Role of youth in community Role of youth in justice system Mission of JJ system Key strategy of JJ

Target of change Client Public safety Control youth behavior

Target of juvenile services Purpose of service delivery Intervention methods

Youth problems and deficits Supervision and control Probation supervision to ensure youth compliance with court orders Individual and family counseling, group therapy (insight-based) Job counseling, community service as punishment Outdoor challenge programs Mentoring, big brother/big sister Remedial education

Agent of change Participant Community wellness Connect youth with social and developmental resources Youth strengths and assets Attachment and engagement Case management to ensure youth access to range of social resources Peer counseling, leadership development, family living skills Work experience, community service as job preparation, career exploration Conservation projects, community development projects, recycling and community beautification projects Youth/adult mentors work together on community service projects, intergenerational projects with the elderly, etc. Cross-age tutoring (opportunities to teach young children), educational action teams, decision-making training

Source: Adapted in part from “Developing delinquent youths: A reintegrative model for rehabilitation and a new role for the juvenile justice system” by Bazemore & Terry, 1997, Child Welfare, 76(5), 665–716.

(Add Health), the National Survey of Drug Use and Health (NSDUH), and other studies have increased our knowledge of young men’s physical, social, and mental health (Eaton et al., 2012; Johnston et al., 2012; Resnick et al., 1997). Twenty-five states and urban school districts included questions about the gender of sexual partners and sexual orientation on the 2011 YRBS, and the National School Climate Survey has documented the school experiences of lesbian, gay, bisexual, and transgender (LGBT) youth for over a decade (Kosciw, Greytak, Diaz, & Bartkiewicz, 2010). On average, males live about five fewer years than females, and significant racial and ethnic disparities exist. Average life expectancy at birth is 78.9 for Latino males, 76.5 for white

males, and 71.8 for black males (Murphy et al., 2012). As seen in figures 25.1 and 25.2, gender disparities in mortality increase during young adulthood (CDC, 2012a). Racial disparities also increase, with black males (128 per 100,000) experiencing higher mortality rates than Latino (81) or white (82) males (CDC, 2012a). As seen in table 25.2, males are more likely to die from the leading causes of death among young people: motor vehicle accidents, homicide, and suicide (NCHS, 2012). In 2009 the homicide rate for black males 15–24 was thirteen times higher than that for white males (CDC, 2012a). Black and Latino males have higher morbidity rates than white males from HIV/AIDS, chlamydia, and other preventable conditions

younG men of color

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127

Deaths per 100,000

120 100 80

74

75

60

Males

46

40

32 18

20

Females

31

13

0 Ages 10-14

Ages 15-19

Ages 20-24

Ages 10-24

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140

128

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120 100 80

73

60

49

82

81

53

76 50

49

40 20

14

16

White Hispanic

23

Black

0 Ages 10-14

Ages 15-19

Ages 20-24

Ages 10-24

fiGure 25.2

(CDC, 2011). Chlamydia and gonorrhea rates peak among males during their early 20s (Weinstock, Berman, and Cates 2004). One-third of the 56,000 people infected with HIV each year are 13 to 24 years old (Hall et al., 2008). Black males 20–24 have the highest rate of HIV infection (145 per 100,000), almost thirteen times higher than white males (eleven per 100,000). The rate for Latino males is three times higher than for white males (38.3 per 100,000). Nine out of ten 13- to 19-year-old males with HIV were infected through male-to-male sexual contact (CDC, 2012). Young men who have sex with men (YMSM) suffer disproportionately from HIV (Kann et al., 2011). Black YMSM

experienced the largest increase of all racial/ ethnic groups in newly diagnosed HIV infections (CDC, 2012c). On a more hopeful note, the U.S. teen birth rate is at its lowest level in sixty years, in part because of increased use of dual methods (hormonal methods and condoms) by females and males (Hamilton & Ventura, 2012). Young adult males, however, are more likely than younger males to be sexually experienced, to have multiple sex partners, to not use condoms, and to be disconnected from care (Cohen, Ward, & Schiller, 2011; Hoff, Greene, & Davis, 2003; Marcell, Klein, Fischer, Allan, & Kokotailo, 2002).

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Deaths per 100,000 for 15- to 24-YearOlds for Selected Causes, by Gender ta b l e 2 5 . 2

Motor vehicle accidents Homicide Suicide

Males

Females

29.8 20.9 16.3

11.8 3.4 3.6

Source: Adapted from “United States, 2011: With Special Feature on Socioeconomic Status and Health” by the NCHS, 2012.

t a b l e 2 5 . 3 Selected Results from the 2011 Youth Risk Behavior Survey

Sex with 4+ partners Drive when drinking alcohol Not wear a seat belt Carry a weapon Be in a physical fight Smoke cigarettes regularly Use marijuana one or more times in past month Offer, sell, or be given an illegal drug on school property Drink a can, bottle, or glass of soda at least once per day Be obese

Males

Females

17.8% 9.5% 8.9% 25.9% 40.7% 7.4% 25.9%

12.6% 6.7% 6.3% 6.8% 24.4% 5.4% 20.1%

29.2%

21.7%

31.4%

24.0%

16.1%

9.8%

Source: Adapted from “Youth Risk Behavior Surveillance—United States, 2011” by Eaton et al., 2012.

Trend data show that current cohorts of young men are less likely to smoke cigarettes, drink excessively, and engage in violencerelated behaviors than past cohorts (Eaton et al., 2012; Johnston et al., 2012; SAMHSA, 2011). Young men, however, are more likely than young women to engage in risk behaviors that increase mortality, morbidity, and injury (Courtenay, 2000; Eaton et al., 2012). Selected results from the 2011 YRBS highlight gender differences in risk behaviors among high school students (table 25.3). The rate of illicit drug use in 2010 among persons aged 12 or older was higher for males (11.2 percent) than females (6.8 percent). Males are more likely to be current users of marijuana (9.1 vs. 4.7 percent), psychotherapeutic drugs (for nonmedical reasons), cocaine, and

hallucinogens. Young men are more likely to minimize the health and mental health risks of substance abuse (SAMHSA, 2011) and to be fatalistic about their chance of living beyond age 30 (Jamieson & Romer, 2008). Compared to males, adolescent females are more likely to experience a major depressive episode (MDE) (CBHSQ, 2012), to feel “sad or hopeless,” and to consider suicide (Eaton et al., 2012). Adolescent males are more likely to commit suicide, and gender disparities increase during young adulthood (CDC, 2012a). The discrepancy between MDE among females and completed suicide among males is puzzling. One explanation for this paradox may be that young men are reluctant to seek help when they feel distressed because of exaggerated beliefs that men should be stoic and self-reliant (“grin and bear it”) (Courtenay, 2000). Beginning in late adolescence/young adulthood, males are less likely to visit a doctor, to have regular checkups, and to be connected to a health care provider (Schiller, Lucas, Ward, & Peregoy, 2012). Latino and black males are less likely to have seen a physician in the past year and to have had a regular source of care (Schiller et al., 2012). Anticipated emotional costs (e.g., fear of hearing “bad news”) deters some: “I feel like what you know won’t hurt you . . . I don’t want to know nothing (that I have an STD). Because I feel like if you find out, that’s a spirit damper” (Kalmuss & Austrian, 2010). Concerns about confidentiality and stigmatization also inhibit help seeking: When we come out (of clinics), it’s like we’re coming out with orange jackets that says STD discussion. And that’s what it is about the specific clinics. Like a girl could go in a specific clinic and she could be like, ‘well I was there to get birth control.’ But if a guy is coming out, people gonna take the negative outlook first. Like ‘yeah, you hit.’ Because soon as you come in the door (of a sexual health clinic), I swear to God, all eyes turn to you. I got to put my black hoodie on (Kalmuss & Austrian, 2010).

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Young men’s health and well-being is further compromised by unemployment, school dropout, incarceration, bullying, and other “social morbidities.” The employment rate for young men has fallen sharply in recent years, reaching 28 percent in 2009, the lowest since 1948. The employment rate for male teens in June 2009 was half as high as June 1978, and 20 points below June 2000 (Sum, McLaughlin, & Palma, 2009). Freudenberg and Ruglis (2007) eloquently point out that education is one of the strongest predictors of health: If medical researchers were to discover an elixir that could increase life expectancy, reduce the burden of illness, delay the consequences of aging, decrease risky health behavior, and shrink disparities in health, we would celebrate such a remarkable discovery. Robust epidemiological evidence suggests that education is such an elixir.

The cost of leaving school without a diploma has never been greater. Individuals without a diploma or GED have diminished lifetime earnings and are less likely to receive health care (Deaton, 2002; Molla, Madans, & Wagner, 2004). Less educated individuals are more likely to smoke, be sedentary, and be overweight (Lantz et al., 1998). While dropout rates are declining for all racial and ethnic groups black (13.9 percent) and Latino (22.5 percent) males are more likely to drop out of high school than white males (11 percent) (Chapman et al., 2011) The United States incarcerates more of its citizens than any other industrialized country. Despite dramatic reductions in violent youth crime, over 2 million young people under 18 are involved in the juvenile justice system each year, i.e., awaiting trial, in prison or jail, or on probation or parole (Snyder, 2004). Nearly 100,000 young people are in juvenile facilities every day. Incarceration is five times higher for blacks than whites, and twice as high for Latinos (Wagner, 2012). Among incarcerated youth, 62 percent are black or Latino and

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85 percent are males (Clark & Gehshan, 2006). Among individuals “stopped and frisked” by New York City police in 2011, 84 percent were people of color, and most were young black and Latino males (Peart, 2011). While young men in the JJ system have significant medical, oral, mental health, educational, and vocational needs, and higher morbidity and mortality rates (Clark & Gehshan, 2006), many are left to cope with the disruptions of incarceration without adequate protection from families, schools, and communities (Golzari, Hunt, & Anoshiravani, 2006). Bullying, i.e., the assertion of interpersonal power through aggression (Pepler & Craig, 2000), is a worldwide epidemic and rates vary across countries (ranging between 2 percent and 36 percent). Adolescent males are more likely to be involved in bullying both as victims and perpetrators (Currie et al., 2012). In 2011 one in five U.S. students were bullied on school property at least once in the past year (Eaton et al., 2012). Fifteen percent of 11-year-old males, 13 percent of 13-year-old males, and 6 percent of 15-year-old males were bullied at school at least twice in the past couple of months (Currie et al., 2012). YMSM are especially hurt by harassment and are inadequately protected in schools and communities. Eighty percent of LGBT students experienced harassment in school because of their sexual orientation in 2009, six in ten felt unsafe, and one-third skipped school to avoid harassment (Eisenberg & Resnick, 2006; Kosciw et al., 2010). Societal context The experience of being a young man in 2012 is markedly different from a century or even a few decades ago. Puberty occurs at a younger age, but transitional markers of adulthood are delayed into the 20s. Establishing economic and emotional independence by moving from school to full-time employment has been pushed back. Half of 18- to 24-year-olds live with their parents (Parker, 2012). Manufacturing jobs that provided low-skill workers with

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living wages, benefits, and dignity have vanished from inner cities and been “outsourced” to places with low overhead and cheap labor. Globalization and the Internet technology revolution mean that far more than a high school diploma is required for a good job. The importance of social and physical environments is underscored by discrepancies in adolescent well-being across the United States: teen death rates (deaths per 100,000 teens ages 15–19) range from a low of thirty-five in Vermont to 100 in Alaska; teen birth rates are as low as twenty in Massachusetts and as high as sixty-six in Mississippi. The rate of teens who are not in school and who have not graduated ranges from 3 percent in New Jersey to 11 percent in Nevada, and the percent not in school and not working varies from 5 percent in New Hampshire to 15 percent in West Virginia (Annie E. Casey Foundation, 2012). Among the factors that account for these differences are diverse public policies that affect access to services. For example, twenty-one states allow all minors to consent to contraceptive services, while twenty-five permit minors to consent with restrictions (e.g., if the minor is married), and four have no explicit policy (Alan Guttmacher Institute, 2012). Public policies influence health and mental health directly and indirectly. The Personal Responsibility and Work Opportunity Act of 1996 for example, reduced or eliminated health insurance for the undocumented. In most states, undocumented individuals became ineligible for publicly funded health services. Recent debates about immigration including draconian law enforcement practices in Arizona and recommendations that undocumented immigrants “self-deport” create an environment of fear that discourages young men from accessing services. Even though undocumented people can receive services at community health centers, and HIPAA policies ensure that services are confidential, young men may avoid care because they believe health center staff will notify immigration authorities.

Poverty, insurance and immigration status, and unemployment are powerful structural determinants of health (Vasquez del Aguila & Aguirre-Molina, 2011). Unlike other industrialized countries, the United States does not guarantee insurance coverage for its people. Hope generated by passage of the Affordable Care Act of 2010 is tempered by the limitations of a patchwork system of medical insurance that leaves millions uninsured. Young men of color are least likely to have coverage (Callahan, Harris, Austin, & Woods, 2002). In 2010, 36 percent of Latino males had no health insurance, compared to 21 percent of black males and 14 percent of non-Hispanic white males (NCHS, 2011). Employment is no guarantee of having benefits, since many young men work part-time, and undocumented young men often work in the informal economy. Sexual and reproductive health (SRH) education also illustrates how environments generate stress. A robust body of evidence has demonstrated that abstinence-only education is not effective, while numerous evaluations have shown that comprehensive sexuality education helps adolescents delay sex and use contraception (Santelli et al., 2006). Comprehensive SRH education has been incorporated into the curricula of public schools, yet many young men do not receive instruction before they become sexually active (Lindberg & Maddow-Zimet, in press). Research shows that parents are the primary sex educators for adolescents (Meschke, Bartholomae, & Zentall, 2000) and communication about sex is associated with delayed sexual initiation and increased contraceptive use (Hadley et al., 2009; Malcolm et al., 2013). Unfortunately, many young men do not talk about sex with their parents. In one study, twothirds said that they did not discuss condoms with their parents prior to having sex, and conversations about SRH occurred earlier among daughters than sons (Beckett et al., 2010). The absence of a service infrastructure for young men similar to that of young women and inconsistent STI/HIV counseling guidelines

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also affect the adequacy of care young men receive (Marcell, Bell, Lindberg, & Takruri, 2010). National initiatives like Bright Futures (Hagan, Shaw, & Duncan 2008) provide a framework for adolescent preventive care, but the unique challenges of serving young men are not addressed. Time constraints and inadequate ancillary support (e.g., “male friendly” health education materials) diminish the quality of preventive services for young males. Socially constructed masculinity beliefs influence young men’s physical and mental health and their decisions to seek care: “Some guys got too much pride— ‘I will not go to the doctor’— Some guys make vows that they will not go to the doctor. Or they can’t be hurt. You know, like they’re impenetrable” (Kalmuss & Austrian, 2010). Beliefs are reinforced by the behavior of older males: half of adult males over 40 in one study did not have a physical or prostate cancer screening in the past year (Sandman, Simantov, & An, 2000). Constructions of masculinity vary depending on culture and class. Latino men may construct masculinity within the concept of “aguantar” (to tolerate) and “descuido” (to be careless), and enact beliefs by ignoring symptoms (Aguirre-Molina, Borrell, & Vega, 2010). Behaviors perceived as careless may be linked to the belief that missing work due to illness isn’t an option because men must support their families. Expressing vulnerability by going to the doctor may clash with expectations that men master challenges on their own. Finally, neighborhood and school environments buffer young men from stress, and sometimes cause distress. For example, YRBS data shows that 16 percent of male high school students are obese. Many low-income young men reside in neighborhoods with easy access to fast foods but limited access to fresh produce, low-fat milk products, and safe environments for exercise (e.g., bike lanes, parks) (Kipke et al., 2007). In New York City, Healthy Bodegas, Green Carts, and Health Bucks programs increase access to fresh produce (NYC DOH, 2010) in low-income neighborhoods.

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Vulnerabilities and risk factors Youth development and prevention science researchers have identified risk factors that increase the likelihood of adverse health outcomes, and diminish the likelihood of successful adulthood (Catalano et al., 2002). Examples of individual-level risk factors include inadequate knowledge, beliefs, attitudes, and norms that contribute to health-compromising behaviors. In one study, for example, two-thirds of young men reported unprotected intercourse, yet less than half thought they were at risk for STIs (Hoff, Greene, & Davis, 2003). Embarrassment, lack of confidence, concerns about reduced sensation, belief that partners will be offended, and beliefs that other men don’t use protection may deter condom use. Family risk factors include family disruption and dysfunction (Cochran, Stewart, Ginzler, & Cauce, 2002). “Coming out” about same-sex orientation or being “outed” may lead to mistreatment of sexual minority males, who may become the focus of family dysfunction. Too often, sexual minority youth are thrown out of their homes and left to survive on the streets because of the intolerance of homes, churches, and communities (Savin-Williams, 1994). Sexual minority youth in fact are overrepresented among runaway youth, yet resources to address their needs are grossly inadequate (Center for American Progress, 2010). It is estimated that half of the approximately 4,000 young people living on New York City streets are gay or lesbian, but shelter beds are available for only 10 percent of these youth (Shapiro, 2012). Street youth are left to fend for themselves by “couch surfing” or exchanging sex for food and shelter. School-level risk factors include grade retention and feeling disconnected from teachers who care about them. YRBS data show that students with low GPAs are more likely to engage in sexual and other risk behaviors (CDC, 2010a). Grade retention and feeling physically “out of sync” with classmates were associated with higher levels of emotional distress (Resnick et al., 1997). Since support for

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schools is tied to tax revenues, schools in poor areas are often overcrowded, in poor physical condition, and unable to provide safe and constructive after-school activities. Funding for extracurricular activities has been reduced in many urban school districts, limiting opportunities for young people to celebrate competency and connect to school through nonacademic activities. Community risk factors include neighborhoods with concentrated poverty, high crime rates, and inadequate physical resources. Communities with poor access to male-friendly health services also create risks for young men. Connection to practitioners who provide information and guidance decreases as young men transition to adulthood (Marcell et al., 2002), and the gender/age cohort most likely to not have insurance is 18- to 24-year-old males (Cohen et al., 2011). Poor access to care was evident in the results of a quality assurance project at one clinic. When males were asked where they would go if the clinic didn’t exist, 31 percent reported that they’d forgo care entirely, 12 percent said they would go to an emergency room, and 38 percent said they’d go somewhere else but couldn’t name a specific provider (Armstrong, 2008). resiliencies and Protective factors Most young men of color are resilient and successfully navigate the turbulent waters of adolescence and achieve healthy adulthood. Resiliency, the ability to “bounce back” in the face of adversity, is bolstered by the presence of physical, cognitive, emotional, social, and environmental resources and opportunities that promote health and well-being. Protective factors are embedded in all ecological levels. Individual protective factors include experiencing success in school. Research shows that students with high GPAs are less likely to be sexually active, to initiate sex before age 13, to have unprotected sex, to have multiple partners, to binge drink or use drugs, or perpetrate violence (CDC, 2010a). Feeling

connected to school, i.e., feeling that teachers care not only about academic success but students’ well-being, reduces youth involvement in virtually every risk behavior (Resnick et al., 1997; Resnick, Ireland, & Borowsky, 2004). Supportive teachers, gay/straight alliances (GSAs), inclusive curricula, and antiharassment policies increase the likelihood that YMSM will experience academic success. Family support is obviously an important protective factor that enables young men to cope with the risks and challenges of adolescence and young adulthood. Positive family interactions, consistent supervision, and high expectations are more important than family structure (Emshoff, Avery, Raduka, Anderson, & Calvert, 1996; Resnick et al., 2004). Eisenberg and Resnick (2006) found that suicide risk among sexual minority youth was significantly reduced when young people felt supported by their parents. Community protective factors include residing in areas that have governmental agencies that protect young people and youth development programs that promote young men’s competency and connection to caring adults. The New York City Department of Health (DOH) protects young men and entire communities through Green Cart, Healthy Bodega, and other initiatives that increase access to healthy foods, by levying high taxes on cigarettes and by enforcing laws that prohibit tobacco sale to minors. Youth development programs like Fresh Youth Initiatives (FYI) and Brotherhood/Sister Sol (BSS) in New York City engage young men of color in activities that prepare them for successful adulthood. FYI cultivates talents and skills, and fosters connection by engaging young men in service projects such as operating food pantries, sewing sleeping bags for the homeless, and visiting the elderly in nursing homes. BSS provides holistic services from childhood through young adulthood, helps young men develop leadership skills, supports educational achievement, and encourages engagement in social justice and community

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development activities. Both agencies provide young men with opportunities to have a voice (independence), experience close relationships (belonging), develop competence (mastery), and feel a sense of purpose by helping others (generosity). Programs and Social Work contributions Social workers promote health, mental health, and positive youth development in the “crossroads” where young men and environments intersect and in ways that are “increasingly addressed to the citizenry at large and decreasingly to a clinically identifiable group” (Meyer, 1970). Social workers provide services in schools, health clinics, GED, WFD, reentry, and other program settings. Social workers improve the “goodness of fit” between young men and their environments through a variety of activities including outreach and case finding, individual counseling and case management, program development, evaluation/ research, social marketing, and training. Some say that ambivalence is the “hallmark” of adolescence. Even when programs are available, young men may not be aware of them or think that services don’t address their needs. Receiving “help” may be perceived as “unmanly.” Young men may not be aware that they need services; for example, those engaged in risk behaviors (e.g., unprotected intercourse with multiple partners while “buzzed”) may not know how STIs are transmitted or that infections can be asymptomatic and may be reluctant to stop self-medicating because they see no other way to alleviate stress. Young men in a reentry program will avoid STI screening if they think urine is tested for drugs since a positive test means re-incarceration. To counter these barriers, social workers venture out from offices, programs, and clinics to engage young men “in the preventive battlefields” of society (Bower, 1961), i.e., in streets and playgrounds, classrooms and hallways, waiting rooms, WFD and GED programs, and other venues where young men congregate.

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Project STAY (Services to Assist Youth) at Columbia University created a communitybased outreach initiative funded by the New York State Department of Health AIDS Institute. STAY has two components—a Specialized Care Center (SCC) at New York-Presbyterian Hospital, which provides medical and psychosocial services for youth living with HIV/AIDS; and an interdisciplinary Youth Access Program (YAP), which includes a mobile health team (MHT) consisting of social workers, an adolescent medicine physician, a nurse-practitioner, and an HIV counselor/health educator. The MHT provides a safety net of services for young people who are left out of traditional health programming. Rather than waiting for young people to present for care, the MHT meets them on their own terms and in settings where they feel comfortable, e.g., alternative high schools, CBOs, WFD, and reentry programs. Services include interactive, multimedia, sexual health education workshops delivered in small-group settings; individual assessment of assets and risks; STI and HIV screening; and linkage to health and mental health care. Of those served, 98 percent are youth of color and 48 percent are male. Social workers develop standardized assessment tools based on an “assets-based” framework; youth identified with health or mental health needs are linked to appropriate resources (Cohall et al., 2011). At CBOs, social workers engage young men of color by embedding positive images of masculinity into routine services. GED programs integrate modules on chlamydia into test prep courses. Photos and brief narratives about clinic staff teach vocabulary (e.g., prevalence, transmission) and math skills (e.g., interpreting bar graphs about health disparities) while disseminating information about the clinic. Crossword puzzles motivate students to think about confidential care at community health centers. At youth development programs, social workers help young males design computer “screen savers” about men’s health. At a high school, social workers empowered students to write three

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front-page articles about men’s health for their school newspaper in one academic year. Recognizing that females play central roles as “gatekeepers” for health and mental health information and services (Raine, Marcell, Rocca, & Harper, 2003), social workers at a family planning clinic link young men to services through “in reach” to females. Social workers lead waiting room groups that focus on four questions: do young men need health care; what keeps men from going to the doctor; where can men get care; and how can women begin conversations about going for help? At the end of the group, females make appointments for male partners. An evaluation found that half of new patients at the men’s clinic affiliated with the family planning clinic came for exams because females had encouraged them. Incarcerated young men need to be connected to a “medical home” before release, and health and mental health services need to be coordinated with community social services (American Academy of Pediatrics, Committee on Adolescence, 2001). Hospital-based social workers build relationships with social workers at reentry programs and co-facilitate weekly orientation groups for young males returning home from jail. Participants watch a brief video featuring a physician who gives advice on how to get the most out of an exam (e.g., writing down questions in advance). A second video presents testimonials from men who have benefited from the clinic. Appointments are made directly to the clinic through e-mail. At a school-based health center (SBHC), a social worker collaborated with health educators, school administrators, teachers, and students to increase clinic utilization. The worker entered students’ life space by venturing outside clinic walls, e.g., hallways between classes, cafeteria during lunch periods, and sidewalks adjacent to the buildings before and after school. To reduce social and emotional distance, the worker participated in activities not directly related to the clinic, e.g., playing an eccentric scientist for an antismoking video produced

by the school’s film program; eating lunch with young men and inviting them to eat dessert at the clinic. The social worker organized afterschool intramural activities, e.g., a running club and an after-school basketball tournament. Trophies were distributed and photographs of young men in the tournament were posted on bulletin boards throughout the school. Male participation in the SBHC increased from 22 percent to 80 percent of enrolled males over a five-year period (Armstrong, 2012). The importance of case management is cited in social work and nursing literature (e.g., Rothman & Sager, 1998). Case management varies across settings and disciplines. Social work case management focuses on individual and environmental assets and needs. Services include assessing needs, collaboratively developing service plans, coordinating referrals, advocating with linkage partners, monitoring service delivery, and providing crisis counseling. Social workers identify resources and resource gaps (e.g., inadequate dental and legal services) and barriers that interfere with obtaining services, then intervene to improve collaborative practice (e.g., by cross-training staff and adapting intake forms at CBOs to ensure comprehensive screening). For example, a social worker from a health clinic was “outposted” one day each week to WFD programs that serve “disconnected” young men. The worker conducted individual health needs assessments for new clients. The worker communicated positive health messages (e.g., “healthy men are important for communities and families”), normalized help seeking (e.g., “many men have questions about what’s normal”), selectively attended to strengths (e.g., “you haven’t gotten a checkup in a while, but it’s great that you are thinking about it now”), and provided health education materials matched to the health literacy level of the men. Each man developed an individualized health plan that included referrals for medical and dental care at community health centers. Prior to launching the intervention, the worker

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recruited public health students (MPH) to asset map (see next section) local community health centers (CHCs). The social worker supervised a “community health navigator” who tracked participants by phone, mail, text messaging, and e-mail, and engaged young men in problem solving when they had trouble making or keeping appointments. Feedback to CHC administrators was provided when barriers surfaced, e.g., when young men reported slow or rude telephone responses from intake staff at the clinics. Albert Einstein said that the most important question to be answered in life is whether the universe is a friendly place. Social workers assume lead roles in program planning and development by ensuring that the clinical ambiance of the Young Men’s Clinic (YMC) in New York City is “male friendly.” Social workers intentionally craft activities and décor in waiting rooms, labs, exam and counseling offices, bathrooms, and hallways so that the physical space communicates that young men are viewed as active partners, not problems to be fixed. Social workers ensure that framed photographs of men of color holding infants, supporting breast-feeding, celebrating graduation, and pursuing other health-promoting behaviors, as well as photos of prominent men of color like President Obama, Colin Powell, and Eric Holder, are disseminated throughout the facility. Posters of heterosexual and YMSM couples from the “Strength Campaign” (“When he wanted to and I didn’t, we didn’t”) (Men Can Stop Rape, 2011) are displayed to explicitly express the clinic’s equity policy. Since 90 percent of the young men who visit the clinic are Latino, social workers developed spooling PowerPoint modules of Caribbean scenes (e.g., Puerto Rico’s El Yunque rainforest) to show in the waiting room (accompanied by Latin music) while men wait for individual care. Social workers collaborate on interdisciplinary teams to conduct quantitative and qualitative research and evaluation that assess young men’s needs (formative evaluation), monitor

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whether programs are conducted as planned (process evaluation), and evaluate intervention effectiveness (outcome evaluation). Formative evaluation occurs when a program, curriculum, marketing intervention, assessment tool, or evaluation instrument is being developed, and supports the process of improving services at early stages of development. Social workers at a community clinic developed videos featuring GED services to help young men reconnect with school. Before filming, workers interviewed young men to learn their ideas about how to make the video engaging and learned that young men wanted the video to (1) be brief, (2) show the physical space of the agency and surrounding streets, (3) contain limited information from professionals and (4) feature testimonials from males who had benefited from the services. Process evaluation focuses on how a program operates and is used to improve quality, assess whether services are being delivered as designed, identify the need for additional resources, and document unexpected challenges. Social workers in a clinic observed that service utilization in the first quarter of the calendar year was lower than expected, and engaged the entire staff in problem solving. Corrective actions included increasing group work with females, conducting in-service training for providers, and creating an electronic newsletter that was distributed to over 300 community partners. Outcome evaluation examines what happens as a result of program activities. In one program, social workers evaluated the effectiveness of a curriculum for young Latino males at a CBO and found significant improvements in attitudes toward health clinics, condom use, and sexual health knowledge, and decreased numbers of sexual partners at three months’ follow-up (Kalmuss, Armstrong, Franks, Hecker, & Gonzalez, 2008). Social workers subsequently provided consultation to practitioners in another city to replicate the program with young black males.

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Social marketing is “the application of concepts and techniques drawn from the commercial sector to promote changes in social behaviors such as drug use, smoking, sexual behavior” (Andreasen, 1995). A Project STAY social worker leads an interdisciplinary professional team that designs videos, posters, and websites that inform young men about health issues, conducts focus groups, and organizes youth advisory boards to ensure that young men’s voices are heard. Project STAY social workers collaborated with the Healthy Monday Campaign and the Elton John AIDS Foundation to produce materials that encourage all men (particularly YMSM) to increase involvement in health behaviors (“Man Up” Monday), and to increase screenings for STIs and HIV (“Check Yourself ” Monday). Components of the awareness campaign include animated videos, website content, and posters that were disseminated to schools and CBOs. (These materials can be viewed online by visiting http://www.mondaycampaigns.org or http:// www.ProjectSTAYnyc.org). Social workers at the YMC conducted formative research before producing marketing videos about the clinic’s health and mental health services. One video included a tour of the facility that featured staff discussing clinic policies. A second video presented testimonials of young men challenging beliefs that deter help seeking (e.g., men should “keep a stiff upper lip” when they feel pain). Social workers and young men designed cartoon stories about hernia, EC, Depo-Provera, STI urine testing, the male exam, and other topics. Each story (1) provided information about a health topic, (2) gave information about how to access the clinic, and (3) celebrated male involvement (e.g., holding a baby; graduating from school). Young men and women want to talk about health and view providers as valuable sources of information (Ackard & Neumark-Sztainer, 2001; Klein & Wilson, 2002). Unfortunately, “teachable moments” are often missed when

young men present for care. Health care providers spend less time, provide less information, and are less likely to discuss prevention with male patients (Courtenay, 2000; Bradner, Ku, & Lindberg, 2000). Insufficient provider training is one reason sensitive issues are not discussed (Ashton et al., 2002). To address the “poor fit” between what men need and what’s provided to them, social workers and physicians train medical, nursing, social work, and public health students as well as community providers through a collaboration with the New York City Department of Health and the Region II STD Prevention Training Center. Skillsbuilding workshops, a training manual, and an accompanying video introduce providers to an “empowerment approach” to screening, educating, and counseling young men (Armstrong & Cohall, 2010). Empowerment is “the process of assisting individuals, groups, families, and communities to discover and expend the resources and tools within and around them” (Saleeby, 2001). Social workers train health care professionals to identify and communicate to young men that participating in health and mental health services demonstrates strength, competency, and responsibility, not weakness. The empowerment approach is guided by the following principles: • Young men’s concerns are “normal” and shared by others • Providers care about young men and see them as integral to the health of families and communities • The provider-patient relationship is a “partnership” with both sides playing active roles • Providers believe in young men’s ability to address needs and solve problems • Young men can contribute to community health by helping others. The empowerment approach incorporates the spirit, principles, and skills from “short-term

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counseling,” “motivational interviewing,” and social work’s “strengths-based perspective.” Shortterm counseling builds on the social influence of “helpers.” Through empathy, nonjudgmental acceptance, and warmth, the helper becomes a “significant other,” i.e., “a reference person whose signs of approval and acceptance are highly rewarding” (Rodin & Janis, 1979; Janis, 1983). Through “referent power” (as contrasted with expert, coercive, or reward power), the provider uses the helping relationship to motivate behaviors. Providers become a significant other by: • Highlighting similarities (interests, attitudes) they share with the young man (“I get nervous too.”) • Giving contingent praise for behaviors that are congruent with the young man’s goals (“I’m impressed that you are studying hard to get your grades up.”) • Conveying a willingness to help with issues the young man sees as important (“Let’s see if we can think of volunteering you can do.”) • Selectively attending to successes (“You didn’t use condoms each time you had sex, but you’re using them more since the last time we met—fantastic.”) • Validating and empathizing (“You make sense. It hurts when someone lets you down.”) • Focusing on assets and expressing confidence in the young man (“You feel confused, but you describe your problems clearly. I think you can work this out.”) • Thinking “with” instead of “for” or “about” the young man (“Let’s think together about how to solve this problem.”) Motivational Interviewing (MI) is a counseling style that helps individuals resolve ambivalence as they move through the change process. Social workers train providers to mobilize young men to think about the benefits and costs of adopting a behavior. Young men

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actively collaborate in a “dance” in which both sides take turns leading and providing input. Confrontation is avoided (“rolling with resistance”) as young men examine behaviors that are discrepant with goals (e.g., wanting to be healthy but continuing to smoke) (Kokotailo & Gold, 2008; Rollnick, Miller, & Butler, 2008). Social work’s strengths-based perspective represents a major shift away from a deficits-based approach. Problems are reframed as challenges and opportunities, labeling is avoided, strengths and resources are identified, resiliency is promoted, ecological context is considered, and collaborative partnerships are forged with young men (Saleeby 1996). Three basic skills in the empowerment “toolkit” are empathic reflection, effective questioning, and careful selection of words. Empathic reflection encourages young men to express fear, joy, and other emotions. Empathic reflection can be difficult with young men who are not used to talking about feelings, those who believe that expressing emotions implies weakness, and those who are disconnected from school, work, or satisfying relationships. Social workers train other service providers to “level the playing field” so that helping is perceived as implying strength by • Being tentative and using words that allow the young male to control the direction and pace of the interview (“I may be wrong, but it seems that . . .”) • Using words that imply thought or action (“I can see you have lots of thoughts [not ‘ambivalence’] about taking meds for your anxiety.”) • Attending to strengths (“You ask good questions about the effect of your girlfriend’s infection on her ability to have babies. I see you have a lot on your mind about the impact on your health too.”) • Normalizing (“Almost every young man who goes for a job interview has concerns about being rejected.”)

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Through effective questioning, providers gather information while allowing the young man to establish the work agenda. Effective questioning communicates that the young man is expected to play an active role. “Open” questions (i.e., “how,” “what,” “describe . . .”) encourage young men to generate alternatives and anticipate consequences. In working with a 16-year-old male who is having difficulty talking to his boyfriend about HIV testing, for example, the provider says, “tell me what makes it hard to talk with him.” Careful selection of words calls attention to words that create partnerships. Subtle shifts in word selection empower young men to participate in conversations. While taking the history of a 17-year-old male who is disconnected from school, for example, the provider says, “tell me how you decided to leave school before graduating” instead of “why did you drop out of school?” Such rephrasing shifts the focus to “choosing” and away from “failing.” Several other empowerment counseling skills are illustrated in a training manual and video produced by the New York City STD/ HIV Prevention Training Center (Armstrong & Cohall, 2010). assessment and interventions Social workers have historically been concerned with helping people adapt to their environment and with changing environments to address human needs. Shifts in the focus of practice, however, have been seen in the answers to recurring questions: How is the “case” defined? Who are our clients? How do social workers help? Where is help best delivered? What outcomes are sought? A “medical model” of practice focuses on deficits of the “individual-already-in-trouble.” Diagnosing and treating the individual through talk with social workers inside the walls of social agencies have often been the primary context of practice. Unfortunately, this perspective leads to linear, cause-effect oversimplifications of

complex problems and to social workers not being fully conscious of the real life style of clients. This limitation has made it difficult to wrest practitioners from the clinic to the world outside, to entice them to assess psychosocial problems in nonmedical contexts, to view health and adaptation as well as pathology, and to enable them to place as high a value upon modes of ‘help’ as upon the more constricting, goal-directed concept of ‘treatment’ (Meyer, 1973).

An ecosystems perspective (Gitterman & Germain, 2008), on the other hand, encourages a broader conceptual framework focused on the transaction between people and their environment. This perspective bridges the gap between “psycho” and “social,” expands the “unit of attention,” and allows action at many points during person:environment transactions. Problems are understood as arising from a “poor fit,” for example, exposure to unsupportive and stressful environments (e.g., disconnection from parents; attending a disorganized, unsafe school) and inadequate coping mechanisms (e.g., having poor academic skills). Social work assessments go beyond just the individual level; assessing qualities of environments is also an essential part of practice. Since poor health is the result of transactions in which an individual attempts to function in an environment with which he is basically incompatible, “nutrients” and “noxious” environmental elements are assessed and modified when necessary. The following section describes social work assessments and practice responses that occur on different levels: community asset mapping, “male friendly” program assessments, and the BIHEADSSS assessment of an individual’s needs and strengths. Asset mapping builds information about available resources that address an identified need in a community with specific boundaries. Kretzmann and McKnight (1993) describe

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three levels of community assets: individuals, community groups, and formal agencies (e.g., clinics, schools, social service agencies). In one clinical program, social workers supervised MPH students who identified, visited, and described health, social service, WFD, education, LGBT, and legal services needed by young men who used the clinic. Social workers identified and prioritized young men’s unmet needs (e.g., for dental care) through analysis of program service data, individual interviews, and focus groups. Social workers informed students of these findings and specified geographic boundaries of the community they wanted to asset map. Students interviewed community providers and informal leaders to identify places to visit, and augmented this information through Internet searches. Students constructed an asset map that organized agencies by category (e.g., WFD, GED, legal, and dental programs). They developed resource guides that included descriptions of services, directions, payment policies, clinic hours, Google maps, and photos of the facilities, uploaded the guides onto the clinic website, and distributed hard copies to clinic staff. Social workers used the resource guides to conduct staff trainings at CBOs, and in turn, CBO staff conducted inservice training for clinic staff about the services their programs offered. Experiences with programs perceived as not welcoming (Banks, 2001), and past negative exchanges with providers discourage some young men from seeking care (Courtenay, 2000). Service programs can be barren “no man’s lands” that are harsh, cold, and unwelcoming, or flowering gardens that are nutritious, uplifting, and welcoming. To ensure that partner health, social service, and mental health agencies were high quality and interested in receiving young men, social workers in one program developed a male-friendly assessment tool to guide asset mapping activities (e.g., assessing agencies’ mission statements, facilities, readiness for change, appropriateness

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of staffing, outreach, health education, and clinical services). Once young men are engaged, social workers assess the “goodness of fit” between what young men need to become competent and happy adults, and how well their social and interpersonal environments support those needs. Assessments include an evaluation of protective factors that buffer young men from risk and those that increase vulnerability. Thorough assessments increase the likelihood that interventions will be appropriately targeted at bolstering adaptive capacities, modifying environments, or both. BIHEADS (Boggio & Cohall, 1990) and HEADSSS (Goldenring & Rosen, 2004) frameworks are useful tools for assessing risk and protective factors with young men: — BI—body image — H—home environment; relationships with parents and other family members — E—educational progress, performance, and aspirations; school environment — A—activities, hobbies, use of free time, peer networks; abuse — D—drug, alcohol, and cigarette use; depression; diet — S—sexual history, including sexual activity, sexual orientation, condom/contraceptive use, pregnancy, parenting; past STIs, HIV risk assessment, and relationships — S—sleeping patterns — S—history of suicidal ideation or behaviors The approach recognizes strengths as central to the helping process, e.g., “tell me your strongest subject at school.” Young men are considered “partners” not “problems,” and are empowered to make changes in their own lives, e.g., reconnecting to a GED program. Assessments also assess common needs identified in Brendtro’s “Circle of Courage”: belonging, mastery, independence, and generosity (Brendtro, Brokenleg, & Van Bockern, 1992).

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cial services through strategically planned and systematically implemented outreach.

illuStrAtion And diSCuSSion

The following case illustrates principles underlying the interdisciplinary work of social workers in a university-hospital-community collaboration that is grounded in an ecosystems perspective of practice. The case of Des, a 19-year-old African American male returning home after several months of incarceration, illustrates how social workers empower young men by helping them tap into personal assets and social resources and assume an active role in bouncing back from adversity. Columbia University’s Mailman School of Public Health (MSPH) (the Young Men’s Health Initiative and the Harlem Health Promotion Center’s Project STAY) and New York-Presbyterian Hospital (NYP) (the Ambulatory Care Network’s Young Men’s Clinic) have provided male-friendly health, mental health, health education, and social services for adolescent and young adult Latino and black males for over two decades (Armstrong & Cohall, 2011; Armstrong, 2003) (see figure 25.3). The YMC provided health, mental health, health education, and social services to males ages 14–35 at over 6,000 visits in 2011. Young men and their environments are viewed as an interconnected system, and their problems are understood as resulting from “discrepancies between needs and capacities on the one hand, and environmental qualities on the other” (Gitterman & Germain, 2008). Young men’s needs are best addressed by comprehensive and integrated interventions that build on the strengths of young men and their communities. The collaboration increases young men’s access to health, mental health, and so-

MSPH/NYP interventions break down “silos” that separate health, employment, education, reentry, legal, and social service systems. As discussed earlier, assessments identify young men’s unmet needs for dental, legal, mental health, educational, and employment services, and MPH students collaborate with social workers to locate male-friendly services. Social workers follow up on students’ visits by visiting each agency themselves in order to establish personal relationships with key intake staff. MSPH/ NYP social workers strengthen partnerships with CBOs and increase the “warmth” of bidirectional referrals by: 1. Developing efficient communication systems, e.g., instructing CBO staff on how to make clinic appointments by e-mail; listing phone numbers and e-mail addresses of key staff on laminated sheets; ensuring that senior staff at each agency are informed when referral problems occur so that prompt corrective action is taken 2. Writing letters of support and linkage agreements when CBOs submit funding grants 3. Marketing CBO services, e.g., producing short videos about GED and WFD services at CBOs, posting them on the YMC website, and showing the videos in clinic 4. Arranging for clinic and CBO staff to visit each other, and periodically meeting in informal settings (e.g., at bagel breakfasts) to assess the efficiency of bidirectional referrals 5. Inviting CBO staff to train YMC staff (e.g., about the reentry process).

Columbia University Mailman School of Public Health

The Young Men’s Health Initiative

fiGureS 25.3

Harlem Health Promotion Center -Project STAY

New YorkPresbyterian Hospital

Ambulatory Care Network -Young Men’s Clinic

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Desmond (Des) is a 19-year-old African American male client in a reentry program. Des had just returned from four months of incarceration for possession of a small amount of marijuana. Social workers from Columbia’s MHT first met him when they visited the agency to provide group education and on-site STI and HIV testing. Des stood out in the group because of his easy temperament, engaging smile and personality, and his excellent decisionmaking, communication, and interpersonal skills. After the group concluded, Des agreed to be tested for STIs and HIV, and readily agreed to meet with the MHT social worker for a brief individual assessment. The social worker initially engaged Des by explaining the rationale for the intervention, normalizing help seeking as something many young men pursue, and reframing males’ low utilization of health services as being due to their having other competing priorities (e.g., “Young men often don’t have opportunities to get health services that are affordable, or don’t know where to get good services they trust. Since you’ve got a lot on your plate settling back in after being away, we thought it might help if we came out to you instead.”). Key policies were explicitly explained (e.g., “We know most young men don’t have much money to pay for a doctor, so there aren’t any charges for these services. I also want you to know that what we talk about here is ‘confidential’ . . . it stays between you, the medical team, and me. We won’t be telling your business to your family or anyone else unless you tell us it’s OK. The only time that would change would be if I thought you were going to hurt yourself or someone else.”). The social worker asked Des to sign a consent form allowing him to release information related to his health care so that services could be coordinated with the reentry social work staff and the YMC, and Des agreed to do so. The social worker engaged Des in a brief SRH history and provided anticipatory guidance about next steps (e.g., reminding him that the tests would take about a week to process, clarifying that “negative” results meant “good news,” reassuring him that the social worker would stay in touch and help if any treatment was necessary). The worker exchanged detailed contact information

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(e.g., cell and home phone numbers, e-mail and mailing addresses, optimal times to call, who to speak with if he weren’t home) so that Des could receive results and arrange for any necessary treatment. One week later the social worker called Des to inform him that his HIV and gonorrhea tests were negative, but that his chlamydia test was positive. Des agreed to come to the YMC for treatment since the clinic’s evening hours were most convenient for his schedule. Since Des was adept at using the Internet, the social worker encouraged him to go to the YMC website to see the facility and providers ahead of his visit, and obtain specific travel instructions. Des visited the YMC as scheduled and was met at the door by the MHT social worker. After signing in and completing all the required intake forms, the MHT social worker introduced Des to the YMC social worker who conducted an initial needs and strengths assessment guided by the BIHeadsss mnemonic and Brendtro’s Circle of Courage. The following summarizes the results of Des’s assessment. 1. Satisfied with appearance; does not think he needs to make any changes. 2. Lives with his mother, sister, and her 6-year-old son. His mother has a serious heart condition, and Des is very worried about her upcoming surgery. Des has a 9-month-old daughter who lives with his ex-girlfriend and her mother. He feels very close to his mother (“she’s my biggest fan”), loves his baby, and gets along “ok” with ex-girlfriend. 3. Is passionate about cooking; interested in computers and systems networking; plays basketball when he can; “hangs” with friends. 4. Left school before getting his H.S. diploma; is pursuing his equivalency diploma at a GED PLUS program for students ages 17–21 at a community college; began studying for GED while incarcerated; says “I’m smart and know I can pass the test.” 5. Works part-time as an after-school day camp counselor with junior high school youth and teaches Microsoft Office programs (ten hours/ week); has concerns about his incarceration record affecting future employment; would like

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to make sure his record does not impede future options. 6. Uses marijuana on occasion and says use has increased in recent weeks; smokes “loosies” when he gets tense; says he’s been drinking more alcohol with friends than before his incarceration. 7. Says he occasionally gets depressed and worries about his future prospects; had previous suicidal ideation in high school precipitated by retention in tenth grade and subsequent incarceration for drug dealing; no current ideation or plans to hurt self. 8. Has no trouble falling asleep but describes being “restless” during the night, and has trouble getting up in the morning. 9. Says he’s been able to stay away from the “guys I used to hang with,” since most are still in jail; does not feel the need to carry a weapon for protection. 10. Currently sexually active with one partner (Jaz) who he “thinks” is using “the pill”; has had multiple sexual partners in past; uses condoms “sometimes.” 11. Feels close to Jaz, has some friends, cares a lot for his nephew, likes the kids at the after-school program, and is very connected to his social worker at the reentry program (who helped him connect to the GED PLUS program). Loves his mother and says biggest love of his life is his 9-month-old baby Alex. He’s proud that his name appears on her birth certificate but knows that means he will be increasingly responsible for supporting her. 12. Is accomplished in computers—likes to put them together, knows multiple programs; feels that he is becoming a good cook. 13. Despite ambivalence about medical providers, he makes the decision to attend the appointment at YMC; says he’s good at following up on things he cares about; proud that he’s made choice to stay connected to his daughter. 14. Takes care of his nephew; visits his baby; cares about kids in after-school program; wants to support his mother through her surgery; agrees to help develop a marketing plan and broadcast the YMC at his GED PLUS program. The social worker was able to take a thorough BIHeadsss history and Circle of Courage assessment

in one visit because of Des’s engaging personal style and his excellent communication skills (completing such a thorough assessment may not always be possible in one visit). The worker encouraged Des to talk about his individual and environmental strengths and assets as well as his needs by asking open questions, e.g.: What things do you do to stay healthy? What are some of the things you’re good at? What do you do to help others? Who’s most important in your life? Who can you count on when you need help? What would you say your biggest responsibilities are at home? At your GED program? With your baby? What do you do for fun? Who do you do fun things with? If I was thinking of hiring you for a job, what are some reasons I’d choose you over someone else? Despite Des’s considerable personal and environmental assets, the social worker was concerned about his substance use, history of depression, and sleep irregularities, and wanted to more thoroughly assess his mental health needs. Des was coping with several stressors (e.g., his mother’s surgery, a baby, getting back on track with school, anxiety about the impact of his incarceration on future life options) and he had indicated a history of depression. To screen for the frequency of depressed mood and anhedonia (inability to experience pleasure from activities that are normally pleasurable) over the past two weeks, the social worker asked Des to complete the twoquestion Patient Health Questionnaire (PHQ-2), a brief screening tool that is an efficient and valid way of identifying undetected cases of unipolar depression and improving diagnostic accuracy (Arrol et al., 2010). Des’s screening was negative. Had he screened positive, the social worker would have further evaluated him with a PHQ-9 to determine whether he met criteria for a depressive disorder. To determine whether a longer conversation about alcohol and drug use was warranted (which it was not), the social worker also administered the six-question CRAFFT test, a brief tool that is a valid method of screening adolescents for alcohol and substance abuse–related problems that are common in general clinic populations (Knight, Sherritt, Shrier, Harris, & Chang 2002). The social worker provided positive feedback to Des to reinforce his resiliency in rebounding from

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a considerable amount of stress, and for landing on his feet and moving forward with his life. The worker intentionally reinforced Des’s strengths, e.g., “it’s great that you decided to keep your appointment, especially since I know you don’t like coming to doctors.” He commented on Des’s generosity caring for his baby and his ill mother, and his success working with his reentry social worker in finding a job that he seemed to be good at and enjoy (i.e., working with children in the after-school program). Prior to Des’s seeing the medical provider for treatment of his chlamydia infection, the social worker reviewed the sexual history conducted by the MHT social worker two weeks prior to his clinic visit (with Des’s consent, the information had been shared between workers, and entered into the electronic medical record). The social worker provided SRH counseling about condom use, and encouraged Des to clarify whether his sexual partner was using contraception. He offered to help link her to a family planning clinic if indeed she was not protected. The social worker maintained regular contact over the next year with Des through multiple channels, e.g., phone, text messaging, e-mail, letters, and periodic face-to-face contact. On one visit, for example, Des told the social worker that he was planning to cook his first Thanksgiving turkey for his mother, sister, and nephew, but was worried because he had heard that it was difficult to cook a turkey without it drying out. The social worker e-mailed him a recipe and shared instructions obtained from his wife about how to baste the turkey to keep it moist. The social worker regularly kept in touch with Des through text messaging, and was especially supportive when his mother successfully underwent heart valve replacement surgery. Even though the worker never met Des’s mother in person, he mailed a “get well” card to her during her recovery from surgery. The social worker used referent power and the helping relationship he had established with Des to connect with the GED PLUS program at the community college. The YMC had recently begun recruiting community college students to be “men’s health ambassadors” who broadcast men’s health services at school health fairs and other

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campus events. The social worker saw an opportunity to embed health services for students at the GED PLUS program and to engage Des in helping the clinic, the social worker, and other men at his program. Des introduced the social worker to the GED PLUS director, who subsequently agreed to collaborate with the YMC to increase the efficiency of bidirectional referrals between the two programs. Des was hired as a men’s health ambassador at his campus, conducted weekly orientation groups for the GED PLUS program about services at the YMC, and was able to receive a small stipend with funds provided by a private donor. Des continued to visit the YMC every six months for STI testing and was able to avoid further infections, even though his condom use remained sporadic. The social worker helped Des organize documentation required for his Medicaid and the Supplemental Nutrition Assistance Program (Food Stamps) application, and introduced him to the Single Stop program colocated at the YMC. It was determined that Des was eligible for both entitlement programs and he was awarded almost $200 per month in food stamp benefits, which allowed him to expend his scarce resources on his daughter and other basic survival needs. Although he continued to use the YMC as his primary health care provider, he used his Medicaid benefits to obtain oral health care at a community health center near his mother’s apartment. The clinic social worker was well informed about community programs like the affordable dental services at federally subsidized community health centers because of MPH students’ continual asset mapping activities, and continued to coordinate service provision with Des’s reentry social worker. In addition to dental services, the social worker was able to link Des to a free legal service that provided guidance about how to expunge his incarceration record. Through coordination with GED PLUS staff, the social worker was also able to connect Des with a fulltime, six-month, tuition-free IT training program that he qualified for after he passed his GED exam. The social worker and Des formed an ongoing helping relationship that was a partnership built on

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Des’s resiliency and his personal and environmental strengths. The worker was able to provide continual and seamless services that enabled Des to adapt to several stressful life events, including incarceration, raising a young baby, coping with a sick mother, balancing relationships, and pursuing educational and vocational opportunities. The assertive outreach and case finding of the MHT social workers made it easier for Des to connect with available resources, in addition to the help he was receiving from social workers at his reentry program. Once connected with the YMC, he was able to thrive even further because of the social worker’s up-to-date, comprehensive, and intimate knowledge of health (including oral health), legal, vocational, and educational services in the community, as well the worker’s familiarity with public entitlements. The social worker’s efforts familiarizing himself with ancillary services (e.g., visiting the legal clinic that helped Des expunge his record), facilitated “warm referrals” to services that Des deemed important. The social worker maintained contact with Des through simple methods that were efficient and effective, e.g., sending e-mail instructions on how to baste a turkey and a get-well card following his mother’s surgery. The strategic use of empowerment skills (e.g., anticipatory guidance, reframing, selective attention to strengths) helped the social worker become a “significant other” in Des’s life, and to subsequently use “referent power” to empower Des to successfully cope with numerous stressors. The social worker’s awareness of social psychological processes (e.g., normativity, ego-centrality, reactance, and reciprocity) that affect young men’s willingness to approach and use help (Addis & Mahalik 2003) informed his overall approach to case management with Des, and shaped even the subtle ways he worded questions and suggestions, e.g.: 1. “Many young men who have been in jail worry about how it will affect their future  .  .  .

let’s talk about that and see what we can do.” (normalizing) 2. “You clearly describe where you feel you’ve come up short; I hope you’re also aware of all your talents  .  .  . I wish I could cook like you.” (selective attention) 3. “Would you be willing to complete this short questionnaire  .  .  . it will give me a better idea about how you’re feeling  .  .  . thanks for doing that.” (asking permission; giving thanks) 4. “Can we talk about making connection with your GED PLUS program . . . I need more help reaching out to guys who need health care.” (joining forces)

conclusion Young men are not “hard to reach” when social workers look in the right places, when social services address young men’s felt needs, and when young men are invited to become partners in their own care. Coordinated interdisciplinary interventions are essential since most of the problems that affect young men are associated with behavioral and environmental factors that can be modified. It is clear that adolescent and young adult males, especially those who are economically and socially marginalized, need and want more help than they are currently receiving. Social workers can play important roles in connecting young men to services and empowering them to choose behaviors that promote health and well-being. By thinking holistically and from an ecosystem perspective, social workers can craft “teachable moments” in which young men interact with caring adults in schools, clinics, social service agencies, and communities. Finally, social workers can promote young men’s physical, social, and mental health by strategically and systematically shaping physical, social, institutional, and structural environments that support young men’s efforts to become healthy and successful adults.1

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noteS

1. The authors would like to thank Ragnhildur Bjarnadottir, RN, MPH, for her assistance in preparing this manuscript.

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Santelli, J., Ott, M. A., Lyon, M., Rogers, J., Summers, D., & Schleifer, R. (2006). Abstinence and abstinence-only education: A review of U.S. policies and programs. Journal of Adolescent Health, 38(1), 72–81. Savin-Williams, R. C. (1994). Verbal and physical abuse as stressors in the lives of lesbian, gay male, and bisexual youths: Associations with school problems, running away, substance abuse, prostitution, and suicide. Journal of Consulting of Clinical Psychology, 62(2), 261–69. Schiller, J. S., Lucas, J. W., Ward, B. W., & Peregoy, J. A. (2012). Summary health statistics for U.S. adults: National Health Interview Survey, 2010. National Center for Health Statistics. Vital Health Stat 10(252), 1-208 Schwartz, R.  G. (2005). Juvenile justice and positive youth development. In R.  M. Lerner, F. Jacobs, & D. Wertlieb (Eds.), Applied Developmental Science (pp. 353–74). Thousand Oaks, CA: Sage Publications. Shapiro, L. (2012). New York homeless youth budget restored but worries linger. Huffington Post, June 27. Snyder, H. (2004). Juvenile arrests. 2002 Juvenile Justice Bulletin. Washington DC: Department of Justice. Sum, A., McLaughlin, J., & Palma, S. (2009). The collapse of the nation’s male teen and young adult labor market, 2000–2009: The lost generation of young male workers. Boston: Center for Labor Market Studies, Northeastern University. U.S. Census Bureau. (2012a). 2010 Census Summary File 1. Washington, DC: U.S. Census Bureau. ——. (2012b). International Data Base. Accessed August 8, 2012. http://www.census.gov/population/international/data/idb/informationGateway.php Vasquez del Aguila, E., & Aguirre-Molina, M. (2011). Is it just a matter of descuido?: The health care seeking journey of Latino men in New York City. New York City: CUNY Institute for Health Equity. Wagner, P. (2012). Incarceration is not an equal opportunity punishment. Prison Policy Initiative. http://www .prisonpolicy.org/articles/notequal.html Weinstock, H., Berman, S., & Cates, W., Jr. (2004). Sexually transmitted diseases among American youth: Incidence and prevalence estimates, 2000. Perspectives on Sexual and Reproductive Health, 36(1), 6–10. World Health Organization (WHO) 64th Assembly. (1946). Resolution WHA64.28. Preamble to the Constitution of the World Health Organization, New York, June 19–22, signed on July 22, 1946. Geneva: World Health Organization. World Health Organization. (1978). Declaration of Alma-Ata. International Conference on Primary Health Care, Alma-Ata, USSR, September 6–12, 1978.

cHaPter 2 6 Women of color editH a. leWiS, izumi Sakamoto, and lorraine m. Gutiérrez

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n the first edition of this text, as we wrote about ourselves as women of color, we noted the ways in which common cultural stereotypes about us had led to unwanted behaviors and beliefs by others who had no knowledge of our rich and diverse social, political, and historical backgrounds. This is no less true in 2012, as is evident in the legal harassment of undocumented and documented Latinas, or the workplace regulations forbidding the use of the hijab worn by many Muslim women. The common stereotypes of women of color as emasculators, prostitutes, welfare queens, unwed mothers, fighters, docile, subservient, low income, illiterate, or sensuous have now been expanded to include terms such as terrorists and illegals. The more accurate portrayal of women of color a decade ago and now includes our existence as resilient women, mothers, community builders, professionals, policy shapers and members of global communities. We have continued to create resources when needed to offset the demands and burdens placed on our families, informal and formal networks, groups and communities. We are also better able to articulate our resilience with the aid of global technological communication methods such as the Internet and SMS messages. This chapter is a renewed celebration of our resilience, and is derived from our experiences both living and working in two North American countries as well as located in the stories of strength being documented around the world. In presenting case examples, we are using a form of storytelling and narrative that is

traditional and familiar in many communities of color. These stories about the experiences of women of color expand our knowledge base about the ways theories about our existence and development have changed in the United States and Canada. The presentation of both risk factors and resilient responses inform us of effective strategies for dealing with contemporary social problems affecting women of color. Our stories here highlight types of resilience within and among women of color rather than merely sources of vulnerability. They also focus on the growing number of strategies and programs used by women of color historically that have relevance for current social work practice. From these stories we identify a set of five practice principles that can foster the resilience of women of color. defining and explaining Women of color and their lives While we use the term women of color in our work (Gutiérrez & Lewis, 1999), we do not intend to mask or deny the rich sources of diversity within and between each group that the term represents. The use of “umbrella terms” such as Latinas, Asian Americans, African Americans, or lesbians can create difficulties for effective social work because they may inadvertently imply that members of these groups are homogeneous and differ on few dimensions. Yet, we chose to use the term women of color in this chapter to embrace the shared experiences of African American, Asian American, Latina, Native American, Arab American, 561

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and undocumented women residing full-time in the United States, because research and practice suggest that women who are members of these groups are still likely to share experiences related to identity, culture, and inequality. Women of color is a political term that recognizes the ways in which similar historical, social, and political forces have influenced our experiences in the United States (Gutiérrez & Lewis, 1999). From our perspective, using the term is a way of naming our collective and complex selves. Despite these similarities, we must also remember the ways in which the umbrella terms of African American, Asian American, Native (Indian) American, Arab American, and Latina mask our diversities. One of the most profound differences in the literature on women of color during the last ten years is its recognition of the complexities inherent in our identities based on social memberships including ethnicity, gender identity, economic class, documented or undocumented status, and religious backgrounds (Chisholm & Greene, 2008). For all women of color, the diversities are further influenced by physical and/or emotional ability or status, geographic birthplace, age, and national origin. For example, the “African American” umbrella can include women from the United States, Cuba, Jamaica, the Bahamas, or Canada. The term Latina encompasses Mexican, Puerto Rican, Cuban, Central American, or South American women (Segal & Martinez, 2007). Arab American women hail from countries including Lebanon, Iraq, Yemen, Saudi Arabia, and Bahrain. Muslim women in the United States hail from virtually every country in the world (Haddad, Smith, & Moore, 2006; Shora, 2009). Over thirty-six ethnic groups are often placed under the single umbrella term of Asian American, but their experiences are quite distinct in terms of a number of variables such as modes of entrance into the United States and interaction with U.S. immigration policy. Native American Indian women are often “invisible” in the social policy development of

the United States; however, they have been a part of the forces that have influenced its development (Zuni Cruz, 2010). demographic Patterns Although the specific ethnic and racial groups encompassed by the term “women of color” differ in many respects, together we share similarities in terms of our strengths, low social status, and power. Women of color experience unequal access to power and resources in our society due to the effects of racism, sexism, and often classism. Average earnings lower than that of white women consequently hamper us, due to overrepresentation in low status-occupations, lower than average levels of education, and overrepresentation among incarcerated populations (Haugebrook, Zgoba, Maschi, Morgen, & Brown, 2010; Schmitz, 2010). Other shared inequities include the lack of access to adequate ethno-conscious mental and physical health care (Comas-Diaz, 2011; Committee on Health Care for Underserved Women, 2012; Lazear, Pires, Isaacs, Chaulk, & Huang, 2008). The poverty rate of women of color is close to twice that of white women: 14.5 percent of all Black women, 14.4 percent of all Native American women, and 12.2 percent of all Latinas live below the poverty line, in contrast to 7.7 percent of all White women. Asian American women have a slightly lower poverty rate than White women, at 6.1 percent (American Community Survey, 2011). The economic challenges faced by women of color who are unmarried while raising minor children are also well established in the literature. In the 2011 American Community Survey, close to one-half (45 percent) of Black, onefourth (25 percent) of Hispanic, and close to one-fourth (22 percent) of all Native American families were female-headed households with no spouse present. In contrast, households headed by women made up about 16 percent of White families and 12 percent of Asian families. Among families headed by solo women, Asian families were most likely to have an employed

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family member (81 percent), while Black families were the least likely to have an employed family member (67 percent). The proportion of White and Latino families maintained by women with an employed family member was 74 and 72 percent, respectively. Among mothers with children under 18, Blacks were more likely to be in the labor force than Whites, Asians, or Hispanics. In 2011, 75.3 percent of Black mothers were labor force participants, compared with 70.2 percent of White mothers, 65.4 percent of Asian mothers, and 61.8 percent of Hispanic mothers (U.S. Department of Labor, 2012). Higher rates of poverty exist, even when women of color are active in the labor force. Among adult women, African American women (62.2 percent) participate in the labor force at a higher rate than White women (59.4 percent), Latinas (59.0 percent), or Asian women (58.7 percent). However, However, Blacks and Hispanics were more likely to be unemployed or in part-time work than were Whites or Asians (U.S. Department of Labor, 2012). Women from different backgrounds are more or less likely to be engaged in different types of work. This affects earnings, job-related stress, and level of benefits. Asian and White women are more likely than other women to work in management, professional, and related occupations (44 percent for Asian women and 42 percent for White women). By contrast, 34 percent of employed Black women and 25 percent of employed Latinas worked in this occupational group. Among employed women, Latinas were more likely to work in either service occupations or sales and office occupations (63 percent), compared with Blacks (59 percent), Whites (52 percent), and Asians (48 percent) (U.S. Department of Labor, 2012). Canada is similar to the United States in many ways and has been partly impacted by its larger and stronger neighbor to the south. For instance, the two countries share similar levels of industrialization and market-oriented economy systems as Global North countries

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(e.g., members of G7/8 and G20); historical immigration patterns initially from Europe and more recently from the Global South; historical oppressive practices toward indigenous peoples (e.g., residential schools for Aboriginal children) and people of color (e.g., internment of Japanese Canadians during the World War II, head tax imposed on Chinese immigrants in the early twentieth century); and various social movements since the 1960s (e.g., ethnic movements, feminist movements). However, differences exist in historical, political, social, and cultural contexts. For example, unlike the United States, Canada is a parliamentary democracy as well as a constitutional monarchy, and has two official languages, English and French, with historic ties to both England and France. Generally, Canada is seen as a socially progressive country with high tolerance for differences among people. In 1971, the Canadian federal government introduced its multiculturalism policy, which was then followed by the passage of the Multiculturalism Act in 1985. In 2005, Canada legalized same-sex marriage nationwide, the fourth country in the world to do so. Even though social progress has been made in recent decades, discrimination and marginalization continue to exist for women of color, perhaps in ways similar to those in the United States. Canada’s population has become diverse in the past few decades, a demographic trend similar to that occurring in the United States. Out of approximately 35 million people estimated to live in Canada (approximately 11 percent of the U.S. population), about 19.1 percent have self-identified as “visible minorities”1 and in addition, approximately 4.3 percent come from Aboriginal backgrounds (Statistics Canada, 2013a, 2013b, 2013c). Further, the 2006 Census showed that 20 percent of the total female population in Canada were immigrants (Urquijo and Milan, 2011). Currently one in five people living in Canada was born outside of Canada, the highest in all the Group of Eight (G8) countries including the United States, and as of 2013,

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at least one in three people in the labor force living in Canada could be foreign-born (Statistics Canada, 2011, 2013b). Since the leading countries of origin for these immigrants are India, China, Pakistan, and the Philippines Pakistan, with immigrants from Asia making up 58.3 percent of the total immigrant compared to 8.5% of immigrants from the same region prior to 1970 (Statistics Canada, 2013b). Other so-called “Global South” countries, which includes Central and South America, the Caribbean and Bermuda and Africa made, made up 10.8 percent of all recent immigrants (Chui, Tran, & Maheux, 2006), it is expected that the Canadian population will have more people of color (thus women of color) as compared to the current population. Despite the growing diversity, inequalities continue to exist. In addition to race and gender, there are other factors that layer the experiences of women of color, such as immigration status, employment, health status, class, and so on (Block & Galabuzi, 2011). For instance, generally speaking, when immigrants arrive in Canada, they are healthier than the domestic populations; however, their health declines over time, which is the phenomenon known as “healthy immigrant effect” (Hyman & Jackson, 2010). In terms of employment and income security, Block and Galabuzi have examined the complex relationship between race and gender in what they call “Canada’s color coded labor market” (2011). According to Block and Galabuzi (2011), visible minority women earned 53.4 cents for every dollar a non-visible minority (white) man earned. Furthermore, immigrant women who are racialized, likely coming from the Global South countries, are reported to “earn only 48.7 cents for every dollar non-racialized male immigrants earn” (Block & Galabuzi, 2011, p. 4). Often immigrants justify their own suffering with the hope that their children will have a more successful future. It is then difficult to comprehend statistics that suggest, for second-generation Canadians, racialized women only make 56.5 cents

per dollar compared with non-racialized (i.e., White) men (Block & Galabuzi 2011). These figures suggest that marginalization experienced by women of color will continue to persist in Canadian society. Vulnerabilities and risk factors The social stigma attached to our ethnic groups, the political actions we have taken in our neighborhoods, and the historical denigration of ourselves as women have all been among the common experiences making our ethnic groups more vulnerable to negative economic, social, and political forces. Within these experiences, however, many examples of our resilience in the face of great adversity can also be found. In this chapter we discuss these similarities, but also “unpack” some of these identities to consider their complexity using the constructs of intersectionality and microaggressions (Mehrotra, 2010; Sue, 2010). The profession of social work and social workers have made some gains during the last decade to recognize the ways in which women of color differ from white women and from men of color. We have most often recognized the impact of powerlessness on women of color from the perspective of institutional racism while overlooking the role of gender inequity in influencing the life chances of women of color. We make an equally grave error when we group all women’s experience together without looking at ways in which women of color are impacted by racism and ethnocentrism (Gines, 2011; McGoldrick & Hardy, 2008). These perspectives have also overlooked the strengths and resources developed by women of color within their own communities. In order to understand women of color in our society, a multidimensional perspective must be used that takes into account the impact of multiple social identities and how that has shaped the worldview, life chances, and survival strategies of the individual woman (Graham & Schiele, 2010). At this period in the first decade of the third

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millennium, the term most commonly used for this multidimensional perspective is intersectionality (McCall, 2005; Mehrotra, 2010). The earlier discussion of demographics identifies problematic aspects of the societal context of women of color. Racism, sexism, ethnocentrism, physical and mental abilities, gender expression, and classism impact women of color directly and indirectly. Our scholarship on persons of color has begun to take gender or sex into consideration when identifying the experiences of ethnic groups of color in the United States in more research than was available when we first wrote this chapter (Graham & Schiele, 2010; Styhre & Eriksson-Zetterquist, 2008). Our earlier edition version of this chapter also suggested that the homogenization of difference was exacerbated by the feminist scholars and in the scholarship about women, because the unique historical, social and political experiences of women of color were not highlighted. A decade ago much of our literature to date used terms such as women and people of color, where the term women was reserved for women of European American descent and the different experiences of women of color were often lost (Jamal & Baber, 2008; Sanchez-Hucles & Davis, 2010). One recent remedy to these omissions is the growing literature on intersectionality. The construct of intersectionality recognizes that those who have more than one marginalizing characteristic experience their lives in quite different ways from those whose marginalization is based solely on one status, such as gender or economic background. The cumulative effect of these multiple statuses is not additive but exponential (McCall, 2005; Mehrotra, 2010) One can now recognize women of color as occupying multiple statuses; each reshaping all of the others. A woman of color professional faces the same health risk factors as her sisters with more limited resources and, despite having greater economic resources, may face the same stigma when interacting with health care providers who assume that her racial or ethnic background deem her unable to provide

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adequate information about her health status. If that same woman is lesbian, bisexual, or transgender, a number of community resources available to other women of color may not be able to reflect her needs for recognition of her same-sex partner (Rahman, 2010). Women of color with long-term intimate women partners face discrimination from communities in which they are members by virtue of their multiple identities of ethnicity, class, and sexual orientation. This has become a source of concern for those working with aging LGBT populations. (Chisholm & Greene, 2008). Expanding the work of Solomon (1976) and Sue et al. (2007), a number of scholars have begun to focus on the construct of microaggressions and their influences on the collective health and well-being of people of color. Solomon (1976) identified how the powerlessness related to the experience of racism, sexism, and other forms of society inequality could lead to the denial of valued identities, social roles, and social resources available to individuals. For example, women of color are disproportionately affected by the direct and indirect power blocks associated with low status and limited access to economic resources (Parsons, 2001 Solomon, 1976). Direct power blocks refers to access to material resources. Because they are disproportionally affected by poverty, women of color have been more likely than white women to suffer from conditions of poor or no housing, insufficient food and clothing, inadequate access to health and mental health services, and being located within low-income and physically deteriorating communities (Zuni Cruz, 2010; Sue, 2010; Ghazal Read, 2011). Indirect power blocks, which are reflected in the adjectives and stereotypes we discussed at the beginning of our article, can limit self-determination and engender a sense of dependency by undermining individual’s self-esteem and feelings of competence. These conditions perpetuate the problems of women of color and their perceived position at the bottom of our social structure.

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Sue et al.’s scholarship (2007) recognizes the cumulative effects of daily expressions of microaggressions experienced by people of color. Their work suggests: Racial microaggressions are brief and commonplace daily verbal, behavioral, or environmental indignities, whether intentional or unintentional, that communicate hostile, derogatory, or negative racial slights and insults toward people of color. Perpetrators of microaggressions are often unaware that they engage in such communications when they interact with racial/ethnic minorities. (p. 271)

Daily experiences of microaggression include second-guessing the reason all of the seats on a bus or train fill before the seat next to you. They are the daily experiences of being served last a store or waiters’ expecting someone white in your party to order for everyone present. Perhaps one of the most prevalent experiences of microaggression is the phrase “But I’m not racist” following an act of blatant discrimination. For example, one of the authors protested a neighbor’s persistent use of the term “Kum Bah Ya moment” when discussing anything to do with racial/ethnic/class/spiritual diversity in the neighborhood. When the background of the song whose title she had used was explained to her as a freedom song and prayer originating on the African continent, she still used it in a derogatory manner while steadily insisting “But I’m not racist.” Sue and colleagues (2007) describe a process of “microinvalidation” with five components: (1) environmental microaggressions; (2) alien in own land; (3) color blindness; (4) myth of meritocracy and; (5) denial of individual racism. In the above example, microinvalidation resulted in the woman of color feeling as though she were an alien in her own neighborhood; being told by other neighbors that the speaker was “color blind” rather than acting in a “racist” fashion; and that the person had, by virtue of her longevity in the neighborhood,

earned the right to be as rude as she pleased. These repeated experiences can negatively influence the mental health of women of color (Nadal, 2010). Perhaps some of the most pervasive microaggressions in the United States are those experienced by Arab American women; particularly during the last decade. In addition to the general inability to distinguish between Muslims and Arab Americans (Abdelrazak, 2007), Muslim women find themselves being required to speak up for their cultural and chosen religious behaviors (Ghazal Read & Bartkowski, 2000; Haddad et al., 2006). For those Arab American women who are not Muslims, the task of explanation becomes even more complex due to the lack of education and/or misinformation of the general population of the United States (Jamal & Baber, 2008). resiliencies and Protective factors A social work perspective conceptualizes individuals as parts of families, communities, and societies, using interactionist, ecological, and/ or feminist models. These frameworks can be used to understand women of color as well (Gringeri, Wahab, & Anderson-Nathe, 2010; Hankivsky & Cormier, 2011; Kemp & Brandwein, 2010). We propose that women of color use their communities of color (identified by the women) as buffers in their interactions with the wider society. While these communities of color are likely to change over the developmental and experiential lives of women of color (in terms of race, ethnicity, geographic location, economic status, gender identity, gender expression, or education), the buffer zone of the community of color can be a space in which women of color develop and strengthen the intersectionality that allows the population to be resilient in this society (Gines, 2011; Lewis, 2009). Critical analyses of the community of color’s utility as a source of key network supports or barriers have become a part of the social work practice literature on working with communities of color. Social networks do not remain

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static: social workers should attempt to understand women of color’s use of the networks to identify the specific networks to which they belong (Comas-Diaz, 2011; Okazawa-Rey, 2002). The extent to which social work practitioners incorporate the bicultural community of color as a focus of the intervention, becomes one method of ensuring the appropriateness of the intervention (Nygreen, 2010). Evidence regarding how the inclusion of a focus on women of color’s community (whether geographic, demographic, or philosophical) affects intervention outcomes is evident in recent scholarship. Lazear et al.’s 2008 study of depression among low-income women of color used focus groups to demonstrate the reliance mothers had on their existing social networks rather than the use of mental health professionals. Nygreen (2010) recognized that, despite her best efforts to be inclusive using a participatory action research strategy, the resultant intervention was still perceived by participants as being an academic conceptualization rather than one based on the shared experience of those engaged in what she had hoped would be a praxis strategy. The participants did not view the strategy as being something they had joined with the project director in creating. How does a community of color strengthen the resilience of women of color? These communities can be places where women can practice using and developing their voice by telling stories and, as they age, can serve as the oral historians for the communities. Several practitioners suggest that prevention and intervention programs at the individual and family levels are most effective when grounded in an understanding of the unique cultural backgrounds of the communities of color, as well as demographic differences (Chisholm & Greene, 2008; Comas-Diaz, 2011; Sue & Sue, 2008). The celebration of Kwanzaa in the United States for more than three decades is an example of African Americans incorporating the principles of both unity and diversity.

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Social policy in the United States has focused on social problems and has often missed the ways in which women of color in particular have built programs and communities in the midst of limited resources. Examples of the resilience of women of color in dealing with the concerns of their communities are found in the long-term efforts of African American sororities. For almost a century, the four major organizations founded by African American college students have provided scholarships to those young women who are interested in going to college; tutorial support for high school students; and backing for cultural and economic development projects, such as the movie Beloved. Initiatives for incarcerated mothers, such as Michigan’s Prisoner Reentry Programs, address the needs of many women of color who are disproportionally represented in the prison population. This initiative assists women in identifying appropriate housing and employment before release and rebuilding relationships with their children when these have been broken. Women of color also share other similarities in terms of strengths and coping strategies. Within our own communities we have highlighted values and developed behaviors that have allowed us to survive in the face of oppression. Economic necessity has traditionally led women of color to participate in the labor market at higher rates than European American women. Although this role has not always been voluntary, it has helped us to develop ties and a sense of self outside of the family and has reduced our economic dependency on men (Lewis, 2009; Shora, 2009). Women of color are also considered to have strong family and community ties, which we use for concrete and emotional support. Our informal and formal ties can be a form of strength. This history of coping and surviving within a hostile world has led many women of color to perceive themselves as strong and capable of dealing with adversity. One important dimension in the lives of many women of color is spirituality. The health

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and mental health fields in the United States have been slow to incorporate the concept of spirituality into practice. In fact, in the United States many of the helping professions have traditionally associated spirituality with religion, and religion was viewed as an unhealthy defense mechanism (Suarez & Lewis, 2012). Professionals were trained to work “around” rather than “with” the spiritual realities of their clients and to view client spirituality as a crutch others leaned on. Practitioners were expected to split off their own spiritual or religious convictions, experiences, and instruction in order to provide quality service. Incorporation of the spiritual acts of meditation, fasting, writing, dance, music, prayer, discernment, and service have been an important element for the survival of women of color in a hostile world. For some women of color, these spiritual acts are combined with religious affiliations, but the lack of a formal affiliation with a recognized religious body does not automatically mean the lack of a spiritual base in the lives of women of color. Some of the membership in formal religious institutions has fostered women of color’s ability to participate in, mobilize around, and monitor social change activities, as in the case of the role of African American women in the civil rights era of the 1950s and 1960s (Robnett, 1997). Another example of the role of religion in helping women of color to influence change in their communities and the society at large is the nationally recognized, comprehensive social services program known as ACCESS—the Arab American Center for Cultural, Economic and Social Services, located in the Southeast Michigan community of Dearborn, which has the largest population of individuals from the Middle East in the United States. For decades, ACCESS has included programs geared toward support for Arab American women, both Muslim and Christian. Each program and service is shaped within the cultural contexts of the diverse populations the agency serves. The development of a critical consciousness can also be a source of resilience

and strength (Gutiérrez & Lewis, 1999). An essential building block for critical consciousness is the recognition of one’s intersectionality and how one’s multiple identities relate to specific communities. These social identities can be shared with others with similar social, historical, or political backgrounds. Thus, there is a potential for ethnic identities, class identities, survivor identities, age identities, and parental identities. There are also many other potential identities for women of color far too numerous to describe in this chapter. Accompanying the numerous identities is a vast social science literature on identity development, much of which is beyond the scope of this chapter. At this point, one might be inclined to consider these complexities as overwhelming and impossible to transcend in practice. It is possible, however, for social workers to take a reflexive stance in their own praxis; regularly reexamining the foundations upon which their work is being done and modifying that work so that it puts the needs of the population receiving services first (Duanne-Cascio, 2010; Jones, 2010). Understanding the construction of women of color’s ethnic and cultural identities may influence many facets of the interactions between these women and social service providers, the wider society, and one another. Mapping their ethnic and cultural identities can provide the service consumer with a visual record of the way women of color have integrated their interactions within their families, their communities, and the wider society. This mapping exercise can include spatial (e.g., where the individual was in terms of geographic location or birth order) or temporal (the age of the individual or the activities occurring on a local or global scale when critical events were taking place in the individual’s life) elements as well. Having the individual woman of color give meaning to how her life events have influenced her current decisions can further solidify what may be a new identity formation. Naming our identities as women of color while simultaneously recognizing the impact

Women of color

of the ways others would name us is of utmost importance. Earlier in this chapter we discuss the use of umbrella terms as convenient but not universally accepted within our ethnic populations. Recognizing the identities important to women of color is one mechanism for building the relationship between social worker and service consumer. We might recognize, for example, that certain umbrella terms like American Indian or Native American are considered “colonized identities,” that is, constructions of identity make by forces unfamiliar with or uncaring about the real social, historical, and political lives of the First Nations communities they supposedly encompass (Zuni Cruz, 2010). We could also recognize that the most salient identities for women of color are those related to social group memberships other than race or ethnicity, even if the two constructs play a supporting role in the primary reason for entering a social work practice situation. It is possible, for example, to recognize the identity of a physical assault “survivor” as primary in a practice situation, while simultaneously recognizing that this identity may be uniquely grounded in contexts of the perpetrator’s ethnicity and the woman’s age. An older woman of color who has been assaulted in her home by an individual from her own ethnic group in a predominantly ethnic community may need to work through a different set of identities and potential outcomes than a younger woman of color who has been assaulted in her workplace by a perpetrator from another ethnic or racial group. The response rates of law enforcement officials may differ, as might the ability to prosecute the perpetrator, or the subsequent portrayals of the women in question in their own communities. A second example is the increasing use of the hijab by younger Muslim women as a strategy of strength rather than persecution. Those who choose to wear the hijab are often doing so as a way of honoring their cultural backgrounds and drawing attention to the lack of freedom unveiled women in the United States face by

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virtue of their gender oppression (Ghazal Read & Bartkowski, 2000). Programs and Social Work contributions Women of color can be clients of any type of social service organization at any point in their life course. Structural and individual barriers can sometimes prevent women of color from accessing social services until problems are more severe. For example, language or cultural factors can make it very challenging for women whose first language is not English to access most mainstream programs. Women not experiencing language barriers will not voluntarily access most programs unless they believe that the organization is capable of comprehending their life experiences. Therefore, many women of color may be more likely to contact programs that are tailored to their cultural group. Where these programs or organizations are not available, they may not see social workers until they are in a more difficult situation. assessment and interventions Social workers will encounter women of color in almost any service setting. Therefore, they must be familiar with the risks and strengths of this group. Social work practice with women of color can build upon sources of strength and resilience to address areas of vulnerability. The material conditions of many women of color lead to increased risk for serious health and mental health problems. Sources of strength and resilience that exist in the identities, communities, and traditions of women of color can, however, be harnessed to directly address these risks. An empowerment approach that engages women actively in the change process is one method that can be used to assist individual women and their families while making changes in their material conditions through changes in communities, organizations, and policies (Gutiérrez & Lewis, 1999). The following guidelines identify ways in which our practice can harness and build sources of strength and resilience for women of color.

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1. Externalizing rather than internalizing the presenting issue and placing women of color in leadership positions within the interventions serving them can support resilience. Empowering practitioners’ work can often begin on the individual, family, or group level. It differs in two respects from non-empowering forms of intervention. First, empowering practitioners have as a goal the linkage of individual and family to group methods to normalize and externalize the presenting target issues and to provide alternative models for change for the person(s) seeking assistance. Women of color, given the social and demographic restraints faced daily, often simply need to know that all of the difficulties they face are not their individual fault. Empowering practice models also attempt to have the social worker serve as a co-facilitator of the intervention process, not its director. Women of color seeking assistance are viewed as the most knowledgeable about their situation. Their resilience in the face of economic, social, or psychological barriers is also recognized. 2. Resilience can be fostered through the development of women’s critical consciousness. The development of critical consciousness occurs when individual problems can be linked to their corollaries at the group, community, and societal levels. Developing a critical consciousness about an issue sometimes takes a great deal of time, however. Social workers must think about these linkages throughout the intervention period. Even when consumers are not initially interested in expanding their targets for action beyond their individual or family situation, empowering social workers can be involved in political and social action projects to address policies and programs contributing to the dis-ease of individuals and families with whom they work. 3. Resilience can be facilitated through addressing key supports and barriers for women of color community change agents. Social workers utilizing empowerment strategies serve as facilitators of social change

movements within communities, rather than their directors. They take an active role in facilitating agency change so that the needs of individuals, families, and groups can be met. This requires social workers to give attention to power differentials throughout their interactions with other women of color, even when they may nominally belong to the same ethnic group as those with whom they work. 4. Normalizing the reactance of the host community and its institutions can facilitate resilience. Institutionalizing a single social change strategy through collective action does not occur overnight. Institutionalizing a series of such strategies is extremely labor and time intensive. Resistance and reactance from those typically in charge suggests that actual change is taking place. Normalizing this response can lead to efforts to continuing work, rather than retreating. 5. Inviting clients to “tell the stories” can facilitate resilience. In a society where the focus is on identifying problems rather than solutions, it is critical for empowering social workers working with women of color to capture and share the stories of success. It is only in doing so, both within and outside of the community of color, that future programs and projects can benefit from the wisdom generated by these communities. Recording the stories also adds to the body of knowledge about the ways in which women of color have designed and implemented successful change strategies within their communities. The social worker’s ability to work with the community of color to record the stories provides potential access to these stories internationally rather than simply locally. This can be done through formal methods of investigation, including single case and survey research, through the completion of case narratives, and through the employment of the oral tradition to tell the stories to youth and other community members.

Women of color

illuStrAtion And diSCuSSion

In our final section we utilize our narrative traditions to describe this practice approach in two separate settings with women of color. The first example is a composite based on our previous practice experiences; the second is a program that is currently being implemented by one of the authors. In both of these examples we identify specific suggestions for assessment and intervention with women of color. Example 1: The Community Partners Project (CPP), a citywide effort to combat forms of violence against low-income communities, began in an individual intake session between Dawn, a woman from a large western city, and Pauline, a social worker who had been working in a community-based health and mental health organization for several years. Dawn had come to the center at the beginning of the year seeking assistance with familial concerns surrounding a daughter who had been sexually abused by a relative. Dawn initially felt helpless and hopeless about this situation but, with Pauline’s assistance, had developed a plan to address the needs of her daughter and help to resolve the impact of this experience on the family unit. Specifically, she identified ways of getting counseling assistance for her daughter with a practitioner skilled in child sexual abuse, and joined (with her husband) a support group for parents of abused children originally facilitated by Pauline but now meeting independently. Ten months after the first meeting with Pauline, Dawn stopped by the community-based organization to discuss her progress. Practice Guideline 1: Resilience Can Be Supported by Externalizing Rather than Internalizing the Presenting Issue and Placing Women of Color in Leadership Positions in Interventions Designed for Them While Dawn was pleased by the gains her own family had made during the period, she felt that her work had not been completed. Dawn had determined, through her discussions with other women in the family support group, that the issue of violence was

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much larger than that perpetrated on individual families, and included the responses of the criminal justice system to child sexual abuse and spousal abuse, the solicitation of poor young women for prostitution by men from outside of the community, and the lack of a restitution system for women who had experienced violence in its varied forms. She had come to meet with Pauline that day to report her findings and dissatisfaction with current methods for addressing these issues. Pauline, cognizant that Dawn’s individual and family work had now expanded to community and societal issues, discussed the utility of taking the same problem-solving strategy they had used in their early individual sessions and expanding it to deal with these larger issues. They immediately began to work to determine who in the self-help parents’ group might be interested in these concerns. After generating a list of potential participants, Dawn began to contact community residents about their interest in either beginning a new self-help group or expanding the scope of the existing family violence group. It became clear after four telephone calls that participants wanted to expand the scope of the group to include community violence and include as many more families as were interested in participating in such a venture. Practice Guideline 2: Resilience Can Be Fostered Through Critical Consciousness Development The expanded group, with fourteen families represented, began to meet in the fall of the year. As they shared their stories, Pauline transcribed and recorded these, and the group spent time during each session identifying the major concerns and strategies for resolution discussed the previous session. The network charged itself with being concerned not only about problems but also about those avenues in and outside of their community that could serve as targets for action or resources for change. Before long, the group had identified needs and resources across the human service infrastructure of their city. By the beginning of the next year, the group, now calling itself The Community Partners Project (CPP),

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organized a conference on community violence. They generated a list of occupied housing in the community, divided the list among members, and individually visited each household on the list to invite them to the community conference, which was held in space donated by the community-based organization. CPP members also invited members of the City Council, the Police Department, community-based social service and health organizations, and the County Department of Public Health to attend, and each of these units sent at least one representative. Again, CPP members reported their preliminary findings about areas of community violence and some of the solutions they had identified for alleviating it. It became clear at the end of the conference that one major system had been omitted from their list: the criminal justice system. Some of the community residents who had not been active with the CPP before had access to information about how the criminal justice system worked in their locality and state, and agreed to be part of a task force targeting this system. Before the conference ended, task forces were established to work on all major targets of concern and charged with reporting their deliberations and findings back to the CPP central group quarterly. The CPP divided itself among the task groups, and worked with each of them to develop an action plan for including resources both in and outside of the community, and to engage key personnel to activate their change strategies. The CPP continued to meet monthly at the community-based organization, which by now had donated a small office and telephone to serve as the CPP headquarters. Practice Guideline 3: Resilience Can Be Facilitated Through Addressing Key Supports and Barriers for Women of Color Community Change Agents Social workers utilizing empowerment strategies serve as facilitators of social change movements within communities, rather than their directors. They take an active role in facilitating agency change so that the needs of individuals, families, and groups can be met. In this case, Pauline’s role was to help Dawn develop a strategy toward the establishment

of procedural justice for the community. Given her ties to the professional community, Pauline may also have identified some actors from other organizations who could be invited to the conference. Pauline also needed to support the creation of a procedural justice perspective within her own organization so that a new program, led and determined by community residents, could be housed in and supported by the physical plant of her agency. When community change agents are given the opportunities to actually direct their efforts, they can successfully identify key personnel within their communities who can effect change. Leadership for the original conference was vested in the CPP, not the community-based organization in which it was housed. The agency could take credit only as a supporter of this effort, but that did not preclude it from contributing space, refreshments, and transportation for the conference. The CPP conference became an annual event. Because of the work of its task forces, the police department began a neighborhood-policing project, which gave residents the ability to target those nonresidents driving through the community to solicit prostitution from the young women. The license plates of the drivers were recorded and called into the new community-policing office; then the individuals were stopped before they could leave the scene, arrested, and had their automobiles confiscated. A second outcome of the CPP’s work was that the state’s list of sex offenders was regularly checked to determine whether there were individuals in the community with prior offenses. When those people were identified, community health workers (neighbors from the community who had been trained to enhance the emotional, physical, and spiritual health of residents) visited them regularly and let them know that the community would be watching them to ensure the well-being of neighborhood children, as well as linking them to formal and informal community resources. One task force continued to facilitate the parents’ group for those whose children had experienced violence, but another group was formed for women who had experienced violence

Women of color

at the hands of their intimate partners. Both groups were co-facilitated by CPP members. The task group charged with addressing needs in the criminal justice system began a letter-writing campaign in newspapers statewide until the state legislature held hearings on the issue, and members drafted a bill to develop a statewide restitution program for children and women who had experienced violence. Practice Guideline 4: Resilience Can Be Facilitated by Normalizing Reactance Institutionalizing a single social change strategy through collective action does not occur overnight. Institutionalizing a series of such strategies is extremely labor and time intensive. The CPP needed to have a plan that included the support of its members through the long period of reactance to social change experienced when new initiatives come up against old institutions and perspectives on social justice. In continuing to support the original selfhelp group for parents whose children had experienced violence, and expanding their work to women experiencing violence in intimate relationships, the CPP provided this support for its members as well as a mechanism to recruit new members whose individual critical consciousness would expand over time to larger community and societal issues.

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Within three years, the CPP had gone from an individual’s recognition of the systemic connections among forms of violence in Dawn’s mind to a network of individuals, families, and professionals who served as a prototype for other empowerment-based programs across the country. At the end of its third year of operation, Dawn was selected to receive the city’s Volunteer of the Year Award. She insisted on accepting it jointly with Pauline, telling the story of her initial visit to the community-based organization and the subsequent birth of the CPP. By telling her story, she was able to communicate to others how an individual’s vision can contribute to larger community change. Example 2: This case study is presented from the context of Canada, to illustrate the practice guidelines for empowering women of color in an international context. It focuses on Asian women who come together to drum, drawing from the experience of a coauthor of this chapter (Sakamoto), who has been a member of the group described. As social workers, we may find it easier to talk about other people’s struggles and empowerment than experiences of our own. Just as how the process of working through struggles toward empowerment unfolds for others we work with, our own process can be lengthy and messy, as well as rewarding and transformative. While it is not often the norm to mix case studies of service users/communities with those of the writers who are social worker academics, we believe that reflecting on our own experiences through the same set of practice guidelines can afford us new insight, humility, and compassion. Since this case study is based on the personal experience of one of the authors, pronouns of “we” are used where applicable in the following section.

Other forms of reactance, from the reluctance of the municipalities’ police department to the community-policing program conceived by the residents, to the state legislature’s reluctance to support a bill to place information about sexual offenders in the public domain, required the connection among CPP members and affiliates as well. The task forces inspired confidence in the CPP members by expanding their skills in developing letter-writing campaigns, effectively using audio and visual media, and learning how to lobby at the state level for a bill. When reactance is anticipated, empowering practice can address it proactively rather than reactively, and determine the skills needed to overcome it.

“Every woman has a well-stocked arsenal of anger potentially useful against those oppressions, personal and institutional, which brought that anger into being. Focused with precision it can become a powerful source of energy serving progress and change.” (Lorde, 2007, p. 127).2

Practice Guideline 5: Resilience Can Be Facilitated by “Telling the Stories”

When the words Asian and women are entered together in a Google search, one likely encounters

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page after page of pornographic and objectifying words and images. Such a search would typically produce a dozen websites on the first page using titles such as “Asian women, brides, Philippine girls dating, single Thai [sic] women,” “Topless Asian women,” “Do Asian women have smallest vaginas?” and “Asian women reveal secrets to keeping a man happy” (a Google Search result on November 10, 2012). Despite these disturbing, persistent stereotypes about Asian women, there are in fact alternate, empowering self-images that Asian Canadians and Asian Americans have created through decades of decolonizing ethnic movements and community engagement since the late 1960s. One powerful example of Asian Canadians’/Americans’ taking charge of individual and community healing, empowerment, and community building is the formation of ethnic arts community organizations to play taiko (meaning “big drum” in Japanese) in ensembles, in which women play a large role. Practice Principle 4: Resilience Can Be Facilitated by Normalizing the Reactance of the Host Community and Its Institutions Raging Asian Women Taiko Drummers (RAW) is a grass-roots taiko group with feminist and antioppression principles. RAW, through brainstorming sessions, has described itself as the following: Raging Asian Women Taiko Drummers (RAW) is a community arts collective of East and Southeast Asian Women in Toronto. We are a Taiko drumming group that exists as a critical response and challenge to both systemic and internalized oppressions. Through performance, education, and community outreach, we seek to challenge, redefine, and represent ourselves, and to inspire others and ourselves. Through collective membership, artistic creation, and active development, we carve space for selfexpression, authentic engagement, community, and healing. RAW was formed in 1998 as one of the only allwomen taiko groups in North America, by three for-

mer members of another taiko group, Wasabi Daiko. RAW traces its lineage through the North American taiko movement’s unique history, one that is integrally linked to the Asian American movement of the 1960s and 1970s when Asian Americans and Canadians mobilized en masse around issues of racial equality, social justice, and political empowerment (http://www.ragingasianwomen.ca). RAW members come together in three-hour sessions twice a week to practice drumming, and share many responsibilities outside of practice time to maintain and develop the group, which is also a nonprofit organization. The group performs at many functions that would fall into the group’s social justice mission, including the anti-G8/G20 event, unions, equity-oriented conferences, antiviolence rallies/events, and more. Toward RAW’s vision of building community, RAW members spearheaded the efforts to organize the first-ever Toronto Taiko Festival, a three-day long event consisting of a public forum, workshops, and a joint concert. The concert featured four taiko groups from Canada and two guest performers from the United States, and was attended by more than 700 people. Making use of Toronto art council funding, RAW has also been successful in reaching out to public schools through week-long residencies to engage children and adolescents, especially Asian/queer girls, in taiko drumming as a form of positive self-expression. Through these activities, the group hopes to show our nonstereotypical existence, and also become role models to those children and adolescents who may not see people like them (in whatever way they identify with) in leadership roles. Much of what the group does resonates with the empowerment principles of women of color described earlier, even though the group’s directions and processes have emerged organically. The group is a living entity, and it constantly evolves with changes in membership and group dynamics as well as what individual group members bring to the group. For the purpose of this chapter, three Practice Guidelines are highlighted with examples from RAW’s activities and experiences.

Women of color

One of the things RAW members do is to try to externalize oppression experienced as Asian women, as the name of the group suggests. The members believe that it is okay to be angry about injustices that happen to us as well as to others; in fact, the members think that it is expected that we carry rage in response to injustices experienced. This is actually the process in itself: to practice (expressing anger) what we think we believe in (thinking that it’s OK to express anger). Growing up in a society that sees Asian girls/women as submissive and quiet, many members have learned to express anger in different ways or in some cases to suppress anger altogether. At one of the performances in a local high school, several RAW members shared their own stories of facing their own anger and reflecting on how they may express it. One member shared how she always stuffed anger inside and was never angry until recently while finding herself being sick all the time since childhood. However, by being among the RAW members who are expressing anger differently, she has come to realize that she, too, had anger inside of her but didn’t know how to recognize it. Another person shared how she was irritable and sometimes mean toward people around her—an expression of anger—until she was able to identify the roots of her anger. In school settings, the group members often talk about how drumming is a way of expressing our anger in a positive manner. In the author’s own experience, too, expressing anger nonverbally through drumming helps to produce mental clarity about what is going on and to tease apart issues that may be contributing to the anger experienced. While many people who look at RAW would focus on anger and the power that anger may generate, it is also our experience that the proper way of externalizing our oppressions with angry responses can serve as precursor to healing as well as individual and collective empowerment. Without the space to express the energy generated by anger experienced in our daily lives, it is difficult to build resiliency to keep fighting oppressions and build community for support. Looking back on the trajectory of three, five, or ten years with RAW, members often

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joke about how being part of RAW is like going to college, dubbed “RAW University.” Being in the group strengthens each member’s individual voice as well as the collective voice, and over time oppressive realities that had been normalized can become visible. RAW is a collective without a leader, which means that everybody is a leader in something that sustains the group. For example, one person who is an excellent negotiator deals with external performance requests and often represents our group in the public sphere (e.g., talking bits during the performances). Another person is very crafty and detail oriented, so she often leads the efforts to maintain and develop equipment. A few members have music backgrounds and thus lead different parts of rehearsals as “song leaders” (e.g., skills-building drills, learning new songs, arranging existing repertoire). Each member volunteers for these roles and, as a nonprofit, voluntary group, it is crucial to have each member’s contribution to sustain and develop the group, which in turn, fosters leadership skills and recognizes different leadership styles. Developing critical consciousness (Pitner and Sakamoto 2005; Sakamoto and Pitner 2005) can largely happen in two domains. The first domain is critically analyzing the roles and status of Asian women in society and undoing internalized oppressions. Typically people do not associate the words Asian women with “raging.” Many people (particularly women) chuckle when they hear the group name, “Raging Asian Women.” Some people question the group name by asking, “what are you so angry about?” or “you all don’t look that angry,” implying that Asian women are not supposed to be angry. While it is hoped that these people’s encounters with RAW would facilitate their critical consciousness raising by demonstrating that there are other kinds of existence for Asian women other than being docile and submissive, RAW members have also explored what being “raging Asian women” would mean for themselves, and in what ways they have intentionally or unintentionally conformed to stereotypes and in what ways they have resisted them.

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The second domain has to do with looking into the notion of “Asian women” itself by identifying and understanding the diversity amongst us. Currently there are eight members and four apprentices in RAW. Eight members have been with the group between four and twelve years, and there is diversity in their ethnic origins (e.g., Korean, Japanese, Taiwanese, Hong Kong Chinese, Japanese/South Asian) and generations/length of living in Canada (e.g., second generation born in Canada; 1.5 generation women who came as children; immigrated five to twenty-plus years prior). There are members who identify themselves as straight, lesbian, bisexual or queer. Some members have children. Some were raised with strong Christian teachings, while some others grew up agnostic and some practice Buddhism. The occupations members hold include family mediator, social worker, sexual health educator, teacher, academic, psychotherapist, and dancer. These identifications are obvious differences, and there are many other differences that the members might not have thought about that exist amongst themselves, but may become an issue during a point of disagreement or conflict. Learning from one another and providing/receiving support from one another have been vital in raising critical consciousness, which can be a difficult process but can also lead to resiliency against sometimes hostile realities. Practice Principle 3: Resilience Can Be Facilitated Through Addressing Key Supports and Barriers for Women of Color Community Change Agents. Practice Principle 5: Resilience Can Be Facilitated by Inviting Clients to “Tell the Stories” Another factor to consider in raising critical consciousness is to learn from people who came before us and honor this history through intergenerational and, in our case, transnational connections. In attempting to do this, RAW traces its distant roots to the Asian American/Asian Canadian movements starting in the late 1960s: we are trying to increase our understanding of and our ties to those who were present at the beginning of these movements. For example, learning from and connecting to PJ and

Roy Hirabayashi of San Jose Taiko3, the third-oldest taiko group in the United States, has been a tremendously positive experience for the group as we trace our distant lineage to San Jose Taiko through two other groups in between. San Jose Taiko came out of the Asian American movement emerging in the late 1960s in California, and had a focus on revitalizing Japantown in San Jose, which was decimated following the Internment of Japanese Americans during World War II. Knowing the history of taiko in North America in light of Asian American movement gives us humility and renewed energy and commitment to social justice, as there are forerunners who have done the work for us over the past forty-some years already. These two examples identify how an understanding of the structural experience of women of color can be used in macro- and micro-level practice. In both of these cases, we utilize practice methods that are focused on identifying and building upon sources of resilience and strength that are within communities. The practice guidelines we identify can be used by any social worker interested in fostering the resilience of women of color and may be incorporated into the design and evaluation of their interventions.

conclusion In this chapter we have identified ways in which women of color can be a group considered to be a “population at risk” for health, mental health, poverty, and other serious problems. These problems most often originate in conditions of inequality that result from the interlocking oppressions of racism and sexism that affect the opportunity structures, resources, and experiences of women of color. However, women of color have not been passive in their experiences of inequality. Individual women and groups of women have developed strategies and resources within their communities that are sources of resilience and strength. Effective social work practice with women of color will recognize and understand how societal conditions have had an impact on the

Women of color

experience of women of color. This practice also requires a multidimensional perspective involving multiple levels of practice and skills for working with individuals, groups, families, and communities. Understanding women of color requires focusing specifically on how individual women have been affected by forces such as racism, ethnocentrism, and sexism and on

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1. In Canada the terms people of color, ethnic minorities, and women of color are not as commonly used in the public domain as they are in the United States. Instead, the terms visible minority or visible minority women may be used in government censuses, and are thus used widely in public discourses, such as the media. Visible minorities are defined in the Employment Equity Act as “persons, other than Aboriginal peoples, who are non-Caucasian in race or nonwhite in color” and may include groups such as Chinese, South Asian, Black, Arab, West Asian, Filipino, Southeast Asian, Latin American, Japanese, and Korean (Statistics Canada, 2012). A similar construct in the United States may be ethnic minorities. However, Aboriginal peoples (First Nations, Metis, and Inuit), who make up approximately 4 percent of the entire population, are not included in the category of visible minorities. People working out of antiracist perspectives may prefer to use people of color, racialized minorities, or racialized communities instead; however, similarly, these constructs often do not include Aboriginal peoples. Since the Census data and other public statistics reports often follow this convention of using visible minorities as a dominant category to refer to racial and ethnic differences, it is not easy to identify the parallel statistics to those of “women of color” in the United States. 2. This excerpt is part of Audre Lorde’s famous speech at the National Women’s Studies Association Conference made at Storrs, Connecticut, in June 1981, titled “The Use of Anger: Women Responding to Racism.” The text of this speech is included in the 2007 version of Lorde’s Sister Outsider book, a compilation of her speeches and essays. 3. PJ and Roy Hirabayashi were the 2011 recipients of the prestigious National Endowment for the Arts (NEA) National Heritage Fellowship Awards, and their bios and interviews are featured on NEA website (http://www.nea.gov/honors/heritage/fellows/fellow.php?id=2011_07&type=bio). For more information about San Jose Taiko that

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ways in which social structures might be challenged. However, because women of color are at the bottom of our social hierarchy in terms of political power, we must also emphasize the interpersonal and political levels of change. As illustrated in our examples, practice with women of color will engage sources of resilience and strength to ameliorate systems on all levels.4

the Hirabayashis have founded, visit http://www .taiko.org 4. Special thanks to Virginia Gonzales, Laura Montero, Esmirna Ramirez, and Margaret Vail, who assisted with the development of this chapter. referenceS

Abdelrazak, A.  T. (Ed.). (2007). Contemporary Arab American women writers: Hyphenated identities and border crossings. Youngstown, NY: Cambria. American Community Survey. (2011). 2011 American Community Survey Improvements. Washington, DC: American Community Survey. http://www.census . g ov / a c s / w w w / a b out _ t h e _ s u r v e y / 2 0 1 1 _ a c s _improvements/ Block, S., & Galabuzi, G. (2011). Canada’s colour coded labour market. Ottawa, ON: The Wellesley Institute. Chisholm, J., & Greene, B. (2008). Women of color: Perspectives on “multiple identities” in psychological theory, research, and practice. In F. L. Denmark & M. Faludi (Eds.), Psychology of women: A handbook of issues and theories (pp. 40–69). Westport, CT: Praeger. Chui, T., Tran, K., & Maheux, H. (2006). Immigration in Canada: A portrait of the foreign-born population, 2006 Census. Ottawa, ON: Statistics Canada. http://www12.statcan.ca/census-recensement/2006 /as-sa/97–557/index-eng.cfm Comas-Diaz, L. (2011). Multicultural care: A clinician’s guide to cultural competence. Washington, DC: American Psychological Association. Committee on Health Care for Underserved Women. (2012). Human Immunodeficiency Virus and Acquired Immunodeficiency Syndrome and Women of Color. Obstetrics & Gynecology, 120, 735–39. Duanne-Cascio, C. A. (2010). White identity development in a multicultural age. Reflections: Narratives of Professional Helping, 18(1), 21–30. Ghazal Read, J. (2011). Culture, class, and work among Arab-American women. Ann Arbor: University of Michigan Press. Ghazal Read, J., & Bartkowski, J. (2000). To veil or not to veil? A case study of identity negotiation among Muslim women in Austin Texas. Gender and Society, 14, 395–417.

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(2007). Racial microaggressions in everyday life: Implications for clinical practice. American Psychologist, 62(4), 271–86. Sue, D. W., & Sue, D. (2008). Counseling the culturally diverse: Theory and practice. Hoboken, NJ: Wiley. Urquijo, C. R., & Milan, A. (2011). Women in Canada: female population. Ottawa, ON: Statistics Canada. http://www.statcan.gc.ca/pub/89–503-x/2010001 /article/11475-eng.pdf U.S. Department of Labor. Bureau of Labor Statistics. (2011). Highlights of Women’s Earnings in 2010. [Report 1031]. Retrieved from: http://www.bls.gov /cps/cpswom2010.pdf U.S. Department of Labor. (2012). Labor force characteristics by race and ethnicity, 2011. Report 1036. Washington, DC: U.S. Department of Labor. Zuni Cruz, C. (2010). Self-determination and indigenous nations in the United States: International human rights, federal policy, and indigenous nationhood. In L. Strelein (Ed.), Dialogues about land justice: Papers from the national native title conferences (pp. 159–69). Canberra, Australian Capital Territory: Aboriginal Studies Press.

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v contributorS

Adeyinka M. Akinsulure-Smith, Ph.D. Associate Professor The City College of New York, The City University of New York Bruce J. Armstrong, D.S.W. Associate Professor Population and Family Health Mailman School of Public Health, Columbia University Astraea Augsberger, Ph. D.. Assistant Professor Boston University School of Social Work F. Diane Barth, M.S.S.W. Psychotherapist, Private Practice Kathryn Basham, Ph.D. Professor Smith College School for Social Work Besa H. Bauta, M.S.W., M.P.H. Doctoral Candidate New York University Silver School of Social Work *Toby Berman-Rossi, D.S.W. Professor Barry University School of Social Work S. Megan Berthold, Ph.D. Assistant Professor University of Connecticut School of Social Work Bonnie E. Carlson, Ph.D. Professor Emerita School of Social Work, Arizona State University Grace Christ, Ph.D. Professor Emerita Columbia University School of Social Work 581

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Alwyn T. Cohall, M.D. Professor Sociomedical Sciences, Population and Family Health, and Pediatrics Columbia University Medical Center Renee Mayer Cohall, M.S.W. Director of Special Initiatives, Project STAY Mailman School of Public Health, Columbia University Lisa G. Colarossi, Ph.D. Lecturer Mailman School of Public Health, Columbia University Jacqueline Corcoran, Ph.D. Professor Virginia Commonwealth University School of Social Work Deborah. M. Courtney, M.S.W. Doctoral Candidate Graduate School of Social Service, Fordham University Kay Davidson, D.S.W. Professor University of Connecticut School of Social Work Jordan E. DeVylder, M.S. Doctoral Candidate Columbia University School of Social Work Diane Drachman, Ph.D. Associate Professor University of Connecticut School of Social Work Ann Marie Garran, Ph.D. Assistant Professor University of Connecticut School of Social Work George S. Getzel, D.S.W. Professor Emeritus Silberman School of Social Work at Hunter College

Alex Gitterman, Ed.D. Zachs Professor of Social Work University of Connecticut School of Social Work Manny J. González, D.S.W. Associate Professor Silberman School of Social Work at Hunter College Geetha Gopalan, Ph.D. Post-Doctoral Fellow New York University Silver School of Social Work Lorraine M. Gutiérrez, Ph.D. Professor University of Michigan School of Social Work Meredith Hanson, D.S.W. Professor Graduate School of Social Service, Fordham University Nina Rovinelli Heller, Ph.D. Associate Professor University of Connecticut School of Social Work Timothy B. Kelly, Ph.D. Professor University of Dundee Shannon R. Lane, Ph.D. Assistant Professor Adelphi University School of Social Work Edith A. Lewis, Ph.D. Associate Professor University of Michigan School of Social Work Ellen P. Lukens, Ph.D. Firestone Centennial Professor of Clinical Social Work Columbia University School of Social Work Jennifer McClendon, Ph.D. Assistant Professor University of Nevada, Reno School of Social Work

contributorS

Brenda G. McGowan, Ph.D. Professor & James R. Dumpson Chair of Child Welfare Studies Graduate School of Social Service, Fordham University Jill Theresa Messing, Ph.D. Assistant Professor Arizona State University School of Social Work Faye Mishna, Ph.D. Dean and Professor Factor-Inwentash Faculty of Social Work, University of Toronto Cristina Mogro-Wilson, Ph.D. Assistant Professor University of Connecticut School of Social Work Linda Openshaw, D.S.W. Professor School of Social Work at Texas A&M University-Commerce Yvonne Patterson, M.S.W. Doctoral Candidate University of Connecticut School of Social Work Kathleen Rounds, Ph.D. Professor School of Social Work, University of North Carolina Izumi Sakamoto, Ph.D. Associate Professor Factor-Inwentash Faculty of Social Work, University of Toronto Lambrine A. Sideriadis, Ph.D. School Social Worker Middletown Board of Education *Deceased

Ellen Smith, Ph.D. Assistant Extension Professor University of Connecticut School of Social Work Charity C. Sneed, M. S. W. Doctoral Candidate School of Social Work, University of North Carolina Mary Sormanti, Ph.D. Professor of Professional Practice Columbia University School of Social Work Jonel Thaller, Ph. D. Instructor of Social Work Ball State University School of Social Work Carol T. Tully, Ph.D. Professor Emerita Kent School of Social Work, University of Louisville Melissa Van Wert, M.S.W. Doctoral Candidate Factor-Inwentash Faculty of Social Work, University of Toronto Lynn Videka, Ph.D. Dean and Professor New York University Silver School of Social Work Nancy Boyd Webb, D.S.W. Professor Emerita Graduate School of Social Service, Fordham University Stephen W. Willroth, M.S.W. Social Worker, Private Practice

]

583

v index

AA. See Alcoholics Anonymous AARP Public Policy Institute, 185 AAS. See American Association of Suicidology ABA. See applied behavioral analysis ABC model of depression, 120 abortions, 206, 207, 210–11, 394, 447 abstinence-only-until-marriage program, 205–6, 210, 215, 218 abuse and neglect: of autism spectrum individuals, 79–80; BPD and, 99, 102. See also child abuse and neglect ACCESS. See Arab American Center for Cultural, Economic and Social Services acculturation, 59, 107–8, 163, 380–81 ACEs. See adverse childhood experiences ACF. See Administration for Children and Families acquired immune deficiency syndrome (AIDS), 33–53, 328; as affirmative experience, 40; bereavement counseling for, 41, 46, 47; biopsychosocial consequences, 33; children orphaned by, 42; defining and explaining, 33–35; demographic patterns, 35–36; depression and, 38, 39; homeless individuals and, 36, 42; IDUs and, 35, 36; medical treatment for, 38–39; as metadisease process, 37; microorganisms parasitic relations and, 2; MSMs and, 35; older persons with, 42; protective factors, 39–40; race and ethnicity, 12; risk factors, 37–39; social worker education on, 37; societal context, 36–37; stigmatized death and, 36, 44; suicide and, 186, 471; of young men of color, 327, 538–39, 542–43, 545. See also human immunodeficiency virus; people living with AIDS acquired immune deficiency syndrome, human face of: advocacy work, 51–52; assessment and intervention,

42–47; caregivers, 46–47; episodic crisis support, 44, 51; functional consequences of, 43– 44; grief work, 51; peer support systems, 41, 49; psychosocial consequences, 43; relationship challenging, 44, 45–46; survival strategies identification, 40 acquired immune deficiency syndrome, social work contributions, 40; acute care hospitals, 42; assessment and psychosocial consequences, 46, 48–49; case management work, 42; child welfare services and, 46; crisis intervention teams, 41; didactic-oriented group programs, 41; ethical and legal issues, 46; family, broad operational definition of, 45; family counseling, 42; support groups, 41, 46; teaching safe-sex behaviors, 45 ACT. See Assertive Community Treatment activity camps, 193 acute care hospitals, 42 acute illness, 180. See also chronic physical illness and disability acute stress disorder, 290 adaptive mechanisms, 4, 58, 147–48, 380–81, 449, 471, 517, 551 Add Health. See National Longitudinal Study of Adolescent Health Addiction Severity Index (ASI), 64 addictive behavior disorders, 54–72; assessment, 64–66; biological factors, 60; case illustration and discussion, 66–69; demographic patterns, 58–59; disease models of, 56; EBP for, 65–66; family factors, 59–60; harm reduction therapy for, 62; individual factors, 61; learning and conditioning models, 57–58; level of care for, 63–64; moral models for, 55–56; programs for, 61–64; psychoanalytical explanations for, 56–58; resiliencies and protective factors, 61; screening 585

586

[

index

addictive behavior disorders (continued) instruments for, 64–65; social factors, 60–61; social work contributions, 61–64; societal context, 59–60; spiritual models for, 56; symptom models for, 56; TCs for treatment of, 63–64. See also alcoholism and other drug addictions; substance abuse ADHD. See attention-deficit/ hyperactivity disorder ADI. See Autism Diagnostic Interview adjustment disorder, 119 Administration for Children and Families (ACF), of DHHS, 271 Adolescent Family Life Act (1981), 210, 215, 220 adolescent pregnancy, 205–26, 539; assessment and intervention, 220–21; case illustration and discussion, 221–23; children of teens, 206, 213–14; communitybased programs for, 218; community characteristics, 213; curriculum-based education programs for, 217; defining and explaining, 205–6; demographic patterns, 206–9; family characteristics, 206, 212–13; mental health and, 212; parent programs for, 218; pregnancy prevention programs, 211, 216–20; programs and social work contributions, 215–20; race and ethnicity disparities in, 208; resiliencies and protective factors, 214–15; sexual abuse victims and, 212; social services for, 220; societal context of, 209–11; substance abuse and, 212; tangible support for, 215; teens in foster care and, 213; vulnerabilities and risk factors, 211–14 adolescents: BPD in, 105–6; contraception and condoms, 209, 210, 211; death of, 306; depression in, 117, 118, 121, 123, 212; eating problems in, 145, 147, 151; fatherhood of, 207–8; in foster care, 272; gay and lesbian, 325, 327; It’s your game. Keep it real intervention for, 217; media influence on, 209–10; parental monitoring of, 214–15; parents, poverty of, 206, 208–9; physical,

emotional and cognitive development of, 211–12; pregnancy and birthrates, 206–7; sexual activity of, 209; STIs and health, 209 adoption, 275, 281 Adoption and Child Welfare Act (1980), 274–75 Adoption and Safe Families Act (ASFA) (1997), 273, 275–76 Adoption Assistance and Child Welfare Act (1989), 273, 275 ADOS. See Autism Diagnostic Observation Schedule adult day care, 425 adulthood, gay and lesbian persons, 321, 327–28, 331 adverse childhood experiences (ACEs), 255 AEDPA. See Anti Terrorism Effective Death Penalty Act AFDC. See Aid to Families with Dependent Children affective disorders, 98–99, 104–5 affect regulation and impulse control, for eating problems, 142 Affordable Health Care Act (2010), 42; EOB statements and, 211; Personal Responsibility Education Program of, 216; teen access to contraceptives, 211 African Americans: BPD and, 107; depression and, 121; life circumstances, 5–8, 11–12; life expectancy of, 11; older persons, 417; protective factors, 4; suicide and, 466–67. See also women of color AFS. See American Federation of Suicidology ageism, 421 age-related cognitive decline, 420 aggression: covert, 227; expressive, in intimate partner abuse, 394; microaggressions of women of color, 566; overt, 227 AHAR. See Annual Homeless Assessment Report Aid to Families with Dependent Children (AFDC), 8 Al-Anon, 62, 65 Alaskan Natives, 467–68 Alcoholics Anonymous (AA), 15, 62, 65, 167 alcoholism and other drug addictions, 2, 4, 54–72; defining and explaining, 54–58; detoxification, 63;

genetic linkages, 1, 61; poverty and, 26; risk factors for, 61; societal context of, 59–60; vulnerabilities and risk factors for, 60–61. See also addictive behavior disorders; substance abuse Alcohol Use Inventory (AUI), 64–65 alexithymia, 147 Alzheimer’s disease, 2, 420, 427, 429 American Academy of Pediatrics, 77, 83 American Association of Suicidology (AAS), 464, 473 American Federation of Suicidology (AFS), 473 American Medical Association, 55 American Psychiatric Association (APA), 117, 160, 290, 319, 471 American Society of Addiction Medicine (ASAM), 63 Amnesty International, 484, 509, 512 Amnesty International Report (2012), 511 anhedonia, 554 Annie E. Casey Foundation, 251 Annual Homeless Assessment Report (AHAR), 347–48, 353 anorexia nervosa, 141–44, 193; DSM-IV-TR on, 143; gender and, 146; personality and family dynamics for, 2 anti-bullying efforts, 234–35 antisocial behavior, 26, 57, 254, 260 Anti Terrorism Effective Death Penalty Act (AEDPA) (1996), 376 APA. See American Psychiatric Association applied behavioral analysis (ABA), 84 Arab American Center for Cultural, Economic and Social Services (ACCESS), 568 Army, U.S., Battlemind program of, 450 ASAM. See American Society of Addiction Medicine ASFA. See Adoption and Safe Families Act ASI. See Addiction Severity Index Asian Americans, 468; child mortality rate, 11; suicide of, 458. See also women of color Asperger, Hans, 73–74 Asperger’s syndrome, 73, 74 Assertive Community Treatment (ACT), 128, 166, 167, 359, 525

index

assessment and interventions: addictive behavior disorders, 64–66; adolescent pregnancy, 220–21; AIDS, 42–49; autism spectrum, 83–86; BPD, 104–9; bullying, 236–38; child abuse and neglect, 256–61; of coping strategies, 20; crime victims and victim services, 295–96; death in family, 308–13; depression, 117–18, 129–33; eating problems, 149–53; of environmental resources, 20–21, 22; foster care, 283–84; gay and lesbian persons, 334–38; harm/loss compared to threat, 20; homeless people, 358–59; immigrants and refugees, 383–84; intimate partner abuse, 404–7; life stressors formulation, 19–21; older persons in need of longterm care, 426–29; reasoned inferences, inductive and deductive reasoning, 21; salient data and, 21; schizophrenia, 169–71; social work practices and, 20–25; suicide and suicidal behavior, 474–75; terrorism, survivors and victims of, 493–502; torture, survivors of, 519–26; transactional disturbances, 18–19; veterans, 451–52; women of color, 569–70; young men of color, 550–51 asset mapping, 550–51 assisted suicide, 465 asylum seekers, 410–11, 511–12, 524, 528n1 attachment theory, 254, 259 attention-deficit/hyperactivity disorder (ADHD), 106 attributions: of crime victims, 291; as protective factor, 14 atypical antidepressants, 129, 130 AUI. See Alcohol Use Inventory Autism Diagnostic Interview (ADI), 84 Autism Diagnostic Observation Schedule (ADOS), 84 Autism Self Advocacy Network, 76 autism spectrum, 73–94; abuse and neglect of, 79–80; Asperger’s syndrome, 73, 74; assessment and interventions, 83–86; behavior therapy for, 74; case illustration and discussion, 86– 90; CDC on, 73, 75; childhood disintegrative disorder, 73;

co-occurring diagnoses and, 77; defining and explaining, 73–75; demographic patterns, 75–76; desensitization techniques for, 85; EBP for, 84–85, 85; environmental factors, 76–77; genetic linkage to, 76; IEPs for, 79; independent living paradigm and, 74; medical model for, 74, 75; MMR vaccine and, 77; negative attitudes toward, 76; neurodiversity and, 76; OT and PT for, 82–83; parent divorce rate, 78; peer relationships, 79; pervasive developmental disorder, 73; physical characteristics of, 74; prevalence of, 75–76; programs and social work contributions, 82–83; resiliencies and protective factors, 80–82; respite care services, 80; safety issues for, 78–79; schizophrenia link to, 74; screening instruments, 83–84; sensory perceptual impairments, 77; siblings supports, 80, 81; societal context, 76; strengths-based approach for, 74, 80–82; theory of mind, 78–79; vulnerabilities and risk factors, 76–80 battered-child syndrome, 273 Battlemind program, of U.S. Army, 450 BDD. See body dysmorphic disorder Beck, Aaron, 125, 475 Beck Suicide Scale for Suicide Ideation (BSI), 475 Behavioral Risk Factor Surveillance System Survey (BRFSS), of CDC, 121–22 behavior therapy: for autism spectrum disorder, 74. See also cognitive behavioral therapy; dialectical behavioral therapy; trauma-focused cognitive behavioral therapy Benkert, Karoly, 318 bereavement counseling: for AIDS, 41, 46, 47; for chronic illness and end-of-life care, 190; counselors, 310–11; for death in family, 304, 306, 313, 315, 316. See also grief Best Practices Registry (BPR), 474

]

bias-based bullying, 228; of children with special needs, 230; consequences of, 233; cyberbullying, 231; disclosure of, 236–37; of LGBTQ youth, 230, 233, 236–37; of overweight children, 230, 233 BIHEADSSS assessment, 550, 551 Billingsley, Andrew, 278 binge eating disorder, 143, 144, 146 biopsychosocial assessments, 257 biopsychosocial model, 33, 524–25 bipolar disorder, 119–20; genetic linkages, 1; medication treatment for, 130–31; schizophrenia and, 162 Bleuler, Eugen, 73, 160, 161 body dysmorphic disorder (BDD), 144–45 “Body-Positive” HIV-positive selfhelp organization, 40 borderline personality disorder (BPD), 95–116; in adolescence, 105–6; affective disorders, 98–99, 104–5; assessment and interventions, 104–9; case illustration and discussion, 109–13; childhood trauma, 99, 102, 103; DBT for, 108–9; defensive structure, 97–98; defining and explaining, 95–101; demographic patterns, 101–2; eating disorders, 105; ego psychology approach to, 98; families of origin, 99; genetic linkages, 2, 98–99; immigration and acculturation, 107–8; labeling, 97; neurologic dysfunction, 98; patientrelated therapeutic alliance for, 109; programs and social work contributions, 104; psychoanalytic treatment and, 97; psychodynamic therapy for, 109; PTSD relationship to, 99–100, 101; race and ethnicity, 107; resiliencies and protective factors, 103–4; screening instruments for, 105; self-injury and suicidality of, 105; social baseline theory, 99; societal context, 102; substance use disorders, 101, 105; time-limited cognitive-analytic therapy for, 109; vulnerabilities and risk factors for, 102; WWW program for mothers with, 106

587

588

[

index

BPD. See borderline personality disorder BPR. See Best Practices Registry Brace, Charles Loring, 269 BRFSS. See Behavioral Risk Factor Surveillance System Survey Brotherhood/Sister Sol (BSS), 544–45 BSI. See Beck Suicide Scale for Suicide Ideation BSS. See Brotherhood/Sister Sol buffering hypothesis, for suicide, 472 Buffett, Warren, 7 bulimia nervosa, 141, 144; DSMIV-TR on, 143; gender and, 146; personality and family dynamics for, 2 bullying, 227–47; anti-bullying efforts, 234–35; assessment and intervention, 236–38; case illustration and discussion, 238–40; covert aggression, 227; defining and explaining, 227–28; demographic patterns, 228–31; ecological systems framework for, 231; gender and, 228–29; individual characteristics, 229; international prevalence of, 228; overt aggression, 227; parental relationships and, 233–34; within peer group, 231; perpetrator characteristics, 232; programs and social work contributions, 234–35; research on, 235; resiliencies and protective factors, 233–34; within school, 231–32; societal context for, 231–32; targeted children of, 229, 232, 234; vulnerabilities and risk factors, 232–33; young men of color and, 541. See also bias-based bullying; cyberbullying Bureau of Labor Statistics, U.S., 7 Bush, George W., 210 CACs. See children’s advocacy centers CAGE substance abuse screening instrument, 64 California Evidence Based Clearinghouse for Child Welfare, 257, 260 Camus, A., 34, 52 Canada, women of color and, 563–64 CAPS. See Clinician-Administered PTSD Scale

CAPTA. See Child Abuse Prevention and Treatment Act CARA. See Combating Autism Reauthorization Act caregivers: for AIDS, 46–47; family, for chronic physical illness and disability, 185; family, for depression, 126 Carrera Program, of Children’s Aid Society, 218 CARS. See Childhood Autism Rating Scale case management, 42, 169, 229, 359, 519, 525; for survivors of terrorism, 496, 498; for young men of color, 546–47 CBOs. See community-based organizations CBT. See cognitive behavioral therapy CDC. See Centers for Disease Control and Prevention CDF. See Children’s Defense Fund Center for Mental Health Services (CMHS), 494 Center on Addiction and Substance Abuse report, 54 Centers for Disease Control and Prevention (CDC): on adolescent pregnancy, 216; on autism spectrum, 73, 75; BRFSS of, 121–22; on HIV, 12, 35–36; Senior Advisor for Disaster, Terrorism, and Mental Health, 493; on suicide, 463, 465 Center to Reduce Cancer Health Disparities, 12 CFSRs. See Child and Family Service Reviews chance, human experience and, 4, 15 CHCs. See community health centers Chicago Women’s Health Risk Study, 291 child abuse and neglect, 248–68; assessment and interventions, 256–61; associated factors, 12–13; attachment and, 254, 259; case illustration and discussion, 261–65; child welfare service system and, 256, 261; cognitive skills and, 264; community risk factors, 253, 255; cycle of coercion, 254; defining and explaining, 248–49; definitional ambiguities of, 274; demographic patterns of, 249–50; EBP for, 257; ecological

approach, 250–51; family group decisionmaking approaches and, 257; home visiting, 258; The Incredible Years, 261; indicated prevention, 259; intergenerational effects, 254; mandatory reporting of, 274; MST, 260–61; multidimensional biopsychosocial assessment for, 257; parental risk factors, 253; parental substance abuse and, 277; parent-child interaction, 253, 254–55; PCIT for, 260; poverty and, 252; programs and social work contributions, 17, 256; Project SafeCare, 260; public health prevention framework, 257; race and ethnicity, 250; resiliencies and protective factors, 255–56; selective prevention, 258; societal context, 250–52; survivors of, 255–56; TFCBT for, 259–60, 263; universal prevention, 257–58; vulnerabilities and risk factors, 252–55. See also foster care Child Abuse Prevention and Treatment Act (CAPTA) (1974), 248, 273–74 Child and Family Service Reviews (CFSRs), 275–76 Child and Family Services Improvement and Innovation Act (2011), 276 Childhood Autism Rating Scale (CARS), 84 childhood disintegrative disorder, 73 childhood poverty rate, 4, 17 childhood trauma, 99, 102, 103, 124 Child Maltreatment, 2010, 249 child protective service (CPS) systems, 248–49, 256, 264 children, 5; chronic physical illness of, 182; of color, foster care disparity of, 278; depression in, 118; in foster care, high-risk behaviors of, 278; immigrant, 280, 373, 376; mortality rates, 11; orphaned by AIDS, 42; with special needs, bias-based bullying of, 230; as survivors of terrorism, 495 Children of the Storm: Black Children and American Child Welfare (Billingsley and Giovannoni), 278

index

children’s advocacy centers (CACs), 256–57, 295, 306 Children’s Aid Society, Carrera Program of, 218 Children’s Aid Society, New York, 269 Children’s Bureau, of DHHS, 271 Children’s Defense Fund (CDF) Report, 272 Children’s Home Society, 269 Child Welfare League of America, 279–80 Child Welfare Organizing Project (CWOP), New York City, 280 child welfare services, 261; AIDS and, 46; parental involvement in, 280; social workers, 256, 281, 306 Christian Right, 324 chronic physical illness and disability, 179–201; activity camps, 193; acute illness compared to, 180; bereavement counseling for, 190; case illustration and discussion, 194– 95; CBT for, 191; children and, 182; coping strategies for, 187, 188; defining and explaining, 180–82; demographic patterns, 182–83; education, 185–86; family caregivers and, 185; family therapy, 193; functional and/or visible limitations, 186; gender and, 186; health care system, U.S., 183; holistic and comprehensive focus on, 183; individual psychotherapy for, 192–93; individual’s thoughts about, 188; in-home support for, 193; interdisciplinary team for, 190–91; Internet research, 184– 85; MBT for, 191–92; medical insurance for, 183; mental health and, 186–87; MFGT for, 193–94; multiple conditions of, 182; older persons and, 186; patient and family-centered care initiative, 189–90; phase or stage of illness, 181; professionals’ relationship to client, 187–88; programs and social work contributions, 189–94; PST for, 191; psychoeducation for, 192; psychological symptoms in response to, 186–87; psychosocial approach to, 179–80; quality-of-life issues, 184; resiliencies and protective

factors, 188–89; social context, 183–85; social support for, 184, 187, 188–89; sociocultural shifts for, 180; support groups for, 192; treatment response, 184; U.S. values and, 183–84; vulnerabilities and risk factors, 185–88 CIDT. See cruel, inhuman, and degrading treatment Circle of Courage assessment, 554 “Client Self-Determination in Endof-Life Decisions,” of NASW, 465 Clinician-Administered PTSD Scale (CAPS), 456 Clinton, Bill, 8 CMHS. See Center for Mental Health Services Code of Ethics, of NASW, 339–40, 451, 492 Code of Federal Regulations, U.S., 485 cognitive-analytic therapy, timelimited, 109 cognitive behavioral therapy (CBT), 16, 58, 65, 296; for chronic illness, 191; for depression, 132–33; schizophrenia and, 165; for servicewomen, veterans, 453; for survivors of terrorism, 496–97; for survivors of torture, 522, 524, 527. See also traumafocused cognitive behavioral therapy cognitive processing therapy (CPT), 457; for servicewomen, veterans, 453 cognitive remediation, 166–69 cognitive skills, TF-CBT and, 264 cognitive style theory of depression, by Beck, 125 Columbia-Suicide Severity Rating Scale (C-SSRS), 475 Combating Autism Act (2006), 82 Combating Autism Reauthorization Act (CARA) (2011), 82 coming-out process, for gay and lesbian persons, 335–36 communities of color, 566–67 Community-Based Abstinence Education program, 210 community-based organizations (CBOs), 537, 545–48, 551, 552 community-based programs: for adolescent pregnancy, 218; for PLWAs, 41 community health centers (CHCs), 547

]

Community Mental Health Act (1963), 161, 349 Community Mental Health Centers Construction Act, 350 Community Partners Project (CPP), 571–72 community risk factors: for child abuse and neglect, 253, 255; for young men of color, 544 community violence: poverty and, 12–14; race and ethnicity, 13 complicated grief, 311–12 Comprehensive Soldier Fitness (CSF) program, 450 concurrent planning, 275 Congressional Social Work Caucus (CSWC), 491 Consolidate Appropriations Act (2010), Teen Pregnancy Prevention Initiative of, 216 Continuum of Care programs, 346, 357–58 contraception, of adolescents, 209, 210, 211 control theory, 291–92 Convention Against Torture and other Cruel, Inhuman or Degrading Treatment or Punishment, UNCAT, 510 co-occurring diagnoses, autism spectrum and, 77 coping strategies, 23; assessment and interventions of, 20; for chronic physical illness and disability, 187, 188; for depression, 127; for eating problems, 142, 146; of immigrants and refugees, 380; intimate partner abuse, 401; for PLWAs, 44; skills as protective factor, 14; for women of color, 567 Council on Social Work Education (CSWE), on gay and lesbian persons, 325 covert aggression, 227 CPP. See Community Partners Project CPS. See child protective service CPT. See cognitive processing therapy CRAFFT test, 554 crime victims and victim services, 3, 26, 289–300; acute stress disorder, 290; assessment and interventions, 295–96; attributions of, 291; case illustration and discussion, 296–98; children’s advocacy

589

590

[

index

crime victims and victim services (continued) centers, 295, 306; control theory, 291–92; cost of, 290–91; crisis intervention unit, 293–94; defining and explaining, 289–90; demographic patterns, 290; domestic violence shelters, 294–95, 402; hate crimes against gay and lesbian persons, 322; just-world theory, 291; programs and social work contributions, 292–95; prosecutor-based victim/witness assistance programs, 289–90, 292–93; resiliencies and protective factors, 292; restorative justice and, 291, 537; revictimization rates, 289, 291; sexual assault, 292; sexual assault centers, 294–95; societal context of, 290–91; victim blaming, 289; victim compensation programs, 292; victim service program, 289, 293–94; vulnerabilities and risk factors, 291–92 Criminal Code, U.S., on terrorism, 485 Crisis Counseling Program, of FEMA, 499 crisis intervention teams, 41, 293–94, 307, 496 crisis intervention theory, 283 critical consciousness, of women of color, 575–76 Critical Incident Stress Debriefing, 495 Critical Time Intervention (CTI), 166; for homeless people, 359 Crossing the Quality Chasm: A New Health System for the 21st Century, of IOM, 189–90 cruel, inhuman, and degrading treatment (CIDT), 514 CSF. See Comprehensive Soldier Fitness program C-SSRS. See Columbia-Suicide Severity Rating Scale CSWC. See Congressional Social Work Caucus CSWE. See Council on Social Work Education CTI. See Critical Time Intervention cultural competence, NASW on, 500–501 cultural identity, 312–13 cultural sensitivity and responsiveness, 280, 453

cultural survivors of torture, 516, 520 culture shock, 377 cumulative stress, 4, 10 curriculum-based education programs, for adolescent pregnancy, 217 CWOP. See Child Welfare Organizing Project cyberbullying, 227–28; bias-based, 231; characteristics of, 230; disclosure of, 236; interventions for, 236; prevalence of, 229–30; research on, 237 cycle of coercion, child abuse and neglect and, 254 cyclothymic disorder, 120 Danger Assessment, 397 Danger Assessment for Immigrant Women, 408 DBT. See dialectical behavioral therapy DD. See dysthymic disorder death: of adolescents, 306; stigmatized, AIDS and, 36, 44; of young men of color, 538, 540 death in family, 301–17; assessment and interventions, 308–13; bereavement counseling for, 304, 306, 313, 315, 316; bereavement counselors, 310–11; case illustration and discussion, 313–15; child advocacy center and, 306; of children, 302, 305–6; children’s response to, 302; child welfare social workers and, 306; crisis teams and, 307; cultural identity and, 312–13; defining and explaining, 301–2; demographic patterns, 302–3; functional unit of family for, 304; grandparents, 301; grief symptoms, 304; hospice care for, 305; of military, 307–8; military social workers, 308; mourning process, 303; of parent, 301–2; programs and social work contributions, 304–8; religion and spirituality, 311, 312–13; school social workers and, 306–7; of sibling survivors, 303; societal context, 303; by violent circumstances, 304; vulnerabilities and risk factors, 303–4; Webb’s Tripartite Assessment, 301, 308–9, 315 Declaration of Tokyo (1975), 510 deductive reasoning, 21 defensive structure, of BPD, 97–98

Deficit Reduction Act (DRA) (2005), 9 demographic patterns: addictive behavior disorders, 58–59; adolescent pregnancy, 206–9; autism spectrum, 75–76; BPD, 101–2; bullying, 228–31; of child abuse and neglect, 249–50; chronic physical illness and disability, 182–83; crime victims and victim services, 290; death in family, 302–3; depression, 121; eating problems, 145; end-of-life care, 182–83; foster care, 271–72; gay and lesbian persons, 320–21; homeless people, 347–49; immigrants and refugees, 372–74; intimate partner abuse, 393–96; of life conditions, 4–6; older persons in need of longterm care, 416–20; of poverty, 3–5; of schizophrenia, 162–64; social work practices and, 4–6; suicide and suicidal behavior, 465–70; terrorism, survivors and victims of, 485–587; torture, survivors of, 511–13; veterans, 443–44; women of color, 562–64; young men of color, 537–41 Demonstration Grants, of EPIAA, 82 Department of Defense (DoD), U.S., 450; on military sexual assault, 445–46 Department of Health and Human Services (DHHS), U.S.: ACF of, 271; on child abuse and neglect, 249; Children’s Bureau of, 271; on cultural competence for disaster mental health programs, 501; HomVEE study by, 258–59; on TANF recipients, 9 Department of Homeland Security, U.S. (DHS), 375; on asylum seekers and refugees, 511; on expedited removal, of immigrants, 376 Department of Housing and Urban Development, U.S.: AHAR of, 347, 353; on prevention programs, 357 Department of Justice (DOJ), U.S., 494; NCVS report by, 290 Department of Veterans Affairs, U.S., 352; on suicide, 463, 470 depression, 117–40; ABC model of, 120; adjustment disorder, 119; in adolescents and, 117, 118, 121, 123, 212; AIDS and, 38, 39;

index

depression (continued) assessment and interventions, 117–18, 129–33; biological vulnerability for, 122; bipolar depression, 119–20; BRFSS on, 121–22; case illustration and discussion, 133–35; CBT for, 132–33; childhood trauma and, 124; in children, 118; of children targeted by bullying, 232; chronic life stressors and, 124–25; cognitive dimensions of, 118; cognitive style and, 125; coping strategies for, 127; cyclothymic disorder, 120; DD, 119, 121; defining and explaining, 117–20; demographic patterns, 121; divorce and, 123, 124; dopamine and, 2; eating disorders and, 146; family and, 120, 122–24, 126; gender and, 121, 123, 126; genetic linkages, 1, 122–23; by geographic location, 121; intimate partner abuse, 124, 404; IPT for, 131–32; levels of care for, 129; MDD, 118–19, 121; medical condition, 119, 120; medication for, 129–30; negativistic thinking and, 125; older persons and, 121; physical (somatic) dimension, 123, 126; programs and social work contributions, 127–29; religious beliefs and, 127; resiliencies and protective factors, 125–27; social learning, 123; social support for, 126; societal context, 121–22; standardized tools for, 118; substance abuse and, 117, 119, 120; suicide and, 117; survivors of terrorism and, 495; of survivors of torture, 515; vulnerabilities and risk factors, 122–25; WHO on, 117 desensitization techniques, for autism spectrum, 85 detoxification, 63 DFI. See Durham Family Initiative DHHS. See Department of Health and Human Services DHS. See Department of Homeland Security, U.S. Diagnostic and Statistical Manual (DSM): acute stress disorder and, 290; on personality disorders, 96; on PTSD, 290 Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR:

on age-related cognitive disorders, 420; on anorexia nervosa and bulimia nervosa, 143; on depression, 117–18; on PTSD, 515; on schizophrenia, 160, 161 Diagnostic and Statistical Manual of Mental Disorders: DSM-5: on autism spectrum, 74–75; on binge eating disorder, 143; on BPD, 96, 100–101 dialectical behavioral therapy (DBT), 108–9; emotion dysregulation, 108; invalidating environment, 108; for suicide, 474 didactic-oriented group programs, 41 disabling grief, 311 diversity: of immigrants and refugees, 374, 380; NASW Code of Ethics on, 492; neurodiversity of autism spectrum, 76; of women of color, 561–62 divorce: depression and, 123, 124; rate, of parents of autism spectrum, 78 Dix, Dorothea, 161 DoD. See Department of Defense DOJ. See Department of Justice domestic violence, 392; homelessness and, 352; shelters, 294–95, 402 Domestic Violence Survivor Assessment (DVSA), 401 “Don’t Ask, Don’t Tell” policy, 448–49 DRA. See Deficit Reduction Act drug addictions. See alcoholism and other drug addictions; substance abuse drugs and drug subcultures, 26 Dubos, Renee, 34 Durham Family Initiative (DFI), 258 DVSA. See Domestic Violence Survivor Assessment dysfunctional interpersonal processes, 18–19 dysthymic disorder (DD), 119, 121 EAPs. See employee assistance programs eating problems, 141–59; in adolescents, 145, 147, 151; affect regulation and impulse control, 142; alexithymia and, 147; assessment and interventions, 149–53; case illustration and discussion, 153–56; coping

]

strategies for, 142, 146; defining and explaining, 143–45; demographic patterns, 145; family and, 146, 147, 148, 151; group work for, 149, 150; hospitalization, 149, 150; individual counseling, 149, 150; Maudsley model for, 149; medications for, 149; programs and social work contributions, 148–49; resiliencies and protective factors, 148; self-regulation and, 152; societal context, 145–46; symptom-focused dynamic psychotherapy, 143; symptoms of, 143, 148; vulnerabilities and risk factors, 146–47. See also anorexia nervosa; binge eating disorder; bulimia nervosa; obesity EBP. See evidence-based practices ecological systems theory: of bullying, 231; for child abuse and neglect, 250–51; on survivors of terrorism, 494–95; techno-subsystem in, 231 economic conditions, societal context of, 6–7 ecosystems perspective, for young men of color, 550 education: chronic physical illness and disability, 185–86; curriculum-based, on adolescent pregnancy, 217; employment and, 8; social worker, on AIDS, 37; of social workers, on survivors of torture, 519; SRH, 542; of young men of color, 541 effective questioning, 550 ego psychology approach, for BPD treatment, 98 Elton John AIDS Foundation, 548 emergency shelters, for homeless people, 357–58 Emerging Answers 2007, 217 emotional object constancy, 152 emotion dysregulation, 108 empathic reflection, 549 employee assistance programs (EAPs), for survivors of terrorism, 492 employment: education and, 8; migration and, 379; poor and low-income neighborhoods and, 10; supported, for schizophrenia, 168

591

592

[

index

empowerment: for autism spectrum, 74; of women of color, 569–670; for young men of color, 548–49 enabling, 23 end-of-life care, 179–201; case illustration and discussion, 194–95; defining and explaining, 180–82; demographic patterns, 182–83; hospice and palliative care, 181–82; programs and social work contributions, 189– 94; resiliencies and protective factors, 188–89; social context, 183–85; vulnerabilities and risk factors, 185–88 English Poor Law, 269 enhanced safety plan, in TF-CBT, 265 environmental change, 17, 18 environmental resources, 14, 21, 22; assessment of, 19–20; change and, 17, 18; as protective factor, 15 environments: exchanges within, 4; social and physical, 19 EOB. See explanation of benefits EPIAA. See Expanding the Promise of Individuals with Autism Act evidence-based practices (EBP): for addictive behavior disorders, 65–66; for autism spectrum, 84–85, 85; for child abuse and neglect, 257; for survivors of terrorism, 496–97 exceptionalism, for PLWAs, 41 Expanding the Promise of Individuals with Autism Act (EPIAA) (2007), 82 expedited removal, of immigrants, 376 explanation of benefits (EOB) statements, 211 external support, as protective factor, 15 family: caregivers, 126, 185; characteristics, adolescent pregnancy and, 206, 212–13; depression and, 120, 122–24, 126; dynamics, for bulimia nervosa, 2; eating problems and, 146, 147, 148, 151; group decisionmaking approaches for, 257; immigrants, refugees and, 372, 375, 381; income of, health of children and, 10–11; psychoeducation,

for schizophrenia, 168; risk factors, for young men of color, 543; schizophrenia and, 162; survivors of torture and, 516; systems, of gay and lesbian persons, 325–26. See also death in family; parents family factors: as protective factor, 15; societal context of, 9–10 family functional unit, for death in family, 304 Family Planning, Access, Care, and Treatment (PACT) program, of California, 217 family planning programs, 210, 546 Family Research Council, 324 family structure: poverty and, 5; protective factors and, 15 family therapy: for AIDS, 42; for chronic illness, 193; MFGT, 193–94 Family-to-Family Education program, for schizophrenia, 169 Family to Family Initiative, of Annie E. Casey Foundation, 280, 282 fatherhood, of adolescents, 207–8 FBI. See Federal Bureau of Investigation Federal Bureau of Investigation (FBI): on terrorism, 485; Uniform Crime Reporting, 26 Federal Emergency Management Agency (FEMA), Crisis Counseling Program of, 499 Federal Violence Against Women Act (1994), 289 FEMA. See Federal Emergency Management Agency feminist perspective, on intimate partner abuse, 393, 396–97 fetal alcohol syndrome, 2 FOCUS project, 450 foreclosure, homeless people and, 345, 347, 352 foster care, 269–88; adolescent pregnancy of teens in, 213; adolescents in, 272; assessment and interventions, 283–84; case illustration and discussion, 284– 86; characteristics of children in, 273, 276–77; children of color disproportionality and disparity in, 278; comprehensive service plan for, 283; cultural sensitivity and, 280; defining and explaining, 269–71; demographic patterns, 271–72;

disruptions, 278; gender and, 271; high risk behaviors of children in, 279; historical background of, 269; homeless children and, 277, 354; immigrant children and youth, 280; kinship, 270, 272, 280; McKinney-Vento program and, 280–81; permanency planning and, 270–71, 279; placement prevention, 274; poverty and, 273, 277, 278; programs and social work contributions, 281– 82; resiliencies and protective factors, 279–81; school performance and, 277–78; societal context, 272–76; trauma and, 278–79; vulnerabilities and risk factors, 276–79 Foster Care and Adoption Assistance Program, Title IV-E, 273 Foster Care Independence Act (1999), 275 Fostering Connections to Success and Increasing Adoptions Act (2008), 273, 276 Fountain House, 166, 167 frail elderly, 415–16 Fresh Youth Initiatives (FYI), 544 Garrett Lee Smith Grant Program, 472 Gault decision, by Supreme Court, 537 Gay, Lesbian, and Straight Education Network (GLSEN), 324–25, 331 gay and lesbian persons, 36, 318–44; adulthood, 321, 327–28, 331; assessment and interventions, 334–38; case illustration and discussion, 338–39; coming-out process, 335–36; defining and explaining, 318–20; demographic patterns, 320–21; economic sector, 323; educational systems, 330–31; family systems, 325–26; hate crimes against, 322; HIV infection of, 328, 333; homelessness and, 354; institutions of learning, 324–25; legal remedies/system for, 322–24; nonfamily households, 320–21; nongay parents of, 325–26; in nongay world, 318–20; old age, 321, 328–29, 331; partner abuse, 328, 337;

index

gay and lesbian persons (continued) poverty of, 321; programs and social work contributions, 331–33; religious community, 318–19, 323–24; research data realities, 319; resiliencies and protective factors, 330–31; risk factors for, 326–30; same-sex marriages, 324; societal context, 321–26; substance abuse of, 328; suicide of, 469; torture of, 509; vulnerabilities and risk factors, 326–30; workplace discrimination against, 323. See also lesbian, gay, bisexual, transgendered, and questioning youth Gay Men’s Health Crisis, in New York City, 41 GED PLUS program, 555 GED programs, 545, 547 gender: anorexia nervosa and, 146; bulimia nervosa and, 146; bullying and, 228–29; chronic physical illness and, 186; depression and, 121, 123, 126; foster care and, 271; intimate partner abuse and, 393, 395, 396; of older persons, 417; suicide and suicidal behavior or, 466, 470–71; veterans and, 441–43 genetic linkages: for alcoholism and other drug addictions, 1, 61; to autism spectrum, 76; for bipolar disorder, 1; BPD, 2, 98–99; depression, 1, 122–23; for obesity, 2; for schizophrenia, 1, 162 Giovannoni, Jeanne, 278 Global South countries, 563–64 GLSEN. See Gay, Lesbian, and Straight Education Network goodness of fit, 551 Grandin, Temple, 75, 85–86 Great Depression, 349 Great Recession, 7 grief: complicated, 311–12; disabling, 311; work, for AIDS, 51. See also bereavement counseling group therapy, 149, 150, 193–94, 524 guiding interventions, 23 Guttmacher Institute, 209 harm/loss, 20 harm reduction therapy, 72 Harrison Act (1914), 55 Head Start, 257 health: of adolescents, 209; challenges, of women of color,

565; needs, of young men of color, 535–36, 541; physical outcome, of intimate partner abuse, 397; promotion of, 17, 18; race and ethnicity, 10–11; of returning servicewomen, veterans, 446. See also mental health health of children: family income and, 10–11; preventative medical care and, 11 Health Survey for Adolescents, 220 Healthy Bodegas, Green Carts, and Health Bucks programs, 543, 544 Healthy Families America (HFA), 258–59 Healthy Monday Campaign, 548 HEARTH. See Homeless Emergency Assistance and Rapid Transition to Housing Act heroic humanitarianism in PLWAs’ AIDS work, 40–41 heterosexual assumptions, by social workers, 333 HFA. See Healthy Families America Hispanics: cultural factors, 10; demographics, 5–6; depression and, 121; HIV, 12; life circumstances, 6–8; older persons, 417; suicide of, 467 HIV. See human immunodeficiency virus HMIS. See Homeless Management Information Systems home care services, for older persons in need of long-term care, 425–26 Homeland Security Advisory System (HSAS), 488 homeless children, 347, 351–52, 356; foster placement and, 277, 354; gay and lesbian, 327; McKinneyVento program for, 280–81 Homeless Emergency Assistance and Rapid Transition to Housing (HEARTH) Act, 346 Homeless Management Information Systems (HMIS) data, 347–48 homeless people, 345–65; AIDS/ HIV and, 36, 42; assessment and interventions, 358–59; case illustration and discussion, 360–61; causes of, 345, 352; children and, 347, 351–52, 356; defining and explaining, 346–47; demographic patterns,

]

347–49; domestic violence, 352; emergency shelters, 357–58; foreclosure, 345, 347, 352; foster care and, 354; gay and lesbian people, 354; historical perspective, 349–50; housing subsidies, 357; incarceration and, 353–54; Internet and, 356; mental health and, 348–51; people with disabilities, 352; Point-In-Time data on, 347–48, 352–53; poverty and, 345; prevention programs, 356–57; programs and social work contributions, 356–58; race and ethnicity of, 348; resiliencies and protective factors, 354–56; rural communities, 349, 356; social estrangement model, 355; societal context, 349–50; substance abuse and, 348, 351; veterans and, 352–53; violence against, 351; vulnerabilities and risk factors, 350–54 home visiting, 258 homicide: in intimate partner abuse, 395, 397; rate of, 13 homophobia, 319–22; institutional, 322–25, 331–33, 336; internal, 322, 330, 332; religious community and, 324 homosexual persons: NASW on, 319; societal prejudice against, 36 HomVEE study, by DHHS, 258–59 hospice care, 181–82, 305 Housing First, 359 housing subsidies, 357 HRC. See Human Rights Campaign HSAS. See Homeland Security Advisory System H-SLIDER program, of National Guard, 450 human immunodeficiency virus (HIV), 33–35, 40; CDC on, 12, 35–36; of gay and lesbian persons, 328, 333; of homeless people, 36, 42; scientific knowledge about, 38; testing for, 38; transmission of, 37. See also acquired immune deficiency syndrome humanitarian forces, for immigrants and refugees, 374, 375, 377 Human Rights Campaign (HRC), 323 Human Rights Watch report, 375; torture documentation, 512 humor, as protective factor, 15–16

593

594

[

index

ICD. See International Classification of Diseases ICE. See Immigration Customs and Enforcement IDDT. See Integrated Dual Disorder Treatment IDPs. See internally displaced persons IDUs. See intravenous drug users IEPs. See Individual Educational Plans IES. See Impact Event Scale IIRIRA. See Illegal Immigration Reform and Immigrant Responsibility Act Illegal Immigration Reform and Immigrant Responsibility Act (IIRIRA) (1996), 374–75 Illness Management and Recovery (IMR), 166, 168, 171, 172 immigrants and refugees, 163, 366–91; acculturation, 380–81; assessment and interventions, 383–84; case illustration and discussion, 385–87; children and youth, in foster care, 280; children of, 280, 373, 376; concentration of, 373; coping strategies of, 380; culture shock, 377; defining and explaining, 367–72; demographic patterns, 372–74; employment and, 379; ethnic communities, 381; expedited removal of, 376; family and social support, 381; humanitarian forces, 374, 375, 377; language and, 379–80; LPR, 372; mixed-status family, 372, 375; physical and social environments, 378; poverty and, 373–74, 379; premigration/departure stage, 383–84; programs and social work contributions, 382–83; public benefits restrictions for, 374–75; race and ethnic diversity of, 374, 380; re-creation of identity, 379–81; remittances of, 371; resettlement stage, 384; resiliencies and protective factors, 380–82; self-help activities, 382; settlement houses, 382; social service agencies, 382–83; societal context, 374–77; suicide of, 468– 69; survivors of torture, 409; torture and, 510, 521; transit/ intermediate country stage, 384;

undocumented/unauthorized, 372; voluntary agencies, 382; vulnerabilities and risk factors, 377–80; women immigrants, 378–79 immigration and acculturation: BPD and, 107–8; schizophrenia and, 163 Immigration Customs and Enforcement (ICE), 375, 376 Impact Event Scale (IES), 456 IMR. See Illness Management and Recovery incarceration, 3; of homeless people, 353–54; of young men of color, 541, 546 The Incredible Years, for child abuse and neglect, 261 independent living paradigm, 74 indicated prevention, for child abuse and neglect, 259 Individual Educational Plans (IEPs), for autism spectrum, 79 Individuals with Disabilities Education Act (2004), 82 individual therapy and psychotherapy, 149, 150, 192–93 inductive reasoning, 21 in-home services and support, 193, 283 Initiative on Depression and Primary Care, of MacArthur Foundation, 128 Institute of Medicine (IOM): health care report of, 189–90; on MMR vaccine and autism, 77 institutional homophobia, 322–25, 331–33, 336 Integrated Dual Disorder Treatment (IDDT), 128–29, 166, 167 interdisciplinary team, for chronic physical illness, 190–91 internal homophobia, 322, 330, 332, 337 internally displaced persons (IDPs), 511 International Classification of Diseases (ICD), on BPD, 96 International Criminal Court, 513 International Criminal Tribunals for Rwanda, 513 international expert consensus group, after 9/11, 498–99 International Society for Traumatic Stress Specialists, 499 Internet: homeless people and, 356; research, on chronic physical illness and disability, 184–85

interpersonal psychotherapy (IPT), 131–32 interpersonal relationships, 19 intersectionality, 564–65 interventions, 18–24; enabling, 23; guiding, 23; interpretation and, 24–25. See also assessment and interventions intimate partner abuse, 3, 392–414; advocacy interventions, 403; assessment and interventions, 404–7; case illustration and discussion, 407–10; child witnesses services, 403–4; coping strategies, 401; defining and explaining, 392–93; demographic patterns, 393–96; depression and, 124, 404; expressive aggression, 394; family violence perspective, 393; feminist perspective on, 393, 396–97; gender and, 393, 395, 396; historical perspective of, 396; homicide, 395, 397; marital rape, 394; mental health and, 398, 399, 407; physical health outcome, 397; posttraumatic therapy, 406; pregnancy coercion, 394; programs and social work contributions, 17, 402–4; PTSD, 398, 409; race and ethnicity and, 395–96; resiliencies and protective factors, 399–402; revictimization, 291, 398–99; safety planning, 405–6; services for abused women/partners, 403; servicewomen, veterans and, 443, 448; social support, 400; societal context, 396–97; socioeconomic status and, 396; stalking, 394–95; substance abuse and, 398, 406–7; survivor therapy, 407; tangible resources, 400; TTM of Change, 400–401; universal screening for, 402; vulnerabilities and risk factors, 397–99 intimate partner rape, 394 intimate terrorism, 393, 395 intravenous drug users (IDUs), 35, 46 invalidating environment, 108 in-vivo desensitization phase, of TF-CBT, 264 IOM. See Institute of Medicine IPT. See interpersonal psychotherapy

index

Iranians prisoners, sexual torture of, 512 Istanbul Protocol, 520 It’s your game. Keep it real intervention, for adolescents, 217 Jedd Foundation, 472 JJ. See juvenile justice John Birch Society, 324 John H. Chafee Foster Care Independence Program, 275 John Hopkins University, 73 Jordan Matthew Porco Memorial Foundation, 473 just practice, by social workers, 256 just-world theory, 291 juvenile justice (JJ) policies, 537, 538 Kanstroom, Daniel, 374 Keeping Children and Families Safe Act (2003), 248 Kennedy, John F., 350 Kids Count Data Book 2011, 251 kinship foster care, 270, 272, 280 Kraepelin, Emil, 160, 161 Ku Klux Klan, 324 language, of immigrants and refugees, 379–80 Lazarus effect, 39 learned helplessness, 125 Lee, Everett, 367 legal or lawful permanent resident (LPR), 372 legislation, societal context of, 8–9 Lenhard-Goehner, Amy, 81 lesbian, gay, bisexual, transgendered, and questioning (LGBTQ) people. See gay and lesbian persons lesbian, gay, bisexual, transgendered, and questioning (LGBTQ) youth, 325–27, 330–31, 541; bias-based bullying of, 230, 233, 236–37; suicide of, 469 LGBTQ. See lesbian, gay, bisexual, transgendered, and questioning youth life conditions: circumstances, events, social work practices and, 2–6; defining, 1–3; demographic patterns of, 4–6; genetic linkages to, 1; neurochemical imbalances and, 2; supportive environments for, 2–3. See also societal context of life conditions

life expectancy, 11 Lifeline, 355 Life Model, 34, 428–29, 493, 520 life stressors: dysfunctional interpersonal processes, 18–19; environmental pressures, 20–22; transitions and traumatic events, 18 Linehan, Marsha, 108 Link-Up, 355 long-term-care facilities, 416, 424–25 lower-income job loss, 8 LPR. See legal or lawful permanent resident MacArthur Foundation: Initiative on Depression and Primary Care, 128; TCM, 128 Mailman School of Public Health (MSPH), Columbia University, 552 major depressive disorder (MDD), 118–19, 121 major depressive episode (MDE), 540 managed care, social work programs impact from, 16 mandatory reporting, 274 MAOIs. See monoamine oxidase inhibitors marital stability, of veterans and servicewomen, 447–48 masculinity beliefs, 543 Mathematica and Child Trends, adolescent pregnancy review by, 216 Mathematica Policy Research, on teen sexual behavior, 210 Matthew Shepard and James Byrd, Jr. Hate Crimes Prevention Act (2012), 322 Maudsley model, for eating problems, 149 MBT. See mindfulness-based therapy M-CHAT. See Modified Checklist for Autism in Toddlers McKinney-Vento Homeless Assistance Act (1987), 346 McKinney-Vento program, homeless children and, 280–81 McLean Screening Instrument for Borderline Personality Disorder (MSI-BPD), 105 MDD. See major depressive disorder MDE. See major depressive episode

]

MDQ. See Mood Disorder Questionnaire measles-mumps-rubella (MMR) vaccine, autism spectrum and, 77 media: adolescents influence by, 209–10; suppression of torture, 513; on terrorism, 488 Medicaid, 9, 215, 374 medical condition, depression for, 119, 120 medicalization of disability, 74 medical social workers, 3–5, 306 medication management, 128–31, 149, 170 men. See fatherhood; gender; veterans; young men of color mental health: adolescent pregnancy and, 212; chronic physical illness and disability and, 186–87; homeless people and, 348–51; intimate partner abuse and, 398, 399, 407; morbidity, of young men of color, 536; of older persons in need of long-term care, 420; outcomes for women of color, 567, 569; services, 16; of survivors of torture, 523; of veterans and returning servicewomen, 447 Mental Health Association, NYC, 9/11 terrorist attack and, 484 Mental Health Parity and Addiction Equity Act (2008), 61 men who have sex with men (MSM), 35. See also young men who have sex with men methadone maintenance, 62 Metro Home and Hospital for Aged (MHHA), 429–36 MFGT. See multi-family group therapy MHHA. See Metro Home and Hospital for Aged MHT. See mobile health team MI. See motivational interviewing microaggressions of women of color, 566 microorganisms parasitic relations, AIDS and, 2 migration: employment and, 379; new economy of, 368; push/pull theory of, 367; social network activity, 368; supply and demand for labor, 367–68; systems theory and, 368; transnational, 366, 367, 369–71; women’s positions and, 378–79

595

596

[

index

military: couples, phase-oriented therapy for, 452, 454–57; death in family of, 307–8; identity of servicewomen, 448; sexual trauma, 442–43, 445–46; social workers, 308. See also servicewomen; veterans Military Occupational Speciality (MOS), 442 Miller, William, 57 Miller v. Yoakim (1979), 269–70 mindfulness-based therapy (MBT), for chronic illness, 191–92 Mississippi scale for Combat-PTSD, 456 mixed-status family, 372, 375 MMR. See measles-mumps-rubella mobile health team (MHT), 545 Modified Checklist for Autism in Toddlers (M-CHAT), 83 Monitoring the Future (MTF), 537–38 monoamine oxidase inhibitors (MAOIs), 129–30 Mood Disorder Questionnaire (MDQ), 105 MOS. See Military Occupational Speciality motivational interviewing (MI), 65; for young men of color, 549 MSI-BPD. See McLean Screening Instrument for Borderline Personality Disorder MSM. See men who have sex with men MSPH. See Mailman School of Public Health MSPH/NYP interventions, 552–56 MST. See multi-systemic therapy MTF. See Monitoring the Future multidimensional perspective: of child abuse and neglect, 257; for women of color, 564–65 multi-family group therapy (MFGT), for chronic illness, 193–94 multi-systemic therapy (MST), 260–61 multi-theoretical framework, for veterans, 453 NA. See Narcotics Anonymous NAASP. See National Action Alliance for Suicide Prevention NAMI. See National Alliance on Mental Illness Narcotics Anonymous (NA), 47 narrative expressive therapy, 524

NASW. See National Association of Social Workers National Action Alliance for Suicide Prevention (NAASP), 473 National Alliance on Mental Illness (NAMI): Peer-to-Peer program, 169; on schizophrenia, 162, 166 National Association of Social Workers (NASW): on assisted suicide, 465; Code of Ethics, 339–40, 451, 492; on cultural competence, 500–501; on homosexuality, 319; against torture, 519 National Campaign to Prevent Teen and Unplanned Pregnancy, 206; updates from, 217 National Center for Health Statistics, on chronic illness, 180–81 National Center for PTSD, 499, 500 National Center for TraumaInformed Care, of SAMHSA, 496 National Center on Child Abuse and Neglect, 273 National Child Traumatic Stress Network, 279, 500; FOCUS project, 450 National Comorbidity Survey (NCS), on depression, 121 National Consensus Project for Quality Palliative Care, 182 National Crime Victimization Survey (NCVS), 290 National Depression Screening Day (NDSD), 128 National Gay and Lesbian Task Force (NGLTF), 323 National Guard, H-SLIDER program of, 450 National Hospice and Palliative Care Organization, 181 National Incidence Study, 2010 (NIS), 249 National Institute on Alcohol Abuse and Alcoholism, 65 National Institute on Drug Abuse, 54, 65, 66 National Intimate Partner and Sexual Violence Survey (NISVS), 393–96 National Latino and Asian American Study (NLAAS), 468 National Longitudinal Study of Adolescent Health (Add Health), 537–38

National Low Income Housing Coalition, 350 National Military Families Association, 457 National Opinion Research Center (NORC), on gay and lesbian persons, 322 National Professional Development Center (NPDC), on autism spectrum, 84 National Registry of EvidenceBased Programs and Practices (NREPP), 474 National School Climate Survey, 538 National Strategy for Suicide Prevention (NSSPP): on assisted suicide, 465; on suicide variants, 462–63 National Survey of Drug Use and Health (NSDUH), 538 National Terrorism Advisory System (NTAS), 488 Native Americans, 467–68 NCANS data, on child abuse and neglect, 249–50 NCS. See National Comorbidity Survey NCVS. See National Crime Victimization Survey NDSD. See National Depression Screening Day negativistic thinking, depression and, 125 neighborhoods, poor and lowincome, 10 neurochemical imbalances, 2 neurodiversity movement, 76 New Deal, 349 New York Association for New Americans (NYANA), 382 New York-Presbyterian Hospital (NYP), 552 NGLTF. See National Gay and Lesbian Task Force 9/11 terrorist attack, 484, 485, 488, 490, 498–99 NIS. See National Incidence Study, 2010 NISVS. See National Intimate Partner and Sexual Violence Survey NLAAS. See National Latino and Asian American Study non-suicidal self-directed violence, 463 NORC. See National Opinion Research Center

index

NPDC. See National Professional Development Center NREPP. See National Registry of Evidence-Based Programs and Practices NSDUH. See National Survey of Drug Use and Health NSSPP. See National Strategy for Suicide Prevention NTAS. See National Terrorism Advisory System NYANA. See New York Association for New Americans NYP. See New York-Presbyterian Hospital OAH. See Office of Adolescent Health Obama, Barack, 82, 215, 377 obesity, 146; bias-based bullying and, 230, 233; genetic linkages, 2 occupation therapy (OT), 82–83 ODD. See oppositional defiant disorder OEF. See Operation Enduring Freedom Office for Refugee Resettlement (ORR), 511, 518 Office for Victims of Crime (OVC), 494 Office of Adolescent Health (OAH), 215–16 Office of Adolescent Pregnancy Program, of Title VI, of Public Health Service Act, 215 Office of Men’s Health, 535 OIF. See Operation Iraqi Freedom Oklahoma City bombing, 485 older persons: with AIDS, 42; chronic physical illness and, 186; depression and, 121; gay and lesbian persons, 321, 328–29, 331; gender and, 417; living arrangements of, 417–18; race and ethnicity of, 417, 422; social isolation, 418 older persons in need of long-term care, 415–40; adult day care, 425; assessment and interventions, 426–29; case illustration and discussion, 429–36; chronic conditions of, 419; defining and explaining, 415–16; demographic patterns, 416–20; ethnic minorities, 422; frail elderly, 415–16; home care services, 425–26; hospitals, 425; Life Model assessment tool, 428–29;

long-term-care facilities, 416, 424–25; mental health of, 420; personal care activities, 416, 419; person-environment fit, 426–27; poverty and, 418–19, 422; programs and social work contributions, 424–26; reduced capacity for self-care, 419–20; rehabilitation programs, 425; resiliencies and protective factors, 423–24; social supports, 423; societal context, 420–23; vulnerabilities and risk factors, 421–23 OND. See Operation New Dawn Operation Enduring Freedom (OEF), 443 Operation Iraqi Freedom (OIF), 443 Operation New Dawn (OND), 443 oppositional defiant disorder (ODD), 106 Oregon Death with Dignity Act (1994), 465 ORR. See Office for Refugee Resettlement OT. See occupation therapy OVC. See Office for Victims of Crime overt aggression, 227 PACT. See Family Planning, Access, Care, and Treatment program palliative care, 312; WHO on, 181–82 Panetta, Leon, 459 parens patriae, 537 Parent-Child Interaction Treatment (PCIT), 260 parent-child sessions, conjoint, in TF-CBT, 264–65 parents: adolescent, 206, 208–9; of autism spectrum, divorce rate, 78; child abuse, neglect and, 253, 254–55, 277; death of, 301–2; involvement in child welfare services, 280; nongay, of gay and lesbian persons, 325–26; programs, for adolescent pregnancy, 218 Parents, Families, and Friends of Lesbians and Gays (PFLAG), 326, 331 patient and family-centered care initiative, 189–90 patient and family council, for chronic illness, 190 patient-related therapeutic alliance, for BPD, 109

]

Patriot Act, 487 PCIT. See Parent-Child Interaction Treatment PDM Task Force 2006. See Psychodynamic Diagnostic Manual peer group: AIDS and, 41, 49; autism spectrum relationships in, 79; bullying within, 231 Peer-to-Peer program, of NAMI, 169 people living with AIDS (PLWAs): community-based programs for, 41; coping strategies for, 44; exceptionalism for, 41; functional family of, 45; heroic humanitarianism in AIDS work, 40–41; movement impact, 39–40; poor treatment of, 33; social work practice with, 42, 45–46; survival strategies, 40 permanency planning, 270–71, 279 Perry, Troy, 324 Personal Experience Screen Questionnaire (PESQ), 64–65 personality conditions, genetic linkages, 1 personality disorder: BPD as, 96; ethnicity and, 107 personality trait theory, 57 personal resources, 22 Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) (1996), 8, 27n2, 374, 542 Personal Responsibility Education Program, 216 person-and-environment service approach, 179 pervasive developmental disorder, 73 PESQ. See Personal Experience Screen Questionnaire PFA. See psychological first aid PFA Guide. See Psychological First Aid Field Operations Guide PFLAG. See Parents, Families, and Friends of Lesbians and Gays phase-oriented therapy, for military couples, 452, 454–57 physical illness, serious. See chronic physical illness and disability physical therapy (PT), 82–83 Pinel, Phillipe, 161 Planned Parenthood, 216 planning: concurrent, 275; in making choices, 15; permanency, 270–71, 279; program, 547; as protective factor, 15; safety, for intimate partner abuse, 405–6

597

598

[

index

PLWAs. See people living with AIDS Point-In-Time, data on homeless people, 347–48, 352–53 population exposure model, on terrorism, 486–87 PORT. See Schizophrenia Patient Outcome Research Team positive youth development (PYD), 536, 538 postpartum depression, 123 posttraumatic growth, 517–18 posttraumatic stress disorder (PTSD), 13, 263, 290–92, 468; BPD relationship to, 99–100, 101; intimate partner abuse and, 398, 409; of servicewomen and veterans, 352, 443, 446, 447; social workers on, 296; of survivors of torture, 514–15; terrorism and, 489 potentially traumatic events (PTEs), 517 poverty, 6, 26; of adolescent parents, 206, 208–9; adolescent pregnancy and, 213; alcoholism and other drug addictions, 26; child abuse and neglect, 252; childhood, 4, 17; community violence and, 12–13; demographic patterns of, 3–5; family structure and, 5; of gay and lesbian persons, 321; health of children and, 10–11; homeless people and, 345; immigrants and, 373–74, 379; of older persons in need of longterm care, 418–19, 422; prolonged and cumulative stress from, 4, 10; of women of color, 562, 563, 565; of young men of color, 542. See also wealth power differentials, between social workers and clients, 23 pregnancy: coercion, 394; of servicewomen, 446–47 pregnancy prevention programs: for adolescent pregnancy, 216–17; federal funding for, 211 pre-military trauma, 444–45 preventative medical care, health of children and, 11 prevention programs: for adolescent pregnancy, 211, 216–20; for child abuse and neglect, 257–58, 257–59; for homeless people, 356–57 primary prevention, 16–17 Problem-Oriented Screening Instrument for Teenagers, 220

problem-solving therapy (PST), for chronic illness, 191 program planning and development, 547 programs and social work contributions: adolescent pregnancy, 215–20; autism spectrum, 82–83; BPD, 104; bullying, 234–35; child abuse and neglect, 256; chronic physical illness and disability, 189–94; death in family, 304–8; depression, 127–29; eating problems, 148–49; end-of-life care, 189–94; foster care, 281–82; homeless people, 356–58; immigrants and refugees, 382–83; intimate partner abuse, 17, 402–4; older persons in need of long-term care, 424–26; schizophrenia, 166–69; social work practices and, 16–18; suicide and suicidal behavior, 473–74; terrorism, survivors and victims of, 490–93; torture, survivors of, 518–19; veterans, 450–51; women of color, 569; young men of color, 545–50 Project Liberty, 491 Project SafeCare, 260 Project STAY (Services to Assist Youth), 545, 548, 552 prolonged stress, 4, 10 prosecutor-based victim/witness assistance programs, 289–90, 292–93 protective factors: for African Americans, 4; environmental resources, 14; external supports, 14; family patterns, 14; humor, 15–16; planning in making choices, 15; resiliencies and, 14– 16; spirituality, 15; temperament, 14. See also resiliencies and protective factors PRWORA. See Personal Responsibility and Work Opportunity Reconciliation Act PST. See problem-solving therapy psychoanalytic treatment, 524; BPD and, 97 Psychodynamic Diagnostic Manual (PDM Task Force 2006), on BPD, 96–97 psychodynamic therapy, for BPD, 109 psychoeducation: for chronic illness, 192; family, for

schizophrenia, 168; PFA, 496, 499–500; phase, of TF-CBT, 263 psychological first aid (PFA), 496, 499–500 Psychological First Aid Field Operations Guide (PFA Guide), 499 psychopharmacology, 524 psychosis, 165 psychosocial perspective: of social workers, 190–91; for survivors of terrorism, 497 PT. See physical therapy PTEs. See potentially traumatic events PTSD. See posttraumatic stress disorder PTSD checklist, 456 public health prevention framework, for child abuse and neglect, 257 Public Health Service Act, 82 push/pull theory of migration, 367 PYD. See positive youth development quality-of-life issues, 184 quantitative and qualitative research, on young men of color, 547 RAAPS. See Rapid Assessment for Adolescent Preventive Services race and ethnicity, 381; adolescent pregnancy disparities of, 208; AIDS and, 12; BPD, 107; child abuse and neglect, 250; community violence and, 12–14; health and, 10–11; of homeless people, 348; of immigrants and refugees diversity, 374, 380; intimate partner abuse and, 395–96; of older persons, 417, 422; suicide and suicidal behavior, 466–68 RAND Corporation, on veteran resilience, 449 Rapid Assessment for Adolescent Preventive Services (RAAPS), 220 Reach for Health-Community Youth Service Learning, 217 reasoned inferences, 21 Refugee Act (1980), 372 Relapse Prevention Therapy, 65 relational theory, 57 relaxation methods, of TF-CBT, 263–64

index

religious beliefs: death in family and, 311, 312–13; depression and, 127 religious community: gay and lesbian persons, 318–19, 323–24; homophobia and, 324 research: on bullying, 235; on cyberbullying, 237; gay and lesbian persons and, 319; Internet, on chronic physical illness and disability, 184–85; quantitative and qualitative, on young men of color, 547; on survivors of torture resilience, 517 resiliencies and protective factors: addictive behavior disorders, 61; adolescent pregnancy, 214–15; autism spectrum, 80–82; BPD, 103–4; bullying, 233–34; child abuse and neglect, 255–56; chronic physical illness and disability, 188–89; crime victims and victim services, 292; definition of, 14; depression, 125–27; eating problems, 148; end-of-life care, 188–89; foster care, 279–81; gay and lesbian persons, 330–31; homeless people, 354–56; immigrants and refugees, 380–82; intimate partner abuse, 399–402; older persons in need of long-term care, 423–24; schizophrenia, 165–66; suicide and suicidal behavior, 471–73; terrorism, survivors and victims of, 490; torture, survivors of, 516–18; veterans, 449–50; women of color, 566–69; young men of color, 544–45 respite care services, for autism spectrum, 80 restorative justice, 291, 537 revictimization: in intimate partner abuse, 291, 398–99; rates of, 289, 291 Richmond, Mary, 349 role-play, 24 rural communities, homeless people in, 349, 356 Safe Horizon, 9/11 terrorist attack and, 484 salient data, 21 same-sex marriages, 324 SAMHSA. See Substance Abuse and Mental Health Services Administration

San Francisco AIDS Foundation, 39 SAP-TBG. See Substance Abuse Prevention and Treatment Block Grant SBCM. See strengths-based case management SBHC. See school-based health center SCHIP. See State Children’s Health Insurance Program schizophrenia, 73, 160–78; ACT for, 166, 167; assessment and interventions, 169–71; autism spectrum link to, 74; bipolar disorder and, 162; case illustration and discussion, 171–73; CBT and, 165; cognitive remediation, 166–69; course of illness, 163; CTI for, 166, 167; defining and explaining, 160–62; demographic patterns of, 162–64; environmental stressors, 164–65; family psychoeducation, 168; family relationship and, 162; Fountain House, 166, 167; genetic linkages, 1, 162; IDDT for, 166, 167; immigration and, 163; IMR for, 166, 168, 171, 172; medication for, 170; PORT for, 166; positive and negative symptoms of, 160, 161; prevalence of, 163; programs and social work contributions, 166–69; psychosocial needs of patients, 162, 164; resiliencies and protective factors, 165–66; social supports for, 165–66; societal context, 164; substance abuse, 163–64; suicide and, 163; symptoms of, 162–63; vulnerabilities and risk factors, 164–65 Schizophrenia Patient Outcome Research Team (PORT), 166 Schneider, Kurt, 160–61 school-based health center (SBHC), 546 schools: bullying within, 231–32; performance in, foster care and, 277–78; young men of color and, 543 school social workers, death in family and, 306–7 Screening for Mental Health, Inc., NDSD of, 128 selective serotonin reuptake inhibitors (SSRIs), 129, 130 self-injury, of BPD, 105

]

self-regulation, eating problems and, 152 self-trauma model, 522–23, 527 Senior Advisor for Disaster, Terrorism, and Mental Health, of CDC, 493 Sensory Behavior Scale, 85 sensory perceptual impairment, 77 serotonin and norepinephrine reuptake inhibitors (SNRIs), 129, 130 Services to Assist Youth. See Project STAY servicewomen, returning, 441–61; CBT, CPT for, 453; DADT policy, 448–49; intimate partner abuse, 443, 448; marital stability, 447– 48; mental health, 447; military identity of, 448; military sexual trauma of, 442–43, 445–46; multi-theoretical framework, 453; phase-oriented therapy with, 452, 454–57; physical health and well-being, 446; pregnancy of, 446–47; pre-military trauma, 444–45; PTSD of, 352, 443, 446, 447; social supports, 449; stereotypes of, 443–44; stress response, 445; substance abuse of, 443, 446; TBI of, 443; tend and befriend by, 445; valuing relationships, 451–52; war zone deployment, 443, 444 SES. See socioeconomic status settlement houses, for immigrants and refugees, 382 sexual abuse victims, 292; adolescent pregnancy and, 212; military sexual trauma, 442–43, 445–46 sexual and reproductive health (SRH) education, 542 sexual assault centers, 294–95 sexually transmitted infections (STIs), 209; of young men of color, 539, 542–43, 545 sexual violence, 392–93 Shanti Project, in San Francisco, 41 short-term counseling, 549 siblings: of autism spectrum, supports for, 80, 81; survivors, death in family and, 303 SIJS. See Special Immigrant Juvenile Status Singer, Judy, 76 situational couple violence, 393 Skills in Psychological Recovery (SPR), 500

599

600

[

index

Smith, Bob, 65 SNAP. See Supplemental Nutritional Assistance Program SNRIs. See serotonin and norepinephrine reuptake inhibitors social and physical environments, 19 social baseline theory, 99 social estrangement model, 355 social justice, 256 social learning theory, 57–58, 123 social marketing, 548 social network activity, 368 social pathologies, 17 Social Security Income (SSI), 82, 374 Social Skills Training, 128 social structure: blue-collar and lower-income jobs loss, 8; childhood poverty, 4, 17; economic crisis, 7; TANF and, 8–9; wealth disparity, 6–7, 10–11 social supports: for chronic physical illness and disability, 184, 187, 188–89; for depression, 126; for immigrants and refugees, 381; intimate partner abuse, 400; older persons in need of long-term care, 423; for schizophrenia, 165–66; servicewomen, returning, 449; veterans, 449 social work contributions: addictive behavior disorders, 61–64; for AIDS, 40–42, 45–46, 48–49; to life events, 16–18. See also programs and social work contributions social workers: adolescent pregnancy role by, 220; AIDS education for, 37; child welfare services, 256, 281, 306; on gay, lesbian persons and homophobia, 334–38; heterosexual assumptions by, 333; in-home services by, 283; just practice by, 256; legal responsibilities of, 273; medical, 3–5, 306; military, 308; as part of addiction treatment workforce, 62–63; power differentials, 23; psychosocial perspective of, 190–91; on PTSD, 296; survivors of torture education, 519; training on terrorism survivors, 490–92; TRICAREapproved, 451. See also National Association of Social Workers

social work practices: assessment and interventions, 20–25; demographic patterns and, 4–6; life conditions and, 2–6; with PLWAs, 42, 45–46; programs and social work contributions, 16–18; societal context of life conditions, 6–10 societal context of life conditions: addictive behavior disorders, 59–60; of adolescent pregnancy, 209–11; AIDS, 36–37; of alcoholism and other drug addictions, 59–60; autism spectrum, 76; BPD, 102; bullying, 231–32; child abuse and neglect, 250–52; of crime victims and victim services, 290–91; death in family, 303; depression, 121–22; eating problems, 145–46; of economic conditions, 6–7; of family factors, 9–10; foster care, 272–76; gay and lesbian persons, 321–26; homeless people, 349–50; immigrants and refugees, 374–77; intimate partner abuse, 396–97; of legislation, 8–9; older persons in need of long-term care, 420–23; schizophrenia, 164; social work practices and, 6–10; suicide and suicidal behavior, 470; terrorism, survivors and victims of, 487–89; torture, survivors of, 513–14; veterans, 444; young men of color, 541–44 societal prejudice, against homosexual persons, 36 socioeconomic status (SES), 121, 396 solution-focused therapy, 16 Sontag, Susan, 44 Southern code of honor, 13 SPC. See suicide prevention contracting Special Immigrant Juvenile Status (SIJS), 280 Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), 215, 222 specific prevention, 17–18 spirituality: death in family and, 311, 312–13; as protective factor, 15; of survivors of torture, 518; women of color, 567–68 SPM. See Supplementary Poverty Measure SPR. See Skills in Psychological Recovery

SPRC. See Suicide Prevention Resource Center SRH. See sexual and reproductive health SSI. See Social Security Income SSRIs. See selective serotonin reuptake inhibitors stages of change model, 400–401 stalking, 394–95 State Children’s Health Insurance Program (SCHIP), 215 State Department, U.S., torture documentation by, 512 STIs. See sexually transmitted infections strengths-based approach, 525; for autism spectrum, 74, 80–82; for survivors of torture, 518; for young men of color, 549 strengths-based case management (SBCM), 525 stress: prolonged compared to cumulative, 4, 10; veterans response to, 445 Stress-Diathesis Model (Vulnerability Stress Model), 164–65 Structured Interview for DSM-IVTR Personality Disorders, 105 substance abuse: adolescent pregnancy and, 212; depression and, 117, 119, 120; of gay and lesbian persons, 328; homeless people and, 348, 351; intimate partner abuse and, 398, 406–7; parental, child abuse and neglect, 277; schizophrenia and, 163–64; of servicewomen and veterans, 443, 446; by survivors of terrorism, 495; of young men of color, 540. See also addictive behavior disorders; alcoholism and other drug addictions Substance Abuse and Mental Health Services Administration, 494; NCTIC of, 496 Substance Abuse and Mental Health Services Administration (SAMHSA), 58, 62, 65, 474 Substance Abuse Prevention and Treatment Block Grant (SAPTBG) funds, 63 substance-induced mood disorder, 119 suicidal ideation, 462, 463 suicidality: of BPD, 105; schizophrenia and, 163 suicidal self-directed violence, 463

index

suicide and suicidal behavior, 462–83; AIDS and, 186, 471; assessment and interventions, 474–75; assisted suicide, 465; buffering hypothesis, 472; case illustration and discussion, 476–80; chronic physical illness and, 186; DBT, 474; defining and explaining, 462–65; demographic patterns, 465–70; depression and, 117; of gay and lesbian adolescents, 327; gender and, 466, 470–71; global statistics for, 462; immigration status, 468–69; of LGB population, 469; programs and social work contributions, 473– 74; psychiatric disease model of, 472–73; psychosocial factors for, 471; race and ethnicity, 466–68; resiliencies and protective factors, 471–73; schizophrenia and, 163; societal context, 470; SPC for, 474; stressful life events/circumstances, 471; suicidal thought, 472; terms for, 463; of veterans, 469–70; vulnerabilities and risk factors, 470–71 suicide prevention contracting (SPC), 474 Suicide Prevention Resource Center (SPRC), 473; BPR of, 474 Supplemental Nutritional Assistance Program (SNAP), 215, 374 Supplementary Poverty Measure (SPM), 418 supply and demand for labor, migration as reason for, 367–68 supported employment, for schizophrenia, 168 support groups: for AIDS, 41, 46; for chronic illness, 192 supports: employment, for schizophrenia, 168; in environments, for life conditions, 2–3; episodic crisis, for AIDS, 44, 51; external, as protective factor, 15; in-home, for chronic physical illness and disability, 193; peer, for AIDS, 41, 49; for siblings, of autism spectrum, 80, 81; tangible, for adolescent pregnancy, 215 survivor or victim theory, 3 survivors of terrorism. See terrorism, survivors and victims of

survivors of torture. See torture, survivors of symptom-focused dynamic psychotherapy, for eating problems, 143 systems theory, 368 TANF. See Temporary Assistance for Needy Families targeted children, of bullying: characteristics, 229; reluctance to tell by, 234; symptoms of, 232 TBI. See traumatic brain injury TCAs. See tricyclic/heterocyclic antidepressants TCM. See Three Component Model TCs. See therapeutic communities techno-subsystem, in ecological systems framework, 231 teen pregnancy. See adolescent pregnancy Teen Pregnancy Prevention Initiative, 216 temperament, as protective factor, 14–15 temperance movement, 65 Temporary Assistance for Needy Families (TANF) (1996), 8–9, 215, 222, 374 tend and befriend, by veterans and servicewomen, 445 termination of parental rights, 275 terrorism, survivors and victims of, 484–507; assessment and interventions, 493–502; case illustration and discussion, 502–4; CBT for, 496–97; characteristics of, 491; children and, 495; defining and explaining, 484–85; demographic patterns, 485–587; depression and, 495; distress symptoms, 490; EAPs for, 492; EBP for, 496–97; intervention principles for, 497; media and, 488; needs assessments, 494; physical consequences of, 490; population exposure model, 486–87; programs and social work contributions, 490–93; psychosocial perspective for, 497; PTSD, 489; resiliencies and protective factors, 490; screening and assessment checklist for, 494; societal context, 487–89; substance abuse and, 495; training manual for mental health responses to,

]

494; vulnerabilities and risk factors, 489–90 terrorist acts: 9/11, 484, 485, 488, 490, 498–99; Oklahoma City bombing, 485; public mental health strategy of response, 495 TESI-C. See Traumatic Events Screening Inventory - Child Version TF-CBT. See trauma-focused cognitive behavioral therapy theory of mind, autism spectrum and, 78–79 therapeutic communities (TCs), for addiction treatment, 63–64 thorazine, 161 threats, 20 Three Component Model (TCM), MacArthur Foundation, 128 Title IV-E: Foster Care and Adoption Assistance Program, 273; Independent Living Program, 275 Title V block grant program, 210 Title VI, of Public Health Service Act, Office of Adolescent Pregnancy Program of, 215 Title XX, Adolescent Family Life Act funding by, 215 TMM. See Transtheoretical Model torture: common types of, 512, 512–13; historical risk factors for, 514; immigrants and refugees, 510, 521; NASW against, 519; perpetrators of, 513; psychological, 513; rape, 513; reasons for, 510; secrecy, media suppression of, 513 torture, survivors of, 509–34; Amnesty International Report on, 511; assessment and interventions, 519–26; case illustration and discussion, 526–28; CBT for, 522, 524, 527; complex presentations of, 515–16; cultural survivors of, 516, 520; cumulative trauma of, 520; defining and explaining, 509–11; demographic patterns, 511–13; depression in, 515; family members of, 516; IDPs and, 511; intentional harm, 510; mental health of, 523; ORR on, 511; physical effects from, 520–21; political activism of, 517; posttraumatic growth of, 517–18; programs and social work contributions, 518–19; PTSD of,

601

602

[

index

torture (continued) 514–15; research on resilience of, 517; resiliencies and protective factors, 516–18; SBCM for, 525; self-trauma model for, 522–23, 527; social and physical environments for, 514; societal context, 513–14; spirituality and, 518; UNHCR on, 511; unlikely reporting of, 511; vulnerabilities and risk factors, 514–16; WMA on, 510 Torture Screening Checklist (TSCL), 518–19 Torture Victims Relief Act (TVRA) (1998), 510 toxic environmental damage, to genetic processes, 2 transitions in life, 18 transnational migration, 366, 367, 369; cross-border contact, 371; mezzo example of, 371; motherhood and, 370 Transtheoretical Model (TMM) of Change, 400–401 trauma: addiction and, 59–60; childhood, 99, 102, 103, 124; of children in foster care, 278–79; military sexual, 442–43, 445–46; pre-military, 444–45 trauma-focused cognitive behavioral therapy (TF-CBT), 496, 524; for child abuse and neglect, 259–60, 263–64; cognitive skills and, 264; conjoint parent-child sessions, 264–65; enhanced safety plan in, 265; in-vivo desensitization phase, 264; psychoeducation phase, 263; relaxation methods, 263–64; trauma narrative phase, 264 trauma narrative phase, of TF-CBT, 264 traumatic brain injury (TBI), 352, 443, 520–21 Traumatic Events Screening Inventory - Child Version (TESI-C), 263 Treatments, Interventions and Services Evaluation Task Force, of EPIAA, 82 TRICARE-approved clinical social workers, 451 tricyclic/heterocyclic antidepressants (TCAs), 129 Tripartite Assessment, of Webb, 301, 308–9, 315 Triple P - Positive Parenting Program, 258

TSCL. See Torture Screening Checklist Tuke, William, 161 TVRA. See Torture Victims Relief Act TWEAK substance abuse screening instrument, 64 two-parent families, poverty of, 5 UN. See United Nations UNCAT. See United Nations Convention Against Torture undocumented/unauthorized immigrant, 372 UNFPA. See United Nations Population Fund UNHCR. See United Nations High Commissioner for Refugees Uniform Crime Reporting, FBI, 26 United Hospital Fund, 185 United Nations Convention Against Torture (UNCAT), 509, 528n1 United Nations High Commissioner for Refugees (UNHCR), 511 United Nations Population Fund (UNFPA), on youth, 536 United Nations (UN) Security Council, on terrorist acts, 485 United States (U.S.): asylum seekers in, 511–12; health care system, 183; values for chronic physical illness and disability, 183–84. See also specific agencies Universal Declaration of Human Rights, UN, on torture, 509 universal prevention programs, for child abuse and neglect, 257–58 U.S. See United States VA. See Veterans Administration Van Arsdale, Martin Van Buren, 269 veterans, 441–61; assessment and interventions, 451–52; case illustration and discussion, 452–57; CBT, CPT for, 453; DADT policy, 448–49; defining and explaining, 441–43; demographic patterns, 443–44; gender and, 441–43; homelessness of, 352–53; intimate partner abuse, 443, 448; marital stability, 447–48; mental health, 447; multitheoretical framework for, 453; phase-oriented therapy with, 452, 454–57; physical health and

well-being, 446; pre-military trauma, 444–45; programs and social work contributions, 450–51; PTSD of, 352, 443, 446, 447; resiliencies and protective factors, 449–50; social supports, 449; societal context, 444; stress response, 445; substance abuse of, 443, 446; suicide of, 469–70; TBI of, 352, 443; tend and befriend by, 445; valuing relationships, 451–52; vulnerabilities and risk factors, 444–49; war zone deployment, 443 Veterans Administration (VA): Health Care System, 444; Medical Center, 444, 451 victim blaming, 289 victimization: of gay and lesbian persons, 327–28; rates of, 14 victims: compensation programs, 292; service programs, 289, 293– 94. See also crime victims and victim services; sexual abuse victims; terrorism, survivors and victims; terrorism, survivors and victims of Victims of Crime Act (VOCA) (1984), 289, 292 violence, 27n5; community, 12–14; exposure impact from, 13–14; against homeless people, 351; homicide rate, 13; poverty and, 12–14; Southern code of honor, 13; victimization rates, 14; youth and, 13. See also domestic violence; intimate partner abuse Violence Against Women Act (1994), 402 Virginia Ultrasound Bill, 211 VOCA. See Victims of Crime Act VOLAG agencies, 382 Volkow, Nora, 54 vulnerabilities and risk factors, 4, 10–14; for alcoholism and other drug addictions, 60–61; autism spectrum, 76–80; for BPD, 102; bullying, 232–33; child abuse and neglect, 252–55; chronic physical illness and disability, 185–88; crime victims and victim services, 291–92; death in family, 303–4; depression, 122–25; doll analogy, 10; eating problems, 146–47; end-of-life care, 185–88; foster care, 276–79; gay and lesbian persons, 326–30;

index

vulnerabilities and risk factors (continued) homeless people, 350–54; immigrants and refugees, 377–80; intimate partner abuse, 397–99; older persons in need of long-term care, 421–23; schizophrenia, 164–65; suicide and suicidal behavior, 470–71; terrorism, survivors and victims of, 489–90; torture, survivors of, 514–16; veterans, 444–49; women of color, 564–66 Vulnerability Stress Model. See Stress-Diathesis Model Walter Reed Army Medical Center, 450 Walton Empire, 7 Watch, Wait and Wonder (WWW) program for mothers with BPD, 106 Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions, 101, 102 wealth: depression and, 123; disparity of, 6–7, 10–11. See also poverty Webb, Nancy Boyd, 301, 308–9, 315 welfare reform: PRWORA, 8, 27n2, 374, 542; TANF, 8–9, 215, 222, 374 Wellness Self-Management (WSM), 128 What Works 2011-2012, 217 WHO. See World Health Organization WIC. See Special Supplemental Nutrition Program for Women, Infants, and Children Wiesel, Eli, 15–16 Wilson, Bill, 65 WMA. See World Medical Association women: feminist perspective, on intimate partner abuse, 393, 396–97; immigrants and refugees, 378–79; transnational migration and, 370. See also abortions; adolescent

pregnancy; gender; intimate partner abuse; pregnancy; servicewomen women of color, 561–77; assessment and interventions, 569–70; Canada and, 563–64; case illustration and discussion, 571–76; communities of color and, 566–67; coping strategies for, 567; critical consciousness, 575–76; defining and explaining, 561–62; demographic patterns, 562–64; diversity of, 561–62; economic challenges of, 562–63; empowerment of, 569–670; health challenges of, 565; identity of, 568–69; key network supports for, 566–67; mental health outcomes, 567, 569; microaggressions of, 566; microinvalidation of, 566; poverty rate of, 562, 563, 565; power blocks and, 565; powerlessness of, 564, 565; programs and social work contributions, 569; resiliencies and protective factors, 566–69; social policy and, 567; spirituality, 567–68; vulnerabilities and risk factors, 564–66 World Health Organization (WHO): on depression, 117; on health, 535; on palliative care, 181–82; on youth, 536 World Medical Association (WMA), on torture, 510 WSM. See Wellness SelfManagement YMC. See Young Men’s Clinic YMSM. See young men who have sex with men young men of color, 535–60; AIDS of, 327, 538–39, 542–43, 545; ambivalence of, 545; assessment and interventions, 550–51; asset mapping, 550–51;

]

BIHEADSSS assessment for, 550, 551; bullying and, 541; case illustration and discussion, 552–56; case management for, 546–47; community risk factors, 544; deaths of, 538, 540; defining and explaining, 536–37; demographic patterns, 537–41; ecosystems perspective for, 550; education of, 541; effective questioning, 550; empathic reflection, 549; empowerment of, 548–49; family risk factors, 543; health needs of, 535–36, 541; incarceration of, 541, 546; JJ policies, 537, 538; masculinity beliefs of, 543; mental health morbidity of, 536; MI for, 549; mortality rate of, 536; poverty of, 542; program planning and development, 547; programs and social work contributions, 545–50; public policies for, 542; PYD of, 536, 538; quantitative and qualitative research and evaluation on, 547; resiliencies and protective factors, 544–45; SBHC for, 546; school-level risk factors, 543; short-term counseling for, 549; social and physical environments, 542; social marketing, 548; societal context, 541–44; SRH education for, 542; STIs of, 539, 542–43, 545; strengths-based perspective for, 549; substance abuse of, 540; youth development, 536 Young Men’s Clinic (YMC), of New York City, 547 young men who have sex with men (YMSM), 539, 541, 544, 547, 548 youth: immigrant, in foster care, 280; UNFPA and WHO on, 536; violence and, 13 youth development: programs, 545; of young men of color, 536 Youth Risk Behavior Survey (YRBS), 535, 537–38, 540

603